{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe proband was a 34 year-old right-handed man. From the age of 26 years, involuntary movements of the bilateral lower limbs, associated with dysarthria, grinding teeth and drooling, appeared and gradually worsened. At 31, he suffered from epileptic seizures, which were considered to be generalized tonic-clonic seizure, but antiepileptic drugs had never been administered. One year later, involuntary movements spread to his upper limbs and orofacial automatisms including abnormal tic-like facial movements, tongue protrusion and biting his lips appeared. Then he was treated with haloperidol (2 mg three times a day) and baclofen (10 mg three times a day) for 2 years for his choreic and dystonic problems, but he responded poorly to drug treatments. At age of 34, his involuntary movements gradually spread to his whole body and epileptic seizures increased in frequency. Since the disease onset, the patient had never suffer from psychiatric problems. Neurological examination revealed poor muscle tone and absent deep tendon reflexes in all limbs. Additionally, right positive babinski sign was elicited. Laboratory data revealed elevated creatine kinase level in the peripheral blood. Acanthocytes were found in 4% of cells on the peripheral blood smear test. Doppler ultrasound examination revealed splenomegaly. Brain magnetic resonance imaging (MRI) showed progressive, symmetrical, mild atrophy of the caudate heads (Figure ). His 24-h continuous electroencephalography (EEG) showed generalized asynchronous theta and epileptiform activity, which mostly originated from the right temporal lobe. A nerve conduction study showed a polyneuropathy, which revealed the right peroneal nerve, right median nerve and bilateral ulnar nerves were partly damaged. His score of Mini Mental Status Examination (MMSE) was 27. The father of the proband did not show any neurological abnormalities and died from pneumonia at 65 years old (Figure ). The mother of the proband (II-3), a 65-year-old woman,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old male involved in high school athletics middle-distance running presented with a 3-week history of pain with more training. He was running up to 300 km/week on streets and cross-country in an even distribution. Although he had taken analgesics, the pain during exercise did not improve, and he presented to our emergency department with lower leg pain (Fig. ). There was no clear abnormality on the radiographs of the tibia, but STIR magnetic resonance imaging (MRI) confirmed a high-intensity area of the distal one-third of the tibia, and the diagnosis of stress fracture and shin splint was made. The patient was instructed to suspend training, and the injury was treated conservatively with follow-up on an outpatient basis (Fig. ). Follow-up radiographs were checked at 2 and 3 months. With this treatment, the fracture healed with no complications, and he decided to return to running after 3 months. At 6 months, radiography showed thickening of the bone cortex in the back one-third of the right tibia and in the back of the distal part of the left tibia, so that he was again instructed to stop training (Fig. ). However, he discontinued coming to the outpatient clinic on his own after 6 months.\nHe was then seen in the emergency department, having sustained an injury to the right lower leg while running a middle-distance race, 1 year after the initial examination. He described how, when he had just started and passed through the first corner, he had felt a ‘‘snap’’ in his right calf, suddenly could not run, and fell and had to abandon the race. He said that his leg was deformed in an impossible direction. It became impossible to run because of the lower leg deformities, and he was brought to our emergency department. He was admitted to hospital, and X-ray examination showed a greatly displaced oblique fracture in the proximal 1/3"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-month-old girl (weight 5.43 kg) suffering from Down syndrome and hypothyroidism was admitted in an emergency setting to the Intensive Care Unit with the symptoms of critical cardiac decompensation. The girl was transferred from another high-reference pediatric cardiology center with the diagnosis of critically narrowed aortic coarctation. In her medical history in the 3rd month of life, weight 3 kg, she underwent an interventional PDA closure in a referring institution.\nIn the last few months the parents observed increasing symptoms of heart failure – shortness of breath, anxiety, lack of appetite, and fatigability – that began just after the intervention. Although the symptoms were persistently reported to the cardiologists by the parents, echocardiographic controls showed a constantly good effect of interventional PDA closure, without any reasonable suspicion of interrupted aortic blood flow.\nTransthoracic echocardiography (TTE) performed on admission showed myocardial injury, with poor contractility and severe valvular incompetence, mild pulmonary hypertension and severe stenosis of the isthmus of the aorta. Further precise TTE showed the critical aortic stenosis of the aorta caused by the aortic disc of the occluder that was used for PDA closure (). Chest X-ray on admission showed a severely enlarged heart silhouette with cardiac index = 0.8 ().\nThe girl was urgently referred for surgical removal of the occluding device. The procedure with extracorporeal circulation (ECC) and deep hypothermia circulatory arrest (DHCA) technique was performed. Intraoperatively there was significant pericardial effusion, and generally impaired contractility of the heart, with enlarged chambers, observed especially in the left ventricle (LV) wall motion. There was a macroscopic inflammatory-type reaction seen in the soft tissues surrounding the PDA, as well as changes in the arterial wall of both sides of the PDA: pulmonary and aortic. The double-disc occluder was removed with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 61-year-old woman who initially presented to her primary care provider in January 2012 with some hematochezia and diarrhea accompanied by lower abdominal pain. After a change in diet failed to resolve her symptoms, she subsequently underwent a computed tomography (CT) scan, which showed severe proctocolitis. The patient was administered steroids in addition to metronidazole, but her symptoms did not resolve. She underwent a colonoscopy in June 2012, which showed the presence of a mass nearly obstructing the rectum.\nOn June 21, 2012, she underwent a low anterior resection of a stage IV rectosigmoid adenocarcinoma (approximately 5 × 4 × 1.5 cm). The tumor was moderately differentiated. A wedge resection of a left hepatic lobe was performed at the same time and yielded a diagnosis of adenocarcinoma consistent with the primary rectal tumor. Colostomy formation was also performed at that time. Her pathology review showed clear margins of the rectal primary, positive margin of the liver resection, and five of 15 lymph nodes positive for metastatic carcinoma. The patient tolerated the procedure well, except for bilateral extremity lymphedema starting two to three weeks after surgery, which improved with compression stockings.\nA subsequent CT scan showed the presence of a secondary liver lesion as well as a 1.2 cm portacaval lymph node, positive for metastatic carcinoma with positron emission tomography (PET) CT. Otherwise, no lymphadenopathy in the chest, abdomen, or pelvis was found.\nPelvic radiotherapy was started with a total dose between 45 and 54 Gy on September 24, 2012. At about that time (September 2012), the patient was started on XELOX chemotherapy (oxaliplatin 100 mg/m2 over two hours, Day 1, every three weeks; capecitabine 850 mg/m2 orally twice daily, Days 1 to 14, every three weeks) and received approximately three cycles. Although the patient tolerated the first cycle well, the day after chemotherapy she had one isolated episode of complete"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is an otherwise healthy 25-year-old male who was brought to our emergency department by ambulance after a fall of 8-10 meters; while leaning against the railing of a third-story balcony he lost balance and fell backward over the rail to the ground below. Emergency personnel at the scene found him comatose and pulseless. After several rounds of cardiopulmonary resuscitation (CPR) and rapid sequence intubation, he was stabilized for transport to our hospital. On arrival to the emergency department, he had developed refractory hypotension and lost a carotid pulse for which he again required a round of CPR before return of spontaneous circulation. Once resuscitated and stabilized, head, spine, chest, abdomen, and pelvis CT scans were obtained. He was found to have bilateral temporal bone fractures as well as a transverse clival fracture, as well as diffuse but predominantly right-sided traumatic subarachnoid hemorrhages with scattered locules of pneumocephalus (Figure ). Spinal imaging revealed intradural air at the L3-L4 levels (Figure ). There was no imaging evidence of direct spinal trauma, nor any evidence of pneumothorax or pneumoperitoneum.\nNeurological examination on arrival revealed an intubated young male with a GCS of 6T: he did not open his eyes nor display any localizing movements but was able to withdraw all of his extremities from painful stimuli. He had dried blood in both ears but was otherwise without otorrhea or rhinorrhea.\nHe was admitted to our trauma ICU and an intracranial pressure monitor was placed and monitoring was noted as normal. A follow-up head CT was unchanged. His GCS improved rapidly and he was extubated 11 hours after admission, and his intracranial monitor was removed. Repeat neurological examination noted that he was coherent and oriented, but amnestic to his injury. He had developed a left facial nerve paresis and was prescribed a two-week course of prednisone without significant improvement noted by the time of discharge. He re"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old, right-hand dominant female who had a known history of right breast carcinoma presented to our clinic for evaluation for open biopsy of a lesion at the base of the coracoid. Four months prior to clinic presentation, she underwent right breast lumpectomy and lymph node dissection. Surgical pathology revealed invasive mammary carcinoma, SBR grade 2 with no involvement of the lymph nodes. Resection margins were negative. She was Her-2-neu negative, estrogen receptor negative, and progesterone receptor positive. A bone scan revealed increased uptake at the eighth thoracic vertebra and in the region of the coracoid in the right shoulder. Further CT imaging of both regions indicated a fracture through the transverse process of T8, though the patient was asymptomatic at this level and had a prior history of a fall from a horse that correlated with this finding. There was no history of any shoulder pain resulting from or subsequent to that fall. CT imaging of the scapula showed osteolytic change at the base of the coracoid. Radiographs and relevant CT scan images are shown (Figures and ). She had received the first cycle of adjuvant chemotherapy with FEC-100 but further cycles were discontinued until further information regarding the possible sites of metastases was collected. Instead, she was placed on Tamoxifen and Clodronate. She was otherwise healthy and took no other medications.\nOn physical exam there was no palpable mass in the region of the right shoulder, no skin discoloration or changes, and her range of motion and strength were normal. She was nontender to palpation over the coracoid process. She had no tenderness to palpation over T8 or elsewhere throughout the spine. Upper and lower extremity neurovascular exam showed no focal deficits.\nThe patient consented to open biopsy of the coracoid and was taken to the operating room. Through a deltopectoral approach, the coracoid was identified and biopsy specimens from the lesion at the base of the corac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old man with a history of peptic ulcer disease was admitted to the Internal Medicine ward for the treatment of septic arthritis. During the hospitalization, he developed hemodynamic instability following acute, massive hematemesis of approximately 750 mL of fresh blood and clot (nadir blood pressure 74/36 mmHg, pulse 110 bpm). Endotracheal intubation was performed along with resuscitation with volume and blood product; a continuous infusion of pantoprazole was initiated and the patient was transferred to the Intensive Care Unit for urgent gastroscopy.\nInitial gastroscopy revealed an adherent blood clot occupying the distal esophagus, extending to the gastric cardia and proximal fundus. The clot could not be dislodged despite attempts with a water jet and wire snare, and neither the underlying lesion nor bleeding site could be identified. Five milliliters of a 1:10 000 solution of epinephrine was injected into and surrounding the clot. The remaining mucosa, as far as the third stage of the duodenum, was unremarkable except for pallor. Blood work revealed an initial drop in hemoglobin from 115 g/L to 86 g/L with a normal INR and platelet count. Four units of packed red blood cells (PRBC) were administered and an infusion of norepinephrine was required to maintain adequate mean arterial pressure.\nDespite aggressive initial management, the patient required an additional four units of PRBCs, five units of platelets and five units of fresh frozen plasma, along with increasing doses of norepinephrine. Therefore, aggressive gastric lavage with over 3 liters of normal saline was performed, followed by immediate repeat gastroscopy. The actively bleeding site was now identified as arising within severely ulcerated esophageal mucosa just proximal to the gastro-esophageal (GE) junction; no esophageal or gastric varices were present. The area was injected with 10 mL of 1:10 000 epinephrine solution and treated with coaptive electrocoagulation, with apparent hemostasis."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old male patient, with an uneventful medical history, came to the emergency department of our hospital after an episode in which he lost consciousness. The patient was hemodynamically stable, with blood pressure and heart rate within normal limits; ECG did not present any abnormalities, either. At the time of presentation, he was in a good neurological condition and did not mention any thoracic or abdominal pain. Blood laboratory investigation showed normal values of hemoglobin, hematocrit, glucose and other markers. He was then admitted to the department of internal medicine for further investigation.\nTwelve hours later, the patient complained of diffuse abdominal pain, while a decrease of hemoglobin was observed (9.5 mg/dL), and hemodynamic instability presented, with an increase in heart rate to 100 bpm. He was initially treated with intravenous fluids; surgical opinion was then seeked. Clinical examination revealed pronounced rebound tenderness on all of the abdominal quadrants and decreased abdominal sounds. In order to investigate the possibility of intraperitoneal bleeding and considering the stability of the patient, an emergency abdominal CT scan with i.v. contrast was indicated. CT scan revealed the presence of a ruptured proximal splenic artery aneurysm measuring 26 mm × 18 mm, 6 cm from its origin ().\nThanks to the rather stable hemodynamic condition of the patient, and the fact that our institution is equipped to provide an endovascular approach, open surgery was excluded as the first therapeutic option; angiography with coil embolization of the aneurysm and proximal splenic artery was then performed. Under local anesthesia (injection of lidocaine solution 2%, Astra Zeneca, Athens, Greece), a percutaneous puncture of the right common femoral artery, and selective catheterization of the splenic artery was performed, using a 4-F Simmons 1 catheter (Cordis, Tipperary, Ireland). Subsequent angiography revealed the aneurysm, but an attempt to pass"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old Saudi male with situs inversus totalis and peptic ulcer presented to the emergency room with 4-day history of pain in the left upper abdominal quadrant. The pain was colicky in nature, radiating to the back and this condition was aggravated by fatty meals. Physical examination showed positive Murphy's sign in the left hypochondrium Ultrasound showed the location of gallbladder on the left side of the body with a 13 mm stone impacted in its neck and signs of acute cholecystitis. Chest X-ray showed dextrocardia []. Laparoscopic cholecystectomy was performed on the following day. The patient made an uneventful recovery and was discharged home on the consecutive day. CT scan shows the transposition of the major abdominal organs [].\nThe patient was placed in the supine position with both the surgeon and camera-man on his right side and the assistant on the left side. There was one monitor that was placed near the head of the patient at the left side. A 5 mm laparoscope was introduced through an umbilical incision. A 10 mm trocar was introduced in the subxiphoid area in the mid-line, passing to the left side. Two 5 mm trocars were introduced in the left mid-clavicular and left anterior axillary lines. A grasper was introduced through the anterior axillary cannula to hold the fundus of the gallbladder and it was pushed laterally to the cephalic position. Another grasper was introduced through the medial cannula for the holding Hartmann's pouch and for manipulating it. This was initially held by the right hand of the surgeon. A dissector was introduced through the subxiphoid cannula and was manipulated by the left hand of the surgeon. This procedure proved to be difficult for a right-handed surgeon. The surgeon frequently changed his hands to grasp the dissector with his right hand, while the assistant held the Hartmann's pouch grasper or moved the dissector to the medial cannula and he used"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old female was admitted into our clinic with a complaint of a 3-month history of a slowly growing mass along the neck midline. The physical examination revealed a 3 × 1.5 cm immobile mass along the neck midline over the thyrohyoid membrane, accompanied by a 3 × 2 cm palpable nodule in the left thyroid gland. A neck US revealed a calcified heterogenic-hypoechoic solid lesion of 30 × 18 mm at the level of the hyoid bone in the submental area, which was not related to the thyroid gland. A thyroid gland US revealed several hypoechoic nodules, the largest being 38 × 24 mm, with some having micro calcifications in the left lobe of thyroid gland, while the study identified no right lobe lesions. FNAB was performed on both the midline neck mass and the left lobe nodule. The FNAB results were reported as being consistent with papillary thyroidal carcinoma for the mass along the neck midline and as benign cytology for the nodule in the left thyroid lobe. MRI of the neck showed a 30 × 20 mm midline solid soft tissue mass with hyperintense signal after injection with contrast media. The MRI also demonstrated cystic changes in the mass and evidence of invasion into the infrahyoid muscle group (). After considering all of the clinical and radiological data, despite a histopathologic diagnosis of benign cytology for the left lobe nodule, we performed a Sistrunk procedure with total thyroidectomy and central neck exploration due to suspicion of simultaneous de novo development of papillary carcinoma in the TDC and the thyroid gland. Informed consent was obtained prior to the procedure.\nDuring the Sistrunk procedure, a solid mass invading the infrahyoid muscle group was encountered, and gross total resection of the tumor was performed. A total thyroidectomy operation was also conducted (). During central neck exploration, samples of the suspected lymph nodes were sent for frozen section pathology, the results of which confirmed the diagnosis of papillary carcinoma metastas"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13 year old female living in a remote rural area came to our clinic with an 8 year history of deformities in the extremities which had gradually became worse till she was unable to walk. The patient over the years had developed recurrent fractures in her legs and arms after minor falls. The family was poor and lived in a remote area far away from proper medical facilities. She was treated by local healers for her fractures which resulted in bowing of legs and arms. There were no gastrointestinal symptoms of abdominal pain or diarrhea. She was brought to the clinic carried by her father. The patient used her arms to drag herself around the house and developed fractures followed by severe bowing of her arms. She had been diagnosed with rickets and iron deficiency anemia by doctors in community hospitals and had received Vitamin D and iron supplements many times without improvement. She had never had a complete workup to find out the cause of her rickets. The patient also had failure to thrive. On examination the patient was pale, weight was 11 kg and height 97 cm (below the 3rd percentile for her age) (Figure ). She had severe bowing of her arms and legs.\nDue to the presence of anemia, failure to thrive and rickets the initial impression was malabsorption probably due to celiac disease and the laboratory work up was done accordingly.\nInitial laboratory investigations that were done are mentioned in Additional file : Table S1. X-rays of her upper and lower limbs showed diffuse osteopenia and bowing of both legs and forearms with blurring of the metaphyseal lines. It also showed dense transverse lines in tibia and ulna suggestive of looser’s zones indicative of severe rickets (Figures and ).Anti- endomysial antibodies titer was 80 (normal is negative), anti-tissue transglutaminase IgA was positive 75 U/ml (normal <2.5 U/ml) and anti-tissue trans"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old male, a seasoned cyclist with no past medical history, presents to the emergency department with complaints of lightheadedness and diaphoresis after a bicycle fall. Patient was participating in a bicycle race when another rider ahead of him fell causing the patient to swerve to avoid him. Patient states that he fell on his left side and hit a tree with his right leg. Patient was wearing a helmet and did not suffer any chest or head trauma. After the fall, he felt lightheaded and diaphoretic and complained of mid back pain. Patient denied any chest pains or shortness of breath. Patient was subsequently brought to the hospital directly following the accident by ambulance.\nIn the emergency department, patient was noted to be in no acute distress; initial blood pressure was 128/69 mmHg with pulse of 65 beats per minute. He was afebrile, not tachypneic, and well appearing with marked right thigh swelling and tenderness to his medial thigh. Given the dizziness and diaphoresis initially, patient had an ECG performed which showed lateral ST segment elevation () and had a subsequent troponin I that was positive, 0.49ng/mL, with a Creatine Phosphokinase (CPK) of 617 U/L.\nThere was initial concern for a possible cardiac contusion, although the patient had no chest wall trauma and thus was admitted for further evaluation. As an inpatient, an echocardiogram was performed demonstrating normal right and left ventricular function and trace pericardial effusion while the patients troponin continued to trend upwards towards a maximum of 21ng/mL. He was loaded with Aspirin and Clopidogrel as well as initiation of a heparin infusion, Lisinopril, and a Beta Blocker. Coronary angiography was subsequently performed demonstrating a spontaneous coronary artery dissection of left anterior descending coronary artery. No further diagnostic study was performed at that time. Further history revealed that he took multiple caffeine Jello shots and drank a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old male came to our hospital with a complaint of defecation pain for 20 days and left lower abdomen pain for 3 days. Abdominal computed tomography showed thickening intestine wall at the recto-sigmoid junction, which leaded to an obvious dilatation of proximal intestine. And the density of intestinal mesentery increased as well as omentum (Fig. ). Through colonoscopy, we found an annular ulcer with irregular bottom and dirty surface near the recto-sigmoid junction, with pathological diagnosis of poorly differentiated adenocarcinoma. Without other obvious anomalies in the preoperative examinations, we performed an exploratory laparotomy on January 25. Massive serous ascites, a recto-sigmoid obstructive lump, and extensive nodules of implantation metastasis in abdomen, especially on the surfaces of intestinal tract and liver, were found during the operation. Considering the advanced stage of the tumor, we decided to perform a palliative Hartmann operation to relieve obstruction and adjuvant chemotherapy was chosen for following treatment. After operation, upper GI obstruction was well-relieved. But on February 10, 16 days after operation, the patient complained of discontinuous abdominal distention and pain again. Digital radiography of upper digestive tract showed a complete obstruction at the horizontal segment of duodenum, while the cavity was so narrow that the contrast agent could not pass through. We presumed that the obstruction was induced by the wide abdominal metastasis of the tumor. Conventional treatments for obstruction were performed, such as fasting, GI decompression, proton pump inhibitor, and parenteral nutrition. However, the intestinal obstruction was not relieved in the following days. Based on his situation, we assessed that the Eastern Cooperative Oncology Group Performance Status of the patient had already reached to 3 which was not suitable for high intensity of chemotherapy. So, targeted therapy was chosen as the further treatment i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 7.5-year-old boy admitted to our Pediatric and Allergology Clinic due to allergy to BL antibiotics for full diagnostics. The patient was born G1P1 with a birth weight of 3450 g and Apgar score of 9/10 points. His neonatal period was uncomplicated. The patient had a history of frequent respiratory tract infections (average once a month) since the beginning of preschool, usually requiring antibiotics. He was vaccinated according to the schedule. A family history of atopic diseases was negative. The boy was diagnosed with asthma and allergic rhinitis due to house dust allergy, and since 2016, he went under subcutaneous immunotherapy. Previously, he had been hospitalized several times due to pneumonia and asthma exacerbation (at the age of 5 and 6 years) and one time for orchitis (at the age of 2 years). According to the interview collected from his mother, due to infection in May 2017, the child had been given oral cefuroxime. About 15 minutes after the first dose of this antibiotic, a disseminated urticaria appeared, followed by edema of the face tissues. He was seen by a medical doctor and had been given intramuscular corticosteroids and antihistamines, achieving improvement of symptoms; the antibiotic had been changed to clarithromycin. After a course of 5 days of treatment, a similar situation developed—disseminated urticaria and difficulties in breathing. The boy had been hospitalized, and he had been treated with intravenous corticosteroids and antihistamines. Up to the date of first hospitalization for anaphylaxis, the patient had been treated with different BL antibiotics without any adverse reactions. The child was referred to our Allergic Department for drug allergy diagnostics. We performed this diagnostic in 3 months after the adverse event, according to the European Academy of Allergology and Clinical Immunology (EAACI) guidelines. Medical examination and laboratory findings confirmed no current infection. Skin prick tests were perfo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old white woman presented to my institution with severe pruritus. She had been diagnosed with stage IV adenocarcinoma of the ovaries with metastasis to the liver 1 year prior. She had undergone three rounds of carboplatin paclitaxel, followed by debulking surgery, followed by an additional six rounds of carboplatin paclitaxel therapy. After her last chemotherapy treatment, her carcinoembryonic antigen normalized. Four months later, she presented with jaundice, dark urine, and pale stools. A computed tomographic scan revealed the cancer had returned to the liver and was now obstructing her biliary duct. A stent was attempted several days later but was not successful. In collaboration with her oncologist, it was decided not to pursue further active treatment, and palliative care was initiated. She was otherwise healthy. The only medication she was taking was pantoprazole 40 mg daily for acid reflux. Her weight was 80 pounds.\nOne month later, she developed intense pruritus throughout her entire body. It was worse at night, and her sleep was significantly disturbed. She indicated her pruritus was 8/10 on a numerical rating scale (NRS), with a score of 0 reflecting no pruritus and a score of 10 reflecting the worst pruritus. She had no significant skin lesions or excoriations. She first tried over-the-counter moisturizers, with minimal effect. Benadryl was then suggested; it decreased her night waking, but she was too drowsy the following day. Loratadine was also attempted, to no effect. Cholestyramine was suggested, but she declined it due to the gastrointestinal side effects and longer time until onset of action.\nThe etiology of her pruritus appeared to be centrally induced, as opposed to prurioreceptive, neuropathic, or psychogenic []. My colleagues and I decided to try paroxetine on the basis of its preferable side effect profile, particularly in that it is less sedating. She was started on 5 mg nightly, with the intention to increase the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18 year old Sri Lankan Muslim female, presented with a 9 month history of colicky right iliac fossa pain and a 5 kg weight loss. She did not have diarrhoea, extra-intestinal manifestations of CD, and contact or past history of tuberculosis (TB). Clinical examination was normal.\nColonoscopy revealed an ulcerated ileocaecal valve and a terminal ileal stricture, while the colon itself was macroscopically normal. Biopsy of these lesions was reported as suggestive of CD. TB polymerase chain reaction (PCR) performed on the specimen was negative. Contrast-enhanced CT abdomen showed a segment of terminal ileum with concentric wall thickening. Mantoux test and Quantiferon gold test for TB were negative and chest X-ray was normal.\nShe was started on treatment for CD with a short course of oral steroids followed by azathioprine. However, she failed to tolerate azathioprine and subsequently 6-mercaptopurine (6-MP), and therefore was started on intravenous infliximab. Despite 3 dose of infliximab she failed to respond, and a follow up colonoscopy showed persistence of the ileal stricture. Therefore she was referred for surgical resection of the involved ileal segment. During the laparotomy, multiple terminal ileal and cecal strictures were noted and unexpectedly, multiple omental and peritoneal deposits were also seen. A limited right hemicolectomy including resection of the involved terminal ileum was performed.\nHistology of the resected specimen showed multiple coalescent caseating granulomata involving full thickness of the bowel wall and extending into the mesentery and pericolic fat, suggesting a diagnosis of ITB (Figs. , ). No evidence of dissemination beyond the intestine was found. She was started on anti-TB treatment (ATT), and 2 months later was free of abdominal pain and has regained 3 kg of weight. Three months after commencing ATT a repeat colonoscopy was performed. There were no macroscopic or microscopic changes in the neo-terminal ileum or residual colon. She"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 55-year-old Chinese female, presented with intermittent diarrhea with little bloody mucosanguineous feces, 4 to 6 times a day, and pain in the lower left abdomen. The symptom could relieve for 10 years. An endoscopy showed rough and eroded mucosa of the rectum and sigmoid colon, the vascular network was not clear, there were a few pus secretions, and 3 polypoid protrusions were seen in the sigmoid colon. An endoscopic polypectomy was performed in 2010, and postoperative pathology revealed inflammatory polyps. The patient was diagnosed with UC according to histopathologic criteria. She received intermittent oral sulfasalazine and mesalazine for maintenance treatment, intermittent hormone enemas, and Chinese medicine. This treatment relieved symptoms, but episodes of diarrhea continued.\nThe patient experienced aggravated symptoms from 2013. Endoscopic examination revealed stenosis of 4 cm at the entrance to the large intestine, mucosa was rough and bleeding easily, and the endoscope could not pass through the colon. Furthermore, the pathologic biopsy revealed rectal adenocarcinoma (Fig. ). On January 5, 2013, a total colectomy and ileostomy were performed with the patient under general anesthesia. The postoperative histology biopsy showed: the ileum 4 cm in length and 4 cm in diameter; the total colorectal anal canal 84 cm in length and 3.5 to 7 cm in diameter; chronic inflammation present in the mucous tissue along the 35 cm ranging from the pectinate line; dilated and congested interstitial blood vessels; erosion ulcers and recess abscesses; focal glands showing atypical hyperplasia; and increased submucous fibrous tissue. The medium and low differentiated adenocarcinomas were found 3 cm from the pectinate line. The volume of the adenocarcinoma was 6 × 3.5 × 0.5 to 0.8 cm, and there was invasion of the fibrous membrane, the recidivist nerve, and the tumor thrombus in the vascular canal. There was no cancer invasion on both sides and metastatic carcino"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-month-old female infant had presented five times to medical services since birth with a history of discharge from the umbilicus. On days 2 and 4, she presented with bleeding from the umbilical stump, which was managed with a pressure dressing. At 2 weeks of age, she attended a general practitioner surgery with discharge of watery liquid from the umbilicus, and it was treated like an umbilical granuloma with silver nitrate application. She came to the paediatric assessment unit of the local district general hospital at 3 weeks of age because of ongoing discharge. The periumbilical skin area appeared raw with features of a chemical dermatitis. An umbilical swab was taken and treatment with oral flucloxacillin commenced. The child presented again with ongoing symptoms. This time, it was diagnosed as excoriated umbilical granuloma with possible tinea corporis infection and she was treated with miconazole and neomycin. The discharge was mainly serous fluid which occasionally turned serosanguinous but did not contain pus.\nAt 6 months of age, she was rereferred by the general practitioner for persistent umbilical discharge with intermittent blood-stained fluid whilst she had been on her third course of antibiotics. On this occasion a consultant paediatrician reviewed the infant. An ultrasound was requested to investigate for remnants of an omphalomesenteric duct because of the persistence of symptoms. The ultrasound showed a cystic structure of 5 mm diameter with echogenic walls situated deep to the umbilicus (see ).\nThere was no communication with the bowel. A fistula extended through the anterior abdominal wall to the umbilicus. She was referred to surgeons for further management. She had a surgical excision of the cyst and sinus tract at 7 months. On macroscopic analysis, it was found to be a hard cystic lesion below the umbilicus surrounded by thick chronic inflammatory tissue. A fistula extended through the abdominal wall with no obvious communication or tract to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old man was transferred to our emergency room for shortness of breath. Two hours before admission, he began to have sudden onset of dyspnea, and was intubated in another hospital. He reported to be healthy before this episode, and systemic review was negative. He did not have a remarkable past medical history, including surgery, allergy or specific medications. However, he had a family history of ischemic stroke; his father died of complication of ischemic stroke at the age of 65 years and his brother had ischemic stroke at the age of 39 years.\nIn the emergency department, he had respiratory distress and tachycardia, with an oxygen saturation of 81% even under the intubated state. The blood pressure fell to an unmeasurable level, and the heart rate was 102 beats/min. There were crackles in both lungs on auscultation. Chest X-ray revealed mediastinal widening and cardiomegaly with bilateral infiltrations. Computed tomography (CT) of the chest showed dilated pulmonary trunk, but there was no evidence of pulmonary thrombus, aortic dissection or lymphadenopathy. The patient was admitted to the intensive care unit with a tentative diagnosis of acute respiratory failure due to severe pneumonia.\nOn hospital day 3, chest X-ray showed decreased infiltration and vital signs were stabilized. However, he developed sudden onset of tachypnea and hypotension on the next day. Arterial blood gas analysis results while breathing ambient air were pH 7.21, PaO2 50.0 mmHg, PaCO2 71.4 mmHg and oxygen saturation 76%. A follow-up chest CT revealed a large thrombus in the right main pulmonary artery and marked dilatation of the pulmonary arteries []. In addition, atrophy of pectoralis and paravertebral muscles was detected []. Transthoracic echocardiogram (TTE) showed pulmonary arterial hypertension (right ventricular systolic pressure 60 mmHg) with D-shaped left ventricle. However, echocardiographic evidence of a thrombus was not identified.\nThe patient received thrombolytic ther"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old woman presented with a left upper lid mass for a 2-week duration. She was seen in a local clinic, diagnosed as a chalazion, and was treated with neomycin/polymyxin/dexamethasone ointment and hot compresses. She was sent to our department after exacerbation of the symptoms and growth of the mass. On review of symptoms, the patient had no other significant medical history, was not immunocompromised and took no regular medications. On examination, her visual acuity was 20/20 OU; the physical examination was significant for large immobile nonfluctuating supra-tarsal mass with red and erythema surrounding the mass []. There were no orbital signs observed on examination; there was full ocular motility in both eyes, no proptosis and color vision was intact. In addition, the dilated funduscopic examination was normal. Computed tomography (CT) scan of the orbits was performed, revealing a large mass extending from the frontal sinus through the soft tissue of the eyelid [ and ]. There was extensive bony erosion with no inter-cranial extension. Initial laboratory investigations were performed, including a complete blood count, chemistry, and coagulation studies, all within the normal limits. A biopsy was performed with a combined approach; both ears, nose, and throat (ENT) team, and oculoplastic teams were present []. The ENT team approached endoscopically using a navigation system to properly locate the lesion within the area of the frontal sinus. The oculoplastic team approached through a lid crease incision, and the material was sent to biopsy. Biopsy revealed an inflammatory infiltrate with many plasma cells and granulation tissue with a lymphocytic inflammatory infiltrate with plasma cells and neutrophils. There was an abnormal ratio of kappa to lambda and a high level of CD: 138 expression. Polymerase chain reaction was also performed and a monoclonal B-cell proliferation was seen. The histopathological diagnosis was plasmacytoma. The hematology department"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe following is a description of the case of a 25-year-old woman with the initials S.K. in her second pregnancy who came to our antenatal consulting centre.\nThe first screening for blood count, blood group, biochemistry (ALAT, ASAT, creatine, urea, blood sugar) showed results within the reference range. Hbs Ag, HIV, Wasserman, IgG, IgM (toxoplasmosis), IgG, IgM (rubella), IgG, IgM (CMV) were negative.\nAt that time the woman was at 6 – 7 weeks gestation. Biochemical screening generally is done at 12 – 13 weeks gestation showed results within the reference range (low risk of development of a baby with an abnormality, low risk of developing preeclampsia in the second half of pregnancy and low risk of premature birth).\nThe patient came for a second comprehensive biochemical screening at 17 – 18 weeks gestation. The results showed the low genetic risk of congenital anomalies. Fetal morphology of the fetus was normal.\nS.K. came again for consultation at 22 weeks gestation in connection with the admittance of her first 3-year-old child to the hospital because of pneumonia. Serological tests of the child had shown elevated CMV titer - specific IgM.\nThen we made new serological tests of the patient and the results were as follows: CMV – specific IgG – 98; CMV – specific IgM – 2.1. It was then understood that the patient was most likely infected by CMV primarily in the first trimester of pregnancy. After consulting about the risk of transmission of CMV to the fetus the woman chose monthly ultrasound scans and refused amniocentesis.\nThe results of all ultrasound scans were normal until that time. At 24 weeks gestation fetal brain ultrasound scan showed thalamic calcifications bilaterally, hyperechogenic foci in the right side of the ventricular wall, asymmetric ventriculomegaly > 10 mm ().\nSimilar changes were imaged at 28 weeks gestation and also cerebellar developmental"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 60-year-old female who presented to the hospital with complaints of dull substernal chest pain. She had chronic atrial fibrillation, chronic obstructive pulmonary disease with home oxygen, osteoarthritis, and anxiety disorder as her comorbid conditions. On examination, she did have chronic dyspnea and was on home oxygen. She did not have any cyanosis, palpitations, paroxysmal nocturnal dyspnea, or orthopnea.\nShe was initially evaluated with a nuclear stress test that did not show any reversible ischemia but dilation of the right ventricle (RV); ejection fraction was identified to be 54%. The patient was further evaluated by a transthoracic echocardiogram (TTE) in order to evaluate the RV dilatation. TTE identified a complete absence of IAS and a CA (). The findings were confirmed with a positive bubble study (). Transesophageal echocardiogram (TEE) was performed that confirmed the absence of IAS, demonstrated free mixing of color flow, moderate to severe tricuspid regurgitation, normal mitral valve structure, normal left ventricular ejection fraction, and enlarged right atrium (RA) and RV.\nThe patient was evaluated with cardiac computed tomography angiogram (CCTA) that demonstrated the right coronary artery to be the dominant artery, all coronary arteries to be ectatic/aneurysmal and measuring up to 8-10 mm, a complete absence of IAS, marked dilation of CA and both ventricles, a coronary arteriovenous fistula (CAF) between the distal left anterior descending and coronary sinus, massive dilation of pulmonary arteries, and no mitral or aortic valvular abnormalities; left ventricular ejection fraction was measured to be 59% (Figures –).\nThe patient underwent an invasive angiography (IA) which demonstrated many abnormal findings. It showed that the patient had coronary artery aneurysms measuring 0.7 cm to 1 cm (). IA was instrumental in taking measurements regarding oxygen saturation and pressure at multiple levels identifying a large interatrial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old right-handed woman presented with involuntary compulsive grasping with her right hand and intermanual conflict with her left hand. The typical symptom of involuntary compulsive grasping and grabbing with her right hand, which was associated with a frontal variant of AHS, manifested in this patient as an inability to release a comb or the hand of the examiner during the muscle strength examination (). In addition, the typical intermanual conflict associated with the callosal variant of AHS occurred while she combed her hair or ate food with her right hand; her left hand counteracted the purposeful movements of her right hand (). However, her hand movements were perfectly coordinated and smooth when she used her left hand for purposeful movement. She said that these symptoms, which were not under her control, affected her daily life. She presented to our hospital because she could not control her left hand. She had not received any medical treatment for this condition until she was admitted to our hospital. She had a history of hypertension. A history of epileptic seizures, cranial demyelinating pathologies, and other neurodegenerative diseases was not elicited. In addition to antihypertensive drugs (calcium channel blocker), there was no other medication history and no relevant family history. The general examination showed no obvious abnormalities, and her vital signs were normal. Neurologic examination revealed positive Babinski and Chaddock signs in her right lower extremity, and the muscle power of the right limbs was 4/5 grade. The grasp reflex was positive. The rest of the physical examination disclosed no abnormalities. Her National Institutes of Health Stroke Scale score was 3 points. Routine laboratory test results were normal.\nMagnetic resonance imaging (MRI) revealed that she had developed ischemic strokes in the corpus callosum and the left frontal lobe due to stenosis of the A4 segment of the anterior cerebral artery. MRI revealed cytotoxic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old man was admitted to the pulmonary hypertension service at Stanford Hospital in December, 2010 with elevated pulmonary arterial pressures and progressive right-sided heart failure. He reported progressive shortness of breath over a period of two months, culminating in dyspnea at rest. This was associated with a 20-pound weight gain, abdominal bloating, and leg edema.\nHe was first evaluated for dyspnea several years prior to admission, where he was diagnosed with bilateral pleural effusions and extensive pericardial calcification on chest computed tomography (CT). Echocardiography and cardiac catheterization were consistent with constrictive pericarditis. He subsequently underwent uneventful complete pericardiectomy in 2008. The pericardium was stripped from phrenic nerve to phrenic nerve and the diaphragmatic and posterior pericardium was removed as well.\nThe patient enjoyed symptomatic improvement for approximately one year but then developed recurrent dyspnea. An echocardiogram demonstrated right ventricular (RV) pressure overload and a right ventricular systolic pressure of 66 mmHg. A trial of sildenafil was initiated but was discontinued after the patient developed a marked worsening of his dyspnea.\nHis medical history was remarkable for pericarditis diagnosed in 1978, which was presumed to be viral in origin. He had permanent atrial fibrillation/atrial flutter which did not respond to an attempted atrial flutter ablation in 2003. He had a history of chronic hypertension and gradually progressing stage 3-4 chronic renal impairment.\nOn admission, his jugular veins were distended to angle of his jaw when upright. Pitting edema was noted up to the mid thighs bilaterally. Crepitations were heard on auscultation of his lungs. N-terminal pro-brain natriuretic peptide was measured to be greater than 30,000 pg/mL. Chest x-ray showed blunting of the costophrenic sulci with coarse reticular linear basilar parenchymal opacities ().\nPrior to admission, ventilat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old man was brought by ambulance to our facility after having been involved in an unhelmeted motorcycle collision. He presented with sinus tachycardia up to 123 beats per minute, a Glasgow Coma Score of 15, and had an obvious deformity of the right lower extremity. His tachycardia improved with 2 L of crystalloid fluid bolus. He was stabilized in a cervical collar and a Sager traction splint on his right lower extremity and taken for CT scans of his head, cervical spine, chest, abdomen and pelvis as well as plain films of his extremities. According to our institutional protocol, he underwent CT angiogram of his neck given his skull base fracture. He was found to have a right kidney laceration with active extravasation, two large hepatic lacerations without active extravasation, a right midshaft femur fracture, bilateral distal radius fractures, a left occipital condyle fracture, a dissection of the left internal carotid artery, and pooling of IV contrast near the bifurcation of his inferior vena cava (IVC). This was concerning for a vena cava or iliac vein injury (Fig. ). Given his hemodynamic stability, we consulted the vascular and interventional radiology teams regarding management. We decided to proceed with visceral arteriogram to control bleeding from the right kidney as well as a venogram to further delineate the suspected venous injury (Fig. ).\nThe visceral arteriogram demonstrated extravasation from the right adrenal artery and superior pole of the kidney, both of which were embolized with microcoils. Post-embolization angiography demonstrated no further evidence of active extravasation. There was no injury to the aortic bifurcation. A venogram was then performed, which demonstrated a 2.8 cm pseudoaneurysm arising from the proximal portion of the left common iliac vein with involvement of the base of the IVC without active extravasation. There was no involvement of the right common iliac vein. The patient continued to be hemodynamically stable so"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old man referred for evaluation to our center with epigastric pain from three days prior to his evaluation. The pain was nonspecific and colicky distributed in periumblical region, did not radiate to any site and was unrelated to bowel movements. He had experienced also nausea, anorexia and intermittent vomiting.\nThere was a history of marijuana and alcohol usage from several years ago. Upon physical examination, he was ill with restlessness. There was mild periumblical tenderness without rebound tenderness. There was no other positive finding in physical examinations.\nThe patient’s laboratory results upon admission showed mild leukocytosis. Other laboratory values such as hemoglobin, platelets, serum amylase, erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and electrolytes were normal.\nHis workup on admission including; chest x-ray, abdominal x-ray, and abdominal ultrasonography were reported normal. An upper gastrointestinal endoscopy was performed after four days of admission that was normal.\nWithin second week after admission, because of continuing pain, colonoscopy was performed. The left and right colon appeared normal. The terminal ileum was also examined and appeared normal. The appendiceal orifice was discovered in the floor of cecum which was draining pus into the lumen ().\nResult of the biopsies of the mucosa at the base of the appendix showed mild nonspecific inflammation with some necrotic materials and staphylococcus organism. The biopsies of the mucosa at terminal ileum, left and right colon demonstrated mild nonspecific inflammation.\nA second abdominal ultrasonography was performed that showed a fluid collection (about 70× 40 mm) in favor of appendiceal abscess in right lower quadrant (). The patient was scheduled for spiral abdomen-pelvic computed tomographic scan which showed a hypodense well defined collection with air fluid level (about 70× 40× 30 mm) in right lower quadrant. T"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Caucasian male presented to his outpatient gastroenterology office with complaints of copious rectal discharge and for discussion of treatment options. His medical history was significant for trauma leading to a T7 spinal cord injury resulting in a thoracic arteriovenous malformation requiring surgical intervention. His postoperative course was complicated by paraplegia leading to him being constricted to a wheelchair. Twenty-five years after his initial surgery, the patient developed a left ischial ulcer and a sacral decubitus ulcer with concomitant methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, which was treated surgically with multiple debridements and prolonged courses of broad-spectrum antibiotics. During this time, the patient also underwent sigmoid end-colostomy placement due to chronic constipation. After another three years without complications, he presented with a new ischial wound and fevers, with wound cultures positive for MSSA, Streptococcus agalactiae, and Morganella morganii. He was treated with incision and drainage along with another eight-week course of ceftriaxone and metronidazole. In the following months, he began to have new onset of copious, purulent rectal discharge, leading to poor healing and further debridement procedures for his wounds.\nWhen inquiring further, the patient previously reported minor mucus drainage from the anus, occurring about once every three weeks. However, in the months leading to his presentation, his purulent fluid drainage increased in both volume and odor, with up to estimated 1 L daily of purulent rectal discharge. He was referred to a colorectal surgeon due to above-mentioned complaints. On presentation, his physical examination was notable for paraplegia, flexion contracture of bilateral knees, and a well-pouched colostomy in the left lower quadrant of the abdomen. No parastomal hernia was noted. His rectal examination was notable for a normal-appearing anus with some minor residua"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 55-year-old woman hospitalized in the Department of Oncology, the 309 Hospital of the Chinese PLA on December 23, 2009 for 4 years of chest pain which was further aggravated for 8 months. Previously, she had paroxysmal dull pain in the chest for 4 years without obvious incentives; unfortunately, no attention was paid to it. The chest pain aggravated since April, 2009, accompanied by cough, white phlegm, hoarse voice, and cough after drinking water. No fever, night sweats, or weight loss was observed. Chest computed tomography (CT) done in another hospital in April, 2009 showed a mass localized in the superior mediastinum with a maximum diameter of 4.3 cm. Routine blood test, erythrocyte sedimentation rate, biochemical test, and tumor marker test were normal, as was abdominal ultrasonography. Thoracic operation was conducted, during which no clear boundary between the mass and surrounding blood vessels was found. As a result, the mass could not be excised and only an incisional biopsy was performed. Postoperative pathologic examination showed reactive hyperplasia of lymph nodes accompanied by charcoal particle deposit. The patient was clinically suspected to have mediastinal tuberculosis lymphadenitis and was given an anti-tuberculosis treatment for almost half a year. No obvious relief occurred and the patient suffered from somasthenia with a weight loss of about 10 kg in 6 months. A chest CT performed in November, 2009 found no obvious change in the superior mediastinal mass ().\nThe patient came to the 309 Hospital of the Chinese PLA for further treatment. Results of the tuberculin (PPD) test and MycoDot TM test were both negative. As a result, the Department of Tuberculosis excluded the possibility of tuberculosis and discontinued anti-tuberculosis treatment. The pathologic specimen of the thoracic mass incised in April 2009 was consulted by Departments of Pathology from several hospitals including the Peking Union Medical College Hospital. In th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old Japanese man presented with dysphagia. He had a medical history of exploratory laparotomy for ileus but no history of anticoagulant medication. Upper gastrointestinal (GI) endoscopy revealed type III esophageal cancer in the middle thoracic esophagus (Fig. a). An upper GI series revealed an irregular stricture in the middle thoracic esophagus. Computed tomography (CT) revealed a primary tumor and swollen cervical and mediastinal lymph nodes (Fig. b, c). Fluorodeoxyglucose-positron emission tomography (FDG-PET) also revealed a primary tumor in the esophagus (Fig. d) and swollen lymph nodes in the mediastinum with abnormal uptake.\nAs a result, he was diagnosed with middle thoracic esophageal cancer (squamous cell carcinoma) and T3N3M0 in clinical stage III according to the criteria of the Japan Esophageal Society. He was treated with combination chemotherapy of docetaxel, cisplatin, and fluorouracil as neoadjuvant therapy. Chemotherapy for 2 months resulted in shrinkage of the primary tumor of the esophagus and lymph nodes in the mediastinum (Fig. e–g). FDG-PET revealed decreased uptake in the primary tumor and lymph nodes in the mediastinum (Fig. h).\nAfter chemotherapy, he underwent subtotal esophagectomy with three-field lymphadenectomy and gastric conduit reconstruction through the retrosternal route by thoracoscopy and laparotomy. Postoperative care was performed under mechanical ventilation in the intensive care unit (ICU). On postoperative day (POD) 1, mechanical ventilation was terminated because of a good respiratory condition. However, he suffered from dyspnea and severe acidosis and chest X-ray examination revealed right pneumothorax, which was observed 5 h after extubation. Furthermore, air leakage was observed from the water seal chamber of the chest drain system. We thought that the respiratory disorder was caused by the right pneumothorax. Therefore, mechanical ventilation was started again. After that, it became clear that the cause of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe present case is about a 27-year-old woman who referred to the private dental clinic in June 2009. Her complaints were slight pain, gum swelling and bleeding on tooth brushing from the upper incisor teeth. She was also dissatisfied with the color of the anterior gingiva. Medical history of the patient was not remarkable. As learnt from her dental history, dental filling, root-canal treatment, apical resection and metal-ceramic crown restoration procedures had been carried out for the upper central incisors from 2006 to 2009. Periodontal evaluation revealed findings of gingival hyperemia, edema, bleeding on probing (BOP), slightly increased pocket depths and first degree mobility at teeth #11 and #21 []. Tenderness to percussion and fistula were also identified at her same teeth. Remaining teeth were healthy and few amount of supragingival deposit existed in lingual aspect of lower anterior teeth. Only an asymptomatic, extensive dental filling was located at tooth #24. In her orthodontic examination, Class I occlusion in the posterior region with slight mandibular anterior crowding was present and there were no occlusal contacts between the maxillary and mandibular anterior teeth in the intercuspal position. The maxillary central incisors were slightly proclined and minimal deep-bite was also present; however, the lips were competent, lower border of the upper lip generated a normal smile-line and there was no speech impediment. Radiographic examination revealed no alveolar bone loss in the anterior maxilla associated with the maxillary incisors and remaining part of the dentition was intact except endodontically treated tooth #24 with no pathological view [].\nA multidisciplinary treatment was planned following clinical and radiographic examinations. It was decided to perform forced eruption before extraction of two incisor teeth to augment the future implant site. The patient was also informed about other treatment options. Before orthodontic phase of treatment,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 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 .\nThe 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"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 20-year-old female who presented to the emergency department (ED) with the complaint of a diffuse whole-body rash. Her past history was notable for depression as she was recently prescribed lamotrigine two weeks prior to ED presentation. She was recently discharged from another hospital two days ago where she was hospitalized for three days due to complaints of blistering of her lips, sore throat, and mild rash on the extremities. She was given the diagnosis of hand-foot-mouth disease and was treated with 1 gram of ceftriaxone. She reported a decrease in the severity of sore throat upon discharge from ED but the rash continued to progress and had spread throughout most of her body parts. The lamotrigine was subsequently discontinued by the primary care physician. She decided to present to the emergency department (ED) for further evaluation.\nIn the ED, she had a temperature of 102.4 F, blood pressure of 152/67 mmHg, heart rate of 120, and a respiratory rate of 22 per minute with an oxygen saturation of 98%. Physical examination was notable for a young female appearing uncomfortable with a diffuse maculopapular erythematous rash with scattered bullae lesions covering approximately 36% of her body surface area (Figure , ). Her lips were blistered with erythematous mucus membranes as well as erythema with erosions of the eyes (Figure ). The Nikolsky's sign was not appreciated. The rest of the physical examination was unremarkable. The laboratory data were unremarkable for signs of active infection given no leukocytosis and sterile blood cultures. Acetaminophen 1 gram was administered orally for fever and she was resuscitated with intravenous fluids. The patient was admitted to the progressive care unit for closer hemodynamics monitoring and supportive care. She was then transferred to a tertiary level burn care center within the next few hours for the continuation of care. She was diagnosed with toxic epidermal necrosis. She was monitored closely and r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old postmenopausal woman presented to the emergency room after a fall that resulted in acute exacerbation of right shoulder pain. She first noticed this pain three weeks prior, but could not identify any inciting factors. In the emergency room, an X-ray was obtained that showed a proximal humeral facture with lytic lesions in the surrounding bone (). She was placed in a sling and discharged with outpatient follow-up. As part of her workup, a computed tomography (CT) scan of the chest, abdomen, and pelvis was obtained and revealed multiple pulmonary nodules, necrotic-appearing mediastinal and hilar lymph nodes, a left adrenal nodule, a mass within the T10 vertebral body with epidural extension and spinal cord compression, and multiple bony lytic lesions. Bony lesions were noted throughout the T1 and T10 vertebral bodies, left ileum, right ileum, left femoral head, and left acetabulum. The pelvis was notable for a fibroid uterus, but was otherwise unremarkable. There was no pelvic lymphadenopathy or ascites.\nOne week later, she presented to the emergency room with rapid onset of lower extremity weakness. She was admitted with a diagnosis of spinal compression and initiated on dexamethasone to prevent further neurologic compromise. Magnetic resonance imaging (MRI) demonstrated a large T11 lesion with extensive epidural extension, a T2 lesion expanding into the prevertebral and ventral epidural space, and numerous other lesions throughout her spinal column (). Neurosurgery took her to the operating room for decompression and performed a T10–T12 laminectomy, tumor resection with T11 vertebrectomy, T9–L1 fusion and reconstruction with titanium cage and bone matrix allograft.\nThe pathology specimen showed a poorly differentiated adenocarcinoma. It was strongly positive for estrogen receptors, progesterone receptors, and Pax 8, suggesting an endometrial or breast cancer. On further interview, the patient reported five months of intermittent vaginal bleeding and a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old previously healthy woman, a college student, was on a waterslide at an amusement park, when her left arm became caught between the side of the waterslide and adjacent rocks. She sustained a forceful twisting and loading injury to her left upper extremity which resulted in a severe pain and deformity to her left arm, forearm, and wrist. She was brought by ambulance to our emergency department. On physical exam, her injuries were closed, her arm and forearm compartments were soft, and she was neurovascularly intact. Radiographs of the humerus, forearm, and wrist demonstrated a left distal third humeral shaft fracture () as well as a left Galeazzi fracture, with a midshaft radius fracture and disruption of the distal radioulnar joint (Figures and ). She was placed in a well-padded long arm posterior plaster splint extending from the posterior shoulder to the fingers, with an additional coaptation component to the splint to stabilize the humerus fracture.\nWithin 24 hours of admission, the patient underwent open reduction and internal fixation of both her humeral shaft and radial shaft fractures. The decision was made to reduce and fix the humeral shaft first. The humeral shaft fracture was amenable to reduction and fixation with an extraarticular locking plate through a posterior approach with the patient in the lateral decubitus position. Because of the manipulation of the forearm, which may be required during reduction and plating of the humerus, we chose to avoid fixation of the radius and the possible transfixion of the distal radioulnar joint until after the operation on the humeral shaft was completed.\nThe surgery was performed under general anesthesia. The patient was positioned on a radiolucent table in the lateral decubitus position with the left arm which was supported over a foam roller. The left upper extremity was then prepped and draped, and 2 grams of cefazolin was administered prior to incision"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man with hypertension and type II diabetes mellitus was admitted to the local community hospital for a six-week history of low grade fever and recent development of chills and shortness of breath on October, 2005. Prior to this admission, the patient had been treated as an outpatient by his primary care physician for possible sinusitis and pneumonia with three different kinds of oral antibiotics including levofloxacin. On admission, the patient had a fever of 37 degrees centigrade and elevated white cell count of 17 × 109/L. Physical examination was significant for a hyperdynamic precordium, 2+ parasternal lift, grade 2–3 out of 6 continuous murmur best heard at the left sternal boarder, and gallop at the apex. The chest x-ray showed right pleural effusion and features consistent with congestive heart failure. An echocardiogram showed a markedly dilated sinus of Valsalva, measuring at least 6.4 cm, with turbulent blood flow in a RVOT. This was felt to possibly represent a left-to-right shunt and the possibility of a ruptured sinus of Valsalva was raised. The echocardiogram also showed a vegetation on one of the pulmonary valve leaflets (figure ). The patient was subsequently treated empirically for infective endocarditis with vancomycin and gentamycin for 28 days. During cardiac catheterization, oximetry studies showed there was no step-up in saturation in the pulmonary valve. This made the presence of a significant left-to-right shunt less likely. Aortic injection revealed significant dilation of all of the coronary sinuses. There was no jet noted from the coronary sinus to the right side of the chamber. Minimal aortic regurgitation was present. Pulmonary artery injection showed mild pulmonary insufficiency. Blood cultures did not grow any organisms.\nOn May 2006, the patient underwent resection of a large aortic root aneurysm, replacement of the aortic valve using a 23 mm St. Jude medical valve conduit, re-implantation of left coronary artery, coronar"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA special needs 16-month-old Saudi boy. The chief complaint was a large ulcer on his tongue that caused pain, bleeding overnight, lack of sleep, and feeding difficulties. The mother reported that she noticed the ulcer 2 months ago and clinically examined by eight separate dentists. One of them thought that the lesion was a fungal infection and prescribing Daktarin oral gel 40 mg but in spite 1 month of treatment, the ulcer got bigger with more feeding and sleeping difficulties.\nThe mother also reported that the child was having a repetitive forward and backward movement of the tongue. The parents were very anxious as some dentists informed them that this lesion could be cancer.\nRegarding familial history, the parents are first cousins and the mother has hypothyroidism. This boy was her only child after two abortions; one born with anencephaly (absent brain). The medical history revealed that he was born preterm (36 weeks) with microcephaly. After delivery, he was hypoactive, hypotonic and had respiratory distress, neonatal convulsion, and poor sucking reflexes. Before their visit to me, they had visited 12 local, national, and international medical centers for clinical examinations and laboratory investigations [].\nOn the first visit, he was not responding, and no eye contact. It was difficult to open his mouth as he had a strong bite and uncontrolled tongue thrust. The intraoral examination revealed an ulcer approximately measuring about 3 cm × 2.5 cm on the dorsal surface of the tongue extended from the tip to the middle of the tongue []. Smoothing the sharp edges by removing mamelons of the lower primary incisors using a diamond bur in a high-speed dental handpiece was completed. A month later, the RFD ulcer had healed successfully []. After 1 year, a follow-up visit disclosed that the boy had stopped the habit of repetitive tongue thrust and no signs of ulcer reoccurrence. A written informed consent had been obtained from the child’s parents"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 65-year-old man with a prior history of repeated plastic surgery for scar contracture of the hands and fingers, ablation surgery for idiopathic ventricular tachycardia, and diabetes. There was no family history of no consanguineous marriage or EB.\nHe had experienced recurrent blistering of the skin that was readily caused by an external force since the time shortly after birth, which had been treated symptomatically. He was diagnosed with EB during a genetic consultation that he had received before getting married at the age of 28 years. Subsequently, he was diagnosed with RDEB at the age of 38 years. Application of a strong external force to the skin results in blister formation as early as 15 min. In June 2012, he presented to a nearby hospital with epigastric pain, where he was diagnosed with cholelithiasis and cancer in the transverse colon and was referred to our hospital. In September 2012, transverse colectomy and cholecystectomy were performed via laparotomy, followed by an uneventful postoperative course. In April 2013, a liver metastasis (S2) was detected. The lesion was a solitary tumor measuring ≤2 cm and was treated by radiofrequency ablation (RFA) in June 2013, again followed by an uneventful postoperative course. In September 2015, a recurrent tumor was detected at the site of RFA, with suspected invasion into the diaphragm. He was then admitted to our hospital for curative open surgery. On admission, although no active blistering was noted, pigmentation and scars due to recurrent blistering were noted especially in the extremities and back. Most fingers in both hands were club-shaped, with a few intact fingers. Blood test showed a mild increase in glucose to 123 mg/dl and increases in tumor markers, including mean levels of CEA and CA19-9 of 25.0 (0–5) ng/ml and 62.1 (0–37) U/ml, respectively.\nAbdominal CT/MRI revealed a 3.5 cm metastatic liver carcinoma with diaphragmatic invasion in the lateral segment"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 35-year-old woman with a history of 2 elective cesarean sections and one miscarriage (G4 P2 A1) was accepted as a referred case to our hospital. The patient was admitted for the elective cesarean section at 37 weeks of gestation. She was referred from the rural primary care hospital where routine ultrasonography revealed low-lying placentation. A Doppler ultrasound at 35 weeks showed complete covering of the cervical os which was attached to the scar with incessant hemorrhagic lesions in the inner anterior myometrium, indicative signs of PA (Figure ). She had diagnosed placentation in the lower uterine segment and had given a history of irregular, painless bleeding of the vagina during the fifth and seventh months of gestation. Further, magnetic resonance imaging (MRI) was performed, images still revealed that the placenta was completely covering the cervical os and suspected implantation of placental villi penetrating the full thickness of the myometrium, which further extending posteriorly up to the bladder wall and anteriorly displayed vascular engorgement (Figure ). On the day of surgery, an expert urologic surgeon had been involved along with the interventional cardiology team. During the cesarean, the uterus was opened along the midline in upper segment of uterus, and a baby of the 3 kg was delivered with a good Apgar score. Due to invasive placentation and bleeding, cesarean hysterectomy was proceeded immediately after the birth of the baby. The lower uterine segment was noted to be relatively thin but was covered by a plexus of deep vessels which spread over the bladder near the broad ligament which was covered by peritoneum. The bladder was opened and repaired due to continuous bleeding as the placenta extended to the bladder. Left-sided salpingo-oophorectomy was also performed due to constant bleeding from the left tubo-ovarian ligament. The estimated blood loss was approximately 3500 mL during the procedure. Afterward, three units of whole blood"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe share the case of a 34-year-old gentleman, office executive in a tertiary care hospital, who presented with weakness of all four limbs of acute onset over a few hours duration. He gave history of low grade fever, dry cough, myalgia, chest tightness and sore throat for 2 days prior to the onset of weakness. His past history was remarkable for acute episodes of muscle weakness dating back from 17 years of age, the last occurrence five years back. His mother also had similar complaints. He admitted inhalation of salbutamol via metered dose inhaler (2 puffs on four occasions) on the previous day at the advice of a general practitioner for chest tightness. Evaluation revealed a comfortable gentleman with respiratory rate of 20/minute and peripheral blood O2 saturation of 97% on room air. Auscultation of chest revealed fine crackles at both lung bases. Neurological examination identified grade 2-3 power of multiple muscle groups of all four limbs with hyporeflexia. Cranial nerve examination was normal and no signs of meningeal irritation were elicited. Considering the present pandemic situation, nasal and throat swab was sent for COVID-19 RT-PCR which returned positive. He was admitted in isolation room and symptomatic medications were started. His blood counts, renal and liver functions, serum electrolytes and thyroid functions were requested. Chest radiograph revealed a few peripheral infiltrates in lower zones []. Serum potassium levels returned as 1.9 meq/l. A possibility of hypokalemic periodic paralysis was entertained considering the low serum potassium levels, episodic paralysis and family history. Potassium supplementation was done via oral and intravenous route. Neurology opinion was taken and alternate differentials like CVA, spinal cord lesions, thyroid disease and myopathies were ruled out with appropriate tests. His muscle strength rapidly improved to grade 5 power in next 6-8 hours with return of potassium level to 4.1 meq/l. The rapid return of potassiu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old man presented acutely to hospital with a week's history of abdominal pain, ‘coffee ground’ vomiting and progressively worsening malaise with signs of dehydration. His symptoms commenced with a sudden onset of severe abdominal pain followed by the inability to pass urine. There was no history of abdominal trauma. He was a smoker with a previous history of alcoholism, however, had been abstinent now for several years. He had no Urological history.\nOn examination, he was significantly dehydrated with a moderately distended generally tender abdomen with a moderate degree of peritonism. No other specific signs were elicited.\nThe patient was resuscitated with crystalloid fluid and bloods were sent for analysis. Noted abnormalities of his blood results included a C-reactive protein of 107, a creatinine of 812 mmol/l and potassium of 5.9 mmol/l. Amylase and hemoglobin were within normal range.\nA non-contrast CT (NCCT) scan was arranged in view of the patient's significant renal impairment; images revealed a moderate amount of ascites, a thickened but collapsed bladder, and a small cirrhotic liver with no evidence of hydronephrosis or pneumoperitoneum []. He was admitted under the general medical team for further investigations including upper gastrointestinal endoscopy which demonstrated signs of esophagitis, gastritis and a chronic duodenal ulcer in the first part of the duodenum.\nHis serum creatinine normalized over the course of a few days and a subsequent ultrasound scan that had been arranged to exclude portal venous hypertension, appeared to show that the ascites had resolved. A week after admission, the patient failed his trial without catheter, with a painful 200 mls clear urine residual on re-catheterization and a subsequent rise in creatinine to 200 mmol/l. On direct questioning, the patient admitted that he had suffered from urinary frequency and nocturia with progressively poor flow for the last year. Digital rectal examination revealed an enlarged"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old man presented to the emergency department (ED) complaining of progressively worsening swelling over the angle of his left jaw associated with difficulty speaking, described as hoarseness and pain with phonation, as well as difficulty swallowing. It began spontaneously one day previously, right after he felt a snap or pop. There were no triggering incidents, although he was unclear if he was talking or swallowing at the time. It was associated with a non-radiating, moderate intensity pain, just below the angle of the mandible on his left side that increased in severity when he moved his jaw to speak, turn, or swallow. Over the course of 12 hours he developed worsening anterior cervical neck swelling and progressive odynophagia, dysphagia, and hoarseness. His medical history was significant for hypertension and left-sided Bell’s palsy since 2014, which was associated with ipsilateral tinnitus.\nOn examination, he was hypertensive with a blood pressure of 187/105 millimeters of mercury, heart rate 91 beats per minute, temperature 98.4° Fahrenheit, and oxygen saturation 100% on room air. The patient’s physical exam was unremarkable with the exception of palpable and visible swelling to the soft tissues below the left side of the mandible and clear discomfort on swallowing. Concern for a vascular abnormality such as aneurysm or thrombosis prompted immediate CT of the neck with IV contrast. This imaging revealed a fracture though an elongated, calcified left styloid process () with hematoma formation causing mass effect on the left lateral hypopharyngeal wall ().\nThe patient was preliminarily diagnosed with a spontaneous fracture of an elongated calcified styloid ligament with hematoma formation and was admitted to observation with otolaryngology (ENT) consultation for airway monitoring and the potential for surgical intervention if worsening airway impingement. He did well with no further progression of symptoms and was discharged after 24 hours. At follow-u"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman without significant medical history visited an outpatient clinic because of radicular compression at L4 level due to scoliosis. The patient underwent posterior pedicle screw fixation with Universal Spinal System (USS) Synthes, which provided segmental stabilization and decompression from D12 to L5. In the first postoperative day, the patient developed mild dyspnea, which prompted the attending clinician to perform an anteroposterior chest radiograph (Figure ). The radiograph revealed bilateral pleural effusion, which was more pronounced on the left side. At the same time, the blood sampling revealed a decrease in hemoglobin levels. Thus, we decided to insert a chest tube to drain blood. In the second PO day, after the blood volume stabilized, the patient underwent a contrast-enhanced CT scan of the chest and abdomen. The CT scan revealed the resolution of the hemothorax (Figure ) and showed the presence of tissue in the thorax with a radiological density similar to that of fat tissue. This finding was associated with the displacement of one pedicle screw that breached the anterior limit of the vertebral body, thereby penetrating into the peritoneal cavity (Figure ). There was no evidence of other thoracoabdominal lesions.\nDiaphragmatic injury and subsequent herniation of the omentum into the thorax were discussed with the general surgeon, neurosurgeon, and anesthetist, and we decided to perform double-access surgery to both remove the pedicle screw in the prone position and to confirm and repair the diaphragmatic injury in the supine position.\nIn the third PO day, after the pedicle screw was removed, we performed explorative laparoscopy with three trocars. We observed a partial axial torsion of the gastric fundus and herniation of the omentum. We checked for the absence of visceral and parenchymal injuries and found a diaphragmatic tear near the left aortic pillar. Then, we reduced the omentum into the abdomen. Primary suture was not a suitable t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis patient is a 68-year-old female, known case of hypertension for the last eight years, presented to us with complaints of anterior neck swelling for about 40 years which had gradually started increasing in size for the last four years. She developed progressive difficulty in swallowing and breathing for the last three months. On examination, there was a presence of large neck swelling, multinodular, which moved on deglutition, with lower limit of swelling not palpable. Prominent dilated veins were appreciated on the neck. A computed tomography scan was done which showed enlarged thyroid with multiple internal calcifications and retrosternal extension up to the level of ascending aorta with multiple collateral vascular channels around mass lesion in anterior mediastinum (). She also underwent total thyroidectomy, sternotomy, and excision of mass lesion. The intraoperative findings were enlarged multinodular goiter with thyroid gland reaching the manubrium. The mediastinal component was also large and separately capsulated from cervical component, extending up to the arch of aorta and superior vena cava with compression of brachiocephalic vein (). The mass was carefully dissected from the above vessels. Specimen was sent for histopathology. Postoperatively, the patient remained well. She was given intravenous analgesia and deep venous thrombosis prophylaxis. She developed respiratory distress on 2nd post-op day, and a chest X-ray showed elevation of the right hemidiaphragm (most likely due to iatrogenic right phrenic nerve injury) and right lower lobe atelectasis and hence was shifted to the intensive care unit for observation. She was managed conservatively with chest physiotherapy, nebulizers, and application of BIPAP. She responded to supportive therapy and recovered well. She also developed asymptomatic hypocalcaemia and was managed with both intravenous and oral replacement. She was discharged from the hospital on eighth postoperative day.\nShe did well on fol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male with a history significant for alcohol abuse presented to our facility with a 3-week history of nausea, vomiting and abdominal pain. Patient had been discharged from our facility approximately 7 weeks earlier after initially being transferred from another facility after respiratory failure secondary to aspiration pneumonia; at the time of transfer from the outside facility patient was found to have elevated amylase and lipase; however, CT did not show any signs of pancreatitis at that time.\nUpon readmission to our hospital another CT was done which showed numerous fluid collections surrounding the pancreas with enhancing rims, representing numerous pseudocysts. It was noted that several of these pseudocysts interconnect. One was noted to measure 8.7 × 10.1 × 12 cm in the undersurface of the body and tail of the pancreas, another measuring 7.8 × 5.9 cm extending towards the lesser curvature of the stomach, and another measuring 9 × 5 cm lateral to the head of the pancreas. CBD was also enlarged at 12.5 mm. Because of the enlarged CBD an MRCP was then ordered which showed some narrowing in the intra-pancreatic portion of the CBD, likely secondary to the inflammatory process secondary to pancreatitis.\nPatient then underwent EUS/ERCP with cystogastrostomy. EUS evaluation confirmed what was seen on prior imaging. We then proceeded with ERCP. After introducing the ERCP side-viewing scope into the stomach, pus was seen coming out of a fistula in the antrum. We then passed a jag wire into the cyst using a hydratome. A cystotome was then introduced to form a tract. A 15 mm × 6 cm balloon was then introduced and the tract was dilated. Finally a 10 mm × 4 cm fully covered SEMS was placed. The pseudocyst was irrigated with 200 cc of saline. Large amount of pus drained into the stomach during the procedure. The patient’s pain improved the following day, patient was started on a clear liquid diet"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n49-year-old gentleman presented to the outpatient department of Head and Neck Oncology services of our institution with complaints of a large lesion in the oral cavity for a duration of one month. The patient also complained of dyspepsia, generalized weakness, malaise and loss of appetite. On examination, the general condition of the patient was poor in view of cancer related cachexia. He had a soft tissue lesion of the upper alveolus extending from the right upper canine to the right superior retro-molar trigone involving the entire upper alveolus and extending into the upper gingivobuccal sulcus (). The mass bled to touch but was non tender. Medially, it extended onto the hard palate for about half a centimetre. On abdominal examination, a mass was palpable in the right hypochondrium extending to the epigastrium. Rest of the abdomen was soft and non-tender. On further evaluation with a contrast enhanced computed tomography of the thorax, abdomen and pelvis, a 7×7×7 cm hypodense mass was noted in the segment VII and VIII of liver, which showed enhancement on arterial phase with washout on venous phase (). The mass was infiltrating the hepatic capsule with a peritoneal deposit abutting the diaphragm and muscles of the chest wall. Enhancing tumour thrombus was noted in the distended main portal vein and its branches. On upper gastrointestinal endoscopy, no varices were noted. Serum alpha fetoprotein was 2440 ng/ml. Liver function tests were normal. He was detected to be positive for Hepatitis B surface antigen. Blocks of the alveolar growth biopsy done elsewhere were reviewed at our hospital and was found to be a metastatic deposit of hepatocellular carcinoma positive for HepPar 1, arginase and focally positive for Glypican 3 whereas negative for CK7, p63, and DOG1 on immunohistochemistry (IHC) (). An ultrasound guided biopsy of the liver lesion was suggestive of hepatocellular carcinoma, positive for Glypican 3 on IHC"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Thai male patient, aged 46 years, presenting with chronic abdominal pain for 3 months. He frequently visited hospital in 3 months about chronic abdominal pain with unidentified cause—recurrent hyponatremia. He underwent upper gastrointestinal endoscopy and ultrasonography of upper abdomen but showed within normal limit of both examinations, so he was treated as chronic dyspepsia and symptomatic treated about hyponatremia but he still not improves. In admission day, he re-visited hospital with abdominal pain and his blood chemistry showed hyponatremic hypokalemic metabolic alkalosis, so gastric outlet obstruction was provisional diagnosis. Saline loading test showed delayed gastric emptying time. Patient was sent for computed tomography of abdomen because previous upper gastrointestinal endoscopy showed normal study. Computed tomography resulted in 5 cm long, enhanced wall thickening at duodenojejunal junction in left lower abdominal region, abutting adjacent sigmoid colon with preserved fat plane separation and markedly dilatation of the proximal duodenum and stomach is detected as in Fig. . The diagnosis of obstructed proximal jejunum was made and exploratory laparotomy was decided. In operative field, a 5 cm Cauliflower mass at proximal jejunum, 15 cm distal to ligament of Treitz, causing proximal duodenal dilatation and distal small intestines collapse was found as in Fig. . No liver, omental or peritoneal nodule was found. Radical segmental proximal jejunal resection (with 5 cm proximal and distal margins, with mesentery that vascular supplied resected jejunal segment) with primary small intestinal anastomosis was done. Operative time was 48 min and estimated blood loss was 50 mL. After operation, patient fully recovered but superficial surgical site infection was found and pus culture showed Proteus mirabilis and Escherichia coli. Pathologic examination showed well differentiated adenocarcinoma of jejunum with extension into perienteric fatty tissue, free all"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old woman experienced choking, chest tightness, and back pain.\nThe patient had experienced choking and chest tightness 2 years prior without any causation and had experienced back pain 1 year ago. Recently, the above symptoms had gradually been aggravated. The patient underwent gastroscopy that showed normal findings.\nThe patient had no other past illness except choking, chest tightness, and back pain.\nThe patient had no remarkable personal and family history.\nThe physical examination was unremarkable.\nThe patient was previously healthy and showed no abnormalities in the laboratory examinations.\nCT revealed a soft-tissue mass approximately 4.2 cm × 3.7 cm × 2.6 cm in the right posterior mediastinum, for which the boundary between some areas and the esophagus was unclear, and the trachea was also compressed (Figure ). In the enhanced CT scan, a contrast agent was injected into the right upper limb. In the early arterial stage, the superior vena cava and the azygos vein arch were filled with the contrast agent, and the azygos vein arch was nodular. The density did not decrease in the venous phase, and there seemed to be a blood shadow during coronary reconstruction. The posterior mediastinal tumor showed delayed enhancement, and its internal density was not homogeneous. No definite filling defect was found. The tumor was connected to the superior vena cava, whose degree of enhancement was the same as that of the superior vena cava, and the boundary between the tumor and the esophagus was clear. The azygos vein valve was observed. The esophagus was compressed by an azygos vein aneurysm (Figure ). These findings indicated that there was a giant hemangioma originating from the azygos vein arch.\nThe tumor was dissected, which revealed enlarged and dilated thin-walled blood vessels with intact endothelial cells on the wall, in which the medial muscle layer was thinned; a large number of red blood cells were found outside the lumen. Multiple red"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63 years old Iranian woman admitted in our hospital due to progressive solid dysphagia and 10 kilogram weight loss in the past three months.She had a history of heart valve replacement surgery at 3 years ago. Physical examination revealed mild temporal muscle atrophy and abnormal heart sound secondary to her known valvular heart disease. Vital signs, lungs, abdomen, pelvic, central nervous, and the musculoskeletal examination were all normal. The patient's laboratory findings including blood cell count, erythrocyte sedimentation rate, and kidney and liver function tests were also normal.\nAs the patient history was suggestive for an esophageal malignancy, an upper gasteroenterointestinal endoscopy was carried out. Endoscopy revealed a short (two centimeters) circumferential symmetrical smooth narrowing in the mid part of the esophagus (from 25 to 27 cm of incisors); the gross appearance of this stricture was normal suggesting external compression. The gastroscope passed through the stricture easily. Other part of esophagus, stomach, and duodenum were normal. Barium swallow confirmed the endoscopic findings but didn't reveal more diagnostic information ().\nContrast Computerized Tomography (CT) scan of the chest was performed for further clarifying the nature of the lesion. CT scan revealed an abnormal Soft tissue density with irregular borders in the posterior mediastinum that was encircling the carina, left main bronchus, esophagus and the mid thoracic aorta ().\nDue to the external pressure the lumen of the involved segment of esophagus did not appear in CT scan. The upper segment of the esophagus proximal to the lesion was dilated and had air-fluid (oral contrast) level. Other parts of thorax including the lungs, pleura, ribs, sternum, and thoracic spines were normal.\nThe patient had no respiratory symptoms but since mediastinal lesion seen on the CT scan was taking over the left bronchus and was in close contact to it, bronchoscopy was performed; there was fine m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old female presented with a history of breast lump for past 6 months. There was a history of rapid increase in size with pain and ulceration for 1 month. She had lost 6 kg of weight in 2 months. There was no history of breast malignancy in the family. On examination, left breast showed a huge foul smelling fungating mass with absent nipple and areola, occupying almost entire left breast. Axillary lymph nodes were palpable. Trucut biopsy elsewhere reported as phyllodes tumor. Mammogram was not done as the tumor was ulcerated. Positron emission tomography scan revealed large hypermetabolic mass in the left breast and few hypermetabolic lymph nodes in the left axilla. There was no evidence of metastasis elsewhere in the body. With the diagnosis of phyllodes tumor probably malignant with skin ulceration, mastectomy with axillary dissection was done.\nSpecimen revealed a large tumor ulcerating and erupting out through the skin. Nipple and areola were absent. The tumor measured 15.5 cm × 13 cm × 7 cm with lobulated margins. An another firm tumor measuring 2.5 cm with spiculated margin was seen at the periphery of large tumor, abutting it []. Histology of the larger tumor showed stromal predominance occupying a low power field [], increased cellularity, spindle cells with moderate atypia, and increased mitosis [] of 13/10 high power field (HPF). Scattered ducts in clefts and leaf like pattern were seen with double layered epithelium. Tumor was ulcerating the skin with surface necrosis. At its periphery, an epithelial tumor is seen without transition zone in between [], consists of cells in tubules and trabeculae with stromal desmoplasiar []. Moderate atypia increased mitosis, and lymphovascular emboli were noted. Eleven axillary lymph nodes were involved by invasive carcinoma. A diagnosis of malignant phyllodes tumor with ulceration with coexisting invasive carcinoma of no special type was rendered. She was currently on"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old man was referred to our hospital for treatment of a rectal SMT detected during a medical checkup at another hospital. Digital examination of the anus and rectum revealed a 20-mm elastic hard tumor palpable on the right and ventral sides of the anal canal and located 2 to 3 cm proximal to the anal verge. Laboratory examination showed no elevation of either carcinoembryonic antigen or cancer antigen 19-9. Colonoscopy showed a 20-mm SMT in the anal canal (Fig. ). Abdominal computed tomography (CT) showed a 20-mm cystic tumor on the right site of the lower rectum with no evidence of lymph node or distant metastases (Fig. ). Magnetic resonance imaging (MRI) also showed a 20-mm cystic tumor on the right site of the lower rectum (Fig. ). These findings strongly suggested a benign cyst in the anal canal; therefore, the patient underwent trans-sacral resection for precise diagnosis of the tumor. The pathological diagnosis of the resected tumor was a mucinous adenoma with high-grade dysplasia (Fig. ) with negative surgical margins. The patient was observed in ambulatory practice. Follow-up CT and MRI 14 months after surgery showed a new cystic lesion near the site of the removed tumor (Fig. ). To evaluate whether the new cystic tumor was a recurrence, the patient underwent trans-sacral resection of the cystic tumor again. Pathological examination of the second resected tumor revealed that the tumor was a mucinous adenocarcinoma of the lower rectum (Fig. ) with a possible remnant tumor at the local site. After providing sufficient informed consent, the patient underwent anal sphincter-preserving intersphincteric resection (ISR) with partial resection of the external sphincter along with prophylactic lymph node dissection. Pathological examination showed that the tumor cells were located at the anal gland under the mucosa of the anal canal and that these cells produced mucin and fibrosis (Fig. ). Immunohistochemical analysis showed that the tumor cells were positi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old Caucasian woman, a mother of three sons, at 30 days post-partum after a full-term pregnancy without any complications and concluded by a vaginal delivery, suffering from diabetes on oral antidiabetic medication, presented to the emergency department with left flank pain with hematuria of one week’s duration. A clinical examination revealed an alert patient, febrile at 38°C, with blood pressure of 158 over 67mmHg, heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute, suffering from pain in the left flank (visual analog score (VAS) = 5), this pain was exacerbated by palpation, which found lumbar contact. Diagnostic studies in the emergency room revealed a urine analysis with 104 white blood cells (WBCs), gross hematuria, and a C-reactive protein level of 88. Her blood cell count revealed anemia at 9g of hemoglobin; blood electrolytes and renal function with serum creatinine levels were normal.\nAn abdominal ultrasound scan showed discrete pyelocalyceal cavities dilation with a slightly enlarged left kidney and without visible urinary obstruction. A CT urography and angiography scan was performed and showed an ectatic left renal vein, seat of a large hypodense thrombus extending from the segmental renal veins to the inferior vena cava, with a large heterogeneous and hypodense region located in the medium and lower poles of the left kidney without urinary tract dilatation or tumoral lesions; this aspect concluded in a perfusion abnormality (renal venous infarction) (Figures \n and\n).\nAnticoagulation heparin therapy was started and our patient was admitted to a medical center for further investigations. Her proteinuria and blood cultures did not show any abnormalities, and her serum albumin levels were normal. The thrombophilia assessment, with protein C or S deficiency, mutation of coagulation factors II and V, lupus and antiphospholipid antibody syndrome (APS) tests, were negative. The outcome was favorable with disappearance of pain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old female underwent abdominal hysterectomy with bilateral salpingo-oopherectomy 2 years and 3 months ago. Histopathological examination of the biopsy specimen showed UPSAC. Adjuvant chemotherapy was given after the abdominal hysterectomy. The patient's Glasgow Coma Scale score was 12/15 at the time of admission to our hospital. She presented with a 20-day history of headache and left hemiparesis, and she could not walk or use her left arm and left hand. Cranial magnetic resonance iaging (MRI) showed three lesions; two were located in the parenchyma of the cerebellum and had perilesional edema. but had no shift effect or obstruction on the fourth ventricle and the third lesion was located in the right frontobasal frontal lobe, and caused a large hemispheric edema and subfalcine herniation []. All the three lesions exhibited contrast enhancement following gadolinium injection. The lesions’ characteristics are shown in Figures -.\nThe patient underwent frontal craniotomy with gross total extirpation of the tumor located in the right frontal lobe on September 12, 2012. There were no surgical complications, such as bleeding or adhesiveness adjacent to the brain tissue during the removal of the tumor. The other two lesions located in the posterior fossa were left untouched because they had no mass effect. Histopathological examination of the biopsy specimen was consistent with metastatic UPSAC [].\nThe patient was able to walk with the assistance of a walker, and underwent follow-up cranial computed tomography (CT) 2 days postsurgery [], which showed that there was no residual tumor in the frontal lobe, the midline shift and subfalcine herniation improved, and less edema than presurgery. The patient was followed-up for 9 months postsurgery and via telephone (last contact on May 14, 2013) reported that she was able to walk independently, and use her left arm and left hand without any difficulty, and that she had undergone 10 days whole cranial radiotherapy and che"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23 year old married female presented in the surgical OPD with complaint of pain in abdomen for past 1–2 years, and loss of appetite and vomiting post meals for 6 months. On observation, the patient had thin built and appeared pale with body mass index (BMI) of 13.3 kg/m2. On clinical examination, she was found to have a 7 × 3 inches large lump in the epigastric region which was freely mobile. Recent blood investigations revealed Hemoglobin to be 11.6 gm/dL with no electrolyte abnormalities. USG epigastrium revealed a well-defined mixed echogenic mass lesion predominantly hyperechoic in echotexture of size ~ 65 × 75 mm. A contrast enhanced CT scan of whole abdomen was performed which revealed over-distended stomach and large heterogeneous intraluminal mass with mottled appearance and small air pockets. Smooth wall thickening of stomach was also seen. A contrast enhanced CT scan of whole abdomen was performed which revealed over-distended stomach and large heterogeneous intraluminal mass with mottled appearance and small air pockets. Smooth wall thickening of stomach was also seen []. On interviewing, her mother mentioned about patient's habit of eating her hair since the age of 3 years. Hence, a diagnosis of trichobezoar was formed and patient was taken for surgical treatment. Laparotomy with gastrotomy and removal of trichobezoar under general anaesthesia was performed. Laparotomy with gastrotomy and removal of trichobezoar under general anaesthesia was performed. []. Postoperatively, patient was sent for psychiatric consultation.\nOn psychiatric evaluation, patient reported history of eating hair since childhood. She would keep hair in mouth when stressed but would not realize that she was swallowing the hair too. Parents made her aware about her hair eating behavior when she was around 6 years old. This behavior would increase whenever she was scolded or had an argument with her family. She also provided history of fainting always following stress"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of an 83-year-old female patient with a previous history of breast surgery with axillary dissection in 1997, followed by adjuvant chemotherapy due to invasive ductal carcinoma of the left breast. The family history was negative for neoplastic diseases, both mammary and belonging to the gastrointestinal tract. Oncological follow-up was negative, and the patient considered disease-free for almost 15 years. During 2012, an X-ray of the spine, performed for the appearance of lumbar pain, revealed the presence of vertebral metastases. The patient was treated with radiotherapy and spinal stabilization. In addition to this, a deep venous thrombosis episode was reported in 2017, and treated with anticoagulant therapy. In the same year, multiple myeloma associated with mild chronic kidney disease was diagnosed. Neither myeloma nor kidney disease had requested specific treatments.\nIn July 2018, the patient was admitted to the emergency department for sepsis and an episode of acute kidney failure, anuria and fever. Right-upper quadrant abdominal pain triggered by food intake and abdominal tenderness was also present, placing the diagnostic suspicion of biliary sepsis due to acute cholecystitis.\nThis condition was conservatively treated with intravenous antibiotic therapy with renal adjusted dose of piperacillin-tazobactam and hemodialysis for two weeks. Subsequently, kidney function improved, diuresis had an increasing glomerular filtration rate and sepsis was cured. Abdominal CT-scan performed during this hospitalization had shown a diffuse thickening of the gallbladder’s wall associated with stones as well as pericholecystic fluid (\n). The CT-scan didn’t highlight pathological findings on the liver, such as enlarged regional nodes. A dilated common bile duct with the presence, in its proximal portion, of tenuously hyperdense material was described.\nEndoscopic ultrasound was performed, and it confirmed the presence of both gallbladder and common duct stones"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWritten informed consent was obtained from the patient for this case report.\nA 57-year-old male presented at another hospital with hoarseness that had gradually worsened over a 4-year period. No pain was present. A laryngeal flexible-endoscopy examination revealed a 5-mm diameter red tumor at the anterior commissure of the larynx and a swelling of the right vocal fold. Resection of the red tumor and biopsy of a white submucosal tumor on the right vocal fold were performed by means of laryngeal microsurgery. Histopathological examination indicated that the possibility of malignancy could not be excluded. The red tumor then recurred at the same site 4 months after the resection, and the patient was referred to our hospital. Neither neurological signs nor skin signs such as cafe au lait spots were found. The patient had never received radiation therapy and had no co-morbidities. He had a history of smoking 20–40 cigarettes a day and drinking 500 ml of beer daily.\nAt the initial visit to our hospital, a laryngeal flexible-endoscopy examination showed a red tumor on the anterior commissure of the larynx and a diffuse swelling of the right vocal fold (). Immunohistochemical examination of the previous surgical specimen indicated the possibility of MPNST because hyperchromatic spindle cells in which MIB-1 labeling index was 20%, P53 protein was overexpression and S100 protein was sporadically positive were identified (Table). In addition, Sox10, CD34 and p16 protein expression was negative. Removal of the recurrent red tumor and several biopsies at different sites in the white submucosal tumor of the right vocal fold were performed again (). The removed red tumor measured 15 × 9 mm. The recurrent red tumor and associated swelling on the anterior commissure of larynx, as well as the midmembranous vocal fold lesions (biopsy 2 in ), were high-grade MPNSTs immunohistochemically; the lesion on the ventral side of the right posterior vocal cord (biopsy 4 in ) was less malignant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nDuring preoperative preparation for posterior cervical decompression in a 66-year-old Caucasian man, an anesthesiologist used ultrasound to access our patient's right internal jugular vein (IJV) to place a venous catheter. After what was presumed to be successful ultrasound-guided venous access, a 7-Fr triple-lumen catheter was inserted. The anesthesiologist noted an arterial waveform arising from the catheter tracing. The catheter was left in situ out of concern that removing it could lead to uncontrollable bleeding, without the ability to directly compress the arterial puncture. The surgical procedure was postponed.\nOur patient was transferred from the operating room to the angiography suite and remained under the general anesthetic. Angiography via the misplaced catheter revealed a flow of contrast in the aortic arch because of the arterial position of the catheter. The decision was made to perform a formal angiogram via his femoral artery to better visualize the catheter entry point into his arterial system. Access through his femoral artery was achieved. An angiogram showed the entry point of the misplaced catheter in his proximal right subclavian artery, just beyond the origin of his right vertebral artery (Figure ). An angiogram of his right vertebral artery revealed a dominant vessel with prominent spinal arterial feeders. A consultation with the cardiothoracic surgeon revealed that, despite the proximal entry point of the misplaced catheter into the subclavian artery, the surgeon would not be able to directly visualize or palpate the artery during surgical exploration. Placement of a covered stent was an attractive alternative. An analysis of the images acquired determined that the dominant right vertebral artery would probably be occluded by the placement of a covered stent and so it was determined that our patient was not a good candidate for the safe placement of a covered stent.\nThe decision was made to remove the catheter and close the puncture site wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman with a history of PLS was scheduled for a left breast simple mastectomy with axillary level I lymph node dissection for recently diagnosed ductal carcinoma in situ. The patient's PLS symptoms included significant deconditioning and generalized muscle weakness requiring wheelchair use, generalized muscle spasms, and dysarthria. At the time of surgery, the patient had no home oxygen requirement. Her documented peak cough flow rate (measure of respiratory muscle weakness) was 70 liters per minute (indicating ineffective cough). Her comorbidities included an increased body mass index (29.9) and hypertension. Preoperatively, the patient's heart rate was 106 beats per minute, blood pressure 143/73, respiratory rate 20 breaths per minute, and oxygen saturation 95% on room air. EKG and chest XR were within normal limits. No pulmonary function tests were available prior to surgery. The patient's pulmonologist and primary medical doctor strongly recommended avoidance of general anesthesia for the surgery due to concerns about increased risks of prolonged mechanical ventilation and postoperative respiratory complications related to her condition. During the preoperative visit, the patient refused general anesthesia and requested a minimally invasive approach. After discussing with the patient and surgery team all the risks and potential complications associated with general anesthesia, including respiratory depression, postoperative mechanical ventilation, and pulmonary complications, the patient's medical condition, anesthetic requirements for the procedure and alternatives, plan was made to proceed with a peripheral nerve block and multimodal monitored anesthesia care. Discussion was also held regarding general anesthesia not being used as a backup plan and aborting the procedure in case of inadequate anesthesia or patient discomfort.\nFor the thoracic paravertebral block placement, the patient was positioned sitting upright with the arms resting on a Mayo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old boy was brought with a history of fever of four days duration with cough and cold. The boy was earlier treated with an injection outside by a private practitioner. On examination, he was toxic with high fever of 102° F, congestion of eyes and throat with maculopapular rash over his face and neck []. He was tachypneic with bilateral crepitations and decreased breath sounds in the right infrascapular region. He was admitted and treated with injection ampicillin for the respiratory infection. On the next day, the rashes increased and appeared on the chest and upper extremities with increasing congestion of eyes. He was thought to have measles as he had contact with a person who had similar illness few weeks back near his home. He was treated with vitamin A, oxygen by face mask, nebulized salbutamol and intravenous fluids. Since fever spikes were persistent and TLC was elevated (21,000/cu.mm) with neutrophilia (90%), antibiotics were changed to injection ceftriaxone after test dose. After a period of two hours he was found to have increasing rashes with audible wheeze, loose stools and vomiting. By this time the rash was found throughout his body with clearing from face. Salbutamol nebulizations were increased in frequency and the child was monitored closely.\nOver the next eight hours child became better, was able to sit up comfortably with minimal distress and he was taking oral feeds. The rashes appeared less prominent. He received the second dose of injection ceftriaxone that afternoon and following that he felt dizzy, vomited and began to have distress. His rash once again increased and became prominent, this time, throughout the entire body involving the face with urticarial lesions in-addition to macula-papular lesions []. He appeared red and was warm with itching all over the body, especially around his ears. Drug allergy was suspected and was promptly treated with oxygen, parenteral pheniramine maleate,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 49 years-old male who was a herder living in Inner Mongolia, the northern part of China. He did not receive any treatment involving corticosteroid nor did he intake large amounts of alcohol. The patient first presented with recurrent fever. A few days later pain in bilateral sides of hips showed. He was admitted to the local hospital, the experimental test indicated that the patient is infected with Brucella spp., plain radiography showed normal contour of the femoral head on the left side whereas the right side had already developed into ARCO Stage IIIA (Fig. ), he did not receive standard treatment for Brucellosis at that time. The patient was also diagnosed with spondylitis and have a history of chronic hepatitis B. His symptom of hips aggravated only after a few months and the patient has been treated with doxycycline and rifampin for 6 weeks at the local hospital. Before discharging the Rose-Bengal Plate Agglutination Test (RBPT) showed weakly positive, the Wright test showed a titer of 1:50 and the Cysteine test showed a titer of 1:20. At the time the patient admitted to our center, both sides of the femoral head were aggravated to ARCO Stage IIIC in plain radiography (Fig. a), and the necrotic lesion showed in magnetic resonance imaging (MRI) (Fig. b). The patient showed limited active and passive hip movement, the abduction and adduction were significantly restricted, Patrick test and Thomas sign were both positive on both sides, Harris Hip Score were 54 on the right side and 45 on the left side. The Agglutination test of Brucella showed weakly positive, and erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels and aspartate aminotransferase (AST) were within the normal range. We performed bilateral total hip arthroplasty (THA), during the procedure, we used iodophors soaking the wound for 3 min and then irrigated before and after intramedullary"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 59-year-old male with a postoperative union of a left tibial plateau fracture who, after open reduction and internal fixation, underwent surgery for implant removal at a local hospital (Fig. ). The first day after surgery, at approximately 9 a.m., he complained of severe pain in the wound region and developed a fever in which the highest temperature reached was 39 °C. Upon examination, the patient was conscious without chills and other discomfort, and the incision was severely swollen and filled with hemorrhagic content. Analgesic therapy was given, but the patient did not feel pain relief. Early on the second morning, the patient started to become irritable and apathetic and the incision was inflamed. The following afternoon, at approximately 3 p.m., the patient felt increasing pain out of proportion to the physical findings accompanied by progressive swelling, numbness, and weakness of the limb. The skin around the wound was darkened, and tension blisters were visible (Fig. ). The patient was delirious on the third morning after surgery, the systemic skin turned yellow, and there was a large amount of dark red, bloody discharge drainage from the incision with bubbles of gas, and a foul, sweetish, unpleasant odor was smelled in the incision. A physical examination revealed subcutaneous crepitus extending along the length of the limb, roentgenograms revealed the accumulation of gas in soft tissue (Fig. ), the lower limb skin temperature decreased, the dorsal artery of the foot could not be touched, and the patient had no response to pain in the lower extremities. Anaerobic infection gas gangrene was highly suspected, and the patient was transferred to our hospital at approximately 7 p.m.\nLeft lower extremity incision decompression was carried out immediately. Upon incision, the musculature was found to be extensively necrotic and crepitant, the appearance of the affected muscles was purplish red and brown with a characteristic foul odor,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old, non-smoking female patient with a medical history of diabetes mellitus (DM) and hypertension (HTN) presented to the Urology Department of King Fahad General Hospital with a three-month history of hematuria. She denied any history of flank pain, dysuria, urgency, fever, or weight loss, or appetite. Clinical examination was normal, laboratory findings were within the normal range, urine analysis showed >40 red blood cells (RBCs) per high power field, and urine culture showed no bacterial growth. Bladder smooth muscle cell markers (smooth muscle actin (SMA), desmin, and calponin) were positive. B-catenin and CD117 were negative. An abdominal and pelvic CT scan with contrast was done and showed a large submucosal urinary bladder mass. An abdominal/pelvic MRI was performed and revealed a large submucosal well-defined round mass with a slightly lobulated smooth margin originating from the submucosal layer of the left anterolateral wall of the urinary bladder. It measured 5 x 7 x 4.5 cm and was isointense to the T1 weighted image's muscle and heterogenous with the cystic component on the T2 image. No suspicious lymph nodes in the pelvis and no infiltration into the adjacent organs and tissues were found. The finding suggests bladder leiomyoma and solitary fibrous tumor (Figure ).\nAn ultrasound-guided biopsy sample was taken and sent for histopathological examination and revealed a spindle cell tumor. On cystoscopy, a normal urinary bladder wall with no obvious exophytic masses and both ureteric orifices were seen, and a urine jet was present, but there was a massive indentation in the left posterolateral site of the urinary bladder extending to the dome of the bladder. The patient then underwent an open partial cystectomy (Figure ). A specimen of 7 x 5 x 3.5 cm was obtained and preserved in formalin for histopathological examination. A well-encapsulated white firm mass measuring 3 x 2.5 cm was found and the histopathological"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Caucasian woman was admitted for elective shoulder replacement for an arthritic shoulder. She was being treated for hypertension with beta-blockers and thiazide diuretics and her blood pressure was well controlled. She had a history of diverticulitis and varicose vein surgery with an uneventful outcome. Her body mass index (BMI) was 34 during pre-operative anesthetic evaluation. She had no family history of DVT/PE. Blood investigations including electrolytes, liver function tests and coagulation screening were normal. Results of her electrocardiogram (ECG) and chest X-ray were unremarkable. The comorbidities were well optimized and she was admitted a day before her operation.\nThe patient was operated under general anesthesia supplemented with an interscalene block for postoperative analgesia. An intermittent calf compression device was used for mechanical thromboprophylaxis intraoperatively. The operation was performed through an anterior deltopectoral approach. The patient had no intraoperative complications. The patient recovered satisfactorily from general anesthesia and was monitored in a high dependency care unit for postoperative optimization. The operated shoulder was supported in an arm sling support for comfort. The patient was prescribed postoperative opioid analgesics and antibiotic prophylaxis with three doses of cefuroxime. No chemical or mechanical thromboprophylaxis were used postoperatively.\nThe patient was already feeling well on the next postoperative day and her blood parameters were satisfactory. Her pain was well controlled and her arm continued to be immobilized by the sling. There was no excessive oozing from the surgical wound and there were no distal neurovascular deficits. The patient's calves were soft and nontender and she was ambulating well postoperatively. A systemic examination of the patient was unremarkable. However, while being monitored she suddenly became breathless, hypoxic and hypotensive and experienced intense s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman had presented in the outpatient services of psychiatry with multiple episodes of seizure for the past 6 years. The episodes of seizure were of generalised tonic-clonic type with a frequency of two to three episodes in a month. She was treated with phenytoin 300 mg/day with partial control of seizures (frequency of seizures was decreased). However, non-adherence to treatment resulted in worsening of seizures. She was diagnosed with hypothyroidism 2 years ago and was on thyroxine supplementation (50 μg/day). There was no history of any other medical illness. There was no history of psychiatric illness or substance use. Her family history was also uneventful. Premorbidly, she was well adjusted to life. She had expressed her concerns and worries related to seizure over the past few months prior to psychiatric consultation. Her distress was not persistent and often increased when seizures occurred more frequently. Current psychiatric evaluation did not reveal any significant psychopathology, other than apprehension about seizures.\nHer general physical examination and systemic examination did not reveal any abnormality. There were no focal neurological deficits. Her cognition was intact. Lobar function tests also did not reveal any abnormality. The patient was investigated for seizure. CT scan of head revealed calcification in bilateral basal ganglia, frontal lobes and cerebellar hemispheres (). On the mental status examination, she had an anxious affect and worries related to persistent seizure. She was diagnosed with Fahr’s disease. Her psychological symptoms were not persistent and mild in severity, so no psychiatric diagnosis was made. It was planned to keep the patient on regular follow-up to see the evolution of symptoms over time. Her routine haemogram, liver function tests and kidney function tests were within normal limits. Her serum calcium (ionic) was 2.84 mg% (normal range: 4.5–5.5 mg%). Parathormone (PTH) level was 14.37 pg/mL (normal rang"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-month-old Caucasian boy was referred to this department for investigation of a raised urea and creatinine. He was born at 37 weeks’ gestation to unrelated parents. He had difficulties with bottle-feeding in the first 2 weeks of life and at the time of weaning he was noted to choke on solids. He was also found to have bilateral profound sensorineural hearing loss on routine screening, which led to him receiving cochlear implants at 18 months. At 8 weeks, he was not fixing and following and was noted to be hypotonic. At 10 months, he became unwell with fever, lethargy and rash. His urea was 44 mmol/L but reduced to 14 mmol/L after rehydration therapy.\nAt the time of his referral he had global developmental delay, truncal hypotonia, delayed visual maturation and bilateral sensorineural hearing loss. He was not on any regular medication. Results of initial blood and urine tests together with serial plasma lactate levels from presentation are shown in Fig. and Table respectively.\nA renal ultrasound scan showed right and left renal lengths were 6.2 cm (30th centile) and both kidneys were echogenic. The presence of renal impairment and echogenic kidneys on ultrasound prompted renal biopsy, which showed significant tubulointerstitial damage with immature glomeruli (Fig. a, b). Electron microscopy of renal tissue revealed abnormal mitochondria affecting the tubular cells (Fig. c). Assessment of oxidative enzyme histochemistry in a muscle biopsy revealed a mosaic pattern of cytochrome c oxidase (COX) activity (Fig. d), which was confirmed by direct measurement of respiratory chain enzyme activities; complexes I and IV were both severely decreased with complex III activity decreased to a lesser extent, and evidence of complex II activity being spared (Fig. e). Taken together, these data are consistent with a generalised disorder of mitochondrial function.\nBrain magnetic resonance imaging (MRI) of the proband was reported to show abnormal signal in the cerebral white matt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31 years old right hand dominant gentleman presented to our orthopedic specialty clinic with fracture distal end radius on left side. On further evaluation, there was deformity in ipsilateral shoulder joint and asymmetry was present as compared to opposite side. There was an anterior globular bony swelling palpable with well defined margins. Transmitted movements from humerus were present confirming it to be bony humeral mass. There was wasting of deltoid muscle as compared to opposite side. Range of motion were flexion upto 170 degrees (), extension up to 10 degree (), internal rotation up to L3 (), and external rotation up to 30 degree () and abduction up to 120 () in both active and passive movements, further movements were restricted and mildly painful. Patient did not have any history of significant trauma to shoulder in past. However he gave a history of seizure attacks three years back following which he had shoulder pathology. He had taken antiepileptic treatment; however no treatment was taken for the shoulder. There were no further epileptic episodes and he was taking antiepileptic treatment. Radiographs of shoulder joint were taken which confirmed anteriorly dislocated humeral head (). Further views of shoulder joint were taken to check for any bony changes. They didn’t show any significant abnormality. CT scan showed anteroinferior dislocation with neocavity with pseudojoint formation (,,). Chronic hillsachs lesion was also seen. MRI Scan showed anteroinferior shoulder dislocation with intact rotator cuff muscles (,) Since the patient had good functional range of movement we explained him the treatment options. He opted for non surgical line of management. Hence was given shoulder mobilization exercises. Presently patient is being followed up with no fresh complaints and maintained join movements.\nAnterior dislocation of shoulder unlike posterior dislocation is most commonly traumatic in nature. The mechanism of anterior dislocation following trauma is"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 51-year-old man diagnosed with NF1, addressed to our consultation for oral pain in his wisdom tooth 48. During anamnesis, the patient informed us about cutaneous café au lait spots since childhood, and that at puberty cutaneous neurofibromas located on the head, abdomen, back, and arms appeared, followed by the occurrence of oral neurofibromas around the age of 20. NF1 was then diagnosed and multiple cerebral MRI were carried out without revealing any lesion. Furthermore, he related having been diagnosed with idiopathic thrombocytopenia during childhood which required high dose corticosteroid treatment leading to side effects such as weight gain and increased hairiness. At the age of 31 years, he sustained surgical excision of multiple neurofibromas in the head and neck region in France. He also mentioned a tibial fracture which occurred five years earlier while skiing which led to an osteoporosis diagnosis, treated by intra-venous denosumab monoclonal antibody (Prolia) twice a year since then.\nThe clinical examination revealed numerous cutaneous neurofibromas on the neck and back of the head as well as on the abdomen and the back, arising to the gluteal fold (). Apart from the infection related to the tooth 48, the intra-oral examination disclosed vestibular gingival nodules on the right side, measuring about one centimeter in diameter, covered by normal mucosa; the anterior one had a round aspect in comparison to the posterior one which had an elongated appearance most certainly due to the dental occlusion (). The patient had however, no complaint in regard of those intra-oral nodules. A facial cone beam CT was performed and revealed no intra-osseus lesions linked to NF1.\nTooth 48 was removed. However, its infection was not in relation with NF1. Two excisional biopsies of the maxillary lesions were also performed to assess a diagnosis and to allow the patient to have better oral hygiene. The histopathological analysis confirmed the diagnosis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old male presented with a pulsatile mass () in his left hand 3 weeks following an open carpal tunnel decompression under general anaesthetic with tourniquet application. Tourniquet application time was less then 30 minutes, and it was released after wound closure and application of pressure dressing. Patient was discharged 24 hours after the surgery, and warfarin was restarted 72 hours after surgery with low molecular weight heparin cover.\nHis early postoperative course was complicated by surgical site abscess formation that was drained on postoperative day 7. There were no signs or symptoms of an embolic phenomenon secondary to infective endocarditis, since he was clinically well with no signs of generalised sepsis.\nThe patient had a past medical history of pulmonary embolism for which he was on warfarin along with previous ischaemic heart disease and minor asthma.\nA Doppler ultrasound of his hand was performed which revealed arterial blood flow within the pulsatile swelling. CTA confirmed the lesion to be a pseudoaneurysm of the superficial palmer arch. Once the diagnosis was established, the patient's case was discussed in the vascular multidisciplinary meeting. He was provided with the options of open operative procedure under general anaesthesia versus endovascular technique, the latter was chosen by patient. Hence, coil embolization of both sides of the palmar arch (Figures and ) was carried out. A postprocedural US confirmed no flow into the aneurysm. His recovery was uneventful, and he was symptom free at 3-week followup.\nAn initial diagnosis of mycotic aneurysm was made on the basis that patient initially presented with an abscess at the wound site on 7th postoperative day. This was drained in accident and emergency department under local anaesthetics. And the subsequent swelling appeared 2 weeks later.\nThe patient did not have any history suggesting he suffered from “hypothenar hammer syndrome”, since he was a retired librarian, and there was no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old female presented to our clinic as a new patient for excision of a previously diagnosed right heel leiomyoma. Six months prior, she had consulted a dermatologist for a painful area on her right heel that had been present for approximately three to six months. The area was raised, tender, firm, and was increasing in size. Physical exam at that time revealed a 2 cm raised, firm, noncompressible nodule on the posterior right heel, which was tender to palpation without any redness or streaking. X-rays were nonspecific and revealed that the soft tissue shadow was “not connecting to bone.” A punch biopsy taken at a follow-up visit with the dermatologist revealed a leiomyoma of the heel. She continued to experience pain (8/10 in severity) and was seen in our clinic for evaluation six months later. She had no other areas of bleeding, itching, or pigment changes of the skin. Physical exam revealed a palpable 2 cm x 1 cm nodule on the posterior aspect of the right heel which was freely mobile and tender to palpation (Figure ). Pulses and sensation were normal throughout in both lower extremities and no other gross abnormalities were noted.\nThe patient did not have a history of frequent running, gout, diabetes, constitutional symptoms, or weight loss. Due to the unusual location of this leiomyoma, Reed’s syndrome was considered in the differential diagnosis, and the patient was referred for a gynecological oncology appointment. However, because she had no personal or family history of other similar soft tissue masses, uterine fibroids, renal cell carcinoma, or skin cancer, there was a low index of suspicion. Her past medical history was nonspecific for any condition predisposing to cancer.\nShe was scheduled for surgery two weeks later. The tumor was excised (Figures -) and sent for pathology confirming cutaneous leiomyoma (Figure ). Follow-up visit at two weeks status post-excision showed a well-healing"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old man was admitted to our hospital, complaining of hematochezia which had lasted for 1 month. His past history involved a high anterior resection of the rectum in our hospital due to intussusception caused by Peutz-Jeghers polyposis (Fig. ). He was hospitalized for 1 month after the procedure. Unfortunately, details of the surgical procedure that had been performed and the reason for his extended postoperative hospitalization were unknown, because clinical records from his previous admission were not available. He was followed up for 3 years after the procedure, during which he had no abdominal symptoms. He remained symptom-free until the month prior to readmission when he began to suffer from hematochezia. On this admission, hematochezia was his only symptom and there were no abnormal abdominal findings on physical examination. Blood test results, including levels of tumor markers, were all within normal limits. Colonoscopy revealed a hemorrhagic tumor with a smooth surface protruding from the anastomosis of the previous high anterior resection, at a distance of 10 cm from the anal verge; a second examination 4 days later revealed that the tumor had disappeared (Fig. ). The biopsied tumor and other small polyps were histologically diagnosed as adenocarcinoma and hamartomatous polyps, respectively (data not shown). We performed a low anterior resection of the rectum, including the anastomotic site with the adenocarcinoma, combined with a resection of the ileum for strong adhesion. The patient was discharged from our hospital 42 days after the operation.\nGross appearance of the resected rectum showed a defect of the rectal mucosa with a smooth edge and a mucosal bulge located at the anastomotic site (Fig. ). Cut surfaces demonstrated a submucosal tumor mainly occupying the proper muscle layer under the defect (Fig. ). Microscopically, the submucosal tumor comprised an adenocarcinoma and a bone lesion at the anastomotic site (Fig. ). The surface of the tum"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old female patient with well-controlled type 1 diabetes mellites (HbA1C 6.7) presented to a private clinic with a massive abscess on the back area. The cause of the abscess was unknown, but a private surgeon incised it at multiple sites and drained the content. The patient was supposed to take care of the wound dressings herself, but she and her family were overwhelmed by the copious amount of odorous exudate and needed professional wound care. After three weeks of irrigating the wound with saline and using regular gauzes, the patient presented to the wound clinic for help. At the first visitation (a, Day 0), the patient had a low-grade fever, was not feeling well with nausea and dizziness, and had severe pain on the whole back (score of 8 out of 10 on a visual analog scale []). She stated that she is depressed, anxious, and stressed, afraid of losing her life. The abscess covers the area of the whole trapezius and part of the latissimus dorsi on the left side of the trunk and upper part of the right trapezius, and wounds are subcutaneously connected. Infection and inflammation were present with a heavy odorous purulent exudate. The tissue was necrotic with the presence of slough and some granulation visible at the base of the wound after irrigation with the edges of the wound rolled and indented. Because of the severity of the infection, a swab was taken to identify the bacterial origin of the infection.\nIrrigation of the wound was performed with a saline solution via a tube adapted to a syringe. Subsequently, wound cavities were filled with L-Mesitran Soft and covered with regular nonadhesive, superabsorbent dressings. After two days, odor and exudate levels decreased. Laboratory results confirmed the presence of multiresistant Staphylococcus aureus (resistant to clindamycin, erythromycin, fusidic acid, and penicillin) and nonresistant Pseudomonas aeruginosa, and because of the uncertain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a 7 year old boy who was referred to the Cardiac Center in Addis Ababa with dyspnea on moderate exertion and palpitations of about 2 years duration. The child was found to have a cardiac murmur at the age of about 2 years but was not subjected to echocardiography due to lack of skill and equipment in his locality. He was not on any medication at the time of presentation.\nOn physical examination, he appeared to be well-grown and healthy-appearing boy with a weight of 39 kg, height of 132 cm and body mass index of 22.4. His blood pressure was 127/55 mmHg and his pulse rate was 84 bpm. His oxygen saturation was 88% on room air. There was no remarkable cyanosis or clubbing of the fingers. Peripheral pulses were palpable. He had a parasternal lift, systolic thrill and a 4/6 ejection systolic murmur, best heard over the left 2nd intercostal space and a pansystolic murmur of grade 3/6 intensity, best heard over the left lower sternal border. There was no hepatomegaly or peripheral edema.\nHis chest X – ray showed marked cardiac enlargement with clearly decreased pulmonary vascular markings. The electrocardiogram showed sinus rhythm with a rate of 88 beats per minute, incomplete right bundle branch block, right ventricular hypertrophy, right atrial enlargement and right axis deviation. Echocardiographic examination showed normal abdominal and atrial situs, with normal position of the heart in the left chest and normal venoatrial, atrioventricular and ventriculoarterial relationships. The right ventricle looked markedly dilated and hypertrophied. The right atrium looked dilated. Right ventricular systolic function appeared grossly reduced on visual inspection and Tricuspid Annular Plane Systolic Excursion (TAPSE). There was a patent foramen ovale with right to left flow by color Doppler. The interventricular septum appeared intact. The mitral and aortic valves were structurally normal. The tricuspid valve looked thickened. The pulmonary valve was thickened"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-yr-old woman presented with colicky lower abdominal pain. Her abdominal pain had developed 3 yr before intermittently, but it had worsened over the past 6 months. She was unable to sleep well due to her abdominal pain, which aggravated after eating meals. She also experienced episodes of abdominal distension, constipation, and urinary frequency or urgency. Other symptoms, as well as her past medical history and family history, were otherwise unremarkable.\nThe patient had a height of 164 cm and weight of 59.6 kg, for a body mass index of 22.2. Physical examination revealed a slightly distended abdomen, but the remainder of the examination was unremarkable. Routine blood tests, including renal function and urine analysis, were normal.\nComputed tomography (CT) of the abdomen and pelvis revealed a homogenous fatty mass in the lower abdominal cavity (). The entire small bowel loop was displaced upward by the mass, and one segment of the ileal loop was slightly straightened by entrapment of the bowel. Small bowel series revealed ileal loop entrapped in fatty tissue and associated ileal diverticula ().\nLaparoscopic surgical resection was recommended because of her symptoms. The laparoscopic surgery showed an encapsulated, yellowish mass originating from the ileal mesentery in the lower abdominal cavity. The mass extended to the antimesenteric border of the small bowel and was free of any adhesions or signs of necrosis. Some segment of the ileum appeared to be \"stretched\" over the fatty mesenteric mass with edema, however, its luminal patency was preserved in spite of luminal narrowing by compression. Lymphadenopathy or fluid collection was not observed. Surgical removal of the fatty mass and the affected ileal loop was performed without difficulty under a laparoscopic magnified view. The resected mesenteric mass was a soft, yellow mass and 19×10×5.1 cm in size (). Microscopically, the mass was characterized by homogenous mature adipose tissue without cellular atypia,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman presented with sudden headache, transcortical sensory aphasia and mild right sided weakness. Initial computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed an acute hemodynamic cerebral infarction of the left frontal and parietal lobes and a focal severe stenosis of the proximal left ICA. Echocardiography showed no evidence of abnormalities of the cardiac valves or of left ventricular dysfunction. Three days after admission, cerebral angiography showed a focal severe stenosis (75%) of the proximal left ICA without abnormal findings in either common carotid artery (). However, six days after admission, fever (40℃) suddenly developed with NIH Stroke Scale (NIHSS) score deteriorating from 4 to 10, due to additional aphasia and worsened weakness. Three days after the onset of fever, brain MRI showed no newly developed acute lesion, and echocardiography showed a newly visible 6×5 mm valvular vegetation of the non-coronary cusp of the aortic valve (). Blood cultures were positive for Staphylococcus aureus 4 days after the onset of fever as the offending microorganism. Intravenous antibiotic therapy was started immediately with a combination of cefazolin and gentamycin. Seven days after antibiotic therapy, the patient was diagnosed with bacterial meningitis, and cerebrospinal fluid (CSF) analysis revealed a white blood cell count of 240/mm3 (leucocytes, 71%; lymphocytes, 29%), red blood cell count of 2900/mm3, glucose concentration: 50 mg/dL, protein concentration: 216 mg/dL, and pH 8.0. Twenty-six days after admission, chest CT, which was performed with the suspicion of the Lt. pleural effusion as the cause of the fever, showed an incidental 22×20 mm thin walled saccular vascular structure located 2 cm distal to the origin of the left CCA suggesting a mycotic aneurysm because of acute development, presence of ongoing fever and inflammatory infiltration around the saccular vascular structure (). Three days after the chest CT,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old woman with past medical history of hypertension and hyperlipidemia, presented with a right cheek nodule in December 2015. Biopsy result was consistent with ulcerated malignant melanoma, nodular type, Breslow depth of at least 2.7 mm. The nodule was locally resected, pathology results were consistent with extensive residual malignant melanoma, Breslow depth of 6.05 mm with multiple microsatellite metastases present, angiolymphatic invasion was identified and one sentinel lymph node was negative for melanoma (0/1). Melanoma in situ extended to the superior margin and medial and lateral specimen tips, therefore procedure was followed with Mohs surgery which showed no residual disease. Six months later, patient presented with two new nodules on her right cheek below the area of her prior excision. At that time, she was also noted to have right submandibular lymphadenopathy. Excisional biopsy of the nodule and FNA of submandibular lymph node showed recurrent malignant melanoma. Staging CT chest/abdomen/pelvis and brain MRI showed no evidence of distant metastatic disease. Multidisciplinary teams agreed on deferring surgery and proceeding with systemic therapy. Patient was subsequently started on anti-PD-1 therapy with Pembrolizumab at a fixed dose of 200 mg every 3 weeks. Patient continued to show a positive response until fourteen months of therapy when restaging CT scans demonstrated a left upper lobe nodule concerning for metastatic disease. PET scan demonstrated a high SUV uptake of 15, also consistent with metastatic disease. A left lung needle biopsy was subsequently completed which was consistent with metastatic malignant melanoma. Mutational analysis revealed double KIT mutations at V559 and N822I, therefore, Imatinib; a tyrosine kinase inhibitor known as Gleevec, was started at a dose of 400 mg daily. This was given in combination with Pembrolizumab at 200 mg every three weeks. Shortly after, patient developed a pruritic rash on her back and shoul"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy looking, 50-year-old Nepali man came to our clinic with a complaint of multiple growths on his scrotum for 15 years. The growths started as a single lesion on the right side of his scrotum, with the gradual appearance of similar lesions on other parts. Several of these lesions coalesced at various places to form large-sized nodules. The condition was mostly asymptomatic with an occasional complaint of itching. There was no history of pain, burning sensation, trauma, ulceration, or discharge. The lesions did not interfere with urination or sexual activities. He was worried because of the increasing size of the growth and hence came to us for advice. He did not give a history of any systemic illness including metabolic, autoimmune, or malignant disorders. There was also no history of a similar complaint in his family.\nOn physical examination, multiple pink to brown nodules ranging in size from 0.5 × 0.5 × 0.5 cm to 3 × 3 × 1 cm involving almost half of his scrotum were noticed (Fig. ). The skin over the nodules was shiny with several yellowish points indicative of underlying calcium deposition. The skin surrounding the nodules, testis, and penis was normal on palpation. The nodules were painless and firm in consistency. On laboratory examinations the following were found to be within normal limits: serum calcium, phosphorus, parathyroid hormone, and vitamin D hormone levels; uric acid; alkaline phosphatase; and lipid profile. Based on clinical features and laboratory reports, a diagnosis of ICCS was made.\nHe was advised a scrotectomy under spinal anesthesia, which he refused. The nodules were excised under local anesthesia in several sittings. The skin was sutured using chromic catgut (4–0). His postoperative period was unremarkable with good cosmetic result and no evidence of recurrence in a 1-year follow-up period. The cut section of nodules showed solid white to yellow homogenous areas."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old male presented to our department complaining of recurrent epigastric and upper right abdominal pain radiating to the back for the last 3 months. No other complaints were prominent. The patient had undergone an uneventful laparoscopic cholecystectomy 2 years earlier. His family history was consistent with a father who suffered lung malignancy and a mother who expired due to hepatoma.\nAn ultrasound performed prior to his admission revealed a hypoechoic 4 × 4 cm lesion close to the pancreatic head. On admission, abdominal examination revealed a soft, nondistended abdomen with local tenderness in the upper right quadrant. No other findings were noted. His blood tests were all within normal limits. CEA and CA 19-9 were normal. Abdominal tomography revealed a 5 × 5 cm, rounded, soft density lesion adjacent to the root of the superior mesenteric artery (SMA) and pancreatic head (fig. ). It was not possible to distinguish the origin of this lesion.\nThe patient underwent endoscopic ultrasound examination that demonstrated a hypoechoic-heterogeneous solid lesion behind and adjacent to the SMA and superior mesenteric vein. No other pathology was demonstrated in the pancreas itself (fig. ).\nPathology obtained by fine needle aspiration from the lesion revealed fragments of mesenchymal tissue that was positively stained for c-kit and actin. DOG immunohistochemistry was negative. Laparotomy revealed a large, 7-cm, hard tumor adherent to the medial border of the pancreatic uncinate process laterally, to SMA medially, posterior to the portal vein and anterior to the inferior vena cava and left renal vein (fig. ). The lesion was successfully dissected from these structures and was completely excised and removed.\nThe patient was discharged after an uneventful postoperative course. The pathological report revealed leiomyosarcoma stained to actin and desmin. The proliferative index Ki67 was 10%. He received radiotherapy, and at 4 years of follow-up, the patient is healthy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old man was admitted to the hospital for 2 days because of left knee joint pain and limited movement caused by a traffic accident. Physical examination on admission showed that the left knee joint was swollen with local tenderness, but no open wounds were present. The floating patella test was positive, and the muscle strength of the left lower extremity was normal. Preoperative imaging revealed a comminuted fracture of the left patella (), determined to be type 34-C3 according to the AO/OTA classification.\nBefore the operation, both sides of the patella were scanned by computed tomography (CT) with a scanning thickness of 1 mm. The collected CT data were imported into Digital Imaging and Communications in Medicine format, and a 3D model was established by Mimics 19.0 software (Siemens, Berlin, Germany). Next, a mirror-image model of the healthy patella was used as a template to virtually reset the affected patella. This allowed us to further design and print the complete patella and the distal and proximal fractured patellar reduction guide plates with the cartilage surface as the mask. The patella model after virtual resetting and the data for the three corresponding reset guide plates were imported into the 3D printer in stereolithography format, and the model and guide plates were then printed out ().\nThe patient underwent spinal anesthesia and was placed in the supine position, and an anterior median incision was made in the left knee joint. First, the local reduction guide plate of the proximal patella was placed behind the articular surface of the patella, and the large pieces adjacent to the cartilage surface were identified. The proximal patellar reduction guide plate was used for splicing, and a 1-mm fine Kirschner wire was used for temporary fixation in the coronal direction. All bone fragments with the cartilage surface at the proximal end of the patella were assembled together and temporarily fixed with a fine Kirschner wire, allowing the prox"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old obese male, with no medical history, presented in emergency room with a closed trauma of the left knee secondary to a traffic accident. He was hit by a car while biking. The mechanism of the injury was a hyperextension and a valgus stress of the left knee. General examination revealed no other significant injury. On physical examination, the patient was totally unable to step on or move his left lower limb. There was a significant swelling around his left knee with no skin defect. The pulses of the A. poplitea, the Arteria tibialis posterior, and the Arteria dorsalis pedis were well palpable. The capillary filling of the toes was present. No motor or sensitive defect was found. Plain radiographs of the left knee showed a Salter and Harris Type 1 physeal fracture of the distal femur with an important displacement of the metaphyseal fragment (). At that time, in front of the spectacular femoral injury, the diagnosis of a Type 3 slightly displaced physeal fracture of the proximal tibia was missed. The patient was operated in the same day. Under general anesthesia, the patient was placed in supine position with the left lower limb pulled in its axis using a fracture table. After a gentle continuous traction, a downward pressure was applied on the distal epiphysis of the femur with the tight been locked. The reduction was found good when checked using the fluoroscopy. Fixation was done using two crossing 24 mm K-wires. A long leg cast was made. Post-operative radiographs showed a good reduction of the distal femur (). At this time, the tibial injury was diagnosed. The slight displacement of the epiphyseal fragment of distal tibia was accepted. Close physical observation in the first post-operative 24 h found no secondary vascular thrombosis. The cast was kept for 6 weeks. After the same period, healing of the fracture was obtained (), hardware was removed, and full weight bearing was allowed. 2 years"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur second case is a 26-year-old male patient with homozygous sickle cell (HBSS) disease. He also had chronic kidney disease which progressed over 3 to 4 years to end stage renal disease (ESRD) requiring hemodialysis. Patient had frequent presentations for painful crises amounting to 16 ER visits and 82 inpatient days in the preceding year at our institution. His painful crises were notably more frequent since he developed ESRD and were localized in his hips and collar bones.\nMost recent HPLC showed HbA of 81.8%, HbF < 1%, HbA2 of 2.7%, and HbS of 14.5% indicating that patient had recently received multiple blood transfusions. Hemogram showed WBC count of 12, Hb of 7.1 g/dL, and platelet count of 333. Blood chemistry was significant for elevated Ca on multiple occasions with a peak of 11.8 mg/dL. Phosphate was high on multiple occasions with a peak of 9.1 mg/dL. PTH was elevated on multiple occasions with a peak of 4078 pg/mL. Vitamin D levels ranged from 13 to 20 ng/mL. Predialysis blood urea nitrogen ranged from 60 to 80 mg/dL and creatinine ranged from 8 to 10 mg/dL. Patient was treated with cinacalcet for secondary hyperparathyroidism but became refractory to treatment after a period of time with persistently elevated calcium and PTH levels. Based on the above investigations, we reached a diagnosis of tertiary hyperparathyroidism due to ESRD.\nImaging studies were done to localize the parathyroid lesion. Radionuclide parathyroid imaging using technetium sestamibi scan showed slow washout in the right lower thyroid region () but CT scan of the neck with contrast showed moderately enhancing foci inferior to the left and right thyroid lobes and superior to the left thyroid lobe which raised suspicion of parathyroid hyperplasia and warranted exploration of all four parathyroid glands. Plain radiography revealed bony resorption typical of untreated hyperparathyroid bone disease at the greater trochanters of both femoral bones and lateral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male patient presented to the emergency room (ER) on account of a 3-month history of hemoptysis as well as a 2-week history of right upper extremity weakness and numbness.\nHemoptysis was associated with pleuritic right-sided chest pain as well as orthopnea and had been previously treated with two courses of empiric antibiotics and steroids at an outside hospital without improvement prompting his presentation to our emergency room.\nWeakness and numbness of the right upper extremity were initially associated with a painful right palmar rash which was resolved with self-administered topical corticosteroids at home.\nPast medical history was significant for untreated latent tuberculosis (TB) diagnosed about forty years prior to this presentation as well as coronary artery disease requiring stent placement twice in the past.\nOn presentation, the patient was not in acute distress but was tachycardic at 100 beats per minute, with a respiratory rate of 16 cycles per minute and an oxygen saturation of 100 percent on room air. Blood pressure was 144/87 millimeters of mercury, and temperature was 99 degrees Fahrenheit.\nOn physical examination, he was afebrile and had normal breath sounds and heart sounds without murmurs. Neurological examination was notable for reduced sensation to light but not crude touch over the right hand with reduced strength of 4/5 in that in same extremity. Laboratory studies were significant for a white blood cell count of 18,400 per microliter with 76.3 percent neutrophils, an erythrocyte sedimentation rate of 90 millimeters per hour, and a C-reactive protein level of 167 milligrams per liter.\nImaging done on admission revealed multifocal lung opacities () concerning for community-acquired multifocal pneumonia (possibly secondary to a resistant organism as patient had completed courses of cefdinir and levofloxacin at the outside hospital without resolution of his symptoms). Other considerations were for possible septic emboli of undeterm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old woman with one-week-old swelling in the left mandibular angle was admitted to our oral and maxillofacial surgery department with the complaints of recurrent episodes of vertigo and consciousness. The vertigos gradually increased in frequency and intensity since they started one month prior her admission. Physical examination revealed a discrete raised, painless mass occupying the left parotid area witch adhered to underlying soft tissue, extending approximately 2 cm in diameter in the sub- and retromandibular regions. There were no restrictions on the cranial nerves supplying this area. No odontogenic cause or any other inflammatory factors could be responsible for the parotid gland swelling. There was no palpable lymphadenopathy in the left neck. Blood pressure was 115/62 mm Hg and the heart rate was 63 beats per minute. Routine laboratory investigations were normal. 24-hour Holter monitoring revealed several episodes of sinus arrest. Ultrasonography showed a well-defined space-occupying lesion of about 31 mm in length and 17 mm in width, which was hypo echoic and located in the deep lobe of the left parotid gland. The rest of the gland showed a homogeneous parenchyma.\nComputerized tomography (CT) showed a large mass extending into the carotid space and protruding into the parapharyngeal space (Figure ).\nA left parotidectomy was performed. The resected gland was a hard mass, which had spread over the bifurcation of the left carotid artery without invading the vessel wall itself. The tumor was oval-shaped, encapsulated, and partially nodular without any regional lymph gland involvement. Upon opening the mass viscous, white-colored fluid was released (Figure A/B).\nThe pathology report showed a lymphoid tissue with multifocal double-row hypereosinophilic epithelium with retention of thickened secretions in the lumen as well as squamous cell metaplasia consistent with typical parotid gland cystadenolymphoma (Figure A/B).\nThe patient started ambulating fro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-month-old Egyptian female baby was referred to our institution for an evaluation of poor growth. She was the first child of healthy and unrelated Egyptian parents. The pregnancy was normal and there was no history of hyperthermia, hypertension, diabetes or exposure to toxic, traumatic or infectious agents or radiation. Delivery was through Cesarean section, at term. Her birth weight was 2,900 g (10th centile) and her length was 45 cm (third centile). A right cleft lip-palate and limb anomalies were noted at birth. On examination, her length, weight and head circumference were below the third centile; she had delayed motor and mental development and she had the scar of repair of her right cleft lip, which was done at the age of two months. An examination of her mouth revealed the presence of a cleft palate. Her scalp hair was sparse and hypopigmented and her skin was dry and rough. Both hands showed a classic lobster claw deformity: her middle digit was absent and the remaining four fingers were parted, two on either side, the cleft almost dividing the palm into two (Figure ). The second and third toes of both her feet were missing and the remaining three toes were divided by a cleft into two parts, the big toe on one side and the other two toes on the other side (Figure ). Her external genitalia were female. Laboratory tests, including a complete blood count, electrolytes and liver tests and kidney, thyroid, anterior and posterior pituitary functions tests, showed no abnormalities. A chest radiography, abdominal ultrasound, echocardiography, ophthalmologic examination, fundus examination, cerebrospinal fluid pressure and hearing tests were normal. Skeletal X-rays (with the exception of the described limb anomalies) were all normal. Her karyotype was 46, XX and a genetic study demonstrated no mutations in any of the coding regions of TP63. In addition, no chromosomal abnormalities have been identified in her parents."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79 year-old male was referred to our hospital with pus discharging for one month from an unhealed intraoral wound in the mandibular symphysis area. The panoramic radiograph showed that there was a 4 x 3 cm size radiolucent lesion over the mandibular symphysis with an irregular border (Fig. ). There was no palpable lymphadenopathy over the bilateral neck area during the physical examination. The patient had a history of NPC one year previously, and had received a complete radiation therapy course (total dose of 6500 Gy), without chemotherapy. A tentative diagnosis of osteomyelitis of the mandible was made. In order to eliminate the possibility of NPC metastasis, a chest radiograph, conventional bone scanning and liver scanning were arranged. The results were negative. CT scanning did not reveal any cervical lymph node involvement in the neck area. Under general anaesthesia, tooth extraction, sequestrectomy and marginal bone resection were performed with a 2 mm safe zone (Fig. ). The tissue specimen was whitish in colour and soft with a granular texture. The wound was marsupialized and an iodoform gauze dressing was placed for 2 weeks. The histopathology report showed an undifferentiated carcinoma with frequent mitoses. In-situ hybridization revealed that the specimen contained Epstein-Barr virus RNA. The ENT department performed a nasopharyngeal examination for the possibility of recurrent NPC and the result was negative. The case was classified as Ho’s stage II, T1N1M1.\nA CT scan was taken one month after the operation. The mandible had healed in the upper border region, but no healing was evident over the lower margin after surgery (Fig. ). The patient was referred for radiotherapy. After the supplemental dose of 50 Gy, further lesion expansion was stopped and early bone formation in the inferior lingual aspect of the lesion was noted in the following CT scan (Fig. ). The remaining apparent discontinuity of the bone in the grafted area most probably represents in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.\nFive years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good pos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old male was referred to our hospital in May 2010 with a two-month history of diffuse abdominal pain and intermittent rectal bleeding. He also reported low-grade fever in the evenings. No weight loss or other symptoms were noted. His previous medical history was unremarkable except for hypertension and type 2 diabetes. On physical examination, the patient had a good general status and was not septic. A painful, poorly defined, and nontender mass was noted in the right hypochondrium; there were no signs of peritoneal irritation. Blood counts, renal and hepatic biochemistry tests, LDH levels, and tumour markers values were all within the normal range. Only the fibrinogen level and the C-reactive protein were elevated (841 mg/dL and 209.1 mg/L, resp.).\nA full-body CT scan revealed a heterogeneous, well-circumscribed mass in the right abdominal loin that seemed to originate from the hepatic flexure colon and descended towards the anterosuperior iliac spine (). The mass displaced the right kidney and appeared to infiltrate the anterior renal capsule. There were air bubbles in the interior of the tumour. There were no other imaging abnormalities. The colonoscopy revealed in the transverse colon, near the hepatic flexure, both an extrinsic compression of the colonic lumen and more proximally an intraluminal tumour that occupied the whole of the circumference and did not allow the further passage of the colonoscope. Biopsies of the mass, however, revealed only necrosis but no malignant cells.\nAn exploratory laparotomy was performed in May 2010. A right colonic mass was seen that occupied the whole right abdominal flank and infiltrated the distal ileum. There was a small quantity of ascitic fluid. The right kidney was not infiltrated. An extended right hemicolectomy with a distal ileal resection was performed. The postoperative course was uneventful and the patient was quickly discharged.\nThe pathologic analysis showed a poorly delimitated 14 × 13 cm tumoural mass,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old Korean man visited the clinic at Kosin University Gospel Hospital for the management of a palpable abdominal mass. Upon presentation at the clinic, he was otherwise healthy. His carcinoembryonic antigen level was 4.65 ng/mL (reference value, <5.0), and the results of a complete blood count, plasma electrolyte analysis, coagulation analysis, kidney and liver function tests, and urinalysis were normal. A physical examination revealed no other significant findings. Abdominal CT showed a large irregular mass at the transverse colon, which had extended to and invaded the duodenum to form a fistula (). A colonoscopic examination revealed poorly circumscribed infiltrating masses with ulceration in the transverse colon (). The mass occupied nearly the entire lumen, which the colonoscope could not access. An upper endoscopic examination revealed a 2-cm fistula tract covered with yellowish exudate (). A multidisciplinary team decided to treat this patient with pre-operative CRT and subsequent surgery. The chemotherapy regimen was FOLFOX4, and radiation treatment was administered at a total dose of 3,000 cGy divided into 10 fractions (5 times per week). After the completion of chemotherapy and radiation treatment, an abdominal CT and upper endoscopic examination were performed to assess resectability. Abdominal CT revealed that the enhancing lobulated mass in the transverse colon had decreased in size and that the invasion of the adjacent anterior abdominal wall and duodenum had also improved (). The upper endoscopic examination showed that a whitish scar had replaced the fistula opening, which was now closed (). The patient suddenly developed abdominal pain while waiting for the scheduled operation, and chest X-ray revealed free air. The patient then underwent an emergency operation; our surgical team, which was aware of his disease status, confirmed that the perforation had occurred in the cancer lesion and performed a transverse colon segmental resection. Hist"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female repeatedly presented to our hospital with a cough for 3 months. No other symptoms were associated with the cough. The findings during the physical examination were unremarkable except that her Body Mass Index was 28.5. Contrast-enhanced computed tomography imaging of her chest revealed a posterior superior mediastinal lesion with an area of approximately 2.7 × 1.3 cm () and a value of approximately 122 HU. The mediastinal lesion manifested as an intensely enhancing mass with a circumscribed and well-defined margin. A bronchoscopy showed that the membranous trachea was raised, a mass oppressing the membranous region of the trachea from the posterior mediastinum. No pedunculated or polypoid tumor was in the trachea lumen.\nA surgical excision was performed using a right thoracoscopy. This procedure revealed a well-circumscribed vascular lesion that was located above the carina and behind the trachea that measured 1.5 cm in length and was highly vascularized. Additionally, the tumor closely adhered to the membranes of the trachea. During the process of tumor resection, to decrease tension, we emptied the balloon of an endotracheal tube with the assistance of anesthetist. After the lesion was resected, the endotracheal tube cuff was inflated and extruded into the chest. Regretfully, we ruptured the membranes in the trachea, which resulted in a longitudinal tear that was approximately 0.8 cm in length. This tear was sutured with interrupted stitches using 4-0 Prolene sutures and a pad of pleura. It was further reinforced with a pedicled pleural flap to avoid small amounts of air from leaking from the suture line (). There was no air leakage when an airway inflation pressure of 20 cm of H2O was applied. The patient experienced an uneventful recovery and no postoperative complications and was discharged home on the 16th postoperative day. Fiberoptic bronchoscopy was performed 1 week, 3 months after surgery. No incidence of tracheostenosis occurred."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male presents with a 5-week history of nausea, vomiting, and abdominal pain. Past medical history is significant for stage IV transitional cell cancer with angiolymphatic invasion treated with neo-adjuvant chemotherapy and radiation followed by radical cystectomy with ileal conduit formation and bilateral pelvic lymphadenectomy. He had also undergone a diverting sigmoid colostomy for rectal outlet obstructive symptoms from metastases to the rectum. Subsequent surveillance imaging and colonoscopies were negative for any recurrence as recent as nine months prior to the current symptoms.\nFor the abdominal pain, patient was evaluated with CT of the abdomen and pelvis which revealed new circumferential thickening and inflammatory stranding involving the ascending colon extending to the hepatic flexure as well as the descending/transverse duodenal junction with adjacent inflammatory stranding (Figs. and ). Diffuse intra- and extra-hepatic biliary ductal and main pancreatic duct dilatation (double duct sign) was noted as well. Transaminases and bilirubin were initially normal.\nMagnetic resonance imaging (MRI) of the abdomen was pursued to further investigate the double duct sign, which did not reveal choledocholithiasis or pancreaticobiliary malignancy. The dilated biliary tree was suspected to be secondary to thickened descending duodenum. This thickening was abutting the hepatic flexure. Additional findings included hydroureteronephrosis on the right with a focally enhancing soft tissue mass (Fig. ).\nUpper endoscopy for evaluation of gastric outlet obstruction demonstrated duodenal stenosis with significant edema and congestion without an obvious ulcer (Fig. ). The stenosis could be traversed only with an ultrathin endoscope but biopsies were nondiagnostic. Based on the MR imaging findings, endoscopic evaluation of the colon was pursued in hope of getting a better yield for diagnosis. Colonoscopy demonstrated a mass at the hepatic flexure (Fig. ). Biopsies"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male, height 172 cm and weight 75 kg, was referred to our institution after having been seen 3 months previously due to worsening lower back pain which radiated to the left buttock and thigh as well as claudication that had lasted three months. His lower back pain had been treated with caudal blocks for the last 3 years. A lumbar spine radiograph revealed degenerative scoliosis and narrowing of multiple intervertebral disc spaces. A magnetic resonance imaging (MRI) scan demonstrated marked lumbar 3-4 (L3-4) intervertebral disc extrusion, lumbar spinal stenosis, and an L3 compression fracture. He was treated with one L3-4 epidural block, medial branch blocks, and received nonsteroidal anti-inflammatory drugs. His radicular pain and claudication improved, but he complained of low back pain consistently. Therefore, a transforaminal epidural block and percutaneous epidural neuroplasty were performed. After the treatments, all symptoms improved, and only mild lower back pain which increased with walking remained. However, 2 weeks later, he was hospitalized for left leg paralysis and excruciating lower back pain that did not diminish when laying down. MRI was repeated, which identified aggravated L3-4 disc extrusion and a dilatated abdominal aortic aneurysm of nearly 6.0 cm (). Careful review of the previous MR images identified a curvilinear atherosclerotic (calcified) lateral wall of an abdominal aortic aneurysm and fusiform aneurysmal dilation of the abdominal aorta anterior to the vertebral body (). The patient was referred to the neurosurgery department of our hospital for further examination and treatment for the disc extrusion and abdominal aortic aneurysm.\nHe presented to our hospital with intractable lower back pain and pitting edema of both lower extremities. His blood pressure was 110-130/79-90 mmHg and his pulse rate was 70-80 min. Abdominal contrast enhanced computed tomography (CT) confirmed a focal lower abdominal aortic aneurysm with crescent"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-month-old baby Ibibio tribe girl was referred in August 2019 to our Radiology Department, UUTH, Uyo, Nigeria from the Orthopedic Unit for plain radiography of her lower limbs; this was on account of her short left lower limb noticed from birth. Her parents said that her left lower limb was getting progressively shorter but she had no other abnormalities. Antenatal history, past medical history, and family history were not remarkable. There was no history of trauma to the mother during pregnancy or perinatal exposure to radiation. Developmental milestones had been normal so far.\nOn physical examination, she appeared otherwise normal and well nourished. Both her lower limbs were actively mobile. Her left lower limb was shortened and in external rotation (see Fig. ). Her right lower limb measured 27 cm from the anterior superior iliac spine to the tip of medial malleolus, whereas her left lower limb measured 23 cm on similar landmarks. Normal range of motion of both knee joints and hip joints were observed. Hip abduction was full and back examination was normal. Her upper limbs showed no anomaly with full range of movement. Aside from umbilical hernia, no other congenital abnormalities were seen on abdominopelvic ultrasonography. A diagnosis of PFFD was made and she was referred for radiographic examinations.\nPlain radiographs of her thigh and lower limbs showed shortened and hypoplastic left femur with preserved left femoral capital epiphysis. Her left femur had normal configuration but had a shorter shaft than the contralateral femur. The shaft of her left femur measured 9.41 cm whereas the shaft of her right femur measured 11.88 cm (see Fig. ).\nOn receipt of the radiographs, the possible plans of management were discussed with her parents. Unfortunately, they have not kept any further appointments. Recent telephone communications in December 2019 with the parents revealed that the child has been left to her fate. This is because of the parents’ belief of spontan"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male patient presented to us in June 2011 with a deformity of the back, weakness of both lower limbs, and with a history of multiple surgeries on the back. At three years of age, spontaneous disappearance of the right clavicle and upper humerus was noticed without any preceding trauma. Biopsy was taken from the lesion and diagnosis of Gorham's disease was made based on the histopathological examination of the tissue. The disease was subsequently not progressive. In May 2010, he noticed progressive deformity of the upper back, spasticity, and an altered gait. He was diagnosed with myelopathy and kyphotic deformity of the spine. On August ninth 2010 he pedicle screw instrumentation with decompression of the cord. The patient experienced an uneventful post-op period. His spasticity reduced and his gait improved over a period of two months and he was then able to walk normally. On May 25th 2011, a routine follow up X-ray showed breaking of the implant for which a revision surgery was performed the same day. Post-surgically, the patient developed complete weakness of both lower limbs with loss of bladder and bowel control. He was taken for immediate decompression. As the patient's neurology did not improve, a revision decompression was performed on 3 days later. The patient noticed the return of some movement in his right lower limb a few days after surgery. His bladder control returned one month later. He was referred to us for rehabilitation (, ).\nOn examination, the patient showed dyspnoea, tachypnoea, and paradoxical breathing. Neurological examination revealed complete absence of motor power on the left lower limb and the power in the right lower limb was 1-2/5. Sensation was decreased from T5 below. Deep tendon reflexes were exaggerated with ankle clonus and extensor plantars. A loss of the rounded contour was observed on the right shoulder with painless exaggerated passive movements. A chest X-ray revealed pleural effusion on the left side. Chylous l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old male visited an otorhinolaryngologist with a chief complaint of bilateral hearing loss since July 2019, which was gradual in onset. In November 2019, the treating otorhinolaryngologist after managing conservatively and reporting no relief in symptoms referred the case to the medical oncology department of a private hospital in New Delhi. On examination by a medical oncologist, the patient reported the loss of hearing and pain. He complained of pain over the preauricular region, which was described as dull, aching, and bilateral. Pain which used to be on and off and started as mild but gradually increased on rare occasions which got relieved by taking tablet tramadol 50 mg. At the clinic, the patient got investigated, and one small growth was found at the posterior nasopharyngeal wall which was confirmed to be NPC on biopsy. PET scan report shows that the disease is confined to its anatomical site of origin and is not metastasized yet. He was given six cycles of chemotherapy (CT) over a span of 9 weeks. He responded to the treatment and planned for further therapies. Then, the patient was given concurrent chemoradiation. The patient got the last radiotherapy on April 10 and chemotherapy on April 8.\nOne week later, he developed a low-grade fever which was considered as a complication of chemotherapy. However, when fever continued, he was suspected of corona infection, so he was sent to the COVID-19 testing center where he came negative. Then, the patient developed urinary retention the next day and found to have some growth in urinary bladder and bladder was overflowing according to CT scan. Urinary catheterization tried but failed, so the patient was planned for suprapubic catheterization. Before the procedure, he was again tested for COVID-19, and the report came out to be positive. Plan for suprapubic catheterization was changed and urinary catheterization tried which was successful this time with smaller size catheter (10 F). Then, the patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old morbidly obese African American, gravida 1, para 0 female presented during the first trimester of her pregnancy with swelling in the right jaw and loosening of teeth. The patient also complained of localized pain but denied fever, weight loss, and other constitutional symptoms. On examination, there was a tender swelling of the right mandible. A biopsy was performed that showed mixed inflammation with numerous foamy histiocytes suggestive of Rosai-Dorfman disease. A CT scan was subsequently performed to delineate the extent of the disease to rule out nodal disease and other possible areas of involvement. The CT scan demonstrated a lytic lesion involving much of the body of the right side of the mandible, extending into the mentum of the mandible and crossing the midline into the anterior aspect of the left body of the mandible (). The lesion showed avid radiotracer uptake on scintigraphy (). Needle core biopsies were performed of the suspicious lymph nodes, which on histopathologic evaluation showed reactive hyperplasia. The patient subsequently underwent a segmental mandibulectomy.\nThe gross specimen received in pathology consisted of a 14.0 cm segment of the mandible with teeth number 19-27 and 31-32 (). Teeth 17-18 and 28-30 had been removed previously. The mandible was markedly asymmetric with an enlarged and bulging right lateral portion. Sectioning revealed a gray, soft, focally cystic mass involving two-thirds of the resected segment of the bone. Histologic evaluation showed a locally destructive lesion composed of numerous foamy histiocytes, admixed with lymphocytes, neutrophils, and scattered eosinophils and plasma cells infiltrating into the peri-mandibular soft tissue ().\nSome of the histiocytes also demonstrated emperipolesis (). Immunohistochemical stains showed the histiocytes to be positive for CD68 and S100 while negative for CD1a (). The morphology and immunohistochemical profile were consistent with Rosai-Dorfman disease. The concomit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasci"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 16-year-old male without a significant past medical history who was transferred to our institution after a gunshot injury to the right lower extremity. On physical examination, two bullet entry points were evident at the right popliteal fossa and dorsal soft tissues of the distal right leg. Initial radiographs were negative for fractures or dislocation.\nComputed tomography angiography (CTA) demonstrated a retained bullet fragment within the popliteal fossa abutting the dorsal aspect of the popliteal artery. An 8 millimeter (mm) soft tissue density abutting the medial aspect of the popliteal artery was also identified, concerning for either a small pseudoaneurysm or short segment intramural hematoma. Streak artifact from the retained bullet precluded adequate assessment of this region. The peroneal artery demonstrated a 10 centimeter (cm) occlusion 2.5 cm distal to its origin but reconstituted distally at the level of the mid-tibia. The anterior and posterior tibial arteries were both normal in appearance and patent. The dorsalis pedis artery was unremarkable. There was subcutaneous emphysema throughout the deep and superficial posterior compartment of the knee and throughout the medial aspect of the leg.\nThe patient was taken to the interventional radiology suite and a right lower extremity diagnostic runoff angiogram was performed. Initial images obtained with the patient’s leg held in extension demonstrated abrupt cutoff of the popliteal artery immediately adjacent to the bullet fragment (Figure ). We then proceeded to reposition the patient’s right leg in the “frog-leg position”. A second diagnostic runoff angiogram was then performed demonstrating mild short segment narrowing of the popliteal artery immediately adjacent to the bullet fragment but with reconstitution of flow down to the level of the tibial-peroneal trunk (Figure ). The anterior and posterior tibial arteries demonstrated patency on both the extension and frog-leg positions. It was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old Korean man visited us with large, infiltrated plaques on his right temporal scalp and soft cystic masses on the ear. The lesions had been present since birth and grew slowly over time. Dermatologic examination showed large, brownish infiltrated plaques studded with numerous follicular comedo-like openings and multiple, various-sized subcutaneous cystic masses on the right temporal scalp and ear (). Mature hairs were barely seen on the lesional scalp. The lesions occurred on the right temporal scalp and ear only, and no other cutaneous lesion was observed in the whole body, including the face, trunk, extremities, and oral mucosa. He had no specific history and familial history of tuberous sclerosis. Moreover, laboratorytests including complete blood count, blood chemistry analysis, and urine analysis showed no other abnormality. He underwent incisional biopsy of a subcutaneous cystic mass on his right temporal scalp under the impression of nevus sebaceous (). The incisional biopsy specimen showed variable-sized multifocal cysts packed with keratin and lined by an infundibular epithelium, comedones plugged with keratin, and sebum in the papillomatous epidermis. The amount and thickness of hyalinized, eosinophilic collagen bundles in the papillary dermis had increased markedly and extended into the subcutaneous fat tissues as fibrous stands. Mature sebaceous glands and hair follicles surrounded by variable concentric fibrosis were observed in the mid dermis. Concentric fibrosis as well as perifollicular fibrosis also involved the small and medium vessels (). Masson's trichrome staining confirmed the increased collagen bundles and the variable concentric fibrosis of hair follicles and other skin appendages (). These characteristic histopathologic findings were not consistent with collagen nevus, nevus sebaceous, and other well-known diseases; thus, we concluded a diagnosis of folliculocystic and collagen hamartoma, on the basis of a literature search revea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 48-year-old male and had a body weight of 95 kg. He was admitted to the hospital on August 31, 2019 for memory impairment and nonspecific dizziness that persisted for 4 months.\nThe preoperative laboratory results were normal, and the chest computed tomography (CT) scan showed no evidence of a pathology. Upon examination, the patient was found to be a little drowsy but was able to obey commands. His vital signs at the time of admission were as follows: blood pressure of 104/66 mmHg, pulse rate of 97 beats per minute, respiratory rate of 24 breaths per minute, and temperature of 36.7°C. His Glasgow coma scale score was 15/15. His vital signs were all within normal ranges. The rest of the neurological and respiratory examination findings were found to be unremarkable. A CT scan of the head showed an intraventricular mass attached to the anterior third of the septum pellucidum and Monro's foramen and enlargement of the left lateral ventricles (Figure ). A magnetic resonance image confirmed an intraventricular cystic tumor 1.9 cm in diameter without enhancement with gadolinium (Figure ). Furthermore, active left lateral ventricle hydrocephalus was present. A colloid cyst was considered the primary diagnosis.\nWith the patient in the supine position and the head turned 10 to 15 degrees to the opposite side, a curvilinear skin incision that was 12 cm long was made around Kocher's point, which was located 1 cm in front of the palpated coronal suture and 3 cm from the midline (along the midpupillary line). A craniotomy that was 5 cm long and 4 cm wide was performed to expose the main part of the middle frontal gyrus. After the cortical surface was coagulated, a soft catheter (Medtronic, Minneapolis, Minnesota, USA, #27703 or 26026) was used for the initial accurate ventricular entry. The catheter was aimed at the ipsilateral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe case concerns a 16-year-old female patient with single ventricle, pulmonary atresia and malposed great arteries after the Hemi-Fontan procedure and aortic valve homograft implantation between the right atrium and right pulmonary artery. The homograft was closed interventionally, while the left lung was separated and supplied by a Blalock Taussig shunt at the age of 7 years []. Nine years later, this shunt became occluded and the left lung was supplied by collaterals only. The shunt was replaced by an 8 mm Gore-Tex tube graft. After an initial increase in the oxygen saturation from 60% to mid 70%, she developed massive left sided pleural effusions with haemodynamic compromise. It was clear that the left sided shunt was too large. So far the only therapeutic option for patients with pulmonary overcirculation due to an inadequate shunt size has been surgery. However, a seventh surgical intervention was much too risky and undesirable for the patient. The decision was made to place several bare stents into the shunt in order to reduce the internal graft lumen. The procedure was performed under general anaesthesia. An initial angiography confirmed a large 8 mm left shunt (). The shunt was crossed with the JR catheter and Terumo glide wire from the right femoral artery. Then the Cook extra-stiff wire and over it the Mullins long 7 Fr sheath were advanced into the left pulmonary artery. Four Genesis XD stents (Johnson & Johnson, NJ, USA; two 10 mm × 25 mm and two 10 mm × 29 mm) mounted on Opta Pro balloons (Cordis, NJ, USA) were implanted into the Gore-Tex tube one over another. Control angiography confirmed the proper position of the devices (). The day after the procedure oxygen saturation rose from 45% to 60% (with no additional oxygen supply) and transthoracic echocardiogram (TTE) showed an increase in the peak gradient across the shunt from 10"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old female with symptomatic paroxysmal atrial fibrillation (PAF), statuspost atrial fibrillation ablation, and prior history of breast cancer, statuspost bilateral mastectomy and left lymphadenectomy, presented with diziness and near syncope and was found to have sinus bradycardia. Given her symptomatic sick sinus syndrome (SSS), she was planned for a dual chamber pacemaker implantation.\nThe placement of a dual chamber pacemaker insertion was attempted from the right side as the patient previously underwent left-sided lymphadenectomy. The right subclavian vein access was obtained and cannulated under fluoroscopy. The right ventricular (RV) lead was advanced attempting to access the right superior vena cava (SVC). While attempting to advance the lead, resistance was encountered and the lead was withdrawn. A venogram was performed revealing the absence of a right SVC with the presence of a persistent left superior vena cava draining into a massively dilated coronary sinus (Figures and ).\nThe lead could not be advanced into the right ventricle, and as a result, the procedure was aborted and cardiothoracic surgery was consulted for possible epicardial lead placement.\nAfter discussing the potential need for cardiothoracic surgery with the patient, she considered another attempt at transvenous placement of a dual chamber pacemaker with us. After repeated attempts, left subclavian vein access could not be obtained. The venogram revealed stenosis of the left subclavian vein. The decision was made to make an additional attempt from the right subclavian vein utilizing the previous pocket. After successful cannulation of the right subclavian vein, an active fixation lead was advanced through the subclavian vein into the PLSVC through the coronary sinus and then through the tricuspid valve into the right ventricular septum. Following successful right ventricular lead placement, an active fixation bipolar pacing lead was advanced into the right atrium using a straight"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old man with a history of rectal bleeding for the previous one month was referred to our clinic. He presented bright blood which was not mixed with the stool. The patient who was otherwise healthy, had no previous history of urologic intervention. Digital rectal examination found a firm, round solid submucosa nodule in the anterior rectum, it was 1cm in size and 5cm above the anal verge. After administration, systemic examination showed normal results with normal level of serum cancer embryo antigen (CEA 2.38 ng/ml) and prostate specific antigen (free PSA 0.8 ng/ml, total PSA 2.38 ng/ml). Colonoscopy confirmed the nodule was 1cm in diameter and in the anterior rectum 5cm above the anal verge with an otherwise normal look of the surface rectal mucosa (). Magnetic resonance imaging (MRI) demonstrated a well-circumscribed and submucosa nodule measuring 1cm in diameter at the level of 5cm above the anal verge protrude to the rectal lumen (), with relatively low intensity on T1-weighted images and high intensity on T2-weighted images, however it was enhanced on the contrast imaging. The border between the nodule and the prostate was clear. After the diagnosis for a nodule in the submucosa rectum was made with the clinically suspicious of carcinoid tumor, local excision of the nodule en bloc with 5mm normal mucosa around the nodule and some superficial muscularispropriawas performed.\nDuring the procedure a well-encapsulated round nodule was found in the submucosa. The nodule was 1cm in diameter, and could be separated from the surrounding submucosa tissue. Postoperative days were uneventful, and the patient was discharged on the second postoperative day. Under the microscope, the histologic sections revealed a well-encapsulated nodule of dilated glandular structures. The nodule was full of dilated glandular structures which was located between the severe burnt rectal mucosa and muscularispropria. The dilated glandular structures were surrounded by a dense fib"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70 year old woman with a history of B-Cell Chronic Lymphocytic Leukemia (B-CLL) presented with a several week history of progressive right upper extremity weakness and increasing confusion. She had no prior history of cardiac surgery or cardiac abnormalities. Pertinent physical exam findings included a normal cardiac exam and 3/5 strength in the right arm. She was afebrile and her white cell count was at her baseline but markedly elevated (> 170 × 103/μL).\nThe initial workup was focused on the patient’s neurologic complaints. A brain MRI revealed multiple bilateral rim-enhancing brain lesions with surrounding vasogenic edema. The differential diagnosis included embolic or metastatic lesions, with a high suspicion for metastatic disease given the patient’s presentation and history. Workup for primary malignancy was negative, and the patient subsequently underwent a right craniotomy for biopsy. The resected lesion was found contain necrotic tissue with branching fungal hyphae suggestive of Aspergillus. Tissue cultures revealed Aspergillus Fumigatus species. IV Voraconazole (6 mg/kg every 12 h day 1 then 4 mg/kg every 12 h) and Micafungin (100 mg daily) were started. The Galactomannan assay was positive but all blood cultures were negative. A 2D echocardiogram was performed to evaluate for possible embolic source for the brain abscesses. This revealed a 1.3 × 1.1 cm pedunculated mass in the inferior wall of the left ventricle (Fig. ). There was no evidence of any cardiac dysfunction and the LV ejection fraction was measured at 55%. Cardiac surgery was consulted and the patient underwent median sternotomy with cardiopulmonary bypass for removal of the left ventricular mass using a left atriotomy incision. The mitral valve was first inspected through the atriotomy incision and demonstrated no vegetations. Subsequently, a retractor was placed through the mitral valve and the left ventricular mass was easily identified. A 1 cm soft, smooth appearing mass was found adhere"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old male with Hepatitis C cirrhosis and hepatocellular carcinoma underwent piggyback orthotopic liver transplantation (OLT). During the immediate postoperative period, the patient had typical recovery with postoperative sonographic interrogation demonstrating expected perioperative edema. Increased velocities were reported near the inferior vena and portal veins which resolved with improving perioperative edema. No additional vascular compromise was identified in the immediate postoperative period.\nThe patient presented 4 weeks following OLT with shortness of breath and was found to have bilateral pleural effusions, recurrent ascites, and acute renal insufficiency. The findings were all assumed to be related to OLT vascular compromise. Thoracentesis and paracentesis (3 liters of ascitic fluid drained) were performed, and the following day ultrasound and Doppler imaging were performed to evaluate the hepatic vasculature. This revealed mild ascites without evidence of hepatic vascular compromise. Clinically, the patient demonstrated no improvement and had additional paracentesis 3 days following admission in which 5 liters of ascitic fluid was drained. On the 10th day following admission, laparoscopic exploration of the abdomen with liver biopsy and lysis of adhesions was performed. The liver biopsy revealed sinusoidal congestion without evidence of hepatic graft rejection or malignancy. On the 13th day following admission, repeat ultrasound with Doppler imaging demonstrated severe stenosis of the intrahepatic vena cava, portal hypertension, and perihepatic ascites. The stenosis was shown to be worse in the supine position.\nThe following day, inferior vena cavagram was performed demonstrating high grade intrahepatic IVC stenosis with extensive collateral flow through the azygous system and thoracolumbar venous plexus ().\nThe pressure gradient across the stenosis measured 11 mm Hg. The stenosis was sequentially dilated with a 12 mm × 40 mm Conquest balloon (C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old woman, G1P0, had a DD (dichorionic-diamniotic) twin pregnancy by in vitro fertilization after 2 years of treatment for primary infertility. She had a history of cervical conization for adenocarcinoma in situ. At 20 weeks of gestation, she visited our hospital with a complaint of abnormal bleeding from her vagina. We found abnormal development of cervical varix by vaginal ultrasound and the bleeding seemed to be caused by varix. We performed vaginal gauze packing for hemostasis and the bleeding was decreased for a week. We performed a cervical pap test at that time and the result was negative for intraepithelial lesion or malignancy (NILM). However, at 21 weeks of gestation, massive bleeding occurred and the amount of bleeding reached almost 800 g. We recommended surgical hemostasis or termination of the pregnancy, but she refused both opinions because of the risks of the surgery, including infection and premature rupture of the membrane, and she wished to have further preservative treatment. Therefore, we added vaginal gauze packing once more and observed her with the administration of blood transfusion. However, the bleeding persisted and the amount of bleeding gradually increased. The total amount of bleeding reached about 2000 g at 22 weeks of gestation. We informed her that the bleeding was becoming life-threatening and that we must perform surgical treatment or termination of the pregnancy. She and her husband finally accepted to try surgical hemostasis by cervical cerclage.\nUnder spinal anesthesia, we detected two bleeding points on the surface of the cervix caused by rupture of cervical varix, the findings of a developed varix by vaginal ultrasound seemed to be match the bleeding points []. We gently held the cervix with the varix using segond uterine forceps and performed the first cerclage by the usual McDonald cerclage method using Teflon tape, enclosing the ruptured points of the varix. However, the bleeding only decreased slightly after the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old woman with diabetes and hypertension presented to our hospital complaining of severe right upper quadrant pain and vomiting. She reported having an elective open cholecystectomy done seven years before and noted that the symptoms she now experienced were similar. She had been hospitalized six times in the preceding two years for similar episodes. Although abdominal ultrasounds were done on these occasions, the emergency room physicians did not entertain the possibility of a stump cholecystitis because the patient insisted that her gallbladder had already been removed. Operative notes were not available but she reported that the operation was uncomplicated and she was discharged 72 hours after open surgery.\nUpper gastrointestinal studies excluded the presence of upper gastrointestinal pathology. Liver function panel and serum amylase levels were normal. Abdominal ultrasound suggested that stones were present in a thick walled gallbladder.\nThe patient's history was revisited on this presentation. She insisted that open cholecystectomy was performed seven years before and there was a surgical scar at the right upper quadrant, but no operative records or histology reports were available to corroborate the surgical history. Once the symptomatology resolved, the patient was discharged with a request for magnetic resonance cholangiography (MRCP) from another institution. This confirmed the presence of a gallbladder remnant with normal biliary anatomy. There was no evidence of choledocholithiasis ().\nShe was prepared for general anaesthesia and taken to the operating theatre for laparoscopic completion cholecystectomy. Laparoscopic shears were used to perform adhesiolysis in order to visualize the structures in the right upper quadrant. There were dense adhesions at gallbladder bed precluding clear visualization of relevant anatomy (). Careful and patient dissection with the cautery hook eventually presented the gallbladder remnant (). The remnant was followed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old male with long-standing hepatitis C virus related cirrhosis, and advanced HCC with portal vein (PV) invasion, diagnosed two months prior to presentation by CT scan and core needle biopsy, was evaluated in the emergency department for dizziness, incoherent speech, agitation, and diaphoresis after completing bowel preparation and fasting for colonoscopy. The patient was initially found to have a blood glucose level of 22 mg/dL, which corrected to normal limits after administration of dextrose. The patient was discharged from the emergency department in stable condition; however on presentation for endoscopy later that day the patient complained of visual changes and was noted to have slurred speech. Blood glucose at that time was 20 mg/dl and the patient was admitted for further evaluation and management of severe hypoglycemia. The patient was treated with continuous dextrose 10% infusion with titration and high carbohydrate diet; however symptomatic fasting hypoglycemia persisted requiring frequent IV dextrose 50% pushes. Insulin level was 0.37 mcIU/mL and the C-peptide level was 0 ng/mL, suggesting a non-islet cell etiology. Surreptitious insulin use was excluded with regular monitoring. His home medications of Tramadol and Lexapro were discontinued on admission due to their potential for hypoglycemia. Adrenal insufficiency was excluded with cortisol stimulation test and a pancreatic protocol CT of the abdomen showed no pancreatic mass. There were no signs or symptoms of sepsis to suggest infectious etiology of this patient's hypoglycemia and infectious workup, including urinalysis, stool culture, and chest X-ray, was negative. Diagnostic paracentesis was not possible due to negligible ascites accumulation. The patient was subsequently started on daily oral prednisolone, with some improvement in the severity of hypoglycemia; however due to frequent episodes of hypoglycemia, continuous dextrose could not be discontinued. A trial of octreotide at 25 mcg/"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old male was admitted to our hospital because of progressive pain and discomfort during swallowing. His past medical history was characterized by surgery for clival giant cell tumor complicated by ICA rupture 10 years ago. Indeed, in 2008, the patient was operated on by a fully endoscopic neuronavigation-guided EEA [, , , , , , , , , , ]. Thanks to the working angle and the better visualization offered by the EEA, we were able to maximize the tumor resection preserving at the same time craniovertebral junction stability and avoiding posterior fixation with his relative complications [, , , , , , , , ]. Indeed, the lesion was completely removed, but during the drilling of the surrounding healthy bone, there was a little tearing of the left ICA. Local control of the bleeding was challenging, but it was obtained by using topic hemostatic agents and balloon catheter for nasal tamponade. Immediately after surgery, the patient underwent angiography disclosing a pseudoaneurysm originating near the inferior meningohypophyseal trunk, which was successfully treated by embolization with coils (Fig. ). After 2 days of intensive care unit stay, the patient was transferred to our department, showing no neurological deficit and no signs of CSF leak or other CSF disturbances [, , ]. The nasal tamponade was removed 4 days after surgery, and no bleeding was observed coming out from the nasal cavity. The patient was dismissed and sent home 1 week later. Histologic evaluation of surgical specimens revealed the aspect of a giant cell tumor with no infiltration of the surrounding bone [].\nRadiation therapy was not performed. Brain magnetic resonance imaging with angiographic sequences was done regularly 3, 6, and 12 months after surgery in the first year and every 6 months for a further 2 years, then annually for a further 5 years. All these examinations showed no tumor recurrence or pseudoaneurysm repermeabilization.\nFor the presence of pain and discomfort during swallowing, t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year old man, who had been a heavy smoker for longer than 30 years, had a remote history of hypertension, hypothyroidism, and repeated surgical procedures (laparotomic surgery for appendicitis at 29, L5-S1 laminectomy at 44 and right hip surgery at 60). At the age of 65 he was diagnosed with a cancer in the sigmoid-rectum (pT3 pN1a adenocarcinoma) and underwent laparoscopic left hemicolectomy. Two days after the intervention, stump dehiscence required further laparotomic surgery. The clinical course was then complicated by bowel obstruction and sclerosing peritonitis which had to be surgically treated 20 and 32 days after the first surgery. During the latter procedure, the microbiological analysis of the surgical wound indicated the presence of a MRSA, and intravenous meropenem 3g/day was started. On day 35 since the first intervention, another surgery was needed because of the development of hemoperitoneum. The patient received repeated transfusions because of the worsening anemia. On day 48 he started developing a renal failure, which eventually required a kidney biopsy leading to the diagnosis of IgA nephropathy. The clinical conditions worsened during the following nine weeks, with fever up to 38.6°C and blood cultural examination positive for MRSA. He was treated with ceftriaxone, and then with methylprednisolon 40mg/day for 3 days. Up to this moment he had never had either neurological or psychiatric symptoms; some days later, however, he became anxious and restless and had a relapse of mild fever. He did not complain of headache and showed psychomotor retardation with preserved orientation and without any significant consciousness impairment. A neurologic consultation indicated an amimic face with bilateral myosis and reduced blinking. A preexisting and already known mild postural tremor was accompanied by almost continuous stereotyped limb movements, generalized weakness and suction-like mouth dyskinesias; no signs of meningeal irritation were found. A"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2008, a 39-year-old man visited Wonkwang Dental Hospital in the city of Daejeon with pain in the anterior region of the mandible originating several months earlier. Intraoral examination revealed a slight gingival swelling and mobility of the mandibular anterior teeth. The past history of the patient was not contributory. There was no cervical or axillary lymphadenopathy. A panoramic radiograph showed an ovoid shaped, unilocular radiolucent lesion with a well-defined margin in the alveolar bone from the left lower lateral incisor to the right lower canine, with involvement of the apices of the mandibular incisors (). An intraoral radiograph revealed that the border of the lesion was non-corticated with beveled edges. The distal part of the right lower lateral incisor showed a typical floating tooth appearance. However, there was no tooth displacement and no root resorption (). The patient underwent root canal treatments of the mandibular left central incisor and right canine for his dental pain (). However, the pain did not subside, and the patient was referred to our department. We suspected an aggressive lesion rather than a cystic lesion due to the non-corticated border and floating tooth appearance. A biopsy of the mandibular anterior lesion was performed, and the patient was diagnosed with eosinophilic granuloma.\nAbout one month later, Cone beam Computed Tomography (CBCT), magnetic resonance (MR) imaging, and whole body bone scintigraphy with a Tc-99m MDP were performed at the dental hospital of Wonkwang University and the medical hospital of Eulgi University in the city of Daejeon. An axial CT showed destruction of the buccal and lingual cortex and a focal bony destructive lesion in the anterior mandible (). An MR image showed a focal high signal intense lesion in the left femur trochanter with adjacent bone marrow edema (). Bone scintigraphy revealed that there was no uptake of radiotracer in the trochanteric portion of the left femur on the initial st"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old male patient reported to the dental clinic with the chief complaint of broken upper left front tooth associated with pain and sensitivity. A detailed history revealed the etiology as a fall from stairs 24 h back. The fractured tooth fragment was retrieved by the patient's mother from the site of injury and was stored in water. Medical history and other events associated with injury were noncontributory. Intraoral clinical examination revealed that maxillary left central incisor had undergone complicated horizontal crown fracture in the cervical one-third []. Palatally, the fracture line was oblique. The fracture fragment was intact, and it was approximating optimally with the remaining tooth structure []. The fragment was transferred to normal saline immediately to prevent dehydration. No mobility was noted in the fractured tooth. An intraoral periapical radiograph was advised to evaluate the extent of the fracture, the root status and to rule out an alveolar bone fracture. The fracture line was passing through the coronal pulp with the open root apex and without any alveolar bone fracture. Electric and thermal pulp testing were performed to evaluate the pulp vitality of all the upper anterior teeth, and the result was negative only on tooth number 21 whereas, all the adjacent teeth displayed a normal response. Hence, the diagnosis was established as Ellis Class III fracture with an open apex.\nA treatment plan was formulated which included apexification with mineral trioxide aggregate (MTA) followed by root canal treatment and either composite build up or reattachment of the fragment using fiber post. Parental informed consent was obtained after explaining the advantages and disadvantages of composite resin build versus reattachment. Since esthetics was the prime concern, fragment reattachment was considered as the best option. The fracture fragment was cleaned and rinsed with 2% chlorhexidine solution and lightly air-dried. Under local anesthesia, roo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-day-old male infant born of full-term normal vaginal delivery was referred to our Tertiary Care Eye Hospital in South India for an eye check-up. The infant was the second born of a third degree consanguineous marriage. There was no family history of anyone born with similar eye and skin problems or cleft lip/palate.\nOn examination, the right eye had a thin band of tissue 1 mm wide and 6 mm long, stretching from the gray line of the medial part of the upper lid and attached to the medial aspect of the lower eyelid inferiorly. The lower eyelid also had notches along its margin, which appeared as freshly de-epithelized lesions []. The band did not restrict the eye from opening []. The palpebral fissure was equally wide bilaterally. Meibomian gland orifices were present. There was no swelling over the lacrimal sac area and no regurgitation of fluid on pressure over the lacrimal sac, suggesting that there was no nasolacrimal duct obstruction. The anterior and posterior segments of the eye were well visualized and did not show any abnormalities. The left eye did not show any band joining the lids, but both upper and lower lid margins showed notching similar to the right eye []. The anterior and posterior segments of the left eye were normal.\nThe infant had multiple patches of hypopigmentation of the skin over all the four limbs [Figs. and ]. The skin over the face, however, appeared normal. There were no skin erosions over the scalp or elsewhere. There was no cleft lip or palate. There were no structural limb abnormalities and no syndactyly. There were no obvious nail lesions. The child was feeding and thriving well.\nAlthough an initial neonatal checkup by the referring doctor did not reveal any systemic abnormalities, the infant was referred to the pediatrician to specifically rule out cardiac, genitourinary, neurological, and odontological abnormalities and advised to review with us. A simple division of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-month-old female child was seen by one of us (SV) in a multi-specialty hospital upon the request of the pediatrician. She was born after a normal full-term vaginal delivery and had no history of consanguinity in her parents. The child was thought to have hemorrhoids with a large hemangioma in the perineal area present since birth. Upon examination the child had a skin-colored perianal protrusion that was clearly located posterior to the anus []. There was in addition a large midline hemangioma that started from the gluteal cleft all the way to the medial root of the thigh skirting around the vulva []. The presence of inflammation around the pyramidal protrusion could not be assessed because of the presence of the large hemangioma. The parents said the child was born with a ‘red patch’ in the area of the hemangioma which evolved over the past 3 months into a hemangiomatous red plaque. The child also had a large hemangioma on the contralateral side of the face with involvement of the lower lip []. There were no neurological complaints. There were also small hemangiomas found on the ventral aspect of the left forearm and dorsum of the left foot. The hemangiomas were explained in detail to the parents and they decided not to give any oral corticosteroid for the perineal hemangiomas and rather wait for a year. A head and neck as well as spine X-ray was performed that did not show any abnormality. CT scan/MRI was refused by patient's parents due to cost factor. A referral was made to the pediatric surgeon for biopsy of the pyramidal lesion which they refused. A provisional diagnosis of large perineal hemangioma with a perianal skin tag was made. The large facial segmental hemangioma was thought to be Sturge-Weber syndrome with no clinical evidence of internal involvement. The patient was prescribed topical clobetasol cream under monthly supervision after which the lesion had flattened a little and showed a whitish area with pronounced flattening."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old male presented to our institution's emergency room with decreased hearing on the right side, ataxia, nausea, and vomiting. On physical examination, an occipital painless subcutaneous mass was noted and audiogram revealed non-serviceable hearing on the right side. A magnetic resonance image (MRI) of brain with contrast demonstrated two separate lesions with similar signal characteristics. A subcutaneous occipital mass measuring 4.8 × 2.9 × 4.1 cm was noted as well as an intradural extraxial 2.6 × 2 × 5.2 cm CP angle mass. There was extension of the CP angle mass into the enlarged jugular foramen and invasion of the internal jugular vein. Both lesions were T1 hyperintense enhancing lesions with a mixed iso and hypointense signal on T2 [Figures and ]. A cerebral angiogram confirmed obstruction of the right sigmoid sinus and jugular vein at the level of the jugular foramen with recanalization distally []. Imaging of the spine by MRI did not reveal other lesions.\nSurgical resection of the two lesions was performed at our institution. The posterior fossa mass was approached through a right translabyrinthine approach and the subcutaneous lesion was resected in the same setting with a separate incision. Electrophysiologic monitoring with cranial nerve monitoring was performed. The extracranial lesion was resected first and did not show any continuity to the intracranial lesion.\nA posterior petrosal translabyrinthine approach was utilized for the intracranial lesion which permitted presigmoid access as well as exposure of the sigmoid sinus and jugular bulb. The dura showed extensive patchy areas of melanocytic coloration over the entirety of the surgical exposure. The intradural lesion was readily visible with invasion of the sigmoid sinus. The sigmoid sinus was opened and found to be occluded with tumor. The sinus was ligated on either side of the tumor invasion and sacrificed. The mass was debulked using a combination of ultrasonic aspiration and suction. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 41-week-gestation male was born to a 30-yr-old mother with good health by normal spontaneous vaginal delivery in November 2009. His birth weight was 3,140 gm. There was no maternal complication during pregnancy. There was neither family history of congenital anomalies nor maternal exposure to drugs during pregnancy. The baby had APGAR scores of 7 and 5 at 1 and 5 min, respectively. He needed positive pressure ventilation with intubation because of progressive respiratory difficulties and hypoxia. The baby was immediately transferred to our hospital for further evaluation and management after stabilization.\nThe physical examination and laboratory findings for the baby were unremarkable on admission. He had the surfactant replacement therapy for acute respiratory failure. For the next few days, we tried extubation several times, but failed to succeed because the baby suffered from recurrent apnea and hypercarbia leading to the clinical suspicious of CCHS. On day 8 of life, a cranial ultrasound study was performed and it did not show evidence of hemorrhage or mass lesions.\nDuring the second day of life, it was noted that the patient had distended abdomen and was unable to pass meconium without rectal stimulation. A gastrografin contrast enema study showed multiple meconium plugs in the colon suggesting meconium plug syndrome (). Meconium was passed and abdominal distension was relieved after contrast study. On day 6 of life, he showed sustained abdominal distension with poor bowel movement. A barium contrast enema study was needed to rule out other causes of lower gastrointestinal obstruction. It showed a transition zone in rectosigmoid colon suggesting HD. The diagnosis was confirmed by rectal suction biopsy with acetylcholinesterase immunohistochemistry (). The infant underwent an open laparotomy on day 12. He was noted to have long segment HD with a transition zone at mid descending colon. Seromuscular biopsies of the bowel taken 3cm proximal and distal to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old woman was referred to our hospital with pancreatic head and neck carcinoma for more evaluations and surgical operation. She had been suffering from abdominal pain for about 1 year, and the pain has become more intense in the last 6 months. The pain was postprandial and localized to the right upper abdomen. She has become icteric with generalized spread plus itching since past 2 months. The patient had no history of alcohol consumption or smoking. The patient was referred to us with a highly probable diagnosis of pancreatic head and neck carcinoma to be consulted for surgery. Also, a plastic stent was implanted for her in the previous health center due to intra- and extrahepatic duct dilation for the relief of patient symptoms and signs. After admission to our hospital, she was evaluated by abdominal computed tomography (CT), endosonographic imaging, and diagnostic ampullary biopsy. The abdominal CT scan with contrast exhibited an 18 mm × 20 mm hypodense mass at the head and neck of the pancreas (). Also, endosonographic imaging was performed to rule out periampullary lesions (). A 20 mm × 19 mm lesion was seen in the pancreatic head and neck region, and the main pancreatic duct was slightly dilated in the body of the pancreas. Moreover, the common bile duct (CBD) was distally thickened and contained sludge. Subsequently, diagnostic biopsy for pathological assessment was done. The biopsy revealed an irregular gray-creamy soft tissue which had undifferentiated malignant tumor features at microscopic evaluations. During the Whipple procedure, after cutting the neck of the pancreas in the left side of the portal vein, the frozen section revealed more involvement of pancreatic tissue. Although additional 2 cm was resected, the pancreas residue still had tumor involvement, macroscopically. Therefore, the patient was undergone total pancreatectomy.\nPostoperative pathological studies were established and indicated a tumor with the greatest dimension of 4 cm wh"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe present case is a 40 year old male patient presented to us with a swelling of the right knee joint of one duration, associated with pain and inability to bear weight on the limb for the past 2 months. He was investigated with radiographs []. The radiographs reveal a geographic pattern of Ludloff’s type 1, with a breach in the posterior cortex. The patient was evaluated for the fitness for anesthesia and for the surgical procedure. We had taken an anteromedial approach to the knee joint. A radical (wide) excision of the tumor was done taking care of avoiding macroscopic spillage of the tumor mass in the operating field. Then the patella was enucleated without disturbing the extensor mechanism of the Quadriceps. Then the ipsilateral Fibula was excised and cut into two struts. The Patella was cut into two fragments. The articular surfaces of the patellar fragments were facing the both condyles of the femur and supported by two Fibular struts vide in []. Thus the joint was reconstructed and the whole construct was stabilized with multiple K wires, a cortical screw and the Quadriceps mechanism was retained by fixing the Patellar tendon to the nearby bone and the limb was immobilized in a plaster of Paris splint. The post op period was uneventful. The plaster was removed after the radiological union was evident and allowed range of movements as much as possible. After a period of one year there was a fracture of lateral Fibular strut which was again re-enforced by one more Fibular strut and followed the same post-op protocol as before. During the follow up period of about 15 years there was good consolidation of the Fibular struts and a reasonably good joint preservation as evident in the post op clinical photographs, video Fig no. & , and the clinical video, vide video no.1r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA six and half year old boy referred to us from another center had complaints of an insidious onset of pain in his right forearm, which initially was less intense. The parents ignored it initially thinking it might be due to his excessive playful nature and cycling. They had a delay of three and half months to consult a doctor in their town when the child complained of an increasing pain. In the meantime, there appeared some swelling in his forearm, which was gradually progressing. A X-ray was done () which revealed an expansile lytic lesion in the proximal half of the radius. He was initially kept under observation and was then referred to a higher center. A repeat X-ray was done, which revealed an expansile lytic lesion involving the proximal half of the radius. On comparing the previous X-rays (), it was seen that the lesion had significantly increased in size with thinning of the cortex rendering it difficult to decide the treatment options. As per the protocol, an MRI was done (–) which revealed low to intermediate signal intensity with a rim of low signal intensity with internal septa. A bone biopsy was done which after radiological correlation was confirmed to be a case of aneurysmal bone cyst.\nThe tumor was expansile with papery thin cortices and hence was not amenable to curettage. It was decided to do wide resection of the tumor. Reconstruction of the radius following tumor resection can be done with different techniques. First to use child’s own fibula may be considered as vascularized or nonvascularized pattern. Second, the cadaveric allograft. Third, an allogenic allograft from the mother. The parents were informed regarding all the options for reconstructing the radius following excision of the tumor. We were a bit concerned with regard to the diameter of child’s own fibula to be used with the radius because of the possible size mismatch as well as the surgical trauma at two sites. The parents were reluctant to use the allograft stored in the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 75-year-old male whom initially presented to our service with a mass on his right upper back. The patient's medical history included coronary artery disease and hyperlipidemia. Further history revealed he had received (2) stents in the past and undergone multiple heart catheterizations (up to seven) approximately seven years prior at an outside facility. During his last catheterization and stent procedure, which took over 4 hours (approx. 33 mSv), he developed a radiation-induced injury to his right back around the T10 dermatome (). During the following years, the burn was closely followed at an outside facility, and the area developed a chronic nonhealing ulcer which continued to evolve over time eventually growing outward from his back and developing a foul odor on his presentation to our facility in 2017. He reported increasing pain at the periphery of the tumor margin. Up to a year prior to presentation, the area was flat and biopsies revealed no evidence of malignancy. Upon presentation to us, however, the physical exam demonstrated a fungating mass approximately 5 × 9 cm with central purulent necrosis and induration surrounding the periphery (Figures –). No additional nodularity or adenopathy was found on physical exam initially. At this time, punch biopsies demonstrated undifferentiated pleomorphic sarcoma along with frankly necrotic debris.\nInitial staging showed only localized disease by MRI with no evidence of metastasis by CT scan (Figures and ). Approximately one month following diagnosis, the patient underwent a radical excision with a 20 × 9 cm elliptical excision of the site. In this case, the patient chose human dermal matrix reconstruction, as primary closure was not possible due to the size of the site. Our patient did not want an additional wound of autologous skin procurement.\nPathology of histologic sections revealed a highly cellular spindle cell neoplasm. Focal areas of necrosis comprised less than 50% of sampled tissu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old Sinhalese male patient presented to our clinic with a complaint of difficulty in swallowing and speaking due to a large growth on the dorsum of his tongue. It had been present from birth and had gradually enlarged over time. Due to the prevailing civil war in the country for over 30 years, he has had limited access to an Oral and Maxillofacial Surgery care during the past years and had been forced to live with this deformity. Though painless, the swelling affected his speech as his articulation was altered. In addition, the lump on his tongue caused difficulty in forming a food bolus and swallowing it, while the bifid tongue affected the cleansing of his mouth. The appearance of the abnormal shape of his tongue had harshly influenced his social life and he was subjected to bullying. He was nonsyndromic, and no other congenital anomalies were detected. On local examination, an asymmetrically bifid tongue involving the left side was noted. A large, firm, pink, nontender tissue mass was seen at the center of the tongue [].\nA lingual thyroid was suspected initially, but the iodine scan showed normal functioning of the thyroid tissue in the anterior neck. Interestingly, iodine was noted to collect in the tongue mass as well, and thereby suggesting salivary/thyroid origin. The patient was otherwise healthy. The treatment plan was the complete removal of the growth and correction of the bifid tongue by closing the primary (or primarily closing it) under general anesthesia []. No intraoperative complications were encountered, and full function of the tongue was preserved. The excised growth was sent for histopathological examination. Two weeks later, the patient was followed up in the speech clinic to assist in speech and swallowing. The histopathology reported that the mass was predominantly mucous salivary tissue. It showed both mixed and mucous lobules, and the histological diagnosis was a salivary hamartoma. The patient had no recurrences at 1-year follow-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male presented to the head and neck clinic with history of a progressive midline lower neck swelling which appeared suddenly, increased in size progressively and became prominent over 6 weeks. On examination, the swelling was about 5 × 2 cm in size, mobile and not adherent to the skin or underlying structures. The swelling was not prominent on tongue protuberance. Thyroid was impalpable and patient was clinically euthyroid with no evident Grave's disease features. It was neither associated with fever nor any other constitutional symptoms. His pressure symptom includes mild dysphagia to solids which compelled him to visit our hospital, but he did not encounter any respiratory complaint.\nPatient was not on any anticoagulants, but he was taking regular medications for diabetes and hypertension for many years.\nFor treatment decision, the patient was referred to radiology department. Ultrasound neck showed a large well defined thin-walled cystic neck lesion measuring about 5.1 × 2.6 cm (transverse x anteroposterior). There was no appreciable internal septation or solid tissue in it (). No hypervascularity was noted within or periphery of the lesion (). The internal content of the cyst was of 2 types, basal part was homogenously low echogenic with curved upper border while rest of the part was filled up with anechoic fluid (). Few tiny echogenic foci were also seen in its low echogenic part which were not giving any comet tail artifact to be confidently called as colloid content (). Thyroid gland was not easily visible due to lateral push by this large cyst. Thyroid isthmus was hardly visible clearly. Lobes were found to be normal, but their echotexture was heterogenous and micronodular with normal vascularity and intact echogenicity. According to the location and content of cyst, the closest sonographic differential in our patient was thyroglossal cyst, but it is usually smaller in size, moves with tongue protrusion and more cranial in position. Other diffe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA four-year-old Japanese girl with no remarkable medical history was referred to our orthopedic clinic for treatment of 2 cm of LLD. She had a two-year history of progressive LM in a wide range of the posteromedial aspect of the right thigh and the medial aspect of the right lower leg. At the first presentation, skin lesions exhibited hyperpigmentation, induration, and xerosis. The range of motion of the right knee was full extension to 80° of flexion. Radiographs of the right lower extremity revealed dysplastic/atrophic femur and tibia. LLD increased with time and reached nearly 10 cm at seven years of age (). As she and her parents refused to undergo epiphysiodesis of the unaffected side of the lower extremity, we performed simultaneous lengthening of the right femur and tibia using a unilateral external fixator (EBI/Zimmer Biomet Carbon Rail Deformity System; Warsaw, Indiana, USA). She had taken low-dose prednisolone every day or every second day prior to the first lengthening procedure. The dosage regimen had been dependent on the disease activity based on clinical and thermographic assessment. Tibial osteotomy was performed with the Gigli saw, whereas femoral osteotomy was done with a multiple drilling technique. No postoperative immobilization was used, and full-weight bearing was encouraged from the second postoperative day. After 14 days of the waiting period, distraction of the femur and tibia was commenced at a rate of 1 mm and 0.5 mm per day, respectively. Femur was lengthened at the same rate throughout the distraction period, whereas the distraction speed of the tibia was gradually decreased after the lengthening callus showed thin and sparse on radiographs. Distraction of the tibia was occasionally interrupted until the callus width and continuity were reestablished. As a result, the lengthening period/amount of lengthening of the femur and tibia were 90 days/83 mm and 163 days/37 mm, respectively, and an overall leg length was 7"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female patient underwent left hepatectomy for an enlarging focal nodular hyperplasia tumor in April 2015. The diagnosis was confirmed by magnetic resonance imaging, which clearly showed typical features of focal nodular hyperplasia. Nevertheless, the patient was accepted for surgery due to the significant growth of the tumor (up to 6 cm in diameter) which doubled its size within 2 years. Following surgery, the patient presented with increasing jaundice (bilirubin of 9 mg/dl on day 7.) and abdominal pain with vomiting. Abdominal ultrasound confirmed a large fluid collection that was adjacent to the liver transection plane and proved to be bilious in origin at percutaneous drainage. A drain was left inside the collection and a biliary leak of around 300–600 ml/daily continued. At endoscopic retrograde cholangiography (ERC) which was performed twice, a slight leak combined with poor filling of the intrahepatic bile ducts was shown. At that time we believed the compromised filling of the intrahepatic bile ducts was due to the narrowing at the confluence. The common bile duct was stented endoscopically with a plastic (8.5 Fr) stent (day 8.) and as the leak continued, a self-expandable metallic stent (day 15.) was inserted. A few hours following the second ERC procedure, the patient presented with sudden abdominal pain, hypotension and a drop in hemoglobin from 12.2 to 6.6 mg/l due to a splenic rupture that was confirmed by the CT scan. An emergent relaparotomy was performed. During surgery, the patient required blood transfusion with inotropic support and her condition was unstable. In view of this, surgery was limited to splenectomy, abdominal lavage and drainage. Considering dense adhesions within the hepatoduodenal ligament and no obvious source of a biliary leak visible, no intraoperative investigations of the biliary tree were pursued. Following splenectomy the condition of the patient improved, however the biliary leak persisted. At this stage, it was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 42-year-old African-American male with no significant past medical history who was admitted for increasing right knee pain over a period of three weeks. The patient had no history of trauma to the area but reported hitting it with a \"pan\" at work, as he works as a chef. The pain was not radiating and was moderate to severe in intensity. He had been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for pain with minimal improvement and could not bear weight on the right knee due to pain.\nThe patient denied any history of sexually transmitted diseases (STDs), recent infection, travel, or sick contacts. The patient has lived in Illinois his entire life and has not seen a doctor in over 20 years. His social history was significant for smoking half a pack of cigarettes daily, occasional marijuana use, and alcohol use in the past. There was no history of intravenous (IV) drug use.\nOn physical examination, the patient's vital signs were stable. His right knee was swollen and tender to the touch with swelling in the medial aspect of the proximal tibia. There were no cuts, abrasions, or signs of obvious trauma locally. The knee had a limited range of motion with pain on movement. Ligament laxity was not assessed because of the discomfort the patient was in.\nHis labs showed elevated inflammatory markers. His C-reactive protein was 205.8 (normal: < 3 mg/L) and the erythrocyte sedimentation rate was 101 (range: 1 to 13 mm/hr). His white blood cell count was within normal limits.\nX-ray of the right knee showed no bony abnormality (Figure ).\nComputed tomography (CT) of the right knee demonstrated two positive findings: 1) prominent soft tissue swelling adjacent to the lateral aspect of the proximal tibial metaphysis with some associated underlying cortical irregularity of the tibia at this location. The findings were suspicious for a soft tissue infection with resultant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 12-year-old male who had his first seizure attack at the age of 10, and had four types of epileptic seizures. The first type of seizure was tonic axial seizures characterized by flexion of the neck and body and the extension of four extremities for several seconds. The tonic seizures could last several seconds. This type of seizure occurred predominantly at night and the frequency was about 4–5 times per week. The second type was atypical absence seizures, which manifested as a sudden loss of consciousness and the resuming of normal activity right after the seizure. This type of seizure could last about 15 s and the frequency was 4–5 times per week. The third type was the myoclonic seizure, presented as prominent myoclonic jerks of bilateral upper limbs. The frequency of this type of seizures was 2–3 times per day. The last type of seizure was the generalized tonic-clonic seizure, which could last about 5 min. The mean frequency of this type of seizure was <1 time per week.\nThe patient was a full-term infant with no history of perinatal asphyxia, head injury, encephalitis, and febrile convulsions. His family history was unremarkable. He had a mild degree of intellectual impairment and learning disability after the onset of the disease. The physical examinations were normal. Auxiliary examinations, including blood routine examination, serum biochemical examination, thyroid function, autoimmunity antibody, and blood ammonia, were normal. The electrocardiogram was normal and the QT interval (QTc) was 372 ms. There was no lesion on the brain MRI. The Wechsler Intelligence Scale showed a borderline cognition impairment. The electroencephalogram (EEG) before treatment showed that there was a large number of 3 to 5 Hz slow waves with middle and high amplitude in the anterior region in the background. Fast rhythms bursts of 16 to 20 Hz and multiple-spike-and-slow-waves of 0.5 to 1 Hz were observed during the sleep period. S"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old female with history of NF-1 (diagnosed at the age of 13) presented to the emergency with right upper-quadrant abdominal pain, progressively worsening over the last 48 hours and associated with nausea and recurrent vomiting. Her vitals at the time of presentation included blood pressure of 224/133 and pulse of 98/min. Apart from typical features of NF-1 (café au lait spots and neurofibromas), the only significant examination findings were signs of dehydration and tenderness in the right upper quadrant of the abdomen. On questioning, she confirmed being diagnosed with hypertension 5 years back but was non-compliant to her medications as none helped improved her BP. She denied being investigated for secondary hypertension while the last anti-hypertensive prescribed to her was labetalol. It is possible if she had been compliant, she may have been diagnosed earlier. Due to concerns for high blood pressure and suspected cholecystitis, she was admitted to ICU for further management. Apart from leukocytosis of 19,000, the rest of her blood workup including bilirubin, liver enzymes and lipase was unremarkable while electrocardiogram had no acute changes. An urgent ultrasound of the abdomen showed cholelithiasis along with pericholecystic fluid suggestive of acute cholecystitis which was confirmed on CT abdomen/pelvis with contrast. She was immediately started on intravenous fluids and antibiotics while the general surgery team was consulted. Due to the patient being very sick, a cholecystostomy tube was placed to decompress the distended inflamed gall bladder.\nDespite the use of multiple antihypertensive medications, the patient continued to have elevated blood pressure. Interestingly, a review of the CT abdomen/pelvis done on admission revealed the presence of bilateral adrenal masses, this finding was concerning for an undiagnosed PHEO. On further evaluation (), she was found to have elevated levels of free meta- and normetanephrine in plasma and urine sample"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 61-year-old male with a history significant for NF-1, hypertension, esophagitis and intermittent gastrointestinal bleeding, who initially presented to an outside institution for acute onset of bleeding per rectum. The patient noted bloody bowel movements with diarrhea for several days, which had increased in frequency over the past 24 hours. The patient reported mild abdominal pain and denied nausea, emesis, chest pain, shortness of breath, syncope or other symptoms at the time. He was not on anticoagulation and denied excessive alcohol or nonsteroidal anti-inflammatory drug (NSAID) use. His family history was significant for NF-1 diagnosed in his mother and brother. He had no significant surgical history other than a total hip replacement.\nOn admission at the outside hospital, the patient’s hemoglobin was 6.6 g/dl, with normal platelets, partial thromboplastin time and prothrombin time. Diagnostic workup at the outside institution included a nuclear medicine gastrointestinal scan (mTc-labeled RBCs), which was negative for abnormal bleeding. On hospital Day 2, his hemoglobin failed to respond appropriately to transfusions and a computed tomography angiogram (CTA) was completed, which showed a 6.9 × 5.8 × 6.8 cm hyper-vascular mass in the left pelvis; abutting the left border of the bladder medially, iliac arteries and veins posteriorly, rectus sheath anteriorly and the small and large bowel (). Vascular supply of the mass was identified to originate from branches of the superior mesenteric artery (SMA) and appeared to be contiguous with the adjacent jejunum. The mass was noted to also abut, but not involve, the sigmoid colon. The CT scan further noted a 9 mm enhancing tumor in the second portion of the duodenum anteriorly (). After administration of five total units of packed red blood cells with limited improvement in hemoglobin, the patient was transferred to our institutions for further management.\nThe patient arrived hemodynamically stable and u"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man complained of left shoulder pain for 2 weeks without any history of trauma. Bloody effusions were aspirated 5 times at a local orthopedic clinic during a 2-week period before the patient was referred to us. He had no previous history related to hemorrhagic factors. On examination, he had slightly limited range of motion, with active forward flexion to 160°, abduction to 120°, external rotation to 30°, and internal rotation to the fifth lumbar spine with the arm at the side. Passive range of motion was the same as active range of motion. Neer's impingement test and Hawkins test were positive. The greater tuberosity was seen irregular on radiography. MRI demonstrated a hematoma in the anterior portion of the subdeltoid bursa and bony erosion of the lateral acromion, similar to case 1 ().\nArthroscopy was performed to determine the cause of the hemorrhage. A hematoma was not observed in the glenohumeral joint. The intra-articular portion of the long head of the biceps tendon had completely disappeared. A bursal-side partial tear of the rotator cuff was noted. The size of the tear was 25 mm in the anteroposterior direction. Crater formation on the undersurface of the acromion and irregularity of the greater tuberosity were observed, which seemed to be kissing lesions (Figures and ). Active bleeding was seen at the exposed bone marrow of the acromion when the pressure of irrigation was lowered. The undersurface of the acromion was coagulated and the greater tuberosity was abraded to avoid impingement (). Acromioplasty was not performed in this case. The bursal-side partial tear was not repaired at that time ().\nOne month later, the patient underwent arthroscopic rotator cuff repair. The patient regained full range of motion 3 months after rotator cuff repair and returned to work as a taxi driver. At the final follow-up, 14 months after the first arthroscopy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nRJS, a 30-year-old woman, was seen at the health post of Corte de Pedra, Tancredo Neves—Bahia, a reference center for diagnosis and treatment of CL. The patient complained of a small papular lesion in her right leg developing over seven to 10 days. When she was 10 years of age, she had an ulcer in the left thigh suspicious of CL that spontaneously healed in about 4 months. Given her prior history of ulcer, she decided to seek help at the health post when the new lesion appeared. On physical examination, a depressed papular lesion measuring 8 × 7 mm in the right leg suspicious of folliculitis was noted. There was also a well-defined atrophic scar in the left thigh, measuring 30 × 20 mm (). There was no lymphadenopathy. Because early CL lesions in L. braziliensis infection may have a papular and nonulcerated aspect [] and the patient lived in an endemic area, the diagnosis of CL was suspected. LST was prepared as previously described []. Briefly promastigotes of L. amazonensis were disrupted initially by multiple freeze and thaw and later by sonication. The material was adjusted to 250 μg/mL with sterile PBS containing Tween 80 and phenol []. An intradermal injection of 0.1 mL was administered in her left forearm. After 48 hours, the intradermal reaction was highly positive with an induration of 38 × 32 mm. Eight days after the skin test, while the folliculitis in the right leg disappeared, a cutaneous round ulcer with raised borders measuring 26 × 24 mm, typical of leishmaniasis, was observed in the site where the LST was administered (). The clinical picture was typical of an ulcerated CL lesion, but the culture of the aspirated material from this lesion was negative for Leishmania. The histopathological analysis () showed chronic perivascular inflammation with granuloma formation and the presence of neutrophils, lymphocyte, monocyte, and plasma cells. Parasites"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male patient was brought by his parents to a genetics clinic with complaints of developmental delay and tremor. He was a full-term infant with an uneventful delivery. He started walking around 18 months of age, spoke his first words at the age of two. Other problems included nervousness, immature behaviors, lack of eye contact during conversations, and aggressive behavior. His mother reported that he began to have a tremor in the hands around three years of age. Diagnostic workup included magnetic resonance imaging (MRI) of the brain, urine organic and amino acids, lactate, pyruvate, and lead levels along with chromosomal and DNA analysis for fragile X which were all unremarkable. His family history was significant for mental retardation. Maternal grandmother had three mentally retarded brothers with tremors, two of whom died in their forties. The patient’s brother also seems to have a speech delay along with tremors since the age of three.\nHis tremors worsened gradually, and he started to have difficulties with fine motor control including difficulty with drinking out of a cup along with increased aggression and behavioral changes. His teachers reported that he was biting, kicking, spitting and getting into conflicts with other children. He was seen by a child psychiatrist at that time and was started on risperidone, valproic acid and Adderall (amphetamine and dextroamphetamine) which seemed to help with his behaviors.\nOn examination, he has high nasal bridge, slightly down-slanting palpebral fissures, long philtrum, and thin upper lip. On neurological exam, he has slightly increased deep tendon reflexes throughout. Babinski sign was positive on the right, but a normal plantar response was noted on the left side. Bilateral hand tremors were noted, both at rest and in action. He was walking slowly without much arm swing and had a slightly stooped forward posture. A full psychological evaluation was done which showed a Leiter scale IQ of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old man was admitted to our center with the chief complaint of consistent fatigue in March 2017. He had a 30-year history of hypertrophic obstructive cardiomyopathy, a 20-year history of chronic viral hepatitis B, and had suffered from gastric ulcers for five years. In addition, he often got pneumonia at least 2 or 3 times a year in the past few years. A Chest CT revealed a 3.7 cm × 2.1 cm mass encircling the main pulmonary artery in the right middle lobe of the lung and another 2.2 cm × 1.5 cm mass in the left upper lobe of the lung, both of which showed slightly contrast enhancements with clear boundaries (Fig. ). However, the patient declined our suggestion for further examinations.\nAs fatigue aggravated 8 months later, he was admitted to our hospital for a second visit. A repeated CT showed that the mass of the right lung increased to 4.7 cm × 3.4 cm, with a little decrease in the lesion on the left side. Meanwhile, hepatic multiple enhanced nodular signals were also detected by the abdominal CT, but liver tumors were further excluded by the abdominal magnetic resonance image (MRI). Apart from fatigue, the patient did not have any other complaint, without cough, chest pain, fever, or other findings by physical examinations. The laboratory findings were negative, white blood cell count, hemoglobin level, platelet count, C-reactive protein, elevated sedimentation rate, and cancer-related antigen were within the normal ranges. The CT-guided lung biopsy of the mass in the right middle lobe of the lung was performed in December 2017. The corresponding histological results revealed that the mass comprised spindle cells without the infiltration of atypia inflammatory cells. The immunohistochemical examination showed that the cells were positive for smooth muscle actin (SMA) and Ki-67 (10%), but negative for CD34, S-100 protein, epithelial membrane antigen, and ALK1 (Fig. ). Thus, the diagnosis of pulmonary"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old girl, who suffered from chronic cyanosis, was referred to our hospital for further evaluation. The patient was well developed with normal growth. On physical examination, a 2/6 systolic heart murmur on the middle left sternal border and mild cyanosis (O2 saturation=80% by pulse oximetry) were the only findings. Her blood pressure and heart rate were 110/70 mmHg and 100 bpm, respectively. She had no history of stroke, dyspnea, dizziness, and syncope. Electrocardiography was normal, and there was no finding in favor of the enlargement of any chamber. Chest X-ray showed mild cardiomegaly with normal pulmonary vascular markings. Her hemoglobin and hematocrit levels were 14 g/dL and 41%, respectively. Transthoracic 2D echocardiography, via the segmental approach, demonstrated the normal continuation of the inferior vena cava to the right atrium. However, the orifice of the RSVC to the right atrium could not be visualized. Instead, it seemed that the RSVC was draining into the left atrium. The left atrium and the left ventricle were mildly enlarged (). The function of both ventricles was normal. Other echocardiographic findings were mild mitral regurgitation and trivial tricuspid regurgitation. The peak pressure gradient of the tricuspid regurgitation was 20 mm Hg, and there was mild pulmonary valve regurgitation. In addition, there were no intracardiac defects or shunts. The pulmonary veins were connected to the left atrium normally. The diagnosis was confirmed through contrast study with agitated normal saline. Injection via the left brachial vein showed the drainage of the SVC into the left atrium, no atrial septal defect, and no left SVC ( & ). Cardiac catheterization and angiography confirmed a systemic oxygen saturation rate of 80% and a normal pulmonary artery pressure (mean pulmonary artery pressure=15 mmHg). Because transthoracic echocardiography and catheterization confirmed the diagnosis (), there was no need to utilize any other imaging modalitie"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male presented with an eight month history of looser stools. His medical history included a right lung lobectomy for tuberculosis aged 20, chronic obstructive airways disease and ischaemic heart disease. He was a long-term smoker.\nGeneral examination showed him to be well with no lymphadenopathy. No mass was palpable on digital rectal examination. Full blood count, urea and electrolytes and liver function tests were all within normal limits.\nFlexible sigmoidoscopy and biopsy identified a rectal adenocarcinoma at 8 cm from the anal margin. MRI showed a normal liver and no para-aortic lymphadenopathy. A moderately bulky tumour was identifiable in the mid/low rectum, 5 cm in length. Local staging with MRI was T2 although the tumour was noted to be very close to the levator plate especially on the left. Perirectal and presacral lymph nodes were seen, the largest of which was 1 cm in short axis. CT scan of the chest did not identify any metastatic disease.\nAt laparotomy no peritoneal disease, liver metastases or abnormal lymph nodes were seen. A low anterior resection with total mesorectal excision was performed. Recovery was complicated by chest sepsis and prolonged ileus and the patient was fit for discharge on day 14 post surgery.\nMicroscopic examination showed complete resection margins of a moderately differentiated adenocarcinoma extending through the muscularis propria. Metastatic adenocarcinoma was also identified in one of the twenty one lymph nodes. By UICC staging this was therefore pT3 N1 MX. There was no evidence of extramural vascular invasion. Several lymph nodes showed partial effacement of the normal lymphoid architecture by an infiltrate of small lymphoid cells in which many pseudoproliferation centres were evident.\nImmunohistochemical studies confirmed the presence of CD20 positive B lymphoid infiltrate that co-expressed CD5, CD23 and BCL2 and was negative for cyclin D1, CD10 and BCL6 (DakoCytomation, Ely, UK).\nThis overall picture was co"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old Caucasian female with extensive history of pelvic surgery but without prior urological history underwent robotic-assisted laparoscopic excision of endometriosis by gynecological surgery team secondary to chronic pelvic pain with suspected endometriosis. On initial laparoscopic evaluation of pelvic contents, visible vermiculation of bilateral ureters was noted as well as suspected findings of endometriosis-like lesions covering the pelvic peritoneum. The pelvic peritoneum was excised with sparing of the urinary bladder. Careful ureterolysis was performed bilaterally, during which the distal left ureter was found to be partially denuded, spanning 2 cm in length (). An intraoperative urologic consultation was requested, and denuded ureteral injury was confirmed by urology on laparoscopic evaluation. Given no evidence of ureteral laceration or obvious extravasation of urine from left ureter, no cystoscopy or contrast studies were performed. A 2 cm x 12 cm AmnioFix membrane was wrapped three times around the left ureter using laparoscopic robotic assistance (Figures and ). The procedure was completed without anesthesia complications and the patient was discharged on postoperative day one in stable condition.\nThe patient was seen by her gynecologist on postoperative day six after experiencing lower urinary tract symptoms and was subsequently started on PO antibiotic therapy. However, her symptoms did not improve, and she developed new left flank pain which brought her back to the hospital for further evaluation on postoperative day seven. She underwent noncontrast CT imaging of the abdomen and pelvis demonstrating moderate left hydroureteronephrosis to the level of the distal ureter. She underwent cystoscopy with left retrograde pyelogram demonstrating 1.5 cm distal ureteral stricture with moderate hydroureteronephrosis (). Continued contrast injection showed a small amount of extravasation from the vicinity of the narrowed ureteral segment (). However, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old female presented with macular extremity and facial rash from a rehabilitation center after having been discharged a month earlier from a revision surgery on her gastric bypass for anastomotic bleeding. The gastric surgery itself had been done four years prior to the presentation. On this admission she was noted to be lethargic for the past few days with neurological assessment revealing a Glasgow Coma Scale [] score at 4, necessitating intubation and mechanical ventilation.\nDuring this time, extensive investigations were done including imaging of the head. The Magnetic Resonance Imaging (MRI) of the brain showed symmetrically restricted diffusion (Figure ) was read as suspicious for hypoxic injury. This stood in contrast to any clinically documented hypoperfusion. Routine blood investigations did not offer a significant clue as her electrolytes, hepatic and renal functions were well within normal limits and the only thing that was seen abnormal was normocytic anemia, which in comparison to her past admissions, was found to be stable without an acute drop. Her thyroid profile, cortisol level, vitamin B12, and ammonia levels were checked for completion of the neurological workup and she was found to have elevated ammonia at 142 micromoles per liter (mmol/L) at the initial check. In the next few days of the critical care admission, she had progressive hyperammonemia to 432 mmol/L, despite treatment with lactulose and rifaximin. Ultrasound exams of the liver done during two different stages of the admission revealed no nodularity or fibrosis.\nContinuous Renal Replacement Therapy (CRRT) was initiated despite normal renal function with the express intent to clear the ammonia and observe for improvement in encephalopathy while awaiting the results of extensive laboratory testing including serum levels of amion acids, essential minerals and vitamins to reveal the etiology. MRI (Figure ) was repeated at that time showing worsening of diffusion weighted abnormal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old female with a history of prior lacunar stroke, hypertension, chronic back pain, and hypothyroidism presented to a community emergency department one hour after the acute onset of severe bilateral lower extremity pain which progressed, within minutes, to bilateral lower extremity generalized weakness and then flaccid paralysis. In addition, within an hour of symptom onset, she developed dull, diffuse abdominal pain with radiation to the bilateral flanks, lasting one hour with subsequent resolution.\nAt presentation, she was found to have a blood pressure of 131/88 mmHg, tachycardia with a heart rate of 110 beats per minute, oral temperature of 96.8 degrees, F and SpO2 of 97% on room air. The patient presented with 0/5 strength and decreased sensation to light touch and areflexia of the bilateral lower extremities. Noncontrast computed tomography (CT) of the head showed a remote lacunar infarct. CT angiography of the abdomen and pelvis showed no evidence of pulmonary embolus, abdominal aortic aneurysm, or aortic dissection. Surface electrocardiogram showed sinus tachycardia without ischemia.\nThe patient was transferred to a tertiary care center for advanced imaging and care, where a T2-weighted magnetic resonance image (MRI) showed a nonspecific central intrinsic signal hyperintensity in the conus region extending to the level of T8, concerning for acute spinal cord ischemia (Figures and ). Transthoracic echocardiogram, performed to determine if there was a cardiac source of emboli, showed atypical dyskinesia with left ventricular apical ballooning and an ejection fraction of 35%, a characteristic of neurogenic stunned myocardium (Figures and ). Cardiology was consulted, and a diagnosis of takotsubo cardiomyopathy was made, with no further recommendation for heparinization or catheterization. Pertinent laboratory results are shown in .\nThe patient was admitted to the neurology inpatient service for supportive care including physical and occupational thera"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-year-old male child was referred from a peripheral hospital to our institute as a case of progressively aggravating dyspnea at rest, cough, intermittent fever, and recurrent chest infections from the last 5 months. The chest X-ray showed a large opacity of the entire left hemithorax (). The child had been put on various antibiotic regimes, but the child's condition worsened day by day. On admission in our institute, the child was in acute distress. On chest auscultation, breath sounds on the left side were absent. There was no adenopathy or testicular mass. Computed Tomography chest was advised which revealed a huge mass occupying the entire left hemithorax with mediastinal shift to the opposite side (). It was adherent to the left anterolateral subcostal pleura and the mediastinal pleura. The lesion showed heterogeneous density. No mediastinal lymphadenopathy, pleural effusion, or thickening was noted. Routine hematological tests and abdominal sonography were within normal limits. Mantoux test was negative. Tumor markers (α-fetoprotein and β-human chorionic gonadotropin) were both normal. Surgical management was first in the priority list of therapeutic options. A left-sided thoracotomy revealed a cystic tumor arising from the left lung. Many adhesions existed with the left pulmonary artery, the left main bronchus, the pericardium, the aorta, diaphragm, and parietal pleura. A combination of blunt and sharp dissection for the division was applied. A purse string suture permitted aspiration of sebaceous content via a small incision in the wall of the mass. As the size diminished, manipulation was facilitated. A pneumonectomy had to be carried out in order to remove the tumor mass. The child was shifted intubated to the Surgical Intensive Care unit in the immediate postoperative period. The child could not maintain oxygen saturation, and his condition deteriorated, and he expired on the second postoperative day. The histopathological examination revealed a benign"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old man, who had had ankylosing spondylitis, was involved in a motor vehicle accident that caused a C6 burst fracture and incomplete spinal cord injury. He presented with marked left paraparesis, particularly weak in his left shoulder and arm. Also, he had had Type 2 diabetes and was wearing a neck collar for cervical spondylosis when the accident took place.\nThere was a burst fracture of the C6 and a fracture of the lamina in addition to a herniated disc at C5-6 level, which caused spinal cord compression and increased intramedullary signal intensity on T2 weighted magnetic resonance imaging (MRI) (Figure ). In order to improve the spinal alignment, the patient was admitted to the intensive care unit for halo traction prior to surgery. The patient then underwent circumferential decompression and fixation, which involved a corpectomy of C6 and total laminectomies of C3 to C7 with anterior instrumentation of plate and screws and posterior lateral mass screws at C5 and C7 (Figure ). The surgery went smoothly and the hospitalization was uneventful. There was a significant improvement in muscle power, and he was able to ambulate at discharge. The patient had been kept in a neck collar postoperation.\nThree weeks postoperation, there was a sudden onset of right hand weakness, the opposite side of his initial presentation. The CT scan demonstrated plate and cage dislodgement that was anteriorly dislocated over the C7 vertebral body (Figures -). There was no dysphagia so we decided to treat him conservatively. He was then put into a halo-vest for immobilization, and his muscle power gradually improved to that of postoperation in a few days. Thus, the patient was discharged to a rehabilitation facility with a halo-vest. At three months postoperation, the patient opted to undergo revision surgery due to the discomfort caused by the halo-vest. Unfortunately, we could only remove the cervical plate rather than restore the corpectomy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old woman presented to our clinic with diplopia, left-sided excessive lacrimation, a history of chronic rhinosinusitis, and redness of the ipsilateral eye. The patient’s medical history was significant for glioma resection and radiation therapy 8 years before presentation, without evidence of recurrence. After several years, she began experiencing excessive tearing of the left eye, followed by generalized redness. These symptoms began approximately 2 to 3 years before presentation. Diplopia began 6 weeks before presentation. She subsequently underwent a limited functional endoscopic sinus surgery (ESS) at a different facility for suspected infection. Pathology results were nonspecific. On our examination, the patient had strabismus, generalized redness, and moderate ptosis of the left eye, with an otherwise nonfocal neurologic examination result. According to the patient, ptosis and redness worsened over the past year. She had slight exotropia of the left eye and did not have pain or a history of orbital trauma.\nA review of previous imaging demonstrated a chronic inflammatory change in the left medial orbital wall and sinuses for several years before presentation. The last computerized tomography (CT) before the operation at a different facility documented erosion of the left medial orbital wall, with loss of the fat plane separating the wall from the medial rectus, and again identified a soft-tissue density in the medial orbit (). Magnetic resonance imaging after the procedure revealed dehiscence of the left lamina papyracea, enlargement of the ipsilateral medial rectus, thickening of nasal mucosa along the medial orbital wall, and a lesion of the left sphenoid sinus (). A CT detected decalcification of the left lamina papyracea. Nasal endoscopy demonstrated crusting and a bulging of the medial orbital wall, with purulent discharge into the nasal cavity (). Cultures from nasal mucosal swab and tissue biopsy were positive for pansensitive Candida tropicali"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female presented with c/o progressive breathlessness since 6 months and recurrent episodes of cough with streaky hemoptysis since 2 months. She was initially evaluated elsewhere. Fiberoptic bronchoscopy (FOB) showed a tumor mass obstructing the left main bronchus (LMB). A biopsy was inconclusive, and, hence she was referred to our institute for further management. She has had an esophageal stent inserted for corrosive stricture of esophagus 3 years ago.\nChest examination revealed few crepitations in the left base. Complete blood count and liver and renal function were within normal limits. Pulmonary function test showed a restrictive pattern. A computed tomography (CT) scan of the thorax was done, which showed the esophageal stent eroding into the LMB []. There was no evidence of any major thoracic vessel invasion in the contrast CT scan. FOB was performed which showed the stent almost completely obstructing the LMB and mimicking a tumor mass []. Upper gastrointestinal endoscopy was performed in which only the upper part of the stent was visible, and the rest of the stent was embedded into the esophagus and covered with granulation tissue []. Since the stent could not be removed endoscopically, the decision for surgical removal was made after discussion with the thoracic and gastro intestinal surgeons.\nThe patient underwent thoracotomy with closure of the esophagobronchial fistula along with laparoscopic esophagectomy and gastric pull through. The esophagogastric anastomosis was done in the chest. Postoperative period was uneventful. Repeat bronchoscopy showed a patent LMB. Patient's symptoms improved, and she did not have any hemoptysis after the surgery. She was started on liquid diet 5 days after the surgery, following a gastrografin study which showed no leak.\nOn the 4th day after starting a liquid diet (postoperative day 9), she developed high grade fever along with cough and breathlessness. Repeat CT scan with oral contrast revealed a microleak a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old Caucasian male presented with a 2-mo history of worsening intermittent dysphagia, persistent cough, and postprandial retrosternal pain. He also complained of persistent dull pain on the left side of his neck, radiating to his left ear, which was not related to meals.\nSuspecting gastroesophageal reflux disease, the patient was started on proton pump inhibitor pharmacotherapy. Upon no relief of symptoms, the patient was referred to an otolaryngologist to evaluate the pharynx with a laryngoscopy; no abnormalities were seen, and therefore the patient was referred to a gastroenterologist. An esophagram was first performed, which showed a voluminous intraluminal lesion within the thoracic esophagus, possibly being a neoplastic process such as a leiomyoma (Figure ). An esophagogastroduodenoscopy was then performed, identifying a polypoid mass, which started at the level of the upper esophageal sphincter with a single stalk and extended all the way down to the esophagogastric junction. The polyp occupied about a third of the esophageal lumen, was heterogeneous in surface appearance, and consistent with a giant fibrovascular polyp; concurrently a small hiatal hernia was also seen. Biopsies from the head of the polyp exhibited benign squamous mucosa with mild acute and chronic inflammation. A computed tomographic (CT) scan of the chest showed a large mass along the entire course of the esophagus (Figure ). After an endoscopic ultrasound excluded the presence of major vessels within the main stalk, endoscopic resection was pursued. While using a flexible esophagoscope to visualize the mass, a snare was passed around the distal end of the polyp on retroflexion and then pulled up around the stalk, which was located on the left side of the esophagus just at the level of the upper esophageal sphincter. The proximal stalk was cauterized and divided with the snare, causing the polyp to drop into the distal esophagus. The polyp was then retrieved transorally using the e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male complained of inability to flex his left elbow since 1 year prior to admission. One and a half year before, he fell down and hit his elbow during football practice. He felt pain and there was swelling on his elbow. However, he didn't seek for medical treatment. He had his elbow massaged every week for 5 months but there was no improvement. His elbow became fixed in extended position. A month later, he went to an orthopaedic surgeon and underwent x-ray examination which revealed a fracture and dislocation on his left elbow. He was then referred to our institution for further treatment.\nFrom clinical examination, range of flexion-extension of the elbow was 300-00 with normal pronation-supination. There was no neurological deficit (). From radiological examination, there was a malunion of medial epicondyle with subluxation of left proximal ulna (). From 3D CT reconstruction, there was a deformity and malunion fracture in humeral capitellum with radial and ulnar postero-superior dislocation (). The patient was diagnosed with extension contracture of the left elbow due to malunion of left capitellum, neglected dislocation of the radiohumeral joint, and neglected dislocation of the ulnohumeral joint. The patient was scheduled to have a contracture release, open reduction and internal fixation, and ulnar interposition.\nIntraoperatively, we did a posterior approach to the elbow. The ulnar nerve was identified and preserved. The fibrotic tissues and heterotopic ossification were excised. We did a contracture release and open reduction and internal fixation using K-Wire. The flexion and extension of the elbow were evaluated and we managed to get 300 - 130° of flexion-extension ROM. Afterwards, ulnar interposition was performed to prevent ulnar impingement. The wound was closed and a single drain was placed. The elbow was immobilized with back-slab in 900 flexion position for two weeks.\nAfter 1 week, the patient went back to our hospital for follow-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 62-year-old male with a recent history of left frontal ICH (Fig. , ), hypertension, and atrial fibrillation (not anticoagulated) who presented to the emergency department after a fall due to suspected seizure while in rehabilitation. There was no other history of risk factors related to ischemic or hemorrhagic stroke. At presentation, the patient was unconscious and intubated with pupils that remained reactive to light. Computed tomography (CT) scan of the brain showed a right cerebellar hemorrhage with surrounding edema and mass effect on the fourth ventricle (Figure , ). The patient’s family was counseled and, after review of the potential risks and benefits, consented to the surgical evacuation of the cerebellar ICH.\nA suboccipital craniotomy was completed without complication. His hospital course was complicated by Klebsiella pneumoniae pneumonia, and despite treatment for this, he required re-intubation and subsequent tracheostomy and gastrostomy placement due to failure to progress. He was later discharged back to rehabilitation in improved condition.\nRadiological assessment regarding the etiology of this patient’s stroke included multiple CT scans, magnetic resonance imaging (MRI) of the brain, including MR angiography of the head and neck, and cerebral angiography. The CT scans demonstrated his prior left frontal ICH and his new right cerebellar ICH at this presentation. His MRI scan did not show any acute ischemic stroke in the cerebellum associated with the new ICH. His cerebral angiography was unremarkable and did not reveal any evidence of vascular pathology or mycotic aneurysms to explain his recurrent intracranial hemorrhages. His blood workup at presentation showed normal coagulation studies and his platelet count was low normal at 119 x 109/L. Post-resection pathology report showed acute intracranial hemorrhage but special stains did not reveal any evidence of amyloid angiopathy or vasculitis (Figure ). Through persistent patient and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old woman was admitted to the emergency department with sudden onset of chest pain for five hours. She had hypertension (treated with β-blockers) as a cardiovascular risk factor. She was diagnosed with advanced non-small-cell lung cancer with liver metastases one month previously. The patient was not considered for surgical resection, she was scheduled for chemotherapy, and, consequently, no antineoplastic treatment had been initiated yet. Prophylactic anticoagulation was not indicated On clinical examination, her blood pressure was 150/90 mmHg with a pulse of 100 beats per minute, oxygen saturation of 95%, and normal heart sounds. The 12-lead electrocardiogram showed sinus rhythm with a heart rate of 102 beats for minutes and ST-segment elevation in all leads except aVR where ST-segment depression was noted (Figure ). Her laboratory test results revealed a baseline troponin T level of 1212 ng/ml (normal range < 26 ng/ml). Also, the echocardiography findings revealed akinetic walls from the mid to apical septum and anterior and inferior walls. The ejection fraction was estimated to be 39%. Therapy was started with clopidogrel, aspirin, and low-molecular-weight heparin. The patient underwent a coronary angiogram from the right radial approach, which revealed the presence of an extended thrombus in the left anterior descending artery (LAD), and another thrombus was found in the second segment of the right coronary artery (RCA) with thrombolysis in myocardial ischemia (TIMI) III flow and without any atherosclerotic lesions in the coronary artery tree (Figure and Figure ), therefore, balloon angioplasty and/or stent placement was not considered. The patient was taken to the coronary care unit (CCU) and tirofiban infusion was administered for a period of 48 hours. In view of persistent breathlessness, pulmonary embolism was suspected. There were no symptoms or clinical signs suggestive of deep venous thrombosis. A computed tomographic pulmonary angiography was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old female patient with a symptomatic gallstones disease and a recent weight loss was admitted to our hospital. The patient’s past medical history was free of other diseases and on physical examination, a Murphy sign was present. The abdominal ultrasound mentioned a large gallstone in the gallbladder and a hypoechoic liver mass. Liver blood tests, including tumor markers CEA and CA 19-9 were normal. Magnetic resonance imaging-magnetic resonance cholangiopancreatography (MRI-MRCP) revealed a liver tumor mass (4.5x3.5 cm) located mainly in segments IVa and VIII of the liver with an extent to segment I (Figure ).\nThe tumor displaced the adjacent hepatic veins and the inferior vena cava (IVC) without any signs of vessel invasion. There were no signs of liver cirrhosis and no dilated bile ducts or capsular retraction were noted. There was no associated lymphadenopathy. At this point, imaging characteristics were controversial regarding diagnosis. The differential diagnosis tilted in favor of ICC, mainly due to the enhancement characteristics and the absence of liver cirrhosis, as seen in Figure .\nThe patient was scheduled for exploratory laparotomy with a provisional diagnosis of an ICC. Intraoperatively, a cholecystectomy and lymph node sampling from the hepatoduodenal ligament were performed and both specimens were negative for malignancy on frozen section. Next, the liver was mobilized and the tumor was carefully dissected free of the hepatic veins, the IVC, and the rest of the liver parenchyma. The gross morphology of the liver specimen revealed a solid, grey-yellow liver lesion with a soft consistency. In the center, a light yellow region was noted, as can be seen in Figure .\nThe frozen section was negative for malignancy. Histologically, the tumor was characterized by a heavy inflammatory infiltrate in myxoid collagen stroma, consisting primarily of plasma cells, lymphocytes, and eosinophils. Fibroblast cells without significant fibrosis composed the str"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is the case of a 57 year old female who presented to the surgical clinic with a one month history of attacks of right upper quadrant abdominal pain, nausea and vomiting. An abdominal ultrasound demonstrated the presence of cholelithiasis and biliary sludge. The patient was diagnosed with symptomatic cholelithiasis and laparoscopic cholecystectomy was recommended to the patient on an elective basis. At the beginning of the procedure the peritoneal cavity was inspected with no masses, scar tissue or other abnormal pathology noted. During dissection of the gallbladder there were chronic omental adhesions noted but the gallbladder was not acutely inflamed. The cholecystectomy was able to be performed without complication and the gallbladder was sent for histopathological assessment. The pathology report was consistent with metastatic adenocarcinoma with signet ring features consistent with metastatic lobular carcinoma as well as chronic cholecystitis and cholelithiasis (see , ). Breast biomarker studies performed on the gallbladder were significant for PASD positive staining, antibodies that were positive included CK88, CK7, BRST2, and GATA3 (see ). Estrogen and progesterone receptors were both strongly positive, HER2 was negative.\nAt her follow-up appointment in the office a focused breast history and physical exam was performed. The patient denied family history of breast cancer. Full risk stratification and oncologic workup was pursued. Her BMI was 32.4, age of menarche was 13, her first pregnancy was at age 35, menopause began at 37 years old at which time she briefly was placed on estrogen therapy. She denied family history of cancer. She had a right breast lumpectomy in 2012 with benign pathology. Her last mammogram was in 2018 with no concerning findings at that time. A Gail score was calculated revealing a 12.5 % lifetime risk of breast cancer.\nBreast MRI revealed several spiculated masses in her right and left breasts as well as suspicious bilateral axilla"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male was admitted to hospital with a history of dyspnea at rest for 2 d, a cough producing mucus, loss of appetite and diarrhoea. Pneumonia was suspected, and the patient received intravenous antibiotic treatment. During the patient's second night in hospital, he was found groggy and walking near his room by the nurses. They took him back to his room and connected a new antibiotic dose to his venous catheter. A few hours later, he was found unconscious, lying on the floor next to his bed. His peripheral venous catheter was connected to a nasal cannula delivering O2 from the wall, with a flow rate of approximately 2 L/min, and the antibiotic dose was found in the garbage can. As post-mortem lividity was present, no resuscitation attempts were performed by the clinicians and the death was pronounced. The body was immediately brought to the University Center of Legal Medicine (Lausanne, Switzerland).\nBefore any manipulation of the corpse, a native CT scan was carried out at around 10 h post-mortem using an eight-row CT unit (CT LightSpeed 8, GE Healthcare, Milwaukee, WI). All scanning parameters are detailed in . A forensic pathologist immediately viewed the native CT images. To evaluate the distribution of gas because of physiological changes in the body after death, the radiological alteration index (RAI) was used as proposed by Egger et al. []. The RAI was based on the analysis of samples from seven sites (heart cavities, liver parenchyma and vessels, left innominate vein, abdominal aorta, kidney parenchyma, L3 vertebra and the subcutaneous pectoral tissues).\nAll images were interpreted in a consensus reading by one board-certified radiologist and one forensic pathologist who were trained in forensic imaging. A post-mortem radiological report was prepared and described all findings from the native CT scan. The native CT scan revealed the presence of subcutaneous, intramuscular and intravascular gas,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male patient reported with a chief complaint of continuous and radiating pain in relation to left maxillary first molar for several days. On clinical examination, the patient’s oral hygiene was found to be fair. Dental examination revealed a left maxillary first molar with a deep carious lesion and there was a full coverage restoration in relation to left maxillary second premolar. The patient also complained of episodes of sensitivity to hot and cold in the involved tooth. Clinical diagnosis was irreversible pulpitis. A preoperative radiograph was obtained []. After detailed clinical and radiographic examination, the left maxillary first molar was prepared for nonsurgical endodontic therapy. After administration of local anesthesia, tooth was isolated with a rubber dam and a conventional endodontic access opening was made []. After removing pulp tissue located in the chamber, four orifices were observed – palatal, mesiobuccal and distobuccal located in regular locations and an extra orifice was located very close to the palatal orifice and was presumed to be a second palatal orifice. The conventional triangular access was modified to a trapezoidal shape to improve access to the additional canal []. The working length of each canal was estimated by means of an electronic apex locator (Root ZX; Morita, Tokyo, Japan) and then confirmed by a radiograph [] and then access was closed with a temporary restoration.\nThere were no variations like second palatal root/ canal observed in the pre-operative radiograph and working length radiograph suggested that the instrument in the extra canal was an MB2, but at an unusual location i.e., adjacent to palatal orifice.\nAt the next visit, the canals were initially instrumented with #15 nickel titanium files (Dentsply Maillefer) under irrigation with 5% sodium hypochlorite and 17% EDTA. Coronal flaring was carried out by using gates glidden burs (numbers 3 and 2; Dentsply Maillefer). Cleaning and shaping of the canals"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old male patient, a labour worker by occupation, had presented to our outpatient department with a diagnosis of concomitant nonunion of the shaft and neck of the left femur of eight months duration. On the basis of history and previous records, it was known that the patient had sustained an open grade IIIA fracture of shaft femur and a closed ipsilateral femoral neck fracture of the left side following road traffic eight months prior to the above presentation. The femoral shaft fracture was managed with an external fixator application, and the femoral neck fracture management was delayed due to unhealthy soft tissue conditions around the proximal lateral aspect of the thigh. The treatment of both fractures was further delayed because the patient developed an infection of the open wound of the femoral shaft fracture. To add to the complications, he had developed pin site infection as well. Following that, open debridement of the femoral shaft wound site was performed, and the external fixator was removed at the primary treating institution. Thereafter, the limb was kept splinted on a Thomas splint. Subsequently, the wound and pin sites were healed and the patient was referred to our center, which is a tertiary care center and teaching medical institute, after a total duration of eight months following injury. Clinicoradiological examination confirmed the non-union of the left femoral shaft fracture and ipsilateral femoral neck fracture (Figure ). Blood investigations revealed raised serum inflammatory markers (erythrocyte sedimentation rate (ESR)=25 mm/hr and C-reactive protein (CRP)=12 g/L). However, there were no clinical signs of local inflammation around the fracture sites, the healed wound, and the pin sites. An MRI evaluation of the hip joint and the affected thigh was planned but was deferred as the patient was claustrophobic and not comfortable. Instead, an ultrasound evaluation along the femoral shaft and the hip joint was performed, which revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old male, who had been a patient of the osteopathic family clinic for over 10 years, presented with his wife to discuss a pre-surgical assessment for the placement of an intracranial shunt. He had a past medical history of diabetes mellitus, hypertension, hyperlipidemia, and a stroke in 2013. The stroke resulted in left hemiparesis affecting the lower extremities more than the upper extremities but was followed by a complete recovery. For the past two years, he developed a progressive short-stepped shuffling gait with hesitancy occurring with turning and swaying only to the right side while walking. Additionally, he described nocturia with increased bladder frequency and urgency and subjective memory difficulty without any mental impairment. The patient ambulated with a cane and stated that his biggest concern was swaying to the right with a fear of falling. He described difficulty in turning and freezing due to this feeling of loss of balance. The patient denied dyskinesias, hallucinations, nightmares, tremors, headache, or nausea. His most recent MRI suggested stable mild-to-moderate diffuse ventriculomegaly. He was referred to a neurologist at NYU Langone who diagnosed NPH and subsequently was referred to a neurosurgeon at Columbia Presbyterian who deemed the patient a candidate for a surgical shunt.\nDue to his hesitancy toward the recommended invasive procedure, the patient agreed to try craniosacral therapy to relieve the NPH prior to getting the shunt recommended by the neurosurgeon. The patient tolerated the first osteopathic therapy session well and returned to the office one week later. He stated that he noticed a significant improvement with his gait two to three days after the first session, but symptoms had slightly returned towards the end of the week. A second craniosacral session was performed, and the patient felt an improvement in his NPH symptoms after the therapy.\nCraniosacral therapy sessions were conducted one week apart lasting 15 min"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old Caucasian woman was admitted with a 2-week history of intermittent colicky lower abdominal pain associated with bilious vomiting and mild abdominal distension. She was previously diagnosed with left breast cancer 18 years ago for which she had undergone an oncological wide local excision, focused external beam radiotherapy and adjuvant treatment with tamoxifen for 5 years. Unfortunately, she developed regional recurrence with bony metastases 17 years following her original diagnosis. She was treated with palliative chemoradiotherapy and had an excellent response to treatment.\nPhysical examination revealed an elderly lady with stable vital signs. The abdomen was mildly distended with tenderness and guarding noted in the peri-umbilical region. Laboratory investigations, including haematological, biochemical, inflammatory and coagulation profiles, were all within normal limits.\nA plain abdominal radiograph was also unrevealing. She proceeded to have computerized tomography (CT) scan of her abdomen and pelvis, which showed dilated small bowel loops consistent with small bowel obstruction. There were two filling defects noted, one in her proximal ileum suspicious for a non-calcified gallstone and the second distally in her terminal ileum (Figs and ). Appearances were suggestive of gallstone ileus. She was adequately resuscitated and underwent a laparotomy. The small bowel was narrowed in two segments: proximally secondary to an impacted gallstone and an area of stricturing noted distally. Both segments were resected with end-to-end anastomosis performed in a two-layer standard hand-sewn fashion. The clinical impression was one of dual pathology including Crohn's disease and gallstone ileus. She did not undergo a cholecystectomy or repair of her cholecystoduodenal fistula. She made an uneventful post-operative recovery and was discharged home well on Day 7.\nHistopathological examination of the resected specimens showed a 3-cm intraluminal gallstone within th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old, nonsmoker, systemically healthy man presents to our clinic with the chief complaint of an opening at the extraction site of the upper right first molar (). The extraction had been performed more than 3 months previously, and since that time, the patient could not eat properly because the food would exit from his nose. Radiographs were taken, and a diagnosis of chronic OAF was acquired (). The patient was advised to undergo surgery to close the opening and eliminate the communicating tract between the oral and nasal cavities. A written and informed consent form was obtained from the patient for surgery and publication of the data. Under local anesthesia, a three-sided flap was created; the bone was then exposed, and a large bone defect (greater than 5 mm) was found (). The soft tissue tract was removed, and bone curettage was performed with a spoon excavator and a round bur drill. Slow-resorption collagen membrane extracted from bovine tendon containing collagen type I (Genoss, Gyeonggi-do, South Korea) was used to cover the bone defect and was fixed in place with nylon suture (). PRF was prepared after blood was withdrawn from the patient (40 mL) and centrifuged for 14 minutes at 1,500 rpm. A PRF clot was isolated from the middle part of the test tube between the red blood corpuscles at the bottom and the platelet-poor plasma at the top; the PRF clot was filtered from the plasma in the form of a thin membrane. The PRF clot was placed above the collagen membrane in two layers (). Periosteum scoring was performed with flap release. Primary closure of the tension-free flap was performed with 4/0 nylon suture. Horizontal and vertical mattress suturing was performed with interrupted stitches between layers (). The patient was given antibiotics (amoxicillin/clavulanate 625 mg, metronidazole 500 mg) and an analgesic (ibuprofen 400"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 57-year-old man who had lost his teeth because of caries, and had been referred to the dental school of Tehran university to replace them by implants in 2005. He had a history of controlled high blood pressure and controlled diabetes. Clinical examination showed that teeth number 18, 19, 30 and 31 had been lost. A comprehensive treatment plan was given to the patient and he was first referred for endodontic, periodontal and restorative treatment of the remaining teeth, and then for placement of dental implants.\nImplant surgery was preformed under local anesthesia (2% lidocaine, 1:100000 epinephrine). On the right side of the mandible, two Replace Select wide platform implants (10mm × 5mm), were placed in teeth 30 and 31 positions. A 10mm × 4.3mm Replace Select regular platform implant was placed in tooth number 19 position on the left side of the mandible and for position 18, a Replace wide platform implant (10mm × 5mm) was inserted.\nThere were no complications during implant placement. The type of bone in the implant areas was type 1.\nA post-operative antibiotic regime of 500mg amoxicillin was prescribed three times daily for 7 days, 400mg gelofen 4 times a day for 3 days and a chlorhexidine mouth rinse 2 times a day for 14 days was also prescribed for the patient. The sutures were removed 10 days later. After initial healing and taking a panoramic radiograph an appointment was set for the patient for impression taking, but he did not refer until 6 years later, in 2011, to continue the treatment. After clinical examination, the implants on the left mandibular side were healthy, BOP was negative without suppuration, with a pocket depth of 2 to 3 mm and without a radiographic sign of bone loss. However, on the right mandibular side, implants 30 and 31 had 7 to 9 millimeter pockets, respectively and were BOP and suppuration positive"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old Brazilian woman presented with a cutaneous ulcer on her left ankle and was treated in the Division of Infectious and Parasitic Diseases, Hospital das Clínicas, University of São Paulo, Medical School, São Paulo, Brazil. She reported had been receiving various drugs to control rheumatoid arthritis, diagnosed several years before. The treatment schedule included 25 mg of methotrexate intramuscularly once a week for two years, 5 mg of prednisone orally and daily for five years, and chloroquine 400 mg orally and daily for two years. During her childhood, the patient used to live in an endemic county for cutaneous leishmaniasis (São Lourenço da Serra - São Paulo) and described the presence of a long-lived skin ulcer, which had appeared at that time and diagnosed as cutaneous leishmaniasis. At examination, the lesion presented as a painful, foul smelling, and edematous 8 cm-diameter ulcer in the fibular malleolus region, which showed fibrin but without infiltrated edges (A). Another atrophic circular scar has also been found on the left pretibial region. Histology of the biopsy obtained from the border of the lesion was compatible with a venous stasis ulcer with intense granular tissue and scarring (B). The patient had started empirical treatment with piperacillin, tazobactam and clindamycin. The patient developed fever, but with no growth in blood cultures. The patient’s treatment was altered to imipenem 500 mg/ day for 7 days resulting in improvement in the patient’s condition and renal function. During the investigation, Leishmania PCR analysis from the aspirate of the lesion was positive (C), resulting in treatment with 3 mg/kg/day of a liposomal amphotericin protocol for ten days (total cumulative dose of 35 mg). The possible reactivation of the cutaneous leishmaniasis diagnosed during her childhood was considered at this point. During the last few doses, amphotericin treatment was discontinued due to worsening of the renal function, but the treatment w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male presented to our Emergency Department with a short history of reduced vision and pain in the left eye. His only known previous ophthalmic history was of corneal foreign body removal 45 years previously although previous medical history included peripheral vascular disease, ischemic heart disease, chronic obstructive pulmonary disease, and osteoporotic vertebral fractures. Initial ophthalmic assessment revealed vision of light perception only, with an inferior descemetocoele and positive Seidel test. His right eye was unremarkable with no evident corneal pathology. Emergency tectonic keratoplasty was performed and culture of samples taken at the time of surgery revealed skin flora only. Recovery following tectonic keratoplasty was complicated by a nonhealing epithelial defect which necessitated an amniotic membrane graft. Eight months following surgery, the patient developed a graft rejection episode; poor concordance with topical steroid medication being a likely contributing factor.\nFour weeks following this rejection episode, he presented again with a painful, injected left eye. Visual acuity remained at hand movements only. Anterior segment examination revealed a large, central, white corneal infiltrate within the tectonic keratoplasty []. A 1 mm hypopyon was present. An initial corneal scrape failed to identify a causative pathogen, and there was no clinical response to topical antibacterial and antifungal medication. A further corneal scrape revealed tiny, fine colonies of long Gram-positive rods [], consistent with mycobacteria. Subsequent auramine phenol staining was positive. Line probe assay of mycobacterial genetic material (Genotype Mycobacterium CM, Hain Lifescience) was performed, which resulted in the diagnosis of M. chelonae.\nTreatment was commenced with topical cefuroxime, amikacin, and gentamicin supplemented by oral linezolid. Following 1 month of therapy, an epithelial plaque and significant scarring remained, so the patient und"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old female Asian patient was admitted to our hospital with epigastric pain and jaundice for 1 week. Before admission, the patient had noted epigastric pain after eating greasy food, especially affecting the upper right abdomen with sustained pain. Gradually jaundice accompanied by darker urine and white, clay-like feces had appeared. She was diagnosed with cholelithiasis and obstructive jaundice in the local clinic, and concurrent anti-inflammatory treatment had been undertaken and her condition improved. Since the onset, she had no nausea or vomiting, no chills or fever, no significant weight loss. She had no appreciable loss of appetite. She had a 20-year history of gallstones. Physical examination showed yellow sclerae, flat abdomen, slight tenderness in the right upper abdomen, no guarding, and no rebound tenderness. The results of laboratory studies are shown in . In addition, hepatitis B surface antigen and hepatitis C virus antibody were negative.\nUltrasonography showed an atrophic gallbladder that was full of stones. Enhanced CT scanning of the upper abdomen demonstrated a smooth liver edge and uniform liver parenchyma, as well as dilatation of the intrahepatic bile duct and the upper pancreatic duct. The gallbladder was irregularly shaped, with thickened walls and uneven internal density. Radiologic observations indicated the presence of cholecystitis and gallstones; biliary stones were observed in the hilum, with secondary biliary obstruction (). MRCP revealed dilatation of the intrahepatic bile ducts and the left and right hepatic ducts, as well as truncation of the common hepatic duct (internal diameter was 5.1 mm). Multiple faint signals were seen in the common hepatic duct and gallbladder (). The MRCP results indicated the presence of cholecystitis, cholelithiasis, common hepatic duct stones, and ascites. The radiologist did not suspect MS or left hepatic atrophy pre-operatively. However, our surgical team had considered the possibility of MS"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old female patient present to our hospital with right upper abdominal severe pain for several hours after a fall. It was accompanied by fatigue. Her upper abdominal CT scan showed intrahepatic round cysts with the largest of size 14 cm × 16 cm. Irregular high-density shadows were seen on the edges of the cysts (). She was initially diagnosed as hepatic cysts with hemorrhage and underwent puncture and drainage of liver cysts. About 600 mL of dark red liquid was drained from the largest of the liver cysts, which improved the symptoms, but the cysts relapsed quickly. She underwent partial hepatectomy (fenestration of hepatic cysts), cholecystectomy and T-tube drain placement in the common bile duct. During the surgery, we found a large cyst large cyst of 20 cm diameter occupying the right lobe of the liver. The common bile duct was dilated about 1.5 cm. We resected the thinner part of the cyst wall and about 2000 mL of bile-like liquid mixed with blood clots and fresh blood were drained. Blood clots were mostly concentrated at the thicker part of the cystic wall and we biopsied the thicker cyst wall. Postoperative pathological report was simple hepatic cyst. 10 days post-operatively, the patient was complaining about paroxysmal abdominal pain which was also colicky. She had flatus but no defecation. Conservative treatment was in vain and hence, on POD 11 she underwent laparotomy as intestinal obstruction was suspected. It was observed that the transverse colon was wrapped around the T tube in the abdominal cavity. There were adhesive tissues due to which the intestine and transverse colon were folded. The adhesive tissues were relieved. 17 days after the surgery, the patient was discharged. 68 days later, the patient came back complaining about right upper abdominal pain and jaundice. Conservative management had no effect. Her CT scan shows a mixture of density at the liver which may be hemorrhage, recurrence"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient B is a 76-year-old white male who presented with microscopic hematuria in 1986 on a routine urinalysis and a diagnosis of left RCC was made by imaging. He then underwent nephrectomy for a 7 × 6 × 5.5 cm tumor extending though the fascia into the perinephric fat. He did well until March of 2006 when he had a routine chest X-ray that showed new lung nodules and a CT scan was ordered. A large retroperitoneal mass posterior to the stomach measuring 10 × 9 × 8 cm was also found along with bilateral lung nodules, with the largest lung lesion measuring 2 cm. Biopsy of the retroperitoneal mass confirmed RCC. MRI of the brain and bone scan was negative. He was seen for the first time at our institution in April of 2006. He was determined to be a candidate for high-dose IL-2 (600,000 IU/kg). After 8 weeks, he did show some response, but was only able to tolerate half of cycle 2 and he declined further IL-2. He was then started on sorafenib and had a minor response at all disease sites until CT scan in January 2007 after 24 weeks showed progression. He was then switched to sunitinib 50 mg daily for 4 weeks of a 6 weeks cycles, and after 12 weeks on therapy had a significant response which he enjoyed until week 54 when CT scanning showed marked disease progression. Sunitinib was discontinued and in January of 2008 he was started on temsirolimus 25 mg IV weekly. He required a 20% dose reduction for thrombocytopenia and oral ulcers. He remained on temsirolimus until April of 2008 when he developed symptomatic mTOR interstitial pneumonitis, so temsirolimus was discontinued. His disease continued to progress off therapy and in October of 2008, bevacizumab 10 mg/m2 given every 2 weeks was started as fifth line therapy. After 24 weeks of treatment the patient was found to have a pulmonary embolus. Lovenox was started and bevacizumab was continued without incident. At the time of submission"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nRC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.\nOn postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis report presents a case of aggressive periodontitis in a 23-year-old female who had previously received periodontal therapy. She was presented to the Department of Periodontics, Seoul National University Dental Hospital in 2004 with the chief complaint that her gums had been swelling (). She requested for dental treatment to address the issue of gum swelling and tooth mobility. Her medical history was unremarkable. Subsequent clinical and radiographic examination led to the diagnosis of generalized aggressive periodontitis (, ). The patient reported of becoming aware of swelled gums and mobile teeth when she was at the age of 13. At that time, she had received scaling and root planning in conjunction with systemic antibiotics which were periodically repeated through the years with no definitive results.\nIn 2008, the patient was referred to the Department of Prosthodontics for evaluation and treatment planning. The objectives of treatment were patient motivation and education, improvement of oral hygiene, improvement of esthetics, and a stable and predictable outcome.\nAll teeth including the canine in the maxilla and left mandibular lateral incisor through right mandibular canine, and left mandibular second premolar were extracted.\nInitially fixed prosthesis using implants in the maxilla were planned, but rapid and severe bone resorption after extraction was observed. Because the maxillary lip required additional support as a consequence of bone loss, the fixed prosthesis treatment plan for the maxilla was changed to an implant-supported overdenture. Facebow transfer and mounting on the casts on the articulator were performed for the diagnostic wax-up procedure.\nThe remaining teeth in the mandible were prepared for the fixed partial prosthesis. A provisional complete denture in the maxilla and provisional fixed partial dentures in the mandible was delivered. A computerized tomography scan with implant stent was taken to select suitable implant sites in the maxill"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old female presented with chronic headache with infrequent exacerbations. She presents with worsening headache for three months with associated vertigo, nausea, and vomiting not responding to analgesics or vestibular sedatives. Her symptoms initially started twelve years ago as a diffused mild headache, which persisted through the day. Gradually, the headache worsened to a severe headache episodically associated with vertigo, nausea, and vomiting. These episodes lasted for two to three days and got resolved. She was treated with flunarizine for suspected basilar migraine but did not show any response. From the last year, she had monthly exacerbations of headache associated with distressing vertigo, unsteadiness of gait, and right-sided body numbness. In between these episodes, she had a significant dull diffuse headache not responding to simple analgesia. She did not complain of fever or night sweats but had constitutional symptoms lasting for several months. All of these symptoms severely affected her daily activities and functionality.\nDuring the last 17 years, she had repeated episodes of neurological deficits. Even before the headache appeared, she has presented with visual impairment of the right eye and right lateral rectus palsy and was treated as retrobulbar neuritis with good response to methylprednisolone. One year later, she developed left-sided visual impairment, which fully responded to methylprednisolone. MRI imaging at that time revealed normal results. Few months after this event, she got admitted with right hemisensory loss with hemiplegia, and a demyelination disease or hemiplegic migraine was suspected. Second MRI was performed at this admission, and no abnormalities were detected again. Eight years ago, she had developed a left lower motor type facial nerve palsy, which was attributed to Bell's palsy. Within the last year, she was diagnosed to have depression and anxiety for which she was treated for few months. Other than the first two"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old male with a past medical history of cystic acne, but otherwise insignificant medication and social history, presented with concern for a parasite on his face. He reported that on the previous night he thought a parasite had crawled out of a healed cystic lesion on his right cheek. He presented a jar with a bloody napkin and paper, stating that he had scraped the parasite from his face with a scalpel and brought it with him to the ED. His physical exam was notable for diffuse excoriations and scaly patches, a 3 × 4 centimeter (cm) abrasion on his right cheek and mild anxiety. Otherwise his vital signs and physical exam were unremarkable.\nNo obvious parasites were appreciated on examination of his skin or in the jar. Basic blood tests including a complete blood count (CBC) and basic metabolic panel were within normal limits. A urine toxicology test was evaluated and reported negative. During his stay, the patient called a provider to the bedside to evaluate his thumb for a parasite actively crawling out of his skin. The provider documented that no obvious insects or wounds were apparent at that time. Delusional parasitosis was suspected and psychiatry was consulted, but the patient eloped from the ED prior to being evaluated.\nThe patient returned to the ED two days later with a complaint of parasitic infection. This time he described seeing white maggots crawling from his skin and presented us with a jar with a flaky material. The patient presented to the outpatient infectious disease (ID) clinic and was directed to come to the ED to obtain a formal ID consult. Although there was low clinical suspicion for an infectious component, ID was consulted for the presumed benefit of reassurance from a consultation service. The flakes presented by the patient were analyzed for ova and parasites and reported to the patient as negative. He was then evaluated by psychiatry who reported that his presentation was consistent with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old female without comorbidities and a 50-pack-year smoking history was referred to the emergency department with a severe right frontal headache. The onset was abrupt and the preceding symptoms and signs included nausea and ataxic gait. Neither cranial nerve abnormalities nor focal limb weakness was spared. Initial laboratory values were within the reference range. The patient underwent a magnetic resonance imaging (MRI) which revealed multiple nodular lesions throughout both cerebral and cerebellar hemispheres with an unusual lamellated pattern of enhancement. The demonstrated significant vasogenic edema did not led to midline-shift (Figures –). Chest X-ray detected opacity with a lobulated contour in the right upper lobe (). A contrast-enhanced chest computed tomography (CT) showed an ill-defined mass in the anterior segment of the right upper lobe and right hilar lymphadenopathy (). No additional abnormalities were observed on subsequent detailed metastatic work-up including abdominal CT and whole body bone scintigraphy. Due to the neurological symptoms, the patient underwent whole-brain radiotherapy (WBRT). Fractionation of 3 Gy per day was used, reaching a total dose of 30 Gy in two weeks; in addition, the patient received intravenously dexamethasone during WBRT. The performed bronchoscopy detected a bulging lesion located at the membranous portion of bronchus of the anterior segment of the right upper lobe. The lesion did not appear to be covered with normal bronchial mucosa. Subsequently, a biopsy was performed (), and the histopathology showed infiltration by atypical melanocytes containing melanin pigmentation (Figures and ). Positive immunohistochemical staining of MART-1, S-100 protein, and HMB-45 and lack of expression of cytokeratin (CK), epithelial membrane antigen (EMA), synaptophysin (Syn), and high molecular weight cytokeratin confirmed the diagnosis of pulmonary melanoma. Molecular profiling was conducted which failed to detect any mutat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old Hispanic female presented with vague abdominal pain and exertional chest pain. She had a ten-year history of worsening epigastric pain attributed to gastritis that was treated with Dexilant. A general physical exam was done and did not reveal any significant abnormalities; she also denied any fevers, chills, weight loss/gain, or change in bowel habits. Environmental history was noncontributory as she denied extensive sun-exposure or use of tanning beds and reported that she regularly would use sunscreen with a 30 SPF. Still, there was an extensive past medical history for anemia, diabetes mellitus type II, coronary artery disease, asthma, hypertension, hyperlipidemia, hemorrhoids, and osteoarthritis. She also had a broad surgical history, involving a coronary artery stent in the left anterior descending artery [2016], percutaneous transluminal coronary angioplasty [2016], tubal ligation [1985], cholecystectomy [2007], bladder prolapse repair [2012], rectal prolapse repair [2012], hysterectomy [2012], and total right knee replacement [2013].\nThere is no report of primary tobacco use; however, she does report an extensive second-hand smoke exposure as a result of her biological father. Her family history is significant for multiple cancers, with her father dying of cancer related complications from a head and neck malignancy at the age of 65. The patient's sister died of breast cancer at the age of 44 and half paternal sister also died of breast cancer at the age of 38. Lastly, her brother died of colon cancer at the age of 70 and her mother's death at the age of 67 was due to a myocardial infarction unrelated to cancer. Interestingly, her eldest daughter was diagnosed with melanoma found in a cutaneous lesion, in 2016. Her physical exam did not reveal any concerning skin lesions or palpable abdominal lesions and her vitals were stable.\nA near total gastrectomy was performed and multiple adhesions from prior surgeries were divided at the beginning of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old girl presented to our outpatient department with a swelling of the tongue of 1-year duration, which was initially slowly growing but later started progressing rapidly in the past 3 months. She was complaining of inability in the movement of the tongue leading to difficulty in speaking and chewing of food. This also resulted in nasal regurgitation of food. She was not suffering from any co-morbid conditions.\nOn examination, her general health was fair (Eastern Cooperative Oncology Group performance status was 1). On intra-oral examination, there was a lobulated swelling involving the entire tongue with an intervening ulcer and there was restriction of the tongue movement. Multiple bilateral level 1A and 1B nodes of varying sizes were palpable and which were fixed to the underlying structures. The largest node was around 3 cm in size, which was on the left side (clinical staging was T4bN2cM0).\nExamination of the skin, abdomen, respiratory system, cardio vascular and the central nervous systems were found to be normal. Magnetic resonance imaging (MRI) of the tongue showed an enhancing mass of more than 5 × 4 cm in its greatest dimension. The mass involved both sides of intrinsic as well as extrinsic muscles with loss of definition of lingual septum []. Extension of the mass was seen into the right-sided sublingual space with encasement of the neurovascular bundle which was also extending anteriorly to the tip of tongue. There was no bony erosion. No extensions were seen into the carotid and bucco-masticator spaces. Magnetic resonance imaging of the neck showed metastatic cervical lymphadenopathy at the level I, II, III, IV on the left and level II on the right []. Clinically, the diagnosis of the lobulated swelling with an ulcer on the tongue, was that of an infiltrative epithelial malignancy or a minor salivary gland malignancy. Limitation of punch biopsy in this case was the presence of a limited intervening area with ulceration on the tongue swelling,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male with a one-year history of renal cell carcinoma was admitted for routine follow-up. The general physical examination and laboratory tests were normal. We observed hypodense-hypovascular cystic lesions with thin septi in the uncinate process and body of the pancreas, and the pancreas measured 5 cm in diameter on the abdominal CT scan (). Contrast-material enhanced MRI revealed numerous diffusely distributed cysts with thin septi, and these cysts ranged in size from a few millimeters to 14 mm in diameter in the body and uncinate process of the pancreas. Contrast-material enhancement in the pancreatic lesions was not observed on the postcontrast (arterial and portal venous phase) T1 weighted (W) images (). The main pancreatic and extrahepatic bile ducts were normal on the T2W sequences. Our preoperative diagnosis was \"cystic neoplasm of the pancreas\", and pancreaticoduodenectomy was performed by general surgeons.\nMacro- and microscopic examination revealed numerous cysts ranging from 2 to 12 mm in diameter with a thin translucent wall in the body and head of the pancreas. The tumor was 5 cm in diameter. The internal surface of the cysts was pink, smooth and glistening and the surface of the cysts had no solid areas or papillary projections. There was no discrete tumoral lesion, necrosis, calcification or hemorrhage observed on further examination of the pancreas (). The duodenum was normal in appearance.\nMicroscopic examination revealed numerous small and large cysts diffusely distributed throughout the pancreatic tissue. The cysts seemed to develop from the surrounding acinar tissue and they were lined by cells with the typical features of normal acinar cells. There were disseminated patchy acinar structures within some small and large cyst walls (). The small cysts were lined by a single layer of bland cuboidal or columnar acinar cells with tendency for crowding. Their nuclei were basally located and regular, and they contained small nucleoli. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old man came to our emergency room seeking medical attention for severe neck pain. He informed us that 2 days before, after excessive consumption of alcohol, he had made an incision into the skin of his penis below the frenulum by means of a needle in order to insufflate air into the opening with a standard ball pump (fig. ) for autoerotic purposes. He had been suffering from severe pain in the neck area since the morning.\nBelow the frenulum, a reddened incision of approximately 5 mm in diameter could be seen which extended into the hypodermis. Apart from that, the penis was without pathological symptoms such as swelling, hyperthermia or redness. Also, the penis was not rigid and there were no crepitations. In the neck area and on the remaining trunk, crepitations could be felt. This was where the patient's pain was located, radiating dorsolaterally from the cervical area into the trapezius muscle.\nThe psychological exploration of the patient's sexuality clarified that he had distinctive sadomasochistic masturbation fantasies. The patient had not pursued these sadomasochistic thoughts so far because he had not been aware of them.\nThe laboratory results were unremarkable. Because the patient was capable of spontaneous and pain-free micturition and the external examination showed no anomalies, a cystoscopic examination of the urethra was not carried out. A CT examination of the abdomen revealed generalized subcutaneous emphysema extending from the scrotum to the abdomen and the cervix (fig. ).\nThe patient was admitted for observation. He received antibiotic treatment with a gyrase inhibitor in order to avoid an infection of the area around the frenulum. The medical focus was on the neck pain caused by the air gradually travelling through the hypodermis from the genital area to the cranial area. The pain was stabilized without difficulty by means of metamizole. After 2 days, it was no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old woman complained of visual disturbances in her right eye that began in July 2002. She did not have a history of any systemic illness, and there was no family medical history of any disease. In 2001, she had undergone a peripheral iridotomy on the right eye for angle closure glaucoma, and she developed the pseudoexfoliation syndrome. Her postoperative intraocular pressure (IOP) in the right eye was 12 mmHg. The depth of the anterior chamber of the left eye was normal and the IOP was 11 mmHg.\nIn May 2002, although the IOP in her left eye was 12 mmHg, the right IOP was 22 mmHg, and we concluded that she had ocular hypertension secondary to the pseudoexfoliation syndrome. We began topical latanoprost in the right eye, and the IOP decreased to 13 mmHg by June. The IOP in the left eye remained at 12 mmHg. In July, she returned reporting visual disturbances and monocular double vision. The lens was partially dislocated in the right eye. At this time, the IOP in the right eye was 20 mmHg and the left eye was 10 mmHg. The right lens had a mild cataract. There were no clear glaucomatous changes in the optic discs, and no other specific findings. The Goldman perimetric fields were full.\nTo examine the effect of latanoprost on the position of the lens, we stopped the latanoprost for two weeks. The IOP was measured with a Goldman applanation tonometer one hour before and after topical latanoprost, and the position of the lens was assessed by slit-lamp biomicroscopy. In addition, ultrasound biomicroscopy (UBM) was performed to measure any changes in the thickness of the ciliary body []. (Figure )\nOne hour after one drop of 0.005% latanoprost, the right IOP decreased from 20 mmHg to 17 mmHg and the IOP in the left eye was reduced from 10 mmHg to 7 mmHg. Slit-lamp bi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 5-year-old girl was referred to our hospital for the investigation of urinary incontinence. The patient had continuous low volume urine leakage requiring 4–5 daily pads. The parents could not specify whether there was any connection with standing, coughing, or effort and she had no urge to void.\nShe was constantly wet but had normal voiding habits. On initial physical examination the external genitalia appeared normal with no vaginal pooling of urine or ectopic ureteral orifice. However, a long-term external genitalia examination revealed normal urethral and vaginal openings, with an intermittent urine leakage through the vaginal orifice, which slightly increased in abdominal pressure.\nIn her past history she had recurrent febrile urinary tract infections (UTIs) since her infancy. At the age of 3 she underwent an abdominal ultrasound that suspected a double left kidney. A voiding cystourethrogram (VCUG) was performed and a vesicoureteral reflux (VUR) grade III on the right kidney was found. She was given chronic chemoprophylaxis without any UTI recurrence. She had a good toilet training and gave up daytime diapers around the age of 3. At this moment parents noticed the urinary incontinence, but this didn't bother them. At the age of 4 parents asked a urologist for help, who considered the symptoms to be the result of an overactive bladder and anticholinergic treatment was recommended. No improvement was noticed, and for this reason the little girl was sent to our department for further investigation.\nComplete blood count, biochemical tests, and urinalysis were all normal and the urine culture was negative.\nAn abdominal ultrasound was performed and both kidneys had normal parenchyma and size, with a duplex-system suspicion on left side; the bladder was normal in appearance. The VCUG was repeated but no VUR was visualized. As we had a high suspicion of an ectopic ureter a contrast-enhanced computed tomography (CT) of the abdomen and pelvis was performed to visualize"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman was admitted to the emergency room for a clinical picture characterized by the episodes (duration 5–10 min) of atypical chest pain irradiating to the upper left limb. The patient reported previous cocaine and heroin abuse and current smoking of about 20 cigarettes per day. Body mass index of 31 was calculated. The electrocardiogram (ECG) showed normal ECG pattern, and the high-sensitivity troponin I resulted normal on several determinations.\nSince 2006, the patient underwent serial echocardiographic examinations that revealed and confirmed alleged bicuspid aortic valve (BAV) with no aortic dilation and mild aortic regurgitation.\nIn her past clinical history, the patient reported noncomplicated peptic ulcer and chronic gastritis, lymphatic adenopathy of undetermined etiology, and recurrent episodes of anorexia/bulimia and panic attacks, treated with antidepressants – selective serotonin reuptake inhibitor, valproate, and diazepam. She reported two pregnancies: one child was diagnosed with right-sided aortic arch congenital anomaly and cleft palate and the other one was in good health status. Patient's father died from myocardial infarction at the age of 55, and her mother was affected by systemic hypertension.\nAt admission to our unit, the clinical examination revealed regular heartbeat and 2/6 levine diastolic murmur; blood pressure was 140/80 mmHg and SpO2 was 98% breathing room air. The ECG showed sinus rhythm, and no abnormal findings were detected: the ECG pattern was overall normal and ventricular repolarization was actually within the normal limits; no changes on ECG were detected when compared to previous ones performed in the emergency room.\nA transthoracic echocardiography (TTE) was performed: biventricular systolic function was considered normal, ejection fraction was estimated 60%, no wall motion abnormalities were found, and left ventricular dimensions were within the normal limits; according to age and body surface area (LVIDd: 53 mm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old gentleman presented as an emergency to our institute with left-sided hemiparesis and aphasia. He had no prior co-morbidities, and the family history was insignificant. On examination, he was found to have a power of 0/5 in all muscle groups, according to the medical research council (MRC) muscle grading system, on the left side along with complete aphasia. However, the function of cranial nerve XII was intact. However, the examination was the neck was unremarkable; there was no palpable mass or skin changes in the neck region. The carotid pulses were palpable bilaterally.\nOn initial workup, Magnetic resonance imaging with angiogram was done, which showed a right middle cerebral artery (MCA) territory infarct and a heterogenous lesion within the neck just above the level of the carotid bifurcation. Subsequently, post-contrast images from the head and neck region were also acquired (). The lesion's appearance and characteristics suggested a glomus tumor of the neck. Further evaluation with an ECG and cardiac echo was performed to rule out the cause of an infarct. ECG and cardiac echo were found to be normal. Computed tomography angiogram of the neck was done (), which showed a highly vascular mass, 2.8 x 3.4 x 6.0 cm in size, arising above the carotid bifurcation with its feeding vessel arising from the right external carotid artery. It was splaying the right internal carotid artery anteriorly and medially and extending up to the hypoglossal canal.\nThe radiologist suggested it as an atypical glomus tumor or a rare peripheral nerve sheath tumor. With consideration of the location, clinical presentation, and imaging features, a working diagnosis of glomus tumor of the neck was made.\nBased on our working diagnosis of Glomus tumor, surgical excision was planned. In order to control hemorrhage intra-operatively, angioembolisation of the tumor was done before surgery, and approximately 90% embolization was achieved ().\nUnder"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male with a history of alcoholism and radiation treatment (total dose of 57.6 Gy) for early-stage vocal cord cancer 16 months earlier was referred to us with radiographic detection of a pulmonary nodule in the right lower lobe. Endobronchial biopsy of the pulmonary nodule revealed the diagnosis of squamous cell carcinoma. Positron emission tomography/computed tomography (CT) revealed accumulation in the pulmonary nodule, but no other lesion was suggestive of metastasis. The tumor was diagnosed as a primary lung cancer, clinical stage IA1 (T1aN0M0), or metastatic pulmonary tumor, and video-assisted thoracoscopic right lower lobectomy with lymph node dissection was performed. Level 8 and 9 lymph nodes were not enlarged; therefore, lymph node dissection of these nodal station was not performed (Fig. a), while the level 7 lymph nodes were dissected. There was no direct injury of the esophagus, and no apparent esophageal damage was visualized on magnified video endoscopic images (Fig. b). The operation was uneventful. The patient was able to resume oral intake from the day after the surgery.\nThe patient tended to need to make a strong effort to cough, with swallowing and expectoration having become difficult, presumably due to the radiation therapy given to the larynx. Three days after the operation, the patient developed severe sudden pain in the right shoulder with high fever (39.6 °C). Findings of the chest X-ray obtained with a portable apparatus showed a few infiltrative shadows in the right lung field, and blood examination revealed no findings that were not compatible with the postoperative status of the patient. The patient was started on intravenous antibiotic administration. Absence of air leakage through the chest tube was confirmed, and the chest tube was removed 4 days after the operation. However, a plain chest X-ray revealed increased infiltrative opacities in the right lung field, and the patient developed a right pneumothorax 5 days after t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old previously healthy young man presented to the Pediatric Infectious Disease Clinic in September of 20151week after arriving in the United States from a refugee camp in Mozambique with a 3-month history of pain and swelling in the upper leg just below the knee. He had no fever noted, no erythema over the knee, and his symptoms had not changed appreciably since arrival in the United States. He had not received any antimicrobial therapy for this condition. His erythrocyte sedimentation rate (ESR) at presentation was 40 mm/h with a C-reactive protein (CRP) level of 0.9 g/dL and a leukocyte count of 6,900 cells/µL (50% polymorphonuclear cells, 37% lymphocytes, 11% monocytes, 1% eosinophils, and 1% basophils). On examination, his affected knee was slightly swollen with mild tenderness over the medial aspect. No discharge or erythema was noted. His range of motion for his knee was slightly decreased for flexion and extension, and an antalgic gait was present. At that time, a plain radiograph demonstrated concerns of chronic osteomyelitis of the right proximal tibia although tumor or subacute fracture was also considered (). Contrasted magnetic resonance imaging (MRI)demonstrated findings consistent with chronic osteomyelitis along the medial aspect of the proximal tibial epiphysis and metaphysis, however, with a cloaca extending from a cortical disruption of the posteromedial tibial metaphyseal cortex (). Given a desire to pursue potential debridement and obtain cultures simultaneously, he underwent surgical debridement of the area the following day, cultures from which were sterile. Given his recent exposure to a refugee camp in Africa, the resulting potential for infection with an unusual organism was also felt to justify the need for an open biopsy with cultures. A cortical window was not created although extensive debridement of the area was performed. The joint space was not entered during the surgery. No orthopedic hardware or antimicrobial-impregnated b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old male was admitted to a hospital in June 2016 because of right arm asthenia and dysarthria and was diagnosed as having cerebral infarction in the left middle cerebral artery area along with deep vein thrombosis. ECG demonstrated normal sinus rhythm and echocardiography revealed no intra-cardiac thrombus or vegetation. The patient was discharged from the hospital following administration of apixaban.\nIn August 2016, the patient was readmitted to the hospital because of recurrent right arm asthenia and dysarthria. MRI revealed multiple cerebral infarctions in not only the bilateral cerebral hemispheres but also the cerebellum. Trousseau’s syndrome was suspected at this time. Apixaban administration was stopped and an intravenous drip of heparin was started. Echocardiography revealed mild mitral regurgitation with vegetation on the mitral valve. Although the laboratory data suggested no evidence of infection, ceftriaxone and gentamicin were added as a precaution against infective endocarditis. The patient was then referred to our hospital for surgery.\nA CT scan revealed a left renal infarction and multiple swollen lymph nodes around both the abdominal aorta and stomach with antral hypertrophy, suggesting an advanced gastric cancer or lymphoma. As the vegetation showed no change despite the heparin and antibiotics therapy, cardiac surgery was performed on day 5 after referral. Extracorporeal circulation was instituted employing aortic and bicaval cannulation. After aortic cross-clamping, the mitral valve was exposed via a left atriotomy. Both mitral leaflets had vegetation on the surface, and major vegetation 15 mm in width was evident on the anterior leaflet (Fig. ). These were resected in their entirety and replaced with a 25-mm Epic bioprosthesis (Abbott). Continuous intravenous heparin administration was resumed on the following day, aiming for an activated partial thromboplastin time of between 40 and 50 s. Histologic analysis revealed that the vegetat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old right master-handed gentleman presented approximately 20 hours after sustaining a crush injury to his left non-master hand in a log splitter at home. His past medical history was significant for hypertension.\nThe patient initially was seen at a neighboring institution for evaluation and treatment. The physical exam on transfer revealed bruising of the distal volar forearm just proximal to the wrist without skin laceration. Radial and ulnar pulses were lacking distal to the area of injury. Clinically, the hand was cool, slightly blue, and lacked digital pulp turgor. Plain X-ray revealed pisiform fracture and scapholunate dissociation. The patient underwent emergency angiogram, which revealed abrupt cutoff of radial and ulnar artery flow into the left hand at the level of the distal forearm just proximal to the wrist junction. There was no evidence of extravasation of dye (). Radiologic interpretation was felt to be consistent with ulnar and radial artery spasm. The patient was not felt to be a candidate for tissue plasminogen activator (tPA), given the nature of his injuries. Since the patient showed no improvement on IV Heparin and the hand remained mottled and cool, emergent surgical exploration was recommended and accepted.\nFasciotomies were performed on the volar forearm, the thenar eminence, and the inter-metacarpal regions in conjunction with a carpal tunnel release. Additionally, a Guyon’s canal release also was performed. The median and ulnar nerves were both intact. The ulnar artery was severely bruised and thrombosed over a length of 8 cm, extending from the ulnar aspect of the superficial palmar arch to 2 cm proximal to the volar wrist crease. At that level in the distal forearm, a total avulsion injury of the ulnar artery was evident with the proximal and distal components of the ulnar artery separated by 5 cm (). The intervening gap between the ends of the ulnar artery contained torn and stretched adventitial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy presented with profound painless progressive diminution of vision of right eye since 3 months. Suddenly, in the left eye, he developed a painful red eye during the last 15 days. On ocular examination, best-corrected visual acuity in the right eye was hand movement close to face with an inaccurate projection of rays and in the left eye was 6/60. The right eye pupil was 8 mm in size, dilated, and nonreacting (), and the retina had exudative retinal detachment around the disc with macular edema (). The left eye was congested and the cornea was edematous. The anterior chamber was filled with fibrinous exudates and hyphema (). Hemorrhagic iris nodules were noted in the iris stroma without iris neovascularization. The pupil was 5 mm in size, irregular with multiple posterior synechiae, and sluggishly reacting and covered with fibrinous exudates. The lens appeared clear, but the details of vitreous and retina of the left eye could not be appreciated. An ultrasonography of right eye showed hyperechoic shadow in vitreous and areas of retinal detachment with subretinal fluid collection, but left eye ultrasonography was normal. Intraocular pressures in right and left eye were 12 and 31 mmHg.\nThe episode was preceded by high-grade fever with chills/rigor and multiple skin rashes involving the face and trunks for the past 4 months. It was also associated with painful subcutaneous nodules over the scalp, trunk, and arms followed by painless enlargement of axillary and cervical lymph nodes.\nOn systemic examination, there were multiple papulonodular rashes over the face () and trunk with a subcutaneous ulcerated nodule in the scalp, arm, and back of trunk (). The cervical and axillary lymph nodes were enlarged, firm, nontender, and not matted. Histopathological examination of skin and axillary lymph nodes revealed dense infiltrate of cells composed of histiocytes, lymphocytes, and occasional eosinophils. The histiocytes have scant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female patient was referred to our department for laparoscopic excision of GIST in the stomach. Prior to our treatment she underwent an esophagogastroduodenoscopy due to epigastric pain and occasional vomiting. Endoscopy showed erosive gastritis, a hiatal hernia, and a submucosal tumour located along the lesser curvature on the posterior wall of the antrum (). The tumour had a central eroded depression but otherwise appeared to be covered with normal mucosa. Several biopsies of the tumour were taken using the bite-on-bite technique. Unfortunately, only scant samples of the submucosa were obtained, which precluded a histological diagnosis of the tumour.\nEndoscopic ultrasonography confirmed a 22 × 13 mm submucosal well-defined solid tumour arising from the fourth, muscular, layer of the stomach (). The tumour appeared to be nodular, with slightly heterogeneous echogenicity. Endoscopic ultrasonography did not demonstrate a significant ulceration or ductal structures. In the diagnostic work-up of abdominal pain and vomiting the patient had undergone transabdominal ultrasonography, which showed no focal lesions in the liver. Before surgery, we performed another endoscopy where the lesion was tattooed proximally and distally.\nLaparoscopy was performed, and on initial exploration of the abdominal cavity, we discovered a tattooed submucosal tumour on the greater curvature of the stomach. Laparoscopic excision was performed and the specimen was recovered in a retrieval bag. The abdominal cavity was irrigated with saline and the fluid aspirated. An abdominal drain was inserted beneath the stomach. The fascia and skin wounds were sutured. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day.\nResection samples were sent for histopathological analysis. The histopathologic analysis report about 6.6 × 3.5 cm excision gastric wall. The mucosa and serosa have normal appearance, muscularis propria and submucosa include a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA male patient aged 49 years reported to the Department of Periodontics, Sri Siddhartha Dental College and Hospital, Tumkur, with the chief complaint of deposits present on his teeth and he desired to get his teeth cleaned. Patient's medical history was not contributory. Patient had undergone extraction of upper right canine 2 years back, with uneventful healing.\nOn intraoral examination, stains and calculus were present along with generalized gingival inflammation and bleeding on probing []. Generalized periodontal pockets and attrition were present. Grade I mobility was present w.r.t. 12, 17, 25, 26, 35, and 36. Periodontal pocket measuring 7 mm was found w.r.t. 35 and 36, and no carious lesion was seen. The patient was advised orthopantomogram (OPG) which revealed presence of generalized bone loss along with a unilocular radiolucent area resembling a “tear drop shape” with a clear sclerotic lining, along with angular bone loss involving the mandibular left premolar and the mesial root of mandibular first molar [].\nThe vitality of the pulp was checked w.r.t. 35 and 36; it showed positive response as that of the contralateral side, and hence, endodontic involvement was ruled out. The patient was explained regarding the presence of lesion and a surgical excision of lesion was planned. The patient showed no symptoms, no history of swelling, discomfort, or pain, and was unaware of the presence of the lesion. Hematological investigation was done prior to surgery and was found to be normal. A comprehensive explanation was given to the patient regarding the intended surgical procedure to be done and an informed consent was taken before starting the procedure.\nFor surgical enucleation of the lesion, crevicular incision was given extending from canine till the first molar region [], with two vertical releasing incisions given, one on the mesial aspect of 33 and the other on the distal aspect of 36. A subperi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old woman was admitted with fever and dull abdominal pain. She had been postmenopausal for 18 months and had no abnormal vaginal bleeding. A physical examination confirmed the presence of a cystic mass 10 cm in diameter on the right posterior of the uterus with clear boundaries, poor activity and no tenderness. The serum levels of CA125 and CA199 were 88.8 U/ml and 40.4 U/ml, respectively. Vaginal ultrasonography revealed a cystic mass full of fine spots that was located in the right ovarian area; the mass had clear boundaries, irregular low echo protrusions on the wall and no blood flow signals on CDFI. A solid mass with clear boundaries and a diameter of 7.3*5.9*6.5 cm was located below the former site of the cystic mass, and abundant arteriovenous blood flow signals could be seen inside and around the mass.\nHer medical history included 30 years of dysmenorrhea and 18 years of endometriosis and adenomyosis.\nWe performed an exploratory laparotomy, and during the operation, a small amount of bloody ascites was observed. We observed that the size of the uterus was approximately equal to that at 6 weeks of pregnancy, and no obvious abnormality was seen in the left ovarian area. A cystic-solid mass with an approximate diameter of 10*15 cm was seen in the right ovarian area. After 600 ml of thin, chocolate-like intracapsular fluid was removed, we observed that the mass was densely adherent to the surrounding pelvic peritoneum and that the rectal pouch was completely closed. The source of the mass was found to be the left accessory ovary, and thus, the left adnexa was completely removed. After the mass was cut open, the contents appeared pale white, crisp and vortex-free and contained a chocolate-like liquid. The intraoperative rapid pathology report described a right ovarian spindle cell tumor with a large necrotic area, which was considered a sex cord-stromal tumor, but a malignant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old left-handed man who works as a mechanic and firefighter presented to our institution with hand pain and cold intolerance for 3 months. He was referred by a local vascular surgeon who had made the diagnosis of hypothenar hammer syndrome (HHS) following an angiogram of the right upper extremity showing complete occlusion of the ulnar artery (). On initial examination, Doppler signals of the ulnar artery, superficial palmar arch, and ring/small digital arteries were absent in the right hand. Subsequently, the patient developed an ulcer on his right long fingertip after minor trauma that had not healed over a 4-week period. He suffered ischemic hand pain and severe cold intolerance. After conservative management failed, the decision was made for operative intervention. We proposed using an arterial graft versus a venous graft in order to improve long-term patency. Our plan was to utilize the descending branch of the lateral circumflex femoral artery (DLCFA) as an arterial graft.\nIntraoperatively, Doppler ultrasound revealed a segmental thrombotic defect extending from the superficial palmar arch, across the Guyon canal, extending 10 cm proximally in the forearm. The ulnar artery was resected back to healthy bleeding pulsatile flow, resulting in a segmental defect of 12 cm. Final pathology of the submitted ulnar artery segment revealed organizing thromboembolus in the lumen, which at the time of resection was adherent to the lumen.\nThe DLCFA was harvested, with care taken to prevent injury to the lateral femoral cutaneous nerve. A 12-cm segment of the artery was circumferentially dissected, as well as approximately 2 cm of 2 branching vessels at the distal end of the segment that would be used to reconstruct the superficial palmar arch and common digital arteries with one graft. With the arterial graft completely dissected, it was ligated both distally and proximally.\nThe arterial graft and recipient vessels were examined under the operative microscope. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man presented with a 16×6 cm2 open wound with an accompanying tibiofibular fracture due to a traffic accident. Free flap coverage was planned, with a necessary pedicle length of 14 cm from the middle of the flap to the recipient vessel and 9 cm from the flap margin. A 20×6 cm2 ALT flap from the patient’s ipsilateral thigh was planned. The perforator that branched at the proximal descending branch of the lateral circumflex femoral artery was found intraoperatively (). The length of the branched perforator was 7 cm, and the available length of the descending branch on the proximal side was 2 cm, so the estimated pedicle length was 9 cm (). For pedicle length extension, dissection was performed on the distal aspect, which resulted in obtaining 7 cm of the distal descending branch. Thus, we were able to obtain a reverse ALT free flap with a total pedicle length of 14 cm in the distal direction. Before elevating the reverse ALT free flap, we clamped the proximal descending branch to check for flap circulation. We confirmed that flap congestion was present due to impaired retrograde flow through the valves of the vena comitans in the distal direction. To resolve flap congestion, one of the venae comitantes of the distal descending branch was isolated and connected to the proximal venous stump in an antegrade manner (). When connecting a 1.5-mm vena comitans of the distal descending branch with the 2-mm proximal venous stump, the diameter discrepancy of the venous anastomosis was not significant (). A modified ALT flap pedicle 15 cm in length was formed to prevent venous congestion and to ensure adequate length to reach the recipient vessel. As a result, the direction of the arterial flow to the flap was retrograde, and the venous flow was antegrade. To evaluate the flap condition after surgery, the flap color was checked and the pin-prick test and Doppler ultrasonography were performed. For 2 days after surgery, the flap status was maintained, with no findin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye \"\". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted \"\". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.\nCases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 54-year-old female, is a known case of carcinoma of the head of the pancreas, which revealed being a periampullary pancreatic adenocarcinoma after histopathological examination. She underwent uneventful Whipple's procedure in September 2010 followed by adjuvant chemotherapy (carboplatin and methotrexate), with the last cycle being five years before her presentation. She has been on regular follow-up with oncology department without local or systemic recurrence.\nIn November 2015, she presented with a progressive painless swelling in the right parietal region of six-month duration. There was no history of trauma or previous head radiation. Before the presentation, patient overall health condition was stable with unremarkable history. Her social history was unremarkable and specifically negative for smoking.\nHer physical exam and vital signs were within normal. Local examination revealed a hard mass of 5 × 6 cm in diameter with distinct edges, fixed to the skull.\nThe scalp over it was mobile and with no discoloration or discharges and no regional cervical lymphadenopathy. Neurological examination revealed a conscious, alert, and oriented patient without a focal neurological deficit.\nLaboratory workup including CBC, renal, hematology, and hepatic profiles was within normal. Chest X-ray identified a small nodule in the left upper lobe.\nInvestigations also included CT brain, which demonstrated a lytic bony lesion with classic sunburst periosteal reaction measuring 4.3 × 3.1 × 5.4 cm (). The lesion was causing mild displacement of the adjunct cortex with no detected calcifications. There was no underlying vasogenic edema, and no other osseous skull lesions were detected. The cerebral and cerebellar parenchyma showed preserved gray-white matter differentiation, with no evidence of acute territorial infarction and no evidence of abnormally enhancing cerebral parenchyma or meninges. There was no midline shift, and ventricular system, basal cistern, and cortical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old woman sought evaluation of a mass in the anterior chest wall. A cardiac pacemaker was placed for bradycardia due to atrial fibrillation 3 years before. Twenty years prior an enlarged hilar lymph node was biopsied and the histologic evaluation revealed an adenocarcinoma that was thought to be a metastatic lung carcinoma, but the origin was not established.\nA magnetic resonance image (MRI) and computed tomography (CT) showed the chest wall lesion on the surface of the sternum and the distal third rib. The tumor size was 4 x 5 cm, and the lesion extended to the subcutaneous tissue and intracoastal spaces between the second and third ribs (). The histologic evaluation of a biopsy specimen was characterized as proliferation of atypical spindle cells.\nThe tumor was resected along with the surrounding normal tissues of the overlying skin, the surrounding subcutaneous tissues, and the pectoralis major muscle. The anterior cortex of the sternum at the proximal and distal cut lines, as well as right lateral aspect of the cortex was cut with a high-speed burr. The left second-to-fourth ribs were cut along the resection line and an additional excision of ~5 mm was made at each second-to-fourth rib to confirm complete pleural reaction and handle the lesion for the next step.\nUnder fluoroscopy the left outline of the sternum was confirmed. As a tip, a 1.5-mm Kirschner wire was placed along the line of the sternum on the skin. A curved pelvis osteotomy chisel was used to cut the sternum from right-to-left, then the blade was used along the anterior surface of the posterior cortex of the sternum. Under fluoroscopy guidance, the blade was directed over the left outline of the sternum, which was marked with a Kirschner wire. Incomplete resection of the left outline of the sternum was cut with the curved chisel from the distal end. The remaining soft tissues, including the internal thoracic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42 year old female presented with a 6 months history of progressively worsening pain over the right shoulder and chest wall, aggravated by movement and with associated right arm oedema and paraesthesia. She believed mild symptoms began 2 years prior to presentation.\nOn physical examination she had a tender mass over the 2nd–5th intercostals spaces with over lying visibly engorged veins. The blood pressure was BP 130/70 mmHg and pulse rate (PR) was 62 bpm and regular.\nA chest xray showed a vague shadow over the 3rd intercostals space mid clavicular line, (Fig. ), a CT scan showed clearly a mass extending to a butting the pleural cavity pleura, see Fig. .\nAn echocardiogram and ECG were normal; cardiac enzymes panel was normal too.\nThe patient was consented for an exploration under general anesthesia, in supine position under general anaesthesia (GA), a 6–8 cm incision was made over the mass and a combination of blunt and sharp dissection the mass was wholly excised without opening into the pleura.\nThe patient was discharged on the 3rd post operation day, pain had significantly reduced and the limb oedema nearly resolved.\nThe histopathological examination revealed a benign lesion; a schwannoma with degenerative changes. The section revealed a benign nerve sheath tumor characterized by a proliferation of band spindle cells arranged in fascicles and variable cellularity and associated with dilated and think walled blood vessels. There was no evidence of malignancy.\nSchwannoma is a benign neurogenic tumour and is usually founded as a solitary lesion. Chest wall schwannoma is rare and usually asymptomatic (Moon et al. ). In this patient it was symptomatic and mimicked a metastatic lesion even though no primary lesion was detected prior to the exploratory surgery. The lesion was completely excised under general anaesthesia and endotracheal intubation in supine position. The procedure lasted 45 min with minimal blood loss. The immediate post operative period was unremarkab"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old Caucasian British woman originally presented to her local hospital in 2002 with shortness of breath secondary to atrial fibrillation. During the admission, chest radiography revealed widespread pulmonary nodular infiltrates, and a subsequent computed tomography (CT) scan confirmed the presence of widespread pulmonary metastases, most marked in the lower lung fields (Figure ). The CT scan also demonstrated extensive retroperitoneal and para-aortic lymphadenopathy and hepatic abnormalities consistent with metastases, but no obvious primary site for the disease (Figure ).\nBefore admission, our patient had no symptoms of liver dysfunction and her medical history was otherwise unremarkable. She had no family history of malignancy. Routine haematology, clotting, serum biochemistry and liver function tests, hepatitis screen and tumour markers were all within normal limits. After the standard medical management for atrial fibrillation was completed, a CT-guided biopsy of the predominant hepatic lesion was performed.\nHistological examination of the biopsy confirmed the presence of an infiltrating tumour with pleomorphic elongated cells that stained positively with the vascular markers Factor VIII, CD31, and CD34. These morphological and immunohistochemical features were consistent with the diagnosis of HEH. In the presence of disseminated disease, surgical management was not indicated, and our patient was referred to the oncology team for ongoing management.\nIn response to radiological evidence of disease progression, first-line therapy with interferon was commenced in accordance with the dosing recommendations published in an earlier case report []. A CT scan performed after three months therapy demonstrated stable disease; however, as our patient was experiencing significant interferon-related side effects, the treatment was discontinued. After a six-month break from therapy, there was evidence of disease progression within the spleen seen on an updated CT sc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA two-week-old female was brought in with an initial complaint of multiple masses that failed to regress since birth. She was born from a nonconsanguineous union and the mother’s pregnancy was uneventful. The baby was delivered vaginally at 37 weeks of gestation and multiples masses were found over the body. The treating physician advised follow-ups on discharge. However, the parents decided to seek more medical help for the child and she was admitted for more investigations.\nOn physical exam, the child was alert and active. She was not jaundiced and no pallor was noted on the extremities. Her vitals were all within the normal range and the birth weight and changes in weight corresponded properly. Two masses measuring 26 mm by 19 mm and 19 mm by 17 mm were observed on the forehead and the scalp (Figures -). One smaller mass was seen on the abdomen, measuring 11 mm by 10 mm (Figure ). All three masses were red and non-hemorrhagic. The parents reported that the size of the masses did not change since birth. No similar family history was found and both parents were healthy. Any hepatosplenomegaly was not observed on palpation nor were any other cutaneous lesions detected. She did not present with any other systemic abnormalities. An ultrasound was performed, and it revealed a normal liver, spleen, and kidneys with no masses or lesions. A Doppler examination also showed a fast-flow vascular lesion, as reported by many other articles []. The full blood count showed normal levels of white blood cells, platelets, hematocrit, and red blood cells.\nThe diagnosis of congenital hemangioma was confirmed and the family was properly educated about the condition as well as possible complications. A wait and watch approach was adopted and the child was scheduled for regular visits at three months. The family was asked to properly monitor the size of the masses and informed that appropriate surgical treatment would be provided if the masses fail to regress or if they continue to grow"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old man with the end-stage renal disease was assessed for decreased appetite, dysphagia, and nausea during the hemodialysis. He was on a routine hemodialysis program for 4 h, three times a week, for 7 years. In his history, he had essential hypertension for 15 years. The etiology of end-stage renal disease may be hypertension or systemic amyloidosis in our patient, but kidney biopsy had never been performed. He had been diagnosed with RA 20 years ago and had been taking leflunomide 20 mg/day regularly. His other medication was darbepoetin alfa 40 mcg/week, acetylsalicylic acid 100 mg/day, calcium acetate 700 mg three times a day, and lansoprazole 30 mg/day. On physical examination, the thyroid was diffusely enlarged (Grade 4) with multiple nodules. He had signs of long-standing RA in the form of joint deformities and rheumatoid nodules.\nLaboratory findings of the patient can be seen in . Abdominal ultrasonography (USG) was performed, and it revealed normal findings. In addition, the fecal occult blood test was negative, and the patient did not have weight loss, so intraabdominal malignancy was not considered.\nOn thyroid USG, the parenchyma was homogeneous. Both of the thyroid lobes were enlarged. A large number of heterogeneous, hypoechoic solid and mixed nodules with cystic and calcified degeneration were found on both the lobes and isthmus, the largest one being on the right lobe (50 × 28 × 24 mm). Aspiration biopsy of the largest nodule showed a benign characteristic. As the patient had a large number of nodules, total thyroidectomy was performed.\nAccording to macroscopic pathological examination, the right lobe was 12 × 7.5 × 7 cm, left lobe was 9.6 × 6 × 5 cm, and whole surface was encapsulated. In the right lobe section, a partially cystic nodule 4 × 3 cm in size separated by marked and regular borders from surrounding tissue was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old female with gallbladder carcinoma presented to our palliative care unit (PCU) with a history of pain abdomen and vomiting. Patient had pain in the right upper quadrant of abdomen, which had increased over the past 15 days. Pain was associated with vomiting for the past 3 days. The patient was taking tablet hyoscine butyl bromide 10 mg tds and tablet metoclopramide 10 mg tds without any improvement.\nA contrast-enhanced computed tomography abdomen revealed gallbladder mass with liver and periportal nodal metastasis. An ultrasound-guided fine-needle aspiration cytology from gallbladder mass was suggestive of adenocarcinoma. Since patient had an Eastern Cooperative Oncology Group 4 status, she was deemed unsuitable for chemotherapy and referred to PCU.\nIn the PCU, she was started on morphine-based analgesic titration. After 3 mg bolus of injection morphine, an infusion of injection morphine 0.5 mg/h was started. She was started on injection metoclopramide 10 mg thrice a day for nausea and vomiting. Her abdominal pain was reduced in intensity, but nausea and vomiting persisted and was severe in nature. Considering liver metastasis, she was started on injection dexamethasone 8 mg twice a day.\nPain was settled but vomiting still uncontrolled. Addition of ondansetron also did not relieve the symptoms. Her vomiting persisted and adversely affected her quality of life (QOL). Hence, injection haloperidol 0.5 mg twice a day was added. Even with the use of a combination of different classes of antiemetics, her nausea and vomiting was not controlled.\nA diagnosis of functional small bowel obstruction was made, and patient was kept on nasogastric tube decompression along with nil per oral for 24 h as per surgical oncology opinion. After 24 h of fasting, intermittent feeds were started with Ryle's tube clamping, but patient symptoms of nausea and vomiting persisted. We decided to start tablet olanzapine 2.5 mg once daily Ryle's tube. There was a dramatic response after"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32y old woman was referred to Yas hospital due to severe low abdominal pain and vomiting on May 2017. Ultrasonographic examination of her pelvis revealed bilateral ovarian cysts. During the 5 days before the admission, she had experienced severe right lower abdominal pain and vomiting especially after a meal. She had a long history of dysmenorrhea and, one cesarean delivery 3 years before. She was taking no medication. Her physical examination report included the temperature of 37°C, systolic blood pressure of 100 mmHg and heart rate of 120 beats per minute. The right lower quadrant of her abdomen was tender along with hypoactive bowel sounds. Laboratory data reported leukocytosis (16×109/L) with neutrophilia, C-reactive protein of 20 mg/dl and erythrocyte sedimentation rate of 60 mm/hr. Abdominal erect X-ray showed dilatation of small bowel segments. Colonoscopy was requested by gastroenterologist for finding the cause and excluding colon neoplasm. Diagnostic colonoscopy showed one small ulcer (8 mm) with the pressure effect of mass like lesion at cecum and scope couldn’t find the ileocecal valve. It was thought that a mass like lesion had caused the ileum obstruction. Colonoscopic biopsies were taken and histopathological examination revealed endometriosis. Afterwards, the patient was taken to the operating room for excision of the mass. At the exploration of the abdominal cavity, adequate exposure was attained by a vertical incision across the midline of the abdomen with a transverse extension to the right. The ileocecal part was covered by the omentum and was adherent to the abdominal wall. The ileocolic intussusception was seen without ischemic changes. Reduction of the intussusception was performed at first. After reduction, a firm mass was recognized at cecum, located close to the ileocecal valve. Then, the ileocecal resection was performed (). Pathological examination confirmed endometriosis.\nThe postoperative period was uneventful and she was discharged o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male patient sought the medical facility complaining of recent productive cough and dyspnea. His past medical history included pulmonary tuberculosis, which was treated few years before, and smoking of 15 packs/year. He had sought medical care several times during the prior 2 months, but was always treated with symptomatic medication until a plain chest radiography was taken, which showed mild mediastinal enlargement and a bulging on the right atrium contour (). This was the reason for the hospital admission and clinical investigation.\nThe initial physical examination revealed an afebrile patient, who presented normal hemodynamic parameters and no peripheral edema. Lung examination was normal, and cardiac auscultation revealed an ejection murmur. Raised jugular venous pressure and hepatomegaly were also observed. The remaining examination was normal and the initial laboratory workup was unremarkable.\nThe echodopplercardiogram showed pericardium thickening with mild effusion and a left ventricular ejection fraction of 60%. Thoracic computed tomography (CT) showed a mass with soft tissue attenuation infiltrating the pericardium and the anterior wall of the right atrium () and multiple, bilateral, scattered, solid pulmonary nodules measuring up to 2.6 cm.\nThe magnetic resonance imaging (MRI) also showed a mass with heterogeneous distinction diffusely involving the pericardium, with compression/invasion of the right ventricle’s outflow tract, pulmonary artery and superior vena cava ( and ).\nThe pericardium was biopsied, but the histological examination did not reveal evidence of malignancy. A pulmonary nodule was subsequently biopsied, which showed a mesenchymal malignancy represented by sinusoidal vascular channels filled with red blood cells and lined with atypical endothelial cells (). The immunohistochemical profile showed positivity for CD31, CD34 (), while Desmin and S100 Protein were negative, rendering the diagnosis of angiosarcoma. Adding the radi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year-old boy was hospitalized in our cardiology department for repeated episodes of paroxysmal tachycardia at 180 bpm (Fig. ). Propranolol was ineffective to control arrhythmia. Because of frequent episodes of tachycardia the family accepted electrophysiological study and ablation.\nThe ECG during sinus rhythm showed no sign if pre-excitation. Echocardiography showed normal values for the age of 9 years (Fig. ).\nDuring the electrophysiological study we mechanically induced PSVT. The coronary sinus catheter confirmed an orthodromic reentrant tachycardia using a left lateral accessory pathway (Fig. ). Our protocol is to perform electrophysiological study with zero or near-zero irradiation in children under 14. We used the NAVX Ensite Velocity system provided by Saint Jude medical (Fig. ). The impedance-based system permits introduction of catheters through the femoral or jugular veins and inside the heart chambers without the use of fluoroscopy. The system delivers a small amplitude electrical signal between surface electrode patches. A catheter that is introduced in the electrical field has a clear position and can be visualized inside the heart chamber. The 3D geometry of the cardiac structure can be thus created. Using the patch surface electrodes from the abdomen and thigh we first created the image of the right common femoral vein, than the right iliac vein, inferior and superior vena cava. Using the previously created contours we placed the catheters inside the right atrium, right ventricle and coronary sinus.\nAfter catheter placement at the His level and right ventricular apex, we punctured the right femoral artery and introduced the ablation catheter retrogradely through the aortic valve at the level of the mitral ring. We reconstructed the descendant, ascendant aorta and the aortic arch and precisely localized the mitral annulus (Fig. ). During tachycardia we mapped the mitral ring and we found a spot where the ventricular and atrial electrograms were fuse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male patient was admitted for weakness and numbness involving the bilateral lower limbs for 18 mo, and disorder of defecation and erectile dysfunction for 6 mo. For the last 3 mo, these symptoms started to worsen.\nThe patient started to present disorders of bilateral lower limbs in January 2016, and defecation and erectile dysfunction in January 2017. Subsequently, he received magnetic resonance imaging examination at a local hospital, which suggested an intramedullary mass located at the level of T9-T10. However, he did not take any cure. In April 2017, the clinical symptoms began to worsen. Therefore, the patient was admitted to our department on July 13, 2017 for further treatment.\nThe patient underwent an appendectomy in 1984, and had suffered from diabetes for 7 years and hypertension for 2 years. He had been taking nimodipine, metformin, and gliclazide to control the blood pressure and blood glucose levels under the supervision of local doctors.\nNeither he nor anyone in his family had a history of primary intramedullary melanocytoma.\nNeurologic examination presented that the myodynamia of the right lower limb was grade 3 and left lower limb was grade 4. Besides, the superficial and deep sense in the right lower limb was clearly worse than that of the left lower limb and these dysfunctions in distal lower limbs were more severe than those of proximal lower limbs as well. Moreover, achilles tendon reflex and patellar tendon reflex were brisk with absence of ankle and patellar clonus. Babinski sign was positive in the right lower limb. Anal reflex revealed a mild decrease and the Romberg sign was positive.\nTotal protein was slightly low (63.2 g/L). Triglyceride (1.75 mmol/L) and low density lipoprotein (3.47 mmol/L) were a little high. Color doppler ultrasound of the stomach and pelvis indicated a single gallbladder polyp (3 mm × 3 mm) and gallstone (5"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old male patient reported with a huge swelling in the left parotid gland region, slowly enlarging in size since 5 years. On inspection and palpation, swelling was non-tender, pyramidal in shape, 12 × 10 cm in size, nodular and firm in consistency; temperature over the swelling was normal with no fixation of the tumor to the underlying structures. The ear lobule appeared to be raised with no facial paralysis or restriction in jaw movements []. On the affected side, the lymph nodes were not palpable. The case was clinically diagnosed as benign salivary gland neoplasm involving left parotid gland.\nHematological investigations showed no significant alterations except increased eosinophilic count. Ultrasonography revealed hypoechoic lesion showing increased vascularity []. Lateral view and posteroanterior view of skull was normal without any underlying bone resorption [Figure and ]. Fine-needle aspirate showed atypical mononuclear cells suggestive of malignancy []. Patient was advised a complete surgical excision. The tumor was excised from superficial lobe of parotid gland. No intra-operative complications were reported. Postoperatively, patient showed signs of paresthesia with transient signs of Bell's palsy, which were taken care of. Then the specimen was sent for histopathological examination. On grossing, it showed a well-encapsulated mass, measuring 10 × 12 cm in size and was firm in consistency. The cut section showed white fibrous mass inside the capsule [].\nHistopathologically, it showed islands of tumor cells separated by dense bands of hyalinized fibrous connective tissue. Islands were composed of small ducts lined by inner luminal cuboidal cells and outer clear myoepithelial cells representing the characteristic biphasic pattern. The cuboidal epithelium was surrounded by clear cells, which interfaced with a thickened hyaline basement membrane. Nests of atypical myoepithelial cells, some in acinar pattern and some scattered in the connective tissue s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old woman presented with worsening dyspnea over the past 12 months. She had no medical or surgical history. Cardiovascular risk factors associated were arterial hypertension, hypercholesterolemia, former smoking history and obesity (body mass index 32.9 kg/m2). The physical examination was normal, except for a 3/6 systolic murmur audible at the apex and along the left sternal border. The electrocardiogram was also normal. Chest X-ray showed situs solitus, levocardia, mildly increased cardiothoracic index, and pulmonary plethora. TTE revealed severe mitral regurgitation (MR) due to a mitral valve structural abnormality. A linear structure was present in the left ventricle outflow tract (LVOT) connecting the basal interventricular septum with the tip of the anterior mitral leaflet, restricting the mitral valve motion and causing severe MR. There was no evidence of LVOT obstruction. Both LV volumes and ejection fraction were normal, with no wall motion abnormalities. An abnormal high velocity systolic jet was visualized in the RA ( and in the online-only Data Supplement) with a peak velocity of 5.2 m/s (). There were no indirect signs of pulmonary hypertension. Therefore, an abnormal communication between the LV and the RA was suspected. The TEE exam confirmed the LV to RA shunt above the septal leaflet of the tricuspid valve consistent with a Gerbode type defect ( and in the onlineonly Data Supplement). TEE also revealed a more detailed linear structure in the LVOT ( in the online-only Data Supplement) connecting the basal interventricular septum with the tip of the anterior mitral leaflet, restricting the mitral valve motion and causing severe MR ( and in the online-only Data Supplement).\nThe preoperative coronary angiography revealed normal coronary arteries. No opacification of the RA during left ventriculography was observed, and the absence of pulmonary hypertension was confirmed at right heart catheterization. The patient underwent successful mitral va"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient, a 58-year-old Caucasian male, presented to the emergency department with the acute onset of quadriplegia extending from C5 throughout the rest of the pan neuroaxis while awakening from bed the morning of presentation. Upon initial physical examination there were no signs of trauma noted that were significant to the presenting symptoms, additionally, patchy sensation was noted in the upper and lower extremities with clonus in the legs only and hyperreflexia in both arms and legs. Initially, our patient was administered one intravenous dose of methylprednisolone and allowed to enter a state of permissive hypertension which improved our patient's arm strength bilaterally to 2/5, but had no positive effects on the lower extremity paraplegia. As a result of minimal improvement, immediate imaging of the cervical spine was ordered and highlighted a severe cervical stenosis from C3 to C7, as seen in Figure , due to extra-axial posterior compressive spinal mass with cord signal change.\nAdditional imaging of the brain was completed as a precautionary measure and was normal. Upon obtaining full patient history and medical records from nearby hospitals, it was found that our patient was on a prolonged regimen of warfarin for many years due to a prior diagnosis of congestive heart failure without regulation and regular INR/prothrombin evaluation. Our patient also did not follow up with his primary care physician throughout the duration of the warfarin regimen. At presentation, our patient's INR was found to be 5.0 necessitating the prompt correction with intravenous injection of fresh frozen plasma (FFP) and vitamin K. Additional magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed large compressive acute epidural hematoma posteriorly compressing the thoracic spinal cord from T6 to T10, visualized in Figure , with cord signal change, as well as L4-S1 posterior acute epidural hematoma compressive of the cauda equine, visualized in Figure .\nUpon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 3: A 24-year-old gravida 6 para 4 female at 31 weeks of gestation presented to the emergency department as a belted passenger in a 45-mph motor vehicle collision. Her pregnancy had been complicated by anemia and obesity. Plain film radiography demonstrated a mildly comminuted and displaced right femoral shaft fracture with foreshortening (). Her obstetric history included four previous full-term spontaneous vaginal deliveries and one elective abortion. She had no other significant past medical history. Laboratory evaluation was remarkable for a white blood cell count of 20.7×103/μL and hemoglobin of 9.1 g/dL, with a normal calcium level of 8.6 mg/dL. She was transferred to labor and delivery where fetal monitoring was reassuring. Uterine tocometry showed contractions every 2–10 mins and the decision was made to give a 12 mg dose of intramuscular betamethasone for fetal lung maturity prior to surgical intervention.\nOn hospital day 1, the patient underwent an uncomplicated anterograde rod insertion of her right femur under general endotracheal anesthesia. Fetal monitoring before and during surgery was reassuring. Total preoperative and intraoperative radiation dosage was 135.2 mGy and a lead apron was used to shield the maternal abdomen during all images. The patient was started on 30 mg twice daily enoxaparin sodium for VTE prophylaxis, physical therapy as well as oral cholecalciferol and calcium acetate for daily supplementation. Throughout her postoperative course, the patient was not meeting ambulation goals necessary for discharge and on postoperative day 5, she was diagnosed with preterm premature rupture of membranes. Azithromycin and amoxicillin were started as latency antibiotics. On postoperative day 7, the patient complained of increasing pain and pressure, the cervix was found to be fully dilated, and she vaginally delivered a live born male fetus at 32 weeks and 1-day gestation from the breech presentation. The patient had an unremarkable postpart"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn August of 2012 a 16-year-old male presented complaining of rest and activity pain worsening for the past year. He denied any history of trauma. The patient reported is worsening left knee pain and decreased range of motion were limiting his daily activities. Radiographs from an outside facility (not available for publication) showed a lobulated well-defined epiphyseal lesion with sclerotic margins and without stippled calcifications. Computerized tomography (CT) further defined a low-attenuation lesion in the medial femoral condyle measuring 13 mm by 16 mm with well-defined sclerotic margins and depression of the subchondral bone at the lesion border (). Differential diagnosis at this time included chondroblastoma, giant cell tumor, clear cell chondrosarcoma, and osteomyelitis. Given the patient's delayed presentation and our increased concern for metastatic disease we elected to proceed with a CT chest, in place of a routine screening chest radiograph. This CT showed no evidence of metastatic disease. Core needle biopsy () showed mononuclear neoplastic cells with intermixed multinucleated giant cells, tumor cells surrounded by dark blue “chicken wire” calcifications, and fibrochondroid islands all consistent with a chondroblastoma. At this point an MRI of the left knee was obtained to evaluate the extent of articular cartilage involvement and to determine reconstruction options after recommended intralesional curettage. MRI demonstrated a lytic lesion with sclerotic borders involving the posterior aspect of the medial femoral condyle and abutting the posterior articular surface with a 3 mm collapse of the subchondral bone and breach of the chondral surface (). Also the significant enhancing of marrow edema in the medial femoral condyle and adjacent soft tissue edema with associated joint effusion is well demonstrated on the T2 STIR images (). The imaging and pathology were reviewed at multidisciplinary tumor board and the surgical approach and reconstructive opt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old primigravida with a singleton pregnancy was referred to our center because of the finding of an oral cyst diagnosed during a routine ultrasound at 26 weeks of gestation.\nThe medical history of the parents was unremarkable and they were nonconsanguineous.\nThe first and second trimester scans performed at 12 and 20 weeks of gestation in another center were normal.\nUltrasounds were performed using a GE Voluson 730 Expert.\nThe initial examination performed at 28 weeks of gestation showed a single male fetus with an oral cystic lesion of 18 × 10 mm, located under the tongue. The tumor appeared to be fluid and homogeneous, without solid components, with well-defined limits and it moved with the tongue movements. The most likely diagnosis with that ultrasound appearance was a congenital ranula or a thyroglossal duct cyst.\nThe fetal anatomic study found no other abnormalities, except a left renal pelvic dilatation of 7.3 mm; fetal biometric parameters and amniotic fluid index were normal ().\nFollow-up ultrasound scans performed every 2 weeks always showed appropriate fetal growth (75–90 percentile) and a normal amniotic fluid index. There were no changes in the measurements of the oral cyst and the most striking finding was that the fetus kept his mouth open during all examinations ().\nFetal magnetic resonance imaging was performed at 31 weeks and revealed a moderate left renal pelvic dilatation and an orofacial lesion of 18 × 14 mm located before the free edge of the tongue and above the lower lip, with cystic characteristics and the same echogenicity as the amniotic liquid, without evidence of fat or signal diffusion restriction. That image could correspond with a cyst probably dependent on the salivary glands ().\nAt term, the oral tumor did not show any changes in measurements and characteristics, there was no evidence of polyhydramnios, and the stomach was visible; we also could see complete tongue movements and we occasionally observed that the fetus was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male with no previous medical history experienced a transient loss of consciousness after two simultaneous head-to-head collisions during a high school football game. Upon regaining consciousness, the patient initially answered questions appropriately; however, he became combative and was intubated due to severe agitation and suspected seizure activity. The patient was transferred to an outside hospital and received computed tomography (CT) scans of the head and cervical spine, both of which reported no acute pathology. An attempt was made to extubate the patient; however, a neurological examination revealed 3/5 left-sided strength with spasticity. Sensation was intact bilaterally, and no carotid bruits were heard. Brain and cervical spine magnetic resonance imaging (MRI) revealed a right MCA infarct on the diffusion-weighted image and questionable right internal carotid artery (ICA) dissection (Figure ).\nThe patient was started on heparin and a CT angiography revealed mild irregularity along with segmental narrowing of the distal cavernous and supraclinoid segments of the right internal carotid artery.\nUpon arrival to our institution, sedation was turned off and the patient was noted to have 1/5 left extremity strength on repeat neurological exam. Neurology and neurosurgery were consulted and the decision was made to perform a cerebral angiogram. The study showed multifocal irregularities of the right supraclinoid internal carotid artery and the M1 segment of the right MCA, highly suggestive of nonflow limiting vasospasm. Distal emboli were observed in the right MCA (Figures , , ).\nAn electroencephalogram (EEG) was performed and the presence of a mild encephalopathy with superimposed right temporal slowing was noted. No epileptiform activity was seen. The patient was started on hypertonic saline due to cerebral edema, valproic acid, and aspirin 325 mg. He was extubated one day after arrival at our facility. Serial head CT scans were performed and reve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old female presented to the emergency room with sudden onset sharp right lower quadrant pain, nausea, and vomiting. On physical exam, she was positive for McBurney's, Rovsing's, psoas, and obturator signs. Her white blood cell count was elevated at 16.5. CT scan showed signs of appendicitis as well as suspicious intraabdominal soft tissue masses (). Five years earlier, she presented to a different hospital with diffuse abdominal pain, and CT scan identified a small bowel lesion; endoscopic biopsy showed GIST. She underwent SB resection without complications. No pathology was available, and according to the patient, no adjuvant chemotherapy was given; on her one-year follow-up CT scan, no evidence for tumor recurrence was found with no additional oncologic follow-up. She remained symptom-free for the next several years, until this episode.\nSecondary to the CT findings suggestive for appendicitis, nonoperative management and further workup were contemplated. The RLQ masses were most concerning for recurrent GIST, and after discussion with the patient, indication for surgery was made. On diagnostic laparoscopy, the appendix wall was found thickened and acutely inflamed with nodular lesions. In addition, multiple up to 2 cm in diameter nodules on the terminal ileum and the parietal peritoneum of the anterior and lateral abdominal walls were visualized (). One larger nodule in the right pelvis could not be mobilized. The liver was found to be free of any lesions. Due to the volume of the separate masses and inability to mobilize the large right pelvic nodule out of the pelvis, the case was converted to laparotomy. A lower midline incision was made. The appendix was mobilized, the mesoappendix was secured using a stapler, and the appendix was resected at the base and handed off for pathology. All visible nodules were then removed from the peritoneum, and a partial resection of the terminal ileum was performed. When the small bowel was run from the terminal ileum"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old male athlete presented to the emergency department with an injured left tibia. The patient reported a left knee forced hyperflexion during a football match, which caused the injury. The described mechanism of injury was violent contraction of the quadriceps muscle against a fixed tibia.\nThe left knee was held in 100° of flexion with complete inability to extend the knee or bear weight. On examination, there was obvious swelling over the proximal tibia and on palpation there was tenderness on the anterolateral part of the proximal end of the tibia. No neurovascular impairment was identified. The patient was able to actively move his ankle, as well as his toes, and both posterior tibialis artery and dorsalis pedis artery were palpable.\nFrom the plain radiographs, a displaced flexion type Salter-Harris type II fracture of the proximal tibia epiphysis was identified ().\nFew hours after admission, the patient was led to the theatre and, under general anesthesia, a closed reduction of the fracture was performed by extending the knee and putting strong pressure over the tibial tubercle. Reduction was confirmed using image intensifier () and stability of the fracture was verified, as there was no displacement at 80° of knee flexion. After reduction, the dorsalis pedis artery and the posterior tibial artery were palpable. Since there was no displacement with that degree of flexion, percutaneous pinning of the fracture was not performed and only a circumferential cast with the knee in full extension was applied.\nPatient was hospitalized in the Orthopaedic Department under close observation of limb neurovascular status. On the same night after reduction, the patient developed severe pain, which subsided after splitting the cast. The next few days, the patient developed severe swelling over the anterior tibia compartment, but there were no clinical signs of compartment syndrome. Posterior tibialis remained easily palpable, whereas the dorsalis pedis became weak bu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year old male patient presented to the otolaryngology clinic with a swelling on the left side of his jaw which had been present for 12 years but had enlarged recently. His medical history included an operation for a swelling on the right side of his jaw at another centre, 17 years previously. However, there was no medical record of that operation. His recent medical treatment included doxazosin for hypertension and inhaler bronchodilator for chronic obstructive pulmonary disease. Pathology examination of the biopsy materials of the swelling excluded malignancy and the patient was scheduled for a parotidectomy operation with a diagnosis of benign Whartin tumor. He was a smoker for 55 years and an ex-coal mine worker and rhonchi were present in his physical examination. Therefore, chest radiography and magnetic resonance imaging (MRI) were performed. In these examinations, a 40 mm ARSA aneurysm was observed posterior of the trachea ( ). Thorax CT angiography with contrast was then performed to determine the relation of the aneurysm to adjacent organs ( ).\nAlthough an endovascular intervention had been planned initially, because of the patient’s comorbidities, the anatomical measurements of the ARSA were inappropriate for placement of an endovascular stent so we decided to perform open surgery. We planned surgical resection of the Kommerell diverticulum through left thoracotomy and repair of the descending aorta with primary sutures or patching of the descending aorta with polytetrafluoroethylene (PTFE) graft. We were also going to implant the left subclavian artery into the left common carotid artery with fine running polypropylene sutures.\nWritten informed consent was obtained from the patient and he was operated under general anesthesia. The chest cavity was accessed through the 4th intercostal space after left lateral thoracotomy. Sudden abundant bleeding from the posterior wall of the aneurysm occurred during surgical exploration of the aortic arch. The patie"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient involved was a healthy 28-year-old G1 at 18 weeks of gestation who consented for pregnancy termination via preparatory laminaria dilators and subsequent operative dilatation and evacuation for a confirmed, lethal diagnosis of Trisomy 18. Aside from an ultrasound-diagnosed lower uterine fibroid, her antenatal course was unremarkable and she had had a normal pelvic examination just prior to conceiving.\nOn preparation of the cervix for dilatation, a speculum exam revealed an obstructing 5-6cm fibroid protruding through the cervix into the vagina. The cervix itself was not visualized due to the size of the fibroid and its protrusion into the vagina. On bimanual exam, the internal os was closed around the fibroid, which appeared to arise from the level of the internal os of the cervix. In order to prepare the cervix for dilation, osmotic dilators were tucked around the fibroid within the cervix. After three hours, the internal os was a finger tip dilated with further ripening required. Rather than a sequential set of dilators which would be challenging to place and maintain around the fibroid due to angulation, a cervical Foley catheter was employed to ripen the cervix further. The intent was to allow proper placement of a dilator without increasing the risk of false passage creation.\nGiven the obstructive fibroid, the patient consented for a myomectomy prior to the evacuation, with the added, increased risk of hemorrhage. The possibility of an operative hysteroscopy was explained, as it would allow for removal of the stalk of the fibroid in its entirety, as well as cauterization of the base itself should it be required. Prior ultrasound had indicated that the fibroid was within the lower uterine segment, and the location of the base could not yet be identified.\nThe following day with the Foley having fallen out and under general anesthetic, examination revealed a sufficiently 3-4cm dilated cervix with the prolapsed fib"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old gentleman presented with a two-month history of bleeding per rectum and altered bowel habits. There was no history of tenesmus but sensation of incomplete evacuation following defecation as well as a feeling of a lump in the anal canal was present. His appetite and weight had been stable.\nClinically he looked well and abdominal examination revealed no abnormality. Per rectal examination revealed a mass in the posterior wall of the rectum with intact mucosa, which had significantly narrowed the lumen. Colonoscopy revealed the presence of a mass in the posterolateral wall of the rectum extending from 4 to 14 cm from the anal verge, with normal overlying mucosa. In addition, there was also a large sessile polyp in the descending colon and an ulceroproliferative growth at the splenic flexure; histopathology confirmed adenomatous polyp and adenocarcinoma respectively.\nComputerised tomography (CT) of the pelvis showed thickening of the distal rectum with an obvious low density poorly enhancing lesion with possible calcification in its wall. Tissue plane between this lesion and prostate was not clearly seen but there was no infiltration of the ischiorectal fat (Figure ). Magnetic resonance imaging (MRI) showed a very large well-defined mass in the left presacral / ischio-anal fossa contiguous with rectal wall and thus almost certainly arising from one of the elements of the rectal wall (Figure ). Barium enema showed an apple core lesion in the splenic flexure (Figure ) as well as narrowing of the distal rectal lumen (Figure ).\nThe case was fully discussed at the colorectal multidisciplinary team meeting and all the surgical options including left hemicolectomy combined with rectosigmoidectomy plus transverse colostomy were fully evaluated. However, the consensus was that the additional presence of an adenocarcinoma as well as an adenoma higher up in the colon combined with the size of rectal schwannoma (12 cms) made panproctocolectomy with permanent ileostomy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.\nComputed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).\nAfter physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.\nOn the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.\nThe examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of eme"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman was referred from a primary clinical to the Department of General Surgery at Asan Medical Center (Seoul, Korea) for an inguinal hernia. She had noticed reducible swellings on both inguinal areas for 10 years but did nothing until the swellings became problematic. These swellings had increased 7 months earlier, accompanied by pain. Ultrasound examination showed a well-defined cyst in the right inguinal area, and a mass with cystic and solid portions in the left inguinal area. Computed tomography showed a 7.4 cm round homogeneously enhanced mass in the left inguinal canal with an enlarged lymph node in the left para-aortic area ().\nThe mass excised from the left inguinal area was well-defined and firm, measuring 7×7×6 cm in size. The cut surface was homogenously creamy white and vaguely lobulated with focal hemorrhage (). The mass in the right inguinal canal was heterogeneously golden yellow to pinkish gray and encapsulated (). Microscopically, the mass of left inguinal area consisted of large uniform cells growing in broad sheet divided by thin septa which infiltrated by lymphocytes. The nuclei of the tumor cells were centrally located and round to polygonal with finely granular chromatin and prominent nucleoli. The cytoplasm was eosinophilic to clear and had distinct cell border (). These features were consistent with seminoma of classic type. Adjacent to the mass was soft tissue composed of atrophic hyalinized seminiferous tubules and interspersed Leydig cell nests in between, compatible with testicular tissue (). The mass from right inguinal canal also had testicular tissue with atrophic hyalinized seminiferous tubules, but the leydig cell nests were larger and more abundant, consistent with leydig cell hyperplasia (). This mass was removed surgically, as was the reducible mass in the right inguinal canal, followed by herniorrhaphy.\nPostoperatively, the surgeon in charge requested a detailed examination of this patient by a gynecologist for fur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA fifty seven-year-old lady who was previously very active and a keen golfer sustained a closed, comminuted proximal humerus fracture/dislocation of the shoulder of her non-dominant upper limb whilst skiing. This was treated with plate and screw internal fixation the day after her injury. Unfortunately, this was complicated by early infection and within six weeks, she presented with a draining sinus from the wound. She was started on oral Clarithromycin and a subsequent drainage and washout failed to isolate causative organisms.\nOngoing pain and stiffness was attributed to a screw protruding through the humeral articular surface (confirmed on shoulder arthroscopy). However, four months after the injury, at surgery to remove this screw the metalwork was found to be bathed in pus, loosening and with a large cavity in the proximal humerus. The metalwork was removed and the affected area curetted and washed out. She was started on intravenous Vancomycin for two weeks followed by a further four weeks of oral Cephradine. Again no organisms were cultured from operative samples. Blood tests revealed a normal white cell count (WCC), an Erythrocyte Sedimentation Rate (ESR) of 21 mm/h and a C-reactive protein (CRP) level of 5 mg/L. She was referred to our unit at this point.\nAt initial assessment, she had no systemic symptoms of infection and the skin defect had healed. She had a poor residual range of shoulder movement with both flexion and extension limited to thirty degrees, abduction to twenty degrees, with no internal or external rotation. All movements were painful. She had no neurovascular deficit. Radiographs confirmed destruction of the joint surface, an un-united fracture with some collapse and mal-rotation (Figure ). MRI scans revealed a cavity in the proximal humerus with marked surrounding oedema in the bone and soft tissues (Figure ).\nClinical assessment revealed that she had almost no glenohumeral movement but had reasonable sc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old woman with a past medical history of hypertension, scoliosis and depression presented with 1 week of flu-like symptoms (diffuse body aches, fatigue, and chills) and generalized weakness that rapidly progressed over several days in June 2018. Her social history is significant for living in a trailer in a wooded area in Florida, living in areas close to a mix of salt and river water, and exposure to mold, rats, and bat droppings near her home. On initial neurological examination, the patient was lethargic but oriented to person, place and time. She had impaired concentration and required occasional tactile or auditory stimulus to maintain attention. There were no cranial nerve deficits. Strength was 4/5 in the bilateral upper extremities and 3/5 in the bilateral lower extremities. There were no pathologic reflexes and sensation to light touch was intact in all extremities. The patient then had a rapid deterioration requiring intubation and mechanical ventilation. Serum laboratory results and serology testing throughout the hospital course are presented in –. Ceftriaxone, acyclovir, vancomycin, and ampicillin were started due to suspicion of meningitis based on the initial clinical presentation and serum testing. Computed Tomography (CT) angiogram of the head was unremarkable. Initial MRI Brain without contrast (hospital day 1) showed abnormally increased T2 FLAIR signal in the deep gray nuclei bilaterally, most prominent in the striatum (). Blood cultures were negative throughout her hospitalization. Cerebrospinal fluid (CSF) analysis was suggestive of meningitis and is presented in . Her CSF arboviral antibody panel is shown in and was initially unremarkable except for California encephalitis IgG 1:256.\nElectroencephalogram (EEG) showed diffuse background slowing and rare left temporal sharp waves. On hospital day 4, neurological exam in the setting of pharmacologic sedation and mechanical ventilation was significant for a comatose state with absent bra"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 75-year-old male whom initially presented to our service with a mass on his right upper back. The patient's medical history included coronary artery disease and hyperlipidemia. Further history revealed he had received (2) stents in the past and undergone multiple heart catheterizations (up to seven) approximately seven years prior at an outside facility. During his last catheterization and stent procedure, which took over 4 hours (approx. 33 mSv), he developed a radiation-induced injury to his right back around the T10 dermatome (). During the following years, the burn was closely followed at an outside facility, and the area developed a chronic nonhealing ulcer which continued to evolve over time eventually growing outward from his back and developing a foul odor on his presentation to our facility in 2017. He reported increasing pain at the periphery of the tumor margin. Up to a year prior to presentation, the area was flat and biopsies revealed no evidence of malignancy. Upon presentation to us, however, the physical exam demonstrated a fungating mass approximately 5 × 9 cm with central purulent necrosis and induration surrounding the periphery (Figures –). No additional nodularity or adenopathy was found on physical exam initially. At this time, punch biopsies demonstrated undifferentiated pleomorphic sarcoma along with frankly necrotic debris.\nInitial staging showed only localized disease by MRI with no evidence of metastasis by CT scan (Figures and ). Approximately one month following diagnosis, the patient underwent a radical excision with a 20 × 9 cm elliptical excision of the site. In this case, the patient chose human dermal matrix reconstruction, as primary closure was not possible due to the size of the site. Our patient did not want an additional wound of autologous skin procurement.\nPathology of histologic sections revealed a highly cellular spindle cell neoplasm. Focal areas of necrosis comprised less than 50% of sampled tissu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman with an intractable pain radiating over the left chest, suggestive of intercostal neuralgia, was referred to our spine center for further evaluation and management. Five weeks earlier, she experienced a ground-level fall, causing severe back pain. According to the initial evaluation conducted elsewhere, she was diagnosed as having OVF of the T10 vertebral body and managed conservatively with a brace and pain medication for one month. Her chief complaint gradually changed from bilateral back pain to an aching pain extending to the left thorax before her first visit to our hospital. What is noteworthy about the history of this case is that 8 years previously, she had had a painful OVF of the T12 vertebral body at the age of 79 years, which was treated with vertebroplasty using hydroxyapatite (HA) blocks and posterior pedicle screw instrumentation followed by iliac bone graft fusion from T11 to L1 at another hospital [].\nOn clinical examination at our hospital, the patient had no neurologic deficits, complaining of nothing but reporting a position-dependent severe chest pain on the left side, which intensified when sitting up from a supine position. Imaging studies revealed neither rib fractures nor abnormal findings of the chest cavity as a possible cause of the chest pain.\nOn the plain radiographs of the thoracic spine (), the anteroposterior (AP) views and the lateral views taken in the supine position showed the IVC within the T10 collapsed vertebral body as a gas-like radiolucent area, which disappeared on the lateral view obtained in the sitting position (i.e., the opening-closing phenomenon) most likely indicating an OVF of nonneoplastic and noninfectious origin [, ]. The lateral radiograph in the sitting position also demonstrated that the fracture line extended through the posterior fusion mass bone, grafted 8 years ago, indicating a potentially unstable flexion-distraction injury. Close observation of the AP radiograph obtained in the sup"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old male presented to our clinic with pain, mechanical limitation, and swelling in the right elbow, that had become increasingly severe over the previous 3 years. In physical examination, there was limitation in extension by 30° and in flexion by 20° when compared to the contralateral elbow. It was detected that there was a palpable, painful, rigid, immobile mass at the anterior and posterior aspects of the elbow joint.\nIn radiological evaluation, it was seen that there was narrowing in the joint space and cortical irregularity in the anterior region (). On computerized tomography (CT) scan, it was seen that there was soft tissue swelling at the right elbow joint, and cortical erosive changes in the distal humerus (). On magnetic resonance (MR) imaging, hyperintense, well-defined, nodular mass lesions were seen in fat suppression sequences ().\nSurgery was scheduled for the patient with an initial diagnosis of SC. First, olecranon fossa was exposed through the lateral and medial tricep muscles following a midline incision at the posterior aspect of the elbow. Numerous chondral loose bodies, which resulted in limitation of extension of the elbow and filled the olecranon fossa leading to enlargement of the joint capsule, were removed after capsulotomy. A second incision was made at the anterior aspect of the elbow for lesion in the anterior region of the elbow. The anterior capsule was exposed by preserving the vascular and neural components. Again, numerous rigid, free chondral loose bodies, which extended to the radius head and a process inside the joint, were removed following capsulotomy (). Both anterior and posterior synovial excisions were made. After excision, the range of motion was assessed intraoperatively. It was noted that preoperative flexion and extension limitations were relieved.\nIn the histopathological evaluation of the chondral loose bodies that were removed, SC was confirmed by observation of well-defined chondrocytes and mature cartilage"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).\nTissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.\nOn the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.\nAn emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old nulliparous pregnant Japanese woman was referred to our institution for prenatal evaluation of a fetal abdominal cyst at 19 weeks of gestation. Fetal ultrasonography showing a distended colon with the presence of bowel calcifications, distal rectal pouch, and undetectable anal mucosa indicated the presence of intermediate- or high-type imperforate anus with rectourethral fistula (Figures and ). No other anomaly or fetal growth restriction was detected (). Fetal ultrasonography at 20 weeks of gestation showed the progression in colon dilation and relatively decreased amniotic fluid but not yet oligohydramnios. Even after informing the parents of possible poor prognosis of the fetus, the parents did not desire termination of pregnancy or amniocentesis. Fetal ultrasonography showed further progression of bowel dilation obviously seen from 26 weeks of gestation, which leads to thoracic compression, and amniotic fluid suddenly decreased after 28 weeks of gestation despite a fluid-filled bladder without hydroureter or hydronephrosis, which implied the presence of fetal urine outflow obstruction but not a decrease in urine production (Figures –, ). Sonographic assessment of fetal well-being, including Doppler velocimetry of the middle cerebral artery, umbilical cord artery, and ductus venous, and biophysical profiling, was normal. MRI was performed at 30 weeks of gestation to assess pulmonary development, which indicated possible pulmonary hypoplasia (). By 32 weeks of gestation, although the fetal bladder was filled, oligohydramnios persisted without any signs of premature rupture of the membranes, placental insufficiency, hydroureter, or hydronephrosis. Taken together with the progression of bowel dilation which distended the fetal abdomen, fetal urethral stenosis or obstruction was expected to have triggered a misdirected urine flow from the bladder to the colon through the fistula. As deterioration of oligohydramnios and bowel dilation which lead to pulmo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old female patient referred to our outpatient clinic with gradual deterioration of vision for the age of 1 year mostly in the right eye, with episodes of sharp headaches. Ophthalmic examination confirmed reduced visual acuity with only perception of light in the left eye. Neurological examination showed no other neurologic deficit. Brain magnetic resonance imaging (MRI) showed a solid mass lesion involving the hypothalamus and the optic chiasm. The lesion was hypointense on T1-weighted images, hyperintense on T2-WI, and showed marked homogenous enhancement after the administration of contrast material []. The patient was operated by the right pterional craniotomy and transsylvian approach. Bulging of the optic chiasm and the site of lamina terminalis were seen. Incision with knife was done on the right side of optic chiasm through the exophytic part of the tumor and tumor evacuation done from inside the chiasm []. Furthermore, resection of the suprachiasmatic part of the tumor was performed and lamina terminalis was opened. Tumor entry sites were planned to minimize the risk of neural injury. Entry to the optic chiasm was performed from the lateral part of the right optic chiasm where tumor was bulging and exophytic with minimal covering neural tissue. Furthermore, this site is far from the median part of the chiasm in which crossing of optic fibers takes place. In the suprachiasmatic part, we also aimed to the exophytic part of the tumor and planned to enter through the lamina terminalis, which is known for its safety for dissection, to the anterior part of the third ventricle. In general, there was no clear-cut plain of cleavage, and dissection was carried on according the difference of color and consistency between the normal tissue and the friable grayish tumor tissue. Yet, subtotal resection of the tumor was achieved due to the absence of this difference between a part of the tumor and the hypothalamus. Thus, we decided to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67 year old man of Greek origin attended the emergency department with a two hour history of dull central chest pain that radiated into his back. There were no other symptoms and he was normally in good health. Examination and investigations (chest radiography, ECG, full blood count, and biochemistry screen) were thought to be normal. His pain subsided apart from some discomfort on swallowing and he was discharged home. She re-attended the department six days later. He complained that he had been cycling up a hill and had developed severe chest pain radiating into his jaw together with some sweating. Moreover, the discomfort of which he had previously complained had persisted. On examination he had a pulse of 98 per minute, BP 142/72 mm Hg, SaO2 97% on air and temperature 37.5°C. There were no cardiovascular or abdominal signs. There was no surgical emphysema in the supraclavicular fossae. On examination of the chest breath sounds were equal bilaterally for the upper lung fields, but absent for the right lower lung lobe. Chest X-ray confirmed the findings of physical examination and demonstrated right pleural effusion, but no radio-opacity was detected and there was no evidence of pneumomediastinum or subcutaneous emphysema (). At this point, a small amount of free air in the right hemithorax was overlooked and the patient admitted to the hospital with the diagnosis questioned for a basal pulmonary pathology.\nBecause of an erroneous belief that pulmonary complication was the cause of this specific clinical picture, the diagnosis of esophageal perforation was not suspected. The original diagnosis of esophageal perforation was delayed because of misinterpretation of right pleural effusion as a basal pulmonary pathology. Finally, three days after admission clinical deterioration with increased respiratory distress and discomfort, fever and chest pain did arouse suspicion of an esophageal perforation. At this point with a thoroughly history taken, the patient admitted"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71 year old female was referred for investigation of a presacral mass found incidentally during a staging CT (figure ) and MRI (figure ) of a recently diagnosed rectal carcinoma. The mass was located anterior to S4 and S5 in the presacral space. She was completely asymptomatic of this mass. Except for the recently diagnosed rectal carcinoma and hypertension, she had no other medical issues.\nHer CT scan revealed a suggestion of an ill-defined presacral mass, reported as possible oedema. The subsequent staging MRI clarified a 3.3 × 1.9 × 2.3 cm presacral mass at the level of S4/S5. Evidence of bony erosion could not be seen.\nInitially, differential diagnoses for this mass included chordoma, schwannoma and plasmacytoma. The mass was further investigated with a whole body thallium study and a CT-guided biopsy (figure ). The thallium study revealed no evidence of a thallium avid tumour in the sacrum or elsewhere. The biopsy revealed fat and haematopoietic tissue, consistent with a diagnosis of extramedullary haematopoiesis (figure and ). The occurrence of EH in the presacral area is an extremely rare finding with only 17 reported cases in the literature.\nThis remarkable diagnosis was further investigated with the help of a haematologist. A full history found no personal or family history of bleeding disorders or anaemia. Full blood examination and liver function tests revealed no abnormality. A bone marrow biopsy was taken which revealed mildly hypercellular marrow, showing a mild increase in trilineage haemopoiesis. This was likely to be reactive. A cytogenetics study was organized to differentiate reactive marrow from early myelodysplasia. No cytogenetic abnormality was detected.\nThe case was discussed at a multi-disciplinary meeting and a decision was made that this mass was benign in nature. No further investigations or treatment was deemed necessary. The patient subsequently underwent an uncomplicated resection of her rectal carcinoma. This is only the second case"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn otherwise healthy, non-smoker, obese (his BMI is 35), adult male patient in his late 20s sought medical assistance following agonizing simultaneous pain in both knees with weight bearing. His Visual Analog Score (VAS) pain was 2/10 at rest but increased to 10/10 with weight bearing, rendering him unable to walk. Pain onset was ten days before his first medical consultation, without any history of specific traumatic incident. Prior to pain presentation, the patient had just completed a ten-day training period in order to meet specific criteria to join the police academy. The training consisted of long walks and running sessions on hard tarmac. Before the training period, his lifestyle was rather sedentary. The patient provided a detailed account of his daily training sessions because he was using a specific application on his smart phone (). He had no previous knee injuries or locking-like symptomatology. The patient denies altering his daily diet habits before, during or after training.\nOn physical examination, no limb malalignment was present. His knees had no apparent effusion/swelling and there were no skin abnormalities. Temperature of both knees was normal. There was significant tenderness over the medial tibial condyle in a wide area including the medial joint line, the pes anserinus and the medial collateral ligament insertion, consistent with the reporting pain site in both knees. Both passive and active range of motion were full and unrestricted and elicited only mild discomfort. Special tests assessing cruciate ligament instability were within normal range. Valgus force test elicited pain, without gross instability. The McMurray test for medial meniscus was positive for both knees, although the examining physician felt that it was non-specific for the patient’s symptomatology. Anteroposterior and lateral plain radiographs of both knees were ordered and were reported back as normal (). Simple painkillers were prescribed and non-weight bearing ambulation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 68 years old woman presenting to the emergency department with macrohematuria and dysuria. She experienced fever several times, starting two months before medical examination. Fever was treated with NSAID. A history of recent pelvic pain was also reported. Her clinical status was good and no other symptoms or concurrent illnesses were present at the time of hospitalization.\nShe was admitted to Gynecologic service for further evaluation.\nThe patient was virgin and in post-menopausal status. Clinical history was unremarkable; negative either for previous medical or surgical procedures. Family history was positive for cancer with one male sibling deceased from a pancreatic malignancy; the remainder two siblings had no positive history for malignancies as well as parents and closest relatives. Social history was negative for use or addiction to drugs, alcohol and exposure to potential risk factors.\nA digital rectal examination had to be performed in place of the gynecologic bimanual examination. A gross, firm mass located in the pelvis was found at physical examination.\nPelvic US, abdominal CT scans, descending pielography, cystoscopy and chest RX were performed to both assess local disease and evaluate the presence of local and distant metastases.\nComputed tomography imaging confirmed the presence of a complex mass in the pelvis (13 × 14 cm) showing irregular contours and small areas of calcifications. Uterus and adnexa could not be clearly recognized, showing as being part of the mass. Iliac vessels and bladder were displaced. Imaging technique reports stated that no vessels or bladder invasion was present. A hypoplasia of the left kidney was also reported. No other metastasis was reported in the abdomino-pelvic cavity.\nPielography showed a delay in the opacification of the renal pelvis associated to a dilation of the right ureter that was compressed and displaced in its pelvic course till entering the bladder. No opacification of the contra late"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old female patient visited hospital for a national health screening program. Esophagogastroduodenoscopy revealed a 0.8-cm-sized depressed lesion at the posterior wall of the first part of the duodenum (, ). Histologic analysis of the biopsy specimen revealed atypical glands forming cell clusters beneath the intact mucosal layer. The atypical clusters were arranged in tubular structures of columnar epithelium consisting of mucin-producing cells. Dystrophic calcification was scattered within the lesion, and foreign body reaction with giant cell formation was noted around the calcified materials (, ). Immunohistochemistry (IHC) for CD56, chromogranin A and synaptophysin showed negative results, excluding the possibility of a neuroendocrine tumor, which is prevalent in this region. The histologic diagnosis was well-differentiated adenocarcinoma, and the patient underwent routine preoperative work-up. Physical examination, blood tests and abdominal computed tomography (CT) scan showed no abnormal findings. A minute duodenal lesion with submucosal invasion was suspected on endoscopic ultrasonography. Since the calcification was minute, it was not recognized by simple X-ray or by CT scan even upon retrospective review.\nEndoscopic resection was not an option because it is usually difficult to remove a lesion by endoscopy at the posterior wall of the duodenum. The possibility of submucosal invasion was also considered; hence, the patient received distal gastrectomy. Since the lesion was located in the duodenal bulb, the duodenal stump was made near the pancreas and the distal resection margin was close to the lesion. D1+ lymph node dissection was performed.\nOn gross examination, the specimen consisted of 2.7 cm long duodenum and 6.5 cm long stomach. On duodenal mucosa, a 0.8 × 0.8-cm-sized superficial depressed lesion was found (). The lesion was located at the posterior wall of the duodenum, 1.9 cm distal to the pyloric ring and 0.3 cm proximal to the distal resec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old gravida 4 para 0 African American woman at 22-weeks gestation presented with vaginal bleeding to an outside hospital. Her obstetric history was significant for 2 therapeutic abortions and 1 spontaneous abortion. During prenatal care, the fetus was noted to have a unilateral dysplastic kidney. The patient’s family history was significant for two family members with cervical cancer and two family members with endometrial cancer. She was placed on bedrest with inpatient admission. 48 h after admission she developed pelvic pain and uterine contractions. She expelled a mass vaginally measuring 11 × 9 × 5 cm with no fetal contents. The pathology from the outside facility showed a showed a highly cellular tumor composed of spindle-shaped cells and bizarre multinucleated giant cells with focal myxomatous change with mitotic count is greater than 50 per 10 high power field (Positive for CD10, SMA, ER, PR, EMA) with the differential diagnosis including endometrial stromal sarcoma and undifferentiated uterine sarcoma. The patient underwent examination under anesthesia, demonstrating a 3 × 3 cm defect of the posterior vaginal wall with active bleeding, which was sutured for hemostasis. The cervix was long, closed, and high with no evidence of bleeding and the fetus was intact with normal heart tones. She was discharged in stable condition.\nAt 27-weeks, the patient was referred to our institution for maternal-fetal medicine, and gynecology oncology consultation. On initial evaluation, she reported no prior abnormal gynecology history and no history of infertility issues. She denied dyspareunia and bulk symptoms prior to or during pregnancy, and her periods before pregnancy were normal. A pap smear at 27-weeks gestation was normal and negative for human papilloma virus. Her intake physical exam at our institution revealed a normal pelvic exam with no evidence of residual vaginal mass, and an ultrasound revealed no intrauterine myomas.\nGiven the differential diagnosi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n52-year-old man, plumber by profession, presented at the emergency department with one day history of having sudden onset spontaneous pain and functional impairment of left knee while he was walking. The patient had history of hypertension. He had no history of taking medications such as corticosteroids or fluoroquinolones and did not remember having suffered any knee pain previously. On clinical examination effusion was present in knee. It was possible to palpate a gap between the distal patellar tendon and the tibial tuberosity and patient was not able to extend the leg. X-ray of the left knee showed a high patella and presence of calcification in the distal part of the patellar tendon (). Ultrasound later confirmed the diagnosis of distal avulsion of the patellar tendon. Although CT scan and MRI are superior modalities for confirmation of the diagnosis but based on our clinical examination, typical radiographic finding and ultrasound imaging, we considered these expensive investigations unnecessary in this case. On the second day, patient was taken to the operating room. Under tourniquet control, patellar tendon was exposed through anterior approach to the knee. Distal insertion of the tendon was found to be completely avulsed from the tibial tuberosity with some flakes of sclerotic bone (). The torn tendon was found to have degenerative changes at the injury site. The tendon stump was debrided and refashioned. Locking double Krackow stitch was taken with FiberWire number 5, and then it was anchored to tibial tuberosity after drilling four 2.0 mm transverse holes in tuberosity. Full range of motion of the knee was performed to evaluate the repair and we found it satisfactory. Repair of paratenon was performed and wound was closed. Postoperatively, knee was locked in a brace at 0 degrees of extension and the patient was encouraged to do isometric quadriceps strengthening exercises. Patient was allowed weight bearing as tolerated. A range of motion exercises were p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman was admitted to our Department with a sudden inability to extend the second finger of her left hand (). No recent trauma was reported. One year earlier she suffered a displaced fracture of the distal radius - 23 C2 according to the AO/OTA classification. Internal fixation by volar plate was performed, using the flexor carpi radialis–radial artery interval (Henry’s approach). The right positioning of the plate, the screws length, as well as the restoration of the volar tilt were intraoperatively assessed by fluoroscopic images. The 4-week x-ray follow-up showed early signs of fracture healing. However, the screws seemed overlong with respect to the dorsal cortical surface in the lateral view (). No extensor tendons functional deficit was found. 12 months later, the patient came back with a complete functional deficit of the index finger extension. Yet, the metacarpo-phalangeal (MCF) and proximal inter-phalangeal (PIP) joint examination proved no stiffness, and the full passive extension was noticed. The Ultrasound Examination suggested an incomplete rupture of the extensor tendon mechanism of the index finger, confirmed by the MRI examination. A second surgery was recommended, consisting in the plate removal and reconstruction of the extensor tendon mechanism, with end-to-end suture or tendon graft in case of a massive tendon defect. The patient rejected the surgery. However, she came back 6 weeks later due to the unacceptable disability and with the result of a chronic lesion. In agreement with the patient it was decided to proceed to the surgical treatment. It was decided to perform a combined dorsal and volar approach, in order to remove the plate and repair the extensor tendon injury. Starting from the dorsal approach, we confirmed the complete rupture of the extensor tendon mechanism of the second finger, the incomplete rupture of the extensor tendon mechanism of the fourth and fifth fingers, and the presence of a widespread tenosynovitis inv"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old man with hypertension and diabetes presented with progressively worsening back pain radiating down the right leg, right flank pain, nausea, and vomiting. He denied hematuria, dysuria, or any problems with urination. He also had an unintentional weight loss of 5 kg during the past 6 months.\nBased on systemic symptoms, CT scan was ordered to rule out malignancy. Radiographic findings were remarkable for hypodense liver lesions, pulmonary nodules, retroperitoneal lymphadenopathy, and increased bone density in L1 and L3 vertebral bodies as well as the right iliac bone. The patient also had moderate right hydroureteronephrosis of both renal moieties with delayed nephrogram and transition point within the proximal common right ureter ( and ). Lumbosacral MRI revealed right L5 nerve root impingement by a lumbar mass. Brain MRI showed abnormal signaling within right temporal lobe concerning for metastasis.\nTo further characterize the ureteral mass as well as to confirm the extent of collecting system duplication, the patient underwent a right ureteroscopy. Cystoscopy revealed bilateral orthotopic ureteral orifices with no ectopic orifice. Right retrograde pyelogram showed a filling defect at the proximal ureter with reduced amount of contrast moving in two levels more proximally, corresponding to a partially duplicated system (). A wire was placed into the upper pole of the kidney. A flexible ureteroscope was advanced alongside the wire confirming a bifurcation of a bifid collecting system at the level of the filling defect. The ureteroscope was advanced into the lower pole ureter, with multiple papillary tumors noted in this segment distally by the bifurcation. Selective barbotage cytology and tissue samples using a Piranha™ grasper (Boston Scientific, Marlborough, MA) were obtained. Narrowing of the proximal right lower pole ureter precluded advancement to the lower pole kidney. Attention was then turned to the upper pole ureter where multiple papillary tumo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old Mexican female with family history of ovarian cancer at her maternal side and personal history of a mass on her right breast clinically and radiologically diagnosed as fibroadenoma 2 years ago. The same mass had a growth of 2 cm so an incisional biopsy was performed at another institution. This was positive for mucinous carcinoma, and the patient was referred to our institution for treatment and follow up.\nAt our institution in the biopsy slides revision, we found a tumor composed of mucinous lakes with numerous tumor cells of medium to large size with a moderate amount of eosinophilic cytoplasm confirming the presence of pure mucinous carcinoma. We could not identify the tumor size and surgical margins by no prior radiological and pathological report. []. The tumor was classified as a Low grade tumor (G1) based on the Scarff Bloom Richardson scale. We did not observe perineural or vascular invasion. On immunohistochemistry the results were 100% and 90% positive for estrogen and progesterone receptors respectively with high intensity, and HER2 receptors negative.\nOn physical examination a surgical injury was seen. Upon palpation, this zone felt indurated, edematous and presented as a rough irregular texture. No other lesions were found. An ultrasound was performed, showing avascular distortion and a heterogeneous mass with microcysts (white arrows) []. MRI showed a hypointense irregular mass that indicates a mild enhancement in contrast sequences and a hyperintense sequence in SPAIR. The evaluation of the lymph nodes was not suspicious for metastasis.\nWith the radiological suspicious of residual tumor and pathological findings accomplished at our institution a partial mastectomy and a sentinel lymph node biopsy was performed. Pathological findings showed a residual mass of 25 mm of pure mucinous carcinoma with negative surgical margins. Sentinel lymph node was negative for metastasis.\nMolecular screening with EndoPredict clinic showed a score of 2.7 cl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.\nPatient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 5-year-old girl was referred to our hospital for the investigation of urinary incontinence. The patient had continuous low volume urine leakage requiring 4–5 daily pads. The parents could not specify whether there was any connection with standing, coughing, or effort and she had no urge to void.\nShe was constantly wet but had normal voiding habits. On initial physical examination the external genitalia appeared normal with no vaginal pooling of urine or ectopic ureteral orifice. However, a long-term external genitalia examination revealed normal urethral and vaginal openings, with an intermittent urine leakage through the vaginal orifice, which slightly increased in abdominal pressure.\nIn her past history she had recurrent febrile urinary tract infections (UTIs) since her infancy. At the age of 3 she underwent an abdominal ultrasound that suspected a double left kidney. A voiding cystourethrogram (VCUG) was performed and a vesicoureteral reflux (VUR) grade III on the right kidney was found. She was given chronic chemoprophylaxis without any UTI recurrence. She had a good toilet training and gave up daytime diapers around the age of 3. At this moment parents noticed the urinary incontinence, but this didn't bother them. At the age of 4 parents asked a urologist for help, who considered the symptoms to be the result of an overactive bladder and anticholinergic treatment was recommended. No improvement was noticed, and for this reason the little girl was sent to our department for further investigation.\nComplete blood count, biochemical tests, and urinalysis were all normal and the urine culture was negative.\nAn abdominal ultrasound was performed and both kidneys had normal parenchyma and size, with a duplex-system suspicion on left side; the bladder was normal in appearance. The VCUG was repeated but no VUR was visualized. As we had a high suspicion of an ectopic ureter a contrast-enhanced computed tomography (CT) of the abdomen and pelvis was performed to visualize"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old woman presented at a hospital with chest pain. Her history included diabetes, hypertension, and hyperlipidemia. On examination, the patient had a pulse of 100 beats/minute and blood pressure of 150/80 mmHg. Her electrocardiogram, echocardiogram, and blood test results were normal. Multislice computed tomography (CT) showed a saccular LMCA aneurysm and significant stenosis in the LAD artery (Fig. ). Coronary angiography revealed a saccular LMCA aneurysm measuring 9.8 × 7.5 mm with 75% stenosis in the proximal portion of the LAD artery. The operation was performed under general anesthesia. A median sternotomy was performed, and after a longitudinal pericardial opening was made, the heart was inspected. The LITA was removed from the inner chest wall in a skeletonized fashion using electric cautery. A distal segment of 1.5–2 cm was procured and reserved for use as a patch repair. Before aortic cannulation, the ascending aorta was dissected from the pulmonary artery. Under cardiopulmonary bypass, coronary artery bypasses of the left internal thoracic artery to the LAD artery were constructed in the beating heart. After aortic cross-clamping, the LMCA saccular aneurysm was exposed without main pulmonary artery transection. The saccular LMCA aneurysm was carefully dissected and completely excised. There was no thrombus in the lumen. Then, the LITA was longitudinally divided and trimmed to fit the incised LMCA. The small internal thoracic artery patch was sutured to the normal and firm lateral coronary arterial wall with a continuous 7–0 Polypropylene suture. Resection of the saccular aneurysm and closure using a small internal thoracic artery patch was then complete. The aortic cross-clamp time was 120 min, and the CPB time was 147 min. The patient had an uneventful hospitalization and was discharged on aspirin therapy. Follow-up multislice CT 10 days after the operation revealed the complete disappearance of the aneurysm and a successful repair with no lumin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female patient was presented with swelling in front of the neck since 12 yrs, initially small in size started in thyroid region and gradually increased to present size (25 × 15 cm) with watery discharge form swelling of 6 months duration ().\nOn examination there were multiple cystic swellings extending from thyroid cartilage to mid sternum. There were about 12–15 cysts with features of intercommunication. The whole swelling moved with deglutition and there was no independent mobility of cysts. A sinus was present on right side of neck with active serous discharge (). Cervical lymph nodes were not enlarged. On indirect laryngoscopy, no abnormality was detected. Thyroid profile was within normal limits. Neck and chest X-ray showed increased soft tissue density seen in neck region extending up to upper sternal region and indenting trachea. Fine Needle Aspiration Cytology of the swelling showed features suggestive of nodular goitre. Ultrasound of the neck showed multiple anechoic areas with areas of calcification and internal septae in the neck extending from carotid level to midsternal level. Lesion seemed to be arising from thyroid tissue showing minimal vascularity suggestive of multicystic goitre or lymphangioma. On computer tomography there were multiple fluid attenuation coalescent cystic lesions in subcutaneous plane of neck and proximal thorax. There were no inhomogenous enhancing areas within the cyst. Thyroid gland could not be visualized seperately from cysts. There was no infiltration of surrounding structures or lymphadenopathy. The cystic lesions seem to be arising from thyroid gland and only part of left lobe of thyroid was visible (). Patient was subjected for surgery. Under general anesthesia Kocher's horizontal incision taken over the swelling and in middle incision extended vertically downwards over right breast as T incision and flaps raised. Fluid in cyst was clear light brown color. Some cysts were intercommunicated and cysts were fou"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old healthy male presented with midthoracic spinal pain with radiation to anterior chest wall since 6 months. Plain radiography revealed mild collapse of D6 vertebra (). Magnetic resonance imaging (MRI) revealed an expansile lytic lesion with multiple fluid levels. Computed topography (CT) revealed thinned out sclerotic margins in anterior aspect of the lesion (). As a first stage procedure, we performed posterior instrumented stabilization from D4 to D9 and biopsy. Histopathological examination was suggestive of aneurysmal bone cyst ().\nThe second stage tumor excision and anterior reconstruction was done after preoperative embolization. Patient was positioned on right lateral decubitus position and standard left transthoracic approach was employed under general anesthesia. A double lumen endotracheal tube was used for allowing single lung ventilation. Fourth rib was excised, parietal pleura was opened up and lungs were hypo-ventilated to expose D6 vertebra adequately. Corpectomy was performed followed by anterior reconstruction. Ventral surface of dura was visualized and completely decompressed. No CSF leak was noticed during the procedure. Inter costal chest drain tube of size 32F was applied and thoracotomy wound was closed in a water tight fashion.\nThe chest drain collections were 350, 600, and 850 mL, respectively on the first, second, and third day following surgery. The patient had 3 episodes of vomiting on the third postoperative night .The next day patient started experiencing headache, giddiness and nausea. On auscultation of chest, breath sounds were diminished on left side. Chest radiograph revealed diffuse haziness of left chest cavity suggesting pleural effusion. The volume of fluid drained, started rapidly progressing. The diagnosis of SPF was made after identifying beta 2 transferrin protein in the fluid which is specific to CSF and the patient was started on noninvasive positive pressure ventilation (NPPV). The patient has given a written"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy presented to Fujian Medical University with giant scrotal elephantiasis and swelling of both lower extremities. The penoscrotal edema began fifteen years earlier, soon after his birth, and it resulted in bilateral lower extremity edema with the penis becoming buried by the scrotum. His scrotal size was massive, and for the past 5 years, the glans penis was not visible nor palpable (Fig. a–c). He had undergone circumcision 13 year earlier and had no history of travel in filariasis-endemic areas. There was also no family history of scrotal elephantiasis or known genetic disorders.\nUpon examination, the patient had a massively enlarged scrotum, with a volume of approximately 16 cm × 13 cm × 7 cm. The anatomical structures and urethral orifice were visible as a deep depression on the scrotum. Both lower extremities exhibited generalized swelling, which was especially noticeable on his ankles. His thigh circumference was 52 cm on the left and 56 cm on the right.\nTissue biopsy of the lower extremities was performed 13 years earlier and revealed lymphangioma and connective tissue hyperplasia. A urinary system ultrasound examination was performed 14 months prior to presentation at our hospital, which confirmed diseased subcutaneous scrotal soft tissues with no abnormalities in the bilateral testicular morphology and blood supply. The results of lower limb lymphoscintigraphy demonstrated that the lymphatic drainage of the lower extremities was obviously tardy. The development of bilateral inguinal and iliac lymph nodes was obviously tardy (Fig. ). The lower limbs and anterior pelvic position was imaged after injecting with the tracer (99mTc-SC) subcutaneously between the first and second toes. The images demonstrated that the lymphatic drainage in both lower extremities were unclear. In the early stage, the images showed that the bilateral inguinal and iliac lymph nodes were blurred, which was obvious on the left side. The concentration of imaging agent (99"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 92-year-old man with osteoarthritis and a remote history of right total hip replacement and bilateral total knee replacements presented with a two-day history of severe right hip pain accompanied by nausea, chills, and fatigue. He was unable to bear weight due to pain, and range of motion in his right hip was severely limited. He denied recent trauma or pain in other joints but had undergone routine dental cleaning one week prior to presentation. He had received 2 gm of amoxicillin immediately prior to his dental procedure. He presented afebrile, mildly hypotensive, and was noted to have exquisite tenderness with passive movement of the right leg and reduced range of motion secondary to pain. He had full range of motion and strength distally. He had a leukocytosis of 15,600 WBC per milliliter. Aspiration of right hip joint revealed cloudy fluid with WBC 68,000 cells per milliliter. The patient was resuscitated with IV fluids and started on vancomycin and piperacillin-tazobactam. On the third hospital day, he underwent prosthetic joint drainage and washout with retention of liners. Joint aspirate culture grew Gram-positive cocci in chains, which we subsequently identified by matrix-assisted desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as S. salivarius. We narrowed antibiotic therapy to ceftriaxone to complete six total weeks of intravenous therapy, after which he was treated with amoxicillin for additional six weeks. At this point, the patient discontinued his oral antibiotics rather than complete a full three months of oral therapy or remain on long-term suppression.\nFive months after completion of the above therapy, the patient presented to the ED with hip and back pain following a mechanical fall at home. He was found to have a fracture of L4 and was admitted. On hospital day 5, he was found to have an occult superior dislocation of the R femoral head on CT and an ESR of 71 and CRP of 12.3. He was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old lady presented with her husband and mother with the complaints of recurrent and intractable vomiting since past 2 years. The vomiting was regular, occurring throughout the day, and it used to increase after meals. For the past 6 months, she was not able to hold even the liquid diet to the extent that few sips of water were sufficient to induce vomiting. Along with vomiting, she also complained of episodic loss of consciousness, which she used to regain after 1-2 h. These episodes of unconsciousness specifically occurred when she was under some stress. Besides this, she was not having any other complaint, e.g., abdomen pain, fullness in the stomach after having meals, diarrhea or constipation, or swallowing difficulties. Her history did not suggest any cardiac problem, focal neurological deficits, or convulsions. At the time of presentation, she was pregnant (second trimester) with normal fetal growth. Her family history was unremarkable except that she had strained relations with her parents-in-law. Though her husband was very supportive but for almost 1 year she was staying at her mother's house due to this illness.\nSince the onset of illness, she was taken to many physicians, gastroenterologists, neurologists, and psychiatrists. She underwent extensive laboratory investigations including upper gastro-intestinal endoscopy, barium meal, and MRI brain but any of the tests did not reveal any finding that could explain the symptoms. Results of her liver and kidney function tests were within normal limits since the onset of illness.\nIn the past, she was treated with a number of drugs including antidepressants, antipsychotics, promethazine, proton-pump inhibitors, and prokinetics for optimal periods without any relief. Her husband also took her for a vacation when suggested by a physician, but it also did not improve the situation.\nLooking at such a long history, multiple consultations, and extensive laboratory work-up, she was interviewed in the presence o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64 years old male diabetic patient with coronary artery disease and a history of myocardial infarction had recently experienced two episodes of transient ischemic attacks. The presumed diagnosis was cerebral embolism since an intracranial hemorrhage was excluded and there was no detected ipsilateral carotid stenosis. The patient was in NYHA class III, with no angina. Thallium-201 myocardial scintigraphy showed a combination of scar and viable myocardium in the territory of the occluded left anterior descending.\nOn coronary angiography he was found to have triple vessel disease, with total occlusion of the left anterior descending branch and of the right coronary artery. Left ventriculography revealed left ventricular dysfunction with a LVEF of 35%, akinesia of the anterior-apical wall and hypokinesia of the inferior wall. He was referred to our department for coronary artery bypass grafting.\nThe operation was performed with the aid of cardiopulmonary bypass, moderate hypothermia and intermittent combined (retro and antegrade) cold blood cardioplegia. Intraoperatively the apical walls were found to be thin and scared and collapsed with ventricular venting.\nWe performed a triple coronary artery bypass with a left internal mammary artery to the intermediate artery (since it was the best target vessel) and two saphenous vein grafts to the obtuse marginal and the left anterior descending. The latter was endarterectomised due to chronic occlusion. Despite the fact that the patient had no absolute indication for a ventricular restoration (SVR) procedure, the extent of the damaged apical wall found intraoperatively and the history of the Transient Ischemic Attacks made us perform a ventriculotomy and an \"anti-remodeling\" procedure. After the ventriculotomy, inspection of the left ventricular cavity revealed a \"round – shaped\" calcification of the peripheral interventricular septum (diameter of 5 cm) with a central crater filled with clot (Figure ).\nWe performed a resectio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 30-year-old male patient who was admitted to our emergency department with a 24 h history of severe abdominal pain, diarrhea and vomiting. During clinical examination, the patient reported mentioned an episode with identical symptoms three months before that was treated conservatively at another institution. The patient’s past medical history included posttraumatic stress disorder and chronic consumption of cannabis via inhalation (10–15 joints a day). The pain intensity was so strong that the patient was observed by his girl-friend to sluice boiling water on his body. In the hospital at admission the patient was aggressive and endangered himself and others. The blood test demonstrated an increased leucocyte count with 16.88 G/l, but a normal C-reactive protein level with 0.1 mg/dl. At first, the patient was treated with lorazepame and olanzapine under clinical suspicion of acute psychosis related to his cannabis consumption. Due to further exacerbation of the pain, a CT scan was performed showing several small bowel intussusceptions in the left abdominal region (Fig. A and B). Because of the acute abdominal symptoms and the findings in the CT scan a diagnostic laparoscopy was performed. Intraoperatively numerous, at least ten, regions of jejuno-jejunal intussusceptions were found (Fig. A, ). The intussuscepted jejunal segments were repositions by careful stretching of the small bowel. During examination of the affected bowel segments there was no evidence of a tumorous lesions or any other pathology (Fig. B). Only the intestinal content appeared thickened and pasty. Most interestingly severe atony of the whole small bowel was observed (Fig. A, ). Because no ischemic leasions or other pathology was found, no intestinal resections deemed necessary and the operation was terminated. The patient developed no surgical complications, and had bowel movements after gastrografin application. Due to a good recovery, he was discharged on postoperative"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 51-year-old woman underwent a neurologic checkup because of persistent, severe headache. An intrasellar, multilobular, and cystic lesion extending to the suprasellar region was detected by brain magnetic resonance imaging (MRI) []. The lesion compressed the optic chiasma upwards. Her endocrinological function was normal, based on the results of several hormone loading tests. She underwent surgical treatment by endoscopic transsphenoidal approach, and the tumor was completely removed. During surgery, the dura on the sellar floor was sutured with a PVDF suture to avoid postoperative CSF rhinorrhea, though intraoperative CSF leakage was not detected. Subsequently, reconstruction of the sellar floor with an autogenous bone graft from the anterior wall of the sphenoid sinus was performed. The pathological diagnosis was null cell adenoma. She took 5 mg oral hydrocortisone daily for 2 weeks after surgery for the prevention of temporary central adrenal failure. She had an uncomplicated postoperative course without recurrence of the tumor. She did not require hormone replacement because her postoperative endocrine function was normal.\nFive years after the TSS, she complained about abnormal odor and visited an otolaryngologist at a local clinic. On rhinoscopy, a white mass was detected in the sphenoidal sinus. A diagnosis of bacterial sphenoiditis was made, and daily intake of oral antibiotic drugs for 2 weeks improved her symptoms. However, after 3 months, the unusual odor recurred. Brain MRI showed a thickened sphenoid sinus mucosa, well-enhanced on T1-weighted images []. During the second rhinoscopy, a fungal ball was suspected, and a second surgery was performed. In the second operation, while the sphenoid sinus mucosa was intact, the end of a dural suture was focused to be the focus of the fungal ball []. The suture protruded into the sphenoid sinus though the gap in the reconstructed sellar floor. We removed the lesion as well as the suture completely. Postope"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old woman presented to her general practitioner with a 2-week history of a painful left breast lump. She denied any history of trauma. Her past medical history included ischemic heart disease, myocardial infarction, type 2 diabetes, dyslipidemia, hypertension, anxiety, depression, and asthma. Examination demonstrated a firm 30-mm breast lesion at 10 o’clock position in her left breast, 7 cm from the nipple. No axillary lymphadenopathy was appreciated. She was subsequently referred to a general surgical outpatient clinic and underwent further investigations.\nMammography revealed a poorly circumscribed mass, measuring 40 × 24 mm, in the lateral aspect of the left breast at the level of the nipple. There were irregular and stranded contours without suspicious calcifications (). The right breast appeared normal. Ultrasound (US) revealed a lobulated, heterogeneous, hypoechoic mass lesion at the region of palpable abnormality (). The mass measured 31 × 17 × 21 mm with accompanying distortion of the surrounding structures in combination with edema and skin thickening. Given the nature of these imaging findings, the lesion was considered suspicious for malignancy.\nFive days following mammogram and US the patient represented to her general practitioner with increasing left breast erythema and swelling. Pus had also begun to be discharged from the upper inner quadrant of the left breast. She was commenced on oral clindamycin for cellulitis and was referred for a US-guided biopsy. US revealed that the lesion had significantly increased in size with marked skin thickening and erythema. This was thought to represent an inflammatory lesion; however concerns remained that this may have occurred secondary to an underlying malignancy. Aspiration of the main lesion was attempted under US guidance with a 19-G needle; however, the highly viscous nature of the pus precluded aspiration. The patient was advised to continue taking oral antibiotics.\nThe patient presented to the em"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old Chinese female presented with pain at the right upper side of the chest and adjacent soft tissue swelling for 3 months. A week before admission to our hospital, she was suffering from a gradually severe pain at the chest and fever. As a result, the patient was referred to our hospital for examination and treatment. Physical examination showed the patient had a mild soft tissues edema at her right upper lateral chest wall and severe pain was elicited upon chest pressure. The patient had a low grade fever of 37.4°C. There was no weight loss and no palpable lymphadenopathy or organomegaly. The laboratory results, including blood count, differential, liver and renal function, were within the normal range. A computed tomography (CT) scan of the chest revealed a single osteolytic lesion in the right second rib with associated soft tissue mass, measuring 6.0 × 5.0 × 5.0 cm in size. The most of rib was observed to be destroyed and the involvement of adjacent pleura and right upper lobe of lung were also noted (Figure ). The lesion showed moderate enhancement after gadolinium injection. There was no enlarged lymph node found in mediastinum and thoracic cavity. A CT scan of neck and abdomen showed no pathologic findings, particularly no lymphadenopathy could be observed. A CT guided needle biopsy was performed initially, but histopathological examination showed pieces of fibrosis with infiltration of inflammatory cells. Therefore, a surgical biopsy followed by a microscopic examination was performed. After diagnosis, the patient underwent polychemotherapy according to a modified COPP protocol (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, oncovin, procarbazine, prednisone) for five cycles before initiation of involved field radiotherapy. The lesion was regressed, and the patient was on regular follow-up for 24 months after radiotherapy. The bone marrow examination was performed at 6 months after radiotherapy, there was no abnormality found. Du"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old female patient presented to a plastic surgery clinic with a lump on her right medial thigh. She noticed the lump eight months ago and it was gradually increasing in size. It was painless initially; however, the lump gradually became tender. The patient was otherwise fit and well with no co-existing morbidities. Closer examination of the right thigh revealed a high consistency mass, with reduced mobility. There was no right inguinal lymphadenopathy or lymph nodes enlargement.\nLaboratory blood tests were unremarkable. An MRI scan was requested to further assess the mass, which was irregular but well-defined in the medial compartment of the thigh, measuring 8.2 x 6.6 x 4.3 cm in size. The mass showed an intermediate signal on both T1 and T2-weighted imaging, appearing hyperintense compared to the adjacent muscular tissue, which also persisted on fat-suppressed imaging. The mass invaded the intramuscular fat planes and caused compression and displacement of the adductor muscles. There was no evidence of intra-muscular invasion. Normal cortical outline and medullary signal intensity of the femur were seen in the right thigh. There was no evidence of bone contusion, marrow oedema, fracture line, or cortical discontinuity. Other muscles of the thigh had a normal outline and signal intensity with no evidence of focal or diffuse oedema. Neurovascular structures were unremarkable. Overall, MRI findings were suggestive of soft tissue neoplasm, with a possibility of a neurogenic tumour. A wide excisional biopsy was then performed to further assess the tissue histologically by the pathologist and confirm the diagnosis. The removed mass measuring 8.5 x 6.5 x 5.4 cm and is shown in Figure . The mass had a smooth outer surface and a soft consistency. The cut surface showed a homogenous tan-white appearance with some slit-like spaces and occasional haemorrhagic spots. Multiple sections were processed for histopathological examination from different planes.\nHistopatholo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 83 year old female, who had been hospitalized for years due to schizophrenia, complained of vomiting and diarrhea for 2 days. She had no history of diabetes mellitus, neurogenic bladder, or previous antimicrobiotic therapy, but had a urinary catheter in place for a considerable period since she was bedridden for many years. The diagnosis was acute enterocolitis and intravenous fluid was administered. After she developed a chill and lower abdominal pain with muscular defense, she was diagnosed as surgical acute abdomen and transferred to our emergency department.\nOn arrival, her body temperature was 38.2°C, blood pressure was 150/70 mmHg with a regular heart rhythm of 110 beats/min, and her respiratory rate was 22 breaths/min. Physical examination revealed tenderness over the lower abdomen with muscular defense, rebound tenderness, and loss of bowel sounds. Laboratory examination revealed a normal white blood cell count with elevated C-reactive protein (24.9 mg/dL). Urinalysis was unremarkable. An X-ray of the abdomen showed gas collection in the pelvic cavity, and CT scans of the abdomen revealed intraperitoneal fluid collection and abnormal gas accumulation in the pelvic space. The distribution of this abnormal gas was between the abdominal wall and retroperitoneal cavity including the urinary bladder wall, and its association with the intraperitoneal cavity was unclear ().\nIn accordance with the history, physical examinations, and radiological findings, the patient was diagnosed as acute peritonitis with possible perforation or penetration of the lower intestine, and exploratory laparotomy was performed. At laparotomy, severe inflammatory changes were observed in the peritoneum from just below the umbilicus to the lower abdomen (). Ascites in the peritoneal cavity was slightly turbid, but without a stool smell and there was almost no intraperitoneal inflammation. Other abdominal structures were intact, however, the bladder was swollen. When the bladder wall was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old military male basic trainee (71 inches, 200 pounds, BMI 27.89) presented with a one-month history of atraumatic bilateral leg pain. He reported pain within the first week of initiating running at basic training. He was diagnosed with bilateral proximal tibia stress fractures at three weeks with instructions to stop impact activities. After failure of his symptoms to improve, he was referred to our facility. On presentation, he had tenderness about the medial aspect of each proximal tibia. Radiographs obtained at that time demonstrated bilateral proximal tibia stress fractures with varus alignment about each knee and articular collapse of the left tibial plateau. Metabolic labs were obtained and significant for a low vitamin D (15), but the remainders of labs including calcium, thyroid-stimulating hormone (TSH), and testosterone were unremarkable. MRI of the left knee demonstrated a medial tibial plateau fracture with two millimeters of articular depression and extension of the fracture to the tibial spine (). MRI of the right knee demonstrated a hypointense linear T2 signal surrounded by diffuse hyperintense signal suggesting a medial tibial plateau stress fracture with surrounding bone edema, without articular collapse or extension (). These fractures were at the level of the physis, and there was surrounding sclerosis on plain radiographs. Given the collapse of the articular surface in his left knee, the patient was indicated for open reduction internal fixation with allograft bone. The patient underwent the aforementioned procedure without complication, and the patient remained nonweight bearing to his bilateral lower extremities (). At the time of surgery, the bone at the fracture distal to the articular surface was softer and more friable in composition than expected for the stress fracture. It was easily debrided back to stable, healthy bone edges, and we were interested in analyzing its composition, so a biopsy was obtained and sent to the lab f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n46-year-old woman with 8 years of primary infertility was admitted to Clinart International Hospital for bilateral multicystic complex adnexal masses diagnosed 4 years ago as bilateral endometriomas. She had 7 IVF attempts and only in 3 cycles; embryo could be transferred with no clinical outcomes. She had a history of laparoscopic endometrioma surgery 8 years ago and endometriomas on both ovaries were aspirated and their capsules were excised together with the laparoscopic excision of a subserous myoma. Ca 12-5 and Ca 19-9 values had been high before the laparoscopic surgery. She had no other medical or surgical history and all biochemical serological and hormonal parameters were normal other than high Ca 12-5 and Ca 19-9 which supported the diagnosis of endometrioma.\nMRI investigation was carried out 2 years ago and bilateral endometriomas were reported without any radiological signs of malignancy. Patient was informed about the possible risks of malignant transformation of the adnexal masses at all times; she was admitted for fertility reasons but surgical intervention was rejected. All attempts for fertility were failed due to either the absence or diminished ovarian response to ovarian hyperstimulation by gonadotropins. Some cycles were monitored naturally with no collected oocytes. It was not easy to differentiate the follicular response by ultrasound and all oocytes retrieved from the follicles were aspirated through the endometriomas and endometriotic fluid was seen in the aspiration tubes. Oocyte retrieval (OR) by bypassing the endometriomas was not possible technically because the masses on both sides were huge and multilobulated and ovaries could not be discriminated easily. In two cycles the endometriomas were aspirated to reduce the size of the mass and to obtain oocytes easily under the suppressive antibiotherapy.\nShe decided to have the surgical operation and admitted for surgery at 31.03.2015. Pelvic MRI (), Ca 12-5, Ca 19-9, and all preoperative tes"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old Japanese woman, gravida 3 para 3, who had undergone cesarean section 2 years previously, presented to our emergency room with a 2-day history of intermittent right flank pain. She had no fever, nausea, vomiting, diarrhea, or cough. She had no history of abdominal trauma, and her past medical history and family history were not significant. She did not have hypertension or cardiovascular disease, and had not taken any anticoagulants. Her bowel and urinary habits were normal, and her menstrual periods were regular. Her last menstrual period had begun 2 days before the onset of right flank pain. On admission, her blood pressure was 115/78 mmHg, pulse 70 beats per minute, body temperature 36°C, and blood oxygen saturation 100%. She was found to be somewhat anemic, with a hemoglobin concentration of 9.8 g/dL and hematocrit of 28.2%. Her white blood cell count was elevated (13,900/mm3), and a urine pregnancy test was negative.\nOn physical examination, her abdomen was diffusely tender without muscle guarding. A pelvic examination revealed a small amount of menstrual discharge and a normal uterus and bilateral adnexae. Abdominal ultrasonography demonstrated a large retroperitoneal hematoma surrounding her right kidney (Figure A). Emergent abdominal and pelvic computed tomography (CT) was performed. Contrast-enhanced dynamic CT revealed a large retroperitoneal hematoma surrounding her right kidney with an enhancing round structure in the center of the hematoma in the arterial phase (Figure B). Although extravasation in the venous phase was not clear, findings on three-dimensional CT angiography were suggestive of a retroperitoneal hematoma due to rupture of an aneurysm of her right ovarian artery (Figure C), and no other responsible lesion was seen. A transfemoral angiography was performed for arterial embolization under a clinical diagnosis of bleeding from a right ovarian artery aneurysm. A selective angiogram of her right ovarian artery revealed a tortuous a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old boy presented to our hospital with severe hydronephrosis in his right kidney. A day before admission, the patient experienced right lower back pain accompanied by nausea, vomiting, fever, polyuria, dysuria and haematuria. Ultrasound examination of the right kidney showed severe hydronephrosis and magnetic resonance imaging (MRI) showed severe hydrops. There were no obvious abnormalities in the patient’s left kidney (). Before this event, the patient had been physically healthy and had no prior history of high blood pressure, diabetes, immunodeficiency or recent foreign travel\nInitially, the patient was thought to have ureteropelvic junction stenosis and so transperitoneal pyeloplasty using the Anderson-Hynes technique was performed. During the laparoscopy it was confirmed that there was right ureteropelvic junction obstruction. Post-surgery, the patient was prescribed a daily intravenous infusion of ceftazidime 2.0 g for two weeks. At the end of this period, a computed tomography (CT) scan of the lower abdomen and pelvis showed that the hydronephrosis of the right kidney had significantly reduced and the ureteral stent was in a good position. However, the previous healthy left kidney showed some high-density shadows in both the ureter and kidney, and hydronephrosis had developed ( and ).\nA retrograde double J ureteral stent was inserted on the left side and intravenous ceftazidime was terminated. The patient’s liquid intake was increased and he was given potassium sodium hydrogen citrate granules to alkalise his urine. Six days later, a CT scan showed that the left ureteral stones had decreased in size and had returned to the renal pelvis and the hydronephrosis had reduced significantly ().\nTwenty-five days after the left kidney catheterization, a subsequent CT scan showed that the kidney stones and hydronephrosis had disappeared completely and so the stent was removed (). Six months after the operation, a CT scan showed no signs of kidney stones or hy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA six-year-old girl was brought to the emergency room after falling from the second floor when playing at home. She is not known to have any chronic medical illness. She could not stand or bear her body weight when standing and complained of left hip pain. The Advanced Trauma Life Support (ATLS) protocol was completed. She was conscious and alert with normal and stable vital signs. A full head-to-toe examination showed superficial bruising over the dorsal aspect of the left foot. Locally, there was tenderness over the left hip on deep palpation associated with lateral and posterior bruises, but there were no open wounds or visible swelling. Her range of motion of the left hip was restricted due to pain. Radiographs of the pelvis showed a type I transphyseal fracture without epiphyseal dislocation and a type III cervicotrochanteric ipsilateral femoral neck fracture (Figure ). An ankle x-ray showed a displaced talus fracture (Figure ).\nAfter studying the x-rays and CT scans for the pelvis, treatment options were discussed with the patient's family (Figure ). The patient underwent a clinical assessment by an anesthesiologist for an urgent operative intervention to fix the fracture. The patient was taken to the operative room and placed in the supine position under general anesthesia with a full aseptic technique. An image intensifier was used as an intraoperative assessment of the fracture reduction and implant placement. A trial of closed reduction failed, thus the surgical team moved to an open reduction technique. Between the sartorius and tensor fasciae latae, the anterior hip approach was performed to reach the capsule of the hip joint and the dissection was made throughout the layers. The hip joint was opened in a T-shape, the fracture lines and three parts were identified as follows: (1) femoral head, (2) slippage physical injury, and (3) neck of femur fracture. Then, the team reduced the fracture using five k-wires"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old man presented with a lesion on the right upper eyelid that had been present for 7 years. The lesion was nodular, measuring 5.0 cm × 7.0 cm, ulcerated, indurated, and erythematous. It involved the lower eyelid (). The patient had no light perception with the right eye and had a visual acuity of 20/20 on the left. Due to the presence of the tumor over the right eye, his intraocular pressure could not be measured, and it was found to be 18 mmHg on the left.\nThe left orbital examination did not reveal any abnormalities. A full examination of his local lymph nodes and lacrimal duct did not reveal any abnormalities. He explained that he did not have any previous therapy for this lesion. He was otherwise systemically well with no relevant family history. He did not have any history of trauma and informed us that he was a farmer by occupation.\nA computed tomography (CT) scan of the orbit revealed right anterior orbital invasion with no bony or lacrimal gland involvement (). A subsequent incisional biopsy revealed squamous cell invaginations extending from the epidermis into the dermis. The invaginations and papillary projections were lined with a bilayer epithelium: the luminal layer was composed of columnar cells with decapitation secretion and the outer layer was composed of small cuboidal cells. These cells had significant nuclear pleomorphism, prominent nucleoli, and increased mitotic activity (). Immunohistochemical staining demonstrated positivity for epithelial membrane antigen (EMA), Cytokeratin 8/18, and a Cytokeratin cocktail of high and low density (). It was negative for GCDFP-15 (protein 15 of the fibrocystic disease of the breast), which excluded a lesion of breast origin and carcinoembryonic antigen (CEA). The diagnosis of SCACP was therefore confirmed. A positron emission tomography (PET) scan did not reveal any metastatic spread.\nThe patient was treated with exenteration of the right orbit to remove the tumor. After 11"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male was admitted to the Department of Surgical Oncology (The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China) in November, 2011 with suspected PTMC and lateral cervical lymph node metastasis identified by careful digital palpation and ultrasonography (US) during a routine health examination. The patient had a >2-year medical history of hypertension, which was controlled with antihypertensive agents (indapamide and amlodipine besylate) and a 10-year history of smoking half a pack of cigarettes per day. There was no remarkable family history and the patient was in good general health with no significant weight loss. The thyroid gland appeared normal upon physical examination and no abnormalities were identified on the chest X-ray, electrocardiogram or pulmonary function examination. Furthermore, laboratory examinations, including thyroid hormone and tumor marker analysis, were unremarkable. Enlarged lymph nodes on the left neck were painless, solid and immobile, and could be identified by palpation; the largest lymph node measured 2.0 cm in diameter. Ultrasonographic examination identified one hyperechoic nodular lesion ~0.4 cm in diameter in the lower pole of left lobe, and three well-circumscribed, heterogeneous hypoechoic nodular lesions with a diameter of ~0.9 cm in the lower pole of the right lobe, ~1.0 cm in the superior pole and ~0.4 cm in the lower pole of left lobe. No obvious indicators of metastasis were identified. In consideration of the abovementioned data, the patient was diagnosed with thyroid carcinoma and consequently underwent a right lobectomy, a partial left lobectomy and a lymph node biopsy. Analysis of the intraoperative frozen pathological sample revealed a diagnosis of bilateral PTMC with metastatic lymph node SCC from a different primary location. Furthermore, all of the thyroid tumors were surrounded by an intact capsule and demonstrated no definitive evidence of capsular extension or invasion, however,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old white man arrived by ambulance to our emergency department with chief complaints of lower abdominal pain and profuse diarrhea. On examination, general signs of poor health were observed. His blood pressure was 150/60 mmHg and pulse rate 90 beats per minute (bpm). His temperature was 37.3 °C and he did not appear to be in distress. A physical examination did not reveal any bowel obstruction. His laboratory findings were within normal range except for an elevated white blood cell count (14.5 × 109/L), slightly low red blood cell count (3.12 × 1012/L), and slightly raised level of creatinine (124 μmol/L). His medical history included recent completion of radiotherapy treatment for a Gleason score 9 prostate adenocarcinoma, previous cerebrovascular event, asbestosis, atrial fibrillation, and chronic lymphoid leukemia. His abdominal surgical history included only an open appendectomy 40 years prior. He is a retired marine engineer and lives with his wife. He reported that he did not drink alcohol and had quit tobacco smoking 30 years ago. His family history is noncontributory.\nComputed tomography (CT) of his abdomen and pelvis was performed and demonstrated a peritoneal recess containing multiple small bowel loops over the anterior side of the intraperitoneum lying between peritoneal lining and the transverse abdominis fascia consistent with a pseudoherniation of a preperitoneal subtype (Fig. ). There was no mass or dilatation of bowel loops and no mass to his upper abdominal organs or retroperitoneum.\nIn view of CT abdomen findings, a surgical opinion was sought. As there was no evidence of bowel compromise, he was managed non-operatively. Fecal polymerase chain reaction (PCR) tested positive for Salmonella and our patient improved on antibiotics with resolution of abdominal pain. He was discharged and followed up 2 weeks later at out-patient clinic and had no abdominal discomfort; therefore, no elective hernia repair was planned and further follow-up was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old Caucasian woman presented to the emergency department with a history of progressive muscular weakness associated with nausea, vomiting, and diarrhea. At baseline, the patient was independently ambulating with a walker. However, she started to have a gradual bilateral upper and lower extremities weakness for two weeks before her presentation. As a result, she became dependent on her roommate to perform daily living activities (i.e., bathing, dressing, toileting, transferring, and feeding). She also reports an associated history of diarrhea three to four times a day since the onset of her symptoms. She reports a history of weight loss, poor appetite, polyuria, polydipsia, memory impairment, decreased visual acuity, and hearing loss on review of systems. She denied any history of shortness of breath or chest pain. The patient stated that she has been drinking 8-10 cans of 16 oz of Pepsi cola every day. The past medical history is remarkable for chronic obstructive pulmonary disease (COPD), history of abdominal trauma with subsequent splenectomy, gastroesophageal reflux with esophagitis and hiatal hernia status post failed Nissan fundoplication, alcohol abuse, and longstanding multiple psychiatric disorders treated with different antipsychotics and antidepressants. The patient stated that she had not taken any of her home medications for more than two weeks before the presentation. In addition, she reports a 20 pack-years history of cigarette smoking and lived with a roommate who has been busy lately and did not provide sufficient support to the patient.\nOn physical examination, vital signs were normal; the patient looked cachexic and dehydrated with dry skin and mucous membranes. She was also confused with impaired remote memory and appeared in poor hygiene as she could not shower or sanitize her excreta for three to four days due to weakness. Neurological examination showed normal cranial nerves, a decreased strength in the upper and lower extremities (3"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male presented with insidious onset diplopia while looking to the right and to distant objects of 3 months duration. There was no history of visual blurring, jaw deviation, facial asymmetry, hearing loss or tinnitus. There was no associated headache, vomiting, seizures or loss of consciousness, limb weakness, gait, and bowel or bladder disturbances. On examination, patient was conscious with stable vital signs. Higher mental functions were normal. There was right side sixth nerve palsy and nystagmus on looking to the right. Visual acuity and visual field examination were normal. There were no other cranial nerve, motor or sensory deficits. Other system examinations were within normal limits. Magnetic resonance imaging of the brain showed an expansile mass lesion involving entire clivus that was T1- and T2-isointense and showed contrast enhancement. There was erosion of posterior wall of the sphenoid sinus with lesion bulging into the sinus. Pituitary was normal []. With a preoperative diagnosis of clival chordoma infiltrating into the sphenoid sinus, the lesion was decompressed by subfrontal trans basal approach.\nMicroscopy showed respiratory epithelium with an underlying neoplasm composed of sheets of plasma cells with a moderate amount of cytoplasm and eccentric round nuclei []. Cells were positive for CD 138, CD 38 and CD 56, while negative for CD 20, cytokeratin and synaptophysin. Ki 67 (MIB) labeling index was < 5%. Cells were kappa light chain positive and negative for lambda light chains thus establishing monoclonality. A diagnosis of plasmacytoma of clivus was given, and workup for myeloma was suggested.\nPatient underwent whole-body X-ray studies, serum and urine electrophoresis, complete blood counts, serum calcium levels and a bone marrow biopsy, as part of myeloma investigations, which were negative.\nPatient received radiotherapy (50 gray given in 25 fractions) and is now 8 months postoperative and doing well. The right side lateral rectus p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male was sent to our institution. The patient had a 3 years history of shoulder pain and sense of posterior instability with recurrent episodes of posterior subluxation events. He experienced had many of these episodes during normal activity of daily living.\nNonsurgical approach did not lead to any benefit. During the first consultation, the patient had a full range of motion, demonstrable generalized ligamentous laxity, hyperextension at the elbows and wrists. All impingement tests were negative, and all strength tests equally. There was a 1.8 cm sulcus sign on the left shoulder, as well as a positive apprehension sign. He demonstrated loss of external rotation of approximately 12° on his left extremity, as compared to his right extremity.\nIn the light of the imaging and clinical presentation, we diagnosed a recurrent posterior instability. We suggested to perform an arthroscopic posterior capsulo-labral repair and surgery was scheduled.\nWhile waiting for surgery the patient had a car accident and sustained a traumatic anterior dislocation of the left shoulder. The dislocation was reduced in the emergency room, and physical treatment started after 1 week []. A new visit was scheduled 4 weeks after the car accident and the patient reported a worsening of instability with extreme apprehension and several new episodes of dislocation which he to be both anterior and posterior and that he was able to reduce by himself.\nAt physical examination his range of motion was 110° of flexion, extrarotation 15°, intrarotation arrived to L-5. Tests for rotator cuff were negative, but the patient had a loss of strength. Tests for instability were all positive (sulcus, Rowe and load and shift test). No vascular or nervous impairment were present.\nFor further evaluation we performed a computed tomography scan that revealed a Hill-Sachs lesion at the posterior aspect of the humeral head, 10-15% (of the total glenoid surface) bone loss at the anterior glenoid rim and about"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old woman in good general health, with no other co-morbidities presented with a long history of chronic right fifth toe pain for 30 years. She reported a history of injuring her right foot when playing sport for 30 years. She when landing recalled that she had twisted her right foot; moreover, the foot was not well treated at that time of the injury. The only treatment for the fifth toe was with the temporary bandage to reduce the deformity. Then, the PIP joint of the fifth toe was redislocated for several times in 6 months after the first injury and the same treatment was attempted each time. After that, the fifth toe gradually became permanently swollen and painful on movement. When the patient presented in the out patient clinic with chronic right fifth toe pain and swelling, (Figure ), the toe was displaced in the dorsolateral plane. The plain radiograph showed a simple dislocation of PIP joint in the dorsolateral direction. The articular cartilage of middle phalanx impinged on the lateral condyle of proximal phalanx. There was no indication of definite joint destruction, erosion or unhealed fracture (Figure ). The distal segment of the toes was unstable because of the chronic and persistent joint subluxation.\nThe decision was made to attempt the correction of the chronic dislocation by open reduction, as the problem had been present for many years and all previous attempts at closed reduction had been non-successful. The dislocated PIP joint was exposed via a dorsal incision, revealing that the joint capsule and attenuated lateral collateral ligament were interposed within the PIP joint space, and the articular cartilage at lateral condyle of proximal phalanx of the fifth toe became eroded (Figure ). The joint capsule and the lateral collateral ligament were dissected away from the joint space. The tight plantar plate was released from plantar lateral aspect of the joint and the corrected position of the PIP joint was maintained by inserting a longitu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man with severe chronic obstructive pulmonary disease (COPD) presented with a feeling of fatigue, weight loss, and reduced physical activities. He was diagnosed with COPD at the age of 69 years and had retired from work the following year. His smoking history included 40 cigarettes per day between the age of 14 and 69 years; his airflow limitation was classified as severe by the Global initiative for Chronic Obstructive Lung Disease; and a chest computed tomography (CT) scan showed severe emphysema. He had started long-term oxygen therapy at the age of 72 years and is currently inhaling 3 L/min of oxygen. Medical and family histories were otherwise unremarkable. Cardiac ultrasound excluded comorbid congestive heart failure or pulmonary hypertension, and CT pulmonary arteriography also excluded chronic pulmonary thromboembolism. As the patient had a history of acute exacerbations of COPD more than twice a year with extreme respiratory symptoms, he was prescribed a combination of inhaled long-acting antimuscarinic antagonist, long-acting beta2-agonist, corticosteroid, and oral carbocysteine, ambroxol, and theophylline. He reported symptoms of dyspnea on exertion, depression and anxiety, and a decrease in physical activity. He also experienced anorexia with a weight loss of more than 5 kg in a year, and no other possible causes of weight loss, such as tuberculosis and malignant tumor, were observed. Therefore, in addition to respiratory pharmacotherapy, we prescribed an antianxiety drug and provided nutritional supplement therapy, patient education, and pulmonary rehabilitation. However, the patient's mental and physical symptoms did not improve after 4 months. Furthermore, he exhibited deterioration in activities of daily living as well as physical and mental weakness; hospital visits were difficult and therefore, he considered home care. Persistent weight loss, poor endurance and energy, and low physical activity levels led to the diagnosis of physical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old male presented with gross total painless hematuria of a 5 days duration. There was no past family history of cancer. General physical examination and systemic examination were normal. Blood workup showed anemia. Renal function and liver functions were within normal limits. An ultrasound showed a polypoidal mass attached to the anterior wall of the bladder of 7 × 5 cm in size, which was further confirmed by a contrast enhanced CT scan (CECT) of abdomen. There was no evidence of lymph node or visceral metastasis. Transurethral resection of the bladder mass was performed. The upper gastrointestinal tract (GI) and lower GI endoscopy was within normal limits. A bone scan did not show any skeletal metastasis. Thereafter, the patient underwent robot assisted partial cystectomy and bilateral lymph node dissection till aortic bifurcation. The histopathology was suggestive of a high-grade urothelial carcinoma with six out of seven nodes showing metastasis. Post operatively, the patient developed fever and intestinal obstruction, initially managed conservatively, however, the patient did not show improvement. A repeat CECT abdomen was done which showed soft tissue lesions in both lungs, with pleural effusion, multiple liver lesions and ascites, suggestive of disseminated metastasis. The patient's general condition deteriorated, and he subsequently succumbed to his disease. An overview of the medical disease history is illustrated in a timeline (). Photomicrographs of the tumor from the urinary bladder showed a high-grade urothelial carcinoma with plenty of large pleomorphic cells and infiltrating the detrusor muscle ().\nWhole-exome sequencing (WES) analysis of the paired tumor-normal sample from the patient was performed. A detailed description of the sequencing methods is provided in the . WES data analysis revealed 558 exonic somatic mutations, of which 360 missense, 26 nonsense, 30 frameshift deletions/ insertions and, also 10 splice site mutations were annota"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA newborn male child, less than one day old, was found to be leaking clear fluid from the skull one hour after birth whilst the mother was holding the child. The child was born at forty-one weeks through a normal vaginal delivery with forceps assistance and no immediate complications. Prenatal screening was unremarkable. The mother was from an indigenous background and in good health and there was no family history of any other similar illnesses. She denied smoking and alcohol use during pregnancy. At birth, no issue with the skull was noted. On further inspection of the child, after the mother raised concerns about the clear fluid leaking from the skull, a 1.5 cm circular defect was identified in the area of the posterior fontanelle with macerated skin edges and underlying membranes and evidence of clear fluid flowing from it. The child had normal haemodynamic parameters throughout and was otherwise examined normally. Further testing of the fluid for beta-trace protein was positive for cerebrospinal fluid (CSF). The neurosurgery team at the tertiary referral centre was contacted at this stage for a suspected encephalomeningocele and the child was transferred there for further management. Further examination at this stage showed a child who was otherwise well, feeding normally, and with normal system review.\nFurther imaging with computed tomography (CT) scan of the head, magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) identified a likely encephalomeningocele (Figures -). The defect was arising from the posterior fontanelle. Characterisation of the surrounding vasculature showed a persistent fetal vein and possibly an associated vein within the defect. An MRI spine to identify any associated NTD was unremarkable.\nThe child was booked in for emergent repair of the encephalocele. During the operation, a vertical incision with an elliptical extension around the defect was marked. Careful dissec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old male patient presented at our clinic complaining of dysphagia from eating and multiple cutaneous nodules.\nOne year earlier, the patient underwent remnant gastrectomy for gastric stump cancer. Postoperatively, due to the patient’s resistance to chemotherapy, he did not return to the hospital for postoperative adjuvant chemotherapy until 3 mo after the surgery. During the follow-up visit, the patient developed dysphagia from eating and also complained of some painless, red, skin nodules approximately 0.5-1.5 cm in diameter on his forehead, back, neck, and arms. Thus, the patient was readmitted to our hospital for a work up for his dysphagia and multiple cutaneous nodules. We consulted with our dermatologist, who suggested a re-biopsy of the cutaneous nodules, despite the negative pathological results for the subcutaneous nodule, when the patient had a remnant gastrectomy for his recurrent gastric cancer. Based on the medical history as well as pathological findings from the immunostaining study, the cutaneous malignancy was further confirmed to be of gastric origin.\nThe patient was initially admitted to our department for laparoscopic-assisted distal gastrectomy with D2 lymphadenectomy to surgically manage antral adenocarcinoma 3 years earlier, a pathological stage of pT4aN3bM0 for his antral ulcerated infiltrating gastric cancer with poorly differentiated tubular adenocarcinoma penetrating the serosal layer and invading the nerve (Figure ), and six cycles of postoperative adjuvant chemotherapy (fluorouracil, folic acid, and oxaliplatin). Additionally, the patient had type 2 diabetes and pneumoconiosis for many years.\nHe was admitted again 1 year ago for the treatment of gastric stump cancer. Following normal preoperative examinations, the patient underwent remnant gastrectomy, during which a single small subcutaneous nodule in the midline of his abdomen was considered suspicious and removed for a histopathological exam to diagnose the nature of the nodu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Saudi Arabian girl weighing 520 g was born at 25 weeks gestational age to a 35-year-old, gravida 4, para 3 mother. There was no family or medical history of a thrombophilic disorder. The infant was a vaginal delivery with Apgar scores of 3 at 1 minute and 8 at 5 minutes. The birth weight was appropriate for gestational age with no dysmorphic features. The infant was immediately intubated, received surfactant, and was mechanically ventilated. The initial chest X-ray was compatible with respiratory distress syndrome. Shortly after birth, the baby developed hypotension. Umbilical venous and arterial lines were inserted, and a dopamine drip was started at 10 mcg/kg/minute with subsequent stability. A partial sepsis workup was performed, and the baby was started on ampicillin and gentamicin. Hyperglycemia on day 2 was managed with an insulin infusion. Cerebral ultrasound on day 3 of life was normal. The umbilical venous and arterial lines were removed on day 7 of life.\nOn day 14, the baby developed acute renal failure secondary to sepsis with poor urine output, hypotension, metabolic acidosis, hyperkalemia, and a raised creatinine. Numerous attempts were made to insert a peripheral arterial line for frequent blood sampling and blood pressure monitoring without success. Due to the severity of illness and need for arterial access, a decision was made to insert a right brachial artery catheter, but after 8 hours the middle, ring, and index fingers of the right hand were noted to be cold, and cyanosed, and the arterial line was immediately removed (). The hand was elevated, and warm compresses were applied to the contralateral limb. Ischemic changes soon became evident and 4 hours later progressed to involve the distal part of the fingers which started showing signs of probable early necrosis (). The international normalized ratio (INR) and partial thromboplastin time were normal. A complete prothrombotic screen was not performed because the event was not spontaneous, ther"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe informed consent was provided by the patient, and ethical approval was warranted by the First People's Hospital of Huaihua.\nA 49-year-old man presented with a 5-month history of back pain who was diagnosed with fourth thoracic vertebral body fracture caused by tumor cells based on pathology results. The tumor cells in the fourth thoracic vertebral body originated from hepatocellular carcinoma. The preoperative thoracic magnetic resonance imaging (MRI) showed a minor intraspinal space-occupying lesion in the fourth thoracic vertebra canal and found pathological fractures of the fourth vertebrae (). Back pain as the only clinical symptom without any weakness, numbness, or other symptoms of spinal cord injury in both lower extremities was reported to the physician. And then, he accepted the percutaneous vertebroplasty (PVP) plus interstitial implantation of 125I particles (10 particles) at a local county hospital (). Back pain was relieved postoperatively, 3 days after he received PVP combined with interstitial implantation of 125I seeds. However, back pain, bilateral lower extremity weakness, and loss of bladder control reoccurred on day 3 after surgery and got worse. A general physical examination and central nervous system examination upon patient admission revealed abnormal findings. The majority of symptoms encompassed pain and hypoesthesia below the processus xiphoideus. The abdominal reflex, the crissum and cremasteric reflex, and the knee and ankle reflex could not be induced. No pathological reflection of Babinski's sign was induced. The strengths of the major muscle of both lower limbs were 3 grades and progressively decreased in the postoperative period. The opiate drugs were used to control pain originating from the surgical site. He was admitted to our hospital after 44 postoperative days because of serious back pain. The postoperative transverse computed tomography (CT) revealed bone cements and metallic implants in T4 without any bone cement leakage,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 41-year-old female with past medical history of appendectomy and dysmenorrhea. She presented to the emergency department with nausea, severe vomiting, and acute pain in the lower abdomen. She reported having experienced asthenia and weight loss for one month. On clinical examination, abdominal distension and tenderness were discovered. Blood tests revealed leukocytosis with neutrophilia, and a contrast-enhanced abdominal computed tomography (CT) showed a 7 × 7 × 4 cm hyperenhanced mass in the cecum that caused complete bowel obstruction (). Also, a 5 × 3 × 3 cm right adnexal mass that compromised the ovary with intimate contact with the uterus was found (). Furthermore, the CT showed dilated loops in the small bowel (>4 cm), some of which had an enlarged wall thickness and presence of intraluminal fluid stasis ().\nWith these findings, particularly the observation of a mass through the CT scan, and due to the evident weight loss that the patient had undergone, neoplasia could not be ruled out. Surgery was decided, and at laparotomy, a volume of 200 ml of inflammatory fluid was found in the cavity. Most of the loops of the distal ileum were dilated, and a 7 × 7 × 3 cm cecum mass was discovered, which compromised the ileocecal valve and caused complete bowel obstruction. Surgical decision was straightforward, the cecum mass was completely resected, and a right hemicolectomy was executed. An ileocolic anastomosis was also performed during the procedure. Furthermore, the right adnexal mass that was previously identified through the CT scan (measuring 4 × 3 × 2 cm) was observed to be firmly attached to the ovary and the fimbriae and displayed a pale external capsule surrounded by a cystic component. Gynecology consultation was required, and due to the size of the mass and its characteristics, surgical removal of the right adnexal mass was performed. After completion, closure of the abdominal wall was performed, and the remainder of the procedure continue"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man who had type 2 diabetes and was toothless visited our hospital because of anal pain that had started a week before. Swelling and redness were observed on his left-side buttock. Digital examination revealed swelling of the left-side anal canal. The blood examination test result showed elevated white blood cell count and C-reactive protein level. The computed tomography (CT) revealed a fluid cavity containing air in his left-side buttock and a high-density linear structure in the cavity (). Furthermore, we found several linear structures in the gastrointestinal tract (). We made a diagnosis of perianal abscess due to a foreign body and performed an emergency operation. We especially suspected a foreign body, particularly a fish bone, in the abscess cavity on the basis of the CT scan findings.\nWe performed an operation under lumbar anesthesia in the jackknife position. We cut on the swollen site on the left-side buttock and drained purulent discharge. We also found and extracted from the abscess cavity foreign bodies, including the fish bone, which were detected on the preoperative CT scan. The foreign body was 5 cm long (). We irrigated the abscess cavity with saline and placed an 8 mm Penrose drain. We did not close the wound to drain discharge after the surgery. The bacterial culture of the sample taken from the abscess cavity showed Escherichia coli. Accordingly, the patient received tazobactam/piperacillin until day 3 and clavulanic acid/amoxicillin between days 4 and 11. In the postoperative course, the amount of discharge from the drain decreased day by day. The findings from the buttocks and the white blood cell count and C-reactive protein level were improved. The drain was removed on day 6, and the patient was discharged from the hospital on day 8. After the operation, the patient remembered that he ate fish (barracuda) before the onset of his symptoms and ate food without his denture because it"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 25-year-old male with a past medical history of chronic sinusitis who was brought to our emergency department by EMS for new-onset seizures. The patient had been complaining of weakness, frontal headache, sinus pain, and nasal congestion for the last 5 days. He was seen at a different emergency department three days before and discharged with a diagnosis of viral syndrome. On presentation to our department the patient was postictal and complained of neck stiffness, headache, congestion, and fever; he was placed in isolation due to concern for meningitis. Initial vital signs included a temperature of 103°F, heart rate of 112 beats per minute, 20 breaths per minute, and blood pressure of 116/61 mmHg. On examination he was diaphoretic and lethargic but was fully oriented and able to answer questions. Cranial nerves two to twelve were intact with no focal neurologic deficits; the remainder of the physical examination was unremarkable except for bilateral frontal sinus tenderness to palpation.\nPoint-of-care glucose, complete blood count with differential, and basic metabolic panel were obtained, all within normal limits. Computed tomography (CT) of the head without contrast was ordered to evaluate for suspicion of intracranial pathology, revealing 1.3 cm attenuation behind the frontal bone and severe frontal sinusitis (). At this point both neurosurgery and otolaryngology specialists were consulted. MRI with and without contrast were subsequently ordered, showing a 2.1 cm epidural lesion in the left frontal region producing minimal mass effect on the left frontal lobe ().\nWhile in the emergency department, the patient received Tylenol, empiric vancomycin, ceftriaxone, levetiracetam for primary seizure prevention, and dexamethasone to decrease intracranial edema. Over the next several hours the patient's fever decreased to 99°F and tachycardia resolved. However he still complained of frontal sinus pain and headache. The patient was admitted to the surgica"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old African American woman presented for an orthotopic heart transplantation following staged resection for a cardiac paraganglioma. The oncologic treatment included an en bloc resection of the heart, portions of the great vessels, several ribs and a portion of pectoralis major muscle (Fig ). The plastic surgery department evaluated the patient intraoperatively for chest wall reconstruction. It was noted that the sternum was divided in the midline and a large portion of the left sternal body, along with 4 ribs to the anterior axillary line, had been resected en bloc with the specimen. This resulted in a 10 × 10 cm2 chest wall defect (Fig ), and a decision was made to proceed with Strattice for chest wall reconstruction. Multiple interrupted 0 polydioxanone suture (PDS) sutures were placed in horizontal mattress fashion 270° around the defect through the ribs and intercostal musculature. The Strattice was trimmed to fit the chest wall defect and was parachuted underneath the rib edges to minimize contact between the bony edges and the heart. The Strattice was then serially secured in place, creating a tight construct to replace the missing segment of chest wall (Fig ). Bone reduction clamps were used to reduce and align the manubrium and residual body of the sternum. Rigid fixation was provided with a locking sternal plating system. The medial edge of the Strattice was then aligned with the contralateral sternum/ribs and this was secured with interrupted figure of eight 0 PDS sutures.\nMuscle coverage for the implants was obtained by elevating the residual pectoralis muscle on the left and approximating this to a composite pectoralis myocutaneous flap that was elevated from the right chest. The patient did well postoperatively and was discharged home on postoperative day 16. A 9-month computed tomographic scan shows stable internal reconstruction and no fluid collection around the graft (Fig ). At a 14-month postoperative visit, her chest wall"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 74-year-old, left-handed man who was a retired upholsterer with just four years of schooling. He reported that he always used his left hand for everyday tasks including writing and doing his work. Family sinistrality could not be corroborated.\nHe reported that about one month and a half before his current hospitalization he began to experience loss of strength in his right leg associated with difficulty in walking. Additionally, he mentioned that he had no control over his right hand and when walking in the street that hand would touch other people without him being aware of it; apparently he would make hand or foot movements without being aware of what was happening and with no control over those actions. Similarly, he sometimes lost his right shoe with no direct knowledge of any movement. One month earlier, after a fall, he had been taken to a hospital.\nThere, the preoperative neurological examination reported headache, disorientation, incomprehensible speech, and right hemiparesis. Three days after admission to the hospital, neurosurgery was performed. Preoperative neuropsychological evaluation could not be conducted due to his neurological status and the limited time before surgery.\nA preoperative MRI () revealed a lesion in the left hemisphere that involved the frontal and parietal lobes and had collapsed the ventricle. It was a hyperdense lesion with significant brain edema that suggested a space-occupying lesion. A brain tumor with a high level of malignancy that was interpreted as a probable glioblastoma multiforme was also found. The lesion was deforming the Sylvian fissure and affecting Brodmann areas 39 and 40, with an extension towards the temporal lobe.\nThe patient was taken to surgery to remove the tumor. A first subtotal resection (80%) of the tumor via craniostomy was performed. Two days after this surgery, neurological examination revealed Glasgow = 15, spontaneous ocular opening, isochoric pupils, photomotor and consensual reflexes"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old boy presented with a large bosselated swelling over the cheek extending to the submandibular, submental, postauricular region and which was still further increasing in size (Figure ). A trucut® biopsy was suggestive of fibromatosis. Computerized tomogram (CT) scan revealed a large soft tissue mass infiltrating the massetter, parotid gland, floor mouth, submandibular gland, the lateral oro-nasopharyngeal wall and the pterygoid muscle. The horizontal ramus of mandible was eroded and the mass extended across the midline. Excision of the mass with segmental mandibulectomy was performed. Reconstruction with a free fibula was deferred for a later stage in view of the young age, large mass and concern of recurrent disease. Since the mucosal defect following excision was not large enough primary closure was performed. Histopathology confirmed juvenile fibromatosis and all cut margins of resection were free of tumour. The patient presented after 13 months with recurrent swelling over the cheek with significant difficulty in swallowing and constant dribbling of saliva due to inadequate mouth closure (Figure ). A CT scan revealed presence of a large recurrent mass in the floor of mouth, infiltrating the infratemporal fossa (ITF) and reaching up to the base of skull (Figure ). In view of the extensive recurrence low dose chemotherapy (weekly vinblastine, methotrexate and tamoxifen) was started. After completion of 12 weeks of chemotherapy, a partial response was achieved. Excision of the mass with ITF clearance was performed subsequently. A portion of tongue and its base along with the lateral oropharyngeal and the soft palate was also excised (Figure. ) The defect following resection was large and a free flap was not feasible as the external carotid artery was ligated at previous surgery. Reconstruction with a PMMC flap for providing mucosal cover and soft tissue bulk for defect was considered. In view of the large mucosal defect a large skin paddle was taken inco"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old female patient presented with a locally advanced tumor of the proximal pancreatic body. The patient showed no signs of obstructive jaundice and did not require biliary stenting. Initially, her tumor was noted to involve the major visceral vessels, including the celiac artery, portal vein, and splenic artery and vein (). The tumor was deemed unresectable and the patient underwent extensive chemotherapy with multiple cycles of gemcitabine, Abraxane, 5-fluorouracil, Alloxantin, Avastin, and Xeloda. After showing a favorable response, she was referred for surgical re-evaluation. The post neoadjuvant chemotherapy CT scan () showed a poorly defined infiltrative pancreatic neck and body mass measuring ∼25 × 15 mm with ill-defined soft tissue encasing the proximal splenic artery, common hepatic artery (CHA), distal celiac axis, and superior mesenteric artery (SMA). The mass also partially encased the portal vein and superior mesenteric vein (SMV). There was no radiologic evidence of hepatic metastasis and there was mild pancreatic duct dilatation. Pre-treatment and post-treatment serum CA 19–9 levels were 46 and 9, respectively. The patient did not receive any additional studies to assess GDA flow or the need for preoperative coiling/embolization. The absolute need for resection of the celiac axis was not determined until the time of the operation. The patient's functional status, perioperative risk, and likelihood of response were weighed and she was determined to be a candidate for an attempt at a modified Appleby procedure. After being properly informed of her various treatment options, she elected to undergo the operation.\nExploration of the duodenum and pancreas revealed a firm mass in the body of the pancreas with a soft pancreatic neck. No gross evidence of metastatic disease was present. There was a benign appearing lesion in the superior aspect of liver segment II, which was excised in its entirety and confirmed to be benign. Cholecystectomy was perfo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man had visited our hospital with a chief complaint of dyspnea in 2004, and at that time, a 3.9 × 3.6-cm tumor in the right hemithorax was detected The tumor was diagnosed as a pulmonary solitary fibrous tumor by transthoracic needle biopsy (Fig. a-c). However, the patient was lost to follow-up. In April 2011, he visited our hospital again with complaints of acute shortness of breath. At that time, a large amount of pleural effusion and a 17 × 15-cm huge mass were observed on the chest radiograph, and a transthoracic needle biopsy and thoracentesis were performed accordingly. The tumor was diagnosed again as a solitary fibrous tumor, and surgical resection of the tumor was recommended. However, the patient refused to undergo the operation. When he visited our hospital to undergo positron emission tomography/computed tomography (CT), loss of consciousness developed suddenly while a blood sample was taken in the fasting state. Thus, he was admitted to the emergency room, and his blood glucose level was 38 mg/dL on admission. An examination of his medical history showed that the medication for diabetes mellitus was started 4 years ago, and this medication was stopped 2 years ago. According to the most recent chest CT scan, the size of the solitary fibrous tumor in the right hemithorax had increased to 18.5 × 14.5 cm, and a large amount of pleural effusion was observed (Fig. a-b). After injecting 50 cm3 of 50% dextrose/water (D/W), his blood glucose level increased and consciousness recovered. To prevent the recurrence of hypoglycemia, 10% D/W was continuously injected, but hypoglycemia and loss of consciousness developed three more times over 3 days after admission to an inpatient ward. A hormone test was conducted to differentiate the cause of hypoglycemia. Although, no abnormal findings were observed and the tumor had enlarged and the blood glucose level decreased despite the patient’s history of diabetes, so"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a primigravid, 33-year old European woman, who was admitted to the emergency department for obstetrics in her 34th week of pregnancy, due to a symptomatic but compensated anemia, which clinically has been manifesting in a 3-week history of fatigue, mild circulatory insufficiency and a hemoglobin level of 4.8 g/dL. The patient negated vaginal or rectal bleedings but mentioned a blackening of stool during the last three weeks, which she attributed to the intake of iron supplements. There were no abnormal findings considering the pregnancy. After transfusion of three packed red blood cells, only a marginal increase in hemoglobin level (5.9 g/dL) was recorded. Considering the symptoms and insufficient increase in hemoglobin levels, a gastrointestinal bleeding was assumed and gastrointestinal endoscopy was advised. Gastroscopy revealed a posterior wall-sided mobile conglomerate tumor in the corpus and antrum with an ulcerated and hypervascularized surface leading to severe hemorrhage. Proximal to the tumor, the posterior wall of the gastric corpus was impressed extraluminally. According to its endoscopic appearance, the tumorous mass was assumed as a highly suspicious finding with the suggestion of an ulcerated malignant gastric tumor or gastrointestinal stromal tumor (GIST) of the stomach. Biopsy or intervention measures were not performed due to the risk of further uncontrollable bleeding. The extent of the tumor was additionally determined by transabdominal ultrasound, which showed an 11 cm mostly cystic tumor mass presumably arising from the pancreatic tissue. At this point, the entity was still not clear. An interdisciplinary team of gynecologists, visceral surgeons and gastroenterologists evaluated these clinical findings with regard to the gestational age and decided to refrain from further diagnostics (magnetic resonance imaging (MRI)/computed tomography (CT)/biopsy/blood tests) and conservative therapy because of the urgent need of maternal treatment."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman was referred to our department for otalgia, yellowish discharge, itching, and hearing loss of the left ear recurring over the last three months. She reported intermittent fever, but neither tinnitus nor vertigo. She denied previous trauma or surgery in this region and was not using a hearing aid. Her past history included atrial fibrillation, diabetes mellitus, arterial hypertension, and glaucoma. Oral antibiotics and anti-inflammatory medications, prescribed elsewhere, were not effective.\nPhysical examination revealed a reddish, round, tender soft mass of the outer third of the inferior wall of the left EAC, discharging a yellowish fluid upon pressure; however, a concomitant ruptured tympanic membrane and otorrhea through this perforation were also found. No cranial nerve palsy was detected. Swelling of the left parotid region and bilateral cervical lymphadenopathy were also present. CT scan of the temporal bone showed a cystic lesion on the inferior cartilaginous part of the EAC but no temporal bone lysis; the middle ear appeared to contain fluid and swelling of the parotid gland and cervical lymph nodes bilaterally were also seen (). The audiogram revealed conductive hearing loss of the left ear. The patient was treated with intravenous cefuroxime. A specimen of the discharge was sent for bacteriological evaluation and turned out to be negative for bacteria.\nThe patient underwent excision of one cervical lymph node and fine needle aspiration (FNA) of the left parotid. Histopathological examination of the lymph node ruled out malignancy, being consistent with a granulomatous process; however blood tests and thorough immunological and rheumatological examination failed to confirm this hypothesis. The FNA examination was nondiagnostic as it showed normal salivary glands.\nThe EAC lesion was surgically excised under general anesthesia, utilizing a transmeatal approach. Macroscopically the resection specimen was a fusiform skin sample measuring 1.9"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old African man presented to our emergency unit with a four-hour history of penile swelling and voiding difficulty. He had earlier tried to suppress an erection before his routine morning religious rituals by kneading on his erect penis. He heard a popping sound with associated minimal pain and sudden detumescence. He noticed no bleeding per urethra but subsequently had difficulty with voiding and urinary frequency. On physical examination, he had a grossly swollen and deformed penis with deviation to the right side (Figure ). A diagnosis of penile fracture with probable associated urethral injury was made. Bedside urine analysis results were negative for blood and he was taken for penile ultrasound and sonourethrography about an hour after presentation to the emergency unit. This was performed using a high-frequency 7.5MHz transducer with our patient in a supine position and the penis supported with towels between the thighs. A generous amount of sonographic acoustic gel was applied on the dorsum of the penis and images were obtained both in longitudinal and transverse planes beginning at the glans and proceeding proximally to the root of the penis. This was performed initially without urethral distension. A 16Fr Foley catheter was then placed at the urethral meatus with its balloon inflated with 2mL of water at the fossa navicularis. Retrograde urethral distension using normal saline was achieved via the catheter and sonographic images were obtained as above. The penile ultrasound showed a tear of the TA covering the ventrolateral aspect of left CC with associated hematoma in the proximal third of the penile shaft, and the real-time sonourethrography additionally revealed an intact urethra (Figures and A,B). He also had retrograde urethrography performed, which also showed an intact urethra (Additional file 1). Three hours after presenting to the hospital he had penile surgery via a subcoronal circumferential degloving incision. A Foley urethral catheter"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old Caucasian lady having a past medical history of obesity, type II diabetes and hypertension presented with bleeding per vagina, hematuria, low urine output, intermittent headache, ataxia, diplopia and blurring of vision. She also experienced a weight loss of 60 pounds over 1 year, shortness of breath on exertion and a dry cough. The patient was treated with multiple antibiotics for a suspected urinary tract infection (UTI). Following an abnormal Pap smear, her vaginal examination revealed a hard mass in the cervix extending to the left vaginal wall, left pelvic wall and inferiorly to the lower vagina and introitus, suspicious of a cervical primary. Cervical biopsy revealed multiple nests of markedly atypical squamous cells and an ulcer bed with numerous deep nests of atypical squamous cells amidst extensive necrosis consistent with invasive poorly differentiated squamous cell carcinoma. Immunohistochemical study showed the tumor cells to be P16-positive and the nests of the invasive tumor were highlighted by pancytokeratin immunostain.\nPhysical examination revealed a pale appearing lady with an ECOG performance status of 2. Neurological evaluation revealed complete restriction of abduction in the right eye indicating sixth cranial nerve palsy and gait ataxia. In addition, there was a 2 cm × 1.5 cm firm, palpable, ovoid mass on the right side of her scalp, which on biopsy showed metastatic poorly differentiated squamous cell carcinoma consistent with origin from the uterine cervix.\nLaboratory analysis showed leukocytosis, a low hematocrit and acute renal failure with creatinine of 3.4 and UTI. She was given intravenous fluids, blood transfusion and antibiotics.\nSubsequently, an MRI of the brain showed multiple intraaxial enhancing lesions involving the frontal lobes, cerebellar hemispheres, right occipital lobe in addition to an enhancing, expansile mass in the clivus with soft tissue component in the right cavernous sinus extending anteriorly into the s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report on a case of a 16-year old male patient who was diagnosed with DF of the right upper thorax in 2011 (Fig. ). The primary approach consisted of partial tumor resection for functional preservation. Systemic therapy with MTX/VBL was started after completion of surgery in order to maintain tumor control. However, MTX-associated nausea and fatigue led to discontinuation of MTX after 6 months of treatment. Instead, sulfonylurea had been added to VBL, but again, nausea limited the applicability of this combination and treatment was provided as single agent sulfonylurea.\nTwo years after the initial resection, a symptomatic tumor recurrence was detected while receiving medical treatment. Local recurrence involved the right brachial plexus, which was incompletely resected for the purpose of function preservation.\nSystemic therapy was reconvened with MTX and vinorelbine, which achieved symptomatic improvement of pain with disease stabilization as best response on MRI. However, the treatment was not sustainable because of grade 1 nausea and fatigue and led to treatment discontinuation after 4 months.\nWithin 4 months, the patient complained of recurrence of grade 1 tumor pain and the MRI showed gradual tumor growth. At this time, radiotherapy was not considered appropriate given the young age and the proximity to the plexus nerves, instead medical treatment was discussed with the patient. Re-challenge with chemotherapy was not preferred by the patient, and an individual approach to medical treatment was sought. Based on the hyperperfusion of the patient’s tumor and the promising results of sorafenib in DF, we implied future treatment with bevacizumab 15 mg/kg q3wks., given the excellent tolerability profile of this agent.\nDuring the course of treatment, tumor pain disappeared and the patient experienced functional improvement. Initial radiological response was detected after 1 month, with a tumorshrinkage of 16 %. Treatment was continued for a total duration of 12 mont"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45 year old female presented to our institution with a diffuse swelling of the left maxilla which caused a mild tumefaction of the left cheek and obliteration of the buccal vestibule, left cheek pain during chewing with auricular and temporal irradiation, and masticatory disorders. The patient reported the onset of symptoms about 3 weeks before, but the exact duration of the swelling is not known. However, the patient remembered that about 3 years ago she was complaining of pain in the molar region of left maxilla and she addressed to her dentist. Without X-ray examination it was decided for extraction of the 2nd molar which presented palatal ectopia, but without caries and no abnormal mobility. Personal or family records were not significant, but noteworthy is that she worked about 10 years as an industrial dyer.\nExtraoral examination revealed a mild diffuse swelling of the left cheek, most obvious at the posterior side of the zygomatic region. It was painless and hard in consistency on palpation. Intraoral examination revealed a diffuse swelling extending from the maxillary left first premolar to the tuberosity and retromolar regions that obliterated the buccal vestibule (Fig. ). The overlying mucosa was stretched but intact. On palpation, at the level of maxillary alveolar process the swelling was hard and painless but became fluctuating and slightly tender in the retromolar region.\nOrthopantomogram showed a radiolucent lesion involving the left maxillary tuberosity, alveolar process, and the maxillary sinus with erosion of lateral wall and floor of the sinus (Fig. ). On computed tomography scan it was noticed an expansile, radiolucent lesion of the left maxilla (about 4 cm in diameter) with scattered areas of calcification which completely obliterated the left maxillary sinus (Fig. ). The scan showed tumor extension and involvement of the alveolar process (behind the first premolar with buccal cortical thinning, erosion and invasion of the soft tissue from ret"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old woman with a six-month history of progressive hoarseness and an abnormal sensation in the throat was referred to the Nanjing Drum Tower Hospital (Nanjing, China). The patient had no history of smoking, coughing, dyspnea or dysphagia; however, it is worth noting that the patient was exposed to iron ore and coal dust for several years in the work place. In addition, the patient had a history of over five years of second-hand smoke inhalation.\nFiberoptic laryngoscopy revealed swelling of the left ventricular fold and laryngeal ventricle that extended backwards to the left aryepiglottic fold. The bilateral vocal cords appeared normal and there was no vocal cord paralysis (). The patient subsequently refused any further examinations. The laryngeal abnormal sensation gradually progressed, and after 18 months the patient underwent a second laryngoscopy, which revealed similar findings to the first without obvious progression (). Computed tomography (CT) revealed a mass involving the left ventricular fold and anterior commissure. The left pyriform sinus was not distinguished (). Neither physical examination or neck CT detected any tumescent lymph nodes in the neck, and the chest X-ray was normal.\nThe preoperative diagnosis that was deemed most likely was that of a laryngeal neoplasm with laryngeal amyloidosis. The subsequent frozen section biopsy of the lesion taken during laryngofissure revealed the nature of the neoplasm. As the patient refused to undergo an expanded total laryngectomy, which is indicated for a locally advanced laryngeal tumor (), local resection of the left ventricular fold, laryngeal ventricle and aryepiglottic fold was performed only (). The margin of the biopsied tissue surrounding the lesion was negative. Although there was no sign of lymphatic spreading, perineural invasion existed, therefore, it was suggested that radiotherapy be performed at one month post-surgery (). However, one month later and prior to this radiotherapy, regional"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old thin built Indian boy belonging to lower socio-economic group presented to the orthopedic department with the chief complaints of pain in the left leg for the last 3 months. There was no fever at presentation. On examination there were three small and scantily draining sinuses in the proximal and middle third of his left leg. The ipsilateral inguinal lymph nodes were not significantly enlarged. There was history of high grade fever for a few days three months back with spontaneous acute onset pain and swelling around the upper left leg with inability to walk, which was managed by a local doctor with some medication that provided some symptomatic relief within a matter of a few days time. The three small non-healing wounds however persisted. After three months the patient attended our hospital for further treatment.\nThe child had no fever or palpable abscess on examination. Clinically, swelling was minimal in the affected site of the leg. Radiograph of the affected limb showed features of chronic osteomyelitis with a large diaphyseal sequestrum on the medial cortex of tibia with incomplete involucrum []. The total lymphocytic count was within normal limits and differential counts were unremarkable. Sedimentation rate was 38 mm per hour. Tuberculin test and fungal smears were negative. The patient could not afford to do magnetic resonance (MR) imaging or a computerized tomography (CT). Wound swab taken from the proximal draining sinus yielded methicillin sensitive Staphylococcus aureus (MSSA) sensitive to 3rd generation of cepahalosporin and aminoglycoside (Amikacin), which were started and continued for a period of six weeks. No surgery was performed; not even incision and drainage. The sinuses healed completely in 6 weeks time. Gradually, over a period of 8 months, the large tibial diaphyseal sequestrum got fully incorporated into the healthy diaphyseal bone indistinguishable from normal bony architecture [Figures and ]. The functional outcome also was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn October 2014, a 46-year-old White male presented to clinic with recent history of rapidly growing, painful swelling in left axilla. He was referred by his GP to Melanoma clinic in view that in February 2010 he had a wide local excision of malignant melanoma on his right upper back with 0.72mm Breslow thickness. Swelling in the axilla has been present for 3 months, and he first noticed it during game of tennis. On presentation the patient was systemically well and had no co-morbidities, no other past medical history and no family history of melanoma, however he reported occasional prolonged sun exposure during holidays and mild sun burns in the past. He is a non-smoker and alcohol consumption was mild.\nOn examination he had a 10 cm firm swelling under left axilla with no obvious surface skin changes. There was no other palpable lymphadenopathy.\nAn ultrasound and fine needle aspiration (FNA) of the mass, confirmed metastatic melanoma with a BRAF V600E mutation. He underwent further scanning to identify any other lesions. Results of brain MRI were normal and PET-CT showed a large FDG avid axillary mass () likely to represent a lymph node with no metabolically active primary lesion.\nGiven the size and location of the mass, it was not amenable for safe surgical resection without significant risk of morbidity. It was decided to commence systemic treatment with the BRAF inhibitor, Dabrafenib.\nFour month following commencement of systemic therapy there was a significant reduction in size of the lesion that made it suitable and safe for surgical resection. Patient was scheduled on the elective list for axillary node clearance and was operated by Consultant Plastic surgeon, procedure was uncomplicated and patient was discharged home the following day. Specimen was sent to histopathology laboratory and subsequently been reported as no malignancy. This was a complete response to Dabrafenib. It was decided to continue with Dabrafenib to complete a full year of therapy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male presented with chest pain similar to acute coronary syndrome. The patient had felt a substernal pain from a period of four days prior to examination, which had begun while carrying out farm work in a squatting position. The severity of the chest pain had fluctuated, and then the patient felt intolerable chest pain that lasted for two hours. An electrocardiogram showed normal sinus rhythm, and cardiac enzymes were normal. However, compared with another chest X-ray four months earlier (), a second chest X-ray revealed left diaphragmatic hernia with a markedly distended stomach and passive atelectasis of the left lower lung (). An abdomen computed tomography showed that the herniated stomach was significantly distended by ingested air due to severe pyloric compression. The diaphragmatic defect was approximately 5 cm in diameter ().\nWe performed an emergency operation because the patient suffered from continuing chest pain, which suggested a strangulation of the stomach. A left lateral thoracotomy was performed through the eighth intercostal space after intubation with a double-lumen endotracheal tube and insertion of a nasogastric tube for decompressing the stomach. We carefully inspected the stomach, which was entirely displaced into the thoracic cavity, including the greater omentum (), and we then reduced the stomach into the peritoneal cavity. A diaphragmatic defect was identified on the highest central tendon and had a round shape, half of which had a well-demarcated margin (). The diaphragm was thinned and unevenly rough owing to senile change. The remaining tissue of the fragile margin was completely excised () and was closed primarily using continuous running sutures and multiple interrupted sutures (). The patient was extubated before leaving the operating room. The chest X-rays before discharge showed complete reduction of the stomach and full re-expansion of the left lung (). The patient was uneventfully discharged and resumed a normal die"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur case began with a 79-year-old female who called 911 from her home for transport to the emergency department (ED) for evaluation of abdominal pain in her left upper quadrant with radiation through to her back and left shoulder, which had been present for approximately three hours. The patient had a past medical history significant for hypertension and hypercholesterolemia for which she took lisinopril and rosuvastatin daily.\nUpon arrival at the patient’s home, the emergency medical services (EMS) team reported that the patient initially appeared well with normal vital signs but then began to deteriorate. The patient’s blood pressure fell to 61/38 mmHg and she had a near syncopal episode prompting EMS to administer intravenous (IV) fluids and commence transport to the ED for further evaluation.\nWhen the patient arrived to the ED she was awake and alert with mild distress from her pain but interacting appropriately. Her vital signs were blood pressure of 101/56 mmHg, pulse rate of 74 beats per minute and an oxygen saturation of 100% on room air. Her physical exam was positive for tenderness in the left upper quadrant of her abdomen, but it was soft with no guarding or rigidity. She showed no signs of focal neurologic deficit, jugular venous distension, heart murmurs or abnormal lung sounds. Her extremities had equal distal pulses with good capillary refill. Her medical history provided no identifiable explanation for her pain. The patient denied any history of trauma but reported she “did sneeze three times” just prior to the onset of her pain. Given the patient’s symptom of sudden onset abdominal pain with radiation to her back accompanied by hypotension, abdominal aortic aneurysm (AAA) was immediately considered. A bedside ultrasound was then performed but results were limited due to bowel gas present. Initial interpretation of her exam showed no obvious AAA, no definite free fluid and no evidence of pericardial tamponade. In the meantime vascular and general sur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old female presented with complaints of pain in the right lower limb and back for 1 month. Ultrasound revealed a retroperitoneal mass adjacent to the lower pole of the right kidney. CT scan revealed a large heterogeneous lobulated mass with intralesional cystic areas of necrosis and heterogeneous postcontrast enhancement in the retroperitoneum measuring 11 × 5.5 × 6 cm in size on the right side at the level of mid and lower pole of the kidney. There was no evidence of calcification in the lesion. The mass had extraneous indentation of the inferomedial cortex of the right kidney. The mass displaced the right renal vein anteriorly and the right proximal ureter anterolaterally with compression of the inferior vena cava anteromedially. Medially, the mass was seen to be infiltrating the psoas muscle and abutting the right lateral cortical margin of the L4 vertebra. The right adrenal gland was seen separately and appeared normal (). 3D reconstruction of the imaging was done to assess the relation of the mass with the surrounding structures.\nSerum cortisol and serum and urine normetanephrines were normal, ruling out a functional tumor. The patient underwent USG-guided core needle biopsy which revealed retroperitoneal ganglioneuroma as presence of mature ganglion cells in a Schwannian stroma with no evidence of mitosis/necrosis.\nThe patient underwent exploratory laparotomy through anterior subcostal incision. The mass was found to be displacing the right kidney and proximal ureter laterally with anterior displacement of right renal vein. The right ureter was looped using a vascular sling and traced upwards to identify the right kidney and the right renal vein. The mass was carefully dissected from the surrounding structures using electrocautery and the base of the mass infiltrating the psoas muscle was fulgurated.\nThe mass was encapsulated and measured 11 × 6 × 5 cm in size. It had a bosselated surface. The cut surface was homogeneous and soft to firm in consisten"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old woman with a previous history of long-term peptic ulcer, under proton pump inhibitor therapy, and hypertensive arterial disease, was admitted to our emergency department with complaints of abdominal distension, upper abdominal pain and alimentary vomit for the last 12 h.\nOn physical examination, she had tenderness and guarding in all abdominal quadrants. All vital signs were within normal range. The laboratorial tests revealed only a mild increase in systemic inflammatory parameters but with no organ failure.\nThe patient underwent an abdominal plain film, which identified a massive gastric dilation and a pneumoperitoneum was suspected (Fig. ). In order to confirm these findings, an abdominal computed tomography (CT) was performed, which clearly identified a massive gastric dilation. The stomach reached the pelvis and had an abrupt stricture at the level of the pylorus. A large pneumoperitoneum was also confirmed (Fig. ).\nAn urgent laparotomy was performed, and intraoperatively an exuberant gastric dilation was detected, with only a small amount of seropurulent free peritoneal fluid. On abdominal exploration, a limited area of necrosis with ∼2 cm was detected in the lesser curvature of the stomach. After inspection, an anterior gastrotomy was performed to empty the stomach (a total of 4 l of fluid was aspirated) and to access the area of mucosal necrosis. At last, an affected area of 3 cm × 2 cm close to the lesser curvature was identified, and an atypical gastrectomy was performed, using a linear stapler. An underlying pyloric stenosis was identified, which was circular and that seemed not to be malignant. Therefore, a Heineke–Mikulicz pyloroplasty was performed besides the partial gastrectomy. During the surgery, it was decided not to perform a vagotomy, considering the patient age and to prevent gastric emptying impairment in a patient who had already a certain degree of gastroparesis.\nThe postoperative period was event free, and the patient was dis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 21-year-old female who, in the month prior to admission to our institution, had been treated multiple times in emergency departments at various hospitals referring epigastric abdominal pain and constipation. The treatment she received was based on the resolution of constipation, antacids and dietary recommendations. The patient was admitted to our emergency department after 1-month of upper quad-rant abdominal pain radiating to the left upper quad-rant, additionally she cited a weight loss of 5 kg in the last month. Her symptoms had become more aggravated two days prior to admission with unquantified fever, chills and night sweats. She had no history of previous peptic ulcer disease or surgical procedures. A review of the family history revealed no significant disease. A physical examination revealed vital sings with a heart rate of 102 beats per minute, respiratory rate 16 breaths per minute, temperature of 37°C, blood pressure of 110/56mmHg, the abdomen was distended, the percussion was tympanic, the bowel sounds were de-creased. Additionally we found a painful, not well limited, mass adhered to deep planes in the abdominal palpation without peritoneal irritation or other alterations. A work-up started with blood chemistry, CBC, and we requested a CT of the abdomen due to clinical examination findings. The preclinical showed no elevation of acute phase reactants and no electrolyte disturbance, the CT scan evidenced an irregular, small collection in the gastric antrum and behind the left rectus muscle of approximately 30x11x16mm, which was associated with increased density of the surrounding fat. Inside this area, the end of a tubular, hypodense structure (compatible with foreign body) was visible coming out from the gastric lumen through the wall, which was perforated ( and ). The findings on CT were dis-cussed with the patient who was questioned again for further information to determine the origin of the foreign body. The patient agreed to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old healthy female suddenly collapsed with short lasting convulsions in January 2015. Patient’s second pregnancy was at gestational weeks 26 + 5. Her first pregnancy had been uneventful and had ended in normal childbirth. At the time of collapse patient was at home with her spouse who immediately called emergency response center. Dispatcher alerted nearest ambulance capable for basic life support within 60 s from beginning of the emergency call. A cardiac arrest was not identified during the emergency call, but after six minutes from beginning of the call the dispatcher alerted the mobile intensive care unit (MICU) according to the alert protocol of unconscious patient. MICU is normally staffed by two paramedics and an emergency physician. However, there was also an extra paramedic in MICU due to rotation of ambulance staff. The emergency physician on duty was a resident of anesthesiology and intensive care.\nThe first ambulance reached the patient 10 min from beginning of the emergency call. Patient was lying on a couch unconscious and not breathing. No CPR was performed by bystander. Patient was moved to the floor by the EMS personnel. The primary rhythm was ventricular fibrillation and cardiopulmonary resuscitation was carried out according to the shockable rhythm protocol. Before arriving to the scene, the MICU emergency physician was informed about the cardiac arrest of a pregnant patient. A plan of first establishing advanced life support and then deciding on the need for prehospital emergency hysterotomy was made. Emergency physician on duty had no previous experience from caesarean sections.\nMICU reached the patient 15 min from beginning of the emergency call. VF had been defibrillated two times and second two minute cycle of compression was going on. A left lateral tilt of uterus was performed. Patient was intubated and intravenous line was established by the MICU staff. Because of long delay of ALS and no bystander CPR fetal heart beats were check"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old man presented with fever and malaise from SAB with no obvious source of infection on examination. He had a background of hypertension and type 2 diabetes mellitus. CT of the thorax, abdomen, and pelvis was not able to elucidate the source of the infection. TOE showed a thickened aortic valve with calcification of the noncoronary cusp but no overt signs of IE (no vegetations or significant valvular regurgitation). Due to a lack of an infective source, he was treated as presumed IE in view of abnormal aortic valve with 6 weeks of antibiotics, and he remained well immediately on discharge.\nTwo years later, he had an ST-segment elevation myocardial infarction (STEMI), for which he underwent primary percutaneous coronary intervention (PCI) with stent to distal right coronary artery. A small aneurysm at the origin of the right coronary artery was noted which was attributed to atherosclerotic disease []. He made an uneventful recovery and was discharged; however, 2 weeks after the STEMI, he represented with fever and chest pain. Two positive blood cultures showed SAB. TTE and TOE again showed thickened abnormal aortic valve but no evidence of IE. However, no other source of infection was identified, and he was again treated as suspected IE and discharged to finish his course of antibiotics.\nHe returned a month later with rigors and joint pains. Again, positive blood cultures revealed SAB. Repeat TTE; CT of the thorax, abdomen, and pelvis; and FDG-PET were all negative. He completed 6 weeks of inpatient intravenous antibiotics and was discharged home.\nThree months after, he presented with nausea, epigastric pain, and a high-grade fever. Three sets of positive blood cultures grew S. aureus (MLST clonal complex 22). WBC-SPECT of the lower chest and abdomen demonstrated a focus of low-to-moderate grade uptake at the root of the aorta, which was suspicious of IE [].\nFollowing this, CT of the thorax with contrast"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year old Caucasian woman without significant risk factors for atherosclerosis presented with headache, right hemiplegia, and right visual impairment. Magnetic resonance imaging revealed a fresh left posterior brain infarction. A duplex ultrasound showed no cerebrovascular stenosis or occlusion, but an echocardiogram revealed a left ventricle pedunculated mobile mass (5 mm in diameter) that was attached to the mitral valve chordae tendineae (Figure ). Left and right ventricular functions were normal, and mitral valve regurgitation was mild. Because the patient did not exhibit findings indicative of having an embolic source, we elected cardiac surgery to resect the cardiac tumor and to avoid further embolic events.\nA CPB was instituted via the femoral arterial and venous cannulation through a 3 cm transverse incision in the right groin. The tip of the venous cannula was positioned under transesophageal echocardiographic guidance in the superior vena cava. The temperature of the patient was cooled to 34°C, and vacuum-assisted CPB was used throughout the procedure. A right lateral mini-thoracotomy (length, 5 cm) was performed via the 4th intercostal space, and the incision was placed in the submammary crease. A video camera was inserted through a 10 mm port in the right 3rd intercostal space and a transthoracic aortic cross-clamp was inserted through the 3rd intercostal space. Antegrade cold blood cardioplegia was administered directly into the aortic root and repeated every 20 min. throughout the procedure, the surgical field was flooded with carbon dioxide via the camera-port. The left atrium was opened posterior to the interatrial groove. Exploration of the mitral valve showed a globular tumor involving the anterior mitral leaflet chordae tendineae (Figure ), which was removed along with the involved chordae tendineae. Neochordae were implanted using the loop technique. The required length of the loop was determined by measuring the distance between the correct"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 32-year-old Korean woman referred because of a cystic lesion below the mandibular right first molar at a local dental clinic. She had no pain or significant systemic disease. Several clinical tests, including electric pulp test, were performed and the affected tooth showed the presence of pulp vitality. There was no tooth mobility.\nPanoramic radiography revealed a round, mixed lesion below the mandibular right first molar (Fig. ). The border of the lesion was clear, but no clear cortication was observed. The effects on the adjacent teeth and inferior alveolar canal were unclear. The lesion was generally radiolucent, but a mixed radiopaque portion was seen adjacent to the anterior boundary of the lesion, resembling the shape of a mixed lesion.\nIn the additionally obtained cone-beam computed tomography scan, a slightly ovoid lesion was observed anteriorly and backwards (Fig. ). Likewise, the boundaries were clear, but no clear cortication was observed. Although thinning of the adjacent cortical bone was observed, no apparent expansion pattern was observed. The radiopaque portion inside the radiolucent portion was mixed at the anterior site of the lesion. The anterior part of the lesion showed the characteristics of COD. The middle and posterior parts of the lesion were suspected of cystic changes, showing low attenuation. The size of the area considered as a cystic portion was not sufficiently large, so it was difficult to distinguish it as a secondary cystic lesion. Considering all radiologic findings, the imaging diagnosis was COD with a cystic lesion, such as ABC or SBC.\nSurgical excision and histopathologic examination were performed. Histopathologically, stromal tissue was composed of spindle-shaped fibroblasts with small blood vessels (Fig. ). Cystic aneurysmal components showed blood-filled cystic cavities lined with a thick membranous structure that comprised multinucleated giant cells and mononuclear cells (Fig. ). The anterior part of the l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old woman presented after falling from an upright position on her left hand and then experiencing difficulty elevating her left arm. She had a six-month history of mild pain in her left elbow after agricultural work for which she used a hoe and a 10-year history of medication with bisphosphonate (alendronate), to treat osteoporosis that was diagnosed after a thoracic vertebral fracture.\nA lateral radiograph of the left forearm upon presentation revealed a transverse fracture at the posterolateral aspect of the proximal ulna (). Computed tomography of the left ulna showed cortical thickening, with transverse fractures and spike formation on the volar side (). X-rays did not reveal any abnormalities of the contralateral side. Biochemical findings showed normal serum calcium, phosphate, alkaline phosphatase, and thyroid hormone values. The mineral density of the distal radius had a T score with a standard deviation (SD) of -1.9 on dual-energy X-ray absorptiometry. The fracture was diagnosed as atypical, and bisphosphonate therapy was stopped. The patient underwent open reduction with internal fixation (ORIF) using a 3.5 mm locking compression plate (DePuy Synthes, Zeist, Netherlands) for the ulnar fracture (). A transverse fracture with cortical thickening was evident during the procedure. Plain radiography showed no signs of fracture healing at three months postoperatively (), when the patient complained of pain at the fracture site. The results of a physical examination and laboratory tests, including white blood cell counts, C-reactive protein, and erythrocyte sedimentation rate, were normal, which ruled out an underlying infection of the surgical site. We diagnosed the fracture site as nonunion; thus, we performed the revision surgery to stabilize and to achieve a union of the fracture site at 4 months after the first operation. Scar tissue and the osteosclerotic lesion from the fracture site were excised under general anesthesia, and the fracture surface"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old male noticed something coming out of his skull while he was combing his hair which he tried to pull out a bit (). The patient had no complaints of pain at that site in the scalp, headache, fever, nausea, convulsions, altered sensorium, loss of consciousness, oliguria, or hematuria. He is a known case of hypertension and diabetes mellitus with a history of alcohol addiction since 36 years. The patient had a past history of hemodialysis in view of leptospirosis-induced acute kidney injury with uremic encephalopathy three years back.\nA CT scan of the head was performed in view of a foreign body coming out of skull. A hyperdense linear foreign body was seen extending from the upper part of the right internal jugular vein, coursing cranially, piercing the right tentorial leaflet, traversing through the right posterior parieto-occipital parenchyma, and exiting extracranially through the right parietal bone. Similar smaller variable-sized metallic structures continued with the aforementioned foreign body, in the right half of posterior fossa and right occipital region were also seen. A small peripherally enhancing hypodense area was seen along the catheter in the right posterior parieto-occipital region, representing a focal-forming abscess. Partial thrombosis of the internal jugular vein was seen (). The patient was taken up for emergency surgery for the removal of the foreign body. In the left lateral position, a skin incision was taken at the exit point and flap was raised. There was a small 0.2 × 0.1 mm-sized opening in the right posterior parietal bone. The wire was gently pulled out as much as possible. Bone wax was applied over a small defect in the bone. Hemostasis was done. The incision was closed over a suction drain. The procedure was uneventful and the patient was apparently all right after regaining consciousness. A postoperative CT head was performed which revealed few (at least four) fragments of retained catheter seen in the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man visited emergency room with right upper quadrant and flank pain. CT revealed calculous cholecystitis without common or intrahepatic bile duct stones. He had not viral hepatitis or previous abdominal pain history. He showed mild fever and normal limit of blood chemistry except leukocystosis with white blood cell count was 13,000. We decided the cholecystostomy for initial treatment of cholecsytitis, after making patient stable and afebrile.\nInitial CT scan showed small mass-like lesion of severely shrunken right hepatic lobe and hypertrophy of the left hepatic lobe (). Right hepatic vein was normally drained to inferior vena cava (), and intrahepatic duct was not dilated. Right hepatic artery and portal vein were not visualized distinctly in CT. GB was identified in a retrohepatic position, and located in beneath the diaphragm with wall thickening demonstrating cholecystitis (). One week after cholecystostomy, cholecystectomy was done. We tried laparoscopic approach with routine 4 port methods, however we could not approach the GB without liver mobilization and position change. Because of severe adhesion of GB with omentum and mesocolon, we decided the open conversion procedure. During the cholecystectomy, excessive bleeding and bile leakage occurred in GB bed requiring two pint of packed red blood cell transfusion. However we could not be sure of hepatic artery or portal vein bleeding. We did not perform liver resection due to absence of pathologic condition of liver parenchyma, and perform bleeding and leakage control by suture ligation. A drain was left in GB fossa and liver dome. On 3rd day after operation, 50 to 100 mL/day of bile drainage was detected in Jackson-Pratt drain. We decided conservative management for bile fistula. CT showed small amount of biloma in GB fossa. Ten day after surgery, the amount of bile drainage increased up to 200 mL/day, and so we decided to perform endoscopic retrograde cholangiopancreatography for therapeutic bil"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis study was conducted in accordance with the ethical standards of the Institutional Review Board of our institution, Des Moines University College of Osteopathic Medicine.\nA 61-year-old male patient presented with progressive pain in his medial left hamstring as well as weakness with left-sided foot drop and paresthesias in the plantar aspect of his foot. Symptoms first presented as impairments in his ability to push off with his left foot during moderate exercise. He did not present with radicular symptoms but did have a previous X-ray of the lumbar spine, which showed no signs of stenosis or compression.\nUpon initial physical examination, the patient was found to have no tenderness to palpation of his lumbar spine. Tenderness was appreciated in the medial left glute and left posterior medial thigh down to the knee. No reproducible pain was noted below the knee, and no obvious foot deformity, erythema, or edema were present. He did endorse decreased sensation in the distal third of the plantar foot including the first metatarsal. The patient was unable to flex or extend his left first metatarsal. Left Achilles tendon reflex was 0/5, with a contralateral reflex of 5/5.\nThe patient was subsequently evaluated by a physical medicine and rehabilitation specialist, who noted diminished left S1 reflex. He was able to stand in plantarflexion on the right, but was unable to flex to full height on the left. Also, weakness of the left flexor hallucis longus and digitorum longus with absent sensation on the plantar surface of the first metatarsal to pinprick and light touch was noted. He was then referred for osteopathic manipulative therapy (OMT). Initial treatments with OMT did offer some relief, but his symptoms persisted. An electromyogram (EMG) was performed, which showed evidence of peroneal nerve injury in the absence of a superficial peroneal sensory response, temporal dispersion when stimulating across the knee, and tibial nerve injury.\nMagnetic resonance imaging ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 40-year old male patient who was referred to our department complaining of a slowly growing mass of the right neck. Previous medical history was nonrevealing except from a trauma to the right neck about 9 years ago. At that point, the patient had noticed the swelling for the first time. However, he did not seek further medical attention since the mass did not cause any symptoms. Thorough physical examination was unremarkable besides the substantial mass of the right lateral neck (Fig. ). Subsequent imaging with ultrasound revealed a septate, cystic formation comprising the entire right cervical region. The septa were partly calcified and showed moderate blood perfusion. Based on these ultrasound findings, a diagnosis of lymphangioma was considered. However, an additional magnet resonance imaging (MRI) was recommended for appropriate assessment of the masses’ size and potential invasion of the surrounding tissue.\nMRI revealed a massive, polycystic formation located right beneath the sternocleidomastoid muscle. The mass had a craniocaudal diameter of 13 cm with a maximum width and depth of 10 cm and 5 cm, respectively. The caudal part surrounded the brachiocephalic trunk and extended down to the upper mediastinum as well as the thyroid isthmus. However, direct communication with the thyroid gland was not reported. Distinct septa displayed slight contrast enhancement, abnormal lymph nodes were not found. These MRI findings were also considered consistent with a lymphangioma.\nConsequently, surgical resection of the presumed lymphangioma was pursued. While the major part of the mass could be successfully resected, intraoperatively (Fig. ), the decision was made to leave the masses’ segment which surrounded the brachiocephalic trunk to avoid potentially fatal injuries.\nThe specimen was sent for histologic assessment to verify the presumptive diagnosis. Microscopic evaluation revealed psammoma body-like calcifications and expression of thyroglobulin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male presented with hematuria, increased frequency, and burning sensation during micturition along with left flank pain for 2 months. There was a history of generalized weakness, weight loss, and loss of appetite during this period. On examination, the patient was poorly nourished with the presence of a palpable left-sided abdominal mass.\nUltrasonography (USG) of the abdomen showed the presence of right ectopic kidney and left-sided hydronephrosis. A heterogeneous mass was noted in the left kidney. Another polypoidal mass was also seen in the lumen of the urinary bladder, attached to its posterolateral wall.\nContrast-enhanced computerized tomography (CECT) of the abdomen helped in the renal anatomy and characterization of the mass, which revealed L-shaped crossed fused renal ectopia. The right kidney was not present in the right renal fossa and was in the midline, anterior to the aortic bifurcation at the L4-L5 level. It was malrotated and fused with the lower pole of the left kidney. The left kidney was enlarged, with a large soft heterogeneous tissue density mass involving the interpolar and lower pole regions that exhibited heterogeneous enhancement with central non-enhancing areas. Few calcified foci were seen in the mass, along with moderate hydronephrosis. In the delayed phase (15 minutes), no contrast excretion from the left kidney was recorded. The interpolar region of the right kidney was contiguously infiltrated by the left lower pole renal mass. Small tumor thrombi were present in the segmental right renal veins draining the interpolar region. Aortocaval, para-aortic and left renal hilar lymphadenopathy were also noted.\nAlong with these findings, a well-defined polypoidal mass was seen in the left posterolateral wall of the urinary bladder, infiltrating the left vesicoureteral junction. The middle and distal parts of the left ureter were contiguously involved by this urinary bladder mass. A peripheral rim of calcification was present.\nBecaus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old, Jamaican female, gravida 7 para 3 presented to the clinic at 8-week gestation for her first prenatal visit. Her first pregnancy was complicated with uncontrolled hypertension resulting in a term primary cesarean delivery. Prior to this pregnancy she was normotensive. As this pregnancy occurred in Jamaica, medical records regarding the details of her care were not available. The indication for the cesarean delivery was not known to the patient. However, the patient reported that her blood pressure normalized after this delivery. This was followed by an uncomplicated pregnancy and repeat cesarean delivery at term three years later. Over the next three years, she had three elective terminations of pregnancy. A year thereafter, she had another pregnancy that was complicated by proteinuria and elevated blood pressure that resulted in a fetal demise at 29-week gestation. After delivery, her blood pressure normalized and she remained asymptomatic. The presumptive diagnosis by the medical team was early onset severe preeclampsia, and therefore no renal biopsy or subsequent workup was undertaken at the time.\nA year after the last pregnancy she emigrated to the United States and presented to our clinic for prenatal care at 8-week gestation. She denied any medical problems and was not using any medications. She smoked one pack of cigarettes per day and denied the use of alcohol or other illicit drugs. Her initial blood pressure was 96/60 mmHg. Prenatal labs, initial complete blood count, and BUN and creatinine levels were normal ( and ).\nAt 12-week gestation, she returned to clinic for follow-up. Physical examination was positive for 1+ bilateral lower extremity edema. Her blood pressure was 102/64 mmHg. A baseline 24-hour urine collection revealed 5047 g of protein excretion. Subsequent workup with renal ultrasound, microscopic urine analysis, urine electrolytes, and a rheumatology panel consisting of anti-nuclear antibody (ANA), CRP, anti-double stranded DNA,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old male presented in emergency with a history of abdominal mass since childhood. The abdominal mass was gradually progressive in size and rapidly increased in the last two weeks. He also complained of breathlessness for one week associated with abdominal pain. The patient never went to any hospital for the abdominal mass. There was no history of vomiting, altered bowel habits, trauma to the abdomen, melena, and passage of any membranes in the stools. There was no history of cough with sputum. On examination, the patient had tachycardia with normal blood pressure. There was no pallor or jaundice. Abdominal examination showed a large mass of almost 20cm x 20cm occupying the epigastrium, right hypochondrium, left hypochondrium, and umbilical region. It had varying consistency - soft in the upper part and firm in the lower and lateral parts.\nRoutine blood investigations, including complete blood counts and renal function tests, were normal. A liver function test revealed mild elevation (174 IU/L) of alkaline phosphatase (ALP). Hydatid serology was positive. Abdominal USG showed the presence of a large hypoechoic cyst with air and debris. Contrast-enhanced CT of the abdomen showed a 20cm x 18cm cyst, arising from the left lobe of the liver having an air-fluid level and few septations or membranes at the inferior aspect of the cyst with debris. The left portal vein was compressed, and the left bile duct was not visualized. The gallbladder had air within it. The common bile duct (CBD) was normal in caliber, and there was no air within it (Figure ).\nThe cyst's fistulous communication with the duodenum was demonstrated with oral contrast CT scan (Figure ). The cyst was closely related to the stomach and had displaced the stomach and spleen laterally. The pancreas appeared normal.\nAs the patient was breathless, a decision was made to put a percutaneous pigtail drain within the cyst to decompress."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old white woman diagnosed with a triple-negative basal-like invasive ductal carcinoma located at the intersection of upper quadrants of the right breast was treated with breast-conserving surgery having free surgical margins (>1.5 cm) and sentinel lymph node biopsy. Pathologic stage of the tumor was pT1N0M0. Adjuvant chemotherapy and radiotherapy were given.\nSeventeen months after the end of the radiotherapy, she presented with a painful mass in her right breast at the surgical bed. There were neither palpable axillary lymph nodes nor elevation of tumor markers. The imaging study with mammography and magnetic resonance imaging (MRI) showed a right breast mass whose pathological study comprising seven breast tissue fragments obtained by vacuum-assisted percutaneous biopsy revealed fat necrosis and fibrosis. These findings were interpreted as sequelae of breast-conserving treatment. Anti-inflammatory treatment was given and close follow-up was recommended.\nAfter three months, the mass had increased in size and patient complaints had also increased. Complimentary mammography and MRI-guided vacuum-assisted biopsy were performed at the core and at the peripheral enhancement of the mass. Twenty-one breast tissue fragments were obtained and, as with previous biopsies, pathologic diagnosis was confirmed with exclusion of malignancy (Figure ). Three months later, the clinical situation was worse with edema and slurring, and skin biopsy was performed excluding malignancy again. One year later, another biopsy comprising twenty fragments of nonmalignant breast tissue was carried out. At this time, the patient suffered from an unmanageable constant breast pain, and a new mammogram showed a diffuse affectation of the right breast. The progression of the mass in different mammography images is shown sequentially from left to right in Figure . Given these clinical facts, a radical mastectomy was indicated with two possible diagnoses: breast cancer recurrence or radio-indu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 35 years old indigenous man, with no stable accommodation for 10 years, identified the street as where he most frequently sleeps. His highest level of schooling was year 8. His first contact with the adult hospital healthcare system was in 2005 when he was hit by a car at the age of 22 years old, causing severe injuries. By this time, he already had severe ataxia (unsteady gait) and intellectual impairment from heavy solvent and alcohol abuse during his teenage years. In 2012 he had a further major car accident causing multiple leg fractures and by 2013, he was permanently wheelchair bound, homeless and a frequent user of street drugs, solvents and alcohol. He reports being regularly assaulted and having had multiple interactions with police, at the age of 30 years old, he was approved for permanent supported care but always left hospital to return to the streets before this could be found. His combination of permanent physical disability, lack of mobility, brain injury and vulnerability to attack and coercion resulted in him scoring 14 on the VI-SPDAT questionnaire in August 2016, reflecting high vulnerability. When asked ‘what do you need to be safe and well’ he simply answered ‘a house’.\nHospital use by this patient for a 27 months period (January 2015 to March 2017) is summarised in and the costs of these ED presentations and inpatient admissions have been computed using the sources described in the methods section. His total estimated costs for the 51 ED presentations over the 27 months period January 2015 to March 2017 was $33,456, and the cost of the 28 inpatient admissions amounted to $299,460. In total, this represents a cost to the health system of almost $333,000 or $12,333 per month over a 27 months period.\nIn early April 2017, this patient was found a place in a supported psychiatric care facility. Since then, he has not presented to any hospital or been"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old African American male presented to the emergency department from the outpatient oncology office with a week of mild abdominal pain, which was not life-threatening. His past medical history was notable for metastatic pancreatic adenocarcinoma, which had been diagnosed one year earlier, from endoscopic retrograde cholangiopancreatography (ERCP) brushings when he presented with obstructive jaundice and required biliary and duodenal stent placement at the time. He had undergone a routine CT scan of his abdomen and pelvis for disease progression two days prior to admission, which revealed a massive pneumoperitoneum (Figures , ). The ominous imaging prompted his admission to the hospital. On presentation to the emergency department, he was in no distress with a blood pressure of 126/85 mm Hg, pulse rate of 93 beats per minute, respiration rate of 18 breaths per minute, and a temperature of 36.9° C. Physical examination was significant for marked abdominal distension with a benign non-peritonitic exam and mild tenderness on palpation. Laboratory tests were unremarkable, except for a white blood cell count of 10.5 x 103/uL with neutrophil predominance (83%). A repeat CT scan showed patent biliary and duodenal stents without a definite source of perforation; however, three suspicious locations were noted by the radiologist containing small foci of free air adjacent to the bowel.\nGiven the initial concern for perforated viscus, the patient was started on broad-spectrum antibiotics and antifungals. He was managed conservatively with intravenous hydration and strict bowel rest. He remained hemodynamically stable and non-septic throughout his hospitalization and continued to have flatus and intact gastrointestinal function. General surgery recommended no acute surgical intervention. In a few days, he was started on a clear liquid diet which he tolerated well. His abdominal distension gradually improved without any surgical intervention, and he was discharged home a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year old man was admitted to the hospital after falling off an electric scooter. He fell on outstretched hands and knees and did not sustain a head injury. He immediately noticed loss of sensation in all four limbs and the abdomen.\nOn admission to the emergency department, he did not have motor or sensory (light touch or pain) deficits on physical examination. Deep tendon reflexes were intact. Deep anal pressure was intact. Anal tone was preserved with normal voluntary anal contraction. Computed tomography (CT) brain at that time did not show any evidence of fracture or haemorrhage.\nHowever, on review 2 hours later, wrist flexion and extension were noted to have dropped to a power of 2/5, and his grip 3/5 based on the Medical Research Council (MRC) manual muscle testing scale. He was also complaining of a tingling sensation throughout his body. Anal tone and sensation remained normal. The neurological level of injury was C5 ASIA Impairment Scale (AIS) D based on the International Standards for Neurological Classification of Spinal Cord Injury. Please see . CT cervical spine showed multilevel cervical spondylosis with marginal osteophytosis and uncovertebral hypertrophy. There was mild central canal stenosis noted at C6/7 and bilateral exit foramina narrowing.\nHe was admitted for observation. Magnetic resonance imaging (MRI) of the cervical spine confirmed the presence of severe cervical spondylosis causing cord compression at C4/5 with associated cord oedema. He was kept in a hard Aspen collar. His symptoms fluctuated minimally over the next few days and his neurological level of injury was C4 AIS D prior to surgery. He underwent C3-C6 posterior decompression and instrumented fusion to stabilise the spine and to prevent further deterioration.There were no intraoperative complications and neuromonitoring of both the motor evoked potentials and somatosensory evoked potentials remained stable throughout the procedure. The cord was well decompressed and noted to be"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old Japanese woman was referred to our hospital for the treatment of a tumor of the ascending colon. The tumor was found by colonoscopy during a checkup for a rectal cancer, which had been resected 5 years earlier, finally staged as pT1 pN0 M0, according to TNM classification of Union for International Cancer Control (UICC). Computed tomography and positron emission tomography revealed that the tumor arose from the appendix and invaded the adjacent ascending colon to expose the mucosal surface. The laboratory data were within the normal range. Because the biopsy from the tumor showed malignancy, ileocecal resection with lymph node dissection was performed. The period after surgery was uneventful, and there was no evidence of recurrence at a 9-month followup, under administration of infusional 5-fluorouracil-based chemotherapy.\nMacroscopically, after formalin fixation, the resected specimen showed a clearly demarcated ulcer, measuring 28 × 20 mm maximum dimensions, in the ascending colon (). The representative cutting surface revealed that the tumor was mainly located at the peripheral part of the appendix and invaded the adjacent ascending colon to expose the mucosal surface. Pathological findings revealed appendiceal mucinous adenocarcinoma showing extraluminal expansive growth, with one pericolonic metastatic lymph node, finally staged as pT4b pN1 M0, according to UICC TNM classification. The tumor contained massive mucin pools, and well-differentiated adenocarcinomas were found floating in the mucin pools. No goblet cell carcinoid or neuroendocrine cell was observed. The noticeable finding of this present case was the SSL which included serrated structure, crypt dilation, and horizontally arranged basal crypts, in the root of the appendix (). Moreover, the SSL combined with dysplastic change extended to the adjacent mucinous adenocarcinoma with an area of gradual transition (); this SSL was pathologically regarded as a potential precursor lesion of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.\nIn the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().\nThe patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.\nA non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().\nAn ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old female was transferred from an outside hospital with a sudden onset of diffuse abdominal pain. Her history is significant for malrotation with subsequent volvulus, small bowel resection done for ischemic bowel, carcinoid tumor of the stomach, multiple gastric ulcers, and a tubular adenoma of the colon. She first presented in 2005 with suspected ischemic bowel, which was resected and repaired with an ileocolic anastomosis. Her next presentation was in January of 2013 at which time she had severe anemia with a hemoglobin of 4.2 mg/dL. An EGD revealed a carcinoid tumor in the lesser curvature of the stomach that was endoscopically removed. A polyp removed during colonoscopy was identified as a tubular adenoma. She presented again the next month and an abdominal CT revealed two lesions in the liver, a left adrenal nodule, and an umbilical hernia. The liver nodules prompted a workup carcinoid syndrome, but the urine was negative for 5-HIAA.\nUpon her arrival to our hospital in August of 2013, she was noted to have moderate generalized tenderness on physical exam and her last bowel movement was earlier that day. An abdominal CT scan done prior to her arrival was suggestive of new marked mechanical traction of the distal small bowel. There were also three target signs present on imaging, a classic representation of intussuscepted bowel (). The patient consequently underwent an exploratory laparotomy. The operation was initiated using a midline incision, and an area of intussusception was revealed in the proximal jejunum () and multiple fibrotic implants were present throughout the bowel and mesentery. The lead point of intussusception was identified (). The compromised portion of bowel was resected and a jejunojejunal anastomosis was created. The bowel was then run from the Ligament of Treitz to the ileocecal anastomosis. An area of narrowed bowel was seen in the distal ileum near the site of the patient's previous ileocolic anastomosis (). An ileoileal anasto"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old, otherwise healthy female was assessed in June of 2017 for her isolated right olecranon injury. She described being bucked off a horse with a direct blow to her right elbow. Her physical exam revealed a closed injury, soft compartments, and intact neurovascular status. Initial X-rays demonstrated a simple transverse fracture pattern of her olecranon with no evidence of articular depression, osteopaenia, or substantial comminution (). She was splinted for comfort and consent was obtained for open reduction internal fixation of the right elbow.\nIn the operating room, she was positioned in lateral decubitus with the right side up and right elbow prepped and draped, and positioned on a sterile padded mayo stand. Alternatively, the patient may be positioned supine or prone with a radiolucent arm board. A tourniquet was applied to the proximal arm prior to prepping and draping, but was not inflated. A 7-cm longitudinal incision was made over the posterior aspect of the elbow. The incision may be curved medially or laterally around the olecranon, so as not to sit directly over the prominence of the olecranon process, and continued along the subcutaneous border of the proximal ulna. Sharp dissection was carried on through the skin and the subcutaneous tissue. The facia was incised midline, and the location of the ulnar nerve medially was identified and protected throughout the remainder of the case. The fracture site was identified and assessed. The broad insertion of the triceps on the proximal fragment was maintained, and control of the fragment was obtained using a sharp towel clip. The elbow joint and fracture surfaces were irrigated and anatomically reduced using sharp bone reduction clamps. The proximal tine was placed away from the olecranon tip as to avoid the start point for the screw. At this point, additional temporary K-wires can be used peripherally to help maintain the reduction"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male was referred to our department for a palpable, slow-growing, painless mass in his left hemiscrotum. The patient admitted that the mass had progressively increased in size during the last 6 years without however causing pain or other symptoms. The patient’s medical history was significant for BPH and diabetes mellitus. At clinical examination, a painless, large, solid, mass was palpated in the left hemiscrotum extending to the perineal region, without being clearly distinguished on palpation from the surrounding scrotal components. The inguinal lymph nodes were not palpable. Laboratory tests were normal and serum markers for testicular cancer (β-HCG, AFP, LDH) were within normal limits.\nUltrasonography showed a large (5×6 cm), hyperechoic scrotal mass separated from the ipsilateral testis. A pelvic magnetic resonance imaging (MRI) was scheduled in order to better define the nature of the mass. MRI confirmed the presence of a mass in the left hemiscrotum extending up to the base of the corpus cavernosum. The mass showed a high T1 signal intensity characteristic of fat-containing tumors (both benign and malignant) and was clearly separated from the ipsilateral testicle. The signal intensity was heteroge-neously high in T2 sequences as well ( and ). The finding was considered indicative of a benign tumor with the differential diagnosis also including a liposarcoma of the scrotum. A routine chest X-ray was normal and the patient having been informed about the, albeit small but present, possibility of malignancy agreed to undergo surgical exploration of the scrotum and excision of the mass.\nAn inguinal incision extending into the left hemiscrotum was carried out and the scrotum was entered revealing a solid vascularized mass. The mass was remote from the testis and epididymis and was completely extirpated with relative ease from the adjacent structures sparing the testis and epididymis. The patient’s postoperative course was uneventful and he was discha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman presented with two supernumerary nipples located along the milk line on each side of the upper abdomen. During a few months before referral, the patient had noticed a firm palpable mass in close relations to the supernumerary nipple on the right side (). She had no other symptoms. Bilateral mammogram and ultrasound revealed normal breast parenchyma. Ultrasound of the supernumerary nipple on the right side confirmed a small mass in relation to this nipple, presenting as a hypoechoic, well-defined area, measuring approximately 10 mm in diameter ().\nUpon clinical examination, the supernumerary nipple on the right side presented with inversion and a palpable firm mass underneath this nipple. Ultrasound-guided needle core biopsy (16G) was performed (). The pathology report described elongated epithelial islands composed of cubic cells, with a small centrally located lumen with focally identifiable cuticles. The epithelial structures were surrounded by a dense fibrous stroma. The microscopic analysis indicated the possibility of SyT and the lesion was categorized as a B3-lesion (a lesion with uncertain malignant potential) ().\nFollowing a Multidisciplinary Team Conference, it was decided to recommend resection with a 5 mm rim of normal tissue, which was subsequently performed ().\nMacroscopically the tumour measured 7 x 5 x 5 mm and was described as a firm and grey-white tumour, in close relations to the supernumerary nipple. Microscopically the tumour measured 13 mm in diameter and was localized in the deep part of dermis and underlying subcutaneous tissue with no relation to the epidermis. The tumour was composed of solid trabecular and glandular imitating formations with focal cysts. The epithelium consisted of cells with slightly irregular nuclei and indistinct nucleoli, surrounded by an eosinophilic cytoplasm. The glandular structures were lined by cuboidal cells. The tumour was in close association with the lactiferous ducts and smooth muscle of t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old woman presented to the neurology emergency department with headaches, lack of mobility in right hand and foot and lost speech ability. On physical examination, there was complete Broca's aphasia and right hemiplegia. Brain computed tomography (CT) scan showed an evidence of embolic infarction in the left middle cerebral artery (MCA) zone and the treatment for cerebrovascular accident was started. Then, the heart and carotids were evaluated.\nCarotid Doppler ultrasound and electrocardiogram (ECG) were normal. The heart rhythm in ECG was normal showing a sinus rhythm. Transthoracic echocardiogram (TTE) was normal in chambers and heart valves, A suspicious mobile mass was seen in the aortic arch in assessment of suprasternal notch. To investigate further, the CT angiography of the thoracic aorta was performed and a filling defect was observed in the aortic arch. TEE was performed emergently. Hypermobile mass was seen in the aortic arch with the dimensions of 4.0 × 0.5 × 0.5. On the histopathology, the resected intra-aortic mass showed a blood clot. Regarding the nature of mass, hypermobility and lack of intracerebral hemorrhage in brain CT scan, the decision was made to urgently resect the tumor. The patient was immediately transferred to the operating room.\nMidsternotomy was performed right after receiving heparin and arterial cannulation of the right atrium was performed with a grade 7 cannula. Anonymous artery was cannulated with a cannula number 14 and the patient was cooled to 18 degrees and then was given health care assistant (HCA). The base of the anonymous artery was clamped and arterial flow was maintained through the anonymous artery cannula to 800 cc/kg. First arc opening and cutting was undertaken during septum.\nA red mobile mass of 4.0 × 0.5 × 0.5 cm was observed at the junction of the ascending aorta and arch, with a soft consistency which was attached with a pike of 0.5 × 0"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old otherwise healthy woman was referred to us with a large tender erythematous morpheaform plaque without ulceration on the lower part of her leg. This plaque had begun as a small nodule on the shin 1 month prior to this visit. It had gradually extended outward in a centrifugal pattern despite oral antimicrobial treatment by her family physician. She was initially diagnosed and treated as a case with cellulitis and with poor clinical response. This patient denied having had a sore throat or arthralgia in the previous months. Other than diabetes mellitus type II, she had no significant medical history. She had been taking oral hypoglycemic agents for many years. On physical examination, it became evident that she had a large erythematous plaque measuring 30 × 30 cm2 on the anterolateral aspect of her lower left leg []. There was mild edema and local tenderness on the leg plaque. The color of this morpheaform plaque varied from red to brown, and its surface was mildly scaling. A skin biopsy specimen was then taken from the newly extending area on the left calf. Histopathological examination revealed that the pathologic changes were mainly in the subcutaneous tissue, in which the septa were thickened and there existed lymphohistiocytic infiltrate and a few neutrophil and occasional multinucleated giant cells. Some inflammatory cells had infiltrated into the periphery of the fat lobules (Septal panniculitis) []. The vessels have not any obvious pathology. A mild perivascular inflammatory infiltrate was also present in the dermis. The overlying epidermis was mildly acanthotic and hyperkeratotic. These findings suggested a diagnosis of erythema nodosum migrans. The results of laboratory investigations were within normal limits. A skin test of PPD and the titer of antistreptolysin O (ASO) proved negative. The chest radiograph has normal appearance. On the basis of the clinical pathological findings, we diagnosed the patient's eruption as erythema nodosum migrans"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58 years-old man presented at our emergency room with fever, cough and left thoracic pain. His past medical history was unremarkable. Blood test showed WBC and C-reactive protein elevation. He had started antibiotics therapy and, given the persistence of symptoms, CT scan was performed showing lower left pneumonia. Incidentally, a 2.5 cm mass was found in the upper anterior mediastinum, with positive contrast enhancement and a 5 mm vessel arising from left brachio-cephalic vein (, ). Because of size and position fine needle aspiration nor anterior mediastinotomy were performed. Radiologic features were consistent with thymoma that usually appears as an ovoid or lobulated, smooth, well-marginated mass, projecting over the mediastinum typically protruding unilaterally, therefore patient underwent (1) neurologic evaluation that excluded myasthenia (2) PET/CT scan that showed the absence of any pathological uptake. However, thymoma was felt to remain a diagnostic possibility and patient was referred for radical surgery, with particular attention to abnormal vascularization. He underwent left thoracoscopy and, in spite of extreme attention, during pleural dissection between mediastinum and sternum, a sudden massive bleeding occurred (about 1,500 cc) requiring emergency conversion to median sternotomy. It was then clear that the bleeding came from tumor and not from brachiocephalic vein or its branches, as initially thought. After controlling the bleeding, we removed the mass but it was necessary to sacrifice the left laryngeal nerve.\nIntra-operative emergency required significant blood transfusions and precautionary transfer in intensive care for 24 h. The patient eventually made a complete recovery. We only recorded transitory dysphonia as in case of laryngeal nerve paralysis. At specimen analysis, the cut surface seemed to have some fresh blood and the soft tissue was taupe with multifocal thrombosis in various stages of organization up to phlebolithes. Histopatholog"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-year-old male patient was brought to the pediatric dental clinic of a public teaching institution for dental treatment. The child had no relevant medical history.\nDuring clinical and radiographic examinations, extensive carious lesions were observed in the deciduous second molars. Because of the patient's poor oral hygiene, the final restorations were not placed until the patient's oral environment had improved. Temporary restorations were placed in the decayed teeth using glass-ionomer cement and the caregiver was instructed about her child's oral hygiene and dietary habits in order to control caries-promoting risk factors.\nUnfortunately, the patient did not show up for treatment for 10 months, and when he returned there was irreversible pulp damage in the lower right primary second molar. As a result, a pulpectomy was performed, and the root canals were filled with iodoform-based paste. Because of extensive coronal destruction involving the occlusal, buccal, and lingual surfaces, the treatment of choice was biologic restoration using a deciduous molar crown obtained from the tooth bank at the same institution ().\nAfter 12 months, a clinical followup of the provisional restorations was carried out. Upper right primary second molar, which had been restored with glass-ionomer cement, was treated with a formocresol pulpotomy and class I restoration with photoactivated resin composites (TPH; Dentsply, Rio de Janeiro, RJ). The other temporary molars were restored in a direct way with resin composite. Clinical visits took place every 3 months and radiographs taken every 6 months to observe the patient on a routine basis and to reinforce the caregiver's and patient's oral health preventive practices.\nFive years after finishing the treatment of the lower right primary second molar, even though there was partial resorption of the root canal filling material, we did not observe any periapical lesion or clinical evidence of unsuccessful endodontics. The same applies to th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old Caucasian woman presented to her primary care physician with a 1-year history of epigastric abdominal pain, occasional nausea, and emesis, and an unintentional 10 pound weight loss. An abdominal CT scan showed a 4.5 × 4.1 cm periampullary mass arising from the pancreas without evidence of metastatic disease. Interestingly, the CT scan also showed the colon to be in a dorsal position in relation to the SMA (). Laboratory analysis revealed normal liver function tests and serum CEA level but an elevated CA 19-9 level. At operative exploration, the entire transverse colon was found to be retroperitoneal and lies dorsal to the SMA and SMV. The duodenum coursed anterior rather than posterior to the mesenteric vessels. The SMA lies further to the right than normal and the SMV–portal vein confluence lies further to the left than usual. Inspection of the duodenum and head of the pancreas revealed a firm mass in the head of the pancreas. A classic pancreaticoduodenectomy was performed. The anterior placement of the duodenum made division of the jejunum beyond the ligament of Treitz relatively easy. The tumor dissected nicely away from the SMA with no uncinate process of the pancreas present. Our standard procedure is to bring the jejunal limb for reconstruction up in a retrocolic position, through a defect made in the transverse mesocolon to the right of the middle colic vessels. This limb is used to create the pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy. Due to the retroperitoneal position of the transverse colon, we brought the jejunal limb up in an antecolic position. Pathology revealed a moderately differentiated PDA with all surgical margins being free of tumor and 1 out of 11 specimen lymph nodes was positive for metastatic disease. The patient tolerated the procedure well and was discharged to home on postoperative day 5. The patient eventually developed recurrent disease and died 34 months postresection."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man had pyothorax after surgery and chemotherapy for lung cancer. He developed sepsic shock and DIC 13 months after undergoing respiratory surgery to excise lung cancer. He was admitted to the intensive-care unit and required dialysis for renal failure. His condition worsened as he developed accompanying PF that affected both hands and feet (). Methicillin-Sensitive Staphylococcus Aureus detected in the pyothorax was considered the main pathogen responsible for sepsis.\nPart of the purple-colored skin changed to black, indicating total necrosis. This brought up the issue of how to proceed with surgical treatment for multiple-leg necrosis considering the patient’s pyothorax, which carried a risk of worsening the general condition. Although general anesthesia was possible, we planned to perform the surgery with local and spinal anesthesia in order to minimize the risk of complications, such as pneumonia, after the surgery. The ultimate goal was for the patient to be able to walk again under his own power.\nFirst, we decided to save as much of the left leg as possible, as the necrosis did not involve the heel (). The left foot was therefore amputated at the level of the metatarsal bone, and all necrotic tissue was excised (). The exposed bone associated with the stump presented a problem in connection with the next surgery, skin graft. As a result, negative pressure wound therapy (NPWT) was applied to the wound exposed bone in order to speed up the healing process and cover the bone with granulation tissue. The effectiveness of this therapy for wounds with exposed bone in the lower extremities has been previously described []. The device we used was an ACTIV.A.C® (K.C.I, San Antonio, USA), and the pressure was adjusted 50 mmHg. After three weeks, the wound improved and exposed bone was now almost completely covered with granulation tissue. The wound bed preparation before performing skin grafting was thus considered to be sufficient (). Finally, a partial-t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old female, teacher by profession, with complaints of weakness and pain in left hand involving 3rd, 4th, and 5th digits associated with pain in wrist, elbow, and shoulder joint on the same side for 2 months. Over the next 15 days she started developing swelling and redness involving last three digits along with blackish mottling of the overlying skin on the dorsal aspect. She also had increased pain sensation in those digits to the slightest of touch such that she would keep her fingers flexed and avoid movements. She sought medical consultation at the dermatology clinic before consulting various other specialties and ultimately being referred to our rheumatology clinic.\nAt dermatology clinic, on clinical examination, ulnar nerve was found to be minimally thickened and palpable along with skin changes including hyperpigmented patches and hypoaesthetic plaques. There was reduced sensation to cold with preserved fine touch and pain sensations. Ulnar nerve biopsy was ordered which came out to be normal. Skin biopsy showed hyperkeratotic epidermis with large number of budding yeasts in stratum corneum and was prescribed fluconazole along with NSAID’S and topical ointments but to no relief.\nPatient visited neurology clinic for her complaints of excessive pain apparently in the ulnar nerve distribution. A possibility of mononeuritis multiplex was considered clinically. She underwent nerve conduction studies of all four limbs and MRI of cervical spine were revealed normal. Patient was started on Tramadol 50 mg twice daily, Gabapentin 150 mg twice daily, duloxetine 30 mg once daily, and Vitamin B-12 supplements but without any relief in her symptoms.\nMeanwhile, the patient consulted many orthopaedicians and physical medicine and rehabilitation centers but to no relief. With every passing day, her pain increased to the extent that she stopped venturing out in public places to avoid any touch on her fingers. Pain became so debilitating that she used to cry and could"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was an 82-year-old female with dyspnea as the primary complaint. She had no particular past or familial history. She used to be a nurse (until the age of 72 years) and had no history of occupational asbestos exposure. There was also no history of residence in an asbestos-contaminated environment.\nRegarding the history of the present illness, she presented with abnormal chest radiographs (a) during a community health screening in July 2006. Still, she left the findings unattended because of the absence of symptoms. On a retrospective review of the plain chest radiographs taken one year before, in July 2005, the right costophrenic angle was already blunted. The plain chest radiographs taken during the community health screening in July 2007 indicated abnormalities again (b). At this time, as the chest radiographs showed a mass in the right thoracic wall in addition to right pleural effusion, the patient was referred to a hospital for close examination. In the chest CT scans taken in July 2007 (), a small amount of pleural effusion was noted on the right side, and pleural masses were found in the right anterior mediastinum and anterior and lateral thoracic regions. A percutaneous pleural needle biopsy was performed for the mass of the right lateral chest wall, and a diagnosis of pleural mesothelioma was made. The pathologist in charge of the needle biopsy described the pathological findings as epithelioid mesothelioma with edematous stroma, and intracytoplasmic mucinous vacuoles are outstanding. However, when we re-evaluated the specimen, it was an epithelioid mesothelioma with abundant myxoid stroma and was completely homogeneous with the histological image at autopsy as described below.\nTherefore, the clinician recommended anticancer drug treatment. However, as the patient did not wish for aggressive treatment, she was followed-up without treatment.\nshows a plain chest radiograph taken in April 2008. Masses were observed in the area corresponding to the r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old man presented to us with complaints of a recurring cough and occasional blood-streaked sputum. The problem started after a dental procedure during which he had a choking episode and aspirated a dental drill, which was being used for a root canal treatment. He denied any fever, chest pain, or shortness of breath. He had no other medical problems of note beside the above. Clinical examination was essentially normal. The patient had brought with him an X-ray of the chest, which was normal, and CECT of the thorax with reconstructions in which the slender metallic FB was seen lodged in one of the basal sub-segments of the left lower lobe [Figures –]. A decision for bronchoscopic extraction was taken. After obtaining informed consent the patient was taken up for fiberoptic bronchoscopy under conscious sedation.\nA bronchoscopy for evaluation was done with a videobronchoscope, outer diameter 5.8 mm, under conscious sedation with intravenous midazolam. The trachea-bronchial tree was largely normal except for the left lower lobe lateral basal segment, where the tip of the FB, a dental drill, was seen pointing straight up. The plastic blunt end of the drill was lying distally embedded in the subsegmental bronchus. An attempt was made to hold this metallic sharp end with a rat tooth forceps but failed. Then, a snare was coiled around the tip, but it slipped through on account of it being too thin. A magnetic tip probe for extraction of metallic FBs also failed to pull out the FB. Finally, a thin fogarty catheter was pushed from the side of the FB with the intention of inserting it distal to the FB, inflating the balloon and then pulling it up to dislodge the FB. However, this attempt resulted in the FB getting pushed in with the catheter and then slipping out of sight into the distal subsegment"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year old girl was seen at a pediatric cardiac clinic of a university hospital for complaints of palpitation and decreased exercise tolerance of around two years duration. History of past illness revealed that the girl was admitted for chronic cough and pulmonary right lung mass at the age of 5 years. Her family report that a CT scan of her chest showed a right lung mass on that admission. They were told that she will undergo thoracotomy but later were told that medical treatment was sufficient (detailed record not available). On physical examination, She weighed 34 kg and her height was 149 cm. Her blood pressure was 121/53 mmHg and her pulse rate was 72 beat per minute. Her saturation was 93% at room air. She demonstrated no pallor or icterus. The chest was clear with good air entry. Peripheral pulses were palpable and there was no precordial bulge. No heave or thrill was noted. Point of Maximum Intensity (PMI) was in the 5th intercostal space along the left mid clavicular line. There was no murmur or gallop. There was no organomegaly or peripheral edema.\nFrontal chest X-ray performed at the time of current presentation showed no lung parenchymal abnormality, no pleural effusion and normal cardio-thoracic ratio and normal cardiac borders. Electrocardiography showed sinus rhythm with 80 beats per minute without any remarkable abnormality. A transthoracic echocardiogram demonstrated a large cystic mass measuring 3.8 cm × 3.4 cm within the interventricular septum, bulging in to the left ventricle (–). No cysts were seen in the liver, kidney or spleen. LV systolic function was reduced (left ventricular ejection fraction of 40% and fiber shortening fraction of 20%). Minimal mitral regurgitation was noted. There was no pericardial effusion.\nThe patient was started on preoperative albendazole to be taken for 3-months. However, due to a misunderstanding during dispensing from the pharmacy, the patient took albendazole for only"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old woman presented to our university hospital emergency department in 2007 with complaints of occipital headache of increasing intensity and worsening blurred vision in her left eye for the last seven months prior to her visit. Recently, she had also noticed that her menstrual periods were becoming irregular. The patient had a history of acromegaly treated with trans-sphenoidal resection of a pituitary tumor in 1989. She was also known to have primary infertility for which she had not sought any medical help. She had been lost to follow-up since her surgery until this visit. On examination, she was found to have acromegalic features and a left eye temporal visual field defect on confrontation and visual field mapping. An x-ray of her skull revealed thickened calvaria with a wide, double-floored sella. An MRI of her brain revealed a multiloculated cystic mass seen in the suprasellar region with extension more to the left side, causing a mass effect on the surrounding structures without midline shift or hydrocephalus (Figure ).\nIn the two months since her first visit, the patient had noticed a significant decrease in her left eye vision with an ability only to perceive light. On examination, her right eye was found to have a new temporal visual field defect. At that time, endocrine testing revealed hypogonadotropic hypogonadism with a serum prolactin level that was mildly elevated at 45 ng/mL. She was also found to have central hypothyroidism. Her GH was not suppressed even after an oral glucose load test. The baseline GH was 17.3 ng/mL; it became 13.0 ng/mL and 10.3 ng/mL at one and two hours. The IGF-1 level of 1006 ng/mL along with the unsuppressed GH confirmed the previous diagnosis of acromegaly. She underwent a left pterional craniotomy with subfrontal approach under microscopic guidance to obtain a tissue diagnosis and drain the cystic tumor. She developed transient diabetes insipidus postoperatively, but her vision improved significantly following s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman (gravida 5, para 3+1) had been delivered of 2 healthy sons and 1 healthy daughter via lower segment CSs in other hospitals 15, 11, and 8 years, respectively, prior to the current presentation. At 32+1 weeks of gestation, she presented at the emergency department of our hospital because of spotting. Her current pregnancy was not registered with any hospital and she had received no antenatal care. She had noted intermittent minor spotting between 28 and 30 weeks of gestation but had not visited any hospital or received any treatment.\nOn presentation to our hospital, she was found to have a hemoglobin (HGB) concentration of 87 g/L. Ultrasonography revealed that the lower edge of the placenta was completely covering the internal cervical orifice and was suspicious of the presence of PPP (Fig. ). A plain magnetic resonance imaging (MRI) revealed that the pernicious placenta previa was completely covering the internal cervical orifice, she had diffuse placenta accreta and also placenta percreta on the lower anterior uterine wall, and distended and twisted vessels were visible on the surface of the lower anterior uterine wall (Fig. ). A diagnosis of PPP was made. The patient was admitted to the obstetric ward and treated with dexamethasone to promote pulmonary maturation.\nAt 33 weeks gestation, she had 450 mL vaginal bleeding and was immediately transferred to the operation room for emergency CS. On arrival at the operating room, her blood pressure was 125/75 mm Hg and heart rate 90 beats/min. A resuscitation team comprising senior staff of the departments of gynecology, obstetrics, anesthesiology, and neonatology, the intensive care unit (ICU), blood bank and laboratories, and a nursing team was immediately established. The anesthesiologist immediately punctured an artery to enable invasive blood pressure (BP) monitoring, and devices for autologous blood recovery were assembled. Nurses established four 16 G intravenous lines immediately for fluid infus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was an 85-year-old Caucasian man with a 30-year history of type 2 diabetes. Sixteen years after being diagnosed with hypertension following a stroke that caused mild residual right hemiparesis, he was successfully treated for prostate cancer with radiotherapy. Ten years later an electromyogram showed mixed peripheral polyneuropathy with axonal predominance.\nWhile the patient was ambulatory, a 2 cm ulcer appeared on his right heel after prolonged exposure to heat, and it increased in size despite appropriate wound care and glycemic control. Less than three months later the patient was unable to walk and was subsequently admitted to our hospital for congestive heart failure.\nA skin examination performed at the time of admission showed the heel ulcer to be extensive (Figures and ), and it was evaluated as grade III according to the Wagner grading system []. Three additional decubital lesions had developed on the sacral area, external malleolus and flexure of the right ankle. These lesions were evaluated as Wagner grade II and were well delineated with a necrotic appearance, without granulation tissue, and covered by purulent exudates.\nA general examination indicated that the patient had congestive heart failure probably due to ischemic heart disease. Echocardiography was not performed, and electrocardiography showed no evidence of myocardial infarction. The patient's diabetes was poorly controlled, with neutral protamine Hagedorn insulin measurements of 40 IU in the morning and 15 IU in the evening, and glycosylated hemoglobin levels >8%, which required adjustments of his insulin dose and addition of on-demand fast-acting insulin. He was also receiving bicalutamide 50 mg/day, candesartan 16 mg/day, furosemide 20 mg/day, triflusal 600 mg/day and calcium dobesilate 500 mg twice daily. These medications were continued throughout the patient's ulcer-specific treatment.\nTreatment of the ulcer itself was initiated by the patient's general practitioner with oral c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year-old boy reported to the Department of Oral and Maxillofacial Pathology, SIBAR Institute of Dental sciences, with an asymptomatic extraoral swelling on the right body of the mandible, which had been evident for 2 months []. According to the patient, the swelling was initially small and gradually progressed to the present size and was asymptomatic. His past medical history and family history were noncontributory. On clinical examination, right facial asymmetry was observed. A solitary, extraoral swelling was seen on the right side of the body of the mandible, which was oval in shape and was 4 × 3.5 cm in size, extending anteriorly 2 cm away from the corner of the mouth and posteriorly 1 cm in front of the angle of the mandible. Superiorly, the lesion was extending up to the line joining the corner of the mouth and the tragus of the ear and inferiorly to the lower border of the mandible. It was hard and nontender on palpation []. Intraorally, the overlying mucosa was intact and smooth and there was no tooth mobility. The regional lymph nodes were not enlarged. The clinical differential diagnosis including central ossifying fibroma, central giant cell granuloma, neurofibroma, neurilemmoma, myofibroma of the mandible and osteoma was considered.\nOn radiographic investigations, the panoramic radiograph of the right mandibular premolar-molar region showed faint periosteal reaction in the vicinity of permanent first molar. The developing tooth buds of right canine and premolars appeared to be uninfluenced by the pathosis in the region as compared to the left side. The periosteal bone reaction was noted []. As the panoramic radiograph revealed no significant findings, an axial computed tomography (CT) was advised. The axial CT view in bone window at the level of inferior border of the mandible showed a massive periosteal reaction on the buccal surface, demonstrating the sclerotic borders of the lesion. The lesion appears to have"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old male presented with a chief complaint of a painless swelling in his right mandible and mobility of lateral and canine teeth in the same side. Swelling was begun from 3 years ago until 8 months before was reached to present size; mobility of teeth revealed from 3 months ago. There were no lymphadenopathy and tenderness [].\nPanoramic radiograph showed a large, multilobular radiolucency with ill-defined borders, located in the body of partial edentulous right mandible and extending from the lateral incisor to the first molar area []. According to preoperative management of patient, routine biochemical and hematological investigations were done, and all were within normal limits. With a differential diagnosis of central giant cell granuloma or odontogenic tumors or any other centrally located mesenchymal tumors, the patient posted for further evaluation.\nIncisional biopsy was done, but the resected tissue was found to be insufficient to arrive at a histopathological diagnosis. The patient refused further incisional biopsy; based on the suggestion of the surgeon, the patient posted for surgery. Under general anesthesia, removing part of the jawbone including tumor with right lateral and canine teeth was performed. In gross, tumor appeared as a combination of cystic and solid areas [].\nHistopathology survey of surgical specimen revealed a combination of cystic and solid areas. The peripheral layer of cystic areas consisted of a parallel arrangement of tall cylindrical cells with reverse polarity [, white arrow] of their hyperchromatic nuclei and vacuolization of the cytoplasm, and in solid area, the accumulations of cell rich in eosinophilic granular cytoplasm were found [, black arrows]. Furthermore, in the periphery of solid part of islands and cords of epithelium, a row of cell similar to ameloblast was found. According to above findings, diagnosis of GCA was given. After 2 months, the radiography which was taken showed acceptable healing improvement and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA cardiologist calls as they are planning a coronary angiogram for a 68-year-old trans woman and are concerned because the estimated glomerular filtration rate (eGFR) is unknown. They are uncertain how to risk stratify her for potential contrast-induced nephropathy. She has a history of longstanding hypertension and hypercholesterolemia, vaginoplasty, and has been on various formulations of estradiol therapy for over 20 years. On review of her investigations, her serum creatinine is 109 umol/L (1.23 mg/dL) but her eGFR has not been reported for the last 18 months. Laboratory providers cannot report eGFR if a male or female marker is not provided on the request form, as this is required along with age to estimate eGFR. Using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, if classified as female, the eGFR would be 45 mL/min/1.73m\nclassed as Stage 3 chronic kidney disease and would meet the guidelines for intravenous hydration prior to procedure. However, if classified male, the patient would have an eGFR of 60 mL/min/1.73m\nwhich would be classed as Stage 2 chronic kidney disease and would not require prehydration. Which is the most appropriate eGFR to use?\nAccurately assessing renal function is essential for not only assessment of renal diseases, but also clinical situations that may potentially affect renal function (such as diabetes or radioiodine contrast administration) as well as considerations for medication dosing of renally cleared drugs. The most commonly used marker of renal function in clinical pathology laboratories is eGFR, which is calculated based upon an individual’s serum creatinine level, age, and sex (). Typically, people presumed male at birth have a higher eGFR than people presumed female at birth at the same level of serum creatinine because the formula assumes a higher muscle mass in men contributing to the serum creatinine independent of renal function. The difference between these groups (given the same age and weight"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman with a 3 month’s history of cough and hemoptysis consulted a nearby clinic. Chest X-ray showed atelectasis of the right upper lobe caused by locally advanced lung cancer with mediastinal invasion. Bronchoscopic biopsy showed squamous cell carcinoma. Chest computed tomorgraphy (CT) showed atelectasis of right upper lobe tumor invasion into the right main pulmonary artery. The SVC was compressed and narrowed but remained patent (Fig. ). No significantly enlarged mediastinal lymph nodes were seen. Bronchoscopy revealed an exposed tumor in the right upper bronchus which completely obstructed the lumen. Brain and abdominal CT, and bone scintigraphy revealed no signs of distant metastases. On the basis of these findings, the tumor was evaluated to be resectable by intrapericardial pneumonectomy. The surgery was performed through a right thoractomy. The pericardial was opened from SVC to the level of right upper pulmonary vein 2 cm posterior and parallel to the phrenic nerve. The SVC was isolated from the atrium to the brachiocephalic trunk, which involved SVC denudation at the point of its connection with pericardium. Then the right pulmonary artery was dissected and ligated between the ascending aorta and the SVC. The right upper pulmonary vein was ligated intrapericardially. The right lower pulmonary vein was dissected and ligated outside of the pericardium. Finally the right main bronchus was manipulated using a stapler to complete the right pneumonectomy. No direct tumor invasion into the SVC was detected. The lower part of pericardium was closed interruptedly and the upper defect was left open. The chest was drained using an intercostals tube that was kept clamped and released for half an hour the next morning. The patient was transferred postoperatively to Intensive Care Unit, and the tracheal tube was withdrawn 2 h after operation. About 18 h after operation, the patient was transferred to an ordinary room. Immediately after a short period of ha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male epileptic patient was brought to our tertiary care hospital with uncontrolled seizure. He had history of focal epilepsy since 5 years and was on antiepileptic medication. He was on carbamazepine, with a total dose of 1000 mg per day, since 1 year. He was apparently doing alright for some time and his quality of life had improved on carbamazepine. However, the seizures recurred once in every 2-3 weeks for the last 3 months because of which he was admitted in neurology department for further management and drug optimization.\nHis general physical examination was normal. There was no history of prior behavioral problems or cognitive deficits. There was no family history of psychotic disorder. His blood investigations for electrolytes, renal function test, thyroid, liver function and other related tests were within normal limits. His computed tomography (CT) scan of brain showed left frontal calcified lesion suggestive of cysticercosis. His CT brain with contrast showed no further new or active lesions. His EEG was normal. His serum carbamazepine level was 10 μg/ml.\nIn view of his poor seizure control and serum carbamazepine level reaching the upper limits of normal, he was added on LEV with an initial dose of 250 mg twice a day and was planned to increase the dose gradually over 2-4 weeks to reach a dose up to a total 1000 mg per day. However, by day 3 the patient developed severe behavioral abnormality characterized by agitation, emotional liability, hostility and depersonalization. He was evaluated by the psychiatrist and was diagnosed as acute psychosis. His mental state examination was normal except for abnormal mood and thoughts. Psychiatric assessment revealed features of depression, mood and thought abnormality, suspicious and withdrawal state with visual hallucination suggestive of psychosis. Delirium was ruled out as there was no fluctuation in sensorium, focal deficits and meningeal signs. As mentioned earlier, the lab investigations were do"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old male was admitted to a hospital in June 2016 because of right arm asthenia and dysarthria and was diagnosed as having cerebral infarction in the left middle cerebral artery area along with deep vein thrombosis. ECG demonstrated normal sinus rhythm and echocardiography revealed no intra-cardiac thrombus or vegetation. The patient was discharged from the hospital following administration of apixaban.\nIn August 2016, the patient was readmitted to the hospital because of recurrent right arm asthenia and dysarthria. MRI revealed multiple cerebral infarctions in not only the bilateral cerebral hemispheres but also the cerebellum. Trousseau’s syndrome was suspected at this time. Apixaban administration was stopped and an intravenous drip of heparin was started. Echocardiography revealed mild mitral regurgitation with vegetation on the mitral valve. Although the laboratory data suggested no evidence of infection, ceftriaxone and gentamicin were added as a precaution against infective endocarditis. The patient was then referred to our hospital for surgery.\nA CT scan revealed a left renal infarction and multiple swollen lymph nodes around both the abdominal aorta and stomach with antral hypertrophy, suggesting an advanced gastric cancer or lymphoma. As the vegetation showed no change despite the heparin and antibiotics therapy, cardiac surgery was performed on day 5 after referral. Extracorporeal circulation was instituted employing aortic and bicaval cannulation. After aortic cross-clamping, the mitral valve was exposed via a left atriotomy. Both mitral leaflets had vegetation on the surface, and major vegetation 15 mm in width was evident on the anterior leaflet (Fig. ). These were resected in their entirety and replaced with a 25-mm Epic bioprosthesis (Abbott). Continuous intravenous heparin administration was resumed on the following day, aiming for an activated partial thromboplastin time of between 40 and 50 s. Histologic analysis revealed that the vegetat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15 years old girl came to our hospital with a complaint of pain and swelling over her left hand with history of fall. She also complained of occasional pain over lower third and inner aspect of her forearm. While we were managing the patient for hand injury we took x-ray of hand with wrist and forearm suggesting of fracture of fifth metacarpal. X ray also showed findings of expansile lytic lesion with multiple septas in diaphyseal region of left ulna. Examination of forearm revealed a mild diffuse swelling over the lower third and inner aspect of her left forearm. The overlying skin was normal. No signs of inflammation were visible. On palpation, there was tenderness over the swelling. The swelling was soft in consistency with a feeling of ‘egg shell crackling’. Movement at all the joints was full in range and was painless. There was no neurovascular deficit. Clinically diagnosis came out to be either Aneurysmal bone cyst or Simple bone cyst. We decided to take FNAC. The report of FNAC was suggestive of Giant cell tumor. For confirmation of diagnosis, we took open incisional biopsy which came out to be giant cell tumor. Diagnosis of giant cell tumor was confirmed as we sent specimen at two different histo-pathology laboratory, both suggestive of GCT. Then after proper counseling of patient and relatives, we decided to excise whole tumor and reconstruct it with a fibular graft. We expose entire tumor with standard ulna surgical approach. We had removed tumor with 1 cm clinically normal looking bone both side. We had also sent intra operative frozen section for safe margin. Report came as negative. The bone gap after excision of tumor in ulna was about 8 cm. We took cortical bone graft from ipsilateral fibula of respective size. We took cancellous bone graft from ipsilateral proximal tibia. Implantation of fibula at recipient site after appropriate freshening of margins, fixation of fibula in between the two ends of ulna with intramedullary ulna nail from"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old man with no relevant medical history attended the School of Dentistry of the University of Granada reporting strong oral pain after a weekend of abundant alcohol and tobacco consumption and lack of rest. Clinical examination revealed multiple ulcers covered with a grayish pseudomembrane in the palatal rugae, papillary necrosis at teeth 21 and 22, and ulceration throughout the gingival margin and gingival papillae of the second quadrant (). Periodontal probing was not possible due to the intense pain.\nPanoramic X-ray examination of the patients ruled out maxillary bone involvement in both cases (). Several exfoliative cytology specimens were obtained from necrotic palatal gingival papillae using sterile swabs. Samples from both cases were stained with hematoxylin-eosin to evaluate cytological features and the presence of bacteria. Histological analysis evidenced acute inflammatory cells and polymicrobial microbiota with a wide variety of bacterial morphotypes and forms compatible with spirochetes and fusobacteria (). Following Mombelli’s technique [], blotting paper tips (No. 30) were inserted in the gingival sulcus for microbiological culture of the crevicular fluid in regenerated Schaedler broth supplemented with hemin and vitamin K. The isolation and identification procedures yielded no conclusive results.\nAfter the two cases were diagnosed with necrotizing stomatitis and written informed consent was obtained, 3% hydrogen peroxide was gently applied to the lesions using sterile swabs, for debridement of the necrotic areas. Both patients were prescribed oral 875/125 mg amoxicillin/clavulanic acid and 600 mg ibuprofen every 8 hours and oral rinses with 0.2% chlorhexidine every 12 hours. Both cases showed a rapid response to treatment, and a major improvement in symptoms was observed at 48 hours, with almost complete resolution of the ulcerated areas, which were covered by a layer of fibrin, and the detachment of necrotic areas with partial decapitation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16 year old Sri Lankan male, diagnosed with FA, presented to University Medical Unit (UMU) of National Hospital of Sri Lanka for further assessment of central cyanosis and clubbing. He was a product of a non consanguineous marriage and had been \"healthy\" up to 13 years of age when he had developed petichiae and found to have thrombocytopenia. There was no organomegaly. His platelet counts were persistently low around 20,000/ɥl. A trephine bone marrow biopsy showed severe bone marrow hypoplasia with haematopoietic tissue accounting for less than 25% of marrow spaces. No abnormal cells were noted and it was concluded to be compatible with severe aplastic anaemia. All other routine blood tests including liver function tests, renal function tests, erythrocyte sedimentation rate and tests of coagulation were within normal limits. Ultrasound scan of the abdomen was also normal. A clinical diagnosis of FA was made and genetically confirmed by chromosomal studies. Three chromosomal cultures with a) no mitomycin C (MMC), b) 10 ng/ml of MMC, c) 50 ng/ml of MMC all demonstrated increased chromosome breaks in metaphase chromosomal spreads in the patient when compared with a control. He continued to be followed up at a regional tertiary care centre where the progressive clubbing and cyanosis were noted. A transthoracic echocardiogram (TTE) performed initially by a paediatric cardiologist revealed a structurally and functionally normal heart without any evidence of an intra-cardiac shunt. Increased interstitial shadowing was noted in bilateral lung fields in the chest roentgenogram and lung function tests revealed a severe restrictive pattern. The high resolution CT (HRCT) of the thorax failed to demonstrate any evidence of pulmonary fibrosis.\nUpon admission to UMU, in addition to central and peripheral cyanosis and grade 5 clubbing, the patient also had persistent desaturation with paltypnoea (breathlessness worsening on sitting up) and orthodeoxia (desaturation worsening with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man presented with colicky abdominal pain in the left lower quadrant for 2 weeks duration. He had a significant weight loss of approximately 30 kg over 2 months associated with decreased appetite. He also has a history of chronic alcoholism and smoking. There was no associated nausea, vomiting, hematemesis, melena, or hematochezia. Review of symptoms was negative for fever, arthritis, skin rash, jaundice, and pruritus. Two months prior, the patient was discharged from another hospital following a 6-week hospitalization for alcohol-induced necrotizing acute pancreatitis, which was treated successfully by conservative measures. Admission vitals revealed an afebrile and normotensive patient with a heart rate of 92 beats per minute and oxygen saturation of 98% on room air. On physical examination, the abdomen was soft with mild tenderness to deep palpation in the left iliac fossa and lumbar region. There were no signs of peritonitis. Laboratory results and abdominal sonogram showed no significant findings. Abdominal CT scan from the episode of acute pancreatitis 2 months ago showed findings consistent with necrotizing acute pancreatitis ().\nA colonoscopy was done because of the abdominal pain and significant weight loss. The scope revealed ulceration with a partial stricture at the descending colon approximately 30 cm from the anal verge (). However, the scope could not be navigated beyond the stricture. Controlled radial expansion balloon dilatation was tried without success in dilating the stricture.\nDue to tuberculosis (TB) being a possible differential diagnosis, a workup for TB was warranted. This included sputum for acid-fast bacillus, chest X-ray, purified protein derivative test, erythrocyte sedimentation rate, and pathological examination, all of which were negative for TB. Biopsy of the lesion revealed active focal colitis with ulceration, but no granulomas were seen. Barium enema and CT colonoscopy were done to assess the length of the stricture"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male patient with a medical history of long-standing hypertension, ischaemic heart disease, obesity, type 2 diabetes mellitus and rheumatoid arthritis was referred by his general practitioner to the hypertension clinic in May 2007, due to uncontrolled hypertension despite three antihypertensive agents at maximum tolerated doses (ramipril, felodipine and atenolol). His mean daytime blood pressure at the time of referral was 168/99 mmHg. He was thoroughly investigated for secondary causes of hypertension, but none were found. His antihypertensive medication regimen was progressively optimised over many years, taking into account intolerances, adverse effects and co-morbidities. His medications at the time of the addition of canagliflozin can be seen in .\nIn view of apparent resistance to treatment, the patient was admitted to hospital for directly observed therapy in June 2013 to exclude non-adherence. His adherence was also confirmed on two separate occasions in 2014 when urinary drug screening became routinely available. Renal denervation (radio-frequency ablation of the renal sympathetic nerves surrounding the renal arteries) was conducted in October 2013. This had no effect, and in fact his blood pressure in June 2014 was higher with a mean daytime blood pressure of 181/105 mmHg.\nThe patient was started on the sodium glucose co-transporter 2 inhibitor canagliflozin 100 mg in May 2015 in view of a high body mass index of 38 and suboptimal diabetes control (HbA1c of 103 mmol/mol). This was uptitrated to 300 mg daily. A significant reduction in the patient’s blood pressure occurred with the best clinic reading being 137/80 mmHg. The HbA1c also reduced significantly (see ), although this cannot be solely attributed to canagliflozin, as the doses of metformin and gliclazide were also uptitrated. The patient did not experience any unwanted effects although the creatinine measurement did increase over this time. In line with manufacturer recommendations, th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe are presenting the case of a 61-year-old African American female patient who was admitted to the intensive care unit with right-sided weakness, numbness, and slurred speech. Further workup revealed a left cortical and cerebellar hemisphere ischemic stroke. TEE was performed as part of stroke management, which was uneventful. Feeding and scheduled oral medicines were started via a Dobbhoff tube, and further stroke management was optimized. On the third hospital day, she developed acute respiratory distress, warranting endotracheal intubation. Chest radiograph revealed a near complete opacification of right hemithorax with slight mediastinal shift (). Preliminary diagnosis was aspiration pneumonia. Treatment with broad-spectrum antibiotics was started after cultures were obtained. Bronchoscopy showed copious, thick, and purulent secretions in the right middle and lower lobar area. However, quantitative culture of bronchoalveolar lavage showed no bacterial growth.\nThe pleural effusion persisted despite thoracentesis. Samples obtained were consistent with exudative effusion (low amylase, high lactate dehydrogenase, low glucose). A chest tube was inserted and drained a fair amount of purulent-appearing fluid. Overtime, her chest tube drainage slowed down but diminished-but-persistent effusion was still obvious in the chest X-ray. Due to notable clinical improvement in her pulmonary status, the patient was weaned off the mechanical ventilatory support and extubated after the 14th day of intubation. Per protocol, she was then referred to the speech therapist for a swallow assessment. A fluoroscopic dynamic swallow assessment showed a clear leaking from the esophagus. A chest computed tomography scan and esophagogram confirmed the leakage of contrast from distal esophagus (esophageal perforation) into the patient’s right chest cavity (). There was no evidence of mass lesion noted.\nThe patient underwent primary repair of the perforated esophagus with muscle flap construct"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Chinese woman was hospitalized on 28 December 2018 with a complaint of anal pressing pain and an anal mass. Anorectal physical examination showed no redness or ulcers in the perianal skin. Preoperative digital anal examination showed moderate anal tightness, a smooth rectum wall, and no swelling or mass. There were also no significant changes in the rectal wall when the mass was pulled. The perianal skin and lower rectal mucosa were smooth, and no ulcers, fistulas, or purulent secretion were found under anoscopy. The tumor was palpable 6 cm from the anal margin at a 7 o'clock direction, with a range of about 5 cm × 5 cm (). Perianal ultrasound suggested an inflammatory mass, with no significant relationship between the mass and the rectum (). The clinical diagnosis was a perianal mass for further examination. The decision was made to perform excision and biopsy. Under general anesthesia, the perianal area was prepped and draped in a sterile manner and the anal mass was identified. Local anesthesia with 25% macaine was injected into the skin around the mass, and an elliptical incision was made around the mass, about 0.5 cm from the edge of the mass. The subcutaneous tissue was taken down by electrocautery. During surgery, the tumor was found to be spreading subcutaneously, with unclear boundaries. It had a hard texture, no capsule, and no fluctuation (indicating a solid mass) and was sent for pathology. The skin was closed using interrupted subcuticular stitches and Monocryl.\nGross examination showed a gray-yellow mass measuring 4 cm × 3 cm × 3 cm (). Hematoxylin and eosin staining revealed nests of mononuclear cells with abundant eosinophilic granular cytoplasm, small central nucleoli, and a small number of vascular structures in the tumor tissues, with no hemorrhage or necrosis. Immunohistochemical examination showed notable and strong positivity for NSE, vimentin, and S-100."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe a case of a 36-year-old black African woman with two previous live births by cesarean section and two previous miscarriages who was referred in her fifth pregnancy after 6 weeks of amenorrhea. Her serum quantitative β-human chorionic gonadotropin (bHCG) was 16,124 mIU/ml. However, an intrauterine or extrauterine pregnancy could not be located on a transabdominal ultrasound scan.\nA copper intrauterine contraceptive device had been removed 2 months prior to her last menstrual period. She reported using one cycle of clomiphene 50 mg with the hope of achieving a twin pregnancy.\nShe had delivered twice by cesarean section for failure to progress. Her last two pregnancies had been first-trimester miscarriages; one was managed expectantly, and the other was surgically evacuated, though the actual procedure was unknown to the patient. She did not have any chronic medical illness and was not receiving any medication prior to this presentation. She stayed in a city suburb that was well serviced. She was a school principal in her second marriage with no children in the current relationship. She did not smoke or drink alcohol.\nOn examination, she had a normal blood pressure of 113/70 mmHg and a pulse rate of 98 beats/min. Her body temperature was 37.5 °C. On examination, her cardiorespiratory and neurological systems were normal. Her abdomen was soft and not tender. The result of her pelvic examination was normal. TVUS showed a gestational sac of 13 mm with irregular margins and a visible yolk sac located on the anterior isthmic portion of the uterus, raising suspicion of a cesarean section scar ectopic pregnancy. She declined a Doppler ultrasound evaluation scheduled for the next day. She was scheduled to have serial bHCG evaluations every 48 h.\nA repeat serum quantitative bHCG done 48 h after the initial test revealed a level of 21,521 mIU/ml, a 33% rise. She defaulted follow-up until 1"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old man who was diagnosed with LDH was referred to our hospital. He complained of radiating pain in the right lower limb for approximately 9 months. The pain radiated from the posterior aspect of the right thigh to the lateral aspect of the leg and right foot. The persistent and intense pain could be aggravated after hip flexion and slightly relieved after rest or hip overextension. The VAS score for pain was 7/10 at the first visit to the clinic, and the pain could wake the patient up from sleep during the night. Moreover, the pain was combined with numbness of the right lower limb. Physical examination revealed a decreased tingling sensation of the right dorsolateral foot and sole skin, grade 3/5 weakness of the quadriceps femoris, grade 2/5 weakness of the extensor hallucis longus and extensor digitorum longus and a positive straight leg raise test. The muscular tension, knee reflex and Achilles tendon reflex were normal, and he had a negative Babinski sign, Chaddock sign, Gordon sign and Oppenheim sign, and there was no tenderness in the lumbar spine. He had received conservative treatment, which included analgesic drugs, acupuncture treatment and local nerve blocks for approximately 6 months in Chengde Central Hospital. Thereafter, the symptoms were slightly alleviated (VAS = 6/10). The patient also underwent a lumbar MRI examination in Chengde Central Hospital that showed L4-5 intervertebral disc expansion. Although LDH was diagnosed in Chengde Central Hospital, the radiological imaging results were inconsistent with the symptoms and signs. To further explore the cause of the radiating pain in the lower limb radiation, the patient was transferred to our hospital and received a detailed physical examination. Fortunately, a soft tissue mass in the area where the sciatic nerve runs in the middle thigh was palpated. The tumour size was approximately 50 × 30 mm, the boundary was not clear, and there was a positive Tinel’"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old Thai male patient presented with progressive pain and swelling of seven-month duration over the antecubital fossa of the right elbow. Initially, there was only slight swelling. Three months later, he complained of dull pain. The patient went to a private clinic where the diagnosis was distal biceps tendinitis. The first doctor gave a local steroid injection, but the symptoms recurred about one month later. Four months later, the patient complained of pain at night and weakness on supination of the forearm and flexion of the elbow. He had no underlying disease, chest symptoms, fever, weight loss, or history of contact with patients suffering from pulmonary tuberculosis.\nPhysical examination of the right elbow when patient visited the hospital in Thailand demonstrated swelling at the antecubital fossa, mild tenderness at the distal biceps, and muscle weakness or pain when attempting to supinate the forearm and flex the elbow. All other systemic examinations were normal. There was a high white blood cell count (12,710 cells/mcL); neutrophil count was 72% and lymphocyte count 17%. Erythrocyte sedimentation rate was 17 mm/hr, and C-reactive protein was 6.69 mg/L. Radiography of the right elbow showed swelling at the antecubital fossa, and chest radiographs showed infiltration of the left upper lung. Magnetic resonance images showed disruption of the distal biceps tendon with an associated ill-defined soft tissue mass (about 2 × 2 cm). A less enhanced area was observed at the inferior part, which was likely to be necrotic or cystic. An abnormal marrow signal was detected at the proximal radius with focal cortical erosion at the radial tuberosity ().\nIn this case, we suspected that the patient had disseminated tuberculosis because preoperative chest radiographs demonstrated left upper lung infiltration, which was likely pulmonary tuberculosis, and there was a soft tissue mass at the distal biceps tendon. We performed an open excisional biopsy and debridement"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old Hispanic male with a known history of type 2 diabetes mellitus presented with 2 days history of acute epigastric abdominal pain with associated postprandial nausea and vomiting. His other medical conditions include hypertension, hyperlipidemia, diabetic neuropathy and seizure disorder. On examination, he was thin built with body mass index (BMI) of 20.1, and vital signs revealed mild tachycardia and hypotension. Remainder of the exam was unrevealing. Pertinent labs revealed creatinine of 1.4 mg/dl, hemoglobin 10.3 g/dl, albumin 1.5 g/dl, prealbumin 4.7 mg/dl and normal liver function tests. Patient had similar symptoms intermittently for the last 2 years. In the past, his symptoms were attributed to gastroparesis due to his long-standing diabetes mellitus. He had multiple CT scans of abdomen done during this period but most of them were without contrast. These scans were either normal or showed mild gastric distension at times which was thought to be secondary to gastroparesis. Of the several scans, he had one CT abdomen with IV contrast approximately one year prior to this presentation, this revealed mild gastric and proximal duodenal dilatation but there was no evidence of duodenal obstruction. He had an upper GI endoscopy recently and this revealed dilated stomach and duodenum along with pyloric and proximal duodenal circumferential ulceration and was treated with proton pump inhibitors. Due to his intermittent symptoms he had poor oral-intake and had a weight loss of about 15 lbs in the last few months (Figs –).\nPatient was admitted for possible gastroparesis exacerbation and peptic ulcer disease. He was treated with intravenous fluids and Pantoprazole. Supportive care with fluids normalized his renal functions but not his abdominal pain, hence CT abdomen with IV contrast was undertaken. This revealed dilatation of stomach and proximal duodenum and decompression of rest of the duodenum and small bowel. The aortomesenteric distance was measured at 3"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year old female patient presented to us with shortness of breath for the last 2 months. There was no history of fever, cough, chest pain, haemoptysis, abdominal pain, vomiting or bleeding per vaginum. There was no lymphadenopathy, clubbing, or pedal edema, but pallor was present. Air entry was decreased bilaterally in the inframammary and infrascapular regions. The cardiovascular system and gastrointestinal system were normal.\nThe laboratory value for hemoglobin (Hb) was 8.0 g/dL. The complete blood cell count (CBC), blood sugar, renal function test and liver function test were all found to be within normal ranges. A posterior to anterior (PA) view chest X-ray () was done which showed homogenous opacity in the bilateral lower lung field along with blunting of both costophrenic angles (CPA) suggestive of bilateral pleural effusion.\nA cytologic examination of pleural fluid revealed adenocarcinoma cells (). A contrast-enhanced computed tomography (CECT) scan of the thorax was done which revealed only bilateral pleural effusion with absence of any mass lesion or any mediastinal lymphadenopathy (). An ultrasound of the abdomen and pelvis showed only ascites; no other abnormality or mass lesion was detected. A cytologic examination of ascitic fluid also revealed adenocarcinoma cells ().\nA CECT scan of the abdomen and pelvis revealed heterogeneous thickening of omentum with nodular appearance and fatty streakiness into the adjacent soft tissues extending up to the anterior abdominal wall and adjacent bowel loops, including transverse and descending colon, suggestive of omental caking with small amount of ascites. The ovaries appeared normal and no other mass lesion was detected ().\nA gynecological examination did not reveal any abnormality. An upper gastrointestinal endoscopy and colonoscopy did not show any abnormal lesion. A breast examination was normal. Examinations of the oral cavity and indirect laryngoscopy were also normal. A laparoscopic examination of the ab"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old female was found to have an incidental FDG-avid right thyroid lesion following staging PET for colorectal carcinoma. She was asymptomatic from the thyroid lesion and biochemically euthyroid. There was no personal or family history of thyroid disease and no prior history of radiation exposure to the head and neck region. CT scan of the neck confirmed a 40mm thyroid nodule, and ultrasound guided fine needle aspiration of this nodule was suggestive of a follicular neoplasm.\nA right hemithyroidectomy was performed. The gross specimen weighed 67 grams and the cut surface revealed a round solid well-circumscribe tan nodule, with scant compressed residual thyroid parenchyma at the superior pole. The entire specimen was submitted for examination. Sections showed the nodule to be entirely encapsulated by a thick fibrous band without capsular or vascular invasion. The tumour showed predominantly areas in keeping with usual follicular adenoma formed by microfollicles with scant colloid and lined by cells with bland round to ovoid nuclei ().\nPresent centrally and entirely within the encapsulated and conventional adenoma was an 11 mm focus showing distinct insular growth pattern with atypical cell morphology. The cells contained round to ovoid nuclei with irregular nuclear membranes, small nucleoli, and high nuclear to cytoplasmic ratio. The mitotic count was very high (8/10 high power fields), although tumour necrosis was absent, meeting criteria for PDTC (). In addition there were several regions, one of which was adjacent to the PDTC-like area, showing formation of trabeculae and high nuclear cytoplasmic ratio, without sufficient nuclear morphology or mitotic count for PDTC criteria ().\nThe PDTC-like focus and adjacent trabeculae region did show noticeably higher proliferation rate by MIB1 immunohistochemical (IHC) staining (). IHC staining showed retained expression of TTF1 (), with loss of thyroglobulin (which was retained in background follicular adenoma comp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old woman presented with vomiting and abdominal pain and had no previous medical history. The patient began experiencing abdominal distension 3 months prior, with intermittent abdominal pain and nausea developing after the first month. As symptoms persisted, the patient consulted the nearby clinic and underwent upper and lower gastrointestinal endoscopy and abdominal CT scan. Findings suggested ileal intussusception, and the patient was referred to our department for detailed examination.\nThe abdomen was flat and soft, and did not show tenderness or rebound tenderness. There were no palpable abdominal masses or Dance signs.\nAbdominal contrast CT scan showed edematous thickening of the distal ileum (), and we observed intussusception developing from a tumor lesion, with fat in the same site (). Mild dilation was observed in the upper gastrointestinal tract, and there were no obvious regions of poor contrast. Based on these findings, the patient was diagnosed with intussusception of the ileum. As there were no findings suggesting gastrointestinal obstruction or impeded blood flow in the intestinal tract, the patient was scheduled for naval single-incision laparoscopically-assisted partial ileectomy.\nLaparoscopy was performed by making a vertical incision measuring 3 cm in the navel. A wound retractor was inserted, and we laparoscopically observed the peritoneum via the suspension method until we located the lesion. The intestinal tract was brought out through the incision, and a mass was palpable in the lumen about 50 cm from the end of the ileum. An inversion in the opposite side of the upper gastrointestinal mesentery was thought to be the base of the mass, and we removed approximately 8 cm of the ileum, including this section ().\nExamination of the mass showed protruding, raised lesions from the opposite side of the ileal intestinal mesentery to the intestinal lumen, which was considered to be an MD inversion. Furthermore, despite observing erosion at the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male patient with compression and dislocation of the inferior vena cava (IVC) by a giant hepatic haemangioma was referred to our surgical department after two episodes of pulmonary thromboembolism. The second episode occurred while the patient was on oral anticoagulant therapy. Based on abdominal and thoracic CT scan, the patient was diagnosed to have a giant cavernous hepatic haemangioma, arising from the caudate lobe. The tumour was surrounding the inferior vena cava (IVC) and occupying segment I, III, IV, V, and in part segment VIII. A CT scan showed compression of the retrohepatic IVC () with thrombosis of the left and middle suprahepatic veins. On the basis of CT-scan imaging, hepatic malignancy such as haemangiosarcoma could not be ruled out () [].\nIn order to prevent the risk of further episode of pulmonary embolism, a liver resection was considered. At laparotomy the exploration of the abdomen confirmed the presence of a huge smooth mass, violaceous in colour, occupying the left and the central segments of the liver surrounding and compressing the IVC. An extended left hepatectomy was planned. During the mobilization of the liver, a laceration of the IVC at the junction of right and the middle suprahepatic veins caused an important bleeding which was difficult to control. After Pringle's manoeuvre a running suture by a 3-0 prolene was carried out. The bleeding was controlled only in part. Soon thereafter a worsening of the venous hepatic outflow was evident as suggested by darkening of the whole liver surface. The mass became diffusely hemorrhagic and despite of hilar clamping the bleeding became soon uncontrollable. We decided to proceed to total hepatectomy and to evaluate the feasibility of ex vivo bench liver surgery. The suprahepatic and infra-hepatic IVC were cross-clamped. The hilar structures were quickly double ligated and resected. A heparinless veno-venous bypass (VVBP) was inserted from the right femoral vein and from the portal vei"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old man presented with macroscopic hematuria, urinary frequency, and accidental leakage of urine. His past medical history only included benign prostatic hyperplasia. Initial assessment by fibroscopy showed a unique tumor developed on the anterior wall of the bladder. The patient underwent transurethral resection of the bladder tumor. Pathological analysis reported high-grade muscle-invasive urothelial carcinoma of the bladder (pT2 stage). The uro-computed tomography (CT) scan did not show any abnormality regarding the upper urinary tract. Metastatic workup with thoracic and abdomino-pelvic CT scan showed clinically localized bladder cancer. The patient was then referred to our department to undergo a curative intent surgery according to the multidisciplinary committee recommendations. Bilateral extended pelvic lymphadenectomy with radical cystoprostatectomy and ileal neobladder reconstruction were performed. Definitive pathological analysis rendered pT2N0M0 high-grade urothelial carcinoma (TNM 2009) with free surgical borders, associated with prostatic adenocarcinoma Gleason score 7 (3 + 4), grade 4 involving 20 % of both prostatic lobes. A total of 15 days after surgery, the patient developed penile pain. Physical examination showed painful induration located on the right corpus cavernosum of the penis. PET/CT imaging showed a high focal intense uptake of 18F-FDG in the right corpus cavernosum of the penis (Fig. ). The report concluded that there was a high suspicion of metastatic spread to the penis. Complementary penile magnetic resonance imaging (MRI) associated with simultaneous fine needle biopsy were realized. Penile MRI showed low to intermediate signal intensity as compared with the surrounding corpus cavernosum on an axial T2-weighted image (Fig. ). Histopathological examination from the right corpus cavernosum biopsy revealed carcinomatous tumor emboli from the urothelial carcinoma of the bladder (Fig. ). The patient was referred to the medical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old woman with no remarkable family history was admitted to our hospital with the following medical history: after undergoing modified radical mastectomy for cancer of the right breast (papillotubular carcinoma, T3N1M0) in March 2009 at another hospital, the patient received postoperative chemotherapy (4 courses of docetaxel+trastuzumab followed by 14 courses of trastuzumab). However, in March 2011, local excision was performed because of a recurrence that appeared at the site of the surgery, and adjuvant chemotherapy was administered. No relapses were observed thereafter.\nWhen the patient was admitted to our hospital, the patient was of moderate build, was well nourished, had no yellowing of the bulbar conjunctiva, had no conjunctival pallor, and displayed no unusual finding in the heart or lungs. The abdomen was flat; the liver and spleen were not palpable. No remarkable finding was observed. An elastic, hard tumor approximately 20 mm in diameter with relatively distinct boundaries was felt in the left C region. The tumor was observed to be not fixed to the pectoral muscle, and it had not infiltrated the skin. No abnormal nipple discharge was observed, and axillary lymph nodes were not palpable. Peripheral blood and blood biochemistry test results were normal.\nBy mammographic examination, a high-density tumor with irregular margins and internal calcification was observed and was classified in Category 4. Because the imaging system at our institution has been changed and all previous imaging data were deleted, there are no mammograms to display here. Ultrasonographic analysis revealed that a 10 × 11 × 9 mm hypoechoic area was observed in the C region of the left breast. The lesion had a Tsukuba elasticity score of 2 and internal blood flow, and malignancy was suspected (Fig. ). By positron emission tomography and X-ray computed tomography (PET-CT), an area of greatly increased uptake was observed in the upper outer quadrant of the left breast (SUV max: 8."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient C was also a 10-year-old girl, who was otherwise healthy other than exhibiting poor growth. At baseline, she was involved in gymnastics; however, this changed when she started to experience right hip pain. This pain persisted at all times of day and was partially relieved by ibuprofen. It was never in the left hip or knees, but she reported some discomfort in her ankles. She had no fevers but developed a transient pustular rash on her palms and soles.\nAs the pain became increasingly disabling, she developed a limp. She was referred to orthopedics, who prescribed crutches and obtained a hip MRI. This showed a lesion in the right medial proximal femur (). A bone scan was then performed to look for additional lesions, but none were found. Biopsy of the lesion was consistent with osteomyelitis but was undifferentiated between an infectious vs. inflammatory cause. The patient was thus referred to both infectious disease and rheumatology.\nInfectious disease specialists suggested that the patient's presentation was more consistent with CRMO than bacterial osteomyelitis, given the chronicity and negative culture on biopsy. Our rheumatology team came to the same conclusion (1-year after symptom onset). When we saw the patient, she was tired and pale appearing, with thinning hair. Her BMI percentile was 1%. Musculoskeletal examination was notable for tenderness in the sacroiliac region and right femur, as well as reduced range of motion of her ankles. There were no skin lesions at the time of our exam. WBMRI showed lesions in her proximal right humerus, proximal right femur, bilateral proximal tibias, and bilateral distal femurs. She was treated with indomethacin and has since clinically improved.\nGiven her history of poor growth, a fecal calprotectin was performed to screen for IBD and was positive. This led to a colonoscopy, which showed granulomas throughout her intestinal tract (Chronic Granulomatous Disease was evaluated and excluded). She was given"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old, previously healthy male was admitted to the hospital with altered mental status of one day duration. The patient was confused and was not answering questions appropriately. Vital signs were remarkable for low-grade fever of 100.7 ºF and tachycardia. His physical exam was remarkable for a holosystolic murmur at the apex, radiating to the axilla. He was alert and oriented to self, but not to place or time. Cranial nerves were grossly intact with no focal neurological deficits. Laboratory evaluation revealed leukocytosis and mild hyponatremia. A computed tomography scan of the head did not show any acute intracranial hemorrhage. A lumbar puncture was performed and cerebrospinal fluid analysis did not suggest meningitis; however, the patient was started empirically on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. Magnetic resonance imaging of the brain showed large area of infarction in the left frontal, left parietal, and left caudate body, suggestive of a cardio-embolic source (Figure ). An echocardiogram revealed a large, mobile, vegetation (1.5 x 1.5 cm) on the mitral valve likely affecting the anterior and posterior leaflets with mild to moderate mitral regurgitation (Figures -). Blood cultures were sent to the lab, which later grew Streptococcus agalactiae. An infectious disease team was consulted and antibiotics were switched to penicillin G and gentamicin.\nA cardiothoracic surgery team was consulted and he was not deemed a surgical candidate as it was thought it would be unlikely that the patient will have a meaningful recovery, and the risks outweighed the benefits of surgery. The patient’s mental status remained the same; he remained alert and oriented to self only despite several days of antibiotics. His repeat blood cultures remained negative.\nIn the third week of his hospitalization, the patient experienced worsening of his altered mental status and he was not responding to questions. An MRI of the brain showed hemorrhagi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old male patient with no relevant medical history presented with left hemiparesis for one hour. He had minor left facial paralysis and dysarthria, severe hemiparesia pointing 9 on the National Institutes of Health Stroke Scale. Brain tomography and angiotomography were performed; no brain lesion, arterial stenosis, or occlusion on cerebral circulation was visible. With clinical history, physical exam and image were compatible with stroke with significant deficits, intravenous thrombolysis was performed. The following day, MRI showed diffusion-weighted increased signal on the right pontine side as expected to a stroke (Figure ). A transesophageal echocardiogram was normal. Initial investigation for rheumatologic and hematologic was normal. The patient had a moderate continuous recovery. Five days after admission, he was discharged to ambulatory care follow-up and was prescribed statins and aspirin. At discharge, neurologic examination revealed left-sided hemiparesis and mild dysarthria.\nTwo weeks after the initial stroke, the patient returned to the ED due to worsening left hemiparesis and dysarthria. MRI showed an expansion of the area of diffusion-weighted increased signal on the right pontine side (Figure ); the patient was managed as a stroke expansion. No indications of infection or hypotension were noted. However, the patient developed right central facial paresis and anarthria 12 hours after admission. A more comprehensive evaluation was performed with brain contrast MRI due to the new symptoms and longer time frame between the first stroke and stroke expansion than expected. The new brain MRI revealed a left pontine infarction (Figure ) with the characteristic “heart appearance” sign. We performed an extensive search for stroke etiology with negative results: arteriography and lumbar puncture were normal and there was no evidence of thrombophilias. After the initial worsening, the patient stabilized and had a stable recovery. He was discharged one m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old Caucasian girl with JIA diagnosed at 2 years of age returned to our pediatric rheumatology clinic with complaints of increased morning stiffness of both knees and a mass of the left knee. Three weeks prior to the onset of knee stiffness, she noticed a mass on the lateral side of her left knee. She had decreased knee flexion and pain with walking that was greater on her left side. She reported a painful snap when she moved her left knee from a flexed to extended position, but no instability or locking. There was no warmth, erythema, interval growth, or fluctuance of the mass. She also did not have any systemic symptoms including fever, chills, or recent weight loss.\nHer past medical history was significant for extended oligoarticular JIA with 5 joint involvement and a positive Anti-nuclear antibody (ANA at 1:80), HLA-B27 negative, and rheumatoid factor (RF) negative. Over the first two years of her illness, she required only NSAIDs until she developed a photosensitive rash with Naproxen. Over the next 6 years, she needed methotrexate and ibuprofen intermittently for flare ups and was maintained on these medications for 1 to 2 year intervals and then tapered off. She had been disease free for three years when she presented with this new knee mass. She had a brief episode of mild iritis earlier in the course of her disease with full resolution while on methotrexate. Our patient lived on a neighboring island far from pediatric rheumatology services. When we were informed about the patient’s knee mass, we were extremely concerned because of her strong family history of cancer and her earlier treatment with methotrexate. Her family had a range of cancers including liver, pancreatic, stomach, throat, lymphoma, melanoma, non-Hodgkin's lymphoma, and glioblastoma in different members of the family.\nOn examination, there was a 1.5 × 2.0 cm well-circumscribed, and non-tender mass."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2.6 kg, 2-day-old female child, delivered by cesarean section, was brought to us with malformed external genitalia and a swelling over the lower part of the abdomen and the perineum.\nPhysical examination revealed a lobulated bowel projection with a skin-covered swelling extending over the lower part of the abdomen and the perineum. The umbilicus was low set, situated just above the upper extent of the swelling. The pubic symphysis was widely separated with a bulging urinary bladder occupying the space in between. The introitus was replaced by the swelling which was continuing on to the lower abdomen. There was duplication of the introitus with two openings, each flanked by the single labia majora located laterally, in the groin area []. The clitoris was bifid. The two orifices on either side were in communication with each other as a catheter introduced from one orifice exited through the other. The urethral orifice could not be seen from the outside; however, both the introitus openings were discharging urine intermittently. The anal opening was absent. An infantogram and cross-prone-lateral X-ray showed a high type of anorectal malformation and the absence of calcification in the area of accessory bowel loop.\nThe baby was resuscitated and undertaken for surgery. A midline laparotomy showed that the small bowel and large bowel were normal and in continuity. The internal genitalia were female type and the uterus was unicornuate with normal fallopian tubes and the ovaries. The urinary bladder was intact although subcutaneous in location. The accessory bowel loop was attached to the lower part of the swelling and the lumen was in continuity with lumen of the terminal part of the rectum. The extra piece of the bowel was excised and the terminal part of rectum fashioned as a neoanus []. A suprapubic cystostomy (SPC) was also inserted as the anatomy of the bladder neck and urethra was still not clear."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-year-old female child was brought to the Pediatric Dentistry Clinic of the School of Dentistry of the Federal University of Rio Grande do Sul (UFRGS), Brazil, for esthetic rehabilitation of anterior teeth. The patient's general health status and past medical history were satisfactory. The mother reported that the primary incisors were darkened and nonuniform, and that the girl would start in the school next year and this clinic situation could disturb her.\nAll posterior teeth had active cavitated carious lesions and/or extensive restorations showing a past history of ECC. In the anterior region, teeth 52, 51, 61, and 62 had extensive restorations associated with carious lesions. All canines have active not cavitated carious lesions and the lower incisors (72, 71, 81, and 82) were healthy (). In the radiographic examination, none of the posterior teeth presented pulpal involvement. Teeth 51 and 61 presented irreversible pulpal involvement with an extensive root resorption and considerable bone loss around them, associated with draining sinus, and tooth extraction was indicated.\nThe treatment plan was settled and explained to the mother, who signed an approved informed consent form authorizing the treatment as well as disclosure and publishing of this case report. Initial dental care consisted of removal of hopeless teeth (51 and 61) and intervention in etiologic factors of caries disease as plaque control, diet, and rational use of fluoride.\nAll posterior restorative treatments were conducted undergoing the selective caries removal technique and a composite resin was used for the restoration. In the anterior region, teeth 52 and 62 had unsatisfactory restorations and 52 have a dentin lesion in the palatal surface, presenting them dark and not aesthetic. A fixed functional space maintainer replacing both teeth 51 and 61 was planed, and direct composite resin veneers in 52 and 62 were placed.\nTeeth 52 and 62 were worn on the vestibular surface to remove old restora"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male with a 20-year history of schizophrenia presented to the emergency department with long history of pharyngeal foreign body sensation which had progressed over one month to include sore throat, odynophagia, and dyspnea. Physical exam revealed asymmetric prominence of the right posterior oropharyngeal wall and trismus with maximal interincisural distance of two centimeters. There were tenderness, edema, and erythema of the right submandibular triangle without palpable mass.\nFlexible laryngoscopy showed fullness of the right posterior pharyngeal wall without mucosal abnormality, resulting in anterior displacement of the right aryepiglottic fold. This was encroaching on the airway but not causing critical airway stenosis. A computed tomography (CT) scan of the neck with contrast was obtained. This demonstrated a linear opacity extending from the oropharynx to the right thyroid ala. Reconstructed 3D images showed a uniform mass consistent with a foreign body (). Further psychiatric history was obtained and revealed a history of auditory hallucinations that had on several occasions led to suicide attempts, including one attempt two years ago in which the patient stabbed himself in the pharynx with a broken toothbrush handle. Prompt removal was recommended given risk for infection and airway compromise.\nThe patient was transorally intubated over a flexible bronchoscope and then underwent direct laryngoscopy. Swelling of the right posterior oropharynx and hypopharynx was noted (). An anterolateral neck incision was made and subplatysmal flaps were raised. The mass was easily palpated overlying the right thyroid ala, and blunt dissection allowed entry into the fibrous capsule surrounding the foreign body (). The capsule was opened, and the foreign body was removed. The length corresponded exactly to the length of the foreign body on the CT (). A sample was obtained for bacterial culture, the wound was irrigated, and a drain was placed. The patient was extu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old Caucasian gentleman was admitted with acute kidney injury discovered on blood tests. He was known to have high-grade prostate intraepithelial neoplasia and atypical small acinar proliferation from prostate biopsies performed for a raised prostate-specific antigen (PSA), with a bone scan negative for potential metastases and was on PSA surveillance with the latest reading of 43 pre-admission. Prior to admission, he had lower urinary tract symptoms in the form of frequency, nocturia, intermittent urinary stream, terminal dribbling and a feeling of incomplete emptying. There was no significant past medical history. On examination, he was haemodynamically stable and afebrile. There was a palpable non-tender bladder with dullness to percussion and no renal angle tenderness.\nBlood tests revealed a Stage 3 acute kidney injury (baseline renal function was normal) with raised inflammatory markers and elevated PSA compared with baseline (Table ). A mid-stream urine specimen sent for microscopy, cultures and sensitivities yielded no growth of organisms. A bedside bladder scan revealed a bladder volume of >999 ml, necessitating the insertion of a urethral catheter with a residual volume of 2.4 l, and intravenous antibiotics were commenced. An ultrasound scan (USS) of the urinary tract was performed to evaluate for the presence of hydronephrosis; but while this demonstrated a minor dilatation of the left renal pelvis, it also found a shallow fluid collection around the left kidney extending into the left lateral retroperitoneum, separate from the left psoas muscle (Fig. ). In the urinary bladder, there was an irregular 4 cm mass on the left posterolateral aspect. In view of the findings, an urgent flexible cystoscopy was performed, revealing a massive median lobe of the prostate protruding up and back into the bladder; the ureteric orifices were not visualized because of this, and the bladder mucosa was normal. The patient subsequently underwent a computed tomograp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient, a 58-year-old Caucasian male, presented to the emergency department with the acute onset of quadriplegia extending from C5 throughout the rest of the pan neuroaxis while awakening from bed the morning of presentation. Upon initial physical examination there were no signs of trauma noted that were significant to the presenting symptoms, additionally, patchy sensation was noted in the upper and lower extremities with clonus in the legs only and hyperreflexia in both arms and legs. Initially, our patient was administered one intravenous dose of methylprednisolone and allowed to enter a state of permissive hypertension which improved our patient's arm strength bilaterally to 2/5, but had no positive effects on the lower extremity paraplegia. As a result of minimal improvement, immediate imaging of the cervical spine was ordered and highlighted a severe cervical stenosis from C3 to C7, as seen in Figure , due to extra-axial posterior compressive spinal mass with cord signal change.\nAdditional imaging of the brain was completed as a precautionary measure and was normal. Upon obtaining full patient history and medical records from nearby hospitals, it was found that our patient was on a prolonged regimen of warfarin for many years due to a prior diagnosis of congestive heart failure without regulation and regular INR/prothrombin evaluation. Our patient also did not follow up with his primary care physician throughout the duration of the warfarin regimen. At presentation, our patient's INR was found to be 5.0 necessitating the prompt correction with intravenous injection of fresh frozen plasma (FFP) and vitamin K. Additional magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed large compressive acute epidural hematoma posteriorly compressing the thoracic spinal cord from T6 to T10, visualized in Figure , with cord signal change, as well as L4-S1 posterior acute epidural hematoma compressive of the cauda equine, visualized in Figure .\nUpon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old lady presented to the emergency department following a fall and sustained isolated capitellar fracture (). On CT scan, this was found to be Type III capitellar fracture according to Bryan and Morrey’s classification (). She was taken to theater on a routine trauma list and an attempt was made to fix the fracture fragment but in view of severe communition and osteoporosis, it was not possible to fix the fracture and hence the fragment was excised (). She was found to have mild valgus instability on table. The elbow was immobilized for few weeks in back slab and then the patient was referred to physiotherapy. She achieved range of motion of 30–90 degrees in elbow joint with full supination and pronation.\nHer repeat radiograph at 4 months showed slight subluxation of the elbow toward radial side with some incongruency in humeroulnar joint. She continued to have pain in her elbow, especially on loading and also features of lateral instability. Radiocapitellar resurfacing option was thought of, but in view of very poor bone stock and subluxation, it was felt that this would not be suitable option for her. Other treatment options were discussed in the form of tendon interposition arthroplasty, total elbow replacement, and allograft reconstruction. All options were discussed with her and having understood the pros and cons of each procedure, she opted for capitellar reconstruction using allograft. The configuration of defect was replicated with the help of 3D printing prepared from her latest CT scans.\nThe freeze-dried humerus allograft was used for surgery. After GA, the patient was positioned supine on table and sterile tourniquet was used. Kocher incision was used and common extensor origin was identified and soft tissue was freed anteriorly and posteriorly to expose the lateral condyle and the size of defect was assessed. Soft tissue and synovium were removed with curette. Defect was measured with the help of ruler and guide wire and was found"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old woman was referred to our outpatient department. She complained of lower left abdominal pain without radiating to other parts of the body, which had occurred for the previous 2 months. She did not complain of any urinary or bowel symptoms such as urinary frequency, urgency, dysuria, or incontinence. She denied any significantly surgical or medical history. Bimanual pelvic examination detected a well circumscribed firm and slightly movable spherical lesion located in the left of the vaginal wall. Urinalysis was within normal limits. Ultrasonography (US) revealed a relatively irregular and heterogeneous mass in the left posterior wall of the bladder. Contrast-enhanced computed tomography (CT) scan demonstrated a 3.2 × 2.5 cm soft, mild enhancement mass near the left posterior wall of the bladder, protruding into the bladder locally (). The cystoscopy found a hemispherical mass located in the left wall of the bladder close to the internal urethral orifice with intact urothelium, indicating that the mass was either external to the bladder or arising from it. The subsequent transurethral resection deep biopsy was normal. Based on clinical evaluation and all complementary findings, an equivocal diagnosis of pelvic mass could only be obtained. The tumor was resected transvaginally for diagnosis and treatment. The operative procedures were as follows: first, bilateral ureteral stent implantation was performed with cystoscope in order to protect the ureters; second, we separated the tumor through the vagina part and partly incised the bladder neck. We found that the mass was intramural of the bladder neck. Finally, we probed and removed the tumor completely without cutting through the whole bladder. The whole process was within simultaneously cystoscopic control. The resected mass had smooth surface and its measured diameter was proximately 3 cm. The cut surface of the tumor showed white laminated periphery. To avoid the possible postoperative complications of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year old girl presented with a history of left-sided submandibular swelling of 1-week duration. There was no reported fever, loss of weight or appetite, or any other generalized symptoms. There was no throat pain or difficulty in swallowing. She was started on broad-spectrum antibiotic treatment with no improvement, and the swelling increased in size. Computed tomography (CT) scan was done outside our institution and showed a large cystic mass lesion in the submandibular area. She had an open drainage procedure as an outpatient on the assumption of an abscess. The family was told that the drainage was successful and no further information was given to the family regarding microbial culture results.\nShe then presented to our outpatient clinic for further investigation since the mass did not change in size. On examination, she had a large submandibular mass measuring 5 cm × 5 cm which was slightly tender on palpation; she had no evidence of fever or tachycardia.\nExamination of the throat revealed normal tonsils and no lesions could be found in the oral cavity. No abnormalities could be found in the nasopharynx or hypopharyngeal area.\nLaboratory examination showed leukocytosis with a white blood cell count of 24,000 with 70% neutrophils, 20% lymphocytes, and 7% monocytes. The C-reactive protein was mildly elevated at 83 mg/L. Levels of serum lactate dehydrogenase and uric acid were normal.\nNeck ultrasound and CT scan [] showed a necrotic mass lesion in the left submandibular region, measuring 5.6 cm × 5.2 cm × 5.2 cm, suggestive of an abscess with associated adjacent reactive appearing lymph nodes.\nThe patient was admitted and was started on intravenous clindamycin and oral augmentin and dexamethasone. The next day, she underwent an open drainage on the assumption of an organizing abscess. During the procedure and on opening the mass, we found an inflamed firm tissue surrounding the wall of a cystic cavity which was attached to the submandibular gland. The salivar"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male presented with complaint of mild grade, intermittent fever without chills and rigor and diurnal variation for last 2 months along with occasional dull aching pain in left hypochondriac region. Ultrasonography revealed multiple abscesses in spleen. He was managed on antibiotics for 21 days but fever continued. Computed tomographic (CT) scan of abdomen showed multiple abscesses in spleen without any other significant findings in abdominal organs. Around 200 ml of pus was aspirated under guidance, which was negative for bacteriological examination. He was kept on parenteral antibiotics but did not have any relief.\nColor Doppler of heart excluded any possibility of infective endocarditis. X-ray chest was normal. Montoux test was positive up to 11 × 11 mm and he was put on antitubercular treatment to which he did not respond in 6 weeks. Surgical consultation was done and it was decided to proceed with splenectomy.\nAt laparotomy, there were dense adhesions between the spleen and the adjacent structures and the diaphragm. The patient went into shock after 2 hours of surgery and was resuscitated and taken back to operation theatre for reexploration. Exploration revealed generalized ooze from the area and hemostasis was achieved but again after 2 hours, the patient went into shock and was reexplored again but the patient succumbed to the continued hemorrhage.\nGross specimen measured 18 × 12 × 6 cm and cut surface showed multiple lobulated, solid, well-circumscribed nodules of variable sizes 1 cm to 7 cm diameter with areas of hemorrhage and cystic degeneration replacing most of splenic parenchyma (Figure ). The microscopic examination on Hematoxylin & Eosin stain showed dilated, sinuous vascular channels surrounded by oval to spindle tumor cells having scanty cytoplasm and hyperchromatic nuclei, mitotic figures were occasional (Figure ). There were areas of hemorrhage and cystic degeneration. The Reticulin stain showed intricate reticulum laid down around"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old woman was diagnosed with cancer in the right breast during health screening. Magnetic resonance imaging (MRI) showed a 70 × 40 × 36-mm non-mass-like enhancement from the exterior of the right breast to the nipple region. Ductal carcinoma in situ (DCIS) was diagnosed on core needle biopsy; thus, mastectomy was considered necessary. As the patient desired to undergo immediate breast reconstruction, she was referred to our department. She underwent nipple-sparing mastectomy (NSM), sentinel node biopsy (SNB) performed by a breast surgeon and breast reconstruction with a de-epithelialized DIEP flap using thoracodorsal vessels as recipient vessels performed by a plastic surgeon (). The cancer was pathologically diagnosed as DCIS. Postoperative hormone therapy was continued at a nearby medical facility. At an outpatient visit three years and eight months after surgery, a tumor measuring 5 mm was detected by palpation at the lower right region of the right breast and a tumor shadow was identified on ultrasound. Fine-needle aspiration cytology indicated the possibility of C4 local recurrence. Thus, we performed enucleation of the lesion, and a subsequent pathological examination confirmed that the tumor was invasive ductal carcinoma (IDC) with the ductal spread. In addition to the enucleated tumor, a contrast-enhanced lesion extended from the upper exterior area to just below the nipple on MRI. The patient was diagnosed with multiple cancer recurrences in the reconstructed breast. As the patient desired to undergo autologous breast reconstruction again, extensive extirpation of the nipple-areola, breast skin including the buried DIEP flap and initial breast reconstruction with an anatomical tissue expander (TE) were performed at another hospital (). We did not give an irradiation to the breast in this case because surgical margins were free from cancer by the intensive pathological examination with 5-mm serial sectioning on the surgical specimen. At one year an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old Japanese woman presented to our hospital with complaints of recurrent fever and subcutaneous abscess on her left upper limb. She had been previously healthy and worked as a nurse in a general hospital. She had a history of multiple subcutaneous abscesses in a year, all occurring after surgeries of the shoulder and forearms performed for bone fracture and impingement syndrome. For 3 months before admission she had repeated episodes of subcutaneous abscess on her left forearm, which was the site of blood collection and arterial line puncture. Cefazolin, cefotiam, piperacillin, sulbactam/ampicillin, clindamycin, ceftazidime, gentamicin, and meropenem were sequentially administered, but the problem was not resolved. The cellulitis worsened in spite of these antibiotic treatments, and finally she developed bacteremia. Incision and drainage of her left upper limb was conducted 1 week before admission, and she was referred and admitted to our hospital for further investigation and treatment.\nShe did not have underlying diseases or any family members with psychiatric disorders, autoimmune diseases, or malignancies. Her social history revealed no trouble with her surroundings, including her workplace. Her physical characteristics on admission were as follows: height, 155 cm; weight, 45 kg; body temperature, 37.4 °C; blood pressure, 122/76 mmHg; heart rate, 70 beats/minute and regular; and respiratory rate, 15/minute. A physical examination on admission did not reveal any focus of infection other than her left forearm. The skin of her left upper extremity had been incised at two points. Redness, swelling, and induration of the skin by cellulitis were seen around the incision (Fig. ). Laboratory data suggested systemic inflammation and mild liver dysfunction (Table ).\nOn admission, we considered the possibility of immunodeficiency, but there were no abnormalities of her immune system, such as changes in the number of lymphocytes and neutrophils, neutrophil phagoc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old caucasian girl is followed at our Department of Pediatrics for type 1 diabetes mellitus since the age of three years with poor glycemic control despite regular insulin therapy. She occurred with a 7-day history of dental pain, facial swelling (extending superiorly from the supraorbital margin and inferiorly to the angle of the mouth), and ecchymosis in the left periorbital region with decreased visual acuity and colour vision, unresponsive to antibiotic therapy with amoxicillin. Physical examination showed left-sided facial numbness, lagophthalmos with inability to complete closure of the left eyelid and tongue deviation to the left. Intraorally there were carious lesions and low sensitivity of the upper teeth. Biochemical investigations revealed neutrophilia and increasing of inflammatory markers. The electromyography showed a severe VII nerve damage. Radiographic examination showed haziness of left maxillary sinus with erosion of lateral sinus wall. Magnetic resonance imaging of her head revealed a marked mucosal thickening of the left maxillary sinus extended to the sphenoid, ethmoid and frontal sinus with moderate inflammatory effusion (Figure ). For three times inflammatory tissue was excised from the sinuses through an Endoscopic Sinus Surgery for microbial eradication and histopathologic examination. The tissue biopsy showed fragments of mucosa lined by respiratory epithelium with chronic aspecific inflammatory infiltrate and growed fungal species belonging to the Zygomycetes. After a 20-day treatment with imipenem, teicoplanin, metronidazole and aciclovir, she was given intravenous amphotericin B to which posaconazole (POS) was immediately replaced, due to the onset of side effects such as hyperglycemia, marked hypothermia and profuse sweating. The follow-up magnetic resonance images showed progression of the disease with significant intracranial extension. The magnetic resonance angiography showed the involvement of the neurovascular retromand"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year old female presented with complaints of on and off episodes of pain in the right upper quadrant of abdomen since 4 months. It was associated with significant loss of weight and generalized weakness since one month. Clinical examination was unremarkable except for hypertension. Her baseline blood investigations were within normal limits. Ultrasonography of her abdomen suggested enlarged right adrenal gland measuring 4.9×3.3 cm. No obvious calcification was noted. Her urinary vanillyl mandelic acid levels and plasma steroid levels were within normal limits. Computed tomography (CT) scan of abdomen and pelvis suggested 4.3×2.5 cm well defined moderately enhancing right adrenal mass with central necrosis (). No calcifications or fat components were seen within the lump. There was no free fluid and no appreciable abdominal lymphadenopathy. Patient underwent ultrasonography guided tissue biopsy of the right adrenal gland. Histopathology suggested it to be tumor composed of spindle cells and permeated by intense inflammatory infiltrate chiefly neutrophils. The tumor cells showed strong immunopositivity for vimentin and focal immunopositivity for epithelial membrane antigen. CT scan of pelvis and thorax was done to search for the primary focus of malignancy but both suggested no obvious focus except patient having a 60% thrombosis of distal arch of aorta. Hence decision was taken for right adrenalectomy. The surgery was completed uneventfully. On gross examination, specimen was brown and nodular measuring 6.5×5.5×3.5 cm and weighed 55 g. Its cut surface showed an unencapsulated firm greyish white tumor (). On microscopy the tumor showed pleomorphic tumor cells with epithelial and spindle cell morphology with evidence of foci of necrosis and intense inflammatory infiltrate with neutrophils and lymphocytes (). The tumor cells on immunohistochemistry showed strong positivity for vimentin (). Focal immunopositivity for pancytokeratin () and Bcl-2. The tumor cells were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man with a T3V1N0M0 rectal tumor underwent laparoscopic APR followed by adjuvant chemotherapy with oxaliplatin, fluorouracil, and calcium folinate. At 1 year control, radiological work-up and colonoscopy showed no signs of recurrence or distant metastases. Thirteen months after the APR, the patient developed a perineal hernia and had a reconstruction of the pelvic floor with a biological mesh (Permacol™) via a transperineal approach. The postoperative course was uneventful, and the initial follow-up with a pelvic–abdominal computed tomography (CT) scan 4 months after the surgery showed no signs of locoregional recurrence or reherniation. Nine months after the perineal hernia operation, the patient experienced weight loss. A thoracic–abdominal CT scan was performed and showed multiple metastases to the liver and lungs. The patient was treated with chemotherapy: bevacizumab, irinotecan, calcium folinate, and fluorouracil. Twelve months after the perineal hernia operation, but only 6 weeks into chemotherapy, the patient developed signs of sepsis with a high temperature, tachycardia, and hypotension and complained of pain in the right buttock. Physical examination showed signs of infection at the area. Possible differential diagnoses could have been local recurrence of the rectal cancer, intraabdominal abscess, or pelvis sepsis. We could have chosen to examine the patient with a positron emission tomography scan or, for example, an ultrasound (US)-guided biopsy, but we chose an acute US examination. This revealed an abscess, and drainage was established by a US-guided procedure. The patient was moved to an intensive unit and started treatment with intravenous fluids and broad-spectrum antibiotics. The following CT scan with contrast given through the drain showed a subcutaneous abscess cavity located in the perineum, with communication to the small bowel (). The patient underwent a laparotomy, and operative findings confirmed a perineal fistula from the di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male patient, with persistent AF refractory to the pharmacologic treatment underwent RFA in our hospital. As a routine practice in our centre, the patient was assessed pre-procedurally by transesophageal echocardiography (TEE) on the day of procedure to delineate anatomy of pulmonary veins and left atrium (LA) and to exclude LA appendage thrombus. During RFA procedure all four PV were individually isolated under guidance of intracardiac echocardiography. RF energy was delivered using a conventional 4 mm and 8 mm tip ablation catheters and a power setting of 30 W, 50 °C around a circular decapolar catheter located at the pulmonary veins ostia. Application of the RF was immediately interrupted when microbubbles were detected by the intracardiac echocardiography (ICE). After a curative ablation therapy patient was kept on aspirin to prevent pulmonary venous or arterial thrombosis and recurrence of AF. Ambulatory follow-up cardiac computed tomography (CT) angiogram was done 3 months following RFA and showed approximately 60% left superior PVS but no intervention was performed because the patient was asymptomatic and he was kept on oral anticoagulation ().\nTwo months later, the patient developed cough associated with hemoptysis, mild intermittent fever, mild left-sided pleuritic chest pain and shortness of breath on exertion. He visited the primary health centre close to his residency where chest radiography was done and showed left upper lobe poorly marginated opacities and minimal left pleural effusion. Further laboratory studies were done to rule out pulmonary tuberculosis (TB) which were within normal limits. A definitive diagnosis was not made and the patient was given broad spectrum antibiotics and referred to pulmonology clinic in our hospital for further investigation.\nPatient presented to our hospital 6 months after ablation without improvement in the symptoms. Non-enhanced CT was done and showed increased parenchymal attenuation and multiple perip"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female Chinese patient was admitted to our department for discontinuation of bowel movements for 2 months. The patient reported the alternation of constipation and diarrhea after an abdominal mass was found 3 years earlier. No laxatives or illicit substances had been used. She had chest tightness and shortness of breath. However, there were no signs of intestinal obstruction, including vomiting or abdominal pain. Family history was unremarkable. On examination, the abdomen was grossly distended, and a hard, round mass was found in the right lower abdomen. No peritoneal irritation was found, and rectal examination revealed an empty rectum.\nThe carbohydrate antigen 125 level in the blood was 91 U/mL, and the hemoglobin was 103 g/L. The serologic test for syphilis was positive. Abdominal computed tomography (CT) revealed fecal accumulation and dilatation of the colon above the sigmoid colon and suspicious wall thickening of the sigmoid colon (Fig. ). Anorectal manometry revealed relaxation of the anal sphincter.\nConservative treatment was ineffective, and an urgent surgical intervention was planned. The laparotomy revealed a significantly dilated transverse and descending colon (Fig. A) and the sigmoid colon was redundant and narrow. The transverse colon was cut open, and a drainage tube was placed to flush intestinal feces. We excised the sigmoid colon partially and performed a transverse colostomy.\nThe postoperative period was uneventful. Histological examination of the sigmoid colon showed chronic inflammation of the intestinal mucosa and a decreased number and the vacuolar degeneration of ganglion cells in the myenteric plexuses, on average more than 4 cells/cm (Fig. B). Inflammatory cells had infiltrated the serosa, and the blood vessels were dilated and bruised. Immunohistochemistry showed the tissue was positive for soluble protein-100 (S-100), synaptophysin, and neuron-specific enolase. The patient did not have a history of chronic constipation or"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43 year old male patient came to the department of Oral medicine and Radiology with the chief complaint of pain in the upper lip for the past 15 days. The patient experienced a mild, intermittent, dull aching type in the same region. His Past medical history was non-contributory and in the past dental history the patient revealed the history of trauma from road traffic accident 15 years ago, during which the patient had suffered from lip laceration and fracture of anterior teeth. Laceration in the lip was sutured immediately and later root canal treatment and crown placement was done. He further added that, 2 years after the trauma, he had developed pain and swelling in the upper lip in relation to 11, 12. A minor surgical procedure was done and a tooth spicule was removed. Constitutional signs and review of all systems appears to be normal on general examination. On local examination, inspection revealed no abnormality in the upper lip, labial mucosa and the entire oral cavity. On palpation a painful tiny hard mass measuring about 5 mm approx was palpable in the upper lip 0.5 cm lateral to the midline in relation to 11 and 12. On hard tissue examination prosthetic crown was present in relation to 11, 12. Considering the chief complaint, history and correlating with the clinical findings the mass in the upper lip was provisionally diagnosed as a foreign body in the upper lip.\nAn intra oral Periapical radiograph of the upper lip revealed a single radiopaque mass measuring about 3 X 2 mm in size (Fig .1).\nBlood investigation was performed which revealed to be within normal limits. Then an excisional biopsy was done by placing a single incision under local anesthesia (Fig.2).\nAll procedures were performed under aseptic condition (Fig.3).\nA review was done after 7thday, first month, third month and after 6 month. All necessary check radiographs were taken. The wound healing was satisfactory.\nHistopathological examination"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old woman had an 8-year history of atrial fibrillation (AF) and severe TR. Her history included mild hypothyroidism and right upper lobectomy for lung carcinoma 11 years previously. For 2 years, she had complained of shortness of breath when lying in the left lateral decubitus position. She had felt dyspnea after mild exercise for 9 months. Recently, she had a sense of abdominal fullness. Although administration of diuretics was started, her symptoms did not completely improve, and she was referred to our department for surgical treatment. The follow-up chest X-ray showed a gradually protruding right-side shadow of the cardiac silhouette, and the cardiothoracic ratio on the chest X-ray reached 88% (Fig. ). The electrocardiogram showed AF with low fibrillatory wave amplitude. Echocardiography showed an enlarged right ventricular (RV) cavity and mild paradoxical motion of the ventricular septum. The tricuspid valve had no findings of an organic and constructive abnormality, with no severe tethering. The annular size of the tricuspid valve was 50 mm, and the tricuspid annular plane systolic excursion was 21 mm (Table ). Repeated preoperative cardiac catheterization showed slightly elevated wedge pressure with mild pulmonary hypertension, although LV function was preserved with a cardiac index of 4.0 (Table ). There was no L-R shunt disease. Computed tomography (CT) findings showed that the maximum size of the RA reached 121 mm (Fig. ). The change in dimension of the RA by CT showed that the size of the RA increased with time (Fig. ). Blood tests showed no liver dysfunction.\nSurgery was performed via median sternotomy. The pericardium was extremely thin on the RA side without any defect. There was no adherence in the pericardial cavity. Cardiopulmonary bypass was established by ascending aorta cannulation with bicaval drainage. The RA was extremely thin and the tricuspid valve annulus was enlarged, with a diameter of 55 mm, but there was no tricuspid structura"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n18 years old, 54 kg male was admitted to the Third Xiangya Hospital for the upper right abdominal pain and fever on 12th October. Ultrasonography and CT scan showed large common bile duct cyst involving left and right hepatic bile ducts. Blood test showed a normal coagulation function with APTT of 45 s, liver enzymes and bilirubin were slightly elevated. There was no bleeding history, no family history of hemophilia either. Conservative treatment included antispasmodic agents, antibiotics, and choleretic medicine, but conservative treatment was ineffective and his symptoms got even severe and with a very high temperature of 39 °C, and his white blood cells count elevated to 20 × 109/L. So, he underwent resection of choledochal cyst and gallbladder followed by Roux-en-Y anastomosis on 24th Oct. The operation went well and finished at 12 AM without any blood transfusion. However, coffee like liquid came out of gastric tube at 4 AM, on first POD, and Hematemesis and hematochezia followed afterwards. The hemorrhage was unstoppable with conservative management, and the hemoglobin reduced to 60 g/L despite of prompt transfusion. The coagulation function test showed aPTT of 47 s at the moment. So, a technique fault related bleeding was suspected and an emergency explorative laparotomy was done at 1 PM, on second POD. No blood was found in abdominal cavity, but the jejunal loop was full of blood clots. After removal of the blood clots, an oozing was found at jejuno-jejunal anastomosis and it was controlled by sutures. The bleeding seems to be stopped for 2 days after the second operation but unfortunately, gastric tube and T tube inside hepatic bile duct drained bloody liquid on the third POD of second laparotomy, and it could not be controlled by conservative treatment. Bleeding even came out of abdominal drain tube on eighth POD of second surgery, so an emergency gastroscopy and DSA were performed, but neither"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Chinese man was found a cervical mass for 1 month. He had a history of coronary heart disease for 2 years, but no relevant personal or family history of malignancy. Physical examination showed bilateral neck asymmetry, the trachea was deflected to the left, the carotid pulse was normal, approximately 6 × 5 cm solid masses were felt in the right lobe of the thyroid gland. The tumor mass border was unclear with smooth surface, and the tumor moved up and down with swallowing. The left lobe of the thyroid gland had no palpable mass and the neck had no palpable swollen lymph nodes. Accessory examination of neck color Doppler ultrasound at our hospital showed increase in size of the right lobe of the thyroid gland, which had abnormal shape. The upper right pole of the thyroid gland had an approximately 5.6 × 6.0 × 4.2 cm sized mass, with unclear margin, and multiple cystic nodules in the thyroid. The CT of thyroid showed increase in size of the right lobe of the thyroid gland, and an approximately 5.6 × 6.0 × 4.2 cm sized mass, the trachea was compressed and deflected to the left, the thyroid cartilage was compressed, deformed and reached the right subglottic region. The right thyroid lump had multiple calcifications, indicative of a tumor (Fig. ). Electronic laryngoscope examination showed ventricular bands thickening, the right ventricular bands compartment showed a rice-like projection, arytenoid region movement was poor (Fig. ). Thyroid function test was 5.07 mIU/L. The patient underwent subtotal thyroidectomy and excisional biopsy of neck mass under general anesthesia. Intraoperative findings indicated a hard mass in the thyroid gland area, the lateral border and the lower bound were closely related to the surrounding soft tissues, but there was an extremely close relationship between the medial border, the thyroid cartilage, and cricoid cartilage, with no gap between them. An ENT doctor was invited for intraoperative consultation, who suggested that so"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-month-old baby boy was presented to our clinic with a one month history of right elbow mass. The patient's mother claimed that the child is moving his right upper extremity actively without any limitation. She also reported gradual increase in the mass size in the last month.\nThe patient is previously healthy without any past medical or surgical history. The patient is a product of full-term pregnancy with no perinatal complications. His developmental history was uneventful with no family history of malignancies.\nPhysical examination revealed a 3 × 2 × 4 cm mobile soft nontender mass extending from the right proximal ulnar aspect volar surface crossing the elbow crease proximally with no signs of erythema (). The full elbow active extension with mild restriction of full flexion is around 15 degrees.\nPlain radiograph of the right elbow showed a lobular soft tissue swelling () with a normal blood profile (complete blood count, ESR, CRP).\nThe MRI of the right elbow revealed a 3.3 × 2 × 4.5 cm (AP, transverse, and CC dimension) lobular juxta articular subcutaneous soft tissue lesion along the medial aspect of the elbow. The lesion appeared multiseptated with a predominantly high T2 signal intensity and contains a 1.8 × 1.8 × 1.5 cm area with low T2 and high T1 signal intensity and no perilesional edema or joint effusion (Figures and ).\nThe overall findings were in favor of an endolymphatic malformation. Decision was taken for radical excision.\nRadical excision was performed under tourniquet control with dissection of the mass from the ulnar, the median nerves, and the antebrachial muscles ().\nPathology specimen of the tumor showed a multiloculated lymphangioma with no evidence of malignancy (). The lesion showed vascular spaces with thick vascular walls incorporating adipose tissue and nerve fascicles. The vascular spaces were lined by regular endothelial cells. Surrounding synovial fluid cytology was negative for malignancy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 19-year-old female was the fifth child of first-cousin parents. One sibling passed away at 20 days of age because of pneumonia and another died at the age of 4 months due to kidney failure. There was also a full-term idiopathic stillborn. Unfortunately, none of them were seen at our institution and we did not have access to their charts. It is not possible to make any inference about the etiology of their diseases.\nThe patient was born uneventfully at 36 weeks of gestational age by caesarean section, had a birth weight of 2600 g (5th–15th percentile) and 46 cm birth length (5th percentile). Head circumference information was unavailable. There was no clinical sign or laboratory findings consistent with cholestasis at neonatal period or in her first 2 years of life. She had global developmental delay that was first recognized after 6 months of age. All domains were affected. She was not able to hold her head up and sit without support until 1 year old. She started walking with support at 6 years old and without support at 7 years old. She started speaking some words at 4 years old. She did not name colors, recognize numbers or letters, and she can only produce scribbles. She started using a spoon at 11 years old. At that moment, her functional age according to Denver II was gross motor 12–13 months, fine motor 15–16 months, language 18–19 months, and personal/social 7 months. A formal neuropsychological assessment was not conducted.\nShe had recurrent hypoglycemia associated with fasting from 6 months to 7 years of age without hyperinsulinism and was not responsive to glucagon. At the age of 10 months, she experienced a febrile seizure without hypoglycemia and at the age of 9 she started having focal motor seizures with impaired awareness and automatisms. The seizures were rare and easily controlled with carbamazepine.\nAn etiological investigation was initiated when she was admitted to our service at the age of 10 years old"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old man presented with sudden headache. A left VA dissecting aneurysm (15 × 6 mm) coexisting with a right internal carotid artery-posterior communicating artery aneurysm was found by MRI at a neighborhood clinic. He had a medical history of hypertension and heavy smoking (30 cigarettes per day for 40 years). On preoperative MRI, the dilated segment started at the height of the jugular foramen, ran transversely at the height of the 7–8th nerves toward the contralateral side, and ended at the point exceeding the midline (). The distal end was >20 mm proximal to the VA union. On preoperative DSA, the common trunk of the anterior inferior cerebellar artery (AICA)-PICA originated from the basilar artery, while the affected V4 had no angiographically identifiable branches (). The contralateral VA was as developed as the affected side. In addition to the irregular-shaped VA aneurysm in the subacute phase, there were other unruptured aneurysms. The patient also requested treatment to allow early return to his work (taxi driver). Thus, we decided to treat the left VA aneurysm at 2 months after onset.\nIt was impossible to maintain the left VA by reconstructive clipping because of the aneurysm shape. However, it was possible to secure the distal neck and trap the aneurysm because it was located caudal to the 7–8th nerves. PICA revascularization was not necessary because the common trunk of the AICA-PICA was well-developed. Note that there was >20 mm space between the distal neck to the VA union. Furthermore, there was a concern that many brainstem perforators would be occluded because of thromboembolism after blinding of this segment by trapping. Thus, to preserve the anterograde blood flow of the VA, it was reconstructed using RAG to anastomose the V4 segment just distal to the aneurysm and the extracranial V3 segment (V3-RAG-V4 bypass) (, ). The actual surgical procedures of case 2 is shown in ."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old gentleman, with a known case of chronic liver disease, presented with complaints of diffuse abdominal distension for two days associated with non-radiating, intermittent, colicky peri-umbilical pain. He had multiple episodes of bilious vomiting. He had not passed stool for one week and flatus for three days. There were no similar events in the past. He was not a known tobacco or alcohol abuser. He underwent no previous surgery.\nOn examination, he was found to be dehydrated with tachycardia. His abdomen was grossly distended and tender with diffuse involuntary guarding and rigidity. There was no mass palpable in the abdomen, no free fluid, and the hernial orifices were free. The bowel sound was absent. Digital rectal examination revealed collapsed and empty rectum with normal stool staining. His other systemic examination findings were clinically unremarkable.\nHis blood investigations revealed elevated blood urea nitrogen of 118 mg/dl and creatinine level of 3.6 mg/dl, suggestive of acute on chronic kidney disease, a normal hemogram, and a serum amylase of 207 IU/L. The serum amylase was at the upper limit of normal, and this was anticipated as such mild elevation is common in acute abdominal emergencies. A plain radiograph of the abdomen revealed multiple dilated small bowel loops with air-fluid levels, and ultrasonography (USG) of the abdomen revealed dilated aperistaltic small bowel loops (Figure ).\nThus, the diagnosis of acute intestinal obstruction was considered. A contrast-enhanced computed tomography (CECT) could not be done owing to a long waiting list for the procedure and also due to underlying renal failure in the patient. He was taken for emergency laparotomy as X-ray showed a classical picture of bowel obstruction and also for fear of poor outcomes in intestinal obstruction while waiting for CECT. As the patient was symptomatic for one week and with adhesive intestinal obstruction ruled out, as there were no prior abdominal surgeries in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year old infertile woman was referred to our center for IVF program (oocyte donation and embryo transfer). She had two previous histories of dilatation and curettage, one after spontaneous abortion and another for diagnostic purposes.\nHysteroscopy was done prior to IVF cycle which revealed a band of adhesion running from anterior to posterior wall for which adhesiolysis was done in the same session. The patient conceived in the second cycle of embryo transfer (oocyte donation). Pregnancy was confirmed by beta-human chorionic gonandotrophin (β–hCG) levels and later on, by ultrasound which confirmed single intrauterine gestational sac with a beating heart. She was followed up regularly for her obstetric examination with no other risk factors except for advanced maternal age.\nLevel two obstetric ultrasound examination was done at eighteen weeks of gestation which ruled out gross congenital anomalies and suggested grade 0 left fundo-anterior placenta with normal invasion and normal amniotic fluid. In the nineteenth weeks of gestation, patient presented in the emergency department of our hospital with acute abdominal pain and signs of early shock (pulse rate 180/min, blood pressure 90/60 mmHg, hemoglobin 7.5 g% and hematocrit of 24%).\nInitially, the patient was revived from shock with adequate fluid replacement and other basic management procedures including central line placement for cental venous pressure (CVP) monitoring. Once the patient's condition was stable, she was sent for ultrasound and CT scan evaluations. Ultrasound examination revealed fresh intrauterine fetal death along with hemoperitoneum with no other gross finding.\nCT scan was done to rule out other causes of heamoperitoneum. Findings were suggestive of weakening of the uterine musculature at the left fundal region with fetus inside the cavity. Patient was taken up for emergency laprotomy and a heamoperitoneum of 3000 ml was found along with a dead fetus coming out of a large uterine fundal defect."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 52-year-old male with a past medical history of cerebral palsy, essential hypertension, depression, and knee arthritis status post total knee arthroplasty, who presented to the emergency department after a mechanical fall. He was found to have a left distal femoral shaft fracture above the total knee arthroplasty which was fixed with an intramedullary rod placement. The patient was discharged home in a stable condition. Three weeks later, he developed increased redness and swelling at the surgical site. Vital signs were all stable on admission. Physical examination was significant for a 10 cm post-surgical wound around the left knee with mild dehiscence. Granulation tissue with drainage of serosanguineous fluid was noted along with mild erythema around the surgical site. Laboratory results including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein were all normal at 3,900/µL, 1 mm/h, and 2 mg/L, respectively. Blood cultures were obtained and remained negative at 72 hours. He was taken to the operating room and underwent extensive excisional debridement including skin, muscle, and bone. There was one screw of the nail that was loose and, therefore, removed. Antibiotic (gentamycin)-impregnated cement beads were inserted. Gram stain from intraoperative culture showed no organisms. He was started empirically on cefepime 2 g IV every 8 hours and vancomycin 1 g every 12 hours postoperatively. After four days, there was no growth from the surgical cultures. Microbiology lab was asked to hold the culture for 10 days for the concern of slow-growing organism. The patient was discharged with ceftriaxone 2 g every 24 hours through a PICC line. Five days after discharge, aerobic cultures grew Corynebacterium species. The specimen was sent to Mayo Clinic (Rochester, Minnesota) for further testing. Quantitative antibiotic susceptibility testing was performed to determine the isolate’s minimum inhibitory concentration (MIC) to various"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-years-old woman brought in by EMS after she was found in distress on a subway platform. The patient with known history of diabetes type II and hypertension presented with stabbing chest pain radiating to the interscapular region after crack cocaine use. In addition to the chest pain and diaphoresis, the patient also complained of progressive pain and cold sensation over left lower extremity. Upon physical examination, the patient was noted to be agitated and combative with a blood pressure (BP) of 205/147 mmHg, a heart rate of 77 beats per minute, 17 respirations per minute, and was afebrile. Initial cardiovascular exam was positive for an S4 gallop and absent left lower extremity pulses. Lung examination was unremarkable. Initial management consisted of intravenous administration of a total of 9 mg of Lorazepam and 35 mg of Labetalol without acceptable reduction in BP. In addition to further Lorazepam, Labetolol later Esmololol infusions, IV Nitroglycerin was started and quickly titrated to 200 mcg/kg/hr but acceptable blood pressure reduction of blood pressure was still not achieved on this regimen (). A contrast-enhanced Computerized Tomography (CECT) of the thorax, abdomen, and pelvis confirmed a Stanford Type B aortic dissection beginning just beyond the left subclavian artery and extending to the iliac bifurcation. Upon arrival to the Cardiac Care Unit, decision was made to begin an infusion of Dexmedetomidine since all other therapies continued to be unsuccessful. The alpha 2 stimulation provided by the Dexmedetomidine was hypothesized to decrease the effects of the adrenergic surge induced by the cocaine thus mitigating alpha 1 and beta-receptor stimulation. Within 10 minutes of Dexmedetomidine bolus and continuous infusion, adjunct antihypertensive and sedative infusions were quickly weaned off. Evolving signs of ischemia in the left lower extremity warranted emergent femoral-femoral bypass. Vascular surgery team performed procedure successfully and un"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old woman presented with an open wound on the left lower leg. It was a de-epithelized abrasion and its size was about 3.5 × 1.5 cm2 (Figure A). The patient had no notable medical history. She works as a janitor, and was cleaning the floor of the building, when she spilled undiluted cleansing solution that consisted of sodium hypochlorite (NaClO) on her left lower leg. After the accident, an abrasion was noted on that area and she visited her local dermatologic clinic for treatment on the very next day. At the clinic, she received HeNe laser therapy directly to the wound daily for 10 days. The treatment continued for 8 to 9 minutes on each occasion. However, we were unable to determine the details of laser therapy, such as power, wavelength, and so on. The treatment was not beneficial and the wound size was constant. The patient visited our clinic three weeks after the injury and we planned an excision of the unhealed area under the local anesthesia.\nDuring the first operation, the open wound was excised and primary repair was done (Figure B). We sent a specimen to the pathology department and the pathologic analysis revealed invasive squamous cell carcinoma, 2 × 1.5 cm2 in size, involving the lateral resection margin. We planned a second operation and evaluated positron emission tomography–computed tomography for metastatic lesions before the second operation. After confirming that there was no metastasis, the patient received a second operation 3 weeks from the first. Wide excision was done with a 2 to 3 cm safe margin (Figure A). During the operation, the resection margin including the tumor base was free from tumors, as demonstrated by a frozen study. The total defect size of the left lower leg measured 9 × 7 cm2 and the defect was successfully reconstructed with a thoracodorsal artery perforator free flap transfer (Figure B,C). Micro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old male collegiate football player presented to the emergency department (ED) with persistent neck pain following an injury at practice. The contact occurred during a blocking drill and reportedly forced his neck into hyperextension. Upon impact, he immediately experienced high cervical neck pain localized to the left side of his neck, although over time this pain became more generalized. The patient was removed from play, and on the sidelines, no weakness or sensory abnormalities were noted on his examination. The pain was exacerbated with palpation at the base of the skull and did not radiate. Cervical range of motion with rotation, flexion, extension, and lateral flexion was limited secondary to pain. The patient had persistent pain later in the evening, not relieved with analgesics and rest, and was ultimately instructed to go the ED for further work- up and evaluation.\nIn the ED, he had continued complaint of neck pain; however, he remained neurologically intact and denied numbness, paresthesias, or weakness on initial evaluation. Of note though, later that evening in the ED, the patient transiently experienced subjective numbness in his left lateral forearm in an ulnar distribution that later spontaneously resolved. He was an otherwise healthy individual with a medical history significant for one “stinger” in the past that completely resolved. Plain films revealed no acute fracture or dislocation []. A computed tomography (CT) scan of his cervical spine demonstrated absent bony fusion of the anterior midline synchondrosis, as well as the midline posterior arch of the C1 bony ring [Figure –]. The osseous components had well-developed cortical margins, strongly suggesting that the midline discontinuities were not the result of trauma. The patient additionally underwent magnetic resonance imaging (MRI) of the cervical spine that demonstrated prominent edema in the pre-vertebral soft tissues extending from the level of the clivus to the vertebral body o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old man with a past medical history of schizophrenia was found outside a behavioral health facility and appeared groggy with slurring of speech. The patient was given naloxone by emergency medical services without improvement in his symptoms and was transported to the emergency department for further evaluation. On presentation, the patient was afebrile and hemodynamically stable. He was alert and oriented to person, place, and time; however, exhibited slurred speech and an inability to stay awake despite repeated stimulation. Lab work did not show electrolyte abnormalities, leukocytosis, or a deranged thyroid-stimulating hormone level (Table ). Urine toxicology was negative for barbiturates, cannabinoids, cocaine, benzodiazepines, amphetamine, and opioids. His serum ethanol level was negative and his acetaminophen level was less than 5 µg/mL. His urinalysis was not indicative of infection. Clozapine level was noted to be 172 ng/mL (reference range: 350-650 ng/mL). Chest X-ray showed no acute cardiopulmonary abnormality. The patient reported that he was in his usual state of health the prior night when he restarted clozapine after approximately six weeks of medication noncompliance due to the inability to see his psychiatrist for a prescription. He stated that he took 300 mg of clozapine at the full dose the previous evening, and did not restart it with a taper. Medication history indicated that the patient had been prescribed haloperidol 5 mg daily and clozapine 100 mg in the morning and 300 mg in the evening for at least three years. He denied using any opioids or alcohol. He also reported no history of recent infection, shortness of breath, chest pain, or trauma. The following day, the patient was alert and oriented to person, place, and time, and was able to converse normally with no drowsiness or somnolence. He was evaluated by the psychiatry service, and his altered mental status was attributed to the resumption of clozapine at full dose after a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old lady presented to the general surgeons with a history of diarrhoea and abdominal distension. Examination revealed ascites and a CT scan was organised; this showed gross ascites with small pleural effusions, bulky ovaries, a fibroid uterus, and multiple peritoneal and mesenteric deposits. Tumour makers were within normal limits with Ca 125 17, CEA 2.1, and Ca19 9 6.2. A gynaecological oncology opinion was sought and an ascitic drain sited for symptom relief and to obtain possible cytological diagnosis. Histological analysis of ascitic fluid on two separate occasions revealed leukocytes, mesothelial cells, and scattered histiocytes with no malignant cells present. Further immunohistochemistry was performed confirming the cells to be lymphoid in origin.\nShe continued to be symptomatic with abdominal distension and vomiting and therefore, a diagnostic laparoscopy was performed by the general surgeons. Laparoscopy confirmed gross ascites with what appeared to be widespread carcinomatosis with peritoneal and omental seedlings, bulky uterus and ovaries. Omental biopsies that were taken revealed an inflammatory process suggestive of possible sclerosing peritonitis. Histology showed omental fat with fibrous proliferation at the surface infiltrated by inflammatory cells and nodules of mesothelial proliferation, with no evidence of neoplastic infiltration. Immunohistochemical analysis was negative.\nHer clinical condition remained unchanged, and she required further ascitic drains for symptom relief. An MRI scan confirmed CT findings, and her case was discussed in detail at the Gynaecology and Colorectal MDT.\nAs extensive investigation failed to establish a definitive diagnosis. In view of the small possibility of the fibroid uterus being responsible for her condition the decision was taken to perform a total abdominal hysterectomy, bilateral Salpingo-ophrectomy, omental biopsy, and serosal bowel biopsy. The gynaecological procedure was completed without difficult"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old man presented to us with a 2-year history of slowly enlarging, painless mass in his left upper lid with resultant progressive ptosis []. The patient complained of constant sense of heaviness in the upper lid as well as partial ptosis. The superior field of vision was reduced. Ocular examination was suggestive of a firm, non-tender nodule of size 2 × 1.5 × 1 cm on the left upper lid. The mass was non-adherent to the skin or the underlying tissue. A small ulcer 5 mm × 8 mm was present on the lateral margin of the mass []. The medial skin and conjunctiva were indurated and signs of inflammation were present. The lid appeared to have lost its function and was unsalvageable. Provisional clinical diagnosis was that of an eyelid malignancy. Fine needle aspiration cytology of the lesion was inconclusive.\nThe lesion was excised using a supratarsal incision. An ellipse was planned along the ulcer present on the lateral margin (0.8 mm) to excise the ulcer in continuity with the swelling. The lesion was 1.5 cm in diameter with a well-defined capsule, located below the subcutaneous tissue and above the muscle layer almost abutting the supraorbital rim. The incision was deepened and the lesion was isolated from the surrounding tissue by blunt dissection outside the capsule. Dissection was easily done in the extracapsular plane and the lesion was excised completely. No communication with the supraorbital nerve could be identified. However, the eyelid had strong evidence of induration and oedema, though no evidence of infiltration by the lesion was seen. As diagnosis of malignancy was suspected initially, the medial portion except for a small lateral margin was excised to ensure clear margins and reconstruction was done using a tarso-conjunctival flap from the lower eyelid in conjunction with a skin graft harvested from the left medial arm []. The lateral rim of eyelid was closed primarily in continuity with the flap. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old healthy boy was referred from the Public Dental Health Services (PDHS) to a prosthodontist at the Oral Health Centre of Expertise (specialist dental care) for treatment of the maxillary incisors. The boy's chief complain was the appearance of his upper front teeth. A history of multiple traumas at the primary teeth was revealed. The first at the age of 1½ years was perceived by the parents as not significant, whereas the second at the age of 2½ years was severe. The boy had fallen off his bicycle against a fence outside the family's house. Trauma was recorded in PDHS with the diagnoses of avulsed teeth #51 and 61 and uncomplicated crown fracture tooth #52. Three weeks after trauma, delayed intraoral wound healing was recorded with gingival retraction buccal for tooth #62 and alveolar fracture at the area was suspected. At the age of 7, teeth #11 and 21 had not erupted. One year later, it was noted that the erupted tooth #11 had atypical crown shape and enamel hypoplasia whereas tooth #21 had not erupted yet. Periapical radiograph showed that tooth #21 had aberrant crown anatomy similar to the erupted tooth #11 (). At the age of 9, the boy was referred to a private orthodontist due to delayed eruption of tooth #21 (). The orthodontist perceived the delayed eruption as a result of a supernumerary tooth and referred the patient to an oral surgeon at the university dental clinic for examination and surgical removal of the supernumerary tooth. Small-volume cone-beam computed tomography (CBCT) revealed atypical morphology of tooth #21 with the root forming a 90° angle to the longitudinal axis of the crown. The root was located parallel to the nasal floor in anterior dorsal direction. It was further described that the crown had an irregular and atypical shape. In addition, CBCT showed that teeth #12, 11, and 22 had varying degrees"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year old woman, with a medical history of 20 pack-years of smoking, was diagnosed lung adenocarcinoma with liver metastasis in September 2009. Molecular analysis of the tumor revealed no EGFR mutation. She was treated with cycles of permetrexed (500 mg/m2) and cisplatinum (75 mg/m2) every 21 days from September 2009 to January 2010, with a stable disease on CT scan evaluation after 6 cycles of chemotherapy.\nIn January 2010, she had a persistent headache associated with photophobia and a progressive decrease of her performance status. Radiological explorations included a CT and a MRI of the brain and were considered normal. A cerebrospinal fluid (CSF) exploration was then performed, revealing the presence of carcinomatous cells, compatible with an adecarcinoma of the lung. The CSF protein level was slightly increased (0.47 g/L), whereas CSF glucose level was normal. Intrathecal DepoCyt® (50 mg) was delivered the 17th of February 2010, followed by marked aggravation of clinical symptoms and worsened performance status, despite oral prednisone intake at 1 mg/kg.\nThe patient was then treated with intrathecal injections of methotrexate (15 mg, day 1-5) and prednisolone 30 mg (day 1) with oral folinic acid rescue (25 mg 12 h after methotrexate, day 1-5) []. A cycle was performed every 2 weeks with repeated lumbar punctures. Four cycles of high dose methotrexate were administered between March and April. A clinical improvement was noticed after the first cycle of chemotherapy, with decrease in headaches, improvement of performance status, allowing the diminution of prednisone intake. Clearance of carcinomatous cells was observed on CSF exploration after the second cycle of chemotherapy and confirmed until the end of intrathecal injections. Treatment was well tolerated and no clinical or biological toxicity was noticed. Interruption of intrathecal treatment was decided with regards to clinical and cytological response after four intrathecal treatment injections.\nAt the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old female presented to the Emergency Department with a complaint of left lower quadrant abdominal pain and cramping that she reported began 2 days prior. Pain onset was followed by bloody stools, both of which resolved the following day aside with only some residual nausea. Abdominal cramping recurred early on in the morning of admission. The patient denied any ingestion of potentially contaminated water or unusual food. The patient history was also negative for recent surgeries, travel, or sick contacts. The patient reported no family or personal history of inflammatory bowel disease and had no other concerns aside from the left lower abdominal pain and bloody stools.\nUpon examination, her vital signs revealed an elevated heart rate of 118 and a slight elevation in blood pressure at 134/88. Her abdominal exam showed normal bowel sounds and a soft abdomen but with mild diffuse tenderness. No rebound or guarding was noted.\nLaboratory testing was largely unremarkable. CT abdomen pelvis with intravenous contrast revealed findings consistent with an ileocolic intussusception (). A tubular structure was seen within the lumen of the intussusception which was determined to be a distended appendix potentially serving as the lead point. No indication of obstruction or bowel perforation was seen, but there was a small amount of intraperitoneal fluid. All organs were unremarkable aside from a non-obstructing stone seen in the right kidney.\nThe patient was admitted to general surgery for further evaluation and management. It was discovered that right colon and distal ileum had intussuscepted into the transverse colon, but it was unable to be reduced laparoscopically and therefore the procedure was converted to open laparotomy. After converting to an open procedure and mobilizing the colon, it was noted that a very long segment of colon had intussuscepted with a firm mass and lead point that had travelled into the transverse colon. The bowel was manually manipulated b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-year-old boy visited a local hospital due to repeated episodes of pneumonia since the age of three months. A chest radiograph and CT revealed an abnormal mass-like lesion in the right lower pulmonary lobe. An attempted total excision was unsuccessful, and only a biopsy was performed in the local hospital. The precise pathologic report of the outside hospital was not available except for information of a kind of vascular mass. Because the boy had long-standing and recurrent symptoms, he was referred to our vascular center for further evaluation and treatment. A plain radiograph showed increased right infrahilar opacity overlapping the cardiac shadow. The right lung was more lucent and smaller than the left one, suggesting an airway problem (). A precontrast CT scan revealed a soft tissue mass containing multiple and well-defined small calcific foci in the right lower lobe of the lung, which were suggested to be phleboliths (). After injecting the contrast material, the anterolateral portion of the mass was intensely enhanced without enhancement of the surrounding region (). The lesion was encasing the right bronchus intermedius and the right lower lobar bronchus, resulting in decreased caliber. The right inferior pulmonary vein was also narrowed by the encasing mass (). The mass abutted the posterior margin of the heart and superior pulmonary vein. Before surgery, an MRI was performed in our hospital three months after the CT scan performed at the outside hospital to further evaluate the mass demarcation with the surrounding tissues; especially in the airway and large vessels. The lesion was found to be isointense with the muscles on T1-weighted images and hyperintense on the T2-weighted images (). There were no signal differences between the enhancing and the non-enhancing part on a contrast enhanced CT on MRI. Because the intravenous administration of MRI contrast agent was not performed during MRI, the comparison of the enhancing pattern between the CT and MRI"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old male visited the outpatient department presenting a one-week history of right-side foot drop. The patient had no history of hypertension, diabetes, hypothyroidism, arthritis, cancer, hepatitis or stroke. He denied any recent traumatic accidents to the right leg. The complete physical evaluation was conducted, showing no abnormalities such as visual changes, fever, chills, dizziness, headache, or bowel or bladder problems. In the detailed neurological examination, he was well oriented and exhibited no signs of cranial nerve function disorders such as dysarthria, dysphagia or facial palsy. Distal pulse and sensation were intact in all extremities including the dorsal aspect of the right foot. Passive range of motion was in a normal range in every peripheral joint. The patient was also negative for the straight leg raise test and femoral nerve stretch test. No pathological reflexes were found bilaterally such as Babinski and ankle clonus, with normal deep tendon reflexes. Individual muscle strength tests were normal for all extremities except for the right tibialis anterior and the extensor digitorum. Muscle tone grades in the right tibialis anterior and extensor digitorum were 0/5 when measured by Modified Ashworth Scale.\nElectromyogram (EMG) and magnetic resonance imaging (MRI) were performed. EMG showed no remarkable findings and lumbar spinal MRI revealed a diffuse bulging disc at the L4-5 disc space level. However, there was no evidence of severe nerve root compression that was susceptible to current condition. Since the lumbar spinal lesions were ruled out for the patient's symptom, a brain MRI was performed to investigate any potential central lesions. Diffusion-weighted imaging (DWI) showed focal high signal intensity on the left upper motor cortex (). An afferent diffusion coefficient (ADC) map revealed low signal intensity on the same area (). Subsequently, the patient was diagnosed with subacute cerebral infarction. After one week of treatment"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old woman with a one-month history of redness and swollen left knee joint was transferred to our general intensive care unit (ICU) due to persistent high fever (up to 39.5°C) and sudden hypotension. After being diagnosed with dermatomyositis 2 years ago, she continued medication treatment on prednisone tablets with a 25 mg daily dose and cyclosporine capsule with a 75 mg dose twice per day. Last month, the results of blood culture and bacterial culture of joint cavity pus as obtained from other medical institutions were shown to be negative, with no special microbiological examination performed.\nWhen the patient visited the rheumatology department for appointment with a doctor, she coughed up sputum intermittently and her body temperature reached up to 40°C. Physical examination revealed that the left knee was red and swollen with positive floating patellar test, along with red rash in the V area of face and neck. The right dark yellow pleural effusion displayed exudate and negative bacterial culture. Vancomycin was thus prescribed to reduce infection, and 20 mg of methylprednisolone was applied twice a day. Four days later, she was transferred to ICU due to hypotension (the detailed clinical course is shown in ). The patient exhibited low blood pressure and high heart rate, which was accompanied by elevated procalcitonin and multiple organ failure. Broad-spectrum anti-infective therapy (imipenem/cilastatin + linezolid) was initiated within the first hour of highly suspected septic shock. ECG suggested cardiac infarction and high myocardial enzyme index. In order to rule out the occurrence of acute cardiovascular event, no infarction was detected immediately after coronary angiography. Given the EF value of 30% for the patient, septic heart disease was suspected. At the same time, the patient suffered acute liver injury, acute renal injury and thrombocytopenia.\nAfter the patient was transferred to ICU, joint cavity pus was also taken for culture in additio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old female patient presented to our emergency department with acute onset of hematemesis and melena. On admission, the patient appeared to have a poor general health condition and was hemodynamically compromised. Her initial laboratory exams revealed a hemoglobin concentration of 7.7 mg/dl without leukocytosis or C-reactive protein (CRP) elevation. The patient had a history of a 6.5 cm gastrointestinal stromal tumor (GIST) of the cardia, for which she initially received downsizing treatment with imatinib 400 mg/d, followed by surgical resection of the gastroesophageal junction and reconstruction with a jejunal interposition (Merendino procedure) 4 years earlier (). Histopathological studies of the tumor revealed a T3-tumor with a positive c-Kit mutation in exon-11 and a Ki-67 proliferation rate of 15%. The risk for disease progression based on Miettinen's criteria was determined as high (size > 5 cm; mitosis rate > 5/HPF), and the patient was subsequently placed on 1st line adjuvant therapy with imatinib 400 mg/d []. After two years on 1st line treatment, the patient developed hepatic and peritoneal metastasis and was placed on sunitinib as 2nd line therapy for metastatic GIST. Treatment with a proton pump inhibitor (PPI) was suspended for an unknown reason two years prior to presentation.\nThe patient was immediately transferred to our intensive care unit, where she was intubated and received two units of packed red blood cells (pRBCs). An emergency gastroscopy was carried out, which revealed active bleeding from a vessel stump in the jejunal interposition, corresponding to a Forrest stage I b upper gastrointestinal bleed. The bleeding was successfully stopped endoscopically by local injection of adrenaline and the application of polymer powder. A CT scan of the thorax and abdomen showed no signs of active bleeding or free abdominal fluid (). The known hepatic and peritoneal metastasis were described as constant in size, but increasingly necrotic compared"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old woman was admitted to the Nagoya City University Hospital, Nagoya, Japan, complaining of an abdominal swelling that had been present for the past 12 months. Her abdomen was markedly swollen and felt hard without tenderness. Peripheral blood examination revealed slight anemia and slight elevation of C-reactive protein. No other disorders, including any tumor markers, were detected. A computed tomography scan (CT) showed two masses in the retroperitoneum, one of which was 26 × 15 × 29 cm and enhanced slightly, and the right kidney was involved and pushed aside. Almost all retroperitoneal cavities were filled with the giant tumor. The other mass was walnut-sized tumor adjacent to the large one, and mostly of low density. Magnetic resonance imaging (MRI) revealed the giant tumor was T1-low intensity and T2-high intensity, but the small tumor was T1-high intensity, with a changed low signal in fat suppression (). This indicated that the small tumor was mainly fat-containing, and the giant tumor appeared to be mainly composed of mucinous tissue. Under general anesthesia, the tumor was excised with the right kidney en bloc. There was not much adhesion to surrounding tissues. Upon gross examination, the tumor was well circumscribed and encapsulated and weighed 8.5 kg (). The tumor had two components as determined by CT and MRI. The two components were very clearly divided. The small one was yellowish, and histopathologically, they were mainly composed of fat cells that varied in size, that is, mature-appearing adipose tissue with scattered lipoblasts exhibiting large hyperchromatic nuclei. Immunohistochemical analysis revealed that the cells were strongly stained by S-100 protein which is a marker for fat (). Therefore, this small tumor was diagnosed as a well-differentiated liposarcoma. On the other hand, giant tumor was white and, histopathologically, mainly contained abundant mucinous mesenchyme and filled with atypical spindle cells. There was extensive in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man was admitted to our cardiology department with exertional angina. He had hypertension and hyperlipidemia as cardiac risk factors. On physical examination, the patient’s vital signs were unremarkable and he had a New York Heart Association functional capacity of II. The respiratory and cardiovascular examinations were normal. The electrocardiogram showed nonspecific ST–T wave changes in leads V1–V6, and the laboratory work was within the normal range except for a low-density lipoprotein level of 170 mg/dL. The exercise stress test was nondiagnostic, and the myocardial perfusion scan revealed inducible ischemia in the anterior septum, mid, and basal portions of the anterior wall. Cardiac catheterization was performed and showed a giant left main coronary artery aneurysm ( and ). All of the left coronary system arose from the aneurysm. The patient had no history of Kawasaki disease in childhood, and nor was the type of the lesion compatible with Kawasaki disease. Multidetector computed tomography coronary angiography confirmed a huge left main coronary artery, measuring 33 × 28 mm in size ( and ). Because of the nonobstructive coronary artery disease in the other parts of the coronary system, the patient was managed with medical treatment. After 3 months of treatment, he referred to us again with exertional angina, which continued for more than 10 minutes. Coronary angiography illustrated no changes in his coronary system. After consultation with the cardiovascular surgery department, the patient was followed up with medical therapy. In the first hospitalization, medical therapy included acetylsalicylic acid (100 mg once a day), metoprolol (50 mg once a day), ramipril (5 mg once a day), isosorbide mononitrate (50 mg once a day), and trimetazidine HCL (35 mg twice a day). After the second hospitalization, warfarin treatment was added because of the giant aneurysm and slow flow. The patient’s first visit was in March 2013, and he was subsequently follow"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case illustrates a 20-year-old female diagnosed with MS at the age of 17. She was initially treated with tocilizumab as neuromyelitis optica was suspected due to bilateral optical neuritis and the presence of spinal cord lesions. However, antibodies against aquaporin-4 and myelin oligodendrocyte glycoprotein were not detected and the magnetic resonance imaging (MRI) of the brain and spinal cord as well as cerebrospinal fluid (CSF) findings were supportive of MS. Apart from persistent bilateral severely reduced visual acuity she had no other signs of neurological dysfunction. She had previously been in good health and had no family history of PID, or other systemic inflammatory diseases.\nEighteen months prior to the episode of arthritis and skin symptoms reported here, she was started on off-label treatment with rituximab (RTX). RTX is the most frequently used immunomodulatory drug for MS in Sweden according to the Swedish MS registry (). Initially, she received 1,000 mg of RTX followed by 500–1,000 mg every 6th month, resulting in depletion of circulating B-cells (<0.001 ×109/L). During this period, there were no signs of neuroinflammatory activity of MS.\nA rheumatologist confirmed the diagnosis of monoarthritis. The right knee had typical signs of inflammation with rubor, tumor, and calor accompanied by a discretely reduced range of motion. The general status was good without fever. The lower right leg was diffusely swollen and two circular erythematous areas around the ankle were seen (). A dermatologist interpreted the skin symptoms as possible panniculitis with atypical erythema nodosum as a potential alternative diagnosis. There were no other clinical or laboratory findings of sarcoidosis.\nTreatment with RTX had been ongoing for approximately one and a half year prior to the onset of arthritis and the cutaneous symptoms had been present for at least 6 months prior to the diagnosis. The last dose of RTX was given 1.5 months before the onset of symptoms rela"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old gravida 3, parity 2 woman was admitted to the hospital for vaginal bleeding and severe abdominal pain. Her past medical history was free of any medical problems. On her obstetric history, she had a vaginal delivery following an uneventful pregnancy course 8 years ago. Her second pregnancy was terminated via hysterotomy at 18th weeks due to multiple fetal abnormalities including hydrocephalus. She was diagnosed to have total anterior placenta previa on her third pregnancy. This last pregnancy was otherwise uneventful and the patient gave birth to a term, healthy infant via planned repeat cesarean section in a private hospital. During the operation, partially adherent placenta had been detected and the adherent part of the placenta had been left in situ. Postoperative treatment had not been given. 20 days after the operation, she had been hospitalized due to massive vaginal bleeding and had been transfused four units of packed red blood cells since her blood count revealed severe anemia with a hemoglobin level of 5.6 gr/dL. She had been discharged from hospital three days later. However, one week later, she had presented to another center due to vaginal bleeding and pelvic pain. She had been referred to our hospital with a presumptive diagnosis of placental retention because ultrasonography showed soft tissue density with irregular contour in the endometrial cavity (). On her admission, she had findings consistent with acute abdomen and moderate abdominal distention was detected. Her blood pressure was 90/60 mmHg and heart rate was 110/minute. Hemoglobin was 8.5 gr/dL on complete blood count. Ultrasonography revealed free fluid filling the pelvis and lower abdomen. Her serum human chorionic gonadotropin was negative. After obtaining informed consent including hysterectomy, an emergency laparotomy was performed. Following drainage of approximately 1000 mL of free blood from the abdominal cavity, a full-thickness defect on the anterior wall of the uterus w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old man, weighing 65 kg, was admitted to our hospital to evaluate a murmur in the routine examination. He had complained of mild shortness of breath on physical exertion for one month. Physical examination on admission revealed a systolic murmur in the left para-sternum, trans-thoracic echocardiography showed a subarterial VSD with a diameter of 8 mm, left to right shunting, pressure gradient via the defect was 70 mmHg. The left ventricle dilated mildly with left ventricle end-diastolic diameter was 57 mm and left ventricular ejection fraction was normal range. Pulmonary artery systolic pressure was 33 mmHg at rest. Mild aortic regurgitation was present.\nThe patient was conducted under general anesthesia with a single-lumen endotracheal tube and placed in supine position as for standard median sternotomy with two arms along the body. Defibrillation pads were placed on the right and left chest before sterile draping. The femoral artery and vein were dissected in preparation for cannulation with a 2–3 cm oblique right groin incision. A 4 cm left parasternal thoracotomy was used to enter the thorax via the third intercostal space (ICS). The left internal thoracic artery was preserved carefully. The third costal cartilage was divided close to the sternum, without resection, to increase exposure. The ribs were slowly spread with a mini-thoracic retractor. The pericardium was opened longitudinally and suspended with stay sutures. The femoral artery cannula was inserted directly into the common femoral artery. A multi-stage venous cannula was inserted using the Seldinger technique with the tip of cannula advanced to the superior vein cava under transesophageal echocardiography guidance. After femoral arterial and venous cannulation, cannulas were secured, and cardiopulmonary bypass (CPB) initiated. CPB was initiated with vacuum-assisted venous drainage and body temperature maintained at approximately 34 °C A long cardioplegia needle (Livanova, London United Kingd"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old female, P3003, presented with postmenopausal spotting on and off for the past 6 months, cough with expectoration, and significant weight loss for past 2 months. For these complaints, she had been put on empirical antitubercular drugs at some outside hospital. She took these medications for 2 months but had no improvement in her chest condition and rather the bleeding episodes and pain in lower abdomen increased significantly. She was then referred to our center. The patient was nondiabetic and nonhypertensive, and there was no history of long-term exposure to estrogen. She was postmenopausal for 3 years. On examination, her general condition was poor. She was cachexic with weight 27 kg and body mass index of 15 kg/m2. On auscultation, bilateral air entry was decreased and rhonchi were present. Abdominal examination revealed a scaphoid abdomen and a lump corresponding to 14 weeks size gravid uterus, hard in consistency, and restricted mobility in the suprapubic region. On per speculum examination, the cervix could not be visualized as it was pointing acutely forward. Hence, cervical screening and endometrial biopsy could not be done. On bimanual examination, a hard mass of around 14 weeks was felt, which was nonmobile and nontender.\nHer hemoglobin was 7.1 g%. Rest all investigations were within normal limits. Ultrasonography showed evidence of a well-defined heterogenous hypoechoic mass lesion 20 mm × 17 mm in part of the myometrium of the fundal region likely intramural fibroid and bulky uterus. However, the magnetic resonance imaging (MRI) report was suggestive of endometrial carcinoma involving more than half of the myometrium. Computed tomography (CT) of the chest was advised to rule out metastasis. However the patient was lost to follow-up for about 2 weeks when she returned back with CT report suggestive of traction bronchiectasis and discrete random nodules with feeding vessel signs in the right lower lobe of lung, likely"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA female baby with a birth weight of 750 g and a male baby with a birth weight of 930 g were born at the gestational age of 26 weeks from a 29-year-old mother. Pregnancy was complicated by the preterm rupture of the membranes. The twins were resuscitated after birth, and they were intubated and surfactant therapy was administered. The male patient was extubated on the fourth day and was started to be followed up with nasal continuous positive airway pressure (CPAP). On the postnatal 28th day, the male patient was separated from CPAP and was started to be followed up with free oxygen. However, mechanical ventilation was continued in the female baby. The patients’ lung radiographic and clinical findings were compatible with severe BPD. It was decided to give MSC treatment on the postnatal 32nd day to both patients. Mesenchymal stem cells (2x106/kg) were given by the intravenous route and 1x107/kg MSCs were given by the intrathecal route. The patients were monitored using lung USG and the images were recorded.\nAtelectasis, consolidation, pleural line abnormalities, alveolar interstitial syndrome (AIS), B lines, and air bronchograms were seen on USG examinations of the lung in both patients before treatment. No significant change was found in lung USG repeated twelve hours after stem cell treatment (, ). Ultrasound examination of the lung performed in the female patient three days after treatment and revealed pulmonary consolidation, partial resolution in divided areas, atelectatic regions, and also, it was observed that pleural line abnormalities persisted. In the male patient, lung USG revealed that B lines and AIS disappeared, but pleural line irregularity persisted.\nLung USG of the female patient performed nine days after the treatment showed that pleural line irregularity reduced, A lines became prominent, and AIS areas gave place to B lines, and the patient’s need for oxygen decreased. A USG examination of the male patient revealed that A lines started to become p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old woman of Cypriot origin presented with an acute onset of palpitations and chest tightness. She reported several weeks’ history of similar palpitations, however, this was the first occasion that the sensation had not self-terminated within minutes and had been associated with discomfort.\nThere was no further medical history of note, no relevant family history, and no regular medications. Our patient admitted to a moderate alcohol intake although no recent intoxication and no recreational drug use.\nOn assessment in the Emergency Department, her electrocardiogram (ECG) demonstrated a narrow-complex tachycardia with a rate of 194 beats per minute (bpm) (Fig. ). Her heart rate varied between 180 and 210 bpm and her blood pressure was 187/101 mmHg on first recording. Suspecting SVT, the assessing emergency physicians proceeded with vagal maneuvers, to no clinical effect. Next, an intravenous bolus dose of 6 mg adenosine was administered. This was followed by immediate development of coarse VF (Fig. ) and circulatory collapse. Rapid deterioration to a fine VF ensued. She was successfully defibrillated with a single 150 J direct current shock. There was immediate return of spontaneous circulation and hemodynamic stability. A 900-mg loading dose of intravenous amiodarone was commenced and our patient was admitted to the cardiac high dependency unit. No further arrhythmias were identified.\nInvestigations revealed normal serum electrolytes, negative serial troponin measurements, normal thyroid function, and negative blood ethanol level. A urine drug screen was negative. A chest radiograph demonstrated clear lung fields. The presenting ECG was reviewed, and was likely to be that of AF with a rapid ventricular response, but with no clear ventricular pre-excitation. Similarly, her ECG in sinus rhythm had no features of ventricular pre-excitation (Fig. ). The Q-Tc interval was within normal range and there were no features of Brugada syndrome. In view of the developm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-month-old female infant had coronary reimplantation at age 3 months for ALCAPA. Postsurgical ejection fraction showed early improvement with subsequent deterioration. A diagnostic left heart catheterization performed as part of a heart transplant evaluation revealed severe ostial stenosis of the LMCA. She was referred for PCI of the left main coronary artery to relieve her heart failure and preempt transplant. Her physical exam was significant for congestive heart failure and failure to thrive. The patient's echocardiogram showed markedly depressed left ventricular function. A cardiac computed tomography angiography (CTA) and initial diagnostic nonselective root aortogram demonstrated stenosis of the LMCA at the site of ALCAPA reimplantation. Selective left coronary angiogram revealed severe kinking of the reimplanted LMCA at the ostium ().\nThe procedure was performed in the Pediatric Cardiology interventional suite after extensive discussion and planning with Pediatric and Adult Interventional Cardiology, Pediatric Cardiac Anesthesia, Pediatric Cardiothoracic Surgery, and Pediatric Cardiac Radiology. General anesthesia and a femoral arterial approach were utilized. An ascending aortic root angiogram was obtained in 2 planes to assess the ostial left main stenosis. Due to the small size of the infant aorta, a 6 Fr JR-4 guide was reshaped to engage the left main coronary artery. A BMW wire was used to cross the lesion. Since the infant left main coronary artery was small but was expected to grow with age, a somewhat larger (3.0 × 8 mm Vision bare metal) stent was carefully implanted in the proximal LMCA at less than nominal pressure to avoid distal dissection. A poststent angiogram showed that the stent had moved during implantation and missed the ostium with residual stenosis of the LMCA origin. Hence, a 3.5 × 8 mm Vision bare metal stent was placed into the LMCA ostium overlapping with the previous stent distally and protruding 1-2 millimeters in the aorta pro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case describes a 23-year-old male who was struck by a motor vehicle. Upon arrival at our hospital, the patient had a GCS of 8. FAST exam, chest radiograph, and computed topography (CT) of the head and cervical spine were obtained and were negative.\nExam of the lower extremities revealed abrasions over the left knee and tenderness over the lateral joint line with an effusion. The right knee was diffusely tender to palpation without effusion. The patient had palpable pulses in both feet with well-perfused extremities. Ankle brachial indices were performed and found to be >0.9. He demonstrated guarding and pain with the attempted Lachman maneuver of the left knee and slight opening of the left knee joint with varus stress. Radiographs were obtained and revealed a left knee Segond fracture ().\nMagnetic resonance imaging (MRI) of both knees was performed to evaluate for ligamentous injury. Left knee imaging demonstrated the Segond fracture along with a grade III lateral collateral ligament (LCL) tear with retraction (), a grade II tear of the popliteus tendon and anterior cruciate ligament (ACL) (), and a grade I medial collateral ligament (MCL) injury (), as well as partial thickness tears of the biceps femoris and vastus medialis. Right knee imaging revealed a grade III tear of the ACL and MCL (), grade II tears of the posterior cruciate ligament (PCL) (), LCL, and popliteus tendon, and a medial meniscus tear. The patient was placed in bilateral hinged braces with the left knee unlocked and the right knee in locked extension to aid with transfers from a bed to a wheelchair. The patient was also given a left foot drop boot for a foot drop discovered during a secondary exam. On hospital day three, the patient was discharged home.\nNine days after the accident, the patient presented to the clinic. He noted that the left-sided foot drop was improving."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man with a history of hypertension, bilateral thalamic hemorrhage, and decreased kidney function was admitted to our hospital because of congestive heart failure with extracellular volume overload. Volume control with drugs, such as diuretics, was unsuccessful and he was started on hemodialysis. Thereafter, he received various antibiotics for bacterial infections, including pneumoniae and urinary-tract and catheter-related infections. Simultaneously, he had continuous watery and sometimes bloody diarrhea, the etiology of which was considered to be CDAD due to a positive stool test for CD toxins. Despite treatment with metronidazole and vancomycin, the severity of the diarrhea was not ameliorated. Abdominal X-ray and computed tomography did not reveal any causal factors, and laboratory tests showed only slight elevations in the white blood cell count and C-reactive protein level. We suspected involvement of uncontrollable CDAD or other type of infection (such as mycosis, tuberculosis, or cytomegalovirus infection) and inflammatory bowel disease (IBD).\nColonoscopy showed multiple segmental ulcers in the ascending, transverse, and sigmoid colon, but not the rectum, which suggested infectious colitis or ischemic colitis (Fig. ). A biopsy specimen showed loss of glands, fibrosis, congestion, and edema, suggesting ischemia, with no findings of infection (Fig. ). Given these results and the fact that the patient was on dialysis and had severe arteriosclerosis, we provisionally diagnosed ischemic colitis caused by arteriosclerosis and hemodialysis. We stopped or adjusted enteral nutrition, avoided low blood pressure, and withdrew antibiotics; however, his diarrhea persisted. It was impractical to perform a second colonoscopy, as his performance status was severely worsened. Finally, he died of cardiac arrest 193 days after admission. The autopsy showed longitudinal and annular ulcers in the sigmoid colon. An autopsy specimen of the ulcers showed inflammatory p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old female with a past medical history significant for protein C deficiency and a history of pulmonary embolism comes with an urticarial rash associated with arthralgia. She did not have any history of fever or joint pain at that time. The episode started recently and was associated with high fever and significant joint pain and stiffness. She was seen in urgent care and treated with prednisone 20 mg. Her rash remained stable but she still had swelling and tenderness of bilateral knee and ankle joints and bilateral wrist and elbow joints.\nShe was seen for the same complaints in the emergency department. An X-ray of the bilateral knee was unremarkable; she was given morphine for pain and was sent for follow-up in the clinic. Meanwhile, suspecting a broad differential of autoimmune etiology, workup was done, including complete blood count, basic metabolic profile, liver function test, urine analysis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), ANA, complements, rheumatoid factor, hepatitis panel, human acquired immunodeficiency virus (HIV) rapid antigen test, and blood cultures. She was admitted to the hospital for increasing pain and fever of 101 F. Her white blood cell (WBC) count at that time was 30.1, with a neutrophilic predominance and significant bandemia; the liver function test was abnormal. Bone marrow biopsy was not performed because of no lab or physical findings of any hematological malignancy. Suspecting infectious etiology she was started on broad-spectrum antibiotics, vancomycin, and cefepime. Her blood cultures and urine cultures were negative. Suspecting infectious endocarditis, echo was done, which was again negative for vegetations, with preserved ejection fraction and normal valves and wall motion. With the given amount of tachycardia, she was also having an elevation of D-dimer. Computed tomography (CT) chest with contrast was done, pulmonary embolism (PE) was ruled out, and the lungs were unremarkable for any pathol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 1 was a 39-year-old male non-smoker who had been diagnosed with HoFH at 14 years of age. He had a positive family history of HoFH in his uncle and three of his first-degree cousins. The patient had been initially treated with oral simvastatin (80 mg) once daily. As the drug had gradually failed to maintain the total and the LDL cholesterol levels within the normal range, he had begun to undergo total plasma exchange and subsequent LDL plasma apheresis at 17 years of age. The combination of LDL plasma apheresis and statin therapy had been effective at that time.\nAt 24 years of age, he had presented with symptoms of heart failure class II according to the New York Heart Association (NYHA) functional classification, namely, angina and shortness of breath, and physical examination had been unremarkable apart from ejection systolic murmur over the second right intercostal space at the right sternal border. Coronary angiography had revealed an ostial right coronary artery (RCA) lesion with approximately 50% blockage and a left anterior descending artery (LAD) lesion with approximately 55% blockage. His echocardiography had revealed valvular aortic stenosis and SVAS with a pressure gradient of 73 mmHg and a mean gradient of 41 mmHg. The aortic annulus had been 1.6 to 1.8 cm, and his ejection fraction had been more than 55%.\nThe patient had been admitted at 25 years of age and undergone the Bentall procedure for SVAS, and he had tolerated the procedure very well. On postoperative day three, the patient had collapsed and had been intubated. Coronary angiography had shown stenotic ostial LAD and RCA. The patient had then undergone emergency CABG with the left internal mammary artery (LIMA) to LAD and saphenous vein graft (SVG) to RCA and obtuse marginal artery (OM). Three years after that, the patient had undergone mechanical mitral valve replacement and CABG reoperation (LIMA to diagonal and SVG to RCA"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old female patient with a medical history of infectious mononucleosis at age 16 and without any personal or familial history of neurological diseases was admitted with a newonset movement disorder. She presented with brief attacks of involuntary, sudden and painful hyperkinetic movements of the left limbs (hyperextension and external rotation of the lower limb and extension-pronation of the upper limb) and a left rotation of the head. She had twenty to thirty attacks daily for two days, lasting twenty to forty-five seconds. There was neither loss of consciousness nor postictal confusion or amnesia. The attacks occurred during position changes or sudden movements or even in cases of emotional stress. She was able to predict the occurrence of the attacks and even trigger them with specific movements of her left leg. Her relatives and her general practitioner thought it might be psychogenic movement disorders or epileptic seizures. The neurological examination was unremarkable between the attacks.\nBlood tests were normal. The electroencephalogram (EEG) showed neither asymmetric nor epileptiform activities. Her brain magnetic resonance imagery (MRI) revealed more than twenty hyperintense lesions in the supratentorial white matter in T2 and fluid attenuated inversion recovery sequences (, , and ). The largest (14 mm) was located in the left semi-oval center. Others were located in the right parietal, left cingular and left frontal areas. One left frontal lesion was enhanced after contrast (Gadovist®, Bayer Pharma AG, Leverkusen, Germany) injection (). Others were within and at the border of the corpus callosum. There were also periventricular lesions with radial disposition (). The spinal cord MRI showed several T2 lesions in the medulla oblongata and the cervical and thoracic spinal cords ( and ), with a discrete enhancement of a lesion facing the third and fourth cervical vertebras.\nThe 2010 McDonald diagnostic criteria of MS were fulfilled, so we did not per"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old man with British ethnicity was referred to a respiratory physician with cough, shortness of breath, and weight loss in February 2021. His CT chest showed mild centrilobular emphysema with scattered lung cysts bi basal dependent changes but no evidence of malignancy. Subsequently, CT abdomen and pelvis demonstrated an incidental finding of a 37 mm x 50 mm x 48 mm right iliac fossa well-defined mass highly suggestive of right SMA branch pseudoaneurysm with surrounding localized bleed showing contrast enhancement on arterial phase.\nFurther patients came under the care of the Vascular team. An urgent CT abdominal angiogram taken in February 2021 showed a pseudoaneurysm arising from a terminal branch of SMA in the right iliac fossa, further suggesting an increase in size from 37 mm x 50 mm (anteroposterior [AP] × transverse [TV]) to 47 mm x 53 mm in maximum axial diameter since last CT scan and concluded as progressing SMA pseudoaneurysm (Figures -).\nAfter discussion in the angiogram meeting in February 2021, by the team of Vascular consultants and Interventional radiologists, the decision was made in favor of endovascular embolization of pseudoaneurysm as an urgent procedure, due to the progression in size of SMA pseudoaneurysm. Supra selective embolization of the SMA pseudoaneurysm was done by the Interventional Radiology team using Right Common Femoral Artery 5F access, and MynxGrip assisted hemostasis in local anesthesia (20 mL of 0.5% levobupivacaine). The SMA and subsequently ileocolic artery were accessed using a Terumo wire and Cobra catheter. Selective SMA angiogram confirmed a right iliac fossa pseudoaneurysm supplied by the terminal branch of the SMA (Figure ). Two fine platinum coils (Spirale) were used to embolize the pseudoaneurysm front and back door with good results and no complications (Figure ).\nA post angiography run confirmed the coil successfully deployed and excluded flow into the pseudoaneurysm. His vital signs remained stable throug"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male was referred to the Oral Medicine Department by Dermatology in July 2008, with an 8-month history of blistering and soreness of the oral mucosa. On examination, there were small erosions and ulcers present on the soft palate and bilaterally on the buccal mucosae. The patient had been under the care of Dermatology since 2003 for an itchy rash on the legs, scalp and chest. A biopsy from a crusted lesion on the scalp (Fig. ) in 2003 revealed acantholysis of the keratinocytes in the upper part of the prickle cell layer (Fig. ), and direct immunofluorescence studies showed IgG positivity around the upper epidermal cells. These features were consistent with a diagnosis of PF. He was started on Mycophenolate Mofetil (MMF) 500 mg twice a day and Prednisolone 10 mg once a day by Dermatology in 2006, which had resulted in excellent control of his cutaneous lesions. Prior to this, Azathioprine alone had been introduced on two occasions by Dermatology, however the patient failed to tolerate it due to nausea and vomiting. Oral involvement only began in January 2008 which required hospital admission for a short period.\nHis only other relevant medical history was hypertension, for which he took Nifedipine. At initial presentation, he was also taking Ranitidine and Alendronic Acid for protection against osteoporosis with prolonged systemic corticosteroid use. He was a non-smoker and had low alcohol intake.\nAt initial appointment, MMF dose was increased to 1 g in the morning and 500 mg in the evening for 2 weeks, and thereafter 1 g twice a day. Full blood count, urea and electrolytes and liver function tests were normal, and regular blood monitoring was carried out appropriately. In light of good response to systemic therapy and as only very small erosions/ulcers were present at this point, oral biopsy was not arranged. He was seen regularly on the joint Oral Medicine/Dermatology clinic and complete resolution"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old nulliparous Caucasian woman had a normal vaginal delivery in hospital at 38-week gestation. She had a spontaneous rupture of membranes and onset of labour 10 hours later. First stage of labour was 4.5 hours and second stage 1.5 hours. Although she did not have a prolonged second stage of labour she had been crying out loudly during the labour, as she had declined an epidural anaesthetic and all other forms of analgesia. She delivered a healthy boy weighing 3500 g.\nHer husband noted that she had a swollen neck on the first postpartum day, and relatives who had been speaking with her over the telephone had commented that her voice was altered. The patient reported that when she first stood up after the delivery she had felt a tight sensation in her neck and upper chest which worsened with deep inspiration. However, she denied any shortness of breath. She did have some difficulty swallowing initially and a sore throat but felt that this had improved and was tolerating a normal diet.\nOn examination she was not in respiratory distress, and oxygen saturation was 98% on room air. She did not appear pale or cyanosed. Blood pressure was 110/70 mmHg and heart rate 90 bpm. She was afebrile. There was palpable crepitus over both sides of her neck up to the level of the preauricular region on the right.\nThere was isolated T wave inversion in lead III of the electrocardiogram which is not unusual in pregnancy. Chest X-ray revealed extensive subcutaneous emphysema in the neck and over the right chest wall with a small pneumothorax on the right and minor pneumomediastinum []. Arterial blood gas analysis was normal.\nShe was transferred to a tertiary centre where she underwent a gastrografin swallow fluoroscopy to exclude oesophageal perforation. The swallow was normal, and she requested discharge from the hospital the next day. However, home reviews by the midwife reported that the subcutaneous emphysema had resolved by day 5 postpartum."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn order was received for microarray based, comparative genomic hybridization (array CGH) on a 3 year-old female due to a delay in social and language development and question of features of autism spectrum disorder. The patient received regular speech therapy due to speech delay (reported to not speak) and occupational therapy. Review of medical records revealed that a hearing evaluation had not been performed due to lack of cooperation. Her diagnoses included attention deficit-hyperactivity disorder, autism spectrum disorder and sensory processing disorder, and developmental language disorder. The patient’s gross motor skills were within the normal range. Normal vision was reported by the parents, but no formal evaluation had been performed. Normal muscle tone and growth was reported by the pediatrician. Orthopedic evaluation revealed no orthopedic concerns. Genetics evaluation revealed no dysmorphic features. The patient was reported to have a latex allergy. Echocardiogram was performed with a normal result. Magnetic resonance imaging (MRI) of the brain revealed Chiari I malformation resulting in moderate effacement of the cerebrospinal fluid space at the cervicomedullary junction. Findings revealed that the cerebellar tonsils project approximately 9 mm into the foramen magnum. See Table for a comparison of the patient’s features to features of 22q11 duplication syndrome described previously.\nThe patient had one full brother who was 4 years-old and was reported to be healthy with no developmental concerns. Her mother was reported to have had a patent ductus arteriosus (PDA) and patent foramen ovale (PFO) not requiring surgical repair and a history of migraines. She was currently 23 years of age with no major health or developmental concerns. Maternal family history was significant for a cousin with a 5 year-old daughter with autism. Maternal ethnic background was Caucasian (German and Irish) and Native American (Comanche). The father was 25 years of age and repor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male suffered a valgus injury to the right knee due to a fall during a bigfoot race he took part in when he was 15 years old. He visited a different hospital because of right knee pain and effusion. However, no obvious ligament injury or fracture was noted on MRI and physical examination, and the patient was followed up at the hospital. At the age of 17, the patient gradually became aware of the valgus deformity of the right knee. At the age of 18, the valgus deformity had further progressed, and the patient visited our department due to continuous right knee pain. There were no comorbidities in particular and no past medical history of note. At the time of his initial visit, the patient was the manager of a high school baseball club. A physical examination revealed that the valgus deformity of the right knee was visibly obvious (). Joint effusion of the right knee and tenderness on the lateral condyle of the femur were noted. The range of motion was 0 (extension) to 140 (flexion) degrees denoting a slight flexion restriction. Lower limb length discrepancy (spinomalleolus distance (SMD)) was −3.0 cm in the right lower limb. X-ray images at the time of the initial visit to our department showed severe valgus deformity with a femoro-tibial angle (FTA) of 160 degrees and % mechanical axis (%MA) of 100% from the medial edge of the tibial plateau (). Valgus deformity of the right knee was pronounced with a mechanical lateral distal femoral angle (mLDFA) of 71 degrees in contrast to that of left mLDFA which was 87 degrees, whereas the medial proximal tibial angle (MPTA) was normal at 85 degrees (left: 85 degrees), suggesting that the femur side was at the center of valgus deformity. X-ray images taken at the time of injury (at age 15) showed no obvious fractures or growth plate fractures (). MRI at the time of injury (T"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old Hispanic female presented with complaints of progressive nasal congestion and mass in the right nasal cavity. Initial biopsy of the mass was felt to be benign. A year later, her right nasal mass recurred and again was reexcised with pathology reported as benign. A few months after her second surgery the mass had rapidly grown in size filling her mouth and causing right facial swelling (). She had difficulty eating and swallowing. CT scan of the neck showed an extensive destructive mass measuring 5.5 cm × 5.3 cm × 7.1 cm with extension into the medial wall of maxillary sinus and extending to the inferior orbit (Figures and ). She had evidence of metastases to her right neck but there was no intracranial extension.\nThe lesion was biopsied and sent to two referral centers for assistance in making the diagnosis. The first referral center determined that the lesion consisted of a “polypoid sinonasal mucosa with ulceration, with acute and chronic inflammation and spindle cell proliferation, favoring reactive changes.” Immunohistochemical stains including smooth muscle antibody (SMA), desmin, S100, and keratin were all negative.\nThe patient went to second referral center for further treatment. At this institution, the report was slightly different, determining the sample to be consistent with an IMT, but found it had scattered positivity for ALK-1 and SMA within spindled cells. This is significant, because a diagnosis of IMT is quite difficult; however, one would expect samples from the same tumor biopsy to show similar SMA staining. The complexity of this tumor is further noted in that another biopsy, three years following the initial pathology report, differed from both of the previous reads.\nMost recently, the second referral center reported immunohistochemistry stains demonstrating a profile different than the prior biopsies, with rare tumor positivity for SMA, and negativity for S100, pan-keratin, p63, and ALK-1. Next-Generation Sequencing- (NGS-) based"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old Thai woman presented with a foreign body in her left orbit that had been retained for 8 months. Eight months previously, she had sustained a gunshot injury to her left eye. There was only a small wound on her left eyelid (Fig. ); she had normal eye movement, a normal visual field, and no pain. A plain radiograph was performed at that time; it detected a round-shaped metallic foreign body located medially in her left eye globe. She was then diagnosed as having a retained foreign body in her left orbit and she was advised to have clinical observation. However, 8 months later, she developed pain in her left eye without any sinonasal symptoms. After discussion about the risk of surgery and retention of an orbital foreign body, an ophthalmologist referred her to our department for the minimally invasive procedure option of removal of the foreign body using an endoscopic transnasal approach. On examination, the movements of her left orbit were not restricted and there was normal visual acuity (20/20) with no proptosis or chemosis. A computed tomography (CT) scan of her left orbit revealed a round-shaped metallic foreign body in the medial intraconal space, and lateral attachment of posterior ethmoid sinus, measuring 6 mm (Fig. ). A transnasal endoscopic approach, with navigator assistance (Brainlab), was used to remove the bullet. Uncinectomy and anterior-posterior ethmoidectomy were performed. The location of the intraconal metallic foreign body was confirmed with a navigator system, then part of the lamina papyracea was removed and the periorbita incision was done. The defect was enlarged and the fibrotically encapsulated bullet was found lying in the orbital fat (Fig. ). The fibrotic capsule was dissected, and the bullet was delivered through her left nostril with probes and curetted (Fig. ). No intraorbital bleeding or damage to any soft ocular structures was noted. A relative afferent"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old male with a medical history significant for hypertension, hyperlipidemia, and chronic smoking underwent evaluation for recurrent chest pain symptoms with coronary angiography. Access was obtained through the right femoral artery and six French sheaths were placed over the guide wire. Coronary angiography did not reveal any evidence of significant coronary artery disease. The sheath was removed without significant problems. A Mynx closure device was deployed and manual pressure was held for five minutes at the access site. The patient tolerated the procedure well and was discharged home the same day and recommended to follow up in the clinic. The patient returned to the clinic two weeks later with complaints of right groin pain, redness, and swelling that has been worsening for last one week. The patient reported that he had groin pain that started a week after the procedure which initially happened during exertion or ambulation and then progressed slowly at rest as well. Follow-up examination revealed a 2 cm mobile, pulsatile, and non-tender right groin mass in the instrumented area with associated bruising of groin and inner thigh and significant edema of the right leg. Lower extremity Doppler ultrasound was performed that showed DVT of the common femoral, superficial femoral and profunda femoral veins (Figure ).\nThe patient did not report any history of trauma, intravenous drug abuse, prolonged immobilization, family history of blood clots, and recent travel. The patient had computed tomography (CT) scan of the chest, abdomen, and pelvis to further evaluate the etiology and extent of the thrombosis. A CT scan of the pelvis showed right groin pseudoaneurysm 3.1 cm x 2.8 cm. The pseudoaneurysm was compressing the femoral veins which were responsible for DVT in the right common femoral and superficial femoral veins (Figure ).\nThe patient was started on low molecular weight heparin drip and evaluated by vascular surgery for thrombin injection the next da"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 32-year-old immunocompetent Iranian male who presented to the emergency room with a generalized tonic-clonic seizure lasting for 3 minutes. He denied any history of trauma, fever, or previous seizures. Furthermore, he did not have any genitourinary symptoms, including dysuria, hematuria, or penile discharge. A computerized tomography (CT) scan of the head failed to show any acute central nervous system insult.\nAfter that, the patient was admitted to the hospital. Prior to this admission, he gave history of an admission 12 months ago to a hospital outside the country, where he complained of fatigue, weight loss, and fever. Reports from the hospital showed that he also had chronic moderate ascites and a left pleural effusion. However, several laboratory and imaging tests were done and it was concluded that there was no evidence of infectious disease, chronic liver disease, or malignancy. It was recommended that he may need more investigations or a laparoscopy with peritoneal tissue biopsy, which was not done.\nUpon the latest admission, the respiratory rate was 12 breaths per minute, the body temperature was 36.9°C, and the blood pressure was 112/70 mmHg. The patient had mild tachycardia of 109 beats per minute. Physical examination was unremarkable including the respiratory system examination. Digital rectal examination was not performed since the patient did not have any genitourinary or gastrointestinal symptoms. During this hospitalization, the patient received anti-epileptic treatments and multiple investigations were done. The laboratory investigations, urine routine and microscopy, cultures, virology screen, including human immunodeficiency virus, as well as the autoimmune markers did not show any significant issues. Also, three sets of sputum acid-fast bacilli smears were done, which were all negative. Further invasive tests were performed including endoscopy and colonoscopy which were unremarkable. A lumber puncture was also performed wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old male presented with a 1-day history of intermittent gross painless hematuria. His past medical history included herniated lumbosacral disk with radiculopathy, otherwise unremarkable. Social history included current smoking, 6 pack/year, and occasional EtOH. The patient was single and had no children; family history was negative for genitourinary malignancies. Physical examination was unremarkable with BMI 23 and BP 120/86 and no prescribed medicines or drug use. Laboratory tests showed normal CBC, normal coagulation profile, and normal renal function.\nAxial, contrast-enhanced CT demonstrated a centrally located, 4 x 4 x 4.6 cm, lobulated mass invading the renal vein and extending into the lumen of the infrahepatic inferior vena cava (). CT angiography of the chest showed no evidence of detectable pulmonary emboli and bone scan was negative for metastases.\nRight radical nephrectomy, partial adrenalectomy, inferior vena cava tumor thrombectomy (infrahepatic), and extended retroperitoneal lymphadenectomy were performed; flexible cystoscopy performed during this surgery showed a bulbar urethral stricture (not clinically significant) and otherwise normal bladder. The intravascular tumor pedicle was easily removed intact from the vein lumen by pulling.\nGross examination of the nephrectomy specimen demonstrated a centrally located tumor with no gross invasion of adjacent tissue but with the pedicle extending into the inferior vena cava (). Grossly, the tumor pedicle had a smooth surface and no attachment to the renal vein. Grossly, the mass was partially cystic with variably sized cysts with a smooth lining. The intervening stroma formed grossly discernible nodules of variable thickness. No tumor necrosis was grossly apparent. The lesion appeared to be well demarcated with no invasion of adjacent kidney parenchyma.\nMicroscopically, the tumor was well demarcated with an elongated pedicle bulging into the renal pelvis and renal vein and a biphasic morphology wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old male with a history of chronic pain secondary to idiopathic retroperitoneal fibrosis (RPF) was referred to our tertiary cancer pain clinic for pain management. The pain started in his low back and primarily radiated across his abdomen and into his lower extremities. His abdominal and pelvic MRI showed an enhancing retroperitoneal mass surrounding the aorta with compression of the ureters and inferior vena cava.\nAfter a complete evaluation, the patient was placed on oral opioids, including methadone and hydromorphone, as well as adjuvant medication therapy, including baclofen and gabapentin. Despite this treatment, he continued to have intractable pain and a decision was made to offer an IDDS trial after a few months. The trial was successful, and he subsequently had a permanent IDDS implantation with morphine infusion. After about two years, his pain symptoms progressed and he was offered a spinal cord stimulator (SCS) as an off-label use for the intractable abdominal, pelvic, and back pain. SCS was implanted after the completion of a successful trial.\nOver the course of treatment, his intrathecal medications were escalated to morphine 33.08 mg/day, clonidine 661 mcg/day, and baclofen 248 mcg/day. Initially, his pain was managed well, but he eventually showed declining functional status with progressive weakness in his lower extremities and increasing pain. At this point, it remained unclear whether his pain and neurological symptoms were due to catheter-tip granuloma, worsening RPF, or a non-functioning SCS. Therefore, a CT myelogram was ordered. The risks of paralysis were explained to the patient; however, he deferred imaging at that time. Later, the patient also reported that his SCS was causing pain at the implantation site and he wanted it removed. Since he began developing progressive neurological deficits, a decision was made to explant his non-MRI compatible SCS. After this surgery, the patient refused to obtain imaging studies as ordered. For"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male was referred to our hospital complaining of left flank pain. At physical examination, nothing relevant was observed and laboratory findings were within normal limits. A CT examination of the abdomen and the pelvis was performed with a multidetector scanner, before and after contrast media administration. Portal phase images showed a large amount of solid tissue in the left perirenal space, infiltrating the renal capsule and the main renal vessels; the tissue did not show significant contrast enhancement. Similar findings were detected also in the right perirenal space (). CT images also revealed a partial stenosis of the common bile duct, with intrahepatic bile duct ectasia owing to hypervascular eccentric tissue (). Hence, a diagnostic integration with endoscopic retrograde cholangiopancreatography was performed to exclude an intraductal proliferation. A biopsy was also performed in the left perirenal space; the pathological samples were composed of connective and adipose tissues, revealing the histological features of a DT or abdominal fibromatosis and also showing immunohistochemical markers typical of muscular tissues, such as actine. The tumour was considered unresectable and medical therapy was started with tamoxifen (20 mg die–1); after an episode of thrombophlebitis, the patient asked to suspend tamoxifen and accepted a new therapeutic regimen (docetaxel 75 mg m−2 every 3 weeks); unfortunately, even this treatment was discontinued after only 4 weeks owing to neuropathy. A new CT examination was then performed to assess the results of the treatment. Unexpectedly, on venous phase images, the perirenal tissue showed a remarkable reduction on the left side and had almost disappeared on the right side (). The peribiliary tissue had equally decreased in size and thickness (). The treatment was then discontinued in accordance with the patient’s decision. 1 year later, both the left perirenal and peribiliary tissues demonstrated no progression and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second case involved a 70-year-old Native American man presenting with upper back pain and numbness of his right foot for approximately 10 days. The symptoms had worsened, and he noticed some difficulty with walking. He did not have any past medical or surgical history. He was a former tobacco smoker and stopped smoking approximately 20 years ago, but it is unknown how many packs or cigarettes per day he smoked. He drank alcohol very rarely and not significantly. He did not have family history of any significance. He was never on medications until he was diagnosed as having HCC. He worked at a warehouse in the past. His job position was unknown. He has no known environmental or drug allergies. On admission, his BP was 166/119 mm Hg, HR was 97 beats per minute, and temperature was 36.7 °C. His physical examination had the following results: he was normocephalic, he had a non-traumatic skull, he had normal hearing, he had no nasal discharge, his chest wall movement was symmetric, his breath sounds were clear, he had no rales/wheezing, his HR was within the normal limit and had regular rhythm with no murmurs or thrills, his abdomen was soft with no distension, there was no palpable mass, there was no hepatomegaly or splenomegaly, a bilateral pedal pulse was present, there was no visible joint swelling, his skin was warm to the touch, he had normal color, and he had no rash/ulcers. A neurological examination had the following results: he was alert and awake; he was oriented to time, his name, and his location; his cranial nerves were grossly intact; he had no gait disturbance or motor deficits; his superficial reflexes were intact; a slight decrease in sensation over his right lower extremity was noted. Abnormal laboratory results were as follows: aspartate aminotransferase level of 104 U/L and alanine aminotransferase level of 90 U/L. CT of his chest"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA twenty-five-year-old female was injured after falling from the back bumper of a moving truck. Her past medical history was significant for unspecified anemia and her surgical history included four previous cesarean sections. The patient presented to the emergency department of our level 1 trauma center and was evaluated by the orthopaedic trauma service and the general surgery trauma service. She was found to have an isolated injury to the left knee. Plain radiographs and computer tomography (CT) scans of the knee showed a lateral split depression type fracture of the tibial plateau (Schatzker type 2), mostly in the anterior portion with a vertical split (Figures and ). Upon application of a knee brace in the emergency department, obvious posterolateral instability was noted. A detailed ligamentous exam in the emergency department was deferred due to the acute injury and the patient's significant discomfort. Based on the physical exam findings, Magnetic Resonance Imaging (MRI) of the knee was indicated. The results of the MRI showed no injury to the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, or meniscal damage (Figures and ). However, the MRI demonstrated a concomitant injury to the posterolateral corner (Figures –).\nThe patient was taken to the operating room on the first day after her injury. Open reduction and internal fixation was performed through a standard lateral approach to the proximal tibia including a submeniscal arthrotomy. Surgical fixation was achieved using a precontoured lateral proximal tibia plate by the manufacturer Smith and Nephew. After the fracture fixation, a detailed ligamentous exam was performed. This physical examination showed joint laxity to varus stress, 1+ at zero degrees and 2+ at thirty degrees. In addition, she had a positive tibial dial test at thirty degrees. These findings confirmed the diagnosis of posterolateral knee instability and established the indication for a PLC repair. A for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old lady reported to our Department of Oral and Maxillofacial Surgery with a chief complaint of swelling in the left preauricular region since six months. The swelling was first small and then gradually increased in size and was not associated with pain []. She gave a history of surgery in the left parotid region, which was done about 10 years prior, but we could not get the details as she had misplaced the previous records.\nOn inspection, there was deformation of the left parotid gland region by a mass measuring about 5.8 × 4.9 cm in dimension. The patient did not present with facial palsy or ear sensory disturbances. The classical sign of parotid swelling, which was elevation of the left ear lobe, was present.\nOn palpation, the swelling was firm in consistency, fixed to the deep planes, and the superficial skin was normal, with no ulceration. In the cervical region level, the I, II, and III region lymph nodes were hard in consistency and fixed, the largest measuring about 3.5 × 2.3 cm in dimension. The level V region lymph nodes were palpable and mobile. Preoperative chest and vertebral radiographs and ultrasonography (USG) of the breast and ovaries were performed, to rule out metastasis. All the three scans showed no distant metastasis. A preoperative CT scan was taken, with contrast, which showed a heterogeneous ill-defined lesion, seen in superficial part of the left parotid gland, with few areas of low-density necrosis. A contrast CT showed heterogeneous enhancement, which did not enhance further on delayed images.\nFine needle aspiration cytology (FNAC) of the parotid gland swelling, from the level V lymph node region, was performed, which showed cells in clusters and singly scattered, round to oval cells, with a pleomorphic vesicular nucleus, prominent nucleoli, and scanty cytoplasm. The background showed necrosis mixed with blood. The Level V lymph node showed numerous aggregates of ductal epithelial cells, showing cellular pleomorphism"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of an 11-year-old girl who presented to the Emergency Department for diffuse pain of the left hip after a fall. Her medical and family history was unremarkable. A clinical examination showed mild, diffuse swelling of the left hip. The swelling was firm and non-tender, with moderate to severe painful manipulation. This was associated with pain-related decreased mobility of the hip. The patient was unable to walk. Plain radiography of the left hip in the frontal and lateral views showed an extensive osteolytic lesion in the proximal metaphyseal femur and femoral neck with thin sclerotic margins, with no invasion of the growth plate (). Magnetic resonance imaging and a computed tomography (CT) scan of the hip showed the presence of an ABC in the proximal third of the left femur, with no extension in the adjacent soft tissue. Selective arterial embolisation was performed to devascularise the tumour, promote healing, and decrease the risk of high bleeding during the biopsy procedure. For this purpose, absorbable gelatine sponge particles were used. A biopsy was achieved through a lateral approach centred on the greater trochanter. A hole was drilled at the inferior pole of the cyst, thus reaching the haemorrhagic lesion where blood and cystic soft tissue were obtained for a histopathological exam. After the diagnosis was confirmed, we performed a second selective arterial embolisation to limit development of the ABC. The patient’s progress was favourable, with decreased local pain, and she gradually regained mobility.\nOne month later, local progression of the ABC was favourable. Radiographic findings showed osteosclerotic margins at the tumour site. Pain in the left hip was further diminished and the full range of motion was regained. At the 8th and 12th weeks of check-up, plain radiography was performed and showed no progression of the bone cyst. After approximately 16 weeks, the patient experienced moderate local pain. An X-ray showed that the osteolyt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old woman presented to the Accident and Emergency department (A&E) with a two-day history of swelling and pain in the left buttock. She had a past history of hypothyroidism, depression and a hysterectomy for menorrhagia. Clinically there was a soft, diffuse, tender mass in the left buttock, with no evidence of abscess or cellulitis. Blood tests including inflammatory markers were normal. The surgical team suspected a diagnosis of a lipoma and discharged the patient with an outpatient ultrasound scan (USS).\nThe patient re-attended A&E three weeks later with increased buttock swelling and discomfort. The USS reported an irregular hypoechoic mass 6.9 × 4.5 × 3.2 cm in size situated 2 cm deep to the skin and extending towards the medial aspect of the left buttock, suggestive of an abscess. However, the clinical examination did not correlate with the radiological diagnosis and the patient was discharged following a brief admission for analgesia. An outpatient magnetic resonance imaging (MRI) scan was arranged.\nThe MRI suggested a large pelvic liposarcoma and hence a staging CT scan was done (Figures , and ). This reported the soft tissue mass displacing the bladder and rectum as it extends from the level of sacroiliac joints and through the greater sciatic notch into the buttock. The CT concludes that a sarcoma is less likely a diagnosis than a cystic neoplasm. The patient was referred to a consultant surgeon at a regional Sarcoma Unit for treatment.\nAn elective admission was arranged for full excision of the tumour via an incision into the buttock, and the patient was discharged at day 10. The main complications postoperatively were pain and a haematoma which discharged spontaneously. Histology confirmed an aggressive pelvic angiomyxoma. The patient is currently under follow-up with repeat MRI scans to assess for local recurrence and is awaiting further investigation of a suspicious lesion seen at her most recent scan, only 12 months post-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 40-year old woman with a history of endometriosis and infertility. In the spring of 2014 she developed pelvic pain. Trans-vaginal ultrasound revealed endometriosis and a complex cystic mass of the right ovary consistent with possible malignancy. The CA-125 was 32. She was taken to the operating room for a laparoscopic right ovarian cystectomy. Based on visible tumor within the ovary at surgery, the operation was converted to a staging laparotomy with traditional cytoreductive surgery with total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymph node dissection, peritoneal biopsies, and peritoneal washings. No residual disease remained after surgery. Pathology disclosed clear cell carcinoma of the right ovary. Examination of the uterus revealed adenomyosis and endometriosis with focal clear cell carcinoma near the parametrial margin; 13 pelvic and para-aortic lymph nodes from the right and 15 from the left side showed no evidence of metastatic disease. The omentum contained a small focus of malignant cells, however the remainder of samples from the pelvis, paracolic gutters, and the undersides of the diaphragms revealed no cancer. She was staged as having FIGO stage IIIA2 clear cell carcinoma of the ovary.\nBeginning in June 2014 she was treated with post-operative, adjuvant, dose dense paclitaxel and carboplatin x 6 cycles, which were completed in October 2014. A post-treatment PET scan in October 2014 revealed metastatic progression with hypermetabolic metastatic disease in the liver and multiple sites of hypermetabolic lymphadenopathy throughout the pelvis including the vaginal cuff. Chemotherapy utilizing pemetrexed and bevacizumab was administered the following week for three treatment cycles until December 2014. In January 2015, another PET scan disclosed new hypermetabolic disease in the left lung measuring 8 mm, additional new hypermetabolic lymph nodes in the left iliac chain, and progression in th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old Bosnian female with prior aortic valve replacement with a bioprosthetic valve for aortic regurgitation was admitted to our facility for worsening shortness of breath, fever, and lethargy. She was on a vacation in Bosnia, where she fell ill, was hospitalized for 1 month, and was treated for suspected sepsis and renal failure. Medical records from her prior hospitalization in Bosnia were not available. She had an extensive past medical history, pertinent for coronary artery disease, diastolic congestive heart failure, atrial fibrillation, chronic kidney disease, systemic hypertension, cerebrovascular accidents, and chronic urinary tract infection (UTI). Physical examination revealed neck vein distention, bibasal crackles, and bilateral pitting edema. Auscultation revealed an irregularly irregular heart rhythm, a grade 3/6 systolic ejection murmur in the left lower sternal border, and a grade 2/6 early diastolic murmur. EKG revealed atrial fibrillation with low voltage QRS, without evidence of bundle branch blocks or conduction delays. Within an hour, she became markedly hypotensive and hypoxic. She was subsequently intubated and started on a dopamine and norepinephrine infusion. The patient was treated for septic shock with intravenous vancomycin and meropenem. Two sets of blood cultures showed growth of Enterococcus faecalis that was sensitive to penicillin and vancomycin. A bedside transthoracic echocardiogram (TTE) revealed new paravalvular leakage around the bioprosthetic aortic valve, raising concern for an aortic root abscess. She was transferred to a tertiary care facility for possible surgical intervention. A transesophageal echocardiogram (TEE) revealed an extensive aortic root abscess involving the entire root and base of the anterior mitral leaflet. The abscess had ruptured into the left atrium, which contained a 5–7 cm cystic mass, with a fistula connecting from the aortic root to the left atrial cavity, running through the mass. The abscess"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male with medical history of hypertension, dyslipidemia, strokes, initially presented to the Neurology clinic with new transient episodes of gait disturbance, left-sided dysmetria, intermittent diplopia, and vertigo. His symptoms were attributed to recurrent transient ischemic attacks involving the posterior circulation. Computed tomography angiogram (CTA) of the neck showed moderate left vertebral artery (VA) V4 and origin stenoses. His symptoms persisted despite being on aspirin, clopidogrel, and atorvastatin. After 4 months, a repeat CTA neck showed progression of left VA stenoses with development of a V4 segment intraluminal thrombus (). He was started on oral anticoagulation for 2 weeks without symptoms improvement; therefore, a decision was made to proceed with elective cerebral angiogram with the intent to treat the left VA origin.\nCerebral angiogram one week later showed 90% left VA origin stenosis and distal V4 segment occlusion. Final angiography following left VA angioplasty revealed markedly improved VA flow, and 50% remaining stenosis of the proximal left VA.\nA few hours postoperatively, the patient developed new onset left upper extremity dysmetria and paresthesia that resolved after 10 minutes. He was discharged from the hospital after 2 days without needing physiotherapy. On the following day, he returned to the emergency room with left hemibody paresthesia and gait unsteadiness. MRI brain showed acute posterior upper cervical cord infarction, confirmed with a dedicated MRI cervical spine (). CTA neck showed no restenosis of the left VA origin and patent V4 segment with resolution of previously seen thrombus (). His physical examination revealed decreased vibration and proprioception and dysmetria on the left upper and lower extremities, with positive Babinski sign ipsilaterally, and no loss of temperature or pain sensations. He was discharged home the following day with the plan to continue aspirin and clopidogrel and outpatient physio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe are reporting a 57-year-old Arabic female who noticed a lesion of the right side of the scalp in July 2019, it was not tender and measured approximately 1.5 cm. She underwent a partial excision at a local hospital with a preliminary diagnosis of a benign lesion. The final pathology was a malignant lesion. No official pathology report was available for review. She refused further management. The lesion progressed again rapidly within one month; she presented herself to another private hospital where more radical surgery was carried out with left selective neck dissection, this was done on October 16, 2019. The pathology report was spindle cell squamous cell carcinoma, all margins were negative and all the lymph nodes were negative. She was referred to King Fahad Medical City, Riyadh, Saudi Arabia, in November 2019 for further management. She was a fit lady, not a smoker or drinker, however, was a known diabetic on oral hypoglycemic drugs for 10 years with fair glycemic control. She was complaining of mild pain at the site of the lesion with no other associated symptoms. On examination, there were two small nodules at the margins of the previous surgical scar. The superior nodule measure 1 cm x 1.5 cm and the other was 1.5 cm x 2 cm at the inferior surgical margin (Figure ).\nShe underwent full reevaluation with magnetic resonance imaging (MRI) of the head and neck and computer tomography (CT) of the chest, abdomen, and pelvis. The MRI showed that there was evidence of residual/recurrent soft tissue tumor at the superior and inferior aspects of the surgical bed. The first lesion at the high left parietal area measured 1.2 cm x 2 cm x 2.1 cm, it demonstrated features of internal hemorrhage. The other lesion noted at the left occipital region measured about 1.2 cm x 2.3 cm x 2.5 cm. Both lesions demonstrate post-contrast enhancement. There was no evidence of underlying bony involvement"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old otherwise healthy female presented to the clinic with complaints of progressive breast enlargement and pain over the past 3 months. Specifically, she described a more pronounced acutely developing enlargement of the right breast when compared to the left, associated with worsening discomfort and pain. Of note, the patient underwent bilateral augmentation mammoplasty using PAAG injections in China 18 years ago. She denied other associated symptoms such as fevers, chills, shortness of breath, or nipple discharge, as well as any new palpable breast masses or previous trauma to the breasts.\nOn physical examination, she was afebrile and well-appearing with stable vital signs. The patient had significant breast asymmetry, with the right breast markedly larger than left, as well as associated tenderness to palpation, enlargement of nipple areolar complex and presence of dilated superficial veins (). The right breast was noted to be more erythematous and warmer to touch when compared to the left. There were no palpable breast masses, axillary lymphadenopathy or inversion of the nipples.\nDiagnostic work up included mammography and magnetic resonance imaging (MRI) of bilateral breasts. Mammography demonstrated presence of breast implants with extensive fibrous capsule discontinuity, suspicious for foci of intracapsular rupture that were more pronounced on the right. There was an air-fluid level within the implant of the right breast, representative of an extracapsular rupture which likely accounted for the size discrepancy between the breasts. MRI demonstrated diffuse nodular thickening of both capsules surrounding the PAAG implants, which was associated with mural nodules with nonvascularized finger-like projections ranging in size from 3 mm to 1.4 cm. Although these findings were benign, the patients acute breast enlargement, pain and evidence of extracapsular rupture with extravasation warranted surgical management.\nThe decision was made to proceed with remov"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old female patient visited the orthodontic clinic with a chief complaint of frequently biting her cheek. Her medical and dental history was insignificant except for the extraction of the upper and lower left first molars and the upper right third molar. The anterior teeth were restored by ceramic veneers, which were not satisfactory. She had undergone multiple root canal treatments. Temporomandibular joints were healthy except for TMJ clicking. The patient was periodontally healthy\nExtra-oral examination revealed good facial proportions with a slightly convex profile and an acute nasolabial angle. The upper midline was centered to the facial midline, and the lower midline was deviated 2 mm to the right of the upper midline. (Figure )\nDentally, the patient had Class I canines and buccal segment relationships, a 4-mm deep bite, a normal overjet, and a normal curve of Spee. There was 2 mm of crowding in the lower anterior segment, while the remaining space for the missing tooth number 37 was about 4 mm. There was a unilateral posterior crossbite on the right side due to unilateral constriction of the maxillary arch, compensated for by lingual tipping of the lower right first and second premolars and lower right second molar (Figure , , ).\nRadiographically, the patient had a Class I skeletal relationship with normal mandibular plane and lower facial height. Upper and lower incisors were retroclined and retruded (Table ). The lower left third molar was partially impacted and in a mesioangular direction. The lower right third molar was mesioangularly impacted (Figure , ).\n- To correct posterior crossbite via unilateral CAE.\n- To resolve crowding, eliminate rotations, and correct lower midline deviation.\n- To close the residual spaces of old extraction sites.\n- To correct the deep bite.\n- To upright the lower left third molar and extract the contralateral one.\n- To achieve functional occlusion with maximum intercuspation,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old male patient presented with complaints of pain in the left hip since 1 year and difficulty in walking for 6 months. There was no history of trauma, fever, weight loss, and not a known case of diabetes and hypertension. The patient was diagnosed as tuberculosis left hip in the outside hospital without any biopsy, for which he had taken anti-tubercular treatment for 9 months, and still patient was not relieved of pain and stiffness. On examination, the patient had mild tenderness over the left hip with the restriction of joint movements. He had flexion deformity of 30°, adduction and external rotation deformity of 10 and 15° respectively. Wasting of the thigh and leg was present with no true shortening. X-ray of the pelvis with both hips anteroposterior and lateral view revealed calcified nodular mass over superior, inferior part of the femoral head, and anterior part of the neck with decreased joint space (). Computed tomography (CT) pelvis showed multiple intra-articular loose bodies with largest measuring 3*2.2 cm with early changes of secondary osteoarthritis and no evidence of joint effusion and erosion (, ). Magnetic resonance imaging (MRI) was suggestive of early arthritis with intra-articular loose bodies. There was <10% of articular erosion of postero superior part of acetabulum. As the patient was disabled with pain, stiffness especially restricted flexion and abduction and difficulty in daily routine activities, we planned for surgical excision of the loose bodies and cheilectomy of the overgrown/ossified femoral head on superior part of the femur to improve the stiffness of affected hip joint.\nThe patient was operated in lateral position under spinal anaesthesia using the lateral approach to the hip. Fascia lata was cut along the line of incision and retracted anteriorly to expose the anterior capsule. Arthrotomy was done using 2 cm incision over the anterior capsule and the anterior, inferior loose bodies were removed. Superior loose bodies"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old previously healthy male () presented with 2 months of MRC grade 3 dyspnea and 9 kg weight loss with no fever or night sweats. On arrival to the emergency room, he was requiring 6 L/min oxygen via nasal prongs to maintain saturations greater than 90%. Chest X-ray and chest computed tomography (CT) () suggested possible pneumonia overlying interstitial lung disease and pulmonary hypertension. CT and ultrasound showed small left axillary lymph nodes unamenable to biopsy. Abdominal ultrasound was grossly normal. Thus, the patient was diagnosed with presumed pneumonia and started on antibiotics, antiviral agents, inhaled corticosteroid, and bronchodilator therapy, with enoxaparin for venous thromboembolism prophylaxis.\nOver the next 5 days, the patient's oxygen saturation was kept above 90% with 8–10 L/min oxygen via nonrebreather mask. Barriers to diagnosis included inability to produce sputum despite induction, high oxygen demands contraindicating bronchoscopy, small lymph nodes unamenable to biopsy, and intolerance of supine position needed for perfusion scans. The patient was transferred to the Thoracic Surgery service for a surgical lung biopsy on day 6. However, the patient experienced right-sided chest pain, diaphoresis, and tachycardia of 160 beats per minute, followed by a convulsive episode with no postictal symptoms. After transfer to the intensive care unit, mean systemic arterial pressures were found to be low, with transient reduction to as low as 40 mmHg when the patient coughed or spoke. Transthoracic echocardiography () showed a dilated right ventricle with globally reduced systolic function. Right ventricular systolic pressures were shown to be 170 mmHg. Milrinone and epinephrine were started for hemodynamic support.\nDue to progressive symptomatic and hemodynamic deterioration, he was transferred to the Cardiovascular Intensive Care Unit under the cardiac surgery service at another hospital to facilitate Novalung insertion via central cann"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case about a 65-year-old male patient with pseudoarthrosis of the first MTPJ, who suffered from a nonunion 12 months after a fusion made of two crossing screws (). Postoperative x-rays showed a correct position of the two crossing screws and a correct position of the dorsiflexion (). The x-ray revealed a nonfusion during follow ups; we recommended the possibility of an extracorporeal shockwave therapy but the patient refused. The blood samples which we had taken before the revision surgery didn’t show any infection signs; additionally, there was no fever or any clinical sign of infection. The patient is a high demand patient, who does sport (hiking and cycling up to 20 km) and gardening quite often. Twelve months after the fusion he still had severe pain and was not satisfied at all with the result of the surgery. At this time the x-ray showed a persistent nonunion. We discussed the pros (definitive solution, a greater load-bearing capacity for our active high demand patient) and cons (a long follow-up treatment) of a revision fusion. On the other hand we informed him about the stability, function, the faster healing and mobilization of the prosthesis. Our patient refused a revision because of the previous failed MTPJ fusion; for this reason we decided to use this new device.\nThe two screws and the connective tissue were removed. We took care that enough resection of the bone and a capsular release of the metatarsal head was made in order to achieve a dorsiflexion of more than 90 degrees intraoperative. Afterwards a hemicup Biopro prosthesis (Biopro, Farmingdale, NY, USA) 18.5 mm was implanted. Intraoperative the final check up showed a dorsiflexion of 80 degrees and a good stability of the joint.\nImmediately, the patient received postoperative-physiotherapy treatments. During hospitalization he learned how to do exercises for mobilization of the great toe, which the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old, single, woman presented to the chiropractic office with ongoing headaches of 2-year duration. Her headaches were on a daily basis and varied in intensity. The pain was described as disabling, going across the forehead, to her nuchal area and right shoulder. She could not maintain daily activities without acetaminophen and aspirin. The patient initially consulted her family physician to rule out possible pathological causes. Her blood tests, brain magnetic resonance imaging, and cervical radiographs all came back unremarkable. She was diagnosed with TTH and then sent for physiotherapy a couple of times, but it did not help. She had also tried acupuncture, traditional Chinese therapy, and alternative medications for quite some time; but nothing had changed her headache pattern. She worked as a primary school teacher and lived alone. She denied substance abuse or any systemic disorder. There was no family history of mental illness.\nSometime later, she started experiencing episodes of extreme low moods, characterized by feelings of overwhelming sadness and seeking an immediate sense of relief. She was referred to the psychiatry services and was diagnosed with a major depressive disorder without psychotic features. Over the past 6 months, a combination of Deanxit (Flupentixol + Melitracen) for treating depression, alprazolam for anxiety, and acetaminophen for pain had been used at different doses at different times. Both disabling headache and severe depression led to impair her job and regular activities. Under stress of health and financial impacts, she had recurrent thoughts of death. She reported that she had once been getting ready for charcoal-burning to end her life at home. A primary concern for her was ending of troubles at all.\nFor evaluation and treatment of neck pain and headache, the patient presented to our clinic with a guarded neck posture. She rated her peak headache intensity to be 6–8/10 on the numeric pain rating scale. Spinal ranges of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman, gravid 5, para 3, abort 2, was referred to our clinic because of continuous vaginal bleeding from 2 months ago after uncomplicated curettage with missed abortion at the first trimester (GA: 12 w + 4 d). Her obstetric history was notable for two previous low-transverse cesarean section deliveries and two curettages were without any complication. The pathology report after curettage was confirmed to be decidual tissue.\nPhysical examination was normal. The gynecologic examination of the vulva and vagina was normal, the cervix was closed, the uterus was larger than normal at about 10-12 weeks of gestation, retrovert axis and she had mild bleeding. In the clinical test, her Hb was 12.4, U/A was NL (without hematuria), BHCG was 112 mUI/mL and other coagulation tests, hepatic and renal tests and electrolytes were normal. Transvaginal sonography was performed as requested: UT > NI, retrovert uterus, endometrial thickness = 2.6 mm, hypoechotic mass about 8 cm in the lower uterine segment with necrotic change and increased vascularity with low resistance was seen around it []. Differential diagnosis included invasive mole, chorio carcinoma and uterine tumors, including degenerating myoma. Total abdominal sonography and chest X ray were normal. Surgical intervention was suggested and arranged to confirm the diagnosis and to remove the lower uterine segment mass. Surgery was performed with the patient under general anesthesia and in the 15-degree Trendelenburg position. A Foley catheter was inserted preoperatively to empty the bladder. She received suction and curettage. After removing the debris and much necrotic tissue, vaginal hemorrhage could not be controlled during operation. The decision fell on laparatomy. The lower segment uterine mass appeared as a large, friable, highly vascularized mass that occupied the whole thickness of the uterine. Hysterectomy was performed immediately for treatment of hemorrhage-induced hypotension, fluid replacement and p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old Japanese male patient with chest pain at rest and syncope 2 months ago who was admitted to the hospital for further evaluation. He had a history of smoking more than 50 years but quit smoking 5 years ago. Rosuvastatin calcium 2.5 mg was administered at a neighbourhood hospital due to dyslipidaemia. His blood pressure was 121/50 mmHg, and his pulse rate was 68/min. There were no abnormal findings regarding auscultation and physical examinations. After routine electrocardiogram and cardiac ultrasonography examinations, we performed computed tomography coronary angiography (CTCAG). After an hour-long administration of 20 mg metoprolol and 5 mg nitroglycerine tape before examination by CTCAG, he complained of typical chest pain and prodrome before syncope. During the attack, bradycardia and inverted T waves in the V5, V6 leads were observed, as shown in . We did not measure the Troponin because his chest pain disappeared within a few minutes. CTCAG revealed severe stenosis (70% <) at the proximal left anterior descending (LAD) artery according to the coronary artery disease reporting and data system (CAD-RADS), as shown in . Hybrid images of CTCAG and thallium-adenosine myocardial scintigraphy revealed no ischaemia in the LAD coronary artery territory, as shown in . We performed coronary angiography. However, LAD artery has a 50% stenosis. We did not measure coronary fractional flow reserve because LAD artery has just 31% stenosis by the analysis of Quantitative Coronary Angiography (, File S1). We administered intracoronary injection of 64 µg ER into the LCA, but no provoked spasm was observed, as shown in . Although we added another 40 µg ER into the LCA, no provoked spasm was recognized ( and Video 1A). After the administration of 80 µg ER into the right coronary artery (RCA), no provoked spasm was found. We administered 20/50/100 µg intracoronary ACh into the LCA without a pacemaker for 30"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old male with a right-sided complete cleft of primary and secondary palate who had primary surgery in childhood at another hospital was referred to our craniofacial centre for management of his facial skeletal deformities []. The patient was concerned about his lower jaw being ahead of his upper jaw, misaligned teeth, and flattened face.\nExamination revealed typical midface deficiency associated with cleft maxilla, which included lack of maxillary projection, flattened malar prominences, depressed nasal supratip and flared ala. Intraorally, the upper arch revealed complete collapse of the two lateral shelves with severe crowding and displacement of the upper dentition, concealing a wide anterior palatal fistula in continuity with an alveolar defect. Overall the maxilla was severely collapsed in all three-dimensional planes []. The discrepancy between the maxilla and mandible was 12 mm in the antero-posterior plane. The clinical and radiographic findings suggested maxillary hypoplasia in transverse and sagittal dimensions resulting in class III malocclusion with double sided cross bite\nThe objective of the treatment was to achieve an acceptable facial profile and dental occlusion with positive over jet and overbite. Treatment plan included the following, viz., correction of the maxillary retrusion by Le Fort I osteotomy; rigid external distraction; increasing the width of the collapsed maxillary alveolar arch; aligning the maxillary dentition, and closure of the oro-nasal fistula over the hard palate.\nThe severity of the dental crowding in the maxillary arch was not conducive for the placement of orthodontic brackets, and the short maxillary arch required lengthening, hence pre operative orthodontics was not carried out. ‘Surgery first’ method was adopted in this case for the same reasons. Rapid palatal expansion was not possible in this case since the expander could not be placed due to severe constriction of the upper alveolar arch in addition to the seve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man, working in a furniture confection plant, experienced severe “tearing” chest pain upon heavy lifting. On presentation in another health facility, a chest computed tomography (CT) scan, with incomplete imaging of the iliofemoral axis, revealed a type A aortic dissection (DeBakey type I). Following transfer to our center, physical examination showed a pulseless left femoral artery, while no sign of acute limb ischemia was present. The patient underwent a mechanical Bentall procedure with hemiarch replacement under circulatory arrest for a total procedure time of 7 hours, 45 minutes. The immediate postoperative course was uneventful. The femoral pulses were symmetrical and well palpable once the patient rewarmed. Thirty-six hours after surgery, the patient was extubated and complained of severe pain to his left buttock. The lower limb pulses were present and no sensory or strength deficit was found. The left limb was normal, while the buttock was tense and painful especially upon flexion and adduction of the hip. A GCS was suspected. A CT angiography scan of the pelvis showed a dissection flap ending proximal to the iliac bifurcation without direct involvement of the iliac arteries. The false lumen was thrombosed and preferentially oriented toward the common left iliac artery. The opacification of the left internal and external iliac arteries was good. Preoperative CT angiography showed left gluteus muscle swelling (\n). This was likely related to a malperfusion following thrombotic or embolic occlusion (\n). The patient was diagnosed with GCS, further supported by a peak creatine kinase of 91 865 U/L.\nA Kocher-Langenbeck procedure (\n) was performed under general anesthesia with the patient placed in a right lateral decubitus position, with his legs bent at a 30° to 40° angle. An incision was made from the posterior superior iliac crest up to 5 cm of the greater trochanter and then to the lateral aspect of the femoral shaft."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 2, who had a homozygous missense mutation (c.1076C>T [p.359Pro>Leu]) at exon 8, was a 47-yr-old female at the time of her muscle biopsy. At her age of 30, she first noticed difficulty in climbing stairs, which progressed to limitations in daily activities by age 44. At presentation, she had difficulty in rising up from chair and could not stand up by herself from sitting position. Her muscle power was reduced to MRC grade 1 in leg adduction, grade 2 in hip flexion, hip extension, and leg abduction, grade 3 in shoulder elevation, elbow flexion, knee flexion and knee extension, and grade 4 in elbow extension and wrist flexion. Her deep tendon reflexes were lost in limbs except for the ankle jerks. She had no affected family members, and her serum CK level was mildly elevated (496 IU/L). The ECG and chest radiography were normal. Muscle biopsy showed a marked fiber size variation, markedly increased adipose connective tissue, many fibers with internal nuclei, scattered necrotic and regenerating fibers, some fibers undergoing fiber splitting, and type I fiber predominance ().\nThe patient 3 had been wheelchair-bound for one year when he first presented to us at age 35. He became symptomatic with gait and running difficulty when he was 13 yr old. Since then, his disease was progressively worsened. He started to use canes at age 32 and became wheelchair-bound at age 34. He had a profound muscle weakness on examination. His muscle power was graded as 1 in leg elevation, leg extension, leg adduction, and leg abduction, 2 in distal leg muscles, 3 in upper extremity muscles, and 4 in quadriceps muscles. He also had generalized muscle atrophy, especially in shoulder, pelvic girdle, and intrinsic hand muscles. His deep tendon reflexes were lost except for the knees. He had no affected family members, and serum CK was slightly elevated to 500 IU/L. His ECG"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 38-year-old nulliparous woman who suffered from infertility of unknown origin. She had been treated with assisted reproductive technologies including artificial insemination and in vitro fertilization for over four years. During her treatment for infertility, cytological review followed by colposcopic biopsy revealed an invasive nonkeratinizing squamous cell carcinoma (SCC). A 1 cm mass was identified in the uterine cervix, but a pelvic MRI did not describe the cervical mass or parametrial invasion. Additionally, a submucosal leiomyoma of 15 mm in diameter was found in the uterus (). CT scans showed no signs of lymph node swelling or distant metastases. Based on these findings, she was diagnosed with stage IB1 cervical squamous cell carcinoma. We offered radical hysterectomy and pelvic lymphadenectomy as standard treatment although she strongly desired fertility preservation. The submucosal leiomyoma may have been the cause of her infertility, and she was keen to resect the myoma during the same procedure. Submucosal leiomyomas can usually be resected with hysteroscopy but was not advised in this case from the oncological viewpoint. As such, we obtained informed consent and performed an abdominal radical trachelectomy followed by abdominal myomectomy.\nDuring the surgery, we first drained the ascites in the pelvic cavity, resected bilateral pelvic lymph nodes, and sent them for intraoperative pathology. They were reported to be negative. The paravesical and pararectal spaces were then developed. The ureters on either side were resected to their insertion into the bladder. The uterine arteries were ligated and cut at the origin where they branched from the internal iliac arteries. Next, the uterosacral ligaments were divided. A colpotomy was performed circumferentially, and the cervical specimen was excised together with the parametrium at least 2 cm below the internal os. During the surgery, a frozen section procedure was performed for histology. Th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old gravida 5 para 3 (all alive) abortion 1 mother with a pregnancy of 4 months was presented with severe lower abdominal pain of 2 days duration following a falling accident on her abdomen 5 days ago. She had easy fatigability, vertigo, and light headedness since two days after the accident, but had no vaginal bleeding, fever, headache, chills, and vaginal discharge and she did not feel fetal movement yet. She had no antenatal care follow up. She was referred from a nearby primary hospital to the Jimma university medical center with diagnosis of septic shock secondary to septic abortion where she was admitted and given antibiotics. Medical abortion was tried, but failed at the primary hospital. She had no personal or familial history of hypertension and diabetes. She had no history of chronic pelvic pain. She had no history of ectopic pregnancy, but had one history of spontaneous abortion which occurred at the 4th month. Prior to this accident, she had no history of abdominal pain, bloating, and epigastric pain.\nOn physical examination, she was acutely sick looking, agitated, and confused in appearance. Her vital signs were as follows: Blood Pressure: 70/30 mmHg, PR: 148 bpm, RR: 24 br/m, T0: 37.5. Her conjunctiva was paper white and had dry tongue and buccal mucosa. Chest was clear and resonant. S3 gallop was heard. On the abdomen there was diffuse lower abdominal tenderness and guarding with positive signs of fluid collection. On pelvic examination cervix was closed with no blood on the examining finger, but, had a right adnexal tenderness.\nOn ultrasound exam, empty uterus was seen. A collapsed fetus with no cardiac activity having femur length measurement corresponding to 16 weeks and placenta measuring 4 cm × 5 cm looks attached to the left cornual part of the uterus was seen. There was significant free fluid in cul-de-sac and paracolic gut"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old single girl, with 10 years of formal education, from rural background presented to surgery outpatient with complaints of pain in abdomen and vomiting for the last 6 months. She would have frequent bouts of vomiting, frequency of which increased in the last few days prior to presentation. On physical examination, she was found to have a mobile mass of 14 × 16 cm size in the upper abdomen, which was tender, with smooth surface and irregular margins. Ultrasound abdomen revealed a bizarre lesion in the right upper and middle abdomen suggestive of gastric bezoars. Upper gastrointestinal endoscopy did not reveal any abnormality in the esophagus and a large mobile mass made of hairs was seen in the stomach. Based on the findings of ultrasound and upper gastrointestinal endoscopy, a diagnosis of trichobezoar was considered and psychiatry consultation was sought. Psychiatric evaluation revealed that the girl was eating hairs and clay since early childhood. She would eat the hairs thrown here and there by her mother, other family members and neighbors. The patient would like the taste of hairs and had a strong and persistent desire to eat hairs. She would often go out searching for the same. Additionally, at times she would also eat clay. The description of the patient was corroborated by the mother too; who described that despite persistence reprimands, the patient persisted to eat hairs and occasionally would eat clay. However, the patient denied pulling out her own hairs. Physical examination of scalp and other body parts did not reveal any evidence of alopecia or pulling of hair/short hair. Past history did not reveal any evidence of depressive disorders, obsessive compulsive disorder, other anxiety disorders, eating disorders, emotional disturbances, mental sub-normality and other impulse control disorders. Also, there was no family history of any mental illness. Investigations in the form hemoglobin level, complete blood counts, serum electrolytes, liver f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nRC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.\nOn postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62 years old male presented with recurrent SCC of the left nasal bulbar conjunctiva. The patient's previous medical history detailed multiple interventions at this site. Initially, the diagnosis of a left nasal pterygium (a wing-shaped growth that starts on the conjunctiva and can spread across the limbus to the cornea affecting visual function) was made 3 years prior to the reported presentation, and was surgically removed with local excision. The lesion recurred 1-year post-surgery, and was subsequently managed surgically with a wide local excision. At this time, pathology revealed positive margins for SCC. A further recurrence 6 months later was treated with Plaque Therapy to a dose of 50 Gy in 5 fractions. Subsequently, the lesion was re-excised with adjuvant cryotherapy 7 months later.\nOn presentation 3 months post-cryotherapy, a recurrent lesion (10 × 5 × 2 mm) was detected on the nasal bulbar conjunctiva (Fig. ). The patient declined enucleation following this SCC recurrence. Subsequently, multidisciplinary consultation offered SXRT as an alternative treatment option (Fig. ).\nThe patient also presented with a history of Crohns Colitis (treated with immunotherapy) and a previous excision of a non-melanoma skin cancer from the right temple, and a subsequent skin graft of the area. The patient was on no other medications and had no allergies.\nThe patient was prescribed a dose of 48.4 Gy in 22 fractions, to a depth of 3 mm. This resulted in a skin surface dose of 54.4 Gy. A 2.0 cm diameter direct applicator was used with a 3 mm margin on the treatment region (Fig. ). To allow for an acceptable treatment margin that encompases the target volume and accounts for set up variability, the left inner canthus and tear duct were included in the treatment field. A single en-face beam of 2.0 mm Aluminium energy (2 mm Al) was used to meet the previously articulated dose"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 55-year-old, Turkish female patient experienced generalized tonic clonic seizures which started 2 years previously and had become persistent during the last 3 months, despite antiepileptic treatment. In addition, the patient had complained of speech defects, forgetfulness, perception deficit for 2 months, cognitive disorders and a weakness in the right side of the body for the 2 days prior to admission. The patient had history of an operation in her left maxillary area due to basal cell carcinoma 7 years previously and then history of radiotherapy due to relapse 2 years later the operation. She had treated with a total dose of 56 Gy radiation, administered in 15 fractions to her left maxillary region, and she had no chemotherapy history.\nDuring neurological examination it was found that the patient experienced confusion and disorientation. However bilateral papilledema was detected on neurological examination. In addition, the patient had right hemiparesis. Her muscle strength grade was 3 (active movement against gravity) in the right side of her body. A cranial CT scan showed hypodense lesions in the left frontal lobe (3 × 4 cm) and in the left temporal lobe (6 × 4 cm). No significant edema was observed around the lesions, which compressed the left lateral ventricle and did not show contrast enhancement (). Cranial MR imaging showed in the left frontal region 3 × 4 cm and in the left temporal region 6 × 4 cm lesions, which were hypointense in T1 (), hyperintense in T2-weighted images. These lesions observed with mild peripheral contrasting. They made us think about cystic masses. An EEG showed reduced bioelectrical activity in the left frontal and left temporal regions. A course of antiepileptic treatment was organized for the patient. The patient, who was using 2 × 500 mg Sodium valproate, was given dual antiepileptic therapy, starting with 3 × 100 mg Phenytoin. In addition, steroid treatment was begun. However, despite this treatment, the patient experienced"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52 year old male smoker undergoing coronary artery bypass grafting for three vessel coronary artery disease and moderately impaired left ventricular function was felt to have a mass arising from the under surface of right costal margin adjacent to right lower sternal margin while sternopericardial ligament was being broken off by finger dissection prior to sternotomy. Preoperative chest X-ray suggested a soft, globular paracardiac shadow in relation to the right pericardiophrenic angle, appreciated better retrospectively (Figure ) Sternotomy was made, the right pleura was opened to facilitate delineation of the mass. The mass measured 8 × 6 × 3 cms and was arising from the right costal margin and the adjacent surfaces of 7th, 8th, 9th and 10th ribs (Figure ). The mass was of firm to hard and variable consistency and was filled with cartilaginous material and there was no definite demarcation between the mass and the chest wall. The chest wall mass was excised in its entirety along with the intercostal muscle and the periosteum (Figure , Figure and Figure ). The frozen section revealed it to be either a chondrosarcoma or teratoma. Quadruple coronary artery bypass grafting to left anterior descending artery and its diagonal branch, obtuse marginal branch of circumflex artery and left ventricular branch of right coronary artery was performed using left internal mammary artery and long saphenous vein for conduits, employing cardiopulmonary bypass with antegrade cold blood cardioplegic arrest. Patient made uncomplicated postoperative recovery.\nHistopathology revealed the overall appearances of grade 1 chondrosarcoma with a tumour composed of lobules of cartilage of varying size separated by fibrous tissue (Figure ). The chondrocytes showed cytological atypia, binucleate cells, focal hypercellular areas with areas of calcification and necrosis (Figure ). The tumour was seen to focally infiltrate into surrounding skeletal muscle.\nThe patient was discussed at the Regional"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male with a past medical history of non-ischemic cardiomyopathy (ejection fraction 10%-15%), hypertension, chronic kidney disease stage G3A, and severe mitral valve regurgitation status post valve repair initially presented for an upgradation of his biventricular pacemaker to biventricular implantable cardioverter defibrillator (BIV-ICD) and replacement of non-functional right atrial lead. The pacemaker pocket was exposed and identified and the atrial and ventricular leads were pulled back under fluoroscopic guidance. A new left coronary sinus lead was placed. Next, right atrial (RA) and right ventricular (RV) leads were placed and access was obtained via the left coronary sinus as the left subclavian vein was found to be occluded with formation of collaterals. The leads were sutured in fascial planes via silk suture. The pacing and sensing parameters were confirmed. BIV-ICD was placed in the pocket, and the pouch was closed via vicryl sutures. The patient had electrocardiogram (EKG) (Figure ) and chest X-ray (Figure ) performed after the procedure. He had developed small pneumothorax from the procedure, which resolved on its own.\nThe patient was asymptomatic for the next seven months and then he developed increasing shortness of breath. At that point, the EKG (Figure ) revealed loss of appropriate pacing function. It was discovered that the patient kept massaging his pacemaker pocket site in the last seven months but he denied manipulating the device itself. He had also been moving his arm up and down frequently, which would have led all his device leads to be pulled up towards the device in a ratchet-like fashion. The patient was scheduled again for revision of BIV-ICD and on incision of the generator pocket, the left ventricular lead was found coiled up in the pocket beside the generator (Figure ). A new left ventricular lead was placed in the coronary sinus and then access was obtained via the right subclavian vein for right"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old male presented to emergency department with tender mass on lower back and posterior aspect of neck. Apparently, he had noticed it on his lower back 6 months ago and had grown in size with another similar swelling appearing on his neck, also they were increasingly painful and sore to touch. He had a history of ongoing sore throat for 3 years for which he was extensively investigated by ENT services. His CT neck and mediastinum did not show any abnormalities at that time. This was followed by laryngoscopy which showed a white patch on the right vocal cord, biopsy of which showed non-specific chronic inflammatory changes and cultures grew candida. Background history included COPD; he was heavy current smoker and smoked about 60 cigarettes per day. His medications included salmeterol/fluticasone propionate and ipratropium bromide inhalers. Vitals were within normal range. On examination, 4 cm nodular, firm, tender, immobile mass on lower back and 3 cm mass on posterior aspect of lower cervical spine were noted.\nHis laboratory investigation including renal and liver function, full blood count and coagulation profile were normal. A CT of thorax, abdomen and pelvis was arranged which showed 2 × 2 cm mass in right lung lower lobe likely malignant with no hilar or mediastinal lymphadenopathy, also 3 × 3 cm soft tissue mass at C6-C7 level posteriorly and 4 × 2 cm mass was noted on lumbar region with multiple prominent inguinal lymph nodes ().\nA referral for bronchoscopy was sent and biopsy of the nodule was planned. While awaiting bronchoscopy appointment, biopsy was taken from mass in lower back and send for histopathology. Histology showed poorly differentiated tumour cells in cohesive groups and sheets with moderate pleomorphism and eosinophilic cytoplasm; immunohistochemistry was positive for AE1/3, cytokeratin 7 and carcinoembryonic antigen antibody stain and periodic-acid schiff. Weak nuclear positivity for TTF-1 was also seen. Overall features were consis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nDiabetic male, 57 year old presented to us with history of pain in left ear for the last 8 days. 48–72 hrs after the onset of otalgia, patient developed facial weakness on left side along with vesicular eruptions on left conchae and in left external auditory meatus. After another 24–48 hrs patient had similar episode on right side. On the day of reporting to us patient was having bilateral facial weakness, impaired taste sensation, dryness of eyes along with decreased hearing on both sides but there was no history of vertigo or any ear discharge. There was history of stressful life events in past 6 months before the onset of rash.\nOn examination, there was bilateral lower motor neuron facial palsy which was complete. Bell's phenomenon was present on both sides Fig-. There were adherent crusts and scabs in left conchae and external auditory meatus. While vesicular eruptions were present in right external auditory meatus. Tuning fork tests were showing bilateral sensorineural hearing loss.\nThe patient was admitted and investigated. His postprandial blood sugar was 339 mg%, HbAIc was 7%. Pure tone audiometery was showing mild to moderate bilateral sensorineural hearing loss, stapedial reflexes were absent on both sides on tympanometery. There was impaired taste sensation from anterior two third of tongue. ELISA and Western Blot tests for HIV infection were negative. Liver function tests, tumor markers, thyroid hormones; serum ACE levels were all with in normal limits. Lumbar puncture revealed normal pressure. Glucose, protein and white blood cell count were all with in normal limits in CSF. Plain X-ray views of mastoid, internal auditory meatus and chest were normal. Computerized tomography of brain stem, cerebellopontine angle, temporal bone and skull base were normal. A smear from floor of vesicle stained with Giemsa stain showed degenerating cells with multiple nuclei. This favoured the clinical diagnosis of herpes zoster oticus. This diagnosis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old Caucasian man was referred to the Stomatology Department, because he presented with a swelling on the right side of his face, which he first noticed 2 months earlier. His medical history included chronic renal failure.\nThe extraoral examination revealed a swelling of the right parotid gland and the submandibular gland, as well as an extensive ipsilateral cervical lymphadenopathy. On intraoral examination, two masses were observed: one on the left side of the palate and the other on the floor of the mouth (). Tongue mobility was normal and there was no evidence of paresthesia of the lingual nerve.\nExamination of the right parotid gland by MRI revealed a solid and expansive mass in the superficial lobe, which was characterized by a hyposignal and a hypersignal on a T1-weighted image (T1W) and a T2-weighted image (T2W), respectively. Another two nodular masses were observed in the inferior pole of the parotid gland. MRI also examined the contralateral parotid gland, and three small nodular masses were observed in the superficial lobe, which presented signal features similar to those on the right side. Moreover, a mass involving the left side of the palate showed continuity, with an ipsilateral narrowing of the pharyngeal airspace ( and ). The posterior two-thirds of the tongue (left side) and both lingual tonsils showed expansive lesions. The epiglottis was posteriorly displaced and the vallecula was obliterated, leading to narrowing of the pharyngeal airspace (). Evidence of expansive masses was also noted on the floor of the mouth and in both sublingual and submandibular areas, without affecting the salivary glands. Bilateral lymphadenopathy was also observed, in contrast with the clinical examination findings (). Considering the clinical and imaging findings, the working diagnosis pointed to a malignant disease.\nAn incisional biopsy was performed on the floor of the mouth, and the histopathological examination showed a monotonous proliferation of smal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 24-year-old male who sustained a gunshot wound to his left shoulder. He presented to the emergency department with a primary complaint of shoulder pain and difficulty in swallowing. On primary survey, the airway was patent and he was hemodynamically stable. A single bullet wound was visualized above the left scapula. On chest radiograph, the bullet was located in the left pulmonary hilum near the mainstem bronchus []. No pneumothorax or hemothorax were apparent; this was confirmed with the radiologist. At this point, the patient complained of increasing difficulty in swallowing and was intubated for airway protection. An orogastric tube was passed erroneously into the airway precipitating vigorous coughing and eventual vomiting of gastric contents. Once this was properly replaced, the patient underwent CT angiography (CTA) of the chest and flexible bronchoscopy. CTA revealed no vascular injury; however, air was present throughout the mediastinum and the subcutaneous tissues of the anterior neck []. The bullet was again seen near the left mainstem bronchus []. There was no pneumothorax or hemothorax. After discussion with our radiologist, we believed that the bullet had likely caused a small airway injury which had quickly sealed, leading to the pneumomediastinum without evidence of pneumothorax or bronchopleural fistula. Flexible bronchoscopy revealed no blood or bullet fragments, but only a small abrasion in the left posterolateral trachea which was thought, at the time, to be due to trauma from the initial orogastric tube placement.\nAs no significant injuries were noted on initial bronchoscopy, the patient continued to be managed nonoperatively. In light of there being no pneumo- or hemothorax, the presumed trajectory of the bullet was from above the left scapula directly to the left pulmonary hilum. Based on this, it was felt that he was at low risk for esophageal injury, and gastrointestinal endoscopy was deferred. He remained intubated,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old female office worker sustained a right anterior glenohumeral dislocation with an associated avulsion of the greater tuberosity, as described by Mutch et al. []. Open reduction and internal fixation of the fracture were performed with a tension band technique, using an anchor screw and nonabsorbable sutures []. The functional outcome was poor. The patient was painful and had marked weakness in external rotation and abduction. Active forward flexion and abduction were 40° with full passive motion, and active external rotation was 30°. Her single assessment numeric evaluation score [] was of 40 %. Past medical history was significant for noninsulin-dependent diabetes mellitus and obesity (BMI 42). Radiographic evaluation demonstrated a complete osteonecrosis and resorption of the greater tuberosity (Fig. ) with a suspicion of massive rotator cuff tear involving both supraspinatus and infraspinatus tendons, without retraction. There was a state 1 Goutalier fatty infiltration of the supraspinatus and infraspinatus muscles. The electromyographic evaluation of the axillary nerve was normal. It was decided to reconstruct the defects with a fresh-frozen Achilles allograft tendon with attached calcaneal bone. Written informed consent was obtained from the patient for publication of this case report and accompanying images.\nUnder general anaesthesia and interscalene nerve block, the patient was placed in the beach chair position, with the operative arm draped free. An open anterosuperior incision with a deltoid split was performed in order to expose the greater tuberosity defect. The long head of the biceps was already resected. The remaining posterosuperior rotator cuff was carefully dissected, and the proximal humeral head was debrided. The quality of the cuff tissue was poor. The Achilles tendon allograft with attached calcaneus was then prepared (Fig. a). The calcaneus was shaped to fill proximal humeral head defect. The Achilles tendon was then split longitu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old man presented with gastrointestinal bleeding due to esophageal varices and liver cirrhosis. Review of his records revealed that he had been diagnosed with GSD at the age of two years following a liver biopsy, when he had a distended abdomen due to hepatomegaly. He had problem with weakness from early childhood. In his childhood, he had frequent nose bleeding and easy fatigability. His growth was very slow. He was on no specific therapy and never suffered from symptomatic hypoglycemia. He went into a late puberty at about 17–18 years, but grew very rapidly and became much taller than his parents. During that period, his muscle weakness worsened and he had been in a wheelchair since he became 24 years old. His weakness in his arms also dated back to his puberty. At the time of presentation, he was unable to brush his hair and had to lean forward to eat. He had not had any heart problem. He had not had any sleep problems or chest infections. He suffered from low back pain after sleeping. His diet was high in protein with lots of meat, nuts, eggs, and yoghurt. He had never tried uncooked corn starch. GSD IIIa, for the first time, was confirmed at the age of 28 in the National Hospital for Neurology and Neurosurgery, Queen Square in London, on April 7, 2004. His parents were unrelated, alive and doing well. There was no family history of other muscle disorders. He had no other medical problems. He had normal schooling and studied engineering at university but had to stop in his 3rd year because of the weakness. He was on no regular medication. He was unable to sitting in wheelchair and needed assistance to be transferred. On physical exam, he appeared dysmorphic, thin, disable but intelligent. His vital signs, chest and heart were normal without any evidence of cardiomyopathy. Abdominal examination revealed a firm and enlarged liver, splenomegaly, and ascites"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old female patient was admitted to hospital with epigastric pain which was lasting for two months. She had no remarkable history except for her mother having DM. Moreover, a physical examination revealed epigastric tenderness on palpation, and laboratory examinations revealed no important findings. Endoscopy revealed edematous and fragile papilla of Vater, and a polyp was seen on the 2nd part of duodenum. A biopsy yielded a hyperplastic polyp, and a biopsy from the papilla was performed due to the imaging findings on endoscopy with suspicion of an ampulla tumor; however, biopsy specimens yielded no malignant cell.\nUltrasonography (US) of the patient showed a diffusely enlarged hypoechoic pancreas with punctate hyperechogenities representing calcifications (). There was no altered vascularization of pancreatic parenchyma on Doppler US. Computed tomography (CT) revealed a huge pancreas, which was enlarged diffusely with multiple calcifications and punctate hyperdensities. The pancreatic duct and peripancreatic fat tissue were normal. There was no inflammation sign (). CT of the thorax did not yield an important feature in the mediastinum and lung parenchyma. On magnetic resonance imaging (MRI), a diffusely enlarged pancreas was seen as hypointense on both T1- and T2-weighted images (). There were hyperintense cystic nodules in pancreas parenchyma on T2-weighted images (). After gadolinium administration, enhancement of the pancreas began in the early phase, and became more prominent at delayed images. Punctate nodular unenhanced areas in pancreas parenchyma were seen on delayed images. Since the patient's history revealed no sign for chronic pancreatitis and amylase levels were normal, a trucut biopsy with an 18 G needle (Bard Biopsy Systems, Tempe, AZ) was performed. According to the histopathological results, the diagnosis was islet cell primary amyloidosis of the pancreas. Only islet cells in the islands of Langerhans were stained red with congo red ink."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old Thai male patient presented with progressive pain and swelling of seven-month duration over the antecubital fossa of the right elbow. Initially, there was only slight swelling. Three months later, he complained of dull pain. The patient went to a private clinic where the diagnosis was distal biceps tendinitis. The first doctor gave a local steroid injection, but the symptoms recurred about one month later. Four months later, the patient complained of pain at night and weakness on supination of the forearm and flexion of the elbow. He had no underlying disease, chest symptoms, fever, weight loss, or history of contact with patients suffering from pulmonary tuberculosis.\nPhysical examination of the right elbow when patient visited the hospital in Thailand demonstrated swelling at the antecubital fossa, mild tenderness at the distal biceps, and muscle weakness or pain when attempting to supinate the forearm and flex the elbow. All other systemic examinations were normal. There was a high white blood cell count (12,710 cells/mcL); neutrophil count was 72% and lymphocyte count 17%. Erythrocyte sedimentation rate was 17 mm/hr, and C-reactive protein was 6.69 mg/L. Radiography of the right elbow showed swelling at the antecubital fossa, and chest radiographs showed infiltration of the left upper lung. Magnetic resonance images showed disruption of the distal biceps tendon with an associated ill-defined soft tissue mass (about 2 × 2 cm). A less enhanced area was observed at the inferior part, which was likely to be necrotic or cystic. An abnormal marrow signal was detected at the proximal radius with focal cortical erosion at the radial tuberosity ().\nIn this case, we suspected that the patient had disseminated tuberculosis because preoperative chest radiographs demonstrated left upper lung infiltration, which was likely pulmonary tuberculosis, and there was a soft tissue mass at the distal biceps tendon. We performed an open excisional biopsy and debridement"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA twenty-two-year-old male with extensive limb deformities reported to the department of Oral Medicine, Diagnosis, and Radiology with a chief complaint of unclear speech and difficulty in tongue movements.\nThe patient's medical history was insignificant. He was the fourth child of normal and unrelated parents. He had four siblings: one brother and three sisters all of whom were normal.\nHis prenatal history revealed that his mother had four episodes of fever during her first trimester and was medicated for the same. She was unable to remember the names of the medications. She had spontaneous vaginal delivery after thirty-nine weeks of gestation to give birth to a male baby with multiple limb deformities. Patient's family history for congenital abnormalities was negative.\nOn general examination, a healthy, moderately built male of normal intelligence presented to the clinic with an altered gait. He had anomalies affecting all the four limbs. His right hand showed brachydactyly (short digits) of second to fourth fingers with hypoplastic thumb and little fingers. Finger nails appeared normal (). In the left hand, hemimelia (missing half the limb) was observed below the elbow with five nubbins attached to its distal part. Radiograph of the right hand showed hypoplastic second and third metacarpals with deficient second to fourth phalanges. Absence of distal part of the radius and ulna was noted in the left hand radiograph with subluxation of the superior radioulnar joint. Lower limbs were also severely deformed. Right limb showed hypoplastic foot with adactyly (missing digits). Left limb had apodia (missing foot) with adactyly (). Radiographically, right limb revealed hypoplasia of the phalanges and first metatarsal bone; left limb revealed absence of tibia, fibula, and both the malleoli. Detailed systemic clinical examinations with appropriate investigations were also performed. Though patient was clinically normal, his chest radiograph showed prominent pulmonary bay. F"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old man presented to the emergency department with a 2-hour history of sudden acute severe back pain at the thoracic level. He described that the pain was initially dull and then became sharp. There was no history of trauma, drug use or any physical exertion. The past medical history was unremarkable. On arrival, he was conscious and alert, with no respiratory distress and normal vital signs. The rest of the physical examination was normal. Initial laboratory tests including complete blood count, chemistry panel and coagulation evaluation revealed no remarkable contributions.\nDuring observation, at 3 hours from the beginning of the pain, the patient complained of weakness and numbness over the lower limbs. A physical examination revealed paraparesis (muscle power scores of 2/5 for thigh flexion muscles and 2/5 for foot flexion on the bilateral lower limbs) with flaccid lower extremities and bilateral extensor plantar responses, decreased sensation below the T10 dermatome with anesthesia in the perineal region, and urine retention. Neurological and neurosurgical consultants were contacted and emergency magnetic resonance imaging (MRI) was ordered.\nMRI of the thoracic spine demonstrated an anterior epidural mass extending from T3-T4 to T8-T9, causing spinal cord compression, especially at T5-T6. The mass had isointensity to the spinal cord on T1-weighted images and hyperintensity on T2-weighted images (Figure ). Diffusion-weighted imaging revealed no alterations in the spinal cord. Based on the clinical presentation and imaging findings, an epidural hematoma of the thoracic spine was suspected. The patient was administered 1 g of methylprednisolone intravenously and was taken to the operating room for an emergency decompression laminectomy at approximately 130 minutes after the initial onset of the spinal cord compression symptoms. A bilateral laminectomy from T5 to T7 was performed. During the operation, an epidural hematoma was discovered and evacuated. Th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female patient with a height of 164 cm and weight of 60 kg was admitted to undergo ethanol sclerotherapy for a large painful vascular malformation in her left leg. Magnetic resonance imaging revealed an AVM measuring 28 × 7 × 4 cm in her left calf (). All preoperative examinations, including laboratory tests, electrocardiography, and chest X-ray, were normal. Vital signs before general anesthesia were stable: her blood pressure was 130/80 mmHg and her heart rate was 82 beats/min. Following the application of routine hemodynamic monitoring (3-lead electrocardiogram, noninvasive blood pressure, and pulse oximetry), anesthesia was induced using a bolus intravenous injection of 120 mg propofol and 40 mg rocuronium. A 20-gauge catheter was inserted into the radial artery to monitor her arterial blood pressure continuously. The target controlled infusion of 2% propofol and remifentanil (2-3 µg/ml and 2-5 ng/ml of the effect-site concentrations, respectively) was applied to maintain anesthesia. Immediately following the injection of ethanol, the patient's blood pressure and heart rate rose slightly to 160/100 mmHg and 100 beats/min, respectively. Thereafter, the patient's blood pressure and heart rate were stable throughout the procedure while she was in the prone position. A total dose of 50 ml of 99% ethanol was injected into the lesion over a period of 30 minutes without the use of a tourniquet. As soon as the patient was turned from prone to supine after finishing the procedure, an abrupt drop in her arterial blood pressure occurred, 40-50 mmHg systolic and 10-15 mmHg diastolic blood pressure with a simultaneous increase in her heart rate to 100-110 beats/min. To restore blood pressure, 20 mg of ephedrine was immediately injected, but the patient's heart rate rather decreased abruptly to < 30 beats/min. Chest compressions were performed along with the simultaneous injection of 50 µg of epinephrine. A few minutes later, the patient's blood pressure and hea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old female had attempted suicide in the morning by burning charcoal and was found unconscious in the evening by her son. She had been diagnosed as having depression for 8 years while her son had mild intellectual disability. She was taken to the emergency room of our university hospital. It was estimated that it took about 27 hours from the time of the suicide attempt to the time of admission. The level of carboxyhemoglobin was within normal range at that time. HBOT (2.5 ATA for 120 min) started immediately after admission, and her unconsciousness gradually resolved and returned to the normal level. However, after the thirteenth session of HBO, it was interrupted to treat her wound because there was a second-degree burn mainly in her upper left limb. Her disorientation and abnormal behaviors appeared about twenty days later after interruption of HBOT. She could not open the door and try to eat hand cream. The EEG at that time showed predominant slow waves (3~7 Hz theta and delta) with poor alpha (8 Hz) waves, and MRI at that time showed diffuse hyperintensity of the bilateral hemispheric white matters consistent with changes of delayed leukoencephalopathy as a result of prior CO injury with hyperintense change of the bilateral globus pallidi (). Three sessions of HBOT were thus performed immediately. Eleven days later, she was transferred to our department for the purpose of detailed examinations and treatment of CO intoxication. Since HBOT and burn treatment could not be performed at the same time, the policy was to give priority to burn treatment. Thirty-two days later, burn treatment was finished and HBOT was thus restarted. During 136 sessions of HBOT, her neuropsychiatric symptoms gradually ameliorated. Her clinical improvement went side by side with the improvement in scores of FAB as observed in case 1. 326 days after her suicide attempt, she was discharged from our university hospital. At that time, the score of FAB was 18/18 and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old man complained of a neck mass with laryngeal invasion and underwent a wide excision of the thyroid bed and a complete laryngectomy in October 2010. The patient was initially diagnosed with a sarcomatoid carcinoma of the neck with unusual histology. The tumor showed epithelioid-tubular structures containing mucin pools, with a fibrous or sarcomatous background, which is not consistent with the typical morphological features of ATC ( and ). The patient received adjuvant radiotherapy (42 Gy) and chemotherapy. However, the size of the residual neck mass and lung nodules increased, and the patient died 9 months after their last operation.\nThe patient had a history of total thyroidectomy for a PTC 6 years previously. In addition, the patient underwent a dissection of neck lymph nodes for PTC recurrence and a total of 200 mCi of radioactive iodine (131I) therapy 3 years previously.\nThe patient's tissue samples were reviewed retrospectively, and additional immunohistochemistry (IHC) staining and direct sequencing of the BRAF gene were performed. The primary PTC samples could not be included due to their poor quality. High expression levels of thyroid transcription factor-1 (TTF-1), thyroglobulin (Tg), paired box gene 8 (PAX8), and human bone marrow endothelial cell-1 (HBME-1) were observed in the recurrent node, but not in the laryngeal mass (). Other data obtained through IHC testing showed identical results for both the recurrent neck node and the laryngeal tumor: positivity for vimentin, p53, cytokeratin (CK) 7 (), and galectin-3; focal positivity for CK19; and negativity for CK20. Although the histopathological findings, as well as the IHC results, of the undifferentiated larynx tumor did not suggest that it originated from the thyroid, the positive result for the BRAF V600E mutation, by direct sequencing, indicated a possible PTC origin for the ATC (). Thus, we performed a BRAF mutation analysis using IHC on metastatic PTC samples in the patient's neck ly"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old japanese man with no previous cardiovascular disease was admitted to our hospital because of paroxysmal nocturnal dyspnea and low grade fever of four weeks duration. He had the history of the resection of subcutaneous abscess in the neck, several days before the onset of symptom. On admission, blood pressure was 104/40mmHg with a regular pulse of 102/min. His body temperature was 37.4C. An early systolic murmur and a diastolic blowing murmur with thrill were detected at the left parasternal border. Increased pulmonary vascular marking was observed in his chest X-ray and the cardio-thoracic ratio was 50%. Electrocardiogram revealed a prolonged P-Q interval of 0.28 second, left ventricular hypertrophy and ST depression in the left precordial leads. After admission, first-degree of atrioventricular block normalized in 0.18 second of P-Q interval. Echocardiography was performed with a Tohshiba 65A after normalization of P-Q interval, which revealed the dilated and hyperkinetic left ventricle and the slightly dilated left atrium. M-mode echocardiography showed premeature mitral valve closure (), and the left ventricular end diastolic dimension was 6.4 cm and the end systolic dimension was 4.4 cm. The right coronary cusp and left coronary cusp of the aortic valve were extremely elongated and the left Valsalva sinus was dilated. Both aortic cusps were prolapsing and no coaptation was seen. Severe aortic regurgitation was observed on color Doppler flow imaging. In late diastole, mitral regurgitation which ran just behind the posterior mitral leaflet and extended to the posterior wall of the left atrium was detected (). The diastolic mitral regurgitation began with the atrial systole and disappeared with the ventricular systole ().\nAlthough several blood cultures were all negative, the diagnosis of acute aortic regurgitation due to infective endocarditis was made from the clinical history and destructive changes of the aortic valve. After intensive antibiotic t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 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.\nHe 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.\nThe 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"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old North African man, with no past medical history, consulted our out-patient clinic for a painless left scrotal mass. There was no history of previous orchitis or scrotal contusion. He noted the mass a month ago. A physical examination found a 2 cm palpable mass in the upper pole of his left testis. There were no signs of scrotal inflammation. The mass had a firm consistency and regular margins. Palpation of his right testis and the lower pole of his left testis were normal. Routine blood tests were normal. As a testicular tumor was strongly suspected, a bioassay of testicular tumor markers was ordered. Alpha-fetoprotein, human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) were in the normal ranges. There was no bacterial growth in urine analysis, including Mycobacterium tuberculosis screening. A scrotal ultrasound showed a homogeneous testicular parenchyma, with a conserved vascularization on Doppler. An extratesticular mass was observed, attached to the upper pole of his testis. The mass was isoechoic to the testis parenchyma, and poorly vascularized Doppler (Fig. ).\nHe underwent a radical inguinal orchiectomy. We first performed a high ligation of the spermatic cord. The operative specimen included the testis and the tunica vaginalis in one piece (Fig. ). The macroscopic aspect of the supratesticular mass looks similar to splenic tissue (Fig. ). There were no macroscopic lesions of the testis and the spermatic cord. His postoperative course was uneventful. He was discharged on the second postoperative day.\nHistological examination of the operative specimen confirmed the presence of regular splenic tissue in the suspect mass, without any signs of malignancy. The splenic proliferation had its proper and regular capsule, demarcating it from the testis. Testicular pulp, the albuginea and the tunica vaginalis had a preserved microscopic architecture (Fig. ). He was examined 3 weeks after orchiectomy and he was examined again 2 months after"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 47-year-old male with past medical history including aorto-occlusive disease status post femoral-popliteal bypass, with peripheral artery disease, coronary artery disease, and tobacco dependence. He initially presented with right groin and lower-extremity numbness with an otherwise unremarkable review of systems. The patient was diagnosed with right limb occlusion with critical limb ischemia of the right lower extremity due to an aorto-femoral bypass graft occlusion. Initial workup included a computed tomography (CT) angiogram of the chest, prior to treatment of the occlusion with a femoral-femoral bypass.\nComputed tomography angiography (CTA) of the chest revealed a 1.4 cm nodule at the left lung apex, slightly cavitary in nature together with a left paratracheal soft tissue density that was suspected to be adenopathy related to pneumonia that was being treated. The lesion was considered to be incidental with the recommendation of short-term follow-up with another chest CT in three months. There was no prior imaging for comparison.\nTwo months later, the patient presented to the emergency room with bilateral chest pain and associated shortness of breath and dyspnea. He was admitted to the intensive care unit (ICU) for respiratory instability and treated for multiple bilateral pulmonary embolisms. The diagnosing CTA of the chest showed an increase in the left upper lobe mass density with 2.5 cm x 2.4 cm dimensions including marked interval increase in diffuse mediastinal and bilateral hilar adenopathy involving levels T5, T10, and T11, suggesting a primary neoplasm with metastatic disease. The primary lesion was pleural based and thought to be invading the pleura. Once the patient stabilized, a CT-guided left upper lobe biopsy was obtained.\nBiopsy revealed a poorly differentiated non-small cell carcinoma consistent with squamous cell carcinoma. Sections showed nests and individual large cells with brisk mitotic activity with medium to large nuclei."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old healthy pregnant lady with a history of 3 previous cesarean sections was scheduled for her 4th cesarean delivery. The operation was performed under spinal anesthesia. Severe adhesion of the urinary bladder to the lower uterine segment was encountered but there was no apparent lower urinary tract injury. Her postoperative period was uneventful and she was discharged home the next day. On the 11th postoperative day she was readmitted to the emergency unit at 11 pm with considerable abdominal distension, shortness of breath and difficulty of micturition with straining to void. Further questioning revealed sudden inability to void 5 days earlier followed by mild hematuria and passing a small amount of urine. On examination she was dyspneic, the abdomen was distended, pulse rate was 100 BPM, blood pressure was 100/60 mm/Hg and afebrile. Immediate resuscitation was started and Foley catheter was inserted which drained 100 ml concentrated urine. Serum creatinine (6.8 mg/dl), blood urea (123 mg/dl) and serum potassium (5.6 meq/l) were high. Abdominal and pelvic ultrasound showed marked ascites (), normal both kidneys with no hydronephrosis. A trial of diagnostic and therapeutic ascitic fluid drainage was performed by putting a percutaneous 12 French pigtail catheter in the right lower abdomen under ultrasonic guidance (). Six and a half liters of clear fluid was drained. Biochemical investigation of the drained fluid showed high urea (145 mg/dl) and creatinine (20 mg/dl). Diagnosis of urinary ascites was confirmed. Later on, there was a dramatic improvement in the general condition of the patient. Next day blood chemistry was repeated and showed normal blood urea and serum creatinine. Through cystoscopy, we detected a perforation at the posterior wall of the bladder (), while both ureters were normal. Then a Foley catheter was fixed to completely drain the urine in addition to the peritoneal drain to allow the perforation to heal. The patient was put on intrav"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old female patient was referred to our department with acute onset postpartum paraplegia with bowel bladder involvement after delivery of her third child by normal vaginal delivery. Her antenatal course had no significant history with any history of antepartum low-back pain, trauma, drug use, or any physical exertion. On examination, she was conscious, well oriented, and afebrile. Neurological examination showed complete paraplegia (power 0/5 with decreased tone), associated bowel bladder involvement, and absent deep tendon reflexes at knee and ankle joint with complete sensory deficit below the level of L1. All necessary blood investigations including coagulation profile came out to be normal. Patient was planned for magnetic resonance imaging (MRI) of dorsolumbar spine with screening whole spine, which revealed extradural broad based ellipsoid lesion, measuring 50 × 9 mm along T12 to L2 vertebra displacing the dura anteriorly and T1 hyperintensity (\n), T2 hypointensity with minimal postcontrast enhancement suggestive of early subacute bleed causing mass effect on adjacent cord with areas of altered signal intensity at the level of lesion.\nOn the basis of clinical evaluation and MRI report, the patient was planned for urgent decompression in emergency operation theater. After preoperative marking of D12–L2 vertebral levels under fluoroscopic guidance, midline exposure done and paraspinal muscles elevated upto medial edge of transverse processes on both sides with the help of cobb's and broad osteotome. Intraoperatively, bilateral complete laminectomy of L1 vertebrae was done with removal of ligamentum flavum, a well-defined firm organized hematoma dark reddish black in color (5 × 1 cm) was seen over the dura which was removed (\n) and checked for adequate decompression utilizing infant feeding tube. Sample removed was sent for histopathological examination reported as organized hematoma. Postoperatively, patient recovered rapidly in terms of neurological d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male patient, farmer by occupation presented to our STD clinic with a large polypoidal growth on the penis, scrotum and right upper thigh since last 10 years. 10 years back he developed progressive itching on the tip of the penis and subsequently within a few days he developed small skin colored lesion with clear fluid oozing from them on scratching. Later the lesions progressively increased in size and circumferentially over the skin of prepuce. Similar polypoidal growth developed over the scrotum and right upper thigh that subsequently increased in size. All these lesions were progressively enlarging became hard, not associated with pain but with a mild itch. There was no history of similar lesions elsewhere in the body. Patient was also able to have sexual intercourse during the initial 2 years.\nOn examination of the patient [], there was the polypoidal growth involving the skin over the prepuce, scrotum and right upper thigh. There was circumferential growth involving the skin of the prepuce, scrotal growth involving its tip and growth over right upper thigh measuring an average size of 3 cm × 2 cm. The perianal area, gluteal region and rest of the body surface were free of similar lesions. The patient was able to urinate without any difficulty. His sexual activity was compromised during the last 8 years. The wife did not complain of any such lesions on her sexual organs and was found normal on examination.\nThe initial diagnosis of giant condyloma acuminata, verrucous carcinoma over genitalia, giant acrochordons (skin tags) was kept in mind, and the patient was investigated. The complete hemogram, liver, and renal function tests and immune status were found to be normal. The patient was taken up for shave excision of the lesions under general anesthesia. The preputial skin with the lesion was excised along with shave excision of similar lesions over the scrotum and right upper thigh"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case report is of a 34-year old man who was married, Catholic, and a construction worker. He had primary school education with no history of previous hospitalizations, surgeries, transfusions, allergies, or known pathologies. He referred only to head trauma suffered 8 months ago by way of physical assault. The assault caused a nose-bone fracture with a nasal septum deviation to the right, but with neither purulent material nor a rinusinusal infectious process. He had only mild, intermittent, and sporadic obstructive dyspnea after the incident. The patient smoked 20 cigarettes a day for 21 years, from 13 to 34 years of age. Up to 5 months prior to his admission, he also suffered from alcoholism for 11 years, drinking 1000 ml of alcohol every week.\nHe was admitted to the hospital with an occipital headache which he had endured for 2 months. For over 1 and a half months, he had also experienced behavioral disorders and a disruption of higher mental functions. He had retrograde and anterograde amnesia with both echolalia and the presence of visual hallucinations. A private physician initially treated him with diazepam, pentoxifylline, diclofenac, and phenytoin, all with standard doses but with no improvement. Three weeks prior to admission, the patient experienced acalculia and multiple apraxia that did not allow the patient to perform ordinary work and other daily activities such as bathing, and dressing. At this point, the patient required the support of a family member. The individual was evaluated by a second physician who prescribed amitriptyline, bromazepam, B complex, and additional phenytoin. Five days later, the patient developed ataxic gait and was evaluated at a regional hospital where he was given treatment for poisoning (benzodiazepines with flumazenil and a gastric lavage with activated carbon). One week prior to admission, the man quickly and progressively lost the ability to hold himself up. He suffered from psychomotor agitation and myoclonic movem"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old patient was referred to a private genetic counseling service because, besides an extensive family history of cancer, she had a 2.0 cm lump detected in her right breast, as assessed by Magnetic Resonance Imaging, of Breast Imaging Reporting and Data System (BIRADS) category 4. The biopsy by fine needle aspiration showed a ductal proliferative breast lesion. The patient had a high risk for breast cancer and family history of cancer, with kindred diagnosed before the age of 50 years. The analysis of her pedigree showed an autosomal dominant disorder from her paternal side () with early onset cases of colon adenocarcinoma, gastric, lung, prostate and pancreas cancer.\nAccording to the ANS guideline, the patient did not meet the criteria to be tested for germline mutations because (i) she had no current or previous cancer diagnosis, (ii) she was not of Ashkenazi jewish origin, and (iii) there were no known mutations in her family. It is important to highlight that the patient was informed she was not the perfect index patient for family genetic counseling since she was not diagnosed with cancer; thus, her result was limited to individual genetic counseling, i.e., a negative result for presence of mutation would not mean the absence of mutation in her family.\nSince Brazil lacks a specific guideline to screen hereditary cancer, the worldwide applied United States National Comprehensive Cancer Network (NCCN) is routinely used. It comprises recommendations on the prevention, diagnosis, and management of malignancies across the continuum of care. The NCCN Guidelines incorporate real-time updates in keeping with the rapid advancements in the field of cancer research and management. For hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch syndrome (LS), the patient should meet revised Amsterdam criteria or revised Bethesda criteria.\nGenetic counseling consultation is a health service that provides information and support to people who have or may be at risk"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old Caucasian woman, gravida 1 para 0, presented to our hospital with repeated attacks of mild vaginal bleeding. Our patient, according to her sure reliable dates, was 16 weeks and three days pregnant. She had a history of primary infertility for seven years preceding this pregnancy, and she had sought medical advice for delayed conception one year after marriage. Male factor infertility was excluded by a single semen analysis and she was informed that her hysterosalpingography was quite normal; she was given medical treatment that she could not recall to improve her cycles (these were infrequent and irregular over the last five years). She used these medications for about four months after which she reported some improvement in her cycles but conception did not occur. A hormonal profile was ordered and our patient was examined transvaginally by ultrasound. Subsequently, she was informed she had bilateral polycystic ovarian syndrome. Her physician prescribed clomiphene citrate (Clomid, Global Napi, Egypt) 100 mg for five days beginning on the second day of her cycle. Our patient continued taking the drug without ovulation monitoring and the regimen was repeated with an increasing dose up to 200 mg daily for six successive months. Laparoscopic ovarian drilling was performed and our patient resumed using clomiphene citrate three months after the operation without prescription. Two months prior to admission, she took 250 mg of clomiphene citrate (five tablets per day) beginning from the second day onwards until the 13th day of the cycle.\nOur patient had a missed period immediately after this haphazard regimen. Pregnancy was confirmed by a urine pregnancy test then by a trans-vaginal ultrasonographic examination that was carried out six weeks and three days after her last menstrual period. According to this ultrasound report, the gestational sac corresponded to seven weeks of gestation. However, there was no comment regarding the presence of theca lutein ovari"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-month-old Middle Eastern boy was born full term at a community hospital in Michigan with birth weight of 3135 g (15.0 percentile). He had normal prenatal ultrasounds. He passed meconium at birth and had no other complications including prolong neonatal jaundice or dehydration. His CF NBS showed serum IRT 139 ng/ml and was negative for the 40 gene mutations panel. At 1 month of age, he developed a wet cough without any other symptoms. He was followed by his primary care provider (PCP), and no treatment was given at the time. His symptoms continued on and off until 1 year of age. At 1 year, the mother noticed increased frequency of productive cough, lack of appetite, and poor weight gain. His weight-for-age percentile ranged from 0.3 to 5.0. His stools were reportedly normal. He had no excessive sweating. He was referred to an outside asthma/allergy specialist for evaluation of asthma. He was prescribed budesonide without any improvement. He had frequent pharyngitis and otitis media that were treated with oral antibiotics that reportedly helped treat acute infection, but the cough persisted. He was also prescribed a H2 blocker for possible gastroesophageal reflux disease, but no improvement in symptoms was noted. Family history was negative for CF.\nAt 30 months of age, he was seen by his PCP for one week of cough and fever. He was treated with amoxicillin. His symptoms continued to worsen despite oral antibiotics, and he had two episodes of small-volume hemoptysis. He was subsequently admitted for community-acquired pneumonia and influenza B. Chest X-ray showed diffuse ill-defined opacities in the perihilar area and diffuse bronchiectasis. During the hospitalization, pediatric pulmonary consult was obtained. Given the negative NBS, it was stated that CF was unlikely and no sweat chloride test was recommended. He had a normal videofluoroscopic swallow study. Immunodeficiency workup revealed elevated immunoglobulin levels, protective vaccine titers"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of 1-year-old male child presented to the ophthalmology OPD with abnormal appearance of both eyes since birth. He was born by an uneventful, full term delivery of a nonconsanguineous couple. At the time of birth, he had slight protrusion of both the eyes with abnormal lids, and bleeding off and on. The eyes continued to protrude until 3 months of age; the condition remains static ever since. He also developed tonic-clonic seizures after 3 months of age which still continued but decreased in frequency, and the last episode was 2 days before the presentation. He also reported having increased head circumference at birth that has not progressed since then. At the time of presentation, the child has abnormally protruded eyes with coloboma of middle 1/3 of right upper lid, and medial 1/2 of left upper lid; an abnormal skin fold present below the malformed left lid. A skin tag was present at the outer canthus of right eye [ and ]. The conjunctiva on the right side appears slightly cystic, both the conjunctiva and cornea were keratinized because of exposure. No other ocular abnormality in the form of orbital cyst or microphthalmia was present. He had frontal bossing with depressed nasal bridge [] and also slight protrusion of tongue. There were focal patches of alopecia with dermal hypoplasia of scalp [Figure and ]. Hyperpigmented patches were seen on the right side of the chest, abdomen and back with a slight extension onto the nape and right arm []. Developmental milestones were evidently delayed. A thorough general and systemic examination did not reveal any abnormality except for decreased muscle strength. Baseline investigations were unremarkable, and an abdominal ultrasound showed a complex splenic cyst of 6 mm.\nMagnetic resonance imaging of the head showed aplasia of cerebellar vermis with enlarged superior vermian cistern. There was subependymal grey matter heterotopia of the postero-inferior aspect of the atrium of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man was admitted with acute onset of confusion, personality change, and intermittent headache. His symptoms worsened over three days prior to admission. There was no history of nausea, vomiting, fever, or seizures. His past medical history was significant for hypertension, but he was not using any medications. He was a non-smoker and never consumed alcohol. In the emergency department, vital signs including blood pressure and temperature were normal. He was confused, disoriented to time and place with no neck rigidity or stiffness. Neurological examination showed a normal tone and power (muscle strength by medical research council scale) with normal symmetrical deep tendon reflexes. His gait was normal, but the examination of coordination and fundi was difficult to perform. Unenhanced computerized tomography (CT) scan of the brain was normal. The patient was taken to the magnetic resonance imaging (MRI) suite, but he was moving and irritable, which made this imaging modality difficult to perform. Routine investigations revealed normal biochemical tests and inflammatory markers. His white blood cells (WBC) count revealed a leukocytosis (20,000) with normal platelets and hemoglobin. Blood and urine cultures and chest radiographs were unremarkable. Examination of cerebrospinal fluid revealed no WBCs or red blood cells, normal glucose and protein with negative gram stain and culture. Polymerase chain reaction tests were negative for common viral pathogens. Electroencephalogram recordings showed a slow background in the theta range with no epileptiform activity or evidence of encephalitis. Two days after admission, his condition deteriorated, and he became more agitated and combative with a drop in his blood pressure to 80/40 mmHg and tachycardia (120 bpm). He was intubated and mechanically ventilated, but unfortunately, his Glasgow coma scale dropped. His pupils became fixed and dilated. Repeat work-up of septic shock was again unremarkable, and he require"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA dead body of a 34-year-old male was found from a gutter line in Thatta district, Sindh. Upon external examination, the dead body was found to have widespread blisters and swollen face and abdomen. The macerated foul-smelling body with a half-opened mouth was missing nose, upper lip, and left eyelid as a result of being eaten by fish/insects dwelling in the gutter. The clothes, hair, nails, and nail scrapings of the dead body were sent for DNA and serological analyses. Upon serological analyses, blood was detected on the clothes of the victim. The DNA profile obtained from the hair and nail of the victim was consistent with a single source of male origin. The DNA profile obtained from nail scrapings was a mixture of at least two individuals with a major and minor component. The major component matched the DNA profile of the hair and nail of the deceased, but the minor component did not match, which further adds weight to the possibility of a homicide. The dead body was then buried without forensic intervention due to a lack of forensic expertise in the rural area of Thatta.\nAfter almost six months post burial, exhumation of the dead body was requested by the investigating officer to ascertain the cause of death, whereafter, it was performed. Upon unearthing, the body was found in an advanced stage of decomposition, with soft tissues decomposed and the underlying skeleton intact (Figure ). Greater cornu of right upper 1/3rd of hyoid bone was found fractured, and both maxilla and mandible were dislocated (Figure ). The rest of the skeleton was unremarkable in appearance. The left clavicle and right femur were reserved for chemical analysis to detect the presence of diatoms and traces of poison (Figure ). Water from the death site (gutter) was taken to compare and detect diatoms. The right clavicle bone"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old male fell while riding a bicycle on the road. On the day of the fall, he had no definite symptoms; however, he complained of a mild, intermittent headache and nausea five days after the incident and visited the hospital. His neurological state was normal and there were no blood stains in the ear, nose, or throat. The brain computed tomography (CT) revealed a linear fracture, small amounts of epidural hematomas and pneumocephalus in the right occipital area. When compared to the left side, a higher density lesion within the right sigmoid sinus was found (). The brain magnetic resonance image (MRI) showed the effusion and hemorrhage in the right mastoid air cell and a signal intensity, which was suspected to be thrombus, in the right sigmoid sinus (). The brain magnetic resonance venography (MRV) revealed an absence of a flow signal between the right sigmoid sinus and the jugular bulb, which was confirmed to be sigmoid sinus thrombosis (). During the physical examination, he showed no papilledema, intracranial hypertension, or otogenic infections such as otitis media. His blood tests, including complete blood count, prothrombin time, partial thromboplastin time, antithrombin III, protein C activity, and protein S activity, were in the normal ranges. The patient was treated conservatively because the patient's symptoms were mild and gradually improved. He was discharged with a full recovery on the 4th day in the hospital. On the 10th day after discharge, the patient complained of vomiting and visited the department of pediatrics. The laboratory tests, including a prothrombotic evaluation and a physical examination, were performed. The results of the laboratory tests were normal. Due to concern regarding the progression of the previous sinus thrombosis, the brain MRV was re-checked, and it showed the recovery of the flow signal in the right sigmoid sinus (). The spontaneous recanalization of sigmoid sinus thrombosis occurred within about three weeks of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year old female patient, who had been suffering from autoimmune thyroid disease for eight years, presented at our clinic with an acute exacerbation of GO. Clinical examination revealed a convergent strabismus fixus with severe hypotropia of both eyes (Fig. ). The patient complained of increasing loss of eyesight and heavy retrobulbar pain. Visual acuity had deteriorated significantly from 0.6/0.5 to 0.1/0.1 within 3 months. A contrast enhanced orbital MRI scan showed distinct swelling of all extraocular muscles with bilateral compression of the optic nerve (Fig. ). There was no history of comorbidities except nicotine abuse. Laboratory tests showed a euthyroid biochemical status with TSH within the normal range, but elevated levels of Anti-Thyroid Peroxidase Antibody, Anti-Thyroglobulin Antibody and Thyroid Receptor Antibody. The patient’s daily medication comprised of 200 μg L-Thyroxin and 200 μg Selenium. Over many years, the patient had shown only mild to moderate symptoms of GO, but following a thyroidectomy, the symptoms had recently worsened dramatically. Since the disease could not be controlled by high-dose systemic glucocorticoid therapy, bilateral three wall orbital decompression had been performed twice previously. In the first step, the medial orbital wall had been resected via an endonasal approach. Due to ongoing findings as before, two months later partial resection of the orbital floor and fenestration of the lateral orbital wall via a combined transconjunctival/transcaruncular approach with piezosurgery had been performed. In addition, high-dose systemic glucocorticoid therapy was conducted prior to surgery and for the first two months after surgery. Glucocorticoid medication had to be gradually reduced until zero because the patient suffered from an upcoming depression and Cushing syndrome. Orbital radiotherapy for the treatment of thyroid eye disease had been considered as a therapeutic option, but the rapid progress of the disease with the g"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old Caucasian female who was a non-smoker, with a history of heart ischemic disease, hypertension, anemia and diabetes, underwent a laparoscopic left radical nephrectomy for a renal neoplasm of 10×7 cm in the superior left renal pole in 2011. The postoperative course was uneventful and the patient was discharged after 6 days. The histological examination revealed the presence of a renal cell carcinoma, Fuhrman grade 2, with extensive necrosis and phlogosis areas (TNM 2009 RCC pT2a). Informed consent was obtained from the patient.\nAfter discharge, the patient was readmitted for a sciatica episode and underwent two abdomen ultrasonography examinations, with no notable pathological findings.\nAfter a few days, the patient noted an indolent swelling in the proximal third of the right thigh. The patient subsequently underwent ultrasonographic evaluation, revealing the presence of a solid, vascularized mass that was ∼40×22 mm in size.\nThe subsequent CT documented the presence of a pathological, solid, dishomogeneous bulk that was ∼4.5 cm diameter, in the front of the right iliac vessels, immediately cranial to the inguinal region. Another smaller (1.5 cm) lesion was observed in the ipsilateral inguinale region, while an additional solid expansive lesion was noted in the rectus femoris muscle ().\nThe fine needle biopsy of the muscle mass documented a metastasis of renal cell carcinoma (). The histochemical analysis revealed positive staining for vimentin and CAM, and negative staining for cytokeratin 7.\nMoreover, we performed a cerebral CT and a total body bone scan, in order to achieve a complete stadiation of the patient. Neither of the examinations revealed further meta-static localization.\nA joint evaluation of the patient was performed with the oncologist, the general surgeon and the radiotherapist. With regard to the pathological stage of the disease and the comorbidity of the patient, it was decided to refer the patient for targeted therapy with sunitinib."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis study is approved by our institutional review board and this patient has signed informed consent.\nA 33-year-old Chinese male initially presented with an epileptic seizure. Magnetic resonance imaging (MRI) detected two extra-axial, homogeneous, well-defined, dural-based lesions. The large one is in the left frontotemporal parietal region, and the small one is in the right frontal region. T1-weighted images show isointense and slightly hyperintense signal intensity, and T2-weighted images show isointense with intralesional hypointense foci, obviously uniform enhancement with an enhancing dural tail sign (Fig. ). This patient was initially diagnosed with multiple convex meningiomas and underwent a craniotomy for resection of the large lesion. After the left lesion was resected, this patient recovered very well and restored normal speech function. We recommended adjuvant hormone therapy or radiotherapy but the patient declined any further treatment until progression was seen on the MRI and the patients suffered from a symptomatic seizure 20 months after surgery. MRI showed the size of the right lesion increased obviously. Then the second craniotomy was taken to remove the right lesion, and the patient recovered again with no neurological deficit. There was no seizure nor tumor recurrence on follow-up so far (2 years follow-up).\nIn the sections from the first operation, microscopic examination showed a large number of lymphocytes and plasma cells infiltrated in fibrous tissue scattered large histiocytic cells with abundant cytoplasm. Immunohistochemical staining showed positive for S100, CD68, but negative for CD1a (Fig. ). Both morphological and immunohistochemical profiles of the left lesion supported the diagnosis of RDD.\nHistopathological examination for the sections from the second operation exhibited similar results as the first one (Fig. ). Histiocytes were the predominant cells and contained abundant pale to vacuolated cytoplasm and mildly pleomorphic vesicu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old Greek female patient was referred to our institution for the management of biliary trauma after laparoscopic cholecystectomy. In her medical history, she had had two laparotomies: an ileoanal anastomosis with j pouch for ulcerative colitis 15 years ago, while 5 years ago she was driven to the operating room after a colonoscopy for peritonitis. Due to non-specific upper gastrointestinal symptoms she had had an upper abdominal ultrasound (US) that revealed cholelithiasis (at least two gallstones of diameter 0.8 and 0.7 cm) 2 months before surgery and elective laparoscopic cholecystectomy was performed 18 months before her referral to us.\nThe duration of laparoscopic cholecystectomy was 150 minutes while the procedure was completed laparoscopically and there is no record of intraoperatively identified biliary injury. From the 2nd postoperative day and up to her referral to our institution, recurrent episodes of cholangitis with severe pain, fever with chills and jaundice began. Magnetic resonance cholangiography (MRC) was performed in order to delineate the biliary anatomy and assess the level of injury. A triple bile duct injury, with right and left hepatic duct ligation and common bile duct cross-section, was revealed (Bismuth type V, Figure ). Attempts at permanent biliary decompression with repeated endoscopic retrograde cholangiopancreatographies (ERCP), combined with percutaneous transhepatic duct catheterization failed and for 1 year postoperatively bile drained from abdominal drains. On the 13th postoperative month, she was referred to another hospital for biliary draining (Figure ). Through the left drain, a guidewire was passed only to be found later during ERCP in the duodenum in a place other than the papilla of Vater via a false route. On the next episode of cholangitis, both left and right biliary trees were successfully decompressed and 18 months after LC, she was referred to our hospital for surgical reconstruction.\nThe intraoperative find"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOtherwise healthy, 12-year-old boy was admitted to the ward with a history of swelling of the right and left forearms, for 1 day duration.\nHe gave a history of a swelling in the right forearm first noticed six weeks prior to the current presentation, and it has resolved gradually without any acute intervention. During the initial presentation, the mother claimed that he was treated with a course of amoxycilline for an upper respiratory tract infection prior to the onset of the swelling. Since then, he was well till this current admission.\nDuring this presentation, the swelling of the right elbow joint along with the forearm swelling worsened progressively. He did not have any history of trauma or febrile illness associated with the current presentation.\nHe denied any bleeding tendency in the past except a history of mild extra bleeding which settled spontaneously following a dental extraction one month back. There was no history of photosensitive skin rashes, renal problems, recent weight loss, or poor appetite. He did not have any family history bleeding disorders.\nOn examination, he was alert, pale but not icteric or febrile. His weight : height ratio lied between 1 SD and median. He did not have lymphadenopathy, hepatosplenomegaly, or ballotable masses.\nExamination of the upper limbs revealed that the range of movements was reduced due to the pain and there was diffused tense swelling of both forearms. But there were no inflammatory changes noted on the over line skin or adjacent joints of the swollen areas. Rest of his systemic examination was unremarkable.\nDuring initial investigations, his full blood count revealed a white cell count of 8.62 × 109 with a normal differential count. His haemoglobin was 7.7 g/dl with a platelet count of 278 × 109/L.\nHis clotting profile showed a normal PT/INR with normal bleeding and clotting time but his APPT was significantly prolonged (patient: 109.9 seconds; control:"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA man who was 42-years-old in 1997, was admitted with a chief complaint of abdominal pain, and was later diagnosed with colon cancer. He was treated with sigmoid colon cancer radical surgery on 23 June 1997. Postoperative histopathological analysis revealed sigmoid colon cancer graded as Dukes C1 (Fig a). The patient did not receive any chemotherapy or radiotherapy after the surgery.\nIn October 2003, the patient again presented with abdominal pain and colonscopy revealed colon cancer. He underwent radial ascending colon carcinoma sugery in 08 October 2003. Histopathological analysis demonstrated moderately and poorly differentiated adenocarcinoma of the ascending colon invading to the outer membrane (Fig b). Following surgery, the patient was then treated with oral Carmofur 150 mg t.i.d.\nIn April 2009, the patient was admitted to the First Affiliated Hospital of Zhejiang University School of Medicine with gross hematuria, which was later diagnosed as bladder cancer. The patient underwent right pelviolithotomy combined with excision of the remaining right ureter and the bladder cuff. Postoperative histopathological analysis revealed (bladder, right ureter and right renal pelvis) multiple invasive stage II urothelial papillary carcinoma (Fig c). The patient was treated with infusion chemotherapy (Doxorubicin) following surgery.\nIn July 2010, the patient again complained of gross hematuria and was subsequently admitted to People's Hospital of Jinyun Town. He received a partial bladder resection and postoperative pathology subsequently indicated invasive high-level papillary urothelial carcinoma of the right wall of the bladder (Fig d).\nIn September 2011, a mass (2 × 2 cm) which was stiff and fixed in the left neck was discovered. With no treatment, biopsy of the mass was taken one month later (23 October 2011) at the Cancer Hospital of Fudan University. Pathological study showed metastatic carcinoma with necrosis (Fig d). Chest CT scan showed a mass (5.9 × 5.0 cm) in t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57 year old woman was admitted to our hospital on July 18, 2017 because of tiredness and fever. The patient had a body temperature of 39 degrees without other discomfort. Physical examination indicated no positive symptoms. MRI of the epigastrium showed that there was an elliptical hyperintense signal below the pancreas on the T1WI (Figure ) and slight hyperintensity on the fat-suppression T2WI (Figure ). The internal signal was heterogeneous and a clearly bounded tumor 3.4 cm × 2.8 cm in size was observed. Marked enhancement on the arterial phase was inhomogeneous (Figure ). In addition, the venous phase and delayed phase continued to intensify (Figure -F). On account of the hypervascular mass located under the pancreas, it was highly possible that the mass was a nerve incretory tumor.\nLaboratory examinations showed that the HIV antibody was negative and the white blood cell count was 14.6 × 109/L. Tumor markers and other laboratory test results were within the normal range. The preoperative diagnosis was an retroperitoneal neuroendocrine tumor. Laparoscopic surgery was performed to remove the retroperitoneal tumor. No ascitic fluid or obvious conglutination were found. When the gastrocolic ligament was incised, the lesion was located behind and below the transverse mesocolon. Intraoperative ultrasonography indicated that the tumor had an abundant blood supply, and its right side was close to the inferior mesenteric artery and vein (Figure ). The flexible tumor was 3.0 cm × 3.0 cm in size with a clear border (Figure ). The tumor was completely removed by blunt and sharp separation for further analysis (Figure ). Rapid histopathological examination revealed that the mass was possibly retroperitoneal CD together with a follicular dendritic cell tumor, which was confirmed by subsequent postoperative pathology (Figure -F). Immunohistochemical staining showed that a portion of cells were positive for CD21 and negative for CK, a small number of cells were positive"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old woman suddenly developed motor impairment of both lower extremities and sensory impairment of the left lower extremity with one day duration. Three years earlier, she had undergone instrumented fusion from T10-S1 at another institution secondary to degenerative lumbar kyphosis and spinal stenosis. On this occasion, she initially presented at another hospital, where she denied any obvious trauma, and was admitted for observation after the radiographs. The motor impairment of both lower extremities deteriorated gradually over 2 days, which prevented her from standing without assistance. She presented at our institution 6 days after the onset of symptoms.\nThe physical examination revealed mild tenderness over the thoracolumbar area. The neurological examination showed positive bilateral Babinski reflexes, motor impairment both lower extremities (grade 1) on the manual muscle test scale, last normal sensory level at T10 with hyposthesia at T11 onwards with preservation of the anal wink and tone, and no bowel/bladder incontinence. The preoperative ASIA score for cervical myelopathy was calculated with a score of 60 on motor. The plain lumbar radiographs revealed instrumental fusion from S1 to T10 and narrowing of the intervertebral disc at T9-10 as well as sclerotic changes and a gas shadow (). Plain lumbar radiography and computerized tomography (CT) of the thoracic and lumbar spinal regions failed to show any evidence of nonunion or ossification of the posterior longitudinal ligament or ligamentum flavum. Magnetic resonance imaging (MRI) revealed localized compression of the spinal cord at the T9-T10 level, and axial MRI showed a mass located around and compressing the dural sac ().\nA posterior approach was used to remove the mass. After a total laminectomy (using a high-speed burr) of T9-T10, the sequestrated disc was detected posterolateral to the dural sac, and was excised without damaging the spinal cord. Instrumented fusion was then performed from T8"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man developed a sudden epigastric pain. He was presented at this hospital as an emergency outpatient. Six years earlier, he underwent laryngoesophagopharyngectomy, bilateral lymph node dissection for hypopharyngeal cancer, and esophageal reconstruction with a free jejunum flap. On physical examination, the abdomen was flat and soft with tenderness in the epigastric region, but no sign of peritoneal irritation. Blood biochemistry findings revealed elevated values: creatinine, 1.16 mg/dl; lactate dehydrogenase, 364 U/l; and creatine phosphokinase, 622 U/l.\nAbdominal contrast computed tomography (CT) revealed twisted mesentery with the small intestine around the point of torsion (whirl sign) and the superior mesenteric artery as the axis. Contrast enhancement was weakened in the same area of the small bowel (Fig. ). Given this information, we suspected small bowel volvulus and performed emergency surgery on the same day.\nA 5-mm camera port was placed in the umbilicus and 5-mm ports in the lower and right lower abdomen. During laparoscopic examination, the upper jejunum adhered to the small bowel close to the terminal ileum with overlapping of the small bowel. The entire part from the upper jejunum to the terminal ileum was twisted clockwise with the superior mesenteric artery and vein as the axes and the adhesion site as the starting point. There were areas of poor color enhancement throughout the twisted section of the small bowel (Fig. ). We laparoscopically separated the adhesion between different sections of the intestinal tract and traced the bowel from the small bowel in the region of the ligament of Treitz toward the anus to confirm the absence of adhesions or torsion up to the terminal ileum. The color of the small bowel improved; hence, the surgery was completed without resecting any part of the intestine.\nPostoperatively, the patient made good postoperative recovery, resumed oral intake on day 2, and was discharged on day 5 after surgery"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 60-year-old man who referred to our emergency department due to worsening dyspnea and hemoptysis since 2-3 days prior to admission. He reported to have dyspnea and hoarseness during the previous year. He had undergone a direct laryngoscopy which had revealed left vocal cord palsy and a chest computed tomography (CT) scan which had shown a mediastinal mass and with possibility of a malignancy process a direct needle biopsy was done which demonstrated inflammatory cells in the background of blood. His past medical history only included a mild stroke 6 years before without any sequel.\nAt the emergency department he had pulse rate of 86 beats/min, respiratory rate of 18/min and blood pressure of 135/80 mm Hg. He had a continuous murmur in left sternal and pulmonic area and decreased breathing sound in left hemithorax.\nA chest x-ray was obtained which showed a large density in mediastinum and left sided pleural effusion. In echocardiography he had normal left ventricle but dilated right sided chambers with supravalvular pulmonic stenosis. Trans-esophageal echocardiography revealed a pseudoaneurysm of distal aortic arch with clot formation and compression of the main and left pulmonary artery. As a result a chest CT scan with contrast and angiographic construction was done which confirmed the previous finding of a 45 mm × 37 mm pseudoaneurysm in lateral side of aortic arch distal to left subclavian origin with associated 9.5 cm × 10 cm hematoma in mediastinum ( and ). At this stage and upon further investigation he remembered to have fallen down from a few stairs 10 years ago which did not result in any injuries and accordingly he did not seek medical advice.\nThe patient initially refused operation but a few days later developed severe chest pain and so finally agreed to a surgical plan.\nThe patient had a preoperative selective coronary angiography via right radial artery which was normal. He underwent left thoracotomy via femorofemoral bypass. A large p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female from Ethiopia presented with a giant skull-based tumor with a massive orbitocranial deformity distorting her facial anatomy and right eye.\nDiagnostic angiography, CT, and MRI revealed a giant, moderately hypervascular, multilobulated, and peripherally calcified expansile mass lesion which appeared to arise from the skull base and occupy the entire nasal cavity, maxillary sinus, and ethmoid sinus regions []. The intracranial extension of the tumor obliterated the sella turcica, bilaterally invaded the cavernous sinuses, and caused extensive elevation and splaying of the internal carotid arteries, anterior cerebral arteries, optic chiasm, and intracranial optic nerves. The mass measured approximately 10 cm × 8 cm × 11 cm. There was no evidence of edema or gliotic reaction in the adjacent brain parenchyma.\nThe patient underwent resection of the tumor through a subcranial transfacial approach. A bicoronal incision was carried down, preserving the galeal layer for possible use as a graft later. An incision was made over the face and nose to expose the front of the tumor. We broke through the thin bony shell and entered the multiloculated cystic tumor cavity. Fluid was drained and the operating microscope was brought into the field. This allowed us to work circumferentially to remove the entire solid tumor components all the way back to the circumferential bony shell. This left a massive cavity measuring over 15 cm in diameter. All soft tissues were removed and bone was drilled down. The lateral wall of the tumor was drilled, allowing for replacement of the globe to a more natural position. Bone was also drilled off the medial wall to decompress the lesion. The dura was never entered. Calvarial bone grafts were harvested by taking a large frontal parasagittal craniotomy.\nA craniofacial reconstructive surgeon with the help of an oculoplastic specialist completed a complex reconstruction. We used the bone grafts to reconstruct a new orbit and mid-face."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 10-year-old girl presented to our emergency department with a history of back pain, fever, and night sweats for 4-month duration associated with progressive walking difficulty and back deformity over the last 2 months. Physical examination revealed middle back swelling with kyphotic (gibbus) deformity. Neurological examination revealed grade 4/5 motor weakness in both lower extremities with normal deep tendon reflexes and sensations. There was no evidence of cranial nerve involvement, meningeal irritation, or cerebellar dysfunction. Laboratory tests showed a normal complete blood count, elevated C-reactive protein of 81 mg/dl, and erythrocyte sedimentation rate of 111 mm/h. Serology testing for HIV was negative. Her Mantoux test was positive of 25 mm although there was no history suggestive of tuberculosis in the family. Chest X-ray was normal; however, spine X-ray demonstrated destruction of the thoracic vertebra (T11) body and inferior end plate of the T10 vertebra with loss of disk spaces between T10, T11, and T12 (). The contrasted magnetic resonance imaging (MRI) of her spine showed kyphotic destruction of thoracic vertebrae T10, T11, and T12 with abnormal high signal on T2 and low signal on T1 in addition to a large heterogeneous multiloculated prevertabral and paraspinal abscess extending from T7 through T12 with a peripheral thick wall that had low T2 and high T1 signal with intense enhancement. These are associated with an epidural collection and retropulsed collapsed T11, which result in complete attenuation of the anterior subarachnoid spaces and compression of the distal cord (). She underwent open surgical drainage of the paravertebral abscess and posterior spine fixation from T6 to L2 with pedicle screws. During surgery, a massive purulent fluid was discharged, and biopsy from the bone and soft tissue was taken and sent for microbiological examination and cultures including Mycobacterium tuberculosis. Both acid-fast staining and my"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65 yr old female presented to the Ear Nose and Throat [ENT] clinic of our institution with a one-month history of a lump in the right neck. On examination, a mobile lump was palpable in the angle of the mandible/upper cervical region. A flexible endoscopy did not reveal any mucosal lesion in the posterior nasal space, oropharynx, hypo pharynx or in the larynx. Clinically a lymph node mass was considered as a possible diagnosis. Fine needle aspiration [FNA] and Magnetic Resonance Imaging [MRI] were then performed.\nMRI showed a well-defined oval shaped mass measuring 3 × 2 cm just inferior to the right parotid gland. The epicenter of the lesion was in the inter muscular plane, medial to the sternocleidomastoid muscle but separate from it. It was heterogeneous on both T1 & T2 W images with a well defined margin (Fig & 2). Following contrast administration, there was moderate heterogeneous enhancement (Fig ) In view of the location of the lesion, a differential diagnosis of lymph nodal mass & Spinal Accessory nerve Schwannoma were considered.\nFNA of the lesion showed a mix of bland epithelial cell, clusters of spindle cells and myxoid matrix, which was typical of a pleomorphic adenoma.\nA decision to perform an excision biopsy was subsequently made. At surgery, the tumor was found to be a pedunculated mass arising from the inferior aspect of the tail of the parotid gland. It was closely related and superficial to the spinal accessory nerve but separate from it. The mass was excised completely incorporating a limited cuff of macroscopically normal parotid tissue, taking care not to injure the inferior branches of the facial nerve.\nHistopathology of the excised specimen showed uniform proliferation of epithelial elements within a patially myxo-chondroid stroma, again, consistent with a diagnosis of a pleomorphic adenoma. There was no definite salivary gland tissue within the specimen."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old female patient was admitted with a six-month history of lower back pain accompanied by a two-month history of intermittent claudication. The patient had visited a community hospital when the lower back pain developed and was diagnosed with osteoporosis following assessment by radiography of the lumbar spine. Despite treatment with medication and physiotherapy, the patient’s symptoms did not subside. Two months prior to this admission the patient began to experience progressive intermittent claudication. The patient was referred to the West China Hospital (Sichuan University, Chengdu, China) as an MRI of the lumbar spine had been recommended three weeks prior to the admission. A neurological examination showed no notable changes in the function of the spinal nerve.\nThe patient had previously been diagnosed with a vulvar melanoma (13 years prior to the current admittance) and had undergone a melanoma resection at the West China Hospital. The patient received post-surgical radiotherapy. No local melanoma recurrence or other metastatic melanoma was reported prior to the present admission. The patient had been treated with anti-hypertensive drugs for 11 years, but had no other medical history.\nThe current MRI revealed compression of the lumbar spinal cord in the spinal canal from the posterior direction caused by an extradural mass at the L3 and L4 level. The mass showed a low signal intensity on the T2-weighted images, a mixed low signal intensity on the T1-weighted images and slight enhancement following a gadolinium-contrast injection (). Over the subsequent week, radiography and computed tomography (CT) of the lumbar spine were recommended. There were no clear changes in the radiograph (). CT scans faintly revealed the mass ().\nAlthough the patient had a medical history of vulvar melanoma, a lumbar stenosis resulting from hypertrophy of the ligamentum flavum was suspected instead of metastatic melanoma due to the extended time-period (13 years) since th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old homeless female presented from an outlying facility with chills and body aches for two weeks. Her medical history was significant for hepatitis C, mitral valve (MV) replacement secondary to MV endocarditis, and IV drug use. At presentation, she was in septic shock, and her blood cultures subsequently yielded group A streptococcus. Of note, she stated that her last use of IV drugs was two weeks before presentation. Fluid resuscitation, antibiotics, and vasopressors were appropriately utilized. Transesophageal echocardiography revealed infected mitral valve leaflets, 2-3 cm vegetation in the left atrium, a 0.9 cm atrial septal defect with the left to right shunt, and LV ejection fraction of 15%. No abscesses were visualized. Two weeks later, transthoracic echocardiography revealed a large LVPA originating from the posterolateral wall as shown in Figures -. Cardiac computed tomography (cardiac CT) scan further elucidated the PA that measured 6.9 x 8.4 x 7.2 cm as shown in Figures -.\nThe cardiac CT also disclosed a fistulous tract communicating from the infected MV annulus to the aneurysmal portion of the LV. A left heart catheterization was performed to rule out a septic embolus to the coronary vessels as a cause for the PA. No coronary artery disease (CAD) or suspicious lesions were discovered. The sheer size of this PA placed this patient at a very high surgical risk. Various institutes were contacted for LVPA repair and redo MV replacement. Due to the high perioperative mortality and poor healthcare coverage, attempts to transfer the patient to tertiary cardiac care centers were futile. The patient’s ongoing drug use also affected her candidacy for MV replacement. When stabilized she was discharged from hospital care on antibiotics and supportive cardiac medications (beta blocker and ACE-inhibitor). She returned to the hospital six weeks later in cardiogenic shock and multi-organ failure. Repeat imaging revealed significantly increased LVPA size. Despi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 54-year-old female was referred to the Neurofibromatosis outpatient clinic of the Oral and Craniomaxillofacial Surgery Department for treatment of numerous cutaneous tumors that preferentially covered her trunk and extremities. On admission, the patient described the tumors to be painless and disfiguring. Besides the cutaneous tumors the patient sought advice for treatment of a painful region of her left small finger (Figure 1 ). For some time the ulnar side of the distal phalanx of this finger had become very touch-sensitive. There was neither a tumor visible nor any other pathological alteration of the skin. However, the finger could not be examined by palpation. The suspected diagnosis was initially a glomus tumor [] or a non-palpable nodular PNF.\nMRI at 3T revealed numerous, popcorn-like, contrast-absorbing, hyperintense formations on T2-weighted images, up to 1.2 x 1.9 cm² in size located on the palmar side of the left hand (Figure 2 ). These small lesions mainly affected the metacarpal bones II and III. MRI also showed a sharply defined lesion of max. 1 cm in diameter in the subcutaneous layer at the level of the radiocarpal joint and distal to first digit that reached to the tendons of the extensor musculature. The bony structures showed a homogeneous signal. The findings were interpreted as disseminated subcutaneous and cutaneous neurofibromas of the entire left hand. Structures were found on the distal phalanx of the left small finger whose intensity pattern corresponded to that of the other lesions.\nDuring surgery for the excision and vaporization of numerous neurofibromas of the trunk and extremities, the pain sensitive finger region was also explored. After incision of the skin, no tumor was visible. Therefore, a circumscribed subcutaneous excision was taken as a tissue sample and examined histologically.\nThe tissue findings confirmed cutaneous neurofibromas for the numerous nodules excised from the trunk and extremities. Surprisingly, there was no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old African American female with a past medical history of refractory immunoglobulin G (IgG) lambda MM, essential hypertension, and chronic kidney disease presented to the emergency department with five days of right upper quadrant pain.\nHer MM was diagnosed one year prior when she presented with altered mental status, uremia, hypercalcemia, hypoalbuminemia, and paraproteinemia. A skeletal survey at that time revealed multiple thoracic spinal lytic lesions and an eroding soft tissue mass at the level of T10. Further evaluation revealed a very high IgG level, elevated M protein band, and a kappa/lambda ratio <0.01 (normal 0.26-1.65). A biopsy from the soft tissue mass revealed a plasmacytoma. Radiation therapy was initiated for 10 days. She received three cycles of bortezomib and dexamethasone followed by two cycles of bortezomib, dexamethasone, and lenalidomide. Her disease progressed, and a subsequent bone marrow biopsy revealed hypercellular bone marrow with 70% atypical plasma cells. The patient subsequently received seven cycles of carfilzomib, lenalidomide, and dexamethasone. She was not a candidate for bone marrow transplantation given the high plasma cell burden.\nOn her current presentation, the pain was sudden in onset, intermittent, worse with eating, and without radiation. The pain was associated with nausea and anorexia, but she was without any change in bowel habits. She denied any previous similar episodes. Upon physical exam, the patient was in distress but remained alert and oriented. Her vital signs were all stable. She exhibited right upper quadrant abdominal tenderness without rebound or guarding. Her initial labs are presented in Table . The patient was admitted to the hospital for further evaluation of her abnormal labs and supportive treatment.\nThe patient was started on intravenous hydration and was made nil per os. An abdominal ultrasound revealed a distended GB with sludge (Figure ). The GB wall was thickened up to 9.5 mm, and the s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old man presented to the Outpatient Department of Elpis Hospital, for evaluation of a chronic bacterial prostatitis. He reported mild irritative voiding difficulties such as urgency, frequency, nocturia, dysuria, a mild low back pain and perineal discomfort. Although there was no urethral discharge, the patient complained of local burning sensation on urination and an itching sensation in the urethra. The symptoms lasted for fifteen days.\nA complete review of systems was unremarkable as well as his medical and family history. The patient's hemogram was normal without leucocytosis. The midstream urine showed microscopic hematuria, pyuria but no bacteriuria indentifying the organism infecting the urinary tract was present. The PSA values were elevated 7,6 ng/ml with a free PSA/total PSA ratio 39%. The transrectal ultrasonography revealed a cystic mass in the transitional zone of the prostate with a solid and a nodular inner portion.\nOn rectal examination, the prostate was normal in size and consistency. The prostatic secretions obtained by prostatic massage showed a number of inflammatory cells (more than 30 white cells per high-power field) but no causative infectious agent was found by culture or other means. Several eggs were observed amongst the inflammatory cells measured 51–59×26–29 μm with one convex side (Figure ). The size and shape of the eggs identified them as a group of Enterobius vermicularis. On examination of the prostatic secretions we found a soft palpable material which was 5 mm diameter in size and spherical shape. Palpation gave the impression of a tissue than a stone. An incision was performed in this material and a 4 mm long living worm was found. (Figure ). The microscopic examination identified the worm as Enterobius vermicularis.\nAlthough there was a speculation that the infection was sexually transmitted, the patient denied it. The patient did not experience any symptoms from the gastrointestinal tract or itching sensation in the a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old female patient visited our oral and maxillofacial department clinic complaining of a sense of discomfort in the right posterior palatal area. The patient did not remember exactly when the symptom began. The patient had no other concerned medical history. On clinical examination, a dome-shaped mass of 2.0 × 2.5 × 1.0 cm with clear border and no ulceration was observed in the right posterior palatal area. On the next days of admission, incisional biopsy was performed under local anesthesia. Pleomorphic adenoma (with central coagulative necrosis, most likely traumatized pleomorphic adenoma) was reported histopathologically. Hence, the patient underwent simple mass excision with safety margin under general anesthesia without any additional examination (Fig. ). Postoperative histopathologic report was epithelial myoepithelial carcinoma with positive basal resection margin. Magnetic resonance imaging of the head and neck and whole-body positron emission tomography were performed for further examination, but there was no evidence of distant metastasis (pT2N0M0, stage II) that was shown (Fig. ). Postoperative radiation therapy was administered to the primary site at the Department of Radiation Oncology, and the total radiation dose was 6148, 5400, and 4500 cGy at the operation site, border area, and lateral cervical lymph node level IB and II, respectively, for 39 days. There were no significant complications other than oral mucositis.\nAfter radiation therapy, a 1.5 × 1.0 cm fistula occurred in the right site, which was the operated site, and a fistula closure was done using two-flap palatoplasty under general anesthesia at 8 months after radiation therapy. However, the operated right side flap, which had poor blood circulation after radiation therapy, was necrotized (Fig. ). We removed the necrotized flap under general anesthesia and designed a facial artery myomucosal island flap containing the right mucosal membrane and buccinators, using the facial artery"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old woman was referred to our dentomaxillofacial radiology center in order to perform a panoramic radiography for dental treatment in March 2012. In panoramic view, we found diffuse sclerosis with a flocculent appearance in the jaws. The width of the mandibular canal was normal; however, the cortical border of the canal was not apparent. In addition, the roots of the teeth were obscured by sclerosis to some extent (). Therefore, we undertook further periapical radiography for greater evaluation of this area and found diffuse sclerosis in these views, too. There was also obscured lamina dura and normal periodontal ligament (PDL) space. No caries or periapical lesions were detected ( - ). In the posteroanterior skull view, increased density with flocculent appearance was found ().\nIn order to make an accurate diagnosis, the patient’s complete medical history was taken, and it was determined that the patient had been diagnosed by PHPT since two years ago. She had had severe pain in her lower back and lower extremities for a long time. Her family physician had referred her to a rheumatologist to perform proper diagnostic laboratory tests in April 2011.\nHer serum levels of calcium (Ca), PTH, and alkaline phosphatase (ALP) were significantly higher than normal limits; however, the results of other blood tests, including renal function tests, were in normal range. Hence, with suspicion of hyperparathyroidism, ultrasonography of the neck region was performed. Ultrasonographic evaluation revealed a 34×22×17 mm mass in the right lower parathyroid gland, and parathyroid adenoma was considered as the first differential diagnosis. Bone mineral density (BMD) was measured in September 2011, and the patient’s T-score and Z-score for the lumbar spine and the femoral neck region were reported to be -3.3 and -3.8, respectively, which were consistent with osteoporosis in both regions. In October 2011, excisional surgery of the mass was performed and, after histopathologic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn 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.\nHis 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"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male patient with aortic dissection originating just above the aortic valve and extending down to the common iliac arteries (Stanford A, Figure ) underwent immediate surgery with repair of the ascending aorta in moderate hypothermia under cardiopulmonary bypass. The arterial line was inserted in the right axillary artery, the vent was placed in the right upper pulmonary vein, and two-stage venous line was inserted through the right auricula. The intact aortic valve was resuspended. Extracorporeal circulation was suspended after induction of moderate hypothermia (25°C) and the aortic cross-clamp from the ascending aorta was removed. The false lumen was then glued and an open distal anastomosis to a prosthetic graft was constructed. Then, extracorporeal circulation was resumed, systemic circulation was deaired and the patient was warmed.\nEarly on the first postoperative day, CT of the aorta was requested because of marked elevation of lactate-dehydrogenase (129 μkat/l) and signs of acute renal insufficiency (creatinine 292 μmol/l). CT showed good postoperative result in the ascending aorta, but large amount of air in the branches of the superior mesenteric artery up to the arcades was found (Figure ). There was absolutely no air in the portal-venous system including the liver. The bowel loops were not distended, and there were no signs of bowel paralysis.\nAt midnight on the first postoperative day, a biphasic CT scan of the abdomen was requested due to elevated intra-abdominal pressure (18 mmHg). The CT showed distribution of the intra-arterial gas more into the periphery and into the wall of the bowel loops that still did not display signs of ileus (Figure ). The next morning, surgical exploration was performed due to increasing intra-abdominal pressure as a sign of imminent abdominal compartment syndrome. An extensive bowel resection from oral ileum down to the splenic flexure had to be performed due to extensive necrosis of the bowel. Shortly after th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old gentleman presented acutely to the surgical assessment unit with a painful, diffuse swelling in the left popliteal fossa. The swelling, which was first noticed 6 weeks prior to admission, came on suddenly and was associated with pain and tenderness. Over the following weeks, it had progressed in size and become increasingly painful. The patient had a background history of hypertension, but was not on any regular medication.\nA provisional diagnosis of a Baker’s cyst had been made by the patient’s primary health care provider and he had subsequently been awaiting an Orthopaedic clinic appointment for this. The swelling continued to increase in size, restricting the range of movement at the knee. The patient subsequently attended the emergency department where a pulsatile popliteal fossa mass was found. The impression was still of a Baker’s cyst and the patient was sent home. In the weeks to follow, the patient struggled to bear weight on the left leg. The 24 hours leading up to his present admission was accompanied by a sudden onset diffuse swelling in the entire left lower leg. An urgent ultrasound was arranged to exclude a deep venous thrombosis which instead revealed a large, 8 cm, popliteal aneurysm in the popliteal fossa, the outer wall of which was not well defined. There was a 5 cm patent channel noted within the centre of this structure with extensive intramural thrombus noted at the periphery. No obvious abdominal aortic aneurysm was seen.\nOn initial surgical evaluation, the patient was haemodynamically stable and apyrexial. The left leg was grossly oedematous from below the knee, with a pulsatile firm tender mass in the popliteal fossa. The pedal pulses were all palpable with good range of movement in the feet; however, there was marked reduction of movement at the knee joint. Initial blood tests including white cell count and C-reactive protein were normal. To get a more detailed image of the aneurysm and arterial tree in the left leg, an urg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 31-year-old woman, gravida 3, para 3, was admitted to the hospital with a history of lower abdominal pain lasting more than two weeks. On the day she was admitted, her pain had suddenly increased in intensity and she had noted the presence of fresh blood on her toilet paper.\nThe woman had been examined by a gynecologist three days earlier after experiencing mild to moderate abdominal pain. She had had a copper intrauterine device (IUD) for three years and usually had regular periods. However, for the last few weeks, she had only experienced some spotting. A physical examination by the gynecologist revealed some vaginal discharge, but no vaginal bleeding. The uterus and the adnexa were tender when bimanual palpation was performed. Ultrasound showed an endometrial lining of approximately 5 mm. The IUD was located in the uterine cavity. Both ovaries were normal, but some fluid was seen in the right fallopian tube. No fluid was visualized in the pouch of Douglas. The gynecologist tried to remove the IUD, but this procedure was unsuccessful since the IUD strings could not be seen. The patient's temperature was 36.7°C. However, routine biochemistry showed that serum CRP was 100 g/L and β-HCG was 412 mIU/mL. The gynecologist concluded that the woman had a pelvic infection and prescribed doxycycline and metronidazole tablets. As the serum β-HCG was suggestive of an early stage of pregnancy, an ectopic pregnancy could not be excluded. A follow-up consultation was therefore scheduled for three days later. The patient was also encouraged to contact a hospital immediately if her condition worsened.\nTwo days later, the patient saw fresh blood on her toilet paper. Her pain was also more intense. Following the recommendation of the gynecologist, she contacted the hospital. When she arrived at the hospital, her condition was in general good. She reported pain of mild to moderate intensity. No blood"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old female initially presented with a history of pain and swelling along her right distal fibula. A physical exam was remarkable for point tenderness along the distal fibula with no skin changes and an otherwise normal neurovascular examination. Radiographs obtained demonstrated a lytic, expansile, geographic lesion with no cortical disruption or periosteal reaction (). MRI revealed a multiloculated, minimally enhancing, expansile lesion (Figures and ).\nShe underwent an open biopsy which showed cyst-like spaces filled with blood surrounded by fibrous septa composed of a cellular proliferation of bland fibroblasts, scattered multinucleated giant cells, and chronic inflammation consistent with the diagnosis of an ABC (). A curettage, application of phenol, and allograft bone grafting were performed, and she was followed with serial radiographs. Six months following surgery, she presented to the clinic complaining of pain with sprinting. Radiographs obtained showed resorption of the bone graft indicating local recurrence. MRI showed a homogeneously lobulated, hyperintense lesion with multiple fluid-fluid levels confirming the recurrence (Figures and ). She underwent a repeat extended curettage with the application of phenol and bone grafting at about one year following her index procedure.\nApproximately eleven months following her second procedure and eighteen months following her index procedure, she again complained of pain in the right ankle with exercise. Repeat radiographs demonstrated another recurrence. Since she had failed two operative treatments, a referral to pediatric oncology was placed for the consideration of denosumab therapy for off-label use. The patient and her mother elected to proceed with the initiation of therapy after the risks including osteonecrosis of the jaw, and hypocalcemia had been discussed. The regimen used to treat giant cell tumor (GCT) was implemented which consisted of subcutaneous denosumab (120 mg) given every 4 weeks (w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old woman who had undergone twice cesarean sections presented with hematochezia and was evaluated by CT scan in August 2011. A CT only detected an enhanced abdominal wall mass near the abdominal scar, which was thought to be desmoid at the time (Fig. a and b). As the hematochezia continued, a further endoscopic workup was performed, and well-differentiated adenocarcinoma was detected at sigmoid colon. The whole body CT scan detected no other distant metastasis. She underwent elective open sigmoidectomy with D3 lymph node dissection for sigmoid colon cancer with mid-line incision in May 2012. Histology of the sigmoid colon showed well-differentiated adenocarcinoma invading to subserosa with 8 out of 20 regional lymph nodes involved. The sigmoid colon cancer was classified as pT3N2b, according to the TNM classification of the Union for International Cancer Control Eights Edition []. Molecular analysis showed KRAS mutation and microsatellite-stable. Postoperative course after sigmoidectomy was uneventful and the patient was treated with 12 cycles of FOLFOX regimen as adjuvant chemotherapy. The patient entered a scheduled clinical follow up program which included: regular physical examinations and CEA test every 3 months, and whole-body CT every 6 months. CT after adjuvant chemotherapy revealed the lesion on the abdominal wall had decreased in size and inguinal lymph nodes were all normal in size (Fig. c and d). In April 2014, a routine follow-up CT scan revealed enlarged left inguinal lymph nodes as well as a growing enhanced mass lesion on the abdominal wall at the site of cesarean section scar (Fig. e and f). 18F-fluorodeoxy glucose positron emission tomography (FDG-PET) revealed significant accumulation at both lesions (Fig. g and h). A CT showed no distant metastases were detected in other organs and laboratory data showed serum CEA level was within the normal range (1.3 ng/ml). Although metastases to both inguinal lymph nodes and the abdominal wall from"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old right-handed man presented to the emergency room, brought in directly from a hospital in Mexico by air ambulance. The medical records accompanying the patient stated he had suffered an upper respiratory tract infection 3 weeks previously, subsequently developing ascending weakness that eventually required intubation and mechanical ventilation 7 days from the onset of symptoms. Further history of the patient revealed that it was his second occurrence of GBS and that he had experienced a complete recovery after the first insult 12 years previously. The patient's family did not choose a hospital close to the United States-Mexican border because they wanted the patient to be seen by the neurologist who treated him during the first occurrence.\nOn arrival, initial vital signs were stable. The patient was heavily sedated, and his physical examination established a GCS score of 3 (1/1/1), fixed and dilated pupils, unresponsive deep tendon reflexes, and flaccid extremities in all four limbs. Initial CT scan of the head and stat EEG returned normal. On repeat evaluation, the pupils regained some activity, but remained highly fluctuating in terms of their size and reactivity to light.\nAfter the initial assessment, the patient was promptly admitted to the intensive care unit. Due to the confounding factor of sedation, a formal assessment of consciousness could not take place for 3 days. Once the designated time had passed, the patient displayed an ability to nod in response to questions. The patient was inquired whether he had retained sensation, to which he responded with a nod, thereby officially establishing a “locked-in” state.\nFamily reported that the patient did not receive any treatment in Mexico, as they could not afford either the IVIG or the plasma exchange. On day 2 of arrival (approximately 10 days after the onset of symptoms), plasma exchange was initiated. Due to the fact that Adventist Health White Memorial only carries medical records up to 8 years"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old male patient was admitted to our hospital with bloody stool and mild anemia for 2 months and he was diagnosed as rectal cancer in our hospital in March 2013. He received surgery for rectal cancer on March 26, 2013 and 6 cycles of chemotherapy were given after the surgery (the chemotherapy regimen is FOLFOX). A single metastatic carcinoma of the liver was discovered in September 2013 and then he was given the RFA in the liver. Since then, the patient was in a stable condition for more than a year. In March 2015, multiple metastatic lesions were found in his liver, and chemoembolization was performed 0n March 25, 2015, then, 4 cycles of adjuvant chemotherapy were given after the operation (raltitrexed + bevacizumab). The patient received PET-CT examination and a recurrence lesion was found in the rectal anastomotic stoma in August 2016. He was given the radiotherapy with a total dose of 70 Gy in the next 50 days. Unfortunately, the patient complained of persistent abdominal pain (physical examination found that the tenderness of left side of abdomen was obviously), diarrhea and hematochezia in June 2017 and he was diagnosed as the RE by colonoscopy soon. It was a pity that intestinal probiotics, intestinal mucosal protectants, antidiarrheal drugs, and other treatments were not effective. The patient was treated with the RFA (COVIDIEN, Barrx Flex RFA Cart 1190A-115A, The United States) on 4 September 2017. The RFA procedure: lesion size and scope were observed by routine colonoscopy. RFA electrode (power 48W 12 J/cm2) was placed on the lesion for burning in order to cause coagulation and necrosis of the intestinal mucosa. Removing the tissue which was solidified and necrotic and repeating the above procedure again (Fig. and Fig. ). The clinical symptoms of the patient were gradually decreased after the RFA. A colonoscopy examination was performed 3 months later and the intestinal mucosa was found healed well ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old gentleman of Indian origin presented to a regional Ear, Nose, and Throat Department as a tertiary referral. The history of a painful lump over the left side of his upper neck was for approximately one year. The patient reported that the lump fluctuated in size and was initially painful but this improved with time. The accuracy of history was limited by the fact that the gentleman had a thick beard and may not have noticed the enlargement during shaving or from the external appearance. The pain was intermittent but worse after talking for long periods. He did not have any difficulty eating, shortness of breath, or alteration of hearing. There was no history of preceding trauma. Otherwise the patient was in good health, with no significant comorbidities.\nOn examination the lump was located in the level 2 area of the neck extending into the preauricular area. The mass was firm and pulsatile. There was no facial nerve weakness or paralysis.\nAll routine blood investigations, which included full blood count, renal function, clotting, C-reactive protein, liver function, fasting glucose, and lipids, were within normal limits. An ultrasound scan (US) of his left parotid region demonstrated a large aneurysm measuring 45 mm in maximum diameter, closely related to the left parotid gland. A subsequent computed tomographic (CT) angiogram was performed (Figure ()). This showed a thick walled aneurysm superficial to the mandible arising from the maxillary branch of the external carotid artery (Figure ()). Doppler US of his aorta and popliteal vessels excluded any further concurrent aneurysms.\nAfter discussions in the vascular surgical multidisciplinary meeting and with the patient it was decided to attempt endovascular embolisation.\nThe external carotid artery was selectively catheterised with a 5 French vertebral catheter. Angiography during the procedure showed a very tortuous maxillary artery and the giant aneurysm arising from its midportion. The outflow branches"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old woman was admitted to our center with recurrent episodes of disabling episodes of palpitation and dizziness for 6 months. The clinical tachycardia presented with abrupt onset and offset and could be terminated by 5 mg of verapamil. She had undergone a left modified radical mastectomy for breast cancer 21 years prior. The patient had been diagnosed with hypertension and diabetes mellitus at that time. A chest radiograph revealed no evidence of cardiomegaly. Echocardiography revealed no evidence of structural heart disease with a normal left ventricular function. The 12-lead electrocardiogram (ECG) at the time of admission demonstrated regular sinus rhythm with a narrow QRS complex and a normal axis (, left panel). An ECG recorded during an episode of palpitations revealed a narrow QRS complex tachycardia with a cycle length of 480 ms. The P wave polarity preceding the QRS complex was negative in leads V4-6, biphasic (initially negative and a late positive component) in leads V1 and V3, and undetermined in the limb leads (, right panel).\nAfter giving informed consent, an electrophysiological study was performed without sedation. Three catheters were introduced to the right atrium, the right ventricular apex, and at the His-bundle region via the femoral veins. Also, a 7-Fr multipolar catheter was advanced within the coronary sinus via the left subclavian vein. During initial ventricular pacing, the ventriculoatrial conduction was absent. A tachycardia was induced and terminated reproducibly with incremental atrial pacing and extrastimulation. During the tachycardia, the local electrogram recorded at the His bundle preceded the onset of the surface P wave by 40 ms and the proximal coronary sinus by 15 ms ().\nTen radiofrequency applications were delivered near the His-bundle region where the atrial activation during the tachycardia recorded from the distal electrodes of the ablation catheter, preceded the onset of the surface P wave by 45 ms. The tachycardi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn otherwise healthy 33-year-old male with a history of bilateral patellar tendonitis and OS presented to a level-one trauma center after sustaining bilateral knee trauma. He was playing volleyball and felt a snap and heard a popping sound while jumping after having both knees in flexion. He sustained a ground-level fall and subsequently could not ambulate and immediately noticed a loss of bilateral knee extension. He denied any significant orthopedic or rheumatologic family medical history and had no recent antibiotic, steroid, or medication usage.\nPhysical exam revealed a fit male with easily palpable defects along the superior poles of both the left and right patellae. There was diffuse surrounding soft tissue edema over both knee joints. The patient was unable to perform a straight leg raise on either side or extend either leg. There were no signs of neurovascular compromise. All laboratory values were unremarkable, including a normal vitamin D level.\nPlain radiographs revealed high-riding patellas bilaterally and increased distance between the tibial tubercle and patella. There was notable central ossification of both patellar tendons, indicative of chronic injury (Figures -). Based on clinical evidence and confirmed radiologically, the patient was diagnosed with closed acute bilateral patellar tendon ruptures.\nThe patient underwent semi-urgent bilateral patellar tendon repair without complications via midline incisions over bilateral knee joints. Torn patellar tendon remnants were identified and a #5 FiberWire (Arthrex, Munich, Germany) suture was used to create two Krackow sutures into the torn distal segment. Four total drill holes were created into the patellar from the inferior to the superior pole. A suture was then passed through to reduce the patellar tendon onto the inferior pole of the patella. The torn medial and lateral retinaculum was repaired with #5 FiberWire sutures. At the completion of the procedure, excellent stability of the patella, along w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 32-year-old otherwise well man who was initially diagnosed with melanoma following excision of a 5 mm naevus from his back in June 2012. The primary pathology showed it to have a Breslow thickness of 5 mm, a Clark level of 4, no evidence of ulceration, and a mitotic count of 7/mm2. Subsequent gene testing demonstrated the tumour to be BRAF positive. On the basis of this poor pathology, a Wide Local Excision and sentinel node biopsy were performed. The positive nodal biopsy resulted in the patient having an axillary clearance (5 out of 30 nodes positive). He had adjuvant radiotherapy (48 Gy to the axilla) and he was enrolled in a clinical trial which involved the administration of two immunomodulatory drugs: Nivolumab and Ipilimumab.\nOn a routine staging CT-abdomen/pelvis in December 2014, the patient was first noted to have a mild left-sided hydroureter. Neither the CT scan nor ultrasound performed soon after demonstrated a clear cause. A repeat CT-abdomen/pelvis in March 2015 showed the development of a 6 mm nodule in the mid left ureter at approximately the level of L4 vertebrae. A PET Scan performed at the time did not suggest it to be a metastatic deposit. A further repeat CT was performed in May 2015 by which time the nodule had progressed to being 10 × 9 mm and the hydroureter had progressed significantly. Throughout this period, serial measurements of renal function did not demonstrate any abnormalities, with a stable Creatinine between 90 and 100 μmol/L. The patient denied haematuria, and urinary cytology was negative. At this time, another metastatic deposit was found (a metastatic deposit in the left parafalcine region of the brain, subsequently treated with stereotactic radiotherapy) in addition to apparent lymphadenopathy.\nOn the basis of evidence of the progression of the nodule and increasing hydroureter, the patient was referred to the Uro-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old female patient presented to the Department of Oral and Maxillofacial Surgery at Homerton University Hospital in East London, UK, with a 4-week history of suspicious upper lip swelling. This patient was referred by her general practitioner on the urgent head and neck cancer referral pathway.\nThe patient's primary concern was the sudden onset of a large upper lip swelling with associated pain. The patient was not forthcoming and defensive when questioned regarding precipitating factors or possible trauma to the region. She was medically fit and healthy with no risk factors for oral cancer, such as smoking and alcohol consumption [].\nOn extraoral examination, the patient appeared to be well with no clinical signs of systemic illness. In general, the upper lip was disproportionately enlarged with an incompetent lip seal (). On close examination, a 2 cm × 1 cm firm, erythematous, swelling was noted in the upper right lip. The lesion was not encroaching on the midline and there was no associated cranial nerve deficit or lymphadenopathy. At the vermillion border, there was a puncture wound on a background of traumatised tissue adjacent to the firm swelling (). The lesion was painful on palpation with no suppuration, induration, or ulceration noted. Intraoral examination revealed a concurrent firm swelling within the labial sulcus. Dental health was unremarkable, and there were no signs of systemic infection.\nUpon revision of the patient's electronic health-care record, it was noted that the patient had attended the Accident and Emergency Department at the Homerton University Hospital four weeks prior. The clinical clerking from this visit showed the main complaint to be swelling of the upper lip following self-injection of a dermal filler, purchased over the internet. When questioned again directly by the OMFS team regarding the true mode of injury, the patient revealed that she had purchased the filler material over the internet. The patient was uncertain of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old boy was brought to the ER after being involved in a road traffic accident, in which the car he was riding in rolled over. He had a history of loss of consciousness and repeated vomiting. There was no history of fits or bleeding from ear or nose.\nOn arrival his pulse was 95 beats per minute with a blood pressure of 95/60 mmHg. His GCS was 12/15, and both his pupils were equal in size and reaction to light. There was a 4-cm laceration on the patient's posterior parietal area on the right side. He had a left-sided hemiparesis with power of 3/5. The patient had a deformity of the right upper limb with suspected fracture of the humerus which was stabilized using a long arm back-slab. The rest of the_neurological and systemic examination was unremarkable.\nThe initial CT scan of the brain showed a large hematoma in right putamenal area with perifocal edema []. There was associated mass effect and midline shift. An X-ray of the right humerus revealed a reduced fracture of humerus, which was immobilized in cast. The rest of the radiological survey was unremarkable. His scalp laceration was sutured and dressed in the ER.\nThe patient was managed nonoperatively with hypertonic saline in Pediatric Neuro-Intensive Care Unit for 24 h after which his imaging was repeated and he was shifted to step down unit, and started on regular limb physiotherapy. He was discharged home after a week on rehabilitation.\nAt 3-month follow up, he was able to perform basic tasks and was seen comfortably playing with a toy. He was also able to walk with support. A repeat CT scan showed an area of hypodensity with decreasing perifocal edema []. He was advised to continue with physiotherapy and regular clinical follow-up. His recovery was not as good as the previous cases as he remained moderately disabled with a GOS score of 4"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old, G2P0010 with 32 weeks pregnancy was admitted in neurosurgery intensive care unit (ICU) with complaints of sudden onset severe headache and recurrent episodes of vomiting for 1 day. Her pregnancy was supervised at a peripheral hospital and her blood pressure records were normal. At 22 weeks of gestation, she had one episode of generalized tonic clonic seizures, lasting for 2-3 minutes. She had no prior history of seizures. She was attended at the peripheral hospital and started on antiepileptics but continued to have headache for which a computed tomography (CT) [] and magnetic resonance imaging [Figure and ] were done at 20e and 28 weeks, respectively, which showed a left frontal hematoma with mass effect in form of effacement of ipsilateral ventricle with edema. She had one more episode of seizure 10 days before reaching neurosurgery department of our hospital. At the time of admission, she was conscious, obeying simple commands but was disoriented. Her pupils were bilaterally symmetrical and reacting to light. She had right hemiplegia. Her abdominal examination revealed a gravid uterus of 30 weeks size, relaxed with fetus, presenting as cephalic having regular fetal heart rate of 142 bpm. A CT angiography was done which demonstrated a left supraclinoid internal carotid artery (ICA) aneurysm. She was posted for digital subtraction angiography (DSA) (with precaution for fetal exposure of radiation). DSA showed a giant supraclinoidal ICA segment aneurysm []. During the procedure, she had neurological deterioration and also developed per vaginal discharge. She went into spontaneous labor at 32 weeks and delivered a male child with birth weight of 1.1 kg. The baby was immediately shifted to the neonatal ICU. In the immediate postpartum period, she developed hypotension and respiratory distress for which she required ventilator support. Repeat CT scan showed rebleed in anterior interhemispheric fissure. She was taken up for surgery after 12 hours postpart"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old pregnant woman was admitted to our department in the 16th week of her first gestation because of suspicion during a routine ultrasound of decreased fetal movements and fetal malformation consisting of postural deformity of both lower limbs associated with a uterine fibroid. The family history was unremarkable and the mother's medical history nonsignificant except for the presence of two intramural uterine myomas diagnosed before the current pregnancy and smaller than 47 mm in maximum diameter in previous control one year before gestation.\nOur ultrasound investigation verified the presence of an intramural-submucosal tumor with a muscular echogenic pattern and a size of 110 × 88 mm in the anterior uterine wall near to the internal cervical os and another intramural one with a size of 28 × 21 mm in the uterine fundus. Fetus presented a normal heart rate pattern and was observed with absent movements and displaced to the right uterine wall in an abnormal position, with hyperextension of head and strongly flexed lower limbs (). Fetal measures according to the gestational age and the amount of amniotic fluid were normal. On the basis of these findings, the diagnosis of arthrogryposis secondary to fetal akinesia due to giant leiomyoma was done.\nAccording to the Spanish legislation, the parents decided the elective termination of pregnancy. A vaginal delivery was induced with local prostaglandins without complications. At the time of birth, the fetus had not cardiac activity and showed external male genitals, a weight of 105 g and a length of 125 mm. His position consisted of internal rotation of the shoulders and stiffness of the limbs with symmetrically flexed and fixed elbows and wrists and severe equinovarus deformities of the feet ().\nThe pathology report concluded that internal organs of the fetus did not present abnormalities. Histopathological examination reported extraconnective tissue developed around the joints and tissue between the muscle fibers"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year old nonsmoker male presented in December of 2007 with right supraclavicular lymphadenopathy. An excisional biopsy of the lymph node was performed. Histopathology () showed the morphologic features of SCLC including small to medium size cells, high nuclear/cytoplasmic ratio, salt and pepper chromatin with inconspicuous nucleoli, nuclear molding, and high mitotic activity. Immunostaining showed that the tumor cells expressed synaptophysin and chromogranin and discontinuous cytokeratin markers. TTF-1 was also positive. Imaging was performed with PET/CT showing a 5 cm right hilar mass and right paratracheal lymphadenopathy and no disease elsewhere including a negative brain MRI.\nThus, he was deemed to have limited stage disease and was treated accordingly with cisplatin and etoposide and concurrent radiation therapy (). He achieved a complete response after 6 cycles of chemotherapy and subsequently underwent prophylactic cranial irradiation. He was monitored clinically and by imaging every 3 months. In May 2009, the disease relapsed with left supraclavicular lymphadenopathy and was confirmed by excisional biopsy. He underwent radiation therapy with concurrent cisplatin and etoposide for 2 cycles followed by 4 cycles of oral topotecan. He had complete response again that lasted for one year. In September 2010, he had a relapse presenting with mediastinal lymphadenopathy. After another 5 cycles of cisplatin and etoposide, he had near complete response, and he was monitored clinically. After progression in September 2011 with increased hypermetabolic activity in the right hilum and paratracheal lymph nodes, he was started on carboplatin and etoposide. He had good response after 4 cycles and was switched to oral etoposide. He again progressed with increased metabolic activity in the right hilar and paratracheal region.\nAt this time, genomic profiling of his prior tumor biopsy was undertaken. This showed that his tumor harbored a novel JAZF1-MYCL1 gene fusion but l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old previously asymptomatic male presented to his primary care physician with a complaint of focal penile irritation related to sexual intercourse. The irritation originates from a lesion along the midline on the dorsum of his penile glans. He was referred to a urologist for further evaluation.\nThe patient reported noticing a small dimple along the midline on the dorsum of his glans for as long as he could remember. The lesion had not previously caused him any discomfort, nor did he report a history of discharge, including urine, semen, blood or pus from the orifice. In recent months, the patient has become more sexually active and he has become aware that during and after intercourse the site is painful and inflamed for a short period of time. The patient wants to make sure there is not something wrong with his anatomy and seeks a solution.\nThe patient had no significant past medical history. There is no family medical history of relevance, specifically no one has reported any genital malformation. Physical examination by a urologist demonstrated a well-developed adult male. A small midline opening was present on the dorsum of the penile glans. There was no focal erythema or discharge present at the time of examination. Manipulation of the opening demonstrated a thin lumen that appeared to continue proximally along the dorsum of the penile shaft. The most likely aetiology was determined to be urethral duplication. Imaging was necessary for confirmation and to delineate the particular anatomic presentation in order to plan treatment. Demonstration of communication with the urethra or bladder would require more extensive surgical intervention to eliminate the sequelae of discharge accumulation in the lumen causing infection, cyst formation or recanalisation of the accessory orifice. The patient was referred to radiology for urethrography.\nSince no urine, semen or other discharge had ever been noted to exude from the accessory urethra, a retrograde urethrogr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old man presented us with chief complaint of reddish-blue discoloration on the left buttock and trunk after receiving IM injection of paracetamol. He experienced pain while the injection was being administered and the pain continued after the injection, after which it regressed and was managed with the use of analgesics. The patient had a history of fever for the last 10 days for which he had taken some oral drugs, and an injection of paracetamol was prescribed to him by the local practitioner. Two days after receiving IM paracetamol in the left buttock, the patient developed reddish discoloration at the injection site, which in a span of 2 days changed to reddish-blue color and spread to the left side of trunk, shoulder, and right shoulder and arm. History of any spontaneous bleeding from any orifice was not reported. History of any joint swelling or any episode of unconsciousness or abnormal body movements was not reported. On physical examination, his vitals were stable. Systemic examination was unremarkable. Cutaneous examination revealed large areas of nonpalpable ecchymotic patches involving left buttock reaching up to the right buttock, left side of trunk, shoulder, and arm and right shoulder, neck, and anterior chest [] . On diascopy, the bluish discoloration persisted, confirming the purpura. Laboratory investigations revealed positive enzyme-linked immunosorbent assay for HIV, which was an incidental finding. Rest of his laboratory tests including platelet count and bleeding, clotting, and prothrombin times were unremarkable. He was advised skin biopsy for histopathological examination in view of the extensive purpuric lesions with some lesions distant from the main site of injection and separated by areas of normal skin. However, consent for biopsy was not given. On the basis of history and a suggestive clinical examination, a diagnosis of NS secondary to IM injection of paracetamol was made. He was managed conservatively with oral diclofenac an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.\nThe patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of delivering the baby. The rest of the case was uneventful. No blood product transfusion was necessary. After"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman visited our hospital for evaluation of a tumor arising in a remnant cystic duct 30 years after cholecystectomy for gallbladder adenoma. Laboratory data, including tumor markers such as carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal ranges. The patient had no chief complaint. Previous medical history included breast cancer that was completely resected three years prior to her visit. Since that time she had taken an aromatase inhibitor. Annual follow-up for breast cancer by contrasted computed tomography (CT) showed an intraductal papillary mucinous neoplasm (IPMN) in the pancreas head and an enhanced tumor image around the hepatoduodenal ligament (). Endoscopic ultrasonography (EUS) demonstrated branched IPMN of the pancreas and a residual cystic duct tumor. The tumor was located at the junction of the cystic duct and was enhanced with Sonazoid (). Endoscopic retrograde cholangiopancreatography indicated that the tumor had not invaded the common bile duct. Enhanced CT in the artery phase revealed a 6 mm round tumor. Surrounding lymph nodes were not swollen. Magnetic resonance cholangiopancreatography (MRCP) showed that the tumor presented with a slightly high signal on T2 weighted imaging, and the periphery remnant cystic duct of the tumor presented as a high-intensity lesion on T2 weighted imaging (). During surgery the tumor was located at the cutoff position of the remnant cystic duct and presented as a white nodule that adhered tightly to surrounding tissue. There was severe adhesion around remnant cystic duct and the hepatoduodenal ligament due to previous surgery. The remnant cystic duct and the tumor could not be separated; however, no invasion toward common bile duct was observed. Rapid intraoperative pathological examination demonstrated that the tumor was a neuroma. The operation time was 251 min, and blood loss was 80 ml. Macroscopic findings had two components; the dilated remnant cyst with white bile, and t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old male patient presented with a two-day history of severe left-sided, lower back pain which disappeared with the appearance of left-sided lower limb pain felt deep inside the whole lower limb and described by the patient as intense internal pressure (VAS 8/10). On examination, power was 5/5 with no sensory deficit and normal reflexes. The patient received NSAID painkillers and active bed rest was advised. However, on the patient's insistence, a lumbar spine X-ray and MRI were done which showed mild IVD protrusion. The patient was reassured and sent home. A week later the patient presented to the ER with an 18-hour history of heaviness and difficulty in raising the left foot when walking, with numbness along the lateral part of the leg and dorsum of the foot. The pain was moderate (VAS 5/10). No sphincter-related symptoms were observed. According to the patient, the decreased pain caused the delay in presentation, against the instructions on first evaluation. On examination of the foot dorsiflexion was 2/5 (movement on gravity alleviation) with decreased sensation along the left L5 dermatome. There were normal reflexes and sphincters. The patient underwent immediate, new lumbar MRI which showed a large disc sequester with disc migration. His status was fully explained; he was admitted and underwent microdiscectomy L4/5.\nThe initial back pain lasted for 2 days, mostly caused by stretching and pressure on the weakened annulus fibrosis. This type of pain disappears or decreases once the annulus opens and nucleus pulposus leaks to the spinal or root canal. Initial left lower limb pain is a typical description of painful radiculopathy where mass pressure and inflammatory irritation of the nerve root and dorsal root ganglion cause neuropathic pain. This is different from nociceptive and referred pain types. Dorsal root ganglion hosts the cell bodies of sensory nerves with bidirectional connections (to the periphery and spinal cord). Injury"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.\nThe procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.\nAt four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube inse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male presented to medical attention with a history of intermittent headache since last 1 month, particularly after doing strenuous activity. Patient advised for computed tomography (CT) scan [] of the brain that showed a large mixed density lesion with mass effect for which he was referred to us. On examination patient was conscious, cooperative, and oriented to time, place, and person. His vitals were within normal range. He had no significant medical history, previous radiation exposure, or family history of vascular malformations. There was no sensory or motor deficit. His both fundus appears to be normal. Magnetic resonance imaging (MRI) of the brain [] showed a large heterogenous partially hemorrhagic, multilobulated mass (68 mm × 69 mm × 74 mm) in right frontal lobe with perilesional edema and midline shift of approximately 15 mm to the contralateral side. Magnetic resonance spectroscopy performed and was nonconclusive for neoplastic pathology. CT angiography of the brain was negative for any Arteriovenous vascular malformation. After interdepartmental discussion and words with Neuroradiologist provisional diagnosis of arteriovenous malformation (AVM) with bleed or a high-grade malignancy with hemorrhage was made. After taking written and informed consent, the patient was taken for surgery. On operation table, his head end was elevated so that cerebral venous drainage improved. Question mark incision made and frontotemporoparietal craniotomy done. Dura opened after applying dural hitches. The brain was tense and edematous. A small opening was made over middle frontal gyrus, and cystic part of lesion aspirated out with help of suction. Cystic fluid was like old blood. Solid part of lesion was soft to firm in consistency and was purple green in appearance. Soft part of lesion was a suckable, but firm part was taken out in piecemeal. There was gliotic reaction all around the lesion that was left in situ. Overall, during surgery parts of the lesion b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old male presented in February 2016 with increasing dysphagia. There was no history of prior abdominal infection or surgery. On esophagogastroscopy, a necrotic and circumferential friable tumor was seen at 33 to 40 cm from the incisors, with an endoscopic appearance of involvement of gastroesophageal (GE) junction and the proximal 2 cm of the stomach. Biopsies of the distal esophageal tumor confirmed poorly differentiated adenocarcinoma. The patient was anemic with a hemoglobin of 89 g/L. Staging endoscopic ultrasound suggested a breach of muscularis propria and four enlarged paraesophageal nodes. Neoadjuvant chemoradiotherapy followed by esophagectomy was initially considered; however, a staging positron emission tomography (PET) scan demonstrated 18-fluorodeoxyglocose (FDG) uptake not only in the primary tumor, but also in the paraesophageal region near the GE junction and upper abdominal lymph nodes extending as far inferiorly as the right renal vessels, in a retrocaval location (Figure ).\nA radiation oncology consultation was sought regarding treatment options of such extensive lymphadenopathy. Palliative radiation therapy (RT) was recommended. The patient was also evaluated by a medical oncologist who advised that chemotherapy may be considered after assessing the response to palliative radiotherapy.\nFrom March 21, 2016 to April 5, 2016, the patient received palliative RT to the symptomatic primary tumor and closest adjacent nodes using a pair of anterior and posterior fields. A total dose of 30 Gray (Gy) was prescribed over 10 daily fractions. As the lymphadenopathy in the lower abdomen was not symptomatic, and would have contributed to increased toxicity, this region was deliberately excluded from the high dose RT volume (Figure ). Other than very mild odynophagia, the patient had no other RT-related side effects. On the first follow-up visit, one month following treatment completion, he had improved swallowing function and a weight gain of six poun"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMale, 46 years old, with complaints of a lump in his penis. The lump first appeared 5 years ago and was removed by another surgeon, but the lump has reappeared in the last 2 years. The lump started to grow like cauliflower (). A tumor encircling the entire penis and scrotum was detected upon physical examination, while the glans penis was free of the lesion. Wide excision of the penile mass was performed with total penectomy, orchidectomy, and perineostomy (). The wound was closed using the Keystone flap technique involving an elliptical incision pattern (), after which the flap is incised on all sides and bluntly dissected down to the fascia. The donor tissue was taken from the right inguinal. A drain was placed beneath the flap. The incisional biopsy revealed squamous cell carcinoma. 2 weeks after the surgery, the patient was given five HBOT sessions (). After the surgery and HBOT sessions, the patient was undergoing chemotherapy.\nPenile carcinoma is a type of invasive epithelial tumor that develops on the penis’ skin or mucosa. There are many causes and risk factors for penile cancer, but the most common cause is human papillomavirus (HPV). The glans penis, coronal sulcus, and foreskin are common sites for penile cancer. Invasive ulcerative penile cancer can harm the root of the penis, causing it to dilate and leading to the organ’s spontaneous amputation. It can even affect the lymph nodes in the inguinal region. The mechanism of HPV infection has several pathways: the disruption of tumor suppressor gene p53 and pRB proteins. Diagnosing cancer requires pathological histological examination. Histologically, penile squamous cell carcinoma has several subtypes, and these have variable rates of metastasis. Penile cancer surgery is performed using several methods depending on the size of the tumor. One such is the Mohs surgery technique, in which the tumor is excised to the bottom layer or until the tumor tissue is"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old pregnant woman was found unconscious in bathroom of her house by her husband. At arrival in the ED, she had a Glasgow Coma Score of 3/15 and dilated sluggish pupils. Additionally, there were no heartbeats or respiration. Cardiopulmonary resuscitation (CPR) was immediately instituted and cardiac monitoring revealed ventricular fibrillation. She was treated with 200 J of direct current energy delivered twice. Intravenous epinephrine (1 mg) was administered after the second rescue shock. Neither atropine nor antidysrhythmic agents were administered. After 2 minutes of CPR, her rhythm has restored to sinus rhythm. Advanced cardiac life support measures were initiated (such as controlled intravenous fluid support, administration of dopamine, adequate oxygenation, and support of respiration with bag ventilation) in ED. There was no tobacco, alcohol or illicit drug use in her history. Her husband stated that she had a brief episode of discomfort palpitations and shortness of breath three weeks prior to her cardiac arrest. However, there was no history of cardiac or respiratory disease. Transabdominal ultrasound confirmed 36 weeks pregnancy with fetal cardiac activity. Noncontrast cranial computerized tomography was nondiagnostic. Laboratory studies taken on admission and urine drug screen were not remarkable. A bedside emergency transthoracic echocardiogram (TTE) demonstrated moderate to severe mitral regurgitation with an estimated regurgitant fraction of 45% (). Additionally, there was no hypokinesis, effusion or ventricular dysfunction. During her emergency department course, the patient began to response from painful stimuli. Propofol was initiated for sedation. Three hours after admission to the ED, she was transferred to the ICU for optimal care. Support of respiration with mechanical ventilation and general supportive measures were provided in ICU. The clinical course of the patient was uneventful. She did not require vasopressors or antidysrhythmics d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old otherwise healthy male presented to the local emergency department on four different occasions over a two-week period with complaints of acute onset, progressive posterior neck pain, and stiffness. On the fourth visit, a two-day history of severe pain causing limited neck mobility and associated odynophagia was described. The patient initially denied any trauma, but in retrospect recalled sustaining a seemingly insignificant fall at work approximately one week prior to the onset of initial symptoms.\nA noncontrast CT scan of the cervical spine was performed in the emergency department revealing a retropharyngeal fluid collection extending from C2 to C6 over a distance of approximately 6 cm, measuring 1 cm in thickness and 2.5 cm in transverse dimension. A small area of calcification was identified at the superior margin of this fluid collection, anterior to C2 (). The otolaryngology service was consulted with the presumed diagnosis of retropharyngeal abscess.\nOn physical examination, the patient was afebrile with normal vital signs and in no obvious distress, except upon neck movement. Flexible nasolaryngoscopy was unremarkable, with no evidence of abnormal protrusion or fullness of the posterior pharyngeal wall. The C-reactive protein level was elevated at 72.4. The white blood cell count and all other bloodwork were normal, with no evidence of an infective process. A CT scan of the neck was repeated with IV contrast showing no enhancement around the fluid collection and a 5 mm focus of calcification within the longus colli muscle anterior to C2 ().\nBased on the clinical picture and pathognomonic CT scan findings, a diagnosis of calcific tendinitis of the longus colli (CTLC) muscle was made. The patient was admitted to hospital to complete his workup and manage his discomfort. He was managed successfully with medical therapy, including 3 doses of intravenous steroid followed by a short course of oral NSAIDs. An initial dose of antibiotic was administer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient's mother was 36 years old, with a total of 5 pregnancies and 1 live birth. Eleven years ago, she gave birth to a healthy boy via cesarean section. She previously had 2 artificial abortions and 1 spontaneous abortion, with no family history of hereditary diseases. Ultrasound test result was normal at gestational week 6. At gestational week 12, nuchal translucency of 1.3 mm was observed, with no positive findings. Non-invasive DNA analysis showed low trisomy 21 risk, low trisomy 18 risk, and low trisomy 13 risk. At gestational week 24+5, ultrasound examination showed abnormal development of the long bones of the limbs (the length of the long bones was shorter than 1% controlled to the same gestational week of normal fetus), thick metaphysis in the right lower limb, irregular vertebral arrangement, and a narrow and small thorax (Fig. A–D). The patient's parents decided to terminate the pregnancy at 27 weeks of gestation considering this as a lethal skeletal dysplasia.\nAfter the termination of pregnancy at week 27, the gross examination of the fetus showed a flat face and nose bridge, short limbs, asymmetric short lower limbs, and bilateral clubfeet with bilateral ankle joint contracture (Fig. A, B). The autopsy report indicated that the left humerus bone was 2.5 cm long; the right humerus bone, 2.0 cm; the left femur, 3.0 cm; and the right femur, 2.2 cm; all were significantly shorter than 4SD measured at the same gestational age. In addition, the shapes of T3 to L3 were abnormal, the vertebral bodies appeared fused, the thorax was small with a maximum circumference of 16 cm, and the abdominal circumference was 26 cm. The autopsy also found subcutaneous edema in the head and face and thick metaphysis in the lower limbs. X-ray imaging showed short femur and humerus bones, a narrow and small thorax, thick metaphysis with a thick “splashed paint"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. As part of our ongoing study “Vaginal delivery after caesarean section”, she underwent saline contrast sonohysterography 6 months after the caesarean section. The caesarean scar had a small indentation and the remaining myometrium over the defect was 7.5 mm (Fig. ).\nIn the current pregnancy, she had a dating scan at around 11 weeks with no remarks. She came for a transvaginal ultrasound examination at around 13 weeks as part of our study. This scan revealed a duplex pregnancy with one viable intrauterine fetus with normal anatomy and placenta located high on the anterior wall and a small gestational sac (8 mm) with a yolk sac without embryo was located in the caesarean scar (Fig. ). There was no extensive vascularity surrounding the sac. One corpus luteum was found in each of the two ovaries. She was asymptomatic.\nShe was informed that not enough evidence existed to advise a specific management of this condition. After discussion with her and her husband, expectant management was chosen with a new ultrasound examination after 5 weeks.\nShe came to our ultrasound department at 18 weeks, 22 weeks, and 30 weeks of gestation. She remained asymptomatic. The ectopic gestational sac was not visualized with transvaginal or transabdominal scans at the 18 weeks examination (Fig. ). The niche in the scar and the thickness of the thinnest part of the remaining myometrium appeared unchanged at all visits. The intrauterine pregnancy developed normally with no signs of abnormal placentation. At 30 weeks of gestation the ultrasound appearance of the scar area did not indicate any contraindications for vaginal delivery. The thickness of the lower uterine segment (LUS) was 4.9 mm (Fig. ). In agreement with our patient, vaginal delivery was planned. The staff of the labor ward was fully informed.\nShe was admitted to the l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old female initially presented for evaluation of a left supraclavicular neck mass. The patient underwent fine needle aspiration of the mass, which revealed adenocarcinoma favoring renal cell. CT scan of the chest, abdomen, and pelvis revealed a large left renal mass 9 cm in diameter. The scan incidentally also detected a possible filling defect in the transverse colon. The patient underwent colonoscopy, and a mass was visualized and biopsied. Histological examination found the mass to be positive for invasive adenocarcinoma.\nPhysical examination of the patient revealed an overweight woman with a past medical history of hypertension. The patient denied any changes in bowel habits or urinary complaints other than intermittent left flank pain. The patient reported that her family history was negative for cancer or polyps. General physical examination revealed a small nodule palpable in the left supraclavicular region of the patient's neck. Laboratory findings were normal except for presence of iron deficiency anemia.\nThe patient then underwent left radical nephrectomy with periaortic lymphadenectomy and extended right hemicolectomy. Histological examination of the left kidney confirmed a 7.5 cm Fuhrman grade 4, clear cell RCC limited within Gerota's fascia with no lymphovascular invasion. The tumor was present in 5/5 periaortic lymph nodes that were resected (T2aN1Mx). The resected large bowel specimens demonstrated tubular adenoma present in the cecum and hepatic flexure; also noted was moderately differentiated invasive adenocarcinoma extending into the submucosa of the transverse colon (T1N0M0) (). Microsatellite instability staining was ordered; results were positive for hereditary nonpolyposis colorectal cancer (HNPCC). Given this patient's negative family history of colon cancer, this was likely a spontaneous mutation. The patient developed chylous ascites and peritonitis with acute kidney injury postoperatively and returned to the operating room for ev"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female patient attempted suicide by ingesting a large amount of OP insecticide. She was admitted in a private hospital in an unconscious, gasping state with frothing from the mouth, smelling of insecticide. Pupils were miotic and fasciculations were evident. She was immediately intubated and was kept on synchronized intermittent mandatory ventilation (MV).\nSeven days later she was brought to Medical and Neurological Intensive care unit of our hospital on MV. On admission, she had poor respiratory effort. She was conscious, oriented, had grade four muscle power in upper and lower limbs, without sensory symptoms. On day 12, lobar pneumonia was diagnosed. She had copious purulent secretions which necessitated tracheostomy. She was treated with Piperacillin-Tazobactam. Chest physiotherapy along with respiratory muscle training by inspiratory muscle trainer with threshold resistance for strengthening of weak respiratory muscles proved an adjunct for the weaning off of the patient from mechanical ventilation. In stepdown care, her muscle power slowly reduced to grade two in upper limb and grade three in lower limb. Three days post-extubation, she developed rapid onset deterioration in muscle power to grade zero and absent deep tendon reflexes, but without respiratory deterioration. She developed bilateral foot drop and claw hand deformity. Nerve conduction studies indicated pure motor axonal neuropathy. Patient developed stridor when an attempt to close the tracheotomy was carried out. Bronchoscopy revealed tracheal stenosis 2.3 cm distal to the vocal chords along with bilateral adductor vocal cord paralysis indicating involvement of recurrent laryngeal nerve, which explains aphonia evident during partial closure trial of tracheostomy.\nForty five days from the ingestion of OP insecticide, she developed grade II spasticity according to Modified Ashwarth Scale in bilateral upper and lower limbs with flexor spasms in lower limbs and exaggerated deep tendon refl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn otherwise healthy 69-year-old white male followed at our outpatient clinic for a bilateral sensorineural hearing loss presented to the Emergency Department of our hospital with a right facial palsy arisen suddenly 2 days before. Four months earlier, he had been diagnosed with a right trigeminal neuralgia, which was treated with gabapentin and oxcarbazepine. The initial diagnosis made at his arrival at the Emergency Department was right Bell's palsy for which he was given prednisone 50 mg for 5 days and 25 mg for the following 5 days in association with valaciclovir 500 mg twice per day for 5 days. In the following days, he showed no improvement of both the facial palsy and the trigeminal neuralgia. Laboratory work-up results were all within normal limits. At the ENT (ear, nose, and throat) evaluation, the patient showed a grade V right facial palsy according to the House–Brackmann grading system. Endoscopic evaluation of the nasal fossae, nasopharynx, and larynx showed no lesions, otoscopy revealed a right effusive otitis media, and audiological evaluation showed a right type B tympanometry, a left profound sensorineural hearing loss (diagnosed a few years before), and a right mixed hearing loss. A gadolinium-enhanced magnetic resonance imaging (MRI) of the head showed an abnormal mass with homogeneous enhancement involving the deep lobe of the right parotid gland, the upper portion of the right parapharyngeal space, the Eustachian tube, and the infratemporal fossa with both the pterygoid muscles, extending along the third division of the trigeminal nerve, through the foramen ovale, to the Meckel's cave and the intracisternal portion of the fifth cranial nerve (\n). Moreover, computed tomography (CT) scan showed enlargement of the right foramen ovale and the greater petrosal nerve canal. We ordered also a positron emission tomography (PET)-CT scan that confirmed a hypermetabolic focus corresponding to the previously identified mass. The primary diagnostic hypothes"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old white male who is an avid skier presented with left calf pain described as sharp on the medial aspect that started after he fell while skiing about two weeks prior. During the fall, his left ankle was forced into extreme dorsiflexion. He had immediate onset of severe pain and had to stop skiing that day. He noticed swelling in the medial calf along with bruising of the area over the next few days. After about a week, he was able to ski again but had pain aggravated by active plantar flexion.\nOn physical examination of his left leg, his knee and ankle both appeared normal and had normal strength and range of motion with no tenderness. Sensation and pulses were normal. There was tenderness over the medial head of his gastrocnemius with a palpable, firm, four-centimeter ovoid mass. Pain was elicited during resisted plantar flexion. His right leg was completely normal.\nRadiographs of the lower leg obtained in the ED were normal. A POCUS was then performed in the ED with specific focus over the mass in the medial head of the gastrocnemius, revealing a swollen, heterogeneous, disorganized mass in the medial head of the gastrocnemius, as demonstrated in –. Comparison views to the unaffected extremity, as seen in , further clarified the findings. We made a diagnosis of muscle tear in the medial head of the gastrocnemius.\nThe patient was instructed on exercises for strengthening and range of motion of the calf and ankle and specifically eccentric exercises that he should complete after an initial rest period of two weeks. On follow-up two months after the initial visit, his symptoms had nearly completely resolved. He reported mountain biking several times per week with only minimal pain after a long ride. The mass in the calf resolved, and he relayed no concerns about his leg for the upcoming ski season."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old woman (height 155 cm, weight 60 kg) first presented to our hospital with left hip pain, limited range of motion, and limping. Trendelenburg gait was observed. She did not have a history of treatment for DDH. She developed hip joint pain and underwent right DTT at the age of 20 years. Her hip pain had improved after the surgery; however, she started to feel pain again at 2 years after DDT. She underwent right-sided THA at another hospital at the age of 47 years.\nRadiographs showed severe osteoarthritis of her left hip joint and the left greater trochanter, which had moved to the level of the lesser trochanter. The past THA on the right hip joint was visible as well (). The LLD was 55 mm.\nThe right THA was performed at the age of 47, and the left THA was performed at the age of 50. The THA procedures comprised conventional cementless THA in the same way as in Case 1 (anesthesia, surgical approach, implants, and rehabilitation).\nIntraoperatively, the surgeon had to pay close attention to identify the gluteus medius and minimus muscles and prevent damage to the same muscle due to hypertension during the reduction after implant placement, similar to the circumstances of case 1. The operation time was 60 min, and the total blood loss was 488 g (intra and postoperative blood loss). The leg lengthening was 27 mm, and 28 mm of the LLD persisted.\nAs in Case 1, the pain improved remarkably; however, the patient presented with LLD due to an abduction contraction following extension of the leg length. The abduction contraction improved within two months under physical therapy. No other complications, such as dislocation, neurovascular abnormality, or infection, were observed. Final radiographs at 11 years after left THA did not show subsidence of the stem or any type of loosening around the cup or stem (). The preoperative JOA hip score was 39 points,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 1: A 56-year-old female presented to our institution with progressive vision loss. Her medical history was non-contributory. An ophthalmological evaluation showed a right central scotoma. Cranial MRI showed a mass suggestive of a carotid artery aneurysm. DSA revealed a 25.3 × 18.5 mm aneurysm with a 4.5 mm neck arising from the medial wall of the right ophthalmic segment (Figure ), and the BOT of the ICA and Allcock’s test were performed to understand the condition of cerebral blood flow compensation. To clip the aneurysm and reconstruct the right ICA, she was offered both surgical and endovascular treatment, considering the risks and benefits. The management plan was formulated to proceed with the hybrid operation as an elective procedure. During the operation, we placed the balloon in the C2-C3 segment of the ICA due to a relatively narrow-necked aneurysm (D/N ratio of 5.6). Then, we performed craniotomy via a pterional approach using the IAC technique to remove the ACP. We found that the right optic nerve was compressed by the giant aneurysm and that the optic nerve was crossed by the aneurysm neck; removal of the ACP and dissociation of the optic nerve from the aneurysm neck sufficiently revealed the aneurysm neck (Figure and ). After the placement of the first clip, first intraoperative DSA showed that the aneurysm had been clipped and that there were small amounts of residue of the aneurysm neck (Figure and ). A supplementary miniature clip was placed during the operation. Second intraoperative DSA showed that the aneurysm had been completely clipped. However, stenosis occurred in the ICA with poor visualization of the optic artery and poor visualization of the distal branch vessel of the ICA (Figure and ). A miniature clip with angular tips was used to replace the original clip. Third intraoperative DSA showed that the aneurysm was completely clipped. The ICA with stenosis was relieved, and visualization of the optic artery and distal branch vessel of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old girl first noted a swollen left knee and underwent repeated arthrocentesis. At age 13, she underwent arthroscopic surgery and was diagnosed with benign TGCT. She subsequently underwent numerous synovectomies to treat local recurrences and radiation therapy to her left knee joint at age 15. Ultimately, her disease spread to her upper calf and posterior thigh. At age 32, her upper calf lesion was resected, and the tumor in her posterior thigh was treated with radiation. At age 34, swelling of an inguinal lymph node was noted and fine needle aspiration was consistent with malignant TGCT. Other staging scans revealed a pelvic mass and a sub-centimeter pulmonary nodule. Her disease remained stable after four cycles of doxorubicin/ifosfamide and she subsequently received gemcitabine/docetaxel as well as radiation therapy to her pelvis with stable disease for three months. She underwent left-sided above the knee amputation and excision of the intrapelvic masses. Eight months later, enlarging pulmonary nodules were resected. She was treated with sirolimus (rapamycin) and remained disease-free for eight months until a pulmonary nodule and two inguinal masses were noted. In 2007, at age 37, she was referred to our hospital and treated with sorafenib for four months with mixed response. She subsequently began on sunitinib 37.5 mg daily. Interval restaging scans showed no evidence of progressive disease for 15 months. She had significant interval progression of a right-sided pelvic mass while she temporarily stopped sunitinib in the perioperative setting of resection of painful metastatic nodules near the amputation stump (Fig. a, b, and c). Given that the drug had a significant role of controlling the disease, her sunitinib was restarted in combination with sirolimus (rapamycin). Her disease was under good control for eight additional months until she had progressive disease in the pelvis and underwent hemipelvectomy. She died of the disease at age of 39, six yea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female presented in July 2007 to a peripheral general hospital with progressively enlarging mass in the anterior abdominal wall of one-year duration. On physical examination, she was well built with normal vital signs. A 7 x 6 cm firm irregular subcutaneous mass was felt in the right lower para-umbilical area of the anterior abdominal wall. On palpation, the abdomen was soft and lax with no intra-abdominal masses. There were no palpable lymph nodes. Her cardiac and respiratory examinations were unremarkable. Computerized Tomography (CT) scan of the abdomen revealed a mass within the abdominal wall. Her laboratory investigations were within normal limits. A plain chest X-ray was unremarkable.\nWide local excision with safety margins of the tumor was done. The postoperative period was uneventful, and she was discharged on the second postoperative day in a satisfactory condition.\nGross examination of the specimen showed an ellipse of skin that measured 13 x 10 cm with subcutaneous fatty tissue measuring 11 cm in thickness. On cut section, a well-defined nonencapsulated grayish yellow mass measuring 7 x 6 cm with foci of necrosis was seen. No skin infiltration or abdominal skeletal muscle involvement was noted.\nMicroscopic examination revealed well-defined but nonencapsulated subcutaneous mesenchymal neoplasm composed of irregular islands of large cells with mostly round to oval pleomorphic vesicular nuclei, with markedly granular cytoplasm, and several large eosinophilic globules (). The nuclear cytoplasmic ratio was variable, with several cells having large nuclei. The tumor nests were surrounded by bands of fibrous connective tissue ().\nMany foci of tumor necrosis and scattered mitotic figures, 4 per 10 HPF at a magnification of 200, were identified (Figures and ). Margins of resection were free of tumor.\nImmunohistochemical stains show the tumor cells to be strongly positive for vimentin, S100 and CD68 (Figures , , and ). Stains for cytokeratin (CK), sm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old woman presented with a painless swelling in the distal aspect of the right humerus of 1 month's duration. She did not report any trauma to the arm. Physical examination revealed a firm, nontender swelling deep to the triceps just above the elbow. The function of the right upper limb was normal, with a full range of movements in all joints and without distal neurovascular deficit and no regional lymphadenopathy.\nPlain X-rays showed a dense sclerotic bony protuberance arising from the posterior cortex of the distal aspect of the humerus (). The MRI showed an exostosis measuring 6 cm in its long axis terminating immediately proximally to the level of the olecranon and with involvement of the underlying medulla (). Chest CT scan and whole body bone scan confirmed no evidence of disease elsewhere. A core needle biopsy was performed which showed features consistent with a parosteal osteosarcoma.\nReconstructing a segmental defect at this site is fraught with difficulties. Although we have reported good results with distal humerus replacements [], we anticipated long term complications such as aseptic loosening using this option in a 12-year-old. Reconstruction with bone transport was not attractive because of the length of time that would have been required and the associated risk of elbow stiffness. Reconstruction with strut allografts requires an adequate bone banking service and presents inherent risks of graft rejection and imperfect fit of the donated graft to the recipient bone defect. Therefore we planned to do an en bloc resection of tumor bearing bone, extracorporeal irradiation of excised bone segment to eradicate the tumoral cells, and reimplantation of the autograft with preservation of the elbow joint. We resected 10 cm of the humerus, stopping 2 cm from the elbow joint and dividing the bone a further 10 cm proximal to this. We then stripped the tumor from the bone surface and underlying intramedullary canal using osteotomes, curettes, and a burr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female presented to our center with a telangiectatic osteosarcoma of the humerus. There was no history of malignancies within the family.\nMRI examination and open biopsy were performed by the previous physician. At the time the results were thought to be malignant lymphoma. After several diagnostic trials, the patient visited our center to seek advice about her telangiectatic osteosarcoma (A).\nWe observed a circumferential mass on the distal part of the right arm with a slight deformity of the arm, with marked venous engorgmnt and distal edema. The mass was warm and solid on palpation. Function of the right hand was still preserved. From the laboratory findings, there were marked elevation of the alkaline phosphatase and lactate dehydrogenase. From humerus X-ray, there was mixed lesions along the humerus with pathological fracture on the midshaft (A). T2-weighted MRI showed iso-hyperintense and expansile lesions along the humerus (A). For the metastatic workup, chest X-ray showed no coin lesions or metastatic characteristics. Patient also had a PET scan and the result was unremarkable. From the Clinico Pathological Conference (CPC) forum, it was concluded that the diagnosis was osteosarcoma of the right humerus stage IIB according to the Enneking classification.\nPatient took neoadjuvant chemotherapy regimen with Doxorubicin and Cisplatin for three cycles from January to March 2016. At the end of the third cycles, clinical and radiological evaluations were performed. Clinically the mass was not getting bigger compared to before chemotherapy (B). From x-ray, the mixed lesions became more marked compared to the previous x-ray (B). MRI showed that the mass was slightly became larger compared to the previous MRI with no involvement of neurovascular bundle (B).\nSix months after the initial complaint, the surgery was performed. We used extensive deltopectoral approach with anterolateral extension through the proximal part and curved backward to complete the p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old immunocompetent Caucasian male presented to the emergency department with 1 week of left hand clumsiness. Physical examination was consistent with mild left upper extremity neglect but otherwise benign. The patient had no relevant past medical history. Computed tomography (CT) scan demonstrated a large hypodense lesion in the right parietal lobe suspicious for neoplasm (). Subsequently, MRI revealed a heterogeneous thick-walled peripherally enhancing lesion of the right parietal lobe with central necrosis and an extensive degree of surrounding vasogenic edema (). Neither T1-weighted imaging nor gradient echo sequences demonstrated evidence of subacute hemorrhage. Initial differential diagnosis included glioblastoma, anaplastic astrocytoma, metastasis, or PCNSL. A metastatic workup was negative. The patient was started on dexamethasone (16 mg per day for 5 days) while hospitalized with improvement in his presenting neurologic symptomatology. Upon discharge, he was prescribed a 6-day dexamethasone taper to 1 mg per day to continue until outpatient follow up. Per patient preference, stereotactic debulking of the lesion was scheduled for 5 weeks from his initial presentation.\nThe patient was admitted to the hospital 4 weeks later (1 week prior to scheduled surgery) with new onset lethargy and respiratory distress. Repeat CT compared to 4 weeks prior demonstrated a dramatic reduction in vasogenic edema and apparent size of the lesion (). The patient was diagnosed with bacterial pneumonia and remained hospitalized for medical treatment and optimization. One week later, a repeat MRI was ordered to evaluate the significant changes seen on repeat CT as well as to determine extent of future operative intervention. Repeat MRI compared to 5 weeks prior revealed a dramatic reduction in contrast enhancement, vasogenic edema, and apparent size of the lesion (). These imaging findings raised suspicion for PCNSL. As such, a stereotactic biopsy was planned to attain tis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 70-year-old female whose past medical history was significant for arthritis and a right total hip arthroplasty approximately 9 years ago. A laparoscopic cholecystectomy (LC) for acute cholecystitis was performed approximately at another hospital approximately two months prior to presentation. She developed a surgical site infection with Escherichia coli (E. coli) bacteremia following her LC and was treated successfully with intravenous (IV) antibiotics. The postoperative course was also complicated by choledocholithiasis requiring an endoscopic retrograde cholangiopancreatography (ERCP) with stone pulverization and placement of two plastic 10F × 12 cm biliary stents. Two days prior to admission, she was hospitalized at an outside facility in septic shock with fevers, chills, lethargy, altered mental status, and blood and urine cultures positive for E. coli. At that time, she endorsed right hip pain and an inability to move her hip or leg. A computed tomography (CT) scan of her right hip revealed two partly calcified soft tissue masses associated with the right iliopsoas and obturator internus muscles (). A CT-guided fine needle biopsy of the right hip and psoas locules aspirated 100 mL of frank pus notable for a nucleated cell count of 344,000 (98% PMNs) with growth of E. coli. As a result, the patient was transferred to our institution with concerns for an iliopsoas abscess and a periprosthetic infection.\nOn admission, she was febrile to 102.7 F without any significant distress. Her physical examination was remarkable for a well-healed, right lateral hip incision with no erythema or drainage. She experienced pain with right hip flexion and internal rotation. Laboratory studies showed WBC, hemoglobin and hematocrit, basic metabolic profile, and liver function tests all within normal limits. A 3 cm hepatic abscess was identified on CT scan of the abdomen and pelvis. An MRI of the right hip showed a large air- and fluid-filled collection tracking alo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old male with no significant past medical, surgical, or social history initially presented to an emergency department in October 2013 with a chief complaint of right, radial-sided wrist pain after a fall on his right arm while playing soccer. No fracture was seen on radiographs, and he was placed in a removable splint for comfort and discharged. The patient was scheduled for follow-up but would not present to an orthopaedic clinic until three years post injury, at age 11. At age 11, when the patient was seen at an outside orthopaedic clinic, he reported continued wrist pain from his initial injury three years prior. He described dull pain in his right wrist with intermittent swelling after several minor falls while playing soccer. Radiographs did not reveal a fracture or other pathology, and the patient was again diagnosed with a wrist sprain and given a brace for comfort. He was compliant with the brace, but 8 months later, he again returned to his pediatrician with continued pain. Interval radiographs revealed a right-sided, displaced scaphoid waist fracture (). He was referred to our clinic for further management. He was noted to have tenderness located at the anatomic snuffbox but full range of motion. A magnetic resonance imaging (MRI) scan was ordered to further evaluate for AVN and osseous bridging given the chronicity of his symptoms, and he was placed in a thumb spica wrist brace. His MRI demonstrated the scaphoid waist nonunion with concerns for AVN (). At this point, the patient and parents elected to undergo surgical fixation of his nonunion. Due to the concern for AVN on MRI, utilization of a vascularized bone graft was considered. However, it was felt that given the young age of the patient, drilling of the bone would be sufficient to stimulate bone growth and avoid the more aggressive procedure.\nThe patient underwent surgery at 11 years and 3 months of age. Open reduction and internal fixation was performed using a dorsal approach centered o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old female presented with anorexia and abdominal pain since 2 years. Patient gave history of undergoing hysterectomy eight years back, for endometrial carcinoma. Postoperatively radiotherapy was advised; but due to extreme morbidity, she could receive only 10 fractions. Details of this treatment were not available as she was treated at a different hospital. Clinically, the patient's vital organs were stable. On per abdomen examination, a 12 × 10 cm firm mobile lump was palpable in the left lumbar region. Her hemoglobin and counts were normal. Renal functions were also normal. Abdominal USG revealed an echogenic mass, 8 × 7 cm, showing posterior acoustic shadowing, probably inspissated fecal matter. A repeat USG performed 4 days later after giving water enema showed the mass unchanged in size and echotexture. CT scan indicated a mass with peripheral calcification [], but was unable to differentiate whether it was in colon or small bowel loops. There was no evidence of any recurrence or metastatic lesion of the endometrial primary. Barium enema revealed an entero-colic fistula with an enterolith at the site of the fistula []. Colonoscopy showed a fistulous opening in region of sigmoid colon. A clinical and radiological diagnosis of enterolith with entero-colic fistula was made. Patient underwent an exploratory laprotomy under general anesthesia after bowel preparation. At laprotomy a fistula between mid-ileum and sigmoid colon was seen, containing a hard nonmobile mass. Rest of the small bowel and colon was normal, no diverticuli were detected. Gall bladder and common bile duct were normal. Segmental enterectomy with sigmoidectomy [] was done and patient had an uneventful recovery. Cut-section of the specimen showed presence of an enterolith obliterating the lumen of the fistulous connection between the two bowel loops. The mucosa appeared normal. Histopathology was unremarkable, showing congestion and acute on chronic inflammation. The presence of enlarged"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old female with no significant past medical history was brought to the emergency department by emergency medical services (EMS) with a complaint of left-sided chest pain. She was in her usual state of health when she went to a scheduled appointment with a vascular surgeon for outpatient elective sclerotherapy for the cosmetic treatment of varicose veins. Shortly after being administered an injection of polidocanol, she began experiencing severe left-sided chest pain radiating to her left back with left arm numbness. She also complained of nausea, one episode of vomiting, pressure in her jaw, and lightheadedness. Prior to being transported to the emergency department by ambulance, she was given two doses of aspirin 81 mg.\nOn arrival to the emergency department, she reported that her symptoms had subsided. Her initial electrocardiogram (ECG) was remarkable for T-wave inversions in leads V1-V3 and sinus bradycardia at 54 beats per minute (), with no prior ECG available for comparison. No ST-segment abnormalities were present. Initial laboratory studies were also notable for an elevated troponin I level of 0.62 ng/mL.\nThe patient was admitted to the inpatient telemetry unit for suspected acute coronary syndrome. Repeat assessment of her cardiac enzymes six hours after her initial bloodwork revealed that her troponin I level had risen to 2.26 ng/mL, at which point the patient had been started on continuous unfractionated intravenous heparin. She remained asymptomatic. The patient was offered cardiac catheterization but initially declined. In a third set of cardiac enzymes, her troponin I level had trended down to 1.15 ng/mL.\nFurther studies, including echocardiogram and nuclear stress testing, were pursued to better define her cardiovascular function. A transthoracic echocardiogram revealed an ejection fraction of 50%, suggestive of mild systolic dysfunction, in addition to the presence of apical hypokinesis (). Grade II diastolic dysfunction was also noted. He"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old boy was evaluated for a two month history of atypical movements presenting in the evening, and lasting an hour after eating. These stereotypical movements with the head and chest bending forward and to the left side, accompanied by a grimace were associated with sensation of breath locking without cyanosis. Pain and dysphagia were absent. The neurological examination was normal. The possibility of Sandifer syndrome posturing occurring with gastroesophageal reflux disease (GERD) was considered but neither pain nor back hyperextension were associated with the atypical movements. PPI did not improve his symptoms. Various prokinetic agents (metoclopramide, motilium, cisapride and erythomycin) were also inefficient.\nUpper endoscopy and esophageal biopsy did not reveal eosinophilic esophagitis or other abnormalities. ENT exam was normal. A severe gastroparesis was demonstrated on milkscan study. Two 24 hour esophageal pH probe studies pointed out severe GER. High resolution manometric evaluation of the oesophagus revealed normal sphincter pressures and relaxations with no dysmotility of the esophageal body. Electroencephalography and polysomnography were normal. Because of the unexplained dyspnea associated with this abnormal posture, a head MRI was performed and revealed a CM I: cerebellar tonsils extending to 12 mm, with syringomyelia (D4-D5) (Figure ).\nFor a long period of time, the child abnormal movements were only considered to be tics and the CM I was considered a fortuitous finding. Since the child remained symptomatic despite medical treatment, it was eventually decided to proceed with surgery. The operative procedure was done one year after the onset of his symptoms. He underwent posterior fossa decompression with upper cervical laminectomy and expansion duroplasty. No postoperative complication occurred. Postoperative MRI confirmed adequate decompression. His atypical posture and dyspnea completely resolved in the week after surgery. More than two"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old girl suffered cervical spine injury after a motor vehicle collision while sitting in the car without wearing a seatbelt. ATLS protocol was performed on the patient at a local hospital and she was referred to the emergency department at author’s hospital within 12 h of the injury. The pediatric surgeon and our orthopedic team re-evaluated that the status of the patient showed head injury with alteration of consciousness, intubation, cervical spine protection with hard collar and first rib fracture without pneumohemothorax. The emergency radiographs x-ray and CT brain including cervical spine showed no intracerebral hemorrhage but the cervical spine suffered unilateral cervical C4–C5 facet dislocation. Radiographic features showed anterior dislocation of the affected vertebral body less than the vertebral body in anterior posterior diameter, discordant rotation above and below involved level, facet within intervertebral foramen on oblique view, widening of the disk space and “Bat wing sign” appearance of the overriding facet (Fig. a-c). The patient was taken to the pediatric intensive care unit (PICU) for resuscitation and closed monitoring after hemodynamic was stable. The patient was evaluated by MRI for preoperative planning, and no spinal cord injury was visible. In the next 24 hours, the patient’s neurovascular status examination was fully conscious and no neurological deficit (Frankel grade E) then extubation followed. The team discussed with her parents treatment plan and complication. Her parents then denied surgery. The authors applied closed reduction maneuver with minerva cast under sedation. The patient was in Frankel grade E without complication after closed reduction and the cervical spine had good alignment in radiographs (Fig. d). The minerva cast was removed at 8 weeks, at which point neck muscle stretching rehabilitation program started. At one-year follow up, the child was asymptomatic, had full active cervical motion and good function."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Caucasian male aged 14 years attending an orthodontic clinic for a routine assessment presented with an incidental radiographic finding. A well-defined calcified mass was visible at the apex of the maxillary right permanent canine on the orthopantomogram (OPG) radiograph ().\nA lateral cephalometric radiograph showed that this mass was significantly superior to the dentition in the antral inferior nasal region (). The mass was a well-defined spherical lesion, measuring 1.5 by 1 cm with a radiopaque, homogeneous internal structure. It lay superior to the canine fossa and anterior to the maxillary sinus anterior wall.\nThis calcified mass had not been present on the OPG radiograph taken previously, at age 10 years ().\nFrom the age of 12, it was reported that the patient suffered with facial AV. He attended a consultant dermatologist who treated the condition successfully. The calcified mass was previously assessed at dermatological review. Despite the fact that it was a solitary lesion, it was diagnosed as dystrophic calcinosis cutis. The dermatologist advised no intervention as there was a significant risk of facial scarring if surgically removed. The mass was asymptomatic and presented little risk of infection. The patient was placed on annual review with his dermatologist.\nAlthough the mass was palpable and mobile, the patient's dermis was intact and acne-free. The mass was not visible clinically on extraoral examination. Facial profile and contour were normal. Orthodontically, he presented with a Class III incisor relationship on a Class III skeletal base with crowding in the maxillary arch. Both the patient and his parents were given the option of orthognathic surgery to treat his malocclusion and underlying significant skeletal relationship discrepancy. After extensive discussions and reviews with a maxillofacial surgeon, they opted for orthodontic treatment only, namely, alignment of the maxillary arch teeth on a non-extraction basis, followed by permanent rete"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old male presented with a history of weakness and constipation, for which he underwent colonoscopy, revealing a submucosal mass in the right colon, compressing on the lumen extrinsically. The mucosa overlying the mass was intact and colonoscopy showed an adjacent 12 mm polyp, which turned out to be a tubular adenoma. He had history of removal of previous tubular adenomas on prior colonoscopies. Computed tomography (CT) imaging showed a 7.0 cm lobulated mass arising from mid-ascending colon with exophytic growth and foci of calcifications. CT findings were consistent with a mesenchymal tumor and carcinoma was less likely. No fatty component was reported (). Subsequently, the patient underwent laparoscopic right hemicolectomy and tumor was resected.\nGross examination of the right hemicolectomy specimen demonstrated a firm and calcified intramural mass in the posterior wall of ascending colon, extending into the mesocolic fat, without involvement of the mucosa. Microscopically, distinct histological patterns were identified, with the majority of the tumor being composed of a central ossified core surrounded by a minor component of a high-grade mesenchymal nonlipogenic tumor and adipose tissue. The central bone forming component showed areas of osteoid matrix with highly atypical cells resembling a high-grade osteosarcoma as well as areas of more mature appearing woven bone trabeculae with intervening mildly atypical spindle cells similar to a low-grade osteosarcoma (LGOS). A thin rim of a high-grade sarcoma composed of atypical spindled and pleomorphic cells was identified in the periphery of the bony mass. In addition, small foci of mature-appearing adipose tissue containing rare atypical hyperchromatic stromal cells were detected adjacent to the high-grade sarcoma and at the retroperitoneal resection margin, raising consideration of a WDL (Figures and ). The findings suggested that WDL may have arisen in the retroperitoneum and secondarily involved the colo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA postmenopausal 56-year old woman, mother of three children, presented with swelling and discharging lesions on the right side of vulva and groin since past 14 months. The lesion first appeared 14 months ago on the right side of vulva and gradually extended to the right groin. There was no history of any kind of bite, trauma, operative procedure, or insertion of intrauterine device in the past. She had normal vaginal deliveries without any operative intervention. There was a history of occasional sexual intercourse, in the past 10–15 years. General examination revealed no physical abnormality. On local examination, multiple nodules were seen on the right vulva extending up to the right inguinal region []. There was a mild serosanguinous discharge in the inguinal area. Closer examination revealed yellowish white granular deposit on top of the nodule, which on further examination, turned out to be sulfur granules []. There was edema over groin, right thigh, and leg []. Inguinal lymph nodes were enlarged on the right side. Routine gynaecological examination was within normal limits. Investigations including hemogram, urinalysis, kidney and liver function tests, ELISA for HIV, and Mantoux test were within normal limits. Chest radiography and ultrasonography of abdomen and pelvis were normal. Cervical Pap smear did not show any evidence of malignancy. Acid fast staining of the purulent material was negative. Crushed sulphur granules on staining with haematoxylin and eosin showed multiple active colonies with surrounding neutrophilic infiltration []. Each colony on staining with MGG stain showed basophilic filamentous centre, and radiating peripheral projections in a sunray appearance (Gupta bodies) []. Fine-needle aspiration cytology from an inguinal nodule on staining showed similar findings along with giant cells and neutrophils. Actinomyces colonies could not be demonstrated in aerobic as well as anaerobic culture media.\nThus the diagnosis of actinomycosis involving"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 70-year-old Caucasian man, with no significant clinical background, who presented to our casualty department with a three-week history of headache and maxillary pain on the right side, together with the recent appearance of dysphonia and dysphagia for solids. No urinary disorder was reported. A neurological examination revealed a paresis of cranial nerves IX and X, manifested by the displacement of the soft palate to the right and difficulty swallowing. Paresis of cranial nerves XI and XII was also observed, indicated by the lowering of the right shoulder and hypotonia of the right trapezius muscle, and was accompanied by displacement of the tongue toward the right, right-side hypotonia and muscle twitching (Figures and ). Results of the rest of the physical examination were normal.\nBlood analysis results revealed an alkaline phosphatase level of 350 UI/L (normal range 44 to 147 UI/L) but no other significant alterations. In view of the paresis of the four lower cranial nerves, a CT scan of the larynx and neck was performed; the CT scan revealed an asymmetrical union between the clivus and the right occipital condyle, adjacent to the jugular foramen, with increased ground-glass bone density. There was no visible lesion to the bone cortex or soft tissues. This study was complemented with an MRI scan, which revealed a bone lesion producing a hypointense signal at sequences T1 and T2. Administration of a gadolinium contrast agent produced a moderate degree of enhancement at the base of the skull, affecting the right occipital condyle and part of the right side of the basilar bone (Figure ). The image corresponded to a moderately space-occupying blastic lesion, visible in the CT scan, which slightly decreased the caliber of the jugular foramen and the condylar canal. Therefore, fibrous dysplasia, Paget's disease and metastasis were considered in the differential diagnosis.\nSubsequently, an additional radiographic examination of the lumbar column"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old woman was referred to our outpatient clinic during her 31st week of pregnancy suffering from shoulder pain of the right side after lifting her 11-month-old first born. During the first pregnancy, one and a half year ago she started noticing dyspnea which was still present at the time of her presentation in our clinic. At that time, this symptom was considered as pregnancy-related therefore no special examination was arranged. Several months later the patient became pregnant again. She was still reporting of dyspnea especially at physical activity and new symptoms, cough and hemoptysis, had appeared. Due to persistent symptoms, the general practitioner arranged a chest X-ray that showed a tumor mass in the right lung in close relation to the scapula (Fig. ).\nClinical examination showed a patient in good general health. There was a local swelling at the medial border of the right scapula with dull pressure pain. The movement of the shoulder was painless at full range of motion and strength. The auscultation of the lung presented a vesicular respiratory sound which was slightly attenuated at the right side. The patient did not suffer from pain. Family anamnesis revealed a breast cancer of the patient’s mother and a bronchial carcinoma of the father. B symptoms were not reported.\nThe case was primarily presented to the department of obstetrics in 31 4/7 weeks of gestation. Ultrasound showed a large for gestational fetus (2205 g, 93rd percentile) with normal amniotic fluid and normal feto-placental perfusion of a 34-year-old gravida 2 para 1 (one spontaneous delivery 1 year ago) with no pregnancy-related complications. A diaplacental cancer cell transmission seemed unlikely for the type of expected tumor.\nMRI scans (magnetic resonance imaging, Fig. ) of the cranium and the thorax were performed and revealed several highly suspicious lesions in the right lung, the mediastinum, the inferior angle of the right scapula with soft tissue component,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old male patient (168 cm, 53 kg) visited our institution complaining of difficulty in swallowing for the past 8 years and the frequent occurrence of aspiration pneumonia for the past 1year. Lateral radiography of the cervical spine demonstrated extensive osteophyte formation from C2 to C4 () and decompression of the osteophyte was planned. His medical history was significant for diabetes. He had been diagnosed with stable angina but rejected PCI. Preoperative electrocardiogram and echocardiogram revealed tolerable status. Blood chemistry revealed hyperglycemia, but hepatic and renal function and coagulation were normal. On physical examination, the patient was alert and afebrile; and his vital signs were stable. Oral examination was unremarkable and neck extension was normal. He had minimal dyspnea in the supine position. Indirect laryngoscopy revealed a large hard mass protruding from the posterior wall of the hypopharynx that concealed the arytenoids cartilage (). A preoperative neck CT showed slight narrowing of the airway at the level of the epiglottis. Vocal fold mobility was preserved. No narrowing of the subglottic region was observed when flexible endoscopy was performed. Preoperative tracheostomy was done under local anesthesia and general anesthesia was induced with thiopental sodium 250 mg and rocuronium 50 mg and maintained with sevoflurane. Complete decompression of the osteophyte was performed for 210 minutes using an anterolateral transcervical approach, which proceeded without any complications. The postoperative course was uneventful. On the second postoperative day, indirect laryngoscopy was performed by an otolaryngologist to decide if removal of the tracheostomy cannulawas appropriate. However, this examination revealed significant laryngeal edema including the epiglottis and posterior laryngeal wall (). On 29th postoperative day, flexible endoscopic examination was performed again and copious secretion, decreased vocal cord mobility an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman was referred to our hospital for the treatment of chest wall necrosis. She had undergone Halsted surgery and postoperative radiation therapy with cobalt-60 (30 Gray) and megavoltage X-rays (30 Gray) 25 years earlier. Following the treatment, her left upper limb became completely paralyzed.\nSix years earlier, she had sustained a left clavicle fracture due to osteonecrosis, and she had subsequently developed a chronic cutaneous fistula measuring 1 cm in diameter. The fracture and cutaneous fistula failed to heal, and she experienced bleeding from the fistula since 1 year. Two months before visiting our hospital, she was hospitalized in the Department of Breast Surgery at another hospital for massive bleeding and local infection. She was treated with antibiotics and cleansing of the fistula and the infection subsided 2 months thereafter. She visited our hospital after discharge.\nAt initial examination, her height was 153 cm and weight was 34 kg. Necrosed clavicle was exposed through the 6-cm-wide skin defect in the left clavicular region, and air entered and exited the opening from deep within the chest while breathing (Fig. ). Computed tomography (CT) revealed the part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Her upper left limb was nourished by retrograde blood flow from the thoracodorsal artery; however, blood flow was weak to the skin of the arm, the surface of which was cold, resulting in complete paralysis of the upper extremity. Several rounds of debridement eliminated the necrotic tissue, and the local infection was completely resolved. Debridement revealed a tissue defect measuring 4 cm × 8 cm and 4 cm deep at the base and approximately 10 bronchial stumps on the surface of the collapsed lung covered in granulation tissue, from which exhaled air and sputum were effusing (Fig. ). She presented with severe emaciation and malnutrition, but no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA male Caucasian baby was born by spontaneous vaginal delivery at 35 weeks of gestation to a 26-year-old gravida 3, para 1 mother. The mother had well-controlled type 2 diabetes mellitus and two previous miscarriages of unclear etiology. No evidence was found of congenital malformations on prenatal ultrasounds. No family history was known of spontaneous thrombosis. The birth weight was 2353 g and appropriate for gestational age. At 20 minutes of life, he became severely tachypneic. A sepsis evaluation was performed and intravenous antibiotics were begun. Chest radiography revealed a right tension pneumothorax and complete left lung field opacity. The infant was intubated and a chest tube was placed. An echocardiogram at 10 hours of life revealed right ventricular dilatation and hypertrophy with flattening of the ventricular septum, consistent with persistent pulmonary hypertension of the neonate (PPHN). Left pulmonary artery (LPA) blood flow could not be visualized and a thrombus appeared to occlude the LPA (Figure ). Inhaled nitric oxide was administered. Computed tomography angiography (CTA) at 16 hours of life was performed and showed an intact tracheobronchial tree and a markedly hypoplastic left lung (Figure ). The main and right pulmonary arteries were normal in caliber, with an occlusion of the LPA by a low-density mass suggestive of a thrombus (Figure ). In addition, large collateral vessels originated from the distal thoracic aorta and supplied the left lung (Figure ).\nA screening evaluation for a possible inherited thrombophilia disorder was completed in this baby. Blood levels for protein C, protein S, antithrombin activity, concentrations of clottable fibrinogen, plasminogen activity, activities of coagulation factors VIIIC and XII, lipoprotein (a) and homocysteine concentration were within normal limits. DNA-based assays (that is, factor V G1691A mutation and factor II G20210A variant) were also normal []. The mother did not complete a thrombophilia scr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 30-year-old Tibetan man, was treated in the Lhasa Hospital for right tibiofibular fracture December 2012 (Fig. ). After the swelling subsided, he underwent right tibia fracture intramedullary internal fixation. Two weeks after the operation, the patient was able to walk with double crutches without load, and was able to walk without crutches and with some load 3 months after the operation. However, the patient complained of pain in his right lower extremity, especially when moving downhill or down stairs, and experienced a limping gait and obvious tenderness at the fracture end. Three years after originally presenting at Lhasa Hospital, the patient was experiencing persistent pain in the right lower extremity, and his daily activities were severely affected. Thus, he was re-diagnosed with nonunion of the right tibial fracture after internal fixation (Fig. ). The main causes of the nonunion of the fracture were considered to be the excessively thin intramedullary nails and unstable fixation of the fracture. The operation was repeated with replacement of the crude intramedullary nails and grafting of iliac bone (Fig. ). Three months after the operation, the tibial fracture had failed to heal, and further surgical treatment was performed. The proximal locking screw of the intramedullary nail was removed with an expectation to eliminate the stress shielding effect and to promote fracture healing by increasing the microdynamic force while retaining the static interlocking nail. Five months after the operation, the patient abandoned the crutches and was able to walk with a heavy load. Nevertheless, 2 years after the operation, active pain of the right leg persisted with some tenderness around the fracture, especially when moving downhill or down stairs. August 2018 the patient was admitted to our hospital. Physical examination revealed that two old incision healing scars, approximately 2 cm in length, were present at the proximal and distal ends of the righ"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old male presented to our hospital due to intermittent claudication of both legs and swelling in his left leg. The claudication had started 4 weeks earlier and was ongoing at the time of presentation, and the pain had worsened. His left lower limb had become swollen 2 weeks before admission. On admission, the pulsation of his bilateral femoral, popliteal, and anterior tibial arteries was weak. The ankle-brachial index (ABI) was significantly low bilaterally.\nUltrasonography showed that there were massive thrombi in the veins extending from the left external iliac vein to the left popliteal vein (). At the same time, there was no discernible arterial blood flow from the infrarenal abdominal aorta to both the common iliac arteries. Further, the inside echo of the occlusion site was low, so the occlusion seemed to be due to a thrombus. Pulmonary thromboembolism was ruled out by echocardiographic examination. The echocardiography showed normal left ventricular function (left ventricular ejection fraction 73%), mild left ventricular hypertrophy, and no tricuspid regurgitation. We considered that if pulmonary thromboembolism had occurred, the grade was not severe. In the computed tomography (CT) findings, the terminal aorta was occluded with thrombus and there was a venous thrombus in his left iliac vein that appeared in the proximal site that was compressed by the left common iliac artery (). The patient was diagnosed with Leriche syndrome accompanied with DVT. His thyroid function tests were normal and his hypercoagulable workup including serum protein C, protein S, anti-cardiolipin antibodies, and lupus anticoagulant antibody was found to be negative.\nOn day 1, a temporary inferior vena cava (IVC) filter was inserted to prevent pulmonary embolism. Oral warfarin administration and intravenous heparin infusion were started for DVT. Oral cilostazol (200 mg/day) was started for ischemia of the lower extremities. Coronary angiography (CAG) and aortography were don"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old male patient presented to the outpatient department with left-sided epiphora and chronic dacryocystitis, without any record of head trauma or previous surgery of the nose or paranasal sinuses. On nasal endoscopy no abnormalities were noted. A diagnosis of saccal NLDO was made by clinical examination including lacrimal irrigation and fluorescein tests (Jones I and II tests) as well as probing of the canaliculi with a blunt probe up to bony contact with the lacrimal sac fossa performed by an ophthalmologist. The imaging studies (CT scan) revealed a 1 cm osteoma of the ventral half of the medial wall of the left maxillary sinus causing total obstruction at the level of the lacrimal sac (Figures , , , and ).\nUnder general anesthesia, an endonasal endoscopic dacryocystorhinostomy (DCR) without flaps [] using a cutting- and diamond-burr drill as well as the osteoma removal using a cutting-burr drill was performed. A temporary silicone stenting of the nasolacrimal duct system was applied. No postoperative complications occurred. An oral antibiotic therapy (amoxicillin and clavulanic acid 1 gr twice a day) was initiated on the day of surgery and continued for 5 days. A concomitant topical therapy with antibiotic and steroid solutions (tobramycin and dexamethasone ophthalmic suspension 2-3 drops twice a day for 5 days) was also given. The patient's total hospital stay lasted 1 day.\nA lacrimal duct system irrigation with natural saline solution into the inferior canaliculus was performed by an ophthalmologist once a week during the first month and twice a month during the second month. An endoscopic endonasal examination to test the patency of the duct system was performed 15, 21, and 30 days postoperatively. The silicone stent was removed 6 weeks postoperatively. An anatomical and functional obstruction of the DCR-window due to granuloma formation at the DCR-window area was noted 8 weeks after surgery on the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old man consulted our clinic with a complaint of swelling in the right buccal region. The patient noticed the swelling 5 years ago and had received aspiration therapy repeatedly to reduce the swelling. He was generally healthy and had no medical history. On examination, an elastic firm, movable mass of 50mm was palpable in the right buccal region (Fig. ). The overlying mucous membrane was normal.\nThe mass was not adhesive to either the mucous membrane or the skin. The maxilla was totally edentulous and only bilateral canines and the left first premolar were present in the mandible. Hypoesthesia or palsy of the right face, trismus, swelling of cervical lymph nodes or the right parotid gland was not observed. CT examination revealed a well-circumscribed oval cystic lesion of 35 mm with the density slightly less than that of muscle in the anterior region of the masseter muscle (Fig. ). On MRI, the lesion showed a low signal on the T1-weighted image and a heterogeneous high signal on the T2-weighted image including intermediate signal in the under portion (Fig. ). Aspiration through the buccal skin revealed whitish liquid with squamous cells and shadow cells with a few neutrophils and lymphocytes in the cytological examination.\nThe clinical diagnosis of epidermoid cyst at the right buccal mucosa was made. The lesion was intraorally extirpated under general anesthesia through the incision along the anterior border of the mandibular ramus (Fig. ). Detachment of the lesion from the surrounding tissue was relatively easy. Stensen’s duct was not related to the lesion. The wound was closed after placing a silicon drain. Wound healing is good and no sign of recurrence has been observed for more than 4 years after the surgery.\nThe lesion was cystic, 30 × 25mm, weighed about 6g and contained brown serous liquid with a few cellular debris or keratin scale (Fig. ). Histologically, the lesion was lined with squamous epithelium"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male with a history of hypertension, 20 pack-years of smoking, thyroid cancer in remission with partial thyroidectomy, and chronic obstructive lung disease (COPD) presented to the emergency department (ED) with acute abdominal pain. Abdominal ultrasound showed gallstones with no evidence of cholecystitis or biliary obstruction. The patient was diagnosed with biliary colic and discharged home with a plan to perform an elective cholecystectomy. Computed tomography (CT) scan of the abdomen was performed as an outpatient as part of the preoperative workup which showed evidence of gallstones, small bilateral pleural effusions, and moderate pericardial effusion with high density suggestive of hemorrhage (). Consequently, the patient was referred to the emergency department for further workup. Upon arrival, the patient was asymptomatic, his vital signs were normal, and his physical examination was unremarkable. An electrocardiogram (EKG) revealed a nonspecific interventricular conduction delay. Chest x-ray showed a mildly enlarged cardiomediastinal silhouette with prominent perihilar opacities suggestive of a prominent vasculature (). Complete blood count and basic metabolic profile were within normal limits. Further laboratory workup showed normal erythrocyte sedimentation rate, rheumatoid factor, complement level, and procalcitonin with negative serology for antinuclear antibodies and double-stranded DNA antibodies. A transthoracic echocardiogram (TTE) showed a large pericardial effusion without signs of tamponade, moderate aortic regurgitation, and normal left ventricular ejection fraction and size. Given the large volume of pericardial effusion, a pericardial window was attempted. A total of one liter of hemorrhagic fluid was drained. Pericardial tissue biopsy showed acute and chronic inflammatory cells with thickened pericardium, and no malignant cells were detected (). Tuberculosis quantiferon assay, acid-fast bacilli staining, and fungal and bacterial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old, previously healthy, African American man presented to an emergency department 45 minutes after the acute onset of left facial droop and right-sided weakness (Fig. ). A thorough history confirmed an episode 1-week prior, during which he developed sudden onset of dizziness associated with nausea and vomiting that resolved within hours. He denied any past medical or surgical history and was taking no medications. He has no family history of tumors. In the emergency room, his vital signs were within normal limits. His physical examination was significant for a left facial droop and right hemiparesis. Auscultation of his chest revealed a regular rate and rhythm with no appreciable murmur. No additional significant findings were noted. Stroke protocol was initiated. A chest X-ray was normal and an electrocardiogram showed normal sinus rhythm. A head computed tomography (CT) scan was negative for signs of intracranial hemorrhage. He was subsequently started on tissue plasminogen activator (tPA) therapy. Magnetic resonance imaging (MRI) of his brain demonstrated a right basal ganglia infarct and an old left cerebral infarct. A carotid ultrasound was negative. TTE demonstrated a 1 cm by 1 cm mass on the posterior leaflet of the mitral valve with a moderate mitral regurgitation In addition, TTE revealed a questionable mass on the left coronary cusp of the aortic valve. These findings were confirmed with TEE (Fig. ), which verified no sign of endocarditis and no atrial septal defect. A complete hypercoagulable workup was negative. Stroke protocol continued with the working diagnosis of cerebrovascular accident secondary to emboli from the mitral valve mass. Within 24 hours, he regained function of the right side of his body and had complete resolution of symptoms. He was diagnosed as having transient ischemic attack (TIA) and discussion was undertaken regarding surgical excision of his mitral valve mass.\nA median sternotomy was performed and cardiopulmonary bypa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old man presented with symptoms of right-sided chest pain, not related to physical activity or exertion. He also complained of shortness of breath on exertion. There was no history of cough, fever, or weight loss. Physical examination did not reveal anything significant. His haematological parameters were normal. The chest radiograph (PA view) showed a well-defined radio opaque shadow with no calcification or cavitations with its medial border merging with the right border of the heart, which was suggestive of an anterior mediastinal mass (). Lateral view confirmed the anterior mediastinal location of the mass (). An axial CT scan showed a heterogeneously enhancing right anterior mediastinal mass with areas of necrosis which was adherent to the pericardium (). Bronchoscopic examination showed extrinsic compression of the trachea and the right main bronchus. With a provisional clinical diagnosis of a lymphoma versus a teratoma, surgical excision was planned through an anterolateral approach. Per operatively, a 6 × 7 cm mass was found in the anterior mediastinum which had a smooth surface. The mass showed plenty of adhesions to the right lung and pleura. The mass was removed in piecemeal and was sent with a portion of the lung for histopathological evaluation.\nThe gross specimen consisted of about 250 gm of grey white soft tissue with extensive areas of necrosis. Also received was a lobe of lung measuring 9 × 9 × 2 cm. On microscopic examination, a biphasic neoplasm was noted with well formed glandular epithelial structures admixed with a spindle cell component (). The spindle cell component was monomorphous and showed a fascicular arrangement. The cells showed elongated vesicular nuclei with mild to moderate nuclear atypia. Mitosis ranged from 3–5 per 10 high power fields. The glandular spaces were lined by cuboidal cells with vesicular nuclei and moderate cytoplasm and showed eosinophilic secretions within their lumens which stained positively with the Alc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male with no known history of cancer presented to our institution with a lump in the left breast that had been gradually increasing for 14 months.\nA physical exam revealed a large, fixed 10 cm mass occupied the entire right breast (-A). The mass itself was adherent to the chest but it did not invade the skin. There was no ulceration, nipple discharge, or retraction. There were no palpable lymph nodes. Clinical presentation had supposed initially as a sarcoma of the breast.\nPreoperative unenhanced CT imaging showed well-defined round heterogeneous soft tissue density with hypo dense areas (-B), necrosis and peripheral and central calcifications measuring 07 cm × 10 cm × 11 cm. It was localized in the 4; 5 anterior thoracic rib. The tumor involves the intercostal muscles but respect the lung. CT scan detected no metastatic tumor.\nA core-needle biopsy was taken, which was suggestive of chondrosarcoma grade II.\nSurgery was initiated for wide excision. Intra-operatively, it was found to be arising from the 4; 5 th rib and pushing the lung without invading it. The whole tumor was excised en-bloc along with 4 th, 5th and 6th ribs with a surgical margin of more than 2.0 cm (-A, B). This resection left a defect measuring 23 × 15 cm on the anterior chest wall. Reconstruction of the defect was undertaken with polypropylene plate and ipsilateral pedicle latissimus dorsi muscle flap was placed on the alloplastic mesh (-D). Intercostal drain inserted. The patient was extubated one days after surgery and discharged in 10 days without complication.\nIn final histopathology report, grossly the tumor has blue-grey color and was attached to bone on one margin and covered by the breast in on one surface. The mass measured 18 cm × 14 cm×13 cm.\nHistological section showed mesenchymal proliferation organized in lobulated architecture with abundant cartilaginous matrix and myxoide areas separated by fibrous"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male came to the emergency room of our hospital and stated that a hand-made silicon rod had accidentally passed into his rectum 12 h prior to presentation. He could not remove it on his own. His vital signs were stable, and a physical examination showed that his abdomen was soft and without tenderness. There was a palpable elastic, hard mass in the lower abdomen and no signs of peritonitis. A digital rectal examination by palpation located the end of the foreign body in the deep rectum. An attempt to manually remove it in a transanal manner failed due to its shape, large size, and deep position. Laboratory data were essentially normal, with the exception of slightly elevated C-reactive protein (1.76 mg/dL). Plain abdominal X-ray imaging showed a foreign body in the pelvic area and absence of free air (Fig ), while computed tomography (CT) revealed an 18 × 4 cm foreign body with a cylindrical shape in the rectum (Fig ). No severe complications, such as perforation or obstruction, were seen. We decided to attempt removal in a transanal manner under endoscopic and X-ray fluoroscopic observation.\nFollowing intravenous administration of 15 mg of pentazocine, a scope (PCF-Q260AZI; Olympus, Japan) was inserted transanally with the patient in a left lateral decubitus position to directly visualize the foreign body. The lateral pelvic view obtained by X-ray fluoroscopy showed the foreign body in the rectosigmoid position. We attempted removal with endoscopic instruments, including a snare, biopsy forceps, grasping forceps, and net, though that failed because of the round shape and large diameter. When manually compressed from the abdominal wall under endoscopic and X-ray fluoroscopic observation, we noticed that the axis of the foreign body changed (Fig ). Thus, we were able to guide it using manual abdominal compression with endoscopic and X-ray fluoroscopic assistance. Once the object moved to the lower rectum,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old female with one-sided nasal obstruction and rhinorrhea in her nose for more than five months referred to our center in the ENT department of Khalili Hospital (Shiraz, Iran) in 2014. She was a known case of papillary thyroid carcinoma with metastases to the pelvic and lung. She had a history of severe bone pain and haemoptysis (more than a year) and was a candidate for total laryngectomy and thyroidectomy due to her advanced thyroid cancer. However, due to the dissatisfaction of her visitors, she only underwent total thyroidectomy. Examination of the patient revealed an ulcer mass covered with crust in the anterior and inferior part of the right-sided nasal cavity.\nPatient’s PNS CT with contrast revealed an irregular border mild enhancing tumoral solid mass measuring 30×30 mm at the anteroinferior of the right nasal cavity without calcification or lytic osseous lesion at adjacent bone and PNS were clear (). Based on the roll out of vascular lesion, a biopsy was done. The biopsy result indicated high suspicious to carcinoma. Thus, the patient was scheduled for mass excision with functional endoscopic sinus surgery (FESS). After a general and local anesthesia, bilateral endoscopic sinus was done. The left nasal cavity was normal for mucosal lesion, but a mass measuring approximately 3×3 cm was seen in the anteroinferior part of the right nasal cavity that involved uncinate posteriorly and inferior turbinate inferiorly. The mass was removed with inferior turbinate. Right uncinectomy, right antrostomy and right anterior ethmoidectomy were done. Right maxillary sinus was viewed with endoscope and showed no mass involvement. Septum showed neither mass nor involvement. The mass was sent for pathology and the report revealed metastatic papillary cell carcinoma (figures -). The patient was symptoms free at 6-month and 1-year follow-up after the surgery.\nWritten informed consent was obtained from the patient for the publication of this case report and any"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old female patient presented with progressive exertional dyspnea and irregular palpitations for 3 months. She had past surgical history significant for excision of a cutaneous myxoma in her left arm. Physical examination revealed a high jugular venous pressure and a diastolic murmur. An electrocardiogram showed atrial fibrillation. Laboratory investigations were within normal limits except for a low TSH and elevated free T3 and T4. Transthoracic echocardiography (TTE) showed a large echogenic mobile mass with central constriction attached to the interventricular septum (IVS), occupying the entire right atrium and right ventricle (RV) and obstructing the flow of the tricuspid valve. There were two other masses of the same echogenicity: one was occupying the left ventricle (LV) and the other was in the left atrium attached to the interatrial septum at the site of fossa ovalis (, Videos ). The left ventricular dimensions and function were normal. Cardiac magnetic resonance showed similar findings with no septal invasion and tissue characterization suggestive of multiple myxomas (). Computed tomography of the chest, abdomen, and pelvis revealed the same findings () in addition to an enlarged thyroid nodule and a left adrenal cyst that measures 65 × 57 mm (). Ultrasonography of the thyroid gland revealed a markedly enlarged right lobe of the thyroid with normal vascularity. Serum aldosterone, dexamethasone suppression test, dehydroepiandrosterone sulfate, and 24-hour urine metanephrines were within normal limits.\nThe patient underwent surgery where all three masses were excised. However, the tricuspid valve was inseparable from the RV mass; hence, it was replaced with a tissue prosthesis. The masses were grossly reddish grey in color, fleshy, and gelatinous in consistency (). The histopathological examination of the excised masses revealed myxomatous cellular proliferations with sparse collagen fibers consistent with multiple myxomas (Figures and ). The patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male patient presented with the chief complaint of pain and swelling in the upper right anterior region for the past 8 months. The patient gave a history of trauma in the same region, after which the swelling had developed and gradually increased in size. The patient was prescribed with analgesic and antibiotic by a local physician, but there was no relief in the symptoms, and hence referred to the institute. Extraoral examination revealed a diffuse swelling of size 4.5 cm × 3.5 cm present on the right side of the face (maxilla), anteroposteriorly 1 cm behind the ala of the nose to the lobe of the ear and superoposteriorly occupying themed region of the face. The swelling had evolved over a period of 8 months. The swelling was firm in consistency and painful, and no local rise of temperature was found [].\nOn intraoral examination, erythematous growth was seen on the right side of the maxilla extending from 14 to 17 [].\nRadiographic examination revealed ill-defined radiolucency and significant bone loss on the right side of the maxilla. Destruction of the lower orbital margin can also be seen. Root resorption of 16 was seen [].\nBased on the clinical examination and radiographic finding, a provisional diagnosis of ameloblastoma was considered. Differential diagnoses of odontogenic keratocyst, primary intraosseous carcinoma and metastatic neoplasm were considered.\nAfter obtaining an informed consent, an incisional biopsy was performed to arrive at a definitive diagnosis.\nMicroscopic examination of hematoxylin and eosin stained histopathological revealed the presence of odontogenic epithelium in various patterns, predominantly in follicular pattern. Sheets like arrangement of the odontogenic epithelial cells were also seen with hyperchromatic nuclei and scanty cytoplasm. Few of the follicles showed stellate reticulum-like cells. There was evidence of increase in cellular atypia and mitotic activity. Connective tissue stroma was fibrocellular [].\nBased on h"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old Caucasian female patient presented to our eye casualty with a sudden onset of painless loss of vision in the left eye. She had no past history of ocular problems or trauma. Because of metastatic adenocarcinoma lung with the tumour demonstrating a mutation in exon 19 of the EGFR gene, she was considered suitable for primary palliative treatment with gefitinib and has been started on this medication three months earlier. Medical history also included palliative radiotherapy on her spine and right shoulder and treatment with morphine sulphate, diclofenac, and gabapentin.\nOn examination, her left eye had very poor vision of perception to light only. Slit-lamp examination revealed a shallow anterior chamber and a perforated corneal ulcer that measured 4.7 × 5 mm, which was plugged by the iris (). The eye was white with no conjunctival injection or anterior chamber cells. There was no evidence of meibomianitis or trichomegaly. It was difficult to visualise the fundus due to the corneal pathology but ultrasound examination demonstrated choroidal detachment with no evidence of intraocular metastasis. The right eye showed no abnormality with good vision.\nAs it was suspected that gefitinib could be the cause of her corneal ulcer, her oncologist decided to stop the medication due to the potential ocular toxicity, although gefitinib treatment had reduced her lung tumour size. Initial ophthalmic management included a bandage contact lens to reform the anterior chamber and topical antibiotics. A subsequent tectonic 6.25 mm corneal graft was performed without complication ().\nPost-operatively, her eye remained quiet, however, because of the development of a dense cataract, her vision only improved to hand movement. Two months after stopping the gefitinib treatment and while awaiting cataract surgery, she developed severe left retroorbital pain. On examination, she had iris prolapse through a melting corneal graft, and the crystalline lens was extruded (). This was ma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old woman with a known history of giant cell tumor of the left first metatarsal was evaluated for worsening left medial midfoot pain. She had previously undergone curettage and polymethylmethacrylate (PMMA) cementation of a biopsy-proven giant cell tumor of the first metatarsal two and a half years prior at a different institution. Six months following the index surgery, she had a recurrence treated with repeat curettage, liquid nitrogen local adjuvant, and placement of bone substitute graft. After the second procedure, she was ambulatory, but occasionally used a boot for comfort and avoided high-impact activities. Physical examination demonstrated a prominent first metatarsal base and a well-healed dorsal incision. She exhibited tenderness to palpation throughout the area of the scar.\nRadiographs of the left foot showed an expansile, radiolucent lesion of the first metatarsal base surrounding the known cement implantation of the first metatarsal (). Magnetic resonance imaging showed a large soft-tissue mass surrounding the first metatarsal circumferentially and abutting the second metatarsal (). There was high T2 signal with no T1 signal changes at the base of the second metatarsal. Computed tomography (CT) scan demonstrated an expansile lucency at the proximal aspect of the first metatarsal base toward the dorsal lateral side (). There were some areas of cortical breach, and the bone was expanded and abutting the base of the second metatarsal. There was no evidence of direct extension into the second metatarsal or areas of osteolysis within the second metatarsal base. She was diagnosed with a second recurrence of giant cell tumor of bone of the first metatarsal base. As the tumor was recurrent, with destruction of the articular surface and little residual bone of the first metatarsal base, a wide resection of the tumor was recommended.\nThe procedure began by harvesting iliac crest bone graft (5 cm in length, 2 cm in depth). The prior dorsal incision was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old woman was admitted to the Pulmonary Outpatient Clinic complaining of fluctuating cough and dyspnea. She had been under immunotherapy for 2 years due to allergic asthma, and, spontaneously, she complained of sore throat and mild haemoptysis. Clinical examination revealed scattered wheezes from the lungs without any abnormal findings from the pharynx. Spirometry showed a typical obstructive pattern, attributed to asthma. Her medical history was remarkable of subclinical hypothyroidism, adequately treated with levothyroxine.\nThe patient was lost to follow-up and returned 3 years later with increased dyspnea, neck discomfort, deepening voice, and wheezing. On examination, she had prolonged expiration with wheezing and worsening in the spirometric parameters. Despite oral corticosteroid administration, the symptoms gradually deteriorated and she developed inspiratory stridor and severe dyspnea with spirometric evidence of severe upper airway obstruction. She was admitted to the Intensive Care Unit for further investigation and management.\nComputed tomography (CT) scan of the neck and mediastinum revealed an abnormal lesion (3.5 × 2.8 × 3.7 cm), originating from the right lobe of the thyroid gland, invading and severely obstructing the lumen of the trachea (). No lymph nodes or other abnormalities were observed. In view of severe dyspnea, a low tracheostomy was performed. An open biopsy from an unstable mass penetrating the anterolateral wall of the trachea and from the endotracheal mass by endoscopy was obtained. The biopsies were compatible of highly differentiated PTC with additional extensive inflammatory lesions and necrotic hemorrhagic material. Eventually, the patient underwent a total thyroidectomy and resection of the endotracheal part of the mass along with the corresponding anterior portions of 3 tracheal rings (). To maintain the patency of the airway, a Montgomery T-tube was placed. The patient was easily extubated, and breathing and speech were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old woman had previously undergone posterior fixation surgery (T12, L1, and L3) for an L2 compression fracture when she was 63 years old and had no other specific medical history. She had no symptoms after the surgery until the age of 67 years but developed numbness and muscle weakness of both her lower limbs 4 months ago and visited another doctor before visiting us.\nHer previous doctor suspected metastatic spinal tumor based on the initial radiography and magnetic resonance imaging (MRI). She was diagnosed with metastases of thyroid follicular carcinoma by a subsequent bone biopsy and was referred to our hospital after total thyroidectomy 2 months before she visited us for the treatment of the spinal lesion.\nThe patient's main complaints were numbness and muscle weakness of both lower limbs. We confirmed deformation of the L2 vertebral body by the initial radiography and MRI from the previous facility revealed hyperintensity/hypointensity of the L1, L2, and L3 vertebral bodies and compression of the spinal canal by the tumor at the same level (Figures and ). After posterior fixation surgery, the vertebral arch (T12–L3) in a CT scan indicated a complete bone union and bridge formation (). PET/CT revealed no uptake in the posterior element, thus demonstrating no residual metastasis (). Assessment of bone density by dual energy X-ray absorptiometry (DXA) indicated osteopenia in the femoral neck (t score: −1.7). Since the primary disorder was thyroid cancer without metastases in other viscera and bones except spinal vertebral bodies and the general condition of the patient was favorable (Performance Status grade 1), we decided to perform radical surgery according to the spinal metastatic tumor scoring system (Tokuhashi score 12 points/Tomita score 3 points) [, ]. We performed radical surgery by posterior fixation and excision of the anterior segment of the vertebral body and reconstructed the anterior segment via the posterior-anterior approach. Successful s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old Turkish man who had fallen on his flexed right knee while walking on ice was referred to our hospital. He suffered from pain and inability to move his right knee. Physical examination revealed prominent swelling and tenderness over the right patella. Plain radiographs showed comminuted displaced inferior pole fracture of the patella (Figure ). His extremity was immobilized initially through a cast brace, and he was then operated under general anesthesia on the following day. During the operation, it was found out that the patellar fracture could not be reduced and repaired. Because of this, a partial patellectomy was performed and his patellar tendon was sutured to the patella with No. 2 polydioxanone (PDS) sutures and augmented with a cerclage wire (Figure ). A long leg cast was then applied and we advised our patient to move using two crutches and bear no weight for three weeks. At the end of the third week, he was started on active and passive ranges of motion exercises of the knee.\nOn his follow-up visit after six weeks, he was already able to flex his right knee by about 100°. After that period, however, he started to experience a gradual decrease in knee movement. Two months after the operation, the active flexion of his knee was only 60°. A lateral radiograph of his right knee showed extensive ossifications at the resected part of the patella and calcifications in the patellar tendon (Figure ). Excision of the ossifications and implant removal were thus planned. During that period, he felt a sudden pain over the tibial tubercle of his right leg while he was descending the stairs. He was unable to extend his right knee.\nPlain radiographs revealed the presence of patella alta. As a result, another operation was performed. It was then discovered that the patellar tendon with ossification throughout its length was avulsed from the tibial tubercle. The cerclage wire from the previous surgery"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe current disease story of our 68-year-old Caucasian male started two years ago, when this patient observed a hard lesion in the anal canal, which, in the first months since he observed it, was neither officially diagnosed nor treated. Ten months after that, he underwent cholecystectomy due to cholelithiasis, and the perioperative diagnostic examination revealed some suspicious lesions in the anal canal and some enlarged pelvic lymph nodes. His comorbidities included only gout, and his Karnofsky performance status was 90. He has never been treated with radiotherapy, and he had a second-degree family history for malignancies. At that time, a digital rectal examination identified mild prostatomegaly, with a palpable suspicious nodule in the left prostate lobe, without any signs of the extracapsular extension. Also, a large ulcerated mass was palpable at the dorsal anal canal wall, without lymphadenopathies in the inguinal region. Subsequent colonoscopy confirmed the presence of a suspicious lesion on the posterior anal canal, extending above up to the anorectic junction. A magnetic resonance imaging (MRI) for the regional staging confirmed an infiltrative lesion of the anal canal with a maximum diameter of 3.2 cm, with a high-grade suspicion of sphincter infiltration, and two enlarged lymphadenopathies in the mesorectum and in the right internal iliac region, respectively, both with a maximal diameter of 2 cm, which is suspicious of tumour metastases. Further, an area with a maximal diameter of 2 cm within the left prostate basis having a restricted diffusion with a lower apparent diffusion coefficient (ADC) than that in the surrounding healthy prostate tissue, which appeared hypointense on ADC maps but hyperintense on the diffusion-weighted maps, was also described. Afterwards, biopsies confirmed a poorly differentiated squamous cell carcinoma of the anal canal, as well as a moderately differentiated prostate adenocarcinoma, with a Gleason score of 7 (3 + 4) in bot"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old primigravida with 6-week pregnancy was brought into emergency department with severe abdominal pain which started two days earlier and had worsened suddenly in the morning she was admitted. She was referred with a suspected diagnosis of ruptured ectopic pregnancy. Initial examination showed tachycardia of 124 beats per minute, marked pallor, and generalised tenderness in abdomen. The rest of her physical examination was normal. There was no history of vaginal bleeding. Her initial blood counts showed haemoglobin of 4.5 g/L. A FAST (Focused Assessment with Sonography in Trauma) scan appeared to suggest intraperitoneal bleed. Abdominal pain with pallor, low haemoglobin, and positive FAST scan was very suggestive of ectopic pregnancy. Therefore, a CT scan of abdomen was arranged. The scan showed large left retroperitoneal hypodense mass with hyperdense strikes. There was evidence of compression on the left kidney, pancreas, and bowel loops with associated moderate amount of ascites. Findings were consistent with massive retroperitoneal haematoma extending from diaphragm (Figures and ) displacing left kidney (Figures and ) and extending into pelvic cavity. The pregnancy was however found intact within uterus (Figures and ).\nThe haematoma was causing marked displacement of the left kidney and was showing varying shades of hyper- and hypodensities. Varying shades of hyper- and hypodensities were suggestive of haemorrhages of different ages which were periodic and of slow episodes (Figures and ). The main source of bleeding was found to be the apical portion of left kidney which appeared as a cystic lesion in continuity with the haemorrhage ().\nPatient was kept in intensive care unit under observation and blood was transfused to her to support haemodynamics and achieve a target of Hb% of 10 G/L. Unfortunately, the lesion could not be evaluated with MRI due to technical problem with the MRI scanner.\nInitial attempt of embolisation of the lesion failed and next"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male patient who underwent radical cystectomy with an ileal conduit for muscle-invasive urothelial carcinoma of the bladder 4 years ago presented with the complaint of progressive swelling in the root of the penis. A large, painless, and penoscrotal mass was detected on physical examination. On pelvic magnetic resonance imaging (MRI), it was a 95 × 65 × 65 mm (AP × T × CC) cyst extending along the proximal half of the penile shaft. Solidified material and septa, probably belonging to an organized hematoma, were noted within the cyst []. The cyst wall, as well as the penile crura and residual urethra, showed enhancement following gadolinium administration []. The cyst was then aspirated, and the material was a dark brown viscous liquid containing clot and purulent material. Cytology revealed invasive urothelial carcinoma, and cyst excision with partial urethrectomy was performed. No connection was detected between the cyst cavity and the urethral lumen during surgery. Comprehensive imaging studies showed no other signs of local recurrence or distant metastasis, and the patient’s routine clinical and radiological follow-up continued.\nTwo years after the cyst excision, the patient presented with a painless hard penile mass. Pelvic MRI revealed a lobulated lesion measuring 52 × 32 × 27 mm (CC × AP × T) in the penile root. The penile mass extended from the cystectomy stump posteriorly into the penile shaft, invading the penile crura, and urethra []. The mass showed heterogeneous high signal in T1-, T2-, and fat-suppressed T2-weighted sequences, consistent with a complex hemorrhagic cystic lesion. There was no anal canal or puborectal muscle invasion, but both corpora cavernosa were invaded. The mass exhibited intense heterogeneous enhancement following gadolinium administration []. A total penectomy was planned. However, the patient did not consent to the operation due to his body image concerns. Therefore, cisplatin-containing combination chemotherapy was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male patient presented with a firm, subcutaneous nodule in the right upper eyelid []. The lesion was present for 10 years, slowly growing and painless. The mass was round, relatively hard and moved freely under the skin, without pain on palpation or mobilization. The overlying skin showed no inflammatory signs or abnormal pigmentation. There was no restriction in ocular movements, and the remaining ophthalmological examinations were unremarkable.\nThe patient underwent an orbital CT scan that revealed an extra-conical mass, adjacent to the lateral rectus insertion, with no distortion of the globe or invasion of the bone or muscular structures. The mass had a heterogeneous density, and two cysts were present in its superoanterior portion [].\nAn excisional biopsy was performed over the upper eyelid dermis, through a 15 mm horizontal incision in the lateral third of the eyelid crease. The tumor was well circumscribed with no adhesions and was easily dissected and removed in its entirety []. The lacrimal gland was found to be independent of the mass, with a normal appearance. The incision was closed with a 6.0 polypropylene suture. The postoperative appearance can be observed in [].\nOn gross pathologic examination, the nodule was well-defined with dimensions 20 mm × 15 mm × 12 mm. A smooth and tan cutting surface was found, with tiny cavitated areas containing a pasty whitish material. The entire specimen was submitted to histologic examination. The tumor was totally encapsulated and presented a biphasic pattern, consisting of a chondromyxoid stroma and an epithelial component []. The epithelium was arranged in nests, cords, and tubes, or glandular branching structures layered by a double epithelium in which the inner epithelial layer exhibited apocrine features, such as decapitation [Figure and ]. There was no significant atypia. Numerous cysts were present in the tumor, lined by metaplastic stratified squamous epithelium and containing keratinized epithel"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old male patient presented to the surgical consultation with recurrent attacks of epigastric pain, melena, and epigastric fullness.\nUpper and lower GIT endoscopies were performed during the first admission which showed no abnormal findings.\nDuring the last presentation, the patient was admitted to the surgical unit.\nThe patients had negative drug history. The family history was negative for any genetic diseases, and the psychosocial history was negative.\nThe general examination revealed pale conjunctivae, palms and oral mucosa. There were no cyanosis or jaundice.\nThe blood pressure was 100/60 mmHg on admission, the pulse rate was 95 beats/minute, the temperature was normal and the body mass index was 38.\nThe abdomen was soft with no areas of tenderness. There were no dilated veins over the abdomen with no stigmata of chronic liver diseases.\nInvestigations were performed for the patient. The hemoglobin level was 8 gm/dl with normal serum electrolytes, normal liver and renal function tests. The patients received 2 units of compatible blood and arrangement was done to perform another endoscopy.\nThe endoscopy this time revealed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. .\nCT-scan of the abdomen was normal with no abnormal findings.\nArrangement was done to perform surgical intervention, during surgery we adopt an upper midline incision, exploration of the abdominal cavity showed normal liver, spleen, and omentum, with no ascites and no dilated veins.\nMobilization (kocherization) of the duodenum was performed, the anterior wall of duodenum was opened, and a pedunculated polyp (about 4 cm in size) was found which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. , .\nExcision of the polyp with its base was performed and was sent for frozen section examination during surgery which revealed a benign lesion with no signs"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old female patient in Medan, Indonesia, came to a dental clinic with a primary complaint of a lesion on the left dorsal surface of the tongue, which caused the difficulty in chewing and speaking. The lesion was of the size of a pea when the patient first noticed it but had grown to attain the size of 8 × 7 × 3 mm over a period of 2 weeks. The lesion had started to bleed when she was presented to the clinic. The patient's medical history was unremarkable. She mentioned that she previously went to a general practitioner and was prescribed amoxicillin, dexamethasone, and mefenamic acid. She consumed the medications for 5 days and reported no improvement. Intraoral examination revealed a single, spherical-shaped, and reddish pink lesion. The lesion had a distinct border and irregular surface (Figure ). The surrounding tongue mucosa appeared to be normal, and the growth was located on the left dorsal surface of the tongue. The lesion had a soft-to-firm consistency and blanched upon pressure.\nThe management of the lesion was a surgical excision, which was carried out under local anesthesia. A thread was tied around the base of the lesion. The lesion was then stretched upward to facilitate accessibility. It was subsequently excised out, and interrupted sutures were placed (Figure ). During the surgical procedure, minimal amount of bleeding from the site was observed. The specimen was then sent for a histopathological examination. After the surgery, the patient was instructed to keep the oral cavity clean by teeth and tongue brushing three times a day followed by chlorhexidine mouthwash. The patient was then asked about whether she had prior history of allergic reactions in relation to the use or consumption of beehive products such as honey, bee pollen, or propolis. She confirmed that she never had any allergic reaction to any beehive product. The patient was then instructed to also apply the commercially available hydroglyceric propolis extract to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 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.\nPhysical 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.\nMagnetic 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.\nHaving 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 ( ).\nThe patient was followed up for 10 years after treatment and during"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old woman presented with dysphagia of solid food for 1 month, which was associated with occasional nausea and vomiting. The patient denied noticeable weight loss, hoarseness, caustic ingestion, and a history of tuberculosis and tumors, among other conditions. After admission, gastroscopy was performed, which demonstrated concentric narrowing of the esophageal lumen at 30 cm from the central incisor; the lumen was approximately 4 mm in size, and the gastroscope could not reach beyond this point. The mucosa overlying the stricture was smooth, and biopsy was performed at this site (Fig. A). Subsequently, the patient underwent barium esophagography and contrast-enhanced thoracic computed tomography (CT). Barium esophagography showed a narrowing of approximately 1.5 cm in length in the middle and lower esophagus without visible disruption of the mucosa; lumen expansion was limited, but the barium was still able to pass through the area (Fig. B). Contrast-enhanced thoracic CT revealed that the wall of the middle and lower oesophagus was obviously thickened, which indicated possible malignancy (Fig. C). However, the biopsy results suggested squamous epithelial hyperplasia (Fig. D).\nFor this patient, gastroscopy indicated only luminal stenosis without the presence of ulcers or masses in the mucosa, and the biopsy was negative for malignancy. However, CT examination revealed a significant thickening of the esophageal wall. It was necessary to determine a better method by which the esophageal lesions could be diagnosed in this patient. EUS revealed that the mucosa overlying the esophageal lesion was significantly thickened and was approximately 8.7 mm thick in the thicker region, with a low echo; the layers of the esophageal wall could not be clearly recognized (Fig. A). Then, in Doppler mode, we performed EUS-FNA 3 times at the thickened esophageal wall (Fig. B). The aspiration smear was sent for aspiration cytology, and the tissue strip was sent for pathological e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male with neurofibromatosis type 1 was referred to our hospital for management of left superior mediastinal tumor. The surgery in this case reports is for the patient at the time of the fourth surgery for malignant peripheral nerve sheath tumor (MPNST). For the first surgery, owing to the rapid growth of the tumor and presence of dyspnea, he underwent an emergent operation through trap door thoracotomy (Figures and ). The tumor was 123 × 120 × 88 mm in size and was originated from the left thoracic vagal nerve distal to the bifurcation of the recurrent laryngeal nerve. We could barely exfoliate the tumor from the LCCA and LSA, and it was diagnosed as MPNST with 56 mitosis cells per 20 high-power fields. Radiotherapy of total dose 60 Gy was administered to the mediastinum owing to pathologically positive margins. In the second operation, a hook approach was used to perform combined resection of the left chest wall including the 2nd-4th ribs for locally recurrent tumor. In the third operation, a distal pancreatectomy was performed for metastasis to the pancreas. Ten months after the first operation, we observed rapid growing local recurrence in the left superior mediastinum. The recurrent tumor was not found on examination a month ago. Chest computed tomography (CT) showed that the recurrent tumor attached the left clavicular head, the first rib, upper sternal bone, the LCCA, and LSA (Figures and ). Preoperative cranial magnetic resonance angiography showed a normal vertebral-basilar system, and a tumor measured 35 mm in size in the occipital lobe. We prioritized the operation of the thoracic tumor due to its rapid growth, and we planned an endovascular technique to avoid intraoperative fatal bleeding. We obtained written informed consent from his parents for the off-label use. An 8 mm in diameter and 60 mm in length polytetrafluoroethylene-covered stent (PTFE-CS) for biliary tract (Fluency®; Bard, Karlsruhe, Germany"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18 year old male presented with pain in his right upper arm after trying to put out a fire in his hand in June 2005. On physical examination, tenderness, swelling, angulation, and crepitus on right upper arm were noticed. Radiographs of the arm revealed a humeral shaft fracture with intramedullary patchy signs of osteoporosis []. After correlating with history, physical examination and radiographs, a diagnosis of pathologic fracture shaft humerus was made. Bone scan and magnetic resonance imaging (MRI) of the right arm were then performed. Bone scan revealed mild nonspecific uptake intensity on shaft of humerus []. No other skeletal abnormalities were noticed on the scan. On MRI, T1-weighted image showed medium intensity at the bone marrow, and high signal intensity at the same area was shown on T2-weighted image. Findings also revealed cortical bone erosion and heterogeneity around fracture lesion with multiple bone absorption []. MRI findings suggested avascular tumor such as hemangioendothelioma or hemangioma. Blood parameters such as calcium, phosphate, alkaline phosphatase, osteocalcine, and calcitonin were all within normal range. Rheumatoid factor was negative. Patient then underwent the curettage with biopsy with open reduction and internal fixation using Limited Contact Dynamic Compression Plate (LC-DCP, Synthes©, Paoli, [PA], USA) on June 2005. Intra operative findings revealed a fibrotic mass located in the medullary cavity and signs of cortical thinning. Histopathological result was chronic inflammation with vascular proliferation. Therefore, he wasn’t diagnosed as Gorham's disease. 7 months postsurgery, the patient consulted the emergency room complaining of right upper arm pain that occurred while trying to stand up after leaning on his right side. Radiographs showed enlarged and new developed radiolucent areas suggesting a nonunion fracture of the humerus. A periprosthetic fracture on the distal plate was also noted []. On January 2006, the patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male patient, a tailor by profession, attended to the department of oral medicine and radiology, with a chief complaint of a swelling in the lower-right facial area for the past 1 month []. At first, it began as a small swelling and gradually increased to the present size.\nMedical history was positive for persistent weight reduction from 6 months and he also had occasional fever and cough. Family history was noncontributory. Social history was positive for tobacco smoking. A general physical examination demonstrated that the patient was conscious, cooperative, well oriented, and moderately nourished with signs of anemia. The weight was 52 kg and temperature was 99°F. The extraoral examination revealed mild facial asymmetry with conspicuous bilateral submandibular lymph nodes in which a single, firm, and nontender node on the right side >1 cm fixed to the underlying structures was evident. The local examination also demonstrated a solitary swelling of size 4 cm × 5 cm on the right lower 1/3rd of the face with extension of the lesion 2 cm away from corner of the mouth to 2 cm in front of the tragus of the ear anteroposteriorly and ala-tragus line to mandibular angle superoinferiorly. The swelling was asymptomatic.\nIntraoral examination uncovered an exophytic growth of size 5 cm × 6 cm extending out from teeth 44 to 48, which was covered by pseudomembranous slough and erythematous areas over the mucosa with everted margins []. On palpation, it was tender and firm in consistency. Missing teeth in relation to 46 and 47 were also noted. The teeth were self-extracted by the patient. The remaining dental examination was not significant except with the grade 1 mobility in relation to 44 and mandibular anterior teeth. Based on the history and clinical findings, a provisional diagnosis of primary malignant neoplasm of the mandible was arrived. Differential diagnosis like tubercular granuloma, central mucoepidermoid carcinoma of the mandible, NHL, Hodgkin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 69-year-old man with history of carcinoma rectum with abdominoperineal resection done 30 years ago. No adjuvant therapy was given postoperation. He had no follow-up afterwards. He presented to us for metachronous tumor over descending colon complicated with large peristomal abscess (Fig. ). Contrast CT found mural thickening ~7 cm in span just proximal to stoma exit with adjacent 3.7-cm thick-walled rim-enhancing lesions around the stoma site. Another 3-cm thin wall fluid collection was noted at the anterior abdominal wall just inferior to the stoma site. Features were suggestive of inflammatory collection. There was an 1-cm left groin lymph node as well. There was no liver or peritoneal metastasis.\nColonoscopy was done via the colostomy showing circumferential stenotic ulcerative growth 3 cm proximal to stoma end and scope failed to negotiate through. Biopsy confirmed to be adenocarcinoma. Incision and drainage of abscess were performed. Intra-operation found 5-cm abscess cavity at 6 o’clock of colostomy extending close to stoma with surrounding cellulitis. There was a circumferential tumor mass 3 cm proximal to stoma end. Tissue for histology confirmed adenocarcinoma. Excisional biopsy of the 1-cm left groin lymph node confirmed no malignancy. The wound was clean with granulation tissue after daily dressing for 2 weeks. The patient underwent wide resection, resiting of stoma and reconstruction of abdominal wall defect with a pedicled ALT flap in a joint-team approach.\nProcedure: The initial stage was preparation of the flap. ALT flap was designed along a line drawn between the anterior superior iliac spine and the superior lateral border of the patella, with the line midpoint located at the proximal portion of the flap to obtain more pedicle length. The surgeon localized the large caliber perforating vessels of the LCFA with Doppler ultrasound, and then mapped out the proposed flap on the skin of the ALT based on the anticipated size of the defect"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 22-year-old nulliparous Japanese woman. Her medical and family histories were noncontributory. She had no previous history of smoking, habitual alcohol drinking, or drug abuse. She was referred to our hospital for fetal anatomical evaluation because of severe oligohydramnios at 13 weeks and 6 days of gestation. The gestational age was calculated from the first day of her last menstrual period. At her 10 weeks and 6 days' visit to the previous clinic, the crown-rump length of the fetus was 34.7 mm and no remarkable abnormalities of amniotic fluid volume were recorded. However, at 13 weeks and 4 days of gestation, a remarkable decrease in the amniotic fluid volume was found. At the first visit to our hospital, we carried out an antenatal ultrasonographic scan and a single live fetus was noted. The crown-rump length, biparietal diameter, and nuchal translucency of the fetus were 66.1 mm, 23.6 mm, and 2.1 mm, respectively. Because of severe oligohydramnios (), ultrasonographic images were not very clear, and no clear 3D images were obtained. As far as we could check, no structural abnormalities were found in the fetal cranium, brain, upper extremities, thorax, and heart. However, the lower extremities remained in the fixed extension, but all long bones were visible (). The lower extremities stayed in the same position, and no individual movements of the two legs were seen, which suggested the fusion of the two lower extremities. Color Doppler ultrasound revealed a single umbilical artery (). Neither kidneys nor the urinary bladder was visualized. Therefore, the diagnosis of type I sirenomelia was made prenatally.\nThe couple was informed about the findings and the suspected poor prognosis of the fetus. They then opted to have a termination of pregnancy, which was performed at 15 weeks and 1 day of gestation. On the postnatal examination, the baby weighed 60 grams and the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old woman in her first pregnancy presents at 20 weeks’ gestational age with shortness of breath, small-volume hemoptysis, sinus tachycardia and left-leg edema. She has no significant past medical history and the pregnancy up until the point has been uncomplicated. Chest X-ray is unremarkable.\nPregnancy increases the risk of VTE, with an overall 1–2 in 1000 rate of venous thrombosis [,,]. Similar to the general population, no specific clinical sign or symptom is sufficiently specific or sensitive for diagnosing VTE. For example, shortness of breath is a common occurrence in pregnancy and can be caused by a broad differential of both physiologic and pathologic processes [].\nThe LeFT score can be used to refine the pretest probability of DVT in pregnancy [,]. The LeFT score includes three clinical criteria: symptoms in the left leg (L); edema with a calf circumference difference ≥ 2 cm (E); and first-trimester presentation (Ft). In the derivation cohort, no DVTs were diagnosed in patients with zero of the above risk factors. Patients with one risk factor had a DVT prevalence of 8.8% and those with two or more risk factors had a DVT prevalence of 58% [].\nIn patients with clinical concern for DVT, ultrasound is the recommended first imaging test, even if there is also concern for PE []. This takes into account the increased risk of lung imaging to both the fetus and mother during pregnancy []. As treatment generally does not differ between patients with DVT and PE and those with only DVT, ultrasound is a safe and accessible mechanism to inform treatment in pregnancy. In patients in whom a DVT is found, imaging for PE is generally not required in pregnancy. However, in patients being evaluated for PE without features of DVT, the diagnostic yield of screening ultrasounds is low and likely of limited utility [].\nBack to the case: The patient has clinical features of both DVT and PE. Applying the LeFT score"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old man with a history of schizophrenia fell and was transferred to our hospital by ambulance. Upon initial physical examination, tenderness and swelling were noted over the right trochanteric region. His right leg was immobile because of severe right hip pain. Moreover, he had no neurovascular deficits or other extremity or systemic injuries. Radiography revealed an AO type 31A2.2 [] and Jensen type 3 [] trochanteric fracture in the right femur (). For treatment, the patient underwent a closed reduction and internal fixation with a gamma 3 long nail (Stryker, Kalamazoo, Michigan, US) according to the manufacturer's instructions. The lag screw was the appropriate length and reached to the subchondral bone of the femoral head. However, the lag screw was inserted anteriorly and a varus malalignment remained (Evans classification was type 1 group 3) in AP view () []. Complications did not occur during the surgery or throughout the 1-month period of hospitalization. The patient was an elderly and had a history of schizophrenia; hence, rehabilitation did not proceed after surgery. Thus, he was unable to walk by himself and was wheelchair-bound when he was discharged. One year after surgery, the patient presented to the clinic for a regular follow-up. Although there were no additional falls or subjective symptoms, radiograph revealed that the intramedullary nail was disassembled with bone fragment displacement. The lag screw penetrated into the pelvis through the femoral head and acetabulum (). No intra-abdominal organ injuries were confirmed on a contrast-enhanced computed tomography scan. The lag screw was located between the internal and external iliac vessels, and tangent to the small intestine; however, no signs of pneumoperitoneum or hematuria were present ().\nTo prevent future concomitant injury of the blood vessels, ureter, and intestine, we decided to remove the implants. If the lag screw had been adhering to the intestine, the threaded part of the scr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old female, who had a history of chronic headaches, previous lumbar decompression and fusion at L3-4 for degenerative lumbar stenosis, presented to the clinic with low back pain. She was found to have an adjacent segment disease at L2-3 with recurrent stenosis at L3-4. The patient failed non-operative management including physical therapy and steroid injections. Consequently, she elected for surgery and underwent a revision lumbar decompression with anterior and posterior instrumentation for spinal fusion, as well as a repair for an incidental durotomy. The patient did well after surgery and was discharged home nine days later.\nApproximately 24 to 36 hours after discharge, the patient fell due to weakness in her legs. She was seen in the emergency department and was found to have progressive weakness, numbness, and areflexia in her bilateral lower extremities. Over the course of the ER visit, she developed ascending paralysis as well. She denied any fever, chills, or symptoms of infection. The initial laboratory workup was negative for infection. At that time, a magnetic resonance imaging (MRI) only showed postsurgical changes. Neurology was consulted and did not recommend a cerebrospinal fluid (CSF) sample due to the recent surgery.\nBecause of a clinical suspicion for GBS, she was admitted to the neurological intensive care unit (ICU) and started on intravenous immunoglobin (IVIG) therapy for six days. The patient’s hospital stay was complicated by the development of respiratory failure, which required intubation. She was eventually converted to a tracheostomy and was finally decannulated. An electromyography (EMG) showed diminished motor and sensory responses in terms of amplitude and conduction velocity in her upper extremities and absent amplitude and conduction velocities in her lower extremities confirming the diagnosis of GBS.\nAfter an approximate four-week hospital admittance, the patient was discharged to a rehabilitation facility and continued ag"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old man presented to the emergency department at our hospital on October 2012 with a 4-month history of worsening lower back pain. There was no history of trauma or falls. He was unemployed and lived with his mother. He took no medications or supplements, did not smoke, consume excessive alcohol, or use illegal drugs, and had never been treated with corticosteroids. He had no history of prior fractures. Family history was negative for gonadal, endocrine, or bone diseases. Review of systems was remarkable for markedly delayed puberty for which he had received testosterone injections starting at 16 years of age. Three years later, testosterone replacement therapy was terminated by the treating physician, after he responded well in terms of growth and development of secondary male sexual characteristics. He remarked decreased libido for several years and absence of morning erections.\nOn examination, he was a well-nourished gentleman in obvious distress due to pain at the level of the lower thoracic/lumbar spine. He had an eunuchoidal body habitus with the arm span (181 cm) exceeding the height (174 cm). The pupils were round, equal, and reactive to light. Visual fields were normal to confrontation. The skin turgor was normal, the mucous membranes were moist and the teeth were in good condition with no decay. Examination of the head and neck was remarkable for hyposmia to a number of odorants. The cardiovascular, respiratory, and abdominal exams were within normal limits. There was no edema in the extremities and neurological assessment was normal. Examination of the integument was remarkable for sparsity of pubic hair. The penile length was normal but testicular volume was decreased (approximately 5 cm3 as determined using the Prader orchidometer).\nOn biochemistry, serum levels for luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, and estradiol were extremely low while baseline values for serum creatinine, electrolytes, thyroid funct"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-month old boy presented with respiratory distress, wheeze and hypoxia. This was preceded by 24 h of coryza, fever and reduced feeding. He was admitted directly to intensive care, where he was diagnosed with pneumonia. Treatment was started with empirical antibiotics. He was intubated and ventilated for 4 days, after which he was extubated and stepped down to high dependency unit (HDU) on continuous positive airways pressure (CPAP) ventilation. He continued to have persistently increased work of breathing, persistent expiratory wheeze and symptoms and signs of air trapping.\nThough he did not progress to respiratory failure, weight gain and oxygenation was achieved only by initiation of Heated Humidified High Flow Nasal cannula therapy (HHHFNC).\nPolymerase chain reaction (PCR) testing of nasopharyngeal aspirates (NPAs) revealed the persistence of rhinovirus and adenovirus for 10 weeks in both NPAs and bronchoalveolar lavages (BALs), with parainfluenza type 3 found in just one NPA sample. Adenovirus was also found in blood by PCR testing. Rhinovirus is not normally tested for in blood samples and there was no validated assay available for this. One BAL and one urine sample were screened for cytomegalovirus (CMV) by PCR also, and found to be negative. One stool sample was tested and found to be negative for rotavirus and adenovirus (despite the persistence of adenovirus in the respiratory samples at this time).\nThere was no significant family history of any genetic diseases and the patient was born at term. Mum is a smoker but states that she did not smoke during her pregnancy. During pregnancy, intrauterine growth restriction was identified. At the time of admission his weight was < 0.4th centile, but this was increasing. His parents report poor feeding since birth and an increased work of breathing from 5 months old. He is known to the allergy services for severe eczema and faltering weight, and has been diagnosed with cow"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn Iranian 24-year-old primigravid woman from Kordistan province presented to our hospital with left flank pain. She had had the pain for a few days and had received adequate prenatal care until her referral to us. She was diagnosed as having had gestational diabetes mellitus since the 12th week of gestation (her fasting blood sugar was between 106 and 116 mg/dL). Insulin therapy was started at a dosage of 4 units of neutral protamine Hagedorn at bedtime. All fasting and postprandial blood sugars had been controlled well.\nShe also complained of having had pulsatile bi-temporal headaches for 2 years prior to her referral to us. Her headaches responded well to common analgesics. She also mentioned that she had hypertension of 140/90 mmHg at one of her prenatal visits during the 32nd week of gestation. However, the physician had not diagnosed hypertension by rechecking her blood pressure at that time. Although her gynecologist had assessed proteinuria via 24-hour urine sample, no proteinuria was detected (119 mg/dL). Her liver enzyme, creatinine, and platelet counts were all in normal range.\nAt the 37th week of gestation she had presented to us with left flank pain and no urinary symptoms. We did not detect costovertebral tenderness, fever, hypertension, or tachycardia at the primary examinations. Urine analysis was completely normal, so we did ultrasound imaging of fetus and kidneys. Ultrasound imaging revealed no problems with her kidneys, but we found a solid mass with fine cystic component of 119 × 87 × 79 mm above her kidney, highly suspicious for an adrenal-originating tumor. The fetus had no abnormality at the ultrasound imaging.\nTo evaluate the mass, we consulted with an endocrinologist to definitely diagnose the incidentaloma. Abdominopelvic magnetic resonance imaging without contrast showed a well-defined 100 × 95 mm heterogeneous mass in her left adrenal region above the kidney which contained some cystic areas and showed some restriction foci on diffusion-w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient in question was a 45-year-old Hispanic female who had lived in Canada for the previous 11 years. She reported a long history of manual labour and subsisted on similar occupations since arriving in Canada. At the time of her presentation, her occupation required prolonged periods of standing. The patient's chief complaint was chronic low back pain. There was no antecedent trauma, bone surgery, or history of cancer. The onset of low back pain was described as insidious, with constant achy pain of at least two years duration which was progressively worsening. The pain remained localised to the central lower back in the area of the lumbosacral junction. The pain was rated at 3/10 (verbal scoring) at its best and 8/10 (verbal scoring) at its worst. An increase in pain was associated with an increased level of physical activity during the day, with the pain typically worse in the evening. During periods of increased pain, there were intermittent incidences of pain radiating to the right-sided posterior thigh and leg with \"pins and needles\" in the lateral toes of the right foot. Treatment to date had consisted of non-steroidal anti-inflammatory medication, which she felt had been of limited benefit. There had been no use of acupuncture, massage therapy, therapeutic exercise, or any manual therapies for this condition. The patient was referred to the department of Medical Imaging for evaluation of chronic lower back pain.\nThe patient reported that no spinal imaging had been performed in investigation of these complaints. This was confirmed by a review of the patient's records.\nImaging specialists typically do not examine patients who are referred into an imaging department for investigation. As such, no physical examination was performed in this case. Permission was granted after the images were interpreted only to interview the patient for this case report.\nA three-phase bone scan was performed with 99 mTc(Technetium)-MDP (methylene diphosphonate) including blo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second patient is a 72-year-old woman with a past medical history including hypertension, type II diabetes, and obesity, who presented with weight loss and steatorrhea. As her symptoms were suggestive of pancreatic exocrine insufficiency, and with the associated weight loss, she underwent a CT scan for additional evaluation. This demonstrated a suspicious 2.5-cm complex cystic pancreatic head mass with associated pancreatic gland atrophy and a dilated pancreatic duct. She was also noted to have fatty infiltration of the liver (although not overt cirrhosis) and ascites.\nShe was then referred for further evaluation. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography demonstrated diffuse dilation of the pancreatic duct up to 7.5 mm with an associated cystic mass in the head of the pancreas, suggestive of main duct IPMN (). EUS was attempted, but was unable to be completed due to severe tortuosity of her esophagus. Positron emission tomography (PET) demonstrated heterogeneous metabolic activity within the pancreatic uncinate process and to a lesser degree within the body and tail. Additional workup included a paracentesis to evaluate the ascites, which was unremarkable and ultimately deemed secondary to poor nutritional status from her exocrine insufficiency. Laboratory results were within normal limits with the exception of tumor markers and a mildly low albumin (3.4 gm/dL). Carcinoembryonic antigen was elevated at 6.0 ng/mL, and CA 19-9 was elevated at 46.7 U/mL. She was placed on pancrelipase, which resolved her symptoms of exocrine insufficiency and helped improve her nutrition.\nDue to the concern for main duct IPMN, she was referred for surgical resection. Again, it was unclear if the diffuse dilation of the pancreatic duct was secondary to involvement by main duct IPMN or due to proximal pancreatic duct obstruction. The patient was planned for a Whipple procedure with possible total pancreatectomy if high-grade dysplasia was noted"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 2: A 20 year-old male was admitted to our hospital on 15th February 2005 with a history of intravenous injection of mercury taken by him and his friend as an aphrodisiac. The patient presented with fever, tachycardia, and swelling of the right hand (which was the primary site of injection) extending up to the forearm [Figures –]. The patient was haemodynamically stable. An attempt had been made for incision and drainage in the emergency room because it was diagnosed as a injection abscess. An X-ray of the hand revealed a radio-opaque shadow overlying the fourth metacarpal, third and fourth intermetacarpal space extending over the carpus, and the wrist joint up to about 1 cm over the distal end of the radius and ulna dorsal to the skeleton. A diagnosis of extravasation of injected mercury was made. After basic investigations, the patient was shifted to the operation theatre where a thorough debridement was performed under general anaesthesia and a large amount of mercury was removed physically from the dorsum of the hand. Some of the mercury could only be removed along with excision of the surrounding soft tissue; the removal of mercury was confirmed by radiography. The wound was left open so that any mercury left behind could find a passage to come out. On the following day, the patient went home against medical advice but came back on the 7th of March with a history of another subcutaneous injection of elemental mercury over the precordium. Once again, an attempt had been made to drain an abscess in another hospital. The patient refused any further surgical procedures although the radiograph showed the deposition of mercury in the subcutaneous plane in the chest wall. The patient turned up in October 2005, with a swelling over the precordium with surrounding inflammation []. This time, he was willing for surgery and the mercury was removed along with surrounding tissue en masse and the wound healed uneventfully.\nOn both occasions, the patient was not willing t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old man presented with dyspnea on exertion and leg swelling for four months. He had undergone surgical repair of ruptured right SVA by direct closure at age of 19, and remained asymptomatic after the operation. On physical examination, a grade 3/6 continuous murmur was heard at his right lower sternal border, with increasing intensity while he was leaning forward. Electrocardiogram (ECG) showed atrial flutter with 2:1 atrioventricular conduction (ventricular rate around 100 beats per minute) and complete right bundle branch block. Chest X ray revealed enlargement of right atrium and ventricle, but no pulmonary congestion. Transthoracic echocardiography revealed bicuspid aortic valve and a large cystic structure protruding from right sinus of Valsalva to the right atrium. The wall of the cystic structure was relatively thick and hyperechoic, which was distinct from the congenital form of SVA (Figure a, b). Color duplex showed a continuous shunt from the aorta to the right atrium through a small defect at the posterior aspect of the aneurysm (Figure c, d, e and Additional file : Movie 1). Gradual bulging of the previous patch sutured at the SVA 38 years ago with recurrent rupture was impressed. Multidetector computed tomography also demonstrated a large SVA with a defect connecting to a dilated right atrium (Figure ).Surgical exploration from both right atrial side and aortic side confirmed the communication between SVA and the right atrium (Figures and ). The defect was located at a weak point of suture between the previous patch and the sinus of Valsalva. Double patch method was performed with bovine pericardium patches. From the aortic side a patch was sutured from the aortic annulus to the inferior rim of the right coronary artery; and from the right atrial side the redundant sac of the SVA was resected and the defect was repaired with another patch. The patient was discharged uneventfully two weeks after surgery."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female patient reported to the Department of Oral Medicine and Radiology, with a chief complaint of a swelling in the right side of the lower jaw, of six months duration. History revealed that the swelling had gradually increased in size since its onset. The swelling was not associated with pain, discharge or paraesthesia. The patient had noticed mobility of her lower right back teeth since 15 days.\nOn extra oral examination, a solitary, diffuse swelling was evident on the right mandibular body that was roughly oval; measuring 2.5 cm × 2 cm, and the surface appeared smooth. The skin was intact with no secondary changes. The swelling was nontender and hard.\nIntraoral examination revealed a diffuse swelling in the mandibular right buccal vestibule, extending from the canine up to the first molar, measuring 2.5 × 1 cm in size. [] The surface appeared smooth and the surrounding area normal. Lingual displacement of the first and second premolars was evident. On palpation, bicortical expansion was evident with an area of decortication at the region of the first molar on the buccal side. The swelling was hard except at the region of decortication. Grade II mobility of the premolars and first molar was evident. Aspiration of the lesion yielded scanty amount of frank blood.\nThe differential diagnosis for the lesion included odontogenic keratocyst, ameloblastoma, pindborg tumor, and nonodontogenic lesions such as central hemangioma, and central giant cell granuloma, as well as central malignancy such as an osteosarcoma.\nIntra oral periapical radiograph showed a well-defined radiolucency extending from the distal margin of the first premolar root up to the mesial margin of the mesial root of first molar tooth, having a uniform internal density, with a sclerotic lining in the superior aspect. External root resorption and displacement of the first and second premolars and the first molar teeth was appreciated. Cross sectional occlusal radiograph showed bicortical e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old female had a history of fever and repeated vomiting for 3 days followed by numbness of hands and feet at the time she admitted to the hospital and positive PCR of nasopharyngeal swabs and bilateral GGO of CT chest were recorded; 1 day later, the patient developed rapid progressive symmetrical weakness of both lower and upper limbs, proximal more than distal, and within 2 days, she became bedridden (rapidly evolving). On examination, the patient was fully conscious, with intact cranial nerves. Motor examination showed hypotonia of both upper and lower limbs, reduced muscle strength (MRC grades were 3 for proximal and 4a for distal muscles of both upper limbs; 0 for proximal and 1 for distal muscles of both lower limbs), with four limbs. Sensory examination revealed a glove and stocking hypoesthesia. Three days after admission, the patient developed deviation of the angle of the mouth to the right side and was unable to close her left eye, dysphagia, hoarseness of voice, and an impaired cough reflex. On examination, there was a left lower motor neuron facial palsy and true bulbar palsy with reduced gag reflex. The EGRIS was 5 and the MRC sum score was 24. Details of laboratory findings are in . ABG showed low PaCO2. Otherwise, PT, PC, INR, liver, and renal functions were normal. All electrolytes were normal (Na+, K+, and Ca2+).\nA neurophysiological study provided evidence of a mixed axonal and demyelinating variant of GBS. Detailed data are given in .\nTen days after admission, the patient received the first session of plasmapheresis, during which she showed a hypersensitivity reaction with respiratory failure. She was admitted to the ICU with an oxygen mask and 40% ventilation. Nasopharyngeal swabs were repeated three times on a weekly basis (firstly at admission) and were positive for COVID-19; the fourth swab was negative. Four weeks later, the patient received 5 days of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman presented to our hospital with low back pain. Trauma history was vague except for falling 40 cm from a bed a month earlier. She had a past history of eosinophilic granulomatosis with polyangiitis and was treated with prednisolone (40 mg/day) 3 months before presenting at our hospital. Her bone mineral density in the hip had a T-score of −4.7, and bisphosphonate and vitamin D were initiated to treat osteoporosis. She underwent computed tomography (CT) and was diagnosed as having a left vertical sacral fracture and treated conservatively. Three weeks after her initial diagnosis of sacral fracture, her low back pain worsened and she started to have radiating left posterior thigh pain with symptoms of stress urinary incontinence, constipation, and loss of anal sensation.\nOn examination, she had weakness of dorsiflexion of her left ankle and flexion of both great toes, in which the muscular power was grade 3/5 and 4/5, respectively, as measured with manual muscle testing (MMT). Sensation to pinprick on her S2 receptive field was impaired. Lumbosacral magnetic resonance imaging using a short inversion time inversion recovery (STIR) sequence revealed an H-shaped fracture in the sacrum, but there were no abnormal findings such as spinal stenosis in her lumbar spine potentially explaining for her neurological symptoms (). Repeated CT demonstrated slightly aggravated displacement of the sacral fracture compared with previous CT ().\nWe consulted a urologist, and the patient was diagnosed as having stress incontinence because of poor function of pelvic floor muscles or the sphincter. However, we speculate that both the weakness of dorsiflexion of the ankle and great toes and loss of anal sensation could be attributed to SIF and recommended that she undergo surgery. She underwent lumbopelvic fixation from L3 to the ilium using a minimally invasive technique with a percutaneous pedicle screw system () []. Her radiating leg pain, motor weakness in her ankles, a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 92-year-old man with osteoarthritis and a remote history of right total hip replacement and bilateral total knee replacements presented with a two-day history of severe right hip pain accompanied by nausea, chills, and fatigue. He was unable to bear weight due to pain, and range of motion in his right hip was severely limited. He denied recent trauma or pain in other joints but had undergone routine dental cleaning one week prior to presentation. He had received 2 gm of amoxicillin immediately prior to his dental procedure. He presented afebrile, mildly hypotensive, and was noted to have exquisite tenderness with passive movement of the right leg and reduced range of motion secondary to pain. He had full range of motion and strength distally. He had a leukocytosis of 15,600 WBC per milliliter. Aspiration of right hip joint revealed cloudy fluid with WBC 68,000 cells per milliliter. The patient was resuscitated with IV fluids and started on vancomycin and piperacillin-tazobactam. On the third hospital day, he underwent prosthetic joint drainage and washout with retention of liners. Joint aspirate culture grew Gram-positive cocci in chains, which we subsequently identified by matrix-assisted desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as S. salivarius. We narrowed antibiotic therapy to ceftriaxone to complete six total weeks of intravenous therapy, after which he was treated with amoxicillin for additional six weeks. At this point, the patient discontinued his oral antibiotics rather than complete a full three months of oral therapy or remain on long-term suppression.\nFive months after completion of the above therapy, the patient presented to the ED with hip and back pain following a mechanical fall at home. He was found to have a fracture of L4 and was admitted. On hospital day 5, he was found to have an occult superior dislocation of the R femoral head on CT and an ESR of 71 and CRP of 12.3. He was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe case is based on a 17-year-old boy with neck pain that had lasted for more than 1 month, with numbness in both upper extremities that started 1 week earlier. He complained that symptoms were aggravated after playing computer games for a longer time than normal. This was accompanied by slight dizziness, nausea, diplopia, paresthesia, and an unsteady gait in supplementary inquiries. In addition, his gastroscopic examination showed gastric ulcer and bile regurgitation in previous medical records. The positive signs of vigilance revealed a stiff neck, limited abduction of left eye, and a positive Romberg test in the patient's physical examination with no other abnormal symptoms.\nA plain film radiograph of cervical vertebrae revealed nonspecific curve and intervertebral space and foramen. In consideration of medical history and alerted signs, the patient was immediately arranged for a craniocerebral magnetic resonance imaging (MRI) examination on the second day of admission. MRI showed huge CPA tumor that extended to the front medulla oblongata (Fig. A–C). The patient was referred for neurosurgical intervention. In surgery, the tumor was presented in the lower left CPA and left side of the medulla oblongata. There was ample blood supply and it had a mass size of 3 × 4 × 3 cm3. The fourth ventricle and left foramen of Luschka were compressed by the tumor that was adhesive to the lower cranial nerves and closely adjacent to accessory nerve and the anterior inferior cerebellar artery (AICA). The large neoplasm was subtotally resected and the tissue adhesive to brain stem was not forcibly removed (Fig. E,F). The pathological diagnosis was CPP (CPP, WHO I) (Fig. D). The clinical symptoms of the patient gradually alleviated after surgery and subsequent radiotherapy treatment. Unfortunately, in a follow-up 2 years later, the tumor was recurrent. Considering his overall health and tumor condition, the young man could not receive another intracranial surgery nor was he able"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old man with no history of eye surgery underwent 25G+ pars plana vitrectomy for proliferative diabetic retinopathy. After retrobulbar anesthesia, a vision system was used to view the surgical field, and an inferotemporal sclerotomy was created using a 25G+ trocar. The trocar obliquely punctured the bulbar conjunctiva and sclera at an angle of 45° (sclerotomy), approximately 4 mm from the limbus and parallel to it. The trocar was twisted into the eyeball, and its orientation was gradually changed perpendicular to the limbus. After confirming that the cannula was inside the eye, we pulled out the trocar and inserted an infusion cannula into the port. Two more sclerotomies were created in the superotemporal and superonasal quadrants. However, when we pulled out the superonasal trocar, the collar of the cannula fell off and the cannula tube was missing (Fig. a). Therefore, a bulbar conjunctival incision was placed to search for the missing cannula. No cannula was found in the subconjunctival space. We used a scleral depressor to look for the missing cannula tube along the peripheral retina and found the broken cannula tip in the ciliary body corresponding to the superonasal sclerotomy site. We created a new sclerotomy 2 mm above the original incision and 4 mm from the limbus and subsequently performed vitrectomy around the broken cannula to mobilize it for extraction. The new scleral incision was extended to 3 mm parallel to the limbus and allowed entry of a foreign body forceps (Fig. b). The broken tip of the cannula was brought into view by indenting the sclera adjacent to the original sclerotomy. We used the foreign body forceps to clamp and pull the fractured cannula toward the central vitreous body (Fig. c). With the help of the light probe, the longitudinal length of the cannula was aligned with the foreign body forceps and retrieved through the enlarged incision (Fig. d)."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman was admitted to our endocrine department with a diagnosis of Cushing’s syndrome (CS) presumably caused by a cortisol-secreting adrenal carcinoma with pulmonary metastases. The patient reported a progressive course of central obesity, moon-shaped face, muscle atrophy and weakness, asthenia and emotional disturbance over the last six years. During this period she had developed arterial hypertension, which was poorly controlled despite five antihypertensive drugs. Five years ago abdominal magnetic resonance (MR) imaging had been performed in the local hospital for further evaluation of a suspected liver hemangioma, and revealed an incidental finding of a 2.5 cm lesion in the right adrenal. No endocrinological evaluation was performed. Three years before admission she underwent abdominal computed tomography (CT) imaging for evaluation of recurrent hypertensive crises. No change of the adrenal tumor size was found. Screening for pheochromocytoma and primary hyperaldosteronism was negative. In the weeks before presentation at our department the patient complained of polyuria and exertional dyspnoe. The family physician diagnosed diabetes mellitus, which was treated with dietary measures. Furthermore, abdominal CT imaging was repeated, which showed an increase of the adrenal tumor size to 3.3 cm. The patient was subsequently admitted to the local hospital for further endocrinological investigation.\nLaboratory tests performed at the local hospital showed failure to suppress cortisol levels after 1 mg dexamethasone and elevated 24-hour urine cortisol secretion. Plasma adrenocorticotropin (ACTH) levels were suppressed indicating an adrenal origin of the hypercortisolism (Table ). A pulmonary nodule was suspected in the abdominal CT imaging and an additional chest CT revealed multiple bilateral pulmonary nodules which were not described in a CT imaging of the chest performed 5 years earlier. A fluorodeoxyglucose positron emission tomography (FDG-PET) was pe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2016, a 67-year-old woman came primarily to our hospital for a consultation about painless mass of the left lower gingiva. Intra-oral examination showed a 46 × 25-mm tumor with induration on the left lower gingiva (Fig. ). A submucosal mass, independent of the gingival tumor, was palpable in the left buccal region. Several cervical lymph nodes on the left side were also palpable. Pathological examination of a biopsy sample taken from the gingival tumor revealed a well-differentiated squamous cell carcinoma.\nA computed tomography (CT) scan with contrast showed a large gingival tumor, with destruction of the adjacent mandibular bone, and four metastatic left-cervical lymph nodes that were markedly enlarged, non-homogeneously enhanced, and partially necrotic. These lymph nodes included two left submandibular and two left upper jugular nodes. CT imaging showed no metastases to the lungs. Magnetic resonance imaging (MRI) showed a large primary tumor on the left side, with its epicenter located in the lower gingiva. The tumor appeared to extend into the sublingual space medially and into the buccinator muscle laterally. A non-homogeneously enhanced mass was identified in the buccinator space along the facial vessels, anterior to the anterior edge of the masseter muscle, and lateral to the buccinator muscle (Fig. ). This mass lay on the cranial side of the primary tumor. The mandibular ramus and pterygoid region that are on the cranial side of BN were not invaded by primary tumor (Fig. ). Moreover, T1-weighted MRI showed a thin layer with high signal, indicative of fatty tissue, between this mass and the primary tumor, indicating that the mass was independent of the primary tumor. Based on its anatomic location, the mass appeared to be metastatic disease to BN. Greyscale sonogram showed some metastatic cervical lymph nodes on the left, and metastatic BN. These cervical lymph nodes were markedly enlarged, round in shape, heterogenous hypoechoic, and without"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 35-year-old African American male presented with a one-month history of worsening lower back and bilateral lower extremity pain, intermittent night sweats, and 32 kg unintentional weight loss over the course of a year. He did not have saddle anesthesia or urinary or fecal incontinence. He was initially seen in a primary care clinic and was diagnosed with sciatica. As symptoms continued to worsen, he underwent a computed tomography (CT) scan of the lumbar scan as an outpatient that was concerning osseous spinal metastasis. He was started on prednisone 10 mg daily and was referred to the oncology clinic at our center. Prednisone gave him minimal symptomatic relief. While waiting to be seen in the oncology clinic, the patient had an episode of leg weakness with near-fall prompting him to present to the emergency department of our hospital and was admitted for further evaluation. His vital signs were stable. He had no palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Neurological exam was normal with intact strength and sensation in both lower extremities.\nHis complete blood count and serum electrolytes were normal including a normal serum calcium level at 8.1 mg/dL. He tested negative for human immunodeficiency virus 1 and 2 antibodies. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine showed several enhancing lesions in T11, T12, L3, L4 vertebral bodies, right sacrum, and ilium that were concerning metastatic disease. There was effacement of the right lateral recess and right neural foramen at the L3-L4 and effacement of the left lateral recess and left neural foramen at the L4-L5 due to tumor retropulsion (Figures –). In addition, a small epidural tumor was noted at the T5 vertebral level without significant spinal canal stenosis or cord compression. Imaging was also concerning osseous metastasis involving the sternum and multiple ribs. Incidentally, narrowing of the neural foramen at"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old man presented to the emergency department with a 1-month history of intermittent nausea, chills, and jaundice. Preoperative laboratories revealed an elevated total bilirubin and alkaline phosphatase. Serum tumor marker analysis revealed a normal carcinoembryonic antigen (CEA) but an elevated CA 19-9. The patient underwent a magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography that revealed thickening of the proximal common bile duct with proximal biliary dilatation and an absence of distant disease. Incidentally noted on the MRI was that the third portion of the duodenum did not cross to the left of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), and the majority of the small intestine lies in the patient's right abdomen, whereas the large intestine lies in the left. Also, the SMA lies to the right of the SMV consistent with gastrointestinal malrotation (). The patient underwent endoscopic retrograde cholangiography with biliary endoprosthesis placement for decompression. Upon surgical exploration, a mass was identified in the proximal common bile duct (with no evidence of disseminated disease) and gastrointestinal malrotation was confirmed. Oncological resection of the extrahepatic biliary tree was performed from the level of the bifurcation of the right and left hepatic ducts to the intrapancreatic portion of the bile duct, along with a portal lymphadenectomy. A biliary enteric reconstruction was created with a Roux-en-Y hepaticojejunostomy. To compensate for the malrotation, the proximal jejunum was divided 50 cm distal to where the duodenum exited the retroperitoneum and the 50 cm Roux limb was brought up in a right paracolic position rather easily, as the hepatic flexure of the colon was absent, such that it simply rested over the top of the duodenum. An end-to-side hepaticojejunostomy was formed in a single layer, and the Roux limb was tacked down to the retroperitoneum to prevent intestinal hernia"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA nine-year-old female was referred to our department for a mass arising in the left hard palate () that had been reportedly growing for the past several weeks and was associated with discomfort with mastication and teeth brushing, as well as minor bleeding. Examination showed an ulcerated firm mass of the left hard palate. The ulcer was not opposing the inferior dentition. CT scan showed a 2.2 × 1.3 × 2.6 cm heterogeneously enhancing expansile mass of the left lateral hard palate with bone destruction, extending into the alveolar recess and maxillary antrum. There was no evidence of orbital extension ().\nA first biopsy was performed at an outside center and reviewed at out institution. The biopsy consisted of a small fragment of ulcerated squamous mucosa with a submucosal bland spindle cell proliferation. Due to the limited biopsy and lack of material to perform further immunohistochemical analysis, it was not possible to establish the nature of the tumor. Consequently, an open biopsy was performed and showed that the spindle cells were characterized by elongated cigar-shaped nuclei, eosinophilic cytoplasm with indistinct borders, and a storiform to fascicular growth pattern. Significant nuclear pleomorphism, increased mitotic activity, and necrosis were absent. The spindle cells showed variable immunoreactivity for muscle specific and smooth muscle actin and had a low Ki67 proliferation index (<5%); they were negative for desmin, S100 protein, cytokeratin (AE1/AE3), and nuclear beta-catenin. The overall findings supported the diagnosis of a myofibroma.\nThe patient was brought back to the operating room for resection which involved a left partial maxillectomy and reconstruction with a buccal advancement flap (Figures and ). The tumor was macroscopically completely resected despite a positive deep margin. The bone of the remaining tumor bed was drilled over the entire surface, which ensured elimination of the microscopically positive deep margin. Postoperatively, th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old female patient reported severe dyspnea and showed tachypnea. She was diagnosed as a pulmonary thromboembolism and immediate anticoagulation with warfarin was started. In the morning two days after anticoagulation, she felt heaviness in both legs and progressive paraparesis. A neurologist evaluated her and requested a lumbosacral magnetic resonance imaging (MRI) of the lumbar spine. While waiting for the MRI, her paraparesis progressively increased and ascended; eventually she became quadriplegic and respiratory distress developed. After checking whole spine MRI, an emergent endotracheal intubation was performed and neurosurgical consultation was taken. On examination, she was alert and no focal cranial nerve sign was observed. However, grade 0 quadriplegia was noticed and tendon reflex was not elicited. An acute epidural hematoma was noted on the high cervical cord (). After informed consent, an emergent decompression of the cervical cord was performed. Unfortunately, her quadriplegia did not improve after surgery. Moreover, self-respiration was not elicited. Thereafter, she was maintained with artificial ventilation during the following three months in the intensive care unit. During the follow-up, no spontaneous, voluntary respiration was observed and the MRI checked at postoperative 3 months showed a myelomalacia at the C2 level suggesting high cervical cord injury (). A standard apnea test did not elicit voluntary respiratory effort. After 3 months of artificial ventilation, we decided to perform a trial of diaphragm pacing, and informed consent was taken. An electromyographic examination of the diaphragm was performed for the verification of contraction of the diaphragm.\nA stimulation lead implantation was performed in right neck under general anesthesia with the head rotated to the left side. Muscle relaxant was not used to monitor intraoperative contraction of the diaphragm. A linear horizontal skin incision about 4 cm was made at 4 cm rostral t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man presented with a large exophytic lesion of the chin, which had been present for 10 years with recent enlargement over the previous 6 months (Fig ). He denied pain or bleeding, but recently noted some ulceration in the central portion of the lesion. Physical examination showed a 1.5 × 1.0 cm mobile lesion centrally located at the mental crease of the chin. There were no notable sensory or motor nerve abnormalities and no palpable lymphadenopathy of the submental, submandibular, anterior, or posterior triangles of the neck. Intraoral examination was normal. Biopsy of the lesion demonstrated eccrine carcinoma. Computed tomography imaging of the neck showed no evidence of metastatic disease.\nTreatment plan involved initial wide excision of the lesion and surrounding borders, including skin and subcutaneous tissue. The defect was closed using a full thickness skin graft from his right neck. Permanent pathology demonstrated eccrine carinoma with positive deep and peripheral margins including platysma muscle invasion. Reexcision involved wider and deeper margins, which were inclusive of the entire chin subunit up to the vermilion border. Frozen sections done at the time of surgery were negative. The total defect measured 9 × 5 cm (Fig ).\nThe submental artery island flap design for defect coverage utilized a fusiform-shaped flap with the superior aspect of the flap beginning 1.5 cm inferior to the bony mandibular margin of the defect, and lateral edges extending to the approximate level of the mandibular angle bilaterally. The total flap skin paddle measured 13 × 6 cm. The submental artery was identified bilaterally just inferior to the mandibular angle. Dissection of the flap proceeded in the subplatysmal plane and right and left pedicles were identified. Marginal mandibular nerves were identified and preserved. The left pedicle was ligated to allow inset of the flap as an island based on the right-sided perforator. Subsequent to passing under a skin brid"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old female patient was referred by a private practitioner who detected a mass of soft tissue on the palatal aspect of tooth 11. The patient had a history of alveolar cleft repair done about 1 year back. Clinical examination revealed an extensive soft tissue mass in a palatal defect of tooth 11 []. Gentle exploration revealed that besides loss of the palatal enamel there was also loss of enamel from the interproximal areas of the tooth. However, the labial surface of the tooth was intact. The tooth responded to thermal and electric pulp testing within normal limits. A periapical radiograph revealed a large irregular radiolucency in the coronal region of the tooth extending mesiodistally and slightly into the coronal radicular dentin []. A diagnosis of Class 2 external cervical resorption was made.\nGlycerol was applied to the adjacent tissues to form a protective film. Isolation was achieved using the cuff rubber dam technique. A small cotton pellet was then dipped in 90 percent trichloroacetic acid and the excess was removed by dabbing it on a piece of gauze. The cotton pellet was then applied over the resorptive tissue mass with gentle pressure for about 1 minute. The tissue mass underwent necrosis with repeated application of trichloroacetic acid which was curetted out till a sound dentinal base was revealed []. Care was taken to see that the interproximal areas of the tooth were thoroughly debrided. The cavity was then refreshed with a high speed bur and restored with glass ionomer cement [].\nTrichloroacetic acid is a chemical escharotic agent that causes coagulation necrosis and renders the resorptive tissue avascular.[] The use of trichloroacetic acid does not necessitate raising a flap to gain access to the lesion. This eliminates the possibility of active resorbing cells present in the flap from being repositioned over the repaired root surface.[] However, due to the caustic nature of the acid, certain guidelines need to be followed as outlined"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old Caucasian man, a full-time student, 1.8 m tall, 77 kg in weight, with no significant medical history, a non-smoker, taking no medications and with no substance misuse, was riding a motorcycle while wearing a helmet; he collided with a moving automobile and was ejected over 30 m into the air. He sustained multiple injuries including a large chest wall avulsion and a severe partial amputation of the left arm. The limb was not salvageable, requiring amputation, with a small residual fragment of the left scapula remaining (Figure ). Left scapulothoracic dislocation and severed left brachial plexus were also found intra-operatively. His head, right arm and lower extremities were grossly intact.\nHe received 10 weeks of acute care in our surgical medical unit, where surgical intervention included repair of the chest wall and internal organs, after which he was transferred to the acute rehabilitation unit where, almost immediately, phantom limb pain became his major issue.\nHe reported his pain episodes as variable in number, ranging from three to six per day. Described as searing, aching or cramping as if his missing hand was clenched in a fist formation, the pain episodes often occurred at random intervals during the day, ranging from 15 minutes to up to an hour and a half. On average, he rated the pain at between 8 to 10 out of 10 on a visual analog scale (VAS).\nAs his entire left upper limb was missing, including the shoulder and parts of the clavicle and scapula, 'stump' pain did not actually apply to his description. Instead, he consistently experienced the feeling that his left fist was severely clenched and he could not release it from the cramping that became a burning, searing pain.\nThis persisted despite a series of aggressive pain management methods through the administration of naproxen 250 mg three times a day, tramadol 50 mg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old woman was admitted with severe abdominal pain, which began a few hours before admission. She had neither a specific past medical history nor any underlying illness. The abdominal pain was continuous and diffuse without localization. The initial blood pressure was 120/80 mmHg, the pulse rate was 84 beats per minute, the temperature was 36.4°C, and the respiratory rate was 32 breaths per minute. On physical examination, the abdomen was soft but moderately tender throughout without rebound tenderness. The laboratory values were as follows: white blood cell count, 11,900/mm3; AST, 26 IU/L; ALT, 11 IU/L; amylase, 210 IU/L; lipase, 316 IU/L. An ultrasonographic examination showed that the gallbladder had no abnormal findings but the small intestine showed diffuse dilatation and wall thickening (, ). A computed tomographic examination of the abdomen and pelvis performed with the intravenous administration of contrast media showed severe thickening of the small intestinal wall and small quantity of ascites without any evidence of bowel perforation or acute appendicitis (). During the next three hours, the patient’s blood pressure fell to 80/50 mmHg and the temperature rose to 38°C. Her abdominal pain worsened with newly developed rebound tenderness and rigidity on abdominal palpation. After deliberating on the patient’s age, clinical manifestation and radiological findings, abdominal angiography was performed to rule out the possibility of acute intestinal ischemia. Abdominal angiography showed multiple stenoses at the superior and inferior mesenteric artery and extensive spasms at the branches of the superior mesenteric artery (). An exploratory laparotomy was performed on with the impression of small bowel necrosis due to acute intestinal ischemia. On exploration, there were neither intestinal necrosis nor intestinal perforation. Only bile-colored ascites was noted. Although the gallbladder appeared normal, bile leaked on a localized focus of the gallbladder"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old-male patient presented initially with lower abdominal pain in March 2006. He was diagnosed with appendicitis based upon his exam and history. A CT scan of the abdomen was performed at that time and demonstrated extensive inflammatory changes in the right lower quadrant with possible interloop abscess (). Two nonspecific calcifications were noted radiographically and the differential diagnosis included appendicitis, ileitis, or diverticulitis. He did not have any urinary complaints at that time. He underwent an uneventful open appendectomy and had resolution of his initial symptoms and no further follow up.\nThe patient presented again in August 2011 with right flank pain and urinary symptoms. A noncontrast CT scan of the abdomen was performed and demonstrated a right ureterovesicular junction calculus with mild right ureteral dilation (). Again, calcifications were noted near the anterior fundus of the bladder (). He was managed medically and discharged with instructions to follow up with an urologist as an outpatient.\nHe subsequently presented again 3 weeks later with severe abdominal pain and induration of his lower abdominal wall. CT imaging now demonstrated interval enlargement of a complex cystic mass inseparable from the anterior superior wall of the urinary balder and abutting the posterior margin of the abdominal wall (). The radiographic diagnosis was an urachal remnant abscess versus tumor. He denied any urologic complaints at that time. He was started on antibiotics, and surgical consultation was performed. After an extensive discussion with the patient regarding his radiographic diagnosis and suspicion of complications related to an urachal remnant, he was scheduled for cystoscopy and surgical exploration.\nAt the time of surgery, cystoscopy did not demonstrate any abnormalities of the bladder. Exploratory laparotomy was performed and an indurated mass and abscess were encountered near the area of the anterior abdominal wall and bladder. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old female with a past medical history of hypertension, peripheral arterial disease, asthma, gastroesophageal reflux disease, and diabetes mellitus presented to our otolaryngology clinic with the complaint of a “nodule” behind her left ear. She stated that the mass had been slowly increasing in size over the last 5 years. It was described as nonpainful and she had never experienced any discharge from the area. Her only other complaints were decreased hearing, xerostomia, and hoarseness; no dysphagia or weight loss was reported. Past surgical history was significant for angioplasty and stent placement in her legs. Social history was significant for a 20-pack-year tobacco history. No significant family history was reported. On physical examination pertinent findings consisted of a left posterior auricular mass approximately 2 centimeters (cm) that was fixed and nontender. All cranial nerves, most notably the facial nerve, were intact. No cervical adenopathy was palpated. Nasopharyngeal laryngoscopy demonstrated arytenoid edema consistent with reflux but the true vocal folds were mobile and no other lesions were visualized. Treatment plan at that time consisted of smoking cessation and a computed tomography (CT) scan with contrast of the neck.\nThe CT scan revealed a multilobulated and cystic mass in the left parotid gland with an infiltrating appearance consistent with neoplasm. There was no pathologic cervical lymphadenopathy reported. The differential diagnosis at this time included benign mixed tumor, Warthin's tumor, epidermoid tumor, and adenoid cystic carcinoma. A fine needle aspiration was performed at this time and the results were nondiagnostic. The decision was made to proceed with a left parotidectomy.\nLeft superficial parotidectomy with facial nerve monitoring was performed approximately one month after presentation. A 2 × 2 cm lesion was removed from the tail of the left parotid gland. The gross description was an encapsulated, lobulated mass wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old Sri Lankan unmarried woman presented with worsening hand, feet, and perioral numbness for 6 months duration and muscle cramps of the lower limbs for 3 years. There were no seizures, headache, chest pain, or features of heart failure. She did not have features supportive of thyrotoxicosis including loose stools, sweating, or palpitations. She did not have limb weakness.\nShe gave a history of reduced appetite and unintended weight loss of 4 kg over 4 months. She did not have evidence of other endocrine abnormalities, including adrenal insufficiency, and there were no features supportive of an autoimmune process, to suggest a polyglandular autoimmune syndrome. She did not have chronic cough, joint symptoms, or skin rash to suggest a granulomatous or infiltrative disorder. She was consuming an average diet with adequate amounts of fish, meat, and milk and getting adequate exposure to sunlight. She did not have a history of diarrhoea or steatorrhoea or a family history of celiac disease to suggest an ongoing malabsorptive process. Her urine output was normal, and she did not have features of uremia. She was not on any drugs such as bisphosphonates or chemotherapeutic agents such as cisplatin which could lead to hypocalcemia.\nShe was diagnosed with follicular carcinoma of the thyroid at the age of 27 for which she underwent total thyroidectomy with lymph node excision 33 years ago. Histology revealed well-differentiated follicular carcinoma with multifocal capsular invasion and lymph node metastases. Operative notes indicate that parathyroid glands had been identified and preserved during the surgery. She was given Iodine-131 treatment once after the surgery. Her records did not reveal an immediate postoperative hypocalcemia. However, she was empirically treated with calcium and calcitriol in the immediate postoperative period for 3 months, after which it was stopped. Following surgery, she was regularly followed up and managed at an oncology unit, and there"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman was admitted to our hospital with a pulsatile mass swelling over the left cervical region and right hemiparesis after cough for 1 day. She had a history of fibromatosis, but no previous history of trauma, operation or inflammation in this region. On physical examination, a 5-cm large pulsatile swelling with blowing bruit was found over the left cervical region and multiple fibromas were found in regions of face, neck, and trunk. Neurological examination revealed muscular strength of grade IV according to the ‘manual muscle test (MMT)' grading system and hypoesthesia of right limbs, including touch and pain sensation. Computed tomography angiography (CTA) and DSA revealed a left high-flow internal carotid-jugular fistula at the first cervical level and twisted left internal carotid artery (ICA) (Figures ). Blood flow from the vertebrobasilar artery and right ICA via the circle of Willis supplied the left anterior cerebral artery and middle cerebral artery and drained backwards into the petrosal segment of left ICA (Figures ).\nWe chose embolization of both the fistula and parental artery, because no appropriate covered stent could be used to pack the fistula in the condition of reservation of left ICA. The purpose of first endovascular treatment was to isolate the fistula, by blocking both the backward blood flow from right ICA and the forward blood flow from left ICA. A Headway-21 stent catheter was selectively inserted into the distal part of fistula in the segment of carotid cavernous sinus, meanwhile an Echelon-10 microcatheter was placed in the distal part of stent catheter. One LVIS 5.5*30 mm stent, with its characteristic relatively compact mesh, was used to cover the distal part of fistula to avoid coils being pushed into internal jugular vein and heart (Figure ). However, the 3.5 cm fistula could not be covered by the LVIS stent. Therefore, 10 coils were additionally used one by one"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old Asian male patient was admitted to our hospital for a refractory migraine of 3 years. He complained hours of pulsatile pain with photophobia, haphalgesia of the scalp, and fatigue during each attack. His medical history was unremarkable, and his magnetic resonance imaging and computed tomography angiography revealed no imaging anomaly. Accordingly, he was treated with naproxen (0.5 g qd) and flunarizine hydrochloride (10 mg qd) with poor improvement. Thus, treatment with an ultrasound-guided stellate ganglion block on each side a time was planned as a complementary therapy.\nWith the patient's informed consent, the first block was successfully performed on the right side with temporary Horner syndrome, decreasing attacks on the first day. Thus, the next block for the other side was administrated the day after. During the practice, the patient laid in the supine position with a thin pillow under his shoulder to ensure the extension of the anterior neck. Before the procedure, the patient was instructed to raise his hand if he felt any discomfort but was not allowed to speak or swallow. He was monitored by pulse oximetry and noninvasive blood pressure. We adopted the in-plane approach because of the clear ultrasonography at the level of the 6th cervical vertebra (C6) transverse process and prepared 4 ml of 1% lidocaine with a 22-gauge needle and 12-MHz linear probe. During the procedure, the needle was supposed to be inserted between the carotid artery and thyroid toward the prevertebral fascia anterior to the longus colli muscle (Fig. ). However, we lost track of the tip when the inserting the needle, which passed the fascia of the artery and thyroid. Hence, the operator cautiously jiggled the needle to detect the tip. After the tip was confirmed by the concomitant jitter of the target tissue (the surface of the longus colli muscle), 0.5 ml of 1% lidocaine was injected; however, the injectate"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 20-year-old female who initially presented to an outside hospital in July 2017 with a 1-month history of progressive low back pain. Initial magnetic resonance (MR) showed a destructive, osteolytic, expansile lesion measuring 4.8 × 3.8 cm centered in the left aspect of the sacrum at the level of S2–S3 with areas of anterior cortical destruction extending into the left sacral neural foramina from S2 to S4. There was also a heterogeneously enhancing soft tissue component that was measured at 6.4 × 3.7 cm that was along the left piriformis muscle. A CT-guided core needle biopsy performed in August 2017 yielded an initial diagnosis of a high-grade osteosarcoma. She was subsequently treated as an osteosarcoma patient with MAP chemotherapy. She completed a total of 12 weeks of chemotherapy, with cumulative doses of cisplatin 360 mg/m2, doxorubicin 225 mg/m2, and methotrexate 24 g/m2. Surgical intervention was determined to result in substantial morbidity, and therefore, the patient underwent proton beam radiation in three fractions for a total dose of 54 Gy. However, due to the lack of increased bone mineralization in response to chemotherapy, the question of osteoblastoma rather than osteosarcoma was raised.\nAfter reviewing the initial pathology, a second pathologist described the tissue specimen as a cellular tumor composed of proliferating osteoblasts with atypia and frequent mitotic figures associated with trabecule of woven bone. Neoplastic cells demonstrated mild cytologic atypia and scattered mitoses of normal configuration. In different areas, the tumors had undergone secondary hemorrhagic and cystic changes. Although difficult to definitively differentiate between the two, an overall impression of osteoblastoma was favored. As a result, a second biopsy was later obtained in December 2017. It in fact demonstrated no neoplastic cells, but instead a cystic wall with bland-appearing spindle cell proliferation, hemosiderin deposition, lamellar and wove"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male presented to our hospital, having been previously treated at another institute. Spme nine days prior, he had developed severe chest pain following retching. A chest x-ray then had showed a hydropneumothorax. Emergency intercostal drainage (ICD) insertion was done and a water-soluble contrast study had showed a leak from the lower oesophagus []. An endoscopic stapling was performed at the other institution where he was managed and that leaked on the third postoperative day. The patient presented to us with septic shock on day nine following the original perforation. A CT scan showed a free leak into the pleural space with a large collection. A new ICD was inserted, but it failed to clear the pleural space. We then decided to proceed with thoracoscopic mediastinal toilet. The patient was administered general anaesthesia with a double-lumen endotracheal tube. He was placed in the lateral decubitus position. A thoracic epidural catheter was placed for postoperative analgesia. A working port was established in the sixth intercostal space in the midaxillary line and two other 5 mm ports were placed. A 30 degree telescope was used for the procedure. A thorough mediastinal toilet was given []. The site of the perforation was identified but was too friable for attempting any form of closure. Local decortication was done. The thorax was drained with two IC drains. A laparoscopic-assisted feeding jejunostomy was carried out. At the end of the procedure, a left-sided cervical loop oesophagostomy was performed. The entire procedure lasted 150 minutes and blood loss was approximately 300 cc. No ventilatory support was required postoperatively. Jejunostomy feeds were started on the second postoperative day. On the fifth postoperative day, the patient was off IV antibiotics and on full jejunostomy feeds. During the course in the hospital he developed lower zone consolidation, which was treated with aggressive chest physiotherapy and IV antibiotics. The cervical o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe herein present a case that was recently managed at our institution, the Department of Surgery of the San Camillo Forlanini Hospital of Rome, Italy.\nA 53-year-old man with previous history of alcohol-related liver cirrhosis presents to our department for routine follow-up. His comorbidities include hypertension managed with oral antihypertensive drugs and diabetes mellitus type 2. He has no significant allergies and never underwent any surgical procedure. He brings an ultrasound, which shows a 4 cm heterogenous mass in segment 8. His alfafetoprotein level is elevated to 76 ng/mL. He has no symptoms and looks in good performance status. We scheduled him for a triphasic CT scan, which shows a lesion of 4.3 cm with brisk arterial contrast and venous washout. According to the LIRADS classification, this lesion could be considered a class 5 with diagnostic features of hepatocellular carcinoma. The patient was discussed in our multidisciplinary tumor board including hepatobiliary and transplant surgeons, hepatologists, radiologists, pathologists, oncologists, and interventional radiologists. The plan was to submit the patient to curative intent treatments given his early presentation according to the Barcelona Clinic Liver Cancer Staging System (BCLC), namely surgical resection or liver transplantation; radiofrequency ablation was excluded given the tumor’s dimensions. Given the good performance status, the position of the lesion (which was right below the Glissonian capsule) and the liver function of the patients, the MDT decided to schedule the patient for surgery. We therefore saw the patient in clinic and discussed the procedure. Informed consent was signed, and liver function was tested using ICG retention rate. We used 0.5 mg/Kg corresponding to 40 mg in this 80 kg patient. The DICOM data of the CT scan of the patient were then submitted to our radiologist who performed a 3D reconstruction of the patient’s anatomy and the relationship of the lesion with the major"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old male was referred to the Department of Dental Medicine complaining of occasional pain and a mucous fistula which persisted for one year in his upper right central incisor. When history was elicited, the patient revealed that there was a fall two years back in school due to which he sustained fracture of his maxillary permanent central incisors. Both teeth underwent endodontic treatment in a private office. According to his medical history, the patient exhibited no systemic disease.\nHis extraoral examination was noncontributory. Intraoral examination revealed enamel-dentin fracture involving the incisal edge in tooth #11, in the upper right lateral incisor region (). Periodontal probing revealed deep narrow pockets on both facial of tooth 12 and palatal root surfaces of tooth 11 of 5 and 6 millimeters, respectively, while the other teeth showed a nonpathologic probing depth of value of 2-3 mm. Pulp sensibility tests showed a negative response in tooth #12. Radiographic evaluation was performed using a film holder which showed the relationship with tooth #12; both central incisors were endodontically treated (). Endodontic treatment of tooth #12 was planned (). A 3-month follow-up appointment and coronal restoration of teeth #12 and 11 was scheduled, followed by another appointment 3 months later, but the patient consulted us only 2 years later complaining of the recurrence of the Fistula. A periapical radiograph with film holder has built evidence to show the relation with tooth #12 (). A Periapical surgery was carried out and revealed a proliferation of granulation tissue around the apex of the lateral incisor (). Periapical curettage followed by a 3 mm root-end resection of tooth #12 () was conducted. After Retrograde root preparation, retrograde filling was performed with glass ionomer cement. The radiological control after root-end filling showed cement excess ().\nA follow-up appointment was given 3 weeks later. The reappearance of the sinus tract w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old Indian man presented to our Out-patient Department with complaints of pain and pus discharge from his left proximal leg for four weeks. He was unable to bear weight on his left leg and had a stiff left knee. He had sustained a left frontal extra-dural hemorrhage with depressed frontal bone fracture and an open fracture of his left proximal tibia in a road traffic accident five weeks ago. He was treated elsewhere with excision of the depressed skull bone fragment and evacuation of the extra-dural hematoma. Open reduction and internal fixation of the proximal tibia fracture with a medial locking compression plate (LCP®; stainless steel) was performed on the same day using a ‘Mercedes-Benz’ incision. Post-operatively, he was given a knee brace. Our patient developed pus discharge from the surgical wound in the proximal third of his leg three to four days after surgery. As the infection could not be controlled with antibiotics, he was referred to us for further management.\nOn examination, there was a Y-shaped scar over the left knee reaching up to the middle third of the leg with three sinuses on the suture line. There was an infected wound of size 4×4cm over the proximal third of the leg exposing necrotic, infected patellar tendon. The medial LCP® implant was also exposed (Figure\n). The left knee was mildly subluxed posteriorly and he had a 10° fixed flexion deformity of his left knee with minimal further flexion. He also had an equinus contracture of his left ankle. A pus sample was sent for culture and sensitivity testing and it showed heavy growth of Pseudomonas, sensitive only to imipenem and meropenem. We decided to perform a single stage debridement, with removal of the exposed LCP® implant, reconstruction of the extensor mechanism and fracture stabilization with a knee-spanning external fixator. He was counseled about the need for surgery and the proposed treatment plan and the prognosis was also discussed."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA female patient in her 30s was referred to our institution with a complaint of persistent cough. Chest radiography revealed a mass in the right middle lung field (). Noncontrast CT showed a mass approximately 8 centimeters in diameter with relatively smooth margins in the right lung segment 6 (). A malignant lung tumor was suspected and fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) was done. FDG accumulation was seen in the lung mass (standardized uptake value max. 3.6) as well as in the mediastinum suggesting a malignant lung tumor with mediastinal lymph node metastasis (). Bronchoscopy revealed a tumorous lesion obstructing right B6 (). Biopsy of this lesion showed proliferation of spindle cells raising suspicion of sarcoma or spindle cell carcinoma.\nNext, contrast-enhanced CT was done, and it showed that the mediastinal lesion pointed out on FDG-PET/CT was actually a continuous extension of the lung mass into the right main pulmonary artery. A skip lesion was also suspected in the periphery of the pulmonary artery trunk ().\nLung ventilation-perfusion scan showed that the right lung was not perfused although sufficiently ventilated. On echocardiography, heart wall motion was intact and no signs of right heart failure were seen.\nCollectively, a sarcomatous lung tumor with extension into the right pulmonary artery trunk or PAS with extension into the right lung was suspected. The patient underwent surgical resection of the tumor under cardiopulmonary bypass through a median sternotomy. The existence and localization of the skip lesion was first confirmed by transthoracic and transesophageal echocardiography. Venous cannulas were placed in the right atrium and the femoral vein, and an arterial cannula was placed onto the femoral artery, and surgery was carried out with the heart beating. The left pulmonary artery was carefully dissected so as not to perturb the skip lesion and was clamped just proximal to the origin of left A3. Although the tumor fill"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old man presented in neurology service with pain in the legs, bilateral foot drop and numbness in the medial aspect of the left forearm of 2 weeks duration. Examination showed pupura and on positive questioning he admitted bleeding from gums starting 2 days prior to neurological symptoms. At the age of 12 years, he had multiple blood transfusions and was told to have aplastic anemia, but a detailed medical report was not traceable. At the age of 22 years, he had an acute hepatitis B infection when the blood counts and hematocrit were documented to be normal.\nAt the time of index admission, he had anemia and multiple purpuric skin lesions []. Systemic examination otherwise was normal. Clinical neurological examination revealed sensory motor involvement of the left radial, left ulnar, right common peroneal and left sciatic nerves suggesting a mononeuritis multiplex. No significant hematomas were seen on the overlying skin of these nerves. An electrophysiology evaluation showed the sensory motor involvement of the left ulnar, left median, left radial, right median, right common peroneal and left sciatic nerves confirming mononeuritis multiplex. There were conduction blocks demonstrable in right peroneal and left ulnar nerves []. After the neurological investigations, he was referred to a Government teaching hospital where his subsequent hematological workup was done.\nHis hematocrit was 33%; total leukocyte count, differential count, and erythrocyte sedimentation rates were normal. The platelet count was grossly reduced to just 5000 cells/cu mm and the bleeding time was prolonged to 9 min. Clotting time, prothrombin time and activated partial thromboplastin time were normal. Corrected reticulocyte count was 2.9% and peripheral blood smear showed marked thrombocytopenia []. The serum bilirubin was marginally elevated to 1.86 mg/dl with the predominant indirect component. Both direct and indirect coomb's tests were negative. Measurements of serum sodium, potassi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old woman was admitted to our hospital for 1 h of persistent severe chest pain. Apart from smoking, she had no cardiac risk factors. At the time of admission, the electrocardiogram showed ST-segment elevation in leads I,avl. Laboratory data showed that the serum creatine kinase and troponin I had elevated. According to the results of electrocardiogram and laboratory data, STEMI was definitly diagnosed. Primary percutaneous coronary intervention (PCI) was indicated immediately. The coronary agiography (CAG) revealed triple vessel disease with left circumflex as the culprit which was occluded in the proximal segment (Fig. ).\nWith the indication of aspiration thrombectomy and percutaneous coronary balloon dilatation, the coronary reperfusion therapy was achieved (Fig. ). The symptom of chest pain was relieved. Meanwhile, the cardiac surgeon was invited for consultation, and his recommendation was to complete the CABG surgery after the acute phase of AMI. We ended the operation because the goal of primary percutaneous coronary intervention was achieved. The initial course went well, and the patient’s condition was stable gradually after PTCA. However, she suddenly exhibited severe chest pain, dyspnea, agitated, and profuse sweating 6 days after hospitalization. Physical examination indicated a blood pressure of 79/44 mmHg, a heart rate of 98 beats/minute. An electrocardiogram examination did not show ST-segment elevation again. She was given dopamine to raise the blood pressure and fluid to maintain the circulation capacity immediately. The patient presented cardiac syncope suddenly following the onset of atrial fibrillation with a heart rate of 140 beats per minute after half an hour. In consideration of further hemodynamic impairment caused by tachyarrhythmia, electrical defibrillation was urgently administered to restore sinus rhythm. Emergency echocardiography demonstrated pericardial tamponade. After pericardiocentesis with ultrasound guidance and continu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old female patient presented initially to the primary care clinic with symptoms of dyspnea, cough, and wheezing along with anterior abdominal wall tenderness. She had a medical history significant for bilateral venous insufficiency, smoking, obesity, and bipolar type II disorders. The patient tested negative for coronavirus disease 2019 and was sent home with a provisional diagnosis of viral respiratory infection. Her condition showed mild improvement with conservative supportive treatment.\nAfter four months, the patient presented to the emergency department with complaints of epigastric abdominal pain, nausea, vomiting, and diarrhea for the past month. Initial laboratory workup in the emergency department was significant for an elevated creatinine of 1.42 mg/dL, C-reactive protein (CRP) of 6.2 mg/L, and an erythrocyte sedimentation rate (ESR) of 41 mm/hour. The polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 was negative. Before diagnostic imaging, a 2 L bolus of normal saline fluid was administered intravenously followed by maintenance fluid. CT scan of the abdomen and pelvis with contrast was significant for RPF, periaortitis involving the distal aorta and its bilateral common iliac arteries, decreased perfusion of the left kidney with mild hydronephrosis, and obstruction of a portion of the left distal ureter (Figure ). A high-resolution chest CT scan reported multiple small areas of clustered cystic and/or emphysematous changes scattered throughout the lungs and a few ground-glass nodules in the right lung apex.\nInterventional radiology was consulted for a percutaneous biopsy of retroperitoneal fibrotic tissue but it was not completed due to a safe window being inaccessible. In addition, urology was consulted due to left hydronephrosis and for intra-ureteral biopsy. X-ray urography with left retrograde pyelogram showed stricture of the left ureter at the distal third region. Therefore, a stent was placed in the left"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 58-year old female, diagnosed with CLL in 2002. Abnormal lymphocytes showed expression of CD5, CD19, CD20, CD22, CD23 and immunoglobulin kappa light chain by flow cytometry. Ubiquitous enlarged lymph nodes were detected. The patient was asymptomatic. First line treatment was required 2003 due to increasing leukocytosis and lymphocytosis accompanied by advancing anemia and thrombocytopenia. The patient was treated with chlorambucil and prednisone (Knospe protocol) according to local standards and therapeutic possibilities at that time. After achieving a partial remission persisting approximately one year, the patient was retreated with continuous chlorambucil for one month but showed no response. Four cycles of oral fludarabine were administered achieving a partial remission for four years. The following two relapses of the disease were treated again with fludarabine, of which the latter course was mainly due to patient’s preference. After documenting resistance to fludarabine the patient agreed to administration of five cycles rituximab in combination with bendamustine. A partial remission could be achieved. Rituximab and bendamustine were used for treating the following relapse 1.5 years later, achieving a partial remission for another eight months. Afterwards the patient received ibrutinib within a clinical trial, but showed progression of disease after only four months of treatment. Massive progression of lymphadenopathy was apparent at that time. Therefore, a lymph node biopsy was done showing a diffuse infiltration with small lymphocytic cells partially resembling centroblasts or immunoblasts, though transformation to an aggressive lymphoma could not be demonstrated. According to the clinical behavior of the disease, rituximab plus CHOP were administered but progression occurred after three cycles of treatment. Alemtuzumab was then administered achieving stabilization of the disease for another year. Ultimately, the patient was treated with le"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old female with no past medical history was transferred to our emergency department from an outside hospital due to concern for intra-abdominal bleeding. She initially presented with lower abdominal pain immediately following vaginal intercourse described as nonvigorous with the patient mostly ‘on top’, and no history of foreign body use or trauma. CT of the abdomen and pelvis with IV contrast performed at the outside hospital revealed an intra-abdominal hematoma with extravasation of contrast questionably from one of the branches of the left internal iliac artery (Figs and ). No adnexal lesions were identified on the CT. Upon arrival, the patient was complaining of constant, sharp, severe bilateral lower quadrant abdominal pain, nausea and fatigue. There was no history of loss of consciousness, vomiting, vaginal or rectal bleeding, or hematuria. A past surgical history consisted of appendectomy. Her last menstrual period was 19 days prior to presentation.\nOn examination, the patient was in painful distress. Vital signs were stable. Abdominal examination revealed bilateral lower quadrant and suprapubic tenderness with guarding. Perineal and genital examination revealed no evidence of trauma. Laboratory investigations revealed a white cell count of 12 200/mm3 and hemoglobin of 9.5 g/dl. Basic metabolic panel, partial thromboplastin time, international normalized ratio, lipase, ethyl alcohol level and urinalysis were normal. β-hCG was negative for pregnancy.\nBased on the CT scan findings, interventional radiology was consulted and selective left internal iliac artery angiogram was performed and identified no active extravasation or pseudoaneurysm. Exploratory laparotomy was then performed to identify the source of bleeding. Preoperatively, blood pressure was 97/47 and the heart rate was 76 bpm. Upon entry to the peritoneal cavity, 900 ml of hemoperitoneum was observed and washed out. Active bleeding was identified from a ruptured area on the left ovary and c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis was a 40 year old, premigravida patient who initially presented to the infertility clinic at our institution for desired pregnancy. Her past medical history was significant for primary infertility. A successful intrauterine pregnancy was achieved via intrauterine insemination. Due to advanced maternal age, the patient underwent extensive prenatal testing and monitoring through the course of her pregnancy. All tests were normal, with the exception of a left ovarian mass that was incidentally detected by ultrasound during the third trimester. The patient was closely followed without prenatal surgical intervention. Her pregnancy advanced uneventfully, and labor commenced at 40-week gestation. Due to failure to progress, a caesarean section was performed resulting in the delivery of a healthy female infant. At the time of caesarean section, a left oophorectomy was performed.\nThe specimen was received fresh for intraoperative pathology consultation. On gross examination, it consisted of an intact, unilocular, thin-walled cyst measuring 15 × 12 × 5 cm and filled with clear fluid. Both the outer and the inner surfaces of the cyst were smooth. The cyst wall ranged from 0.1 cm to 0.8 cm in thickness and showed marked edema. Based on the gross findings, an intraoperative interpretation of benign ovarian cyst was made. No frozen section was performed.\nOn subsequent microscopic examination, the cyst was lined by single to multiple layers of large cells with abundant eosinophilic cytoplasm (Figure ). Most cells showed small, round and regular nuclei, but focal cells displayed enlarged and bizarre nuclei with hyperchromasia and occasional mitosis (Figure ). The outer fibrous wall of the cyst showed edema and nests of luteinized cells that were morphologically similar to the cyst lining cells. Special stain showed reticulin fibers around nests of luteinized cells in the cyst lining (Figure ) and in the outer cyst wall. Adjacent residual ovarian tissue exhibited a corpus luteu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old man with history of prior myocardial infarction presented to our hospital with chest pain and shortness of breath; 8 months previously, the patient had been treated at the local hospital for ST segment elevation myocardial infarction with acute high lateral wall injury. He was treated with thrombolytic therapy. The patient was discharged without an echocardiogram and cardiac catherization due to limited resources, and he had not had a follow-up with a cardiologist because both doctors and the patient did not pay much attention to his condition as the symptoms had almost disappeared by then. Recently, our patient had been complaining of intermittent and slight chest pain, shortness of breath at rest, and frequent awakening due to chest distress at night for a duration of 2 weeks.\nResults of a physical examination indicated a blood pressure of 145/85 mm Hg, a heart rate of 88 beats/minute, a slightly expanded left margin of the heart, and a continuous 3/6 grade murmur between the third and fourth intercostal spaces at the left sternal border. An electrocardiogram examination revealed qR in leads I and aVL and inverted T-waves in leads I, II, aVL, and V3 to V6. Echocardiography showed a 13.1 × 8.8 cm limited oval anechoic area with a distinct boundary at the lateral posterior of the left ventricle, which was connected to the left ventricle at the basal segment of the lateral posterior wall of the left ventricle. Color Doppler sonography showed two streamlines of blood flow with a distance of 0.7 cm between the anechoic area and the left ventricle. Three-dimensional ultrasound indicated an echo dropout in an oval area in the basal segment of the lateral left ventricular wall, with a stroke volume (SV) of 70 mL, an ejection fraction (EF) of 63% and a cardiac output (CO) of 5.3 l/min. It indicated AMI and a perforation in the lateral wall of the left ventricle suggestive of a ventricular"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old woman presented with four days of moderate to high fever (104oC) and headache followed by progressive weakness. On the third day, she was suffering from vomiting five times in three hours, which ultimately weaken the patient. After four days of fever and headache, she consulted a doctor who had prescribed her paracetamol and advised to perform some clinical investigations such as complete blood count (CBC), dengue NS1, and the Widal test. The Widal test report was found to be negative, but the dengue NS1 test was reported positive. After consultation with the doctor, she got admitted to the hospital.\nAfter hospitalization, all the tests were conducted again, including the immunoglobulin M (IgM) antibody test and the factor VIII test. The results confirmed DF along with haemophilia A. On examination, the patient was found to be severely dehydrated with low blood pressure (60/85 mmHg) and was managed with continuous intravenous infusion of a multivitamin containing normal saline. Paracetamol was continued as the only drug for the treatment but headache and body pain were not alleviated. Platelet count was decreasing rapidly and due to continuous intravenous (IV) infusion, the patient developed cold and nasal congestion. Xylometazoline hydrochloride 0.1% drop was prescribed to treat nasal congestion, as the patient experienced mild breathing problems. On the second day, after the automatic cell counting test, the patient was found to be suffering from lymphopenia and leukocytopenia (Figure ).\nThe different haematological parameters were monitored continuously during the hospital stay (Table ).\nOn the fourth day, in the morning, the platelet level dropped to 31 x 10^9/L and the patient experienced bleeding from the nose with a mild earache. Tranexamic acid 100 mg/ml was administered to reduce the bleeding, which stopped completely after two days. An ultrasonogram of the whole abdomen revealed mild hepatomegaly with infiltration of the liver, splenomegaly,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old girl was having a bath at approximately 11 pm. She wore a moisturising gel mask covering most of her face, the only exposure to the air was via the apertures over her eyes and mouth. The lower half of her body lay completely submerged beneath the water, leaving her upper chest, arms and head above water. She had been using a commercially available pliable bubble foam spray manufactured to produce bubbles in the bath, and these had covered the surface of the water. The windows of the bathroom were left opened throughout and scented tea candles were placed along the peripheries of the bath. She accidently tipped one of the scented tea candles into the bath causing an immediate purple flash flame which engulfed her upper torso. She immediately commenced first aid comprising of a cold water shower over 20 min. She then presented to the local regional burns centre. On examination, her airway was patent with no sign of inhalational injury on oropharyngeal examination. However, she sustained partial thickness burns to her lips, face, right upper breast, neck and right arm which were patchy in distribution. There was also singing of eyelashes bilaterally but sparing of the eyebrows as these were covered by the face mask. Her lips appeared grossly oedematous and were the worst affected area, this was probably due to the aperture in the gel mask exposing this area. No ocular injury was noted on fluorescein examination. Final estimation of total burn surface area (TBSA) post debridement of blisters was approximately 1.5% superficial partial thickness burn with larger areas of surrounding erythema. She was managed conservatively with topical paraffin ointments and silicone dressings. Given the severity of lip burns, and the nature of flash burn which occurred in a small room, she was admitted for overnight for airway observation and pain management, and was discharged 24 h later ()."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female patient presented with the chief complaint of swelling in the right side of the palate of 1-month duration associated with dull, intermittent pain. History revealed that the patient had applied rock salt over the swelling to alleviate pain. Medical history revealed that the patient was undergoing infertility treatment for 7 months and had undergone surgery for uterine fibroid 6 years back. There was no history of dry eyes, dry mouth, joint pain or weight loss. The patient was a nonsmoker and nonalcoholic and had no tobacco chewing habits.\nOn intraoral examination, a single diffuse ovoid swelling measuring approximately 1.5 cm × 1 cm was present on the right side of the posterior hard palate []. The surface of the swelling was predominantly smooth with a focal shallow ulceration in the center. On palpation, the swelling was nontender, soft to firm in consistency and fluctuant. No tooth in the quadrant was tender on percussion. There were no clinical signs of dental caries or periodontal disease.\nIntraoral periapical radiograph of the right maxillary first molar and maxillary lateral occlusal radiographs revealed no significant changes. Cone-beam computed tomography of maxilla revealed a soft-tissue shadow in the right side of the hard palate in relation to maxillary right first molar with pressure effect on adjacent bone and thinning of cortical bone with no evidence of breach in the continuity of bone [Figures and ]. There was no periapical lesion in relation to maxillary right premolars and molars. We excluded a palatal abscess or a cyst by clinical and radiographic examination. The ulceration was shallow, associated with a smooth swelling and likely to have been caused by the abrasive effects of rock salt and hence necrotizing sialometaplasia was considered unlikely. Hence, a provisional diagnosis of benign salivary gland tumor or cyst was made with the differentials of malignant salivary gland tumor and nonodontogenic soft-tissue neoplasms.\nU"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA forty-year-old G3, now P2012, underwent a spontaneous vaginal birth after cesarean section presented to labor and delivery in active labor at term. The patient delivered a viable female infant weighing 3757 grams with APGARs of 8 and 9 at 1 minute and 5 minutes, respectively. Following spontaneous delivery of the placenta, the fundus was noted to be slightly prolapsed through the internal os. A fourth degree laceration occurred at the time of delivery due to the emergent maneuvers utilized to replace the uterus. Brisk vaginal bleeding was noted and 500 cc of blood clot was removed the uterus. Given the patient's inability to tolerate the exam, 1000 mcg of cytotec was placed rectally and the patient was moved to the operating room where general anesthesia was administered. Manual exploration of the uterus was again performed and an additional 1000 cc of blood clot was removed and an anterior fibroid with partial prolapse of the uterus was noted. The fundus was manually replaced superiorly and attention was then turned to the 4th degree laceration which was repaired in standard fashion without complication. Following the 4th degree repair, the uterus was noted to be atonic again and uterine massage and manipulation elicited an additional 500 cc of blood clot. The patient was given two doses of hemabate 250 mcg and the uterus was noted to be firm and hemostasis was confirmed. Total blood loss at the time of delivery was estimated to be 4.5 liters and the patient received 8 units of packed red blood cells (pRBCs) and 4 units of fresh frozen plasma. The postpartum course was uncomplicated and she was discharged home on postpartum day three.\nAt seven weeks postpartum the patient presented to the local health department with complaints of persistent vaginal bleeding since delivery. Upon speculum exam, she was noted to have a 5 cm prolapsed vaginal fibroid and was referred to the local tertiary center. Initial gynecology exam confirmed a prolapsing vaginal fibroid and she"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female came to our observation due to a limitation in mouth opening range. She also reported crepitus sounds at the left TMJ as well as pain, exacerbated by function (e.g., chewing) and increasing in intensity over the past three months. Clinical assessment showed a limited mouth opening (i.e., 22 mm) and pain with palpation at the left joint and all the main masticatory muscles, more severe on the left side. At the first appointment (T0), mandible manipulation was performed to achieve a forced opening of about 40 mm. A magnetic resonance (MRI) was prescribed to assess the disc-condyle relationship as the possible source of limitation in mouth opening and to gather some pictorial evaluation of the presence of joint effusion (). Despite the clinical suspicion of TMJ arthritis, computerized tomography was not prescribed at this stage due to the expected low impact on treatment planning decisions.\nMRI showed a regularly shaped condyle, with an anteriorized disc at closed mouth. At the maximum mouth opening, the condylar translation is reduced and the disc is not recaptured. Joint effusion of severe entity is also present. A conservative approach to provide pain relief and to manage muscle tension was provided, based on counseling, a home program of self-exercise and a stabilization appliance to wear at night. After three months, symptoms improved only partially, with a reduction of pain with muscle palpation but a steady pain at the left joint.\nBased on that, a cycle of five arthrocentesis plus viscosupplementation with hyaluronic acid (Sinovial, IBSA) has been performed weekly. Clinical data has been recorded at each time point before each injection and 15 days after the last one ().\nAfter one month from the last arthrocentesis plus viscosupplementation, the patient still showed some pain and, more important, still felt a limitation in the unassisted mouth opening and right laterotrusion. A diagnosis of TMJ intermittent locking on the left side was thus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old man, long time tobacco smoker, presented with two week history of marked thyroid pain and swelling. He also reported fever (up to 39 °C), weight loss and hoarseness. The patient’s GP initially diagnosed SAT based on the pain, fever and high ERS and started treatment with NSAID with initial pain relief. After a few days the severe pain relapsed despite treatment, and the patient was referred to hospital. In our Department his ESR was 93 mm/h and biochemical features of thyrotoxicosis were present, which may indeed strongly suggest SAT. In the neck, there was a hard, painful tumour, about 7 cm in size. The laboratory results obtained in our Department are presented in Table . US revealed slightly enlarged right thyroid lobe and significantly enlarged left lobe (65 × 57 × 101 mm) dominated by a heterogeneous tumour size of 55 × 50 × 72 mm, with numerous calcifications and a heterogeneous fluid space corresponding to abscess (Fig. ). Tumour vascularisation was reduced. Almost the entire left lobe showed a faded structure of the parenchyma, with no evidently visible capsule, with features of infiltration of the neck structures. FNAB confirmed the presence of abscess, and after introduction of antibiotic therapy, the concentration of free thyroxine (FT4) gradually normalized. In the remaining FNAB material only blood and numerous granulocytes and macrophages were described. Neck CT revealed large tumour of the thyroid, with visible compression and displacement of the trachea and infiltration of the surrounding structures (Fig. ). In chest CT, in both lungs, numerous milk-glass areas were present and the CT image corresponded to the diagnosis of lympangiosis carcinomatosa. The patient was referred to a surgery clinic, where only a small piece (20 mm) of the neck tumour was wedged to release the trachea; the complete surgery was impossible due to the extent of infiltration and hardness of the tumour. Histopathologically purulent necrosis was mostly observed, b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a morbidly obese (375 lbs) 58-year-old woman who presented to the head and neck surgery clinic with a right parotid mass and intact facial nerve function. She underwent a fine needle aspiration which was consistent with a Warthin's tumor. CT imaging demonstrated a 5.8 cm right parotid mass. She was scheduled for surgery, but was lost to followup. She presented again to the head and neck surgery clinic one year later with significant interval growth of the mass and a partial right facial paresis (Figures and ). A CT scan demonstrated a 11.2 × 9.4 × 10.7 cm mass centered in the right parotid effacing the jugular vein and abutting the mandible and skull base with extension along the facial nerve to the geniculate ganglion (Figures and ). She was taken to the operating room and underwent a radical parotidectomy with facial nerve sacrifice, radical neck dissection, parapharyngeal space resection, and lateral temporal bone resection (Figures , , and ). The tumor was found to be invading the jugular foramen requiring occlusion of the sigmoid sinus and packing of the jugular foramen for vascular control. The tumor was also noted to be extending medially to the geniculate ganglion of the facial nerve. Gross tumor removal was accomplished (). We were not able to obtain a negative margin on the proximal facial nerve; thus, the ipsilateral masseter nerve was grafted to the buccal and marginal mandibular branches of the distal facial nerve. Her face was further rehabilitated with a static palmaris longus sling and temporary tarsorraphy, which was later replaced with a gold weight. The defect was reconstructed with a large cervicofacial rotation flap and a radial forearm free flap (). Pathologic examination revealed a 14 cm low-grade acinic cell carcinoma with extensive perineural and lymphovascular spread. The lymph node dissection yielded 29 lymph nodes, all of which were negative for malignancy. Postoperatively, she received 6000 cGy in 30 fractions using intens"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old gravida 4 para 3 with a history of three previous cesarean deliveries presented at 16 weeks 6 days of gestation for follow-up ultrasound of perigestational hemorrhage seen at 10 weeks and 4 days. A large uterine cavity pseudoaneurysm measuring 4.2 × 3.8 × 3.7 cm and appearing to arise from abnormal placentation at the previous cesarean scar was identified (). Repeat ultrasound six days later revealed a normal active fetus in breech position compressing the pseudoaneurysm upon contact. An unenhanced MRI one week later confirmed a 4 cm hypointense lesion projecting into the lower right uterine cavity at the inferior margin of the placenta (Figures and ). Management options were discussed to include conservative imaging observation versus embolization. Due to high maternal mortality risk from spontaneous hemorrhage, elective termination was also discussed but was rejected by the patient.\nA novel use of dynamic time-resolved contrast-enhanced MRA utilizing a functional MR urography protocol™ was performed for enhanced characterization of feeding arteries and treatment planning/mapping []. The specific MRA parameters utilized can be viewed in detail online at . Although not FDA-approved for a second trimester fetus, Gadobutrol® contrast agent was selected to reduce risk of gadolinium deposition. Gadobutrol is a macrocyclic agent that imparts strong chelation of the substrate to gadolinium. It reduces potential toxicity from free gadolinium and, at the time, was the only FDA-approved agent for patients below 2 years of age (down to 37 weeks of gestation). Gadobutrol was dosed per the manufacturer's protocol with recommended weight-based dosing of 0.1–0.3 mmol/kg. Informed consent was obtained for this unique use of MRA at 20 weeks of gestation.\nMRA revealed two suspected feeding vessels: a branch off the right ovarian artery parasitized to the uterine arcuate artery () and a branch off the right uterine artery parasitized to the uterine arcuate and radial ar"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur hepatobiliary surgery outpatient department accepted a 66-year-old woman, who presented with a year-long history of aggravating abdominal discomfort that was mainly associated with distension and symptoms such as epigastric fullness, eructation, decrease of food intake and early satiety. She did not report any loss in body weight. A physical examination revealed a palpable mass in the upper abdomen, extending from the right hypochondrial region to the left hypochondrial region, with ordinary consistency and a smooth surface. Her liver and spleen were not palpable distance from the costal margin, and were not tender on palpation. All routine blood and biochemical markers were normal. The levels of tumor markers assessed, including carbohydrate antigen 125 and carcinoembryonic antigen, were within the normal ranges.\nAn upper gastrointestinal barium series revealed the antrum, fundus and body of her stomach, as well as the jejunum, were prominently compressed and infraplacement (Figure ). However, the gastroscope examination did not show any abnormality. An abdominal ultrasound revealed a sharply defined mass with an intact capsule and opaque dark areas of fluid detected in the middle region, suggestive of a huge cystic solid myoma. We were not able to identify any connection between the adjacent organs and the mass because the tumor was too large to obtain a clear view.\nEnhanced abdominal computed tomography (CT) scans demonstrated a deformed liver of abnormal size and structure, and a large low-density region featuring a well-circumscribed border that overlay the entire left liver and partially overlay the right liver. The tumor contained inhomogeneous cystic components mixed with solid elements (Figure ). In the arterial phase, complete filling of the tumor with contrast material was never observed; patchy enhancement indicated possible tumor necrosis in the low-attenuation areas. The area of lower density also did not enhance completely on delayed scans. There"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old male presented 9 months post TAVR at another institution with PVR complaining of NYHA class III symptoms of increasing fatigue, dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. A 26 mm Edwards Sapien 3 bioprosthetic TAVR valve had been implanted, but the intraoperative sizing at that time was based on transesophageal echocardiography (TEE) instead of CT scan imaging. Unfortunately, that procedure was also complicated by a Stanford Type B descending thoracic aortic dissection that required emergent thoracic stent coverage to treat visceral malperfusion. The patient developed mesenteric ischemia requiring bowel resection. After a prolonged hospitalization, he was found to have moderate aortic regurgitation on follow-up echocardiography, which was managed medically until his presentation to our center.\nPhysical exam revealed a diastolic murmur and 1+ lower extremity edema. A TEE revealed moderate paravalvular aortic insufficiency comprised of two jets: the largest was along the postero-medial aspect including approximately 20% of the valve circumference, while a smaller jet was along the antero-lateral aspect of the valve and involved an additional 10% of the valve circumference. TEE also showed dilation of the mitral annulus with subsequent moderate mitral regurgitation and reduced left ventricular ejection fraction of 40% to 45%.\nGiven his frailty, comorbidities and history of aortic dissection he was not an open surgical candidate. Transcatheter methods including Amplatz plug versus redo-TAVR were considered and the patient underwent computed tomography evaluation of the aortic root and review of his previous left heart catheterization.\nGiven the multiple jet PVR consensus formed that ViV TAVR would be a superior solution to surgical or transcatheter placement of vascular occluder devices. Based on repeat computed tomography and transesophageal imaging we hypothesized the initial valve was undersized, resulting in the multiple foci of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 30-year-old Tibetan man, was treated in the Lhasa Hospital for right tibiofibular fracture December 2012 (Fig. ). After the swelling subsided, he underwent right tibia fracture intramedullary internal fixation. Two weeks after the operation, the patient was able to walk with double crutches without load, and was able to walk without crutches and with some load 3 months after the operation. However, the patient complained of pain in his right lower extremity, especially when moving downhill or down stairs, and experienced a limping gait and obvious tenderness at the fracture end. Three years after originally presenting at Lhasa Hospital, the patient was experiencing persistent pain in the right lower extremity, and his daily activities were severely affected. Thus, he was re-diagnosed with nonunion of the right tibial fracture after internal fixation (Fig. ). The main causes of the nonunion of the fracture were considered to be the excessively thin intramedullary nails and unstable fixation of the fracture. The operation was repeated with replacement of the crude intramedullary nails and grafting of iliac bone (Fig. ). Three months after the operation, the tibial fracture had failed to heal, and further surgical treatment was performed. The proximal locking screw of the intramedullary nail was removed with an expectation to eliminate the stress shielding effect and to promote fracture healing by increasing the microdynamic force while retaining the static interlocking nail. Five months after the operation, the patient abandoned the crutches and was able to walk with a heavy load. Nevertheless, 2 years after the operation, active pain of the right leg persisted with some tenderness around the fracture, especially when moving downhill or down stairs. August 2018 the patient was admitted to our hospital. Physical examination revealed that two old incision healing scars, approximately 2 cm in length, were present at the proximal and distal ends of the righ"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 57-year-old man who presented in July 2009 with decreased vision bilaterally, left sided facial weakness, ataxia, and short-term memory loss. The patient had also presented previously with a history of seizures, most recently a few months prior to the current presentation. A craniopharyngioma or another parasellar mass was suspected, and an ophthalmology consult was obtained.\nMRI showed a large intrasellar mass with considerable suprasellar extension and chiasmatic compression with the displacement of the inferior frontal lobe. There was also hydrocephalus with gross enlargement of the lateral and third ventricles (). A hormone panel showed increased levels of FSH and LH of 46.3 mIU/mL and 12.3 mIU/mL, respectively. Plasma ACTH, IGF-I, growth hormone, prolactin, total cortisol, and testosterone were all within normal limits. CSF analysis identified no malignant cells.\nThe patient was determined to be an excellent candidate for surgery, the only other comorbidity being glaucoma treated with Lumigon. Because of the location of the tumor, it was decided that the patient would undergo a right pterional craniotomy/transsylvian approach for the resection of the tumor and the placement of a ventriculostomy catheter. After placement of a ventriculostomy catheter, the major part of the craniotomy followed. The first line of incision was made in a curvilinear fashion that began at the area 1 centimeter anterior to the tragus of the ear near the root of the zygoma. It curved superiorly up around the temporal bone and parietal bone and then extended toward the midline frontal bone. Dissection proceeded to expose the appropriate amount of cranial anatomy. The tumor was eventually exposed by opening up the sylvian fissure to separate the frontal lobe from the temporal lobe. The tumor was noted to have both cystic and solid components. Fluid aspirated from the cystic component was thick and yellow, with the appearance of oil or cholesterol. There were odd appearin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year old man presented to the emergency department of a general hospital with progressive weakness of the right side of his body and speech difficulties, 3 years after his first transient ischaemic attack. Five days previously he had attended the emergency department because of loss of strength in his right foot. Examination at that time, at the department of neurosurgery, revealed a disc herniation, providing an explanation for his symptoms, and surgery was planned. In the following days, he developed new complaints, with difficulty speaking and movement problems of both the right arm and right leg. When he could no longer take care of himself, he again attended the emergency department, where investigation revealed a semirecent ischaemic stroke.\nHe had a history of diabetes mellitus type II, a transient ischaemic attack in 2016 (occlusion of the arteria cerebri media on the right side) with complete recuperation, and back surgery. On clinical examination, he was alert, but showed delayed movements on the right side. Cranial nerve examination was normal, except for a slight paresis of the facialis nerve on the right side. There was a right-sided hemiplegia, hyperreflexia and sensibility disturbances. There was spasticity grade 2 on the modified Ashworth Scale in the upper extremity and grade 1 in the lower extremity. There was dysarthria and word-finding problems. An unexpected sign was that he was unable to release his grip in the Jamar and pinch test. He was oriented in place and time, but there were moderate deficits in concentration and attention. There were no arguments for visual neglect. There were slight extrapyramidal symptoms, which were new and had not previously been described in his medical history. For treatment of his extrapyramidal symptoms, the neurologist was started medication (Prolopa, Levodopa, Roche Belgium) without further investigation.\nBrain magnetic resonance imaging (MRI) revealed hyperintense signal changes periventricular to cortic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman was referred to our hospital with liver masses in an ultrasound study that was requested because of vague upper abdominal pain. She also mentioned mild nausea that started one month earlier. Medical history revealed three normal vaginal deliveries and she was receiving medroxyprogesterone acetate injections every 3 months for contraception.\nThe patient’s physical examination was normal as well as her laboratory tests, which included complete blood count (CBC), liver biochemical tests, tumor markers, sedimentation rate (ESR), and C-reactive protein (CRP) (). Esophagogastroduodenoscopy (EGD) was done, which showed only Los Angeles grade B reflux esophagitis.\nThe initial ultrasound study showed three hypoechoic subcapsular nodules with maximum diameters of 25 mm in the right hepatic lobe in a background of normal liver parenchyma (). Abdominal and pelvic computed tomography (CT) with intravenous/oral contrast revealed two hypodense lesions of 10 and 12 mm diameters in the anterior segment of the right hepatic lobe and one 25 mm diameter lesion with more density in the posterior segment of the right hepatic lobe. Red blood cell single photon emission computed tomography (RBC-SPECT) was performed to rule out hemangioma (). Ultrasound guided liver biopsy was done to make a definite diagnosis. Two 1×10 mm biopsy specimens were sent for histopathological study. Hematoxylin and eosin stained (H&E) sections of liver specimens showed multiple foci of proliferating bile ducts composed of bland cuboidal cells and duct formation in the fibrotic and inflamed portal spaces. Bile duct proliferation was compatible with BDA (). Immunohistochemical (IHC) staining was done for CK7 and P53, which showed positive for CK7 and negative for P53.\nAs no risk factors were known to have a relationship with BDA, the patient was advised to discontinue medroxyprogesterone. A proton pump inhibitor was started to treat the esophagitis. She was then followed up for two years by rou"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn September 2008, a 43-year-old woman presented to the Emergency Department at Frenchay Hospital with a 3-month history of back pain, right hip and knee pain, right leg weakness, constipation and urine incontinence, altered sensation in the limbs, and visual disturbance with flashing lights in the left eye. Two weeks prior to this admission she was seen at Frenchay Hospital with cauda equina symptoms. She has had an MRI of the spine, which showed a disc prolapse but did not explain the symptoms. The patient was discharged. However, her pain continued to worsen, and sensation changes progressed across the whole of the perianal region. She was unable to sit down for 8 weeks due to pain on flexion and started using a stick as her right leg was weak.\nOn examination she had a decreased sensation in the perianal area. Neurological examination of the upper limbs revealed a slight numbness of the radial side of the forearm. Neurological examination of the lower limbs revealed the following: reduced power in the right hip flexion (1/5) and extension (2/5), the power in the left leg was 4/5, absent reflexes in both legs, reduced sensation in the right medial aspect of the distal right calf dorsum of the foot sole and the lateral dorsum of the left foot and the sole of the left foot. On examination of her visual fields, she demonstrated a loss of outer vision in her left eye.\nCT and MRI of the head showed metastases in the right parietal occipital region, together with some smaller metastases associated with the dura and skull base (fig ). MRI of the spine revealed fairly diffuse infiltrating nodules in the nerve roots of the lumbosacral plexus. Her performance status was 3 due to progressive leg weakness.\nThe diagnosis was meningeal carcinomatosis with brain metastasis from breast cancer. No other signs of metastatic breast cancer were seen on CT at this point.\nA year prior to presentation, she had been diagnosed with 4 × 3 cm grade"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man presented to the outpatient department with complaints of an intermittent headache and a right swollen ankle, which became worse after activity. His history included a craniocerebral trauma related to a fall during alcohol intoxication. In the first quarter of 2015, during the removal of cranial epidural hemorrhage, percutaneous catheterization of central veins via the right femoral vein was attempted because of the need for intravenous infusion. After the surgery, the patient was sent to the intensive care unit for postoperative care. A few days later, the patient was discharged home; he demonstrated a slight weak muscular tension in his right upper extremity and had difficulty in speaking extended sentences. Approximately 1 and a half months after the surgery, the patient was re-examined by CT. The CT scan showed that 1 guidewire had ascended in the superior vena cava and the heart. Despite this finding, the hospital was unable to perform the surgery to remove the guide wire, and the doctors suggested that he should have a follow-up visit in every few months. The patient ignored the guide wire, took no medication, and continued to lead a normal life. In January 2016, the patient received another CT scan which revealed that the guide wire had arrived at the cerebrum. However, the patient did not have any symptoms of discomfort. The doctors suggested that the patient should go to a better hospital for further treatment.\nAt this point, the patient presented with swollen ankle and headaches, and as a result, he wished to have the guidewire removed. The patient then underwent a comprehensive CT scan, which revealed that the guide wire had broken into 2 segments. One segment (with a diameter and length of 2.0 mm and 535 mm, respectively) had arrived at the right brachiocephalic vena cava, and the other segment (with a diameter and length of 1.2 mm and 323 mm, respectively) had arrived at the cerebrum (Figs. and ). Both the diameter and the length"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nClinical case 2: a 48-year-old female patient who, since 2009, has been showing weight gain, predominantly on the face and thoraco-abdominal area, with facial erythrosis and joint pain. She was admitted to our department for diagnosis and treatment. Physical examination on admission showed: a height of 145 centimeters; a weight of 82 kilograms; a blood pressure of 180/85 mmHg; capillary blood glucose at 0.91 g/l, with a typical clinical picture of hypercorticism with the presence of pain on palpation of the thoracolumbar spine. A hormonal panel found a UFC level elevated to twice the normal at 520 μg/24h, plasma ACTH was at 18 μg/ml (10-60). Adrenal CT scan showed a right adrenal gland containing a nodule which is enhanced shortly after injection of contrast agent and measures approximately 28 mm, the left adrenal was of normal non-hypertrophic morphology. High blood pressure, left ventricular hypertrophy shown on echocardiography and depression were all complications of hypercorticism that were found in the patient.\nOnce the diagnosis of Cushing's syndrome was made, a laparoscopic right adrenalectomy was performed. Histological examination showed a right adrenal gland measuring 45 x 30mm. The multiple samples examined show an adrenal parenchyma surrounded by a thin and sometimes moderately thick fibrous shell with emanations towards the parenchyma. On microscopic examination, it was a hyperplasia of the adrenal parenchyma involving the cells of the medulla and the cortex with a predominance of spongiocyte, as well as the presence of small foci of compact cells with nuclear atypia. In conclusion, it was macro nodular adrenal hyperplasia. Five years after the surgery, clinical evolution was marked by the regression of the signs of Cushing syndrome and the persistence of a slight facial erythrosis, the weight went from 82 to 64 kilograms, although the patient kept residual high blood pressure, it was less severe, measured at 160/90 mmHg. On the paraclinical level, pla"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old male patient presented with a history of pain in the left hip for the past 6 months. The pain was insidious in onset, intermittent, occurred predominantly at night, progressively increasing with time, 6/10 on a visual analog scale and was present over the anterior aspect of the left hip. It was non-radiating and there were no aggravating factors for pain. However, he got some relief with over-the-counter analgesics. There was no history of antecedent trauma and the remaining history and general examination did not reveal any significant abnormalities. Local examination revealed diffuse tenderness over the anterior aspect of the left hip. There was no palpable swelling or wasting of the leg muscles. The range of motion of the left knee and ankle joints was normal and there was no neurovascular deficit distally.\nX-ray left hip showed the small radiolucent area with sclerotic margin in the left femur neck along its superior border (). CT scan of the left hip showed, presence of osteoid osteoma in the region of the superior border of the femoral neck of diameter 0.5 cm (). After all the necessary investigations, the patient was planned for radiofrequency ablation of the tumor under CT guidance. Magnetic resonance imaging hip showed a rounded cortical based lesion with internal specs (nidus) suggestive of osteoid osteoma ().\nAfter all the necessary investigation and routine workup, the patient was taken for the procedure under the CT guidance.\nUnder all aseptic precautions, the procedure was started. CT scan was obtained to precisely localize the lesion and multiplanar reconstructions were used to plan the optimal transcutaneous approach. Close attention paid to the adjacent blood vessels and nerves, since these structures must carefully be avoided. A penetration cannula with an inner stylet was introduced through the skin and soft tissue according to the previously established access route. New CT images are then obtained to verify the correct position of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMrs. A. A, a 40-year-old Para 2-+-0 with no living child, (last child birth was 3 years and last menstrual period was 2 weeks prior to presentation) was seen at gynecological clinic with a history of abdominal distension of 3 years duration. The distension started gradually in the suprapubic region: - it later progressed to involve the entire abdomen. There was no change in the menstrual period and cycle. There was no change in urinary or bowel habit. There was no vomiting, cough, jaundice or abnormal vaginal bleeding. There was associated with mild abdominal discomfort and weight loss. She had been taking herbal medications since the onset of the above problem. When the mass became very large, it prevented the patient from carrying out her normal activities. The patient sought medical care at Awka General Hospital where a diagnosis of ovarian tumor was made. She was subsequently referred to Nnamdi Azikiwe University Teaching Hospital, Nnewi for expert management. She attained the age of menarche at 14 years. She was neither aware of Pap smear nor contraceptives. The past medical history was not contributory. There was no family history of such ailment. She was the third wife of her husband who was a farmer. She did not take alcohol or tobacco in any form.\nOn examination, she was chronically ill looking and pale. She was neither jaundice nor febrile. The pulse rate, blood pressure, and temperature were normal. Her body weight and height were 63 kg, and 160 cm, respectively. The cardiovascular and respiratory systems were normal. Abdominal examination revealed grossly distended abdomen, which was tense and visible veins [Figures and ]. The abdominal circumference was 126 cm measured at the level of the umbilicus. The liver, spleen and kidneys were difficult to assess due to the tensed abdomen. On vaginal examination, the vulva, vaginal and cervix appeared normal. The uterine size and adnexae were also difficult to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn March 2016, a 47-year-old male patient was admitted to the Oral and Maxillofacial Surgery and Traumatology service of a public hospital, referred by the medical team with the chief complaint of respiratory difficulty after the appearance of a soft palate lesion. On anamnesis, the patient reported rapid weight loss, drug use for more than 10 years, and the development of a hard palate lesion three years earlier, which was left untreated. In addition, the patient reported the development of a soft palate lesion one month earlier. Intraorally, an extensive mass of mucosa-like color was present in the palate region, which obstructed the oropharynx and consequently caused dyspnea.\nThe sagittal computed tomography (CT) image reveals a soft tissue mass in the nasal cavity extending to the posterior portion of the nasopharynx and the lower part of the sphenoid sinus, with lowering of the entire musculature of the soft palate (A). The coronal CT image shows density loss of the septum in the nasal cavity and nasal conchae, maxillary sinus opacification, and lesion extending to the sphenoid cavity floor (B). The axial CT image reveals the soft tissue mass observed in the nasal cavity with opacification of the maxillary sinuses (C).\nAfter the initial examinations, the patient was submitted to tracheostomy (A) and intraoral incisional biopsy under general anesthesia (B). Intraoperatively, the tumor had a fibrous consistency and showed normal bleeding. The specimen was sent for histopathological analysis (A). Microscopically, the presence of a densely collagenated connective tissue was observed, with numerous blood vessels that were usually of small caliber and sometimes congestive; also, foci of hemosiderosis were visible (B). Based on the microscopic reports, clinical-radiological characteristics and physical examination, the diagnosis of NA was established.\nThe patient was referred for excision of the lesion. However, due to the extension of the lesion and the patient's sys"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old male patient was referred to our hospital because of chronic low back pain for 10 years, acute worsening with radiating pain to left lower extremity over a month. The patient had a chronic low back pain for 10 years. He was diagnosed with LDH and lumbar fasciitis and received conservative treatment in local hospital. The back pain was acute worsening with radiating pain and numbness to the left shank and 1st toe over a month. The patient had experienced Traditional Chinese Medicine (TCM) acupuncture treatment on lower back for five times in the past 1 month before admitting to our hospital. The patient told the longest needles were about 7–8 cm and he could feel the needle hit on the bone during the process of acupuncture. He had a history of hypertension which was controlled well with medication for 10 years without history of any kinds of infection. There was no contact history of cows, goats or raw milk as well. The patient had a 30 years history of smoking, about ten cigarettes per day. There was no history of tuberculosis (TB), alcohol abuse or illicit drug use as well as family history of other diseases for him. On physical examination, the patient had no fever or loss of weight, and his vital signs were stable. However, he had tenderness points on his low back, and had 3/5 dorsiflexor strength in his left 1st toe. Decreased sensation of pin prick over left lateral shank and medial dorsal foot was documented. The straight leg raising test was positive in this patient’s bilateral lower extremities. The Visual Analogue Score (VAS) was 7.\nLaboratory examinations indicated a normal white blood cell count of 7.6 K per mm3, erythrocyte sedimentation rate of 69 mm h− 1, and C-reactive protein of 47 mg L− 1. Lumbar X-ray showed degeneration of lumbar spine, hyperplasia of vertebrae, no significant narrowing of inter-vertebral space at L4-L5 level"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old male kidney transplant recipient affected by Lowe's syndrome was admitted to our hospital for a hematoma on his left forearm.\nThe patient had a history of end-stage renal disease (ESRD) and had undergone hemodialysis for 11 years through a distal AVF on his left forearm. In 2013, the patient received a deceased-donor kidney transplant and has been treated with immunosuppressive therapy with tacrolimus 1 mg + 0.5 mg daily ever since. He also had a recent history of ischemic stroke and accidental fall at home which caused a trauma of his left wrist.\nA week before the admission, the patient was evaluated by the surgical team of our department because of a painful and swelling mass on his left forearm where the AVF for hemodialysis was originally created.\nThe enlarging mass first appeared two months before and was treated in another hospital as a complicated AVF, and thus the vascular access was closed.\nDuring the hospitalization in our Nephrology Department, the patient underwent surgical revision of the hematoma and ligation of the distal radial artery. A left wrist radiogram was also performed which showed an area of diaphyseal osteolysis of the radius surrounded by a voluminous soft-tissue swelling. After a few days, the radial artery required ligation right after its origin from the brachial artery because of enlarging hematoma.\nAfter a short time of apparent stability, the patient was admitted once again to our emergency department because of active bleeding from the surgical site which required urgent evacuation of the hematoma. Although the specific source of the hematoma was undetectable, the hemostasis was achieved using surgical glue devices. A surgical reduction of the brachial artery's diameter was also necessary. The hospitalization was complicated by two events of severe anemia which required blood transfusions.\nDuring the follow-up, because of chronic anemia and worsening of the forearm lesion, the patient was readmitted to our department."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Brazilian male patient was admitted to the hospital with a palpable lump in his right breast, located at the junction of the upper quadrants of the right breast (Fig. ). On physical examination, the lesion appeared firm with irregular margins. Axillary lymphadenopathy was negative and there were no palpable supraclavicular nodes. On breast imaging, ultrasonography showed a hypoechoic mass with partially defined contours measuring 4.0 × 3.0 cm, located at the upper region of the right pectoralis major muscle at the 12 o’clock position with muscle infiltration (Fig. ). Histological examination of core biopsy samples revealed a malignant tumor. Preoperative exams, such as X-rays and chest CT scan, abdominal US did not show any signs of disease. Radical mastectomy was then performed, due to pectoralis major muscle infiltration, consisting in removal of the breast along with the major and minor pectoralis muscles. Biopsy of the sentinel lymph node was performed. Gross examination revealed a solid tumor measuring 3.7 × 3.5 cm with a yellowish-tan cut surface and local foci of hemorrhage. Histopathology showed intravascular papillary proliferation of endothelial cells, spindle cell areas and necrosis, atypia and prominent mitotic figures, consistent with the diagnosis of high-grade angiosarcoma with areas of infiltration of the pectoralis major muscle (HE staining, magnification of 400×) (Fig. ). Histopathology also demonstrated a surgical specimen with clear margins, absence of angiolymphatic and perineural invasion, in addition to sentinel lymph node free of metastasis. Immunohistochemical study revealed a tumor positive for CD31 marker (Fig. ), confirming the vascular nature of the tumor. At the two-week follow-up of the surgical procedure, adequate wound healing was observed, without any evidence of the disease. The patient was transferred to the clinical oncology department, where he presented with severe headache and seizures after the second cycle of a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a 67-year-old female admitted with dyspnea and new onset atrial fibrillation with rapid ventricular rate. She was diagnosed with Graves' disease 3 weeks earlier and had been started on 20 mg of methimazole daily. Thyroid function tests showed suppressed TSH with elevated Free T3 and Free T4. Details of lab results are given in . Pro-BNP was elevated at 1762. Chest X-ray revealed unilateral right pleural effusion which was subsequently drained by thoracentesis and was consistent with transudative effusion. She was managed as a case of congestive heart failure. Her heart rate control was optimized and the dose of methimazole was increased to 30 mg once daily. She was discharged home but readmitted 2 days later with recurrent dyspnea. A repeat chest X-ray showed recurrence of the right pleural effusion. Transthoracic echocardiogram was done showing normal ejection fraction and diastolic function. Her heart rate was controlled. Repeat thyroid function tests showed a normal free T3 and almost normal free T4. Patient was diuresed, and the unilateral right pleural effusion was drained again. The fluid characteristics showed a transformation from transudative to exudative likely in the setting of recent diuretic use.\nShe was then discharged home after she had improved clinically only to be readmitted again with worsening dyspnea attributed to reaccumulation of the right pleural fluid a few days later. A repeat drainage with pleural catheter was performed, and the fluids revealed an exudative process with elevated LDH. This was further evaluated with a CT scan of the chest with contrast (Figures and ) which showed mediastinal lymphadenopathy and a diffuse ground glass process involving the right lower lobe suggestive of pneumonitis. A bronchoscopy was also performed. The bronchoalveolar lavage showed neutrophil predominant fluid, and cytology and adenosine deaminase were negative. Patient also had an endobronchial ultrasound-guided biopsy of the lymph nodes (EBUS)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old female patient with localized intrahepatic bile duct dilatation was found by physical examination for 20 years. For recent 3 years, the patient felt repeated right upper abdominal pain and distension, and aggravated for half a year, without fever and jaundice. She was admitted to our hospital for further examination and treatment. The patient's physical examination and hematological tests, including tumor markers Ca-199 were unremarkable. Enhanced CT and magnetic resonance cholangiopancreatography (MRCP) suggested that the intrahepatic bile duct dilatation in segment 4(S4) with an extent of 2.5*3.0 cm (Fig. a, b). Hepatobiliary ultrasound revealed localized dilatation of bile duct with local acoustic enhancement in S4 of the liver (Fig. c). On the basis of these findings, a diagnosis of S4 localized bile duct dilatation with lithiasis was made. Given the recurrent and persistent symptoms, the patient opted for surgical resection of biliary dilatation. Correspondingly, we selected to perform a combined resection of segment 4b and part of 4a with the guidance of subsegmental ICG staining, so as to facilitate the laparoscopic operation more simply and accurately, as well as to retain normal tissues in a certain extent.\nIntraoperatively, after mobilization of the liver, relationships of the pathological segment with the hepatic vessels were confirmed by LUS, which was consistent with the preoperative CT imaging (Fig. d). ICG fluorescence positive staining method was performed to define the exact anatomical location of the lesion. Portal vein branch of the target hepatic segment was super-selected and visualized longitudinally, followed by punctured with a 18G needle by LUS guidance, then an injection of 0.05 mg ICG was performed gently (Fig. a, Additional file ). The specific configuration method of dilution was as follows: 25 mg ICG was dissolved in 10 ml sterilized water, and then taken 1 ml of which into 100 ml saline. Significantly, special attention m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 55-year-old African American male with a significant past medical history of known breast cancer, who presented to an academic teaching hospital in February of 2018 after a surveillance computed tomography (CT) scan of his chest, abdomen, and pelvis showed incidental acute appendicitis. The patient was asymptomatic on his original presentation but subsequently developed nausea and vomiting along with right lower quadrant abdominal pain in the following days resulting in admission to the general surgery service for treatment of appendicitis. The patient did not have any contributory family, drug, or psychosocial history.\nOn chart review, the patient had an extensive past oncological history dating back to 2014 after resection of an enlarging, exophytic, ulcerating chest mass on the right side just lateral to the midline. Pathology from the wide local excision of this mass demonstrated estrogen receptor (ER) positive, progesterone receptor (PR) positive, and HER2/neu negative metastatic adenocarcinoma with an unknown primary source at the time. He underwent esophagogastroduodenoscopy (EGD) and colonoscopy to rule out a primary gastrointestinal malignancy, however, both were normal. He was followed closely by medical oncology and treated with tamoxifen for hormone therapy. Due to an enlarged anterior mediastinal wall lymph node discovered on routine CT surveillance in May of 2017, the patient underwent CT-guided biopsy and positron emission tomography (PET). The biopsy was negative for malignancy, however, the PET demonstrated abnormal, hypermetabolic activity within a retrosternal nodule, intense activity in a mixed focus in the manubrium, and several hypermetabolic nodes within the mediastinum. It also showed an abnormal hypermetabolic focus in the cecum suspicious for a colon primary (, ). An attempt was made to complete a colonoscopy at the time, but the gastroenterologist could not advance the colonoscope past the transverse colon due to technica"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old female patient had first reported to the ENT Department of the Cantonal Hospital in St. Gallen, Switzerland, in 2001, with severe and progressive nasal blockage. Symptoms had begun 5 years earlier but had been left untreated. She was however known to have an aspirin and histamine intolerance. In addition, she had suffered from symptoms that had been interpreted as hay fever and asthma since her youth and reported a positive family history for nasal polyposis.\nPhysical findings documented at the time included a normal appearing external nose, complete bilateral obstruction of the nasal cavities by nasal polyps, and anosmia. The anosmia was determined by testing with Sniffin' sticks whereupon the patient was able to identify 3 out of 12 possible odors.\nA CT scan showed hypoplastic frontal sinuses and a complete obstruction of all the other paranasal sinuses, with normal bony anatomy of the external nose. After medical treatment with topical and systemic steroids failed, the patient underwent an endoscopic sphenoethmoidectomy and maxillary sinus fenestration in 2002. Upon histologic examination of the polyp tissue respiratory mucosa with severe chronic eosinophilic inflammation was found. Postoperative treatment included topical and systemic corticosteroids. Aspirin desensitisation therapy was repeatedly discussed but declined by the patient. The sense of smell returned and the patient now identified correctly 11 out of 12 possible odors. The patient was free of recurrence during 5 months of follow-up in the hospital before continuing follow-up in the vicinity of her home. During this further follow-up, the sense of smell was not documented.\nIn March 2014, the 38-year-old patient was again referred to the ENT Department of Cantonal Hospital in St. Gallen, Switzerland, because of complete bilateral nasal obstruction with polyps visible in both nares and a progressive widening of the bony and cartilaginous nose. The patient reported a recurrence of nasal ob"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old male of Indian origin, who was moderately built and nourished presented for treatment of mobile lower front teeth. However, the patient had also noticed a swelling in the floor of the mouth of five months duration. Initially pea sized, the swelling had constantly and gradually increased in size. The swelling nevertheless did not cause any pain, discomfort, dysphagia nor speech or masticatory difficulties to the patient.\nExtra orally there was no clue of the swelling. Clinical intra oral examination revealed periodontally compromised mandibular anteriors. The floor of the mouth revealed a solitary, well circumscribed, distinct, dome shaped sessile midline swelling extending from the lingual aspect of the mucogingival junction of mandibular anterior teeth up to the mandibular molars bilaterally. The mucosa over the swelling appeared normal without any secondary changes. Tongue was slightly raised but the morphology of the swelling did not vary with tongue moment (Figure ). On palpation the swelling was soft to firm, non tender, smooth, fluctuant and was not associated with any discharge. Although submandibular and sublingual gland orifices could not be assessed because they were masked by the swelling, bilateral milking of the glands produced thick, mucous saliva.\nMandibular cross sectional radiograph did not disclose any calcifications. The buccal and lingual cortical plates were normal with no indication of expansion or decortication.\nAspiration from two different sites using an 18 gauge needle yielded scanty white cheesy material. Complete hemogram and ESR were within normal limits.\nUltrasonography showed a well defined submucosal oval mass in floor of mouth in the midline measuring approximately 4.0 × 3.0 cms in diameter with internal echoes. The underlying tongue musculature was normal.\nFNAC showed few squamous cells with mild hyperchromatic nuclei visible in the background of sheets of macrophages, few lymphocytes, abundant keratin flakes and anucl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Hispanic male with a history of coronary artery disease, hypothyroidism, and arthritis underwent a CT scan of the abdomen and pelvis for an unrelated complaint and was incidentally found to have a hypervascular left renal mass suspicious for malignancy. He was referred to an outpatient percutaneous transcatheter renal artery embolization, in preparation for a subsequent radical left nephrectomy with a view to decrease intraoperative bleeding at surgery. Physical examination prior to the procedure was essentially normal and did not reveal any cardiopulmonary abnormalities. The patient received intravenous conscious sedation over a period of 60 minutes consisting of 100 mcg fentanyl and 1.0 mg midazolam, administered in intermittent doses, while undergoing continuous physiologic monitoring. Per protocol [], the procedure was performed using a total of 40 mL of pure ethanol divided into three doses and administered in slow pushes at 15-minute intervals. This dose was derived based on a weight of roughly 80 kg, using the lower end of the recommended dose of 0.5–1 mL/kg. The result was a significant reduction in tumor vascularity, with approximately 10% residual renal artery tumor perfusion.\nAfter the third ethanol injection, the patient developed cough, agitation, and acute respiratory distress with hypoxemia (SpO2 of 80%; normal >92%). He required sedation and emergent intubation for airway protection. Given the concern for pulmonary embolism, pulmonary angiography was immediately performed and showed patent pulmonary arteries, without central or segmental pulmonary artery embolus or vessel occlusion. The procedure confirmed the presence of PAH with a mean pulmonary artery pressure (mPAP) of 70 mmHg (normal <25 mmHg). Acute pulmonary vasospasm due to venous shunting from the systemic intra-arterial ethanol administration was suspected. A Fogarty balloon was inflated in the renal artery to prevent further dissemination of ethanol into the systemic circulat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old obese Hispanic young man presented to the orthopedic surgery service with right-sided ankle pain. His pain began after a sports injury approximately one year prior to presentation but did not respond to immobilization, physical therapy, or prolonged rest. The pain was located at the medial side of the ankle, was worse with activity, and was accompanied by intermittent swelling. He took ibuprofen at night occasionally that provided modest relief.\nHis past medical history was unremarkable. Family history was negative for autoimmune disease including JIA. His only medication was occasional ibuprofen, and his immunizations were up to date.\nOn examination, the patient was heavyset, weighing 142.8 kg and standing 173.6 cm tall, with a BMI of 47.4. His vital signs were normal and he was in no distress. Musculoskeletal exam revealed bilateral limited ankle dorsiflexion, worse on the right. He had tenderness to palpation over the medial aspect of his ankle just anterior to the medial malleolus. All other joints were normal.\nHis initial work-up consisted of radiographs of his right ankle, showing evidence of a healing osteochondritis dissecans (OCD) lesion. He was instructed to continue physical therapy and follow up in three months with the possibility of arthroscopy of the affected joint if there was no improvement.\nAt follow-up, his pain was unchanged. Radiographs showed the previously seen presumed OCD lesion, now with a sclerotic border. He was scheduled for an MRI of the ankle, which was read as more consistent with a chondroblastoma versus an inflammatory process.\nSeveral months later, he began complaining of left shoulder pain and decreased range of motion of gradual onset. He denied any trauma causing this new complaint. He was again seen by the orthopedic service and found to have significantly decreased range of motion and AC joint tenderness. Radiographs of the shoulder did not show any abnormalities. He was diagnosed with adhesive capsulitis and ins"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male patient presented with minimal weakness of the left ankle/toes plantar-flexion, which worsened with gait.\nThe magnetic resonance imaging (MRI) showed a large sacral mass causing compression of the S1 and S2 roots on the left side. It was hypointense in T1 and hyperintense in T2, originating mainly from the left side of S1, extending into the left side of S2 with extension into the left paravertebral space and through the neural foramen into the extradural intraspinal canal, causing severe compression and displacement of the thecal sac to the right side (Figure ). It exerted a mass effect on the adjacent parts of the sigmoid, but there was no evidence of invasion. An invasion into the left iliac vein was noted. There was a suspected blood fluid level seen at the posterior aspect of the mass. The left sacroiliac joint was involved by the tumor. Informed patient consent was obtained for treatment.\nCT scan confirmed a large lytic lesion with a soft tissue mass at the left sacroiliac joint extending to the midline of the sacrum medially and to the sacroiliac joint laterally (Figure ). No metastatic lesions were identified on other imaging.\nImage-guided biopsy confirmed the diagnosis of Ewing’s sarcoma. Surgical resection of the tumor with safe margins was planned. Three sessions of chemotherapy were administered preoperatively to shrink the tumor.\nA sacrectomy was planned as a two-stage procedure, anterior and posterior. During the anterior approach, the tumor was freed from major vessels and the bowel. Surface cuts were done in the iliac bone anteriorly with a 2 cm margin outside the tumor. These cuts were guided by the navigation system to be precisely outside the tumor (Figure ). It served as markers on the navigation system when the posterior approach was performed as the second stage. During the posterior approach, the surgical procedure included lumbar spine instrumentation with right iliac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old man with a history of chronic alcoholism presented with abdominal distension. The previous day, the patient had presented to a local hospital with anal bleeding and abdominal pain after an incidental insertion of barbecue skewer per anus in the drunken state; subsequently, he had undergone sigmoid loop colostomy for rectal perforation. However, after the operation, the patient had become hemodynamically unstable. At presentation, his systolic blood pressure was 90 mmHg and the pulse rate was 135 beats/min. Although there was no gross rectal bleeding, the digital rectal examination revealed a penny-sized anterior rectal wall defect 6 cm from the anal verge (AV). Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with active bleeding in the pelvic cavity and a pseudoaneurysm in the anterior wall of the rectum (). Since the patient was hemodynamically unstable, an emergency operation was performed. During the operation, a massive subperitoneal hematoma in the rectovesical pouch and large amount of blood in the peritoneal cavity were found. After evacuation of the hematoma and blood, oozing continued in the rectovesical pouch (). Thus, compression with gauze was performed for 30 min until the oozing stopped. The Hartmann procedure was performed with the suspected bleeding focus included, but the perforation site was not included.\nAlthough the postoperative course was uneventful and there was no evidence of recurrent bleeding on the follow-up CT on the 7th postoperative day (POD), a focal enhancing lesion in the anterior wall of the rectum indicating a residual pseudoaneurysm was noted (). On the 11th day POD, his hemoglobin decreased from 11.6 g/dL to 7.9 g/dL, and the follow-up CT revealed recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity and the residual pseudoaneurysm (). Following the diagnosis of recurrent bleeding from the residual pseudoaneurysm, an angiography was performed. However, the angiography failed to localize the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.\nShe reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.\nDuring her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.\nThe oncology team became involved at this time. Her CLL was the suspected etiology of the neck mass and lymphadenopathy, and intravenous fluids and allopurinol were started to prevent tumor lysis syndrome. Further laboratory workup showed the predominantly lymphocytic, elevated WBC count as before and a normocytic anemia, hemoglobin 10.6 g/dL. Smudge cells were present on the peripheral blood smear. Iron studies, B12, and folate were normal. Flow cytometry"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA forty four year old man presented to the Geisinger clinic emergency department for an evaluation of worsening abdominal pain associated with low grade fever, nausea and vomiting that had started one day prior to admission. The patient denied prior abdominal complaints, recent trauma, or changes in bowel habits. On the physical examination, he appeared to be anxious, mildy tachypneic and pale with heart rate of 132 beats per minute. An abdominal palpation showed moderate distention, diffuse rigidity with guarding, rebound tenderness, and hypoactive bowel sounds. Complete blood count showed a leukocytosis of 22.5 mg/dl, bandemia of 14%, hemoglobin of 9.6 mg/dl (baseline of 15 mg/dl). Liver function tests, pancreatic enzymes, and lactic acid were all within normal limits.\nA CT scan showed an abnormally located spleen in the lower pelvis measured 15.7 × 10 × 9.2 cm (Figs. and ). The splenic artery descended inferiorly through the midabdomen and was markedly tortuous, suggesting a pedicular volvulus. The splenic parenchyma failed to enhance following intravenous contrast injection as what typically would have been seen in a normal spleen. The body and tail of the pancreas appeared to be coiled around the splenic vessels (). Significant volume of high density fluid consistent with hemoperitoneum was observed. No free air was identified.\nExploratory laparotomy was promptly performed revealing a large rush of blood upon entering the peritoneal cavity. Once the midline incision was advanced inferiorly, a large mobile spleen was found in the pelvis which was easily brought up into the operative field. There was a volvulus of the splenic pedicle and distal pancreas. Following detortion and inspection, the spleen appeared to be permanently infarcted. A routine splenectomy was performed. Approximately one liter of blood was suctioned and the abdomen was thoroughly irrigated using three liters of normal saline. There was no other obvious pathology found.\nPostoperatively, the pa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2008, 72 year old female was diagnosed of small cell lung cancer incidentally after she was hospitalized for anxiety and dizziness. She was hyponatremic and series of tests which included a CT scan of the chest which showed right hilar lymphadenopathy and mediastinal lymphadenopathy (Figure ). She then had a mediastinoscopy which was consistent with small cell lung cancer. PET/CT scan findings were consistent with CT scan. She was staged as limited stage small cell carcinoma of lung. She was started treatment with etopside and carboplatin. In July2008, after receiving two cycles of chemotherapy, she presented with new onset memory difficulties.\nFurther work-up included a MRI of brain with and without gadolinium as well as PET scan showed no evidence of metastatic disease to the brain. These symptoms were thought due to underlying anxiety or depression.\nFew days later she started with ataxia, vertigo and hearing loss. She was prescribed meclizine which provided no relief. She then went to emergency department. At that time she was found to orthostatic. She was rehydrated and discharged.\nAudiogram was done which revealed bilateral sensorineural hearing loss greater on the left side. The paraneoplastic workup was sent to rule out paraneoplastic syndrome. The anti-Hu antibody came positive. The diagnosis of anti-Hu syndrome was entertained. She was started on radiation therapy in addition to her chemotherapy for consolidation. She received 3960 cGy of radiation to the mediastinum in August 2008.\nThree weeks later, she began developing loss of smell sensation to the point that she was completely anosmic. Her unsteadiness reached to the point that she needed assistance for walking short distance. MRI of brain showed new area of edema and inflammation in the right medial temporal lobe as well as enhancement in the underlying meningi (Figure ). She was admitted for to the hospital for empiric IV acyclovir therapy for possible herpes encephalitis. The Lumber puncture"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old man came to our gastrointestinal outpatient with complaint of a narrowing in the caliber of the stool without obvious cause for about 1 year. Otherwise, he had no history of asbestos exposure, hematochezia, diarrhea, constipation, abdominal pain and distention. He had a history of prostatectomy due to benign prostatic hyperplasia and he denied recent weight loss. Digital examination of rectum showed the lower boundary of a mass in the rectum was 2 cm from the anal margin, and the upper boundary could not be palpated. Therefore, the patient underwent colonoscopy endoscopic electrocoagulation resection.\nA soft tissue shadow was occasionally found by pelvis CT examination in the right pelvic wall. The mass had well-defined boundary and was oval shape with size of 7.3 × 5.3 cm. No calcification was found within the mass. On unenhanced CT images, the mass was heterogeneous with suspected necrotic area (Fig. a). In arterial, venous and delayed phases, CT values were 32–61 Hu, 65–90 Hu, and 46–77 Hu, respectively. The lesion showed mild heterogeneous on delayed enhancement CT images (Fig. b-d). Otherwise, the rectum and prostate were pressed, and no sign of destruction was observed in the adjacent bone. The CT examination suggested that the mass may originate from striated muscles with malignant transformation, and it may belong to neurogenic benign tumor. The source of blood supply to the mass was identified by pelvic computed tomography angiography (CTA), which showed the mass was mainly supplied by the right internal iliac artery (Fig. b). Unfortunately, the local dissection of the right common iliac artery was observed by CTA, and delayed the treatment of pelvic mass. Then, the right common iliac artery dissection was treated in other hospital more than a month later.\nSix month after the discovery of the pelvic mass, the mass was slightly larger observed by CT examination (Fig. a). The patient underwent radical excision of pelvic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 73-year-old man with a history of three previous open right inguinal hernia repairs at other institutions as well as a robotic prostatectomy who presented with a recurrent right and symptomatic left inguinal hernia. Given the patient's history of multiple prior open hernia surgeries, we initially favoured a laparoscopic approach. Given the history of robotic prostatectomy with a post-operative pelvic haematoma and the likelihood of adhesions, we decided on a robotic TAPP approach, which would allow for easier lysis of adhesions, reduction of the hernia sac and sutured closure of the peritoneal pocket.\nOn insufflation of the abdomen, placement of robotic trocars and docking of the da Vinci Si system, a large right indirect inguinal hernia defect containing small bowel was visualised lateral to the inferior epigastric vessels. The peritoneum was incised and the hernia sac reduced into the peritoneal cavity with subsequent development of a pre-peritoneal pocket. An extra-large Bard 3DMax polypropylene mesh (12.4 cm × 17.3 cm) was tacked into place to the pubic tubercle and onto the anterior pubic ramus at Cooper's ligament. The peritoneal defect was then closed using 2-0 absorbable V-Loc (barbed) suture in a running fashion. The left-sided hernia was repaired in the same manner.\nThe patient was discharged home on the same day after surgery but returned to the emergency room on the 2nd post-operative day with complaints of significant abdominal pain, nausea, vomiting and obstipation. He was diffusely tender on abdominal examination and a computed tomography (CT) scan [] was performed demonstrating a high grade closed-loop small bowel obstruction with a transition point in the right lower quadrant. The patient was urgently taken to the operating room where he underwent a diagnostic laparoscopy. The peritoneal closure on the right had dehisced, and a loop of small bowel had incarcerated within it [] which upon reduction appeared bruised but viable"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male motorcyclist with a history of hypertension, hyperlipidemia, and coronary artery disease was brought to the emergency department after being struck by another car on the highway at speeds of at least 40 miles per hour. Upon presentation, the patient was evaluated using Advanced Trauma Life Support (ATLS) principles. He had a patent airway on arrival and was breathing spontaneously on room air. His initial heart rate was 87 beats per minute, and his blood pressure was 124/63 mmHg without signs of significant hemorrhage. He had an initial Glasgow coma score (GCS) of 15 with equal and reactive pupils. The patient admitted to consuming alcohol and had a serum alcohol of 243 mg/dL. A later CT of the head demonstrated a subcutaneous hematoma without any intracranial abnormalities. His remaining physical examination revealed left lower quadrant abdominal pain without signs of peritonitis, ankle deformities bilaterally, pain with hip range of motion, and blood at the urethral meatus. Given his physical examination findings, subsequent imaging confirmed an unstable pelvic fracture with diastasis of the symphysis pubis of 6 cm, widening of the left sacroiliac joint, a left ischial pubic ramus fracture, and a urethral injury (). He also had a left ankle dislocation and a right compound fracture of the distal tibia and fibula. No intraabdominal injuries were identified on CT imaging of the abdomen. The pelvis was stabilized with a binder by the orthopedic surgeons with subsequent emergency irrigation, debridement, and open reduction and internal fixation (ORIF) of the open ankle fracture as well as reduction of the left ankle dislocation. He was extubated after the procedure and monitored in the ICU while the remaining preoperative medical workup was completed including X-rays and CT scans with 3D reconstructions of the pelvis reconstructions. A hydromorphone patient-controlled analgesia (PCA) pump was utilized for pain control.\nOn hospital day 2, the patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old Caucasian man with a history of hypertension and stage I clear cell type renal cell cancer underwent right nephrectomy in 2004. In 2009, he was found to have a right upper lobe lung metastasis and underwent video-assisted thoracoscopic surgery with lung node resection. He had since been doing well without recurrence. In March 2016, he presented with a 1-month history of intermittent chest pressure, predominantly occurring at night times.\nOn physical examination, his blood pressure was elevated at 183/96 mm Hg with a normal heart rate of 78 bpm. The patient's lungs were clear on auscultation with no abnormalities in the cardiac examination. The abdomen was soft and nontender, and no masses were palpable.\nComplete blood count, chemistry panel, thyroid function, and cardiac enzymes were normal. An electrocardiogram showed normal sinus rhythm, with T wave inversions in leads II, III, avF, and V4-V6. A transthoracic echocardiogram followed which revealed reduced ejection fraction of 35% with hypokinesis of the apical segments and a suspicious lesion in the left ventricle. In view of the patient's age and risk factors for coronary artery disease and heart failure, he was scheduled for cardiac catheterization. Cardiac catheterization was performed and did not show significant coronary artery obstructions but revealed an abnormal accumulation of contrast in the apex, suggestive of a highly vascular mass (Fig. ). To further characterize the mass, cardiac magnetic resonance imaging (MRI) was performed, which confirmed the findings of a left ventricular mass measuring 4.2 × 3.6 × 3.1 cm with full-thickness involvement of the myocardium, causing moderate dyskinesia of the left ventricular wall (Fig. , Fig. ). Open myocardial biopsy was performed, and pathologic evaluation was consistent with metastatic clear cell RCC.\nGiven the location of the mass and its involvement of the full thickness of the left ventricle, the patient was not felt to be a surgical candidate,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man was transferred to our emergency department due to the left side weakness. On arrival, he also presented with dyspnea and cough productive of purulent sputum. Three months prior to the current admission, he was hospitalized in a local clinic due to right hemiparesis and was diagnosed with acute left anterior cerebral artery infarction by brain magnetic resonanace imaging (MRI). Chest computed tomography (CT) revealed the mass suspicious of lung cancer in the right lower lobe. The mass was originated from right lower lung field and invaded right pulmonary artery, vein and LA. Biopsy of the lung lesion was recommended for additional diagnostic confirmation but his family rejected the performance of further evaluation.\nWhen he visited our hospital, he had a blood pressure of 100/60 mmHg, a pulse rate of 76/min, a temperature of 36.3℃, and a respiratory rate of 25/min. His general appearance was chronically ill-looking and he was in a drowsy status. His white blood count (12,400/µL) and high sensitive C-reactive protein (6.79 mg/dL) were elevated and chest X-ray showed multifocal pneumonic infiltration in both lung fields as well as a huge mass in the lower zone of the right lung. His brain CT showed the old cerebral infarction in the left medial-frontal area and the acute cerebral infarction in the right fronto-temporal area (). Transthoracic echocardiographic (TTE) examination was performed to investigate the cause of his recurrent cerebroembolic episodes, revealing a very huge, mobile mass in the LA which originated from the right main pulmonary venous trunk accompanied by a small amount of pericardial effusion (). The mass moved in a to-and-fro fashion through the mitral valve with neither significant obstruction of the mitral inflow nor pressure gradient between the LA and left ventricle (LV). LV ejection fraction and LA size were within normal range. In order to figure out the relation of the mass to the surrounding structures,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man with a history of progressive increase in dyspnea saturation for 1 month presented to a peripheral hospital. On examination he was tachypneic (room air –84%) with decreased air entry on the right side and with normal hemodynamics values. Cardiac auscultation revealed normal heart sounds and no cardiac murmur. A chest X-ray was done which showed a massive right-sided pleural effusion, and a right intercostal tube drainage was done at an outside hospital which drained 1 L of blood immediately and 1 L subsequently.\nThe patient was referred to our institute with the diagnosis of massive right hemothorax. An ultrasound of the chest was done which showed gross right pleural effusion with collapse of underlying lung. A well-defined retrocrural collection of size 7 × 6 cm was noted. The liver was normal in echotexture. Emergency computed tomography angiography (CTA) was suggestive of massive right hemothorax, with an aortic rent at the T7 level communicating with the right pleura and multiple aortic rents at the T10–11 level with a surrounding 8 × 4 cm hematoma (\n).\nOn detailed history taking, the patient informed us that 6 years ago he had laparoscopic cholecystectomy during which his common bile duct was inadvertently injured and eventually a Roux-en-Y hepaticojejunostomy was done.\nWith a provisional diagnosis of a leaking pseudoaneurysm, the patient was taken for surgical exploration to repair the aortic rent as well as the communication with right pleura through a left thoracoabdominal approach. After taking proper proximal and distal aortic control, the descending thoracic aorta was opened above the renal arteries, but the aortic wall was found to be normal with no rents. The aorta was closed. Surgical exploration could not be extended on the right side because of dense adhesions due to the past surgery.\nThe patient was then repositioned and right thoracotomy done, which showed a 2 × 2 cm laceration on right lower lobe of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 42-year-old woman who presented in our clinic due to recent diagnosis of early left breast cancer. The computer tomography performed revealed no other organs compromised or distant metastatic extension. The patient did not have relevant medical history of interest, except for a Darier's disease known for many years.\nThe patient underwent a lumpectomy with axillary lymph node dissection. The pathological diagnosis was moderately differentiated invasive ductal carcinoma (IDC) of the right breast of 2.3 cm in size with metastasis detected in 1/18 lymph nodes removed (pT2 pN1 M0). Immunohistochemical study of the tumor cells showed positive staining for both estrogen receptors (ER) and progesterone receptors (PR) in 95% and 95%, respectively, and showed positive membrane staining of HER-2 marker. With this diagnosis, the patient received postoperative adjuvant chemotherapy consisting of 6 cycles of FEC followed by maintaining treatment with trastuzumab for 1 year and adjuvant hormone therapy with tamoxifen 20 mg daily during the following 5 years. Then, the patient was referred to our radiation oncology department where she received adjuvant radiotherapy (50 Gy) on left-breast residual tissue.\nShe was primarily diagnosed of DD in 1991 with pruritic eruption on the trunk. There was no family history of a similar skin summer. A biopsy specimen revealed acantholytic dyskeratotic cells in the upper epidermis, suprabasal clefts with focal hyperkeratosis, and parakeratosis which were consistent with the clinical diagnosis of Darier's disease. Various therapeutic options had been applied: lotions containing cortisone, estrogens, or testosterone and several homeopathic options. Due to progression disease, the patient was treated with oral retinoids (acitretin: initial 10 mg) plus cyclosporine, obtaining an initial good response with disappearance of the skin lesions. After nine months using systemic retinoid and cyclosporine, the papules have reappeared"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is the case of a 21-years-old man who was diagnosed with β-thalassemia major at the age of 8 months. He underwent splenectomy at the age of 10 years and has been receiving monthly blood transfusions ever since. Three months prior to admission, he presented to a peripheral emergency department with a sudden episode of dyspnea and central cyanosis and was suspected to be infected with COVID-19. Chest CT scan was made and ruled out any interstitial lung involvement and revealed the presence of bilateral pulmonary emboli. Anticoagulation therapy with warfarin was started, but on follow-up the patient developed progressive exertional dyspnea, deteriorating to NYHA functional class III.\nThe patient was referred to our institution because of worsening symptoms. Physical examination showed clinical evidence of right heart failure and pulmonary hypertension, with a mild drop in arterial oxygen saturation (93%). Echocardiography revealed a dilated right atrium (RA) which contained a large 47 × 35 × 16 mm hyperechogenic mobile mass attached to the RA free wall near the orifice of the inferior vena cava. The right ventricle (RV) was severely dilated and dysfunctional, with tricuspid annular plane systolic excursion (TAPSE) of 13 mm and severe tricuspid regurgitation. Estimated systolic pulmonary arterial pressure (PAP) was 85 mm Hg. Lung perfusion scintigraphy was not available at our center. Chest CT angiography showed bilateral defects in the pulmonary arteries consistent with bilateral chronic pulmonary thromboemboli (Figure ).\nOn the basis of this evaluation, the diagnosis of CTEPH was established and PTE was performed, the technique of which was reported previously. Total circulatory arrest time was 45 minutes, and total cardiopulmonary bypass perfusion time was 94 minutes. A large organized clot was removed from the RA, in addition to removing the thickened intima and organized thrombi from lobar and segmental pulmonary arteries of the left middle and lower lobes, as"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old man visited the emergency room for abrupt-onset chest pain. He had undergone a closed thoracostomy for left hemothorax in another local clinic. Whole body computed tomography imaging indicated a possible ruptured thoracic aortic aneurysm; the maximal diameter of the thoracic aorta was 65 mm (). The patient underwent an urgent thoracic endovascular aortic repair procedure the next day. Since the proximal landing zone of the stent graft was estimated to be between the innominate artery and the left common carotid artery (zone I), he concomitantly underwent the debranching of the arch vessels. All procedures were performed in the operating room. The extrathoracic exposure of the arch vessels was performed via two small supraclavicular incisions. The debranching of the arch vessels was done by bypassing the left common carotid artery and the left subclavian artery to the right common carotid artery using a single 8 mm vascular graft (InterGard Woven; InterVascular, La Ciotat, France). The course of the graft crossed above the trachea and above the left internal jugular vein. The thoracic endovascular aortic repair procedure was carried out using a SEAL thoracic aortic stent (SEAL Thoracic 38/34×180 mm; S&G Biotech Inc., Seongnam, Korea) via both femoral arteries. All procedures were uneventful. The patient underwent perioperative cerebrospinal fluid drainage to prevent paraplegia.\nPostoperatively, the patient twice failed to be weaned off the ventilator because of intractable stridor and desaturation immediately after extubation. He underwent reoperation on postoperative day four due to suspected airway edema caused by the obstruction of venous return. When neck ultrasonography was performed in the operating room, a large amount of thrombi was found in the left internal jugular vein and no flow was found through the left internal jugular vein. In the operative theater, the left internal jugular vein was found to be totally obstructed by thrombosis (), whic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe here report a 25-month-old male child born by full-term vaginal delivery presented to us with sudden onset of left-sided hemiparesis lasting 2 hours, not preceded by constitutional symptoms or seizure activity. He had similar episodes of transient hemiparesis on either side in past which relieved spontaneously without any neurological deficit. First episode of right-sided focal seizures occurred at age of 4 months. Frequency of seizures increased and child was started on antiepileptic drugs. Since age of 11 months, child had recurrent episodes of transient hemiparesis on either side with or without associated seizures, lasting 2-3 days and relieved by itself. There was history of developmental delay noticed after the age of 4 months and presently he could only walk with support corresponding to developmental age of 11 months. On examination he was afebrile with normal vitals. There was port-wine stain of 4 × 1 cm in an atypical site involving midline of forehead extending over nose []. His modified GCS was 13/15, had UMN type left facial nerve palsy with left-sided hemiparesis. Rest neurological and systemic examination was unremarkable. Contrast CT scan of brain showed linear hyperdense area in right high parietal lobe with gyriform enhancement along with enlargement of right choroid plexus and left frontal atrophy [Figures and ].\nEEG done urgently revealed no ictal activity, excluding postictal hemiparesis. PET scan revealed hypoperfusion and decreased metabolism in cortex surrounding the leptomeningeal angioma. Therefore the hemiparesis was presumed to be of vascular in origin. Child was started on aspirin to prevent further recurrences of these thrombotic events. On 3rd day of admission, child developed right-sided tonic clonic seizures with facial twitching lasting 15 minutes, and loss of consciousness followed by right-sided hemiparesis. Meanwhile his hemiparesis on left side improved. A concurrent EEG revealed epileptic activity with focus on left side, su"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-year-old male presented with a painless mass over the superior aspect of the globe for the last three months which was progressively increasing in size. The child had progressive, painless loss of vision in the same eye for the last three years. On ocular examination, visual acuity was no perception of light in the same eye and 6/6 in the other. Firm, non-tender mass measuring 4cm x 3cm was noted in the superior aspect of the globe (). It was covered by conjunctiva in the posterior half, while conjunctiva was adherent on the anterior half. Its surface was irregular with some vascularization. The cornea was hazy due to scarring, and inner details could not be evaluated. The examination of the left eye was within the normal limit. Systemic examination was normal with no palpable lymph nodes. B-scan ultrasound showed homogenous opacity in the anterior part of the eye with moderate reflectivity persisting up to 70dB. CT-Scan of the orbit revealed hyperdense focus attached to the anterior surface of the eyeball with surrounding thickening, likely foreign body with an irregular wall of the globe with areas of internal hyperdensity likely a hemorrhage or infection ().\nAfter consent, enucleation was performed with minimal manipulation under general anesthesia with the orbital implant and conformer. The specimen was sent for histopathological examination.\nGross examination of a cross-section of the enucleated globe revealed a solid grey lesion with exophytic and endophytic components (Figure 2.a and b). Histopathological examination revealed thick bands of polarized epithelium resembling medullary epithelium along with thinner cellular strands of acellular myxoid stroma (Figure 3.a). The tumor cells aggregated radially along the central space forming Flexner Wintersteiner rosette (Figure 3.b). It also involved the anterior chamber and vitreous cavity, but the optic nerve stump was free of tumor. This was highly suggestive of medulloepithelioma grade II. The origin of m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old female was transferred to the department of hematology with a primary central nervous system posttransplant EBV-associated lymphoproliferative disorder. Biopsy from the tumor showed a highly necrotic polymorphous infiltrate of variably sized lymphocytes. The large cells displayed pleomorphic nuclei, with prominent nucleoli, some of which had immunoblastic appearance (). Immunohistochemical studies showed the large atypical cells to be positive for CD20 (). The histological diagnosis of the tumor was diffuse large B-cell lymphoma, and EBV was detected in the tumor cells by immunohistochemistry for latent membrane protein-1 (LMP-1) (). The patient had been diagnosed with diabetes mellitus type 1 at age 7; a renal transplantation was performed 3 years earlier because of diabetic nephropathy. After the transplantation, the patient was initially treated with cyclosporine, and, after 6 months, the immunosuppressive therapy was changed to tacrolimus (4 mg twice a day). Prior to the admission, the patient had suffered from headaches, nausea, and dizziness for several weeks. A magnetic resonance imaging (MRI) of the CNS showed a 3.8 × 7.8 cm tumor infiltrating the right parietooccipital region; there was surrounding edema and compression of the right lateral ventricle and right side of the mesencephalon (). A complete resection was not possible, and treatment with prednisolone, 100 mg per day, was started. A bone marrow examination and computer tomography (CT) of the neck, chest, and abdomen did not show lymphoma outside the CNS. HIV testing was negative. An MRI 3 days after the operation showed a 3 × 6 cm resection cavity with contrast in the remaining tumor and nonresolved compression of the ventricle system. Obviously, intrathecal therapy was not possible, and, due to considerable comorbidity, intensive chemotherapy and/or radiation therapy was not feasible. Instead, the patient was treated with the monoclonal antibody rituximab, ganciclovir, and continuous"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old male patient was referred to the Oral and Maxillo-Facial Surgery Service at Federal University of Paraná after occasional finding on a routine panoramic radiograph. The patient experienced no symptoms. A computed tomographic (CT) was requested and showed a well-defined hyperdense mass showing a hypodense center inside the left maxillary sinus measuring approximately 15 mm × 10 mm situated in a posterior position of this anatomical space (). It was observed that this calcified mass was associated with the roots of the impacted third molar. Treatment proposed was the complete excision of the lesion through an intraoral approach and Caldwell-Luc access to reach the maxillary sinus.\nUnder general anesthesia, an incision from the superior left first molar extending to retromolar area, with anterior and posterior relaxant incisions, was conducted to provide a sufficient access to the region of interest without causing gingival tissue tension. Osteotomy of the lateral maxillary sinus wall was conducted in order to expose its membrane. Once the sinus membrane was exposed, it was carefully detached from the bone without it disrupting until the calcified mass was reached (). The third molar with calcified mass associated with the roots was removed.\nThe chosen postoperative drug therapy was cefazoline-oral (500 mg) each 8 hours during 7 days, nimesulide (100 mg) each 12 hours during 5 days, and dipyrone (1 g) for each 6 hours during 3 days. Patient experienced no infection symptoms and drug therapy showed to effective in swelling and pain control.\nPathological mass removed was stored in 10% formalin and sent as excision biopsy for further histopathological investigation. It was fixed in 10% neutral formalin, subjected to decalcification in formic acid, bisected in a mesiodistal direction, and then processed for light microscopic examination. Histopathology showed that the calcified tumor mass was composed of sheets of cementum-like tissue with lack of interstitia"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 4 (PA-4) experienced premature loss of deciduous teeth since he was one and half years old. The physical examination was unremarkable, other than the absence of the upper and lower anterior incisor and canine teeth (Fig. m). Serum ALP activity was 42 U/L at diagnosis when he was 4 years old. Panoramic X-ray showed a reduced alveolar bone of whole dentition (Fig. n). His wrist and knee X-ray revealed normal growth plates without any evidence of defective bones (Fig. o and p). Patient 4 was diagnosed as odonto HPP at 4 years old (Table ).\nIn order to confirm the diagnosis of HPP and correlate the phenotype with specific genotype, mutational analyses of the ALPL gene were performed in all four patients and their parents except the mother of patient 1 was not involved in this study. The ALPL variants in patient 1 and patient 3 were identified using next generation sequencing and confirmed with Sanger sequencing, whereas the variants in patient 2 and patient 4 were identified and confirmed by direct Sanger sequencing. A 3D structural modeling of the TNSALP constructed based on its sequence homology to the placental isozyme (PDB ID: 1EW2), was used to locate the missense mutation [].\nSix different variants were identified in the ALPL gene in our four patients, including five missense variants and one small insertion variant (Table ). All variants were inherited from their unaffected parents except patient 1 (Fig. ). As the most severe and lethal infantile HPP in the present study, patient 1 carried a novel homozygous variant of c.359G > C (p.G120A) at exon 5 of the ALPL gene, which was predicted to be disease-causing by in-silico analysis of bioinformatics software. His father demonstrated a heterozygous status, while his mother was not involved in this study. To further investigate the effect of the novel missense mutation of c.359"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old man was admitted to the emergency department of our university hospital with sudden onset of nausea, vomiting, slight mental disability, and abdominal pain. Cardiovascular, respiration, and gastrointestinal system examination findings were normal. The neurological examinations of the cranial nerves and limbs were normal. He was clinically dehydrated. On the first day of his admission, laboratory studies revealed a BUN level of 35 mg/dL, creatinine level of 3.17 mg/dL, calcium level of 8.6 mg/dL, and moderate metabolic acidosis with a pH of 7.30. The urinalysis showed hematuria [++++], leukocyturia [++], and proteinuria [+]. A lot of red blood cell casts and white blood cell casts with a few granular casts and epithelial cell casts were observed in urine sediment. Renal ultrasound showed normal sized kidneys with no hydronephrosis. The fractional excretion of sodium (FeNa) was 4%, and he was diagnosed with acute kidney failure. He was admitted to the nephrology department, and intravenous fluid therapy was started immediately due to his dehydration status. Kidney function tests and blood gases were monitored daily. His condition was stable until the 3rd day. On the 3rd day, anuria was developed, and his creatinine level increased to a level of 13,5 mg/dL and revealed a blood gas pH of 7.19 with high anion gap metabolic acidosis. He was admitted for urgent venovenous hemodialysis intervention for two hours via a jugular hemodialysis catheter. On the 4th day, a kidney biopsy was performed. On the 5th day, unilateral right peripheral nerve palsy developed abruptly (). His temporal computerized tomography scan was normal, and electromyography showed a lesion on the right facial nerve. There was no history of cold exposure, and diabetes mellitus, vasculitis, and neuropathic disorders were ruled out by the negative autoantibody screen, normal serum electrophoresis, and negative HIV test. On the 7th, day pathological examination of the kidney specimen revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 2-year-old boy from Russian republic of Ingushetia. Both parents and younger sibling (female) were asymptomatic. Family history is not burdened. Parents may be related, as the mother of the child and the grandmother (father's line) are from neighboring villages of Malgobek region of Ingushetia.\nThe patient is the first child of healthy parents. Pregnancy proceeded against the background of gestosis in the first and second trimester, threats of interruption for a period of 12 weeks, anemia, and lack of hydration. The child was born as a result of fast unassisted childbirth. His birth weight was 3570 g and height was 55 cm. Apgar scores were 6/7. Early motor development slightly delays: He attained head holding at 3 months, sitting without support at 6 months, by the year the boy got up and walked with support. From the age of 8 months, the baby had a weight loss of 2 kg for 2 months with episodes of repeated vomiting. At the age of 1 year 2 months against a background of acute respiratory viral infection, there was a regress in development—the boy stopped walking. Subsequently, rachitic skeletal changes, an increase in the volume of the abdomen appeared, and a loss of motor skills progressed. Magnetic resonance imaging (MRI) of brain revealed a mildly expressed leukopathy in white matter of parietal lobes. Proteinuria and glucosuria appeared at the age of 1 year 8 months.\nAt the age of 2 years 2 months, he was admitted to Russian children's clinical hospital with psychomotor retardation and treatment resistance. On physical examination, he was observed to have a pronounced delay in psychomotor development (he did not get up, walk, crawl; he could only keep his head and turn over). Neurological examination revealed muscular hypotrophy, tendency to hypotension in axial musculature, and uniform decrease in tendon reflexes from hands and feet. MRI of brain revealed subat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old male patient presented at our hospital in September 2008. He was suffering from a sudden onset of headache that had awoken him from sleep and increased with eye movements. He also had vision loss in his left eye. A neurological examination identified only bilateral papilledema, and a visual field examination demonstrated bilateral (more prominent on the right side) peripheral narrowing. He had no known systemic disease and no drug use, except for amoxicillin one week prior to his presentation.\nAll tests performed to determine the symptom etiology were negative. His cranial magnetic resonance imaging (MRI) was within normal limits. Cranial MRI venography demonstrated that the left transverse sinus and sigmoid sinus were hypoplastic, and the right side was dominant (MRI venography) (). The patient did not benefit from medical treatment. He underwent daily lumbar punctures for one week. The opening cerebrospinal fluid (CSF) pressure was above 40 cm H2O. The patient's headaches improved, but his vision loss remained constant.\nThe patient was diagnosed with PTC. We took him into surgery and implanted a lumbo-peritoneal shunt in January 2009. The operation was carried out under general anesthesia in the left lateral decubitus position, with bilateral lower limbs in the bent position. The L2-3 intervertebral space was selected as the point of puncture, through which a 1-cm opening was made with a sharp knife. A modified spinal puncture needle was inserted 5-7 cm along the midline. When an obvious breakthrough feeling was noted, this indicated that the needle was penetrating the spinal dura mater, at which point the needle core was withdrawn until the needle had been inserted through the subarachnoid cavity, with CSF flowing. Meanwhile, the shunt tube was inserted 7-9 cm into the subarachnoid cavity through the spinal puncture needle, and when CSF flowed through the shunt tube, the spinal puncture needle was pulled out. The shunt tube was tunneled to 2 cm late"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old Caucasian man, service engineer presented to accident and emergency with sudden onset of low back pain whilst lifting a washing machine at work. Pain radiated to groins and was associated with progressive bilateral weakness with numbness in the legs, with more marked symptoms on the left side. There were no cardiovascular symptoms, and the patient had normal observations. He was previously fit and well. He had no medications. He was a smoker for around 40 years and smoked twenty cigarettes a day. He was referred to the orthopedic team as a possible case of cauda equina syndrome secondary to a prolapsed intervertebral disc.\nNeurological examination revealed profound motor deficit in the legs with Medical Research Council (MRC) grade 2/5 muscle power in the hip flexors and complete paralysis in all other groups distally. All reflexes including the plantar reflexes were absent, and sensation was altered throughout both legs. Sensory and motor functions at level T12 were preserved. Perianal tone and sensation were both markedly reduced and he was unable to feel the passage of a bladder catheter. His vital signs were stable with normal pulse and blood pressure. Complete cardiorespiratory examination was normal and all peripheral pulses were palpable. However, abdominal examination revealed a nontender pulsatile mass.\nBaseline laboratory investigations including Erythrocyte Sedimentation Rate were normal with the exception of a white cell count of 14.4 × 109/Lt. Lumbar puncture was unremarkable. His other blood parameters including LFT, Renal functions and bone profile were normal apart from slight raised cholesterol 6.2(5.3 mmol/lt). Plain radiographs revealed mild degenerative changes in the spine. An urgent MRI scan was requested to rule out caudaequina due to disc prolapse. An MRI revealed () multiple disc protrusions in the lumbar spine, in particular at the L5/S1 level, but there was no evidence of acute cord or caudal compression. The scan also reveal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 50-year-old Caucasian male who presented to the emergency department with complaints of lower abdominal pain, fever and sweating. On examination, the patient had tenderness to palpation in the right iliac fossa, with significant rebound tenderness and guarding. Body temperature was recorded at 38.5°C.\nThe patient's past medical history was significant for an incident of similar pain six months prior to presentation. He was diagnosed with sigmoid diverticular disease confirmed by computed tomography (CT) scan and managed conservatively. A subsequent colonoscopy confirmed the diagnosis, and did not reveal any other colonic pathology.\nFurther investigations revealed a raised white blood cell count of 16,000 per microliter. CT scan of the abdomen and pelvis disclosed evidence of extensive free gas under the right dome of the diaphragm confirming suspicion of a perforation. Fluid-filled prominent loops of small bowel were noted. However, none of them were dilated to suggest obstruction. Mild bowel thickening was also noted around the cecum. Pneumatosis coli suggestive of ischemic bowel, extending from the cecum to the proximal ascending colon was seen. A blind ending structure with calcifications was also seen (Figure ). Other significant findings on the scan included a liver cyst, consistent with the patient’s previous CT scan, and consolidation at the base of the right lung.\nSubsequently, the patient underwent an emergency laparotomy and a diffuse four-quadrant peritonitis was seen. A giant perforated MD, 80 cm proximal of the ileocecal valve was identified as the cause of the peritonitis. The giant MD measured approximately 10 cm in length and 2.5 cm in width (Figure ). A small perforation at the tip of the MD was observed. No other intraabdominal pathology was identified, in particular, there was no evidence of colonic ishchaemia. Resection of the segment of small bowel bearing the MD was performed with a side-to-side stapled anastomosis.\nPatho"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year old boy with OI presented at the Stomatology service of the Federal University of Ceará (Sobral). The OI type was not identified, the genetic test was inconclusive, and the patient had no family history of OI. Physical findings included short stature, blue sclerae, and locomotion difficulties due to deformed and arched limbs (). The medical history included reports of 16 bone fractures and intravenous administration of pamidronate disodium infused over a period of 3 days and repeated every 4 months. Anterior and posterior cross-bites, Angle class III malocclusion, and mild mandibular prognathism were observed on oroscopy. The anterior teeth were brownish, especially the lower incisors. Hypomineralization was observed on the vestibular surface of the upper left lateral incisor and a gray band was seen on the posterior teeth, especially the molars, suggesting DI (). The remaining deciduous teeth (the upper right maxillary canine and the right mandibular molars) were more brownish than the permanent teeth and were undergoing exfoliation, requiring extraction. Periapical radiography revealed enlarged pulp chambers, with insidious early obliteration of the coronary pulp chambers of the lower incisors and a thin layer of dentin deposited along all the teeth producing a taurodontic appearance. The teeth had ample crowns and cervical constrictions, with molars taking on a bell-like shape resembling a crown (). Panoramic radiography confirmed large pulp chambers in all teeth, but no agenesis, impaction, or supernumerary roots (). The primary mandibular molar teeth (first and second left mandibular teeth) presented physiologic mobility for some time, but were retained in spite of the underlying erupting premolars, which generated dental plaque accumulation, pain, and gingival bleeding during mastication and tooth brushing. Thus, these teeth were extracted to prevent further discomfort and to allow proper dental eruption. The child's mother requested the extraction o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old super-super-morbidly obese female (BMI 90 kg/m²) with a past medical history of chronic obstructive pulmonary disease and cor pulmonale presented to the emergency department with altered mental status and difficulty ambulating secondary to lower extremity edema. Vitals revealed an elevated heart rate of 100 beats per minute and decreased respiratory rate of 10 breaths per minute. Physical exam was significant for lethargic mentation and denuded abdominal wounds under her pannus. Bi-level positive airway pressure and intravenous clindamycin were started due to hypercapnic respiratory failure and concerns for infection. Chest X-ray showed hyperinflated lung volumes without obvious signs of pneumonia (Figure ). Arterial blood gases demonstrated elevated serum bicarbonate, consistent with chronic carbon dioxide retention. The patient was admitted to the intensive care unit and emergently intubated due to worsening respiratory status. General surgery recommended discontinuation of clindamycin in favor of local wound care.\nOn hospitalization day seven, palliative care was consulted around goals of care and tracheostomy tube placement. Percutaneous endoscopic gastrostomy (PEG) tube or gastrostomy tube placement were discussed for nutrition; however, the ICU and surgical teams presented concerns of abdominal wall thickness and potential displacement into the peritoneal and abdominal cavity. The family was counseled regarding the risks and benefits and elected to proceed with a tracheostomy tube and PEG placement with full code status. Standard approaches for tracheostomy and PEG tube placement were performed. Directly post-procedure, however, the patient developed atrial fibrillation with a rapid ventricular response. Advanced cardiac life support (ACLS) protocols with phenylephrine, midazolam, cardioversion, and amiodarone were successively given in addition to a heparin drip, which stabilized the patient. Two hours after direct current cardioversion, the pat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45 year-old right hand dominant gentleman sustained a fall on his left shoulder in a skiing accident in Colorado. He was in significant pain and shortness of breath and therefore referred to a local hospital for evaluation. A chest radiograph was unremarkable and particularly revealed no evidence of a pneumothorax, hemothorax, or widened mediastinum (Figure ). Due to significant tenderness over the left sternoclavicular joint, a CT scan was obtained which demonstrated a locked posterior sternoclavicular dislocation (Figure ). The patient was transferred to our academic Level 1 trauma center for definitive care. On arrival in our emergency department, the patient complained of significant pain in his chest and left shoulder, as well as left-sided neck pain. The upper airway was patent, and the patient was hemodynamically stable and fully awake, alert, and oriented, with a Glasgow Coma Scale (GCS) score of 15. A CT-angiogram of the neck revealed no sign of an acute cervical spine injury or associated vascular injury (not shown). Due to the locked position of the clavicle behind the manubrium (Figure ), no attempt for a closed reduction maneuver was made, and the patient was consented for surgical open reduction and internal fixation. As part of the pre-operative planning, we ensured immediate availability of a vascular surgeon, and the presence of a sternal saw and vascular set in the operating room, for immediate access in case of an accidental intraoperative vascular laceration. The patient was placed in supine position with a bump placed under the left shoulder. The left upper extremity freely draped. The surgical approach consisted of an incision of 10 cm length along the superior border of the medial clavicle, with a slight curve just medial to the sternoclavicular joint, across the midline of the manubrium. A full-thickness soft tissue dissection was performed down to the left sternoclavicular joint utilizing a meticulous dissection technique to avoid accident"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old woman from a Middle Eastern country presented to the Jefferson Pancreas, Biliary and Related Cancer Center for evaluation of a recurrent pancreatic mass. She complained of right upper quadrant fullness, and physical examination revealed a remote right subcostal incision. At the age of 12 years, she had first developed decreased appetite, weight loss, fatigue, pruritus, and subsequently became jaundiced. Medical records from that episode revealed that an endoscopic biliary stent was placed with surgical exploration through a right subcostal incision and partial resection/enucleation of a pancreatic mass. In the intervening 12 years, the mass had persisted and enlarged, although the patient was asymptomatic, having neither anorexia, pruritus, nor jaundice.\nRoutine hematology and basic chemistry panels were normal. The tumor marker cancer antigen 19-9 was mildly elevated at 89 U/mL (<35 U/mL). An abdominal computed tomography (CT) scan with contrast revealed an 8.2 × 7.6 cm heterogeneous-enhancing lesion, prominently involving the uncinate process of the pancreas (). The pancreatic head and neck were displaced and splayed around the anterior aspect of the tumor. The mass abutted the superior mesenteric vein (SMV) as well as the superior mesenteric artery (SMA). There was no evidence of main pancreatic ductal dilatation and the pancreatic neck, body, and tail were normal. Imaging showed no evidence of metastatic disease to the liver or regional lymph nodes. The mass was believed to be an SPT, based on the previous partial resection and the accompanying pathology report.\nThe patient underwent an open cholecystectomy and a difficult classic pancreaticoduodenectomy. The operative time was 12 h and the estimated intraoperative blood loss was 1500 mL. There was no evidence of metastasis, but the tumor had adhered extensively to the SMV and portal vein and surrounded the SMA. We were able to accomplish the separation of the tumor from the venous structures witho"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old female presented with a new 3 cm mass in the pancreatic head that was found on an annual surveillance computerized tomography (CT) scan eight years after a radical left nephrectomy for renal cell carcinoma (RCC). Her initial nephrectomy was for an 8 cm clear cell RCC that had one positive periaortic lymph node (LN). The patient had no further treatment and denied abdominal pain but reported progressive weight loss (>60 lbs) over the last several months. She was not jaundiced and there was no evidence of duodenal or biliary duct obstruction on the CT scan. Other diagnostic modalities (endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging (MRI)) confirmed the pancreatic head mass. A bone scan and a chest X-ray were negative for metastatic disease. The patient underwent a diagnostic laparoscopy with pelvic washing and biopsies from peripancreatic tissue, celiac, splenic and periportal lymph nodes. There was no evidence of peritoneal, omental or hepatic spread and all biopsies were negative for malignancy. A pancreaticoduodenectomy (Whipple procedure) was performed for presumptive pancreatic cancer. Section through the specimen showed multiple solid yellowish necrotic and hemorrhagic areas (0.5 - 2.2 cm). The histologic exam was consistent with metastatic clear RCC (Figure ), two of nine peripancreatic LN were positive for metastases. There was no neoplastic thrombus in the pancreatic duct and the margins were free from disease. Immunohistochemical stain showed tumor focally positive for cytokeratin 7 and keratin AE1/AE3 but negative for cytokeratin 20 and carcinoembryonic antigen. The tumor stained strongly positive with vimentin; all consistent with RCC. The pathology was identical to the slides from initial nephrectomy. Four months later, a gradually enlarging right lobe thyroid nodule was noticed associated with dysphagia. The nodule was cold on radionuclide scanning and solid on ultrasound, measuring 2.9 x 2.6 x 2 cm. Do"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman with a history of hypertension and arrhythmia presented to the emergency room with severe pain and immobility in her left elbow, which resulted from a previous traffic accident. The patient complained of severe, painful limitation of motion on straightening or bending of the elbows, and her left hand was heavily bruised and swollen. Physical examination using palpation revealed burning and local tenderness. X-ray revealed a displaced fracture of the left olecranon with soft tissue swelling. The fracture was defined as a type IIA olecranon fracture according to the Mayo classification system.[ The orthopedic specialist suggested surgical open reduction with internal fixation, but the patient hesitated under the consideration of increased surgical risk due to her history of hypertension and arrhythmia. Therefore, the orthopedic surgeon fixed her left elbow with protective clothing only. Later that day, she visited our outpatient clinic to seek help from TCM.\nIn the first visit, we used the TCM methods for manipulative reduction of the fracture after physical examination. The physician held the patient's left palm in one hand and held the left elbow of the patient in the other hand. Next, the doctor pushed the proximal end of the patient's elbow with his finger to move closer to the distal end, and at the same time, straightened the patient's elbow slowly. Finally, the patient slowly buckled the elbow to 60°. It was then braced securely. We also asked the patient to avoid flexion and extension activities of the elbow and to fix the elbow with protective clothing for about 1 month, until her fracture had healed. That duration depended on X-ray interpretation to ensure complete union of the fracture. The protective clothing, similar to a triangular scarf, was for fixation and immobilization of the displaced olecranon fracture. The patient removed the protective clothing after about 1 month and then started rehabilitation. At the same time, we prescrib"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old male with a past medical history of asthma, spastic paraplegia, hypertension, hyperlipidemia, peptic ulcer disease, and tibial osteomyelitis post-infected hardware removal was admitted for altered mental status. He was admitted to the orthopedic service for infected hardware removal one month prior to the current admission. He was subsequently started on IV cefepime 2g every eight hours for tibial osteomyelitis and then discharged to a skilled nursing facility for six weeks. Approximately 17 days later, the staff at the nursing facility reported that the patient was delirious, slurring his speech, and pulling out his peripherally inserted central catheter (PICC) line in the night. He was then hospitalized at an outside facility for four days where he had an extensive workup, including a CT head, MRI head, and EEG without any conclusive etiology for his altered mental status. The EEG showed generalized slowing and evidence of metabolic encephalopathy and he was discharged. He returned to an outside emergency department three days later for persistent neurological symptoms, where he was found to have acute kidney injury. Following administration of IV fluids, he was discharged to his skilled nursing facility. His mental status did not improve. After consultation with the infectious disease team, the patient was admitted to our hospital for further workup. Upon admission, his vitals were unremarkable and physical examination showed confusion and disorientation without any other focal neurological deficits. Laboratory results were unremarkable except for an elevated creatinine of 1.8mg/dL (baseline 1-1.2mg/dL) indicative of unresolved acute kidney injury. Cefepime was discontinued, and the patient’s mental status and speech improved over the next 72 hours. Nephrology was consulted. After extensive workup, acute kidney injury was presumed to be secondary to cefepime toxicity with a component of acute tubular necrosis given the hyaline and granular casts see"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old female presented to the emergency department (ED) with upper abdominal pain and melanotic stools. She had an elective open juxtarenal abdominal aortic aneurysm repair a month before her index presentation. She was hemodynamically stable. Her pertinent initial labs showed a hemoglobin of 6.7 g/dl (baseline 9.6 g/dl) with a hematocrit of 23%. Patient did not have any fever or leukocytosis. A CT abdomen with contrast done in the ED for abdominal pain showed nonspecific findings, i.e, irregularity of the “aneurysmal sac” with a small amount of fluid around the sac (see ) which was read by the radiologist as early postsurgical changes. She was admitted and was started on proton pump inhibitors. An esophagogastroduodenoscopy (EGD) was performed that revealed mild duodenitis. Her hemoglobin remained stable the next couple of days, and she was discharged home with a 6-8-week course of proton pump inhibitors. Two months later, she presented again with similar complaints with a drop of hemoglobin. A repeat EGD was performed that did not reveal any obvious source of bleeding, and she was discharged home after stabilization.\nA month later, she came for the third time into the ED with abdominal pain, hematochezia, and profound hypotension. Her pertinent laboratory findings include leukocytosis, low hemoglobin and hematocrit, thrombocytopenia, and transaminitis. She was resuscitated with IV fluids and blood transfusions. She was started on broad spectrum antibiotics after blood cultures were drawn. A CT abdomen and pelvis was performed which showed tiny foci of air at the anterior aspect of the native aneurysm wrap just inferior to the location where duodenum crosses (see ). At that time, a decision was made to perform push enteroscopy instead of simple EGD to evaluate second and third portion of duodenum which showed an aortoduodenal fistula with infected graft adherent to the bowel wall and extruding purulent exudate (see ). She underwent emergent"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male with no previous medical history, presented with right upper quadrant pain and mild elevation of total bilirubin to 2.9 and Ca 19-9 was elevated at 559 u/mL. All other laboratory values were within normal limits. Evaluation included a right upper quadrant ultrasound (U/S) and computed tomography (CT), which demonstrated left intrahepatic bile duct dilatation. No stones were noted in the biliary system or gallbladder. ERCP and MRCP demonstrated a mural nodule arising from confluence of the left hepatic duct and the common hepatic duct (). Brushings were nondiagnostic. During staging laparotomy, what initially appeared to be metastatic satellite lesions proved to be dilated intra-hepatic biliary system (, arrow head). The planned surgical resection was undertaken with curative intent: resection of the common bile duct with en bloc left hepatectomy, caudate resection, and regional lymphadenectomy. Reconstruction was performed with a Roux en Y hepaticojejunostomy to the secondary right hepatic bile ducts. Two exophytic polypoid tumor masses were identified within the left intrahepatic bile ducts, 2.5 and 2.9 centimeter in size (). Microscopic analysis demonstrated well-differentiated adenocarcinoma arising within a hepatobiliary cystadenoma (). Multifocal severe dysplasia was seen within the left intrahepatic biliary tree without evidence of invasive carcinoma. The remaining right biliary ducts and distal common bile duct were uninvolved. A 1 mm focus of metastatic disease was identified in the regional nodes (1/13).\nThis patient was taken to surgery for treatment of a suspected intrahepatic cholangiocarcinoma not hepatobiliary cystadenocarcinoma. Radical resection with regional lymphadenectomy was performed with curative intent and frozen section only obtained at the right biliary margin (negative for dysplasia and cancer). Microscopic analysis demonstrated well-differentiated adenocarcinoma arising within a biliary cystadenoma with multifocal severe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old female patient was referred to our department with acute onset postpartum paraplegia with bowel bladder involvement after delivery of her third child by normal vaginal delivery. Her antenatal course had no significant history with any history of antepartum low-back pain, trauma, drug use, or any physical exertion. On examination, she was conscious, well oriented, and afebrile. Neurological examination showed complete paraplegia (power 0/5 with decreased tone), associated bowel bladder involvement, and absent deep tendon reflexes at knee and ankle joint with complete sensory deficit below the level of L1. All necessary blood investigations including coagulation profile came out to be normal. Patient was planned for magnetic resonance imaging (MRI) of dorsolumbar spine with screening whole spine, which revealed extradural broad based ellipsoid lesion, measuring 50 × 9 mm along T12 to L2 vertebra displacing the dura anteriorly and T1 hyperintensity (\n), T2 hypointensity with minimal postcontrast enhancement suggestive of early subacute bleed causing mass effect on adjacent cord with areas of altered signal intensity at the level of lesion.\nOn the basis of clinical evaluation and MRI report, the patient was planned for urgent decompression in emergency operation theater. After preoperative marking of D12–L2 vertebral levels under fluoroscopic guidance, midline exposure done and paraspinal muscles elevated upto medial edge of transverse processes on both sides with the help of cobb's and broad osteotome. Intraoperatively, bilateral complete laminectomy of L1 vertebrae was done with removal of ligamentum flavum, a well-defined firm organized hematoma dark reddish black in color (5 × 1 cm) was seen over the dura which was removed (\n) and checked for adequate decompression utilizing infant feeding tube. Sample removed was sent for histopathological examination reported as organized hematoma. Postoperatively, patient recovered rapidly in terms of neurological d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male presented to the emergency department of the local primary hospital with abdominal pain and a bruised bulge on the left lower abdominal quadrant immediately after a bicycle accident. He was examined by an emergency physician, and a supine chest and abdominal radiography were performed. He was hemodynamically stable and had abdominal tenderness but no signs of peritoneal irritation. No serious pathologies were revealed, and a dressing was applied to the wall hernia. He was discharged to home with follow-up instructions and next-day review. After 3 hours, he began vomiting, and the abdominal pain slowly increased in severity. Approximately 9 hours after the accident, he returned to the same hospital, and an on-call general surgeon examined the patient. The patient was in diffuse abdominal pain but with stable vital signs except for tachycardia. US revealed intraperitoneal pelvic free fluid and bowel wall thickening, and the patient was administered intravenous fluid and monitored. However, the pain developed in intensity and became unbearable for the patient, and before the general surgeon was able to recheck the patient, the family refused further care and transferred to our hospital 20 hours after the accident. On examination, the patient was unable to walk, anxious, pale due to severe pain, dehydrated, tachycardic, and hypotensive. He had diffuse abdominal tenderness and peritonism. He reported that while he was performing an acrobatic maneuver on his bicycle, one of his slippers fell off, causing him to lose his balance and fall. UAXR in a sitting position revealed pneumoperitoneum and air-fluid levels the in intestine. US was repeated and revealed free fluid in the abdomen. Ileal and sigmoid perforations were detected on emergent exploratory laparotomy and were repaired with resection and anastomosis and with primary anastomosis, respectively. Peritoneal lavage was also performed. A drain was inserted into the rectovesical pouch. The postoperat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female was referred by an otorhinologist with a large chin ulcer and toothache. The medical history was unremarkable, having never had a medical consultation due to the poor socioeconomic situation. There was a 20-year history of gradually enlarging black papule on her chin. The patient complained of unpleasant facial appearance and a dull pain in the chin region. On extra oral examination, there was a large ulcer (10×6.5 cm) with a firm and indurated margins on the chin extending to the mandibular vestibule and necrosis was evident in surrounding bone (). On palpation, drainage of pus was evident from the ulcer. The mandibular right lateral incisor and canines were mobile. Central incisors were prior to admission due to extreme mobility. Radiographic examination revealed an ill-defined radiolucency of the mandibular symphyses (). Cytological examination did not show any evidence of spirochete infection. Although the lesion had an atypical appearance, the slow course, in addition to clinical characteristics such an enrolled boarders, destructive ulcer, and concurrent involvement of skin and bone led the diagnosis of BCC as the first possibility. Incisional biopsy was performed at the margin of the ulcer. Other differential diagnosis included necrotizing ulcerative gingivostomatitis with facial involvement (noma), osteomyelitis, leishmaniasis, Wegener granulomatosis, deep fungal infection, and amelanotic melanoma. The histopathologic sample consisted of uniform ovoid, and dark staining basaloid cells with moderate sized nuclei and relatively little cytoplasm. The cells were arranged into well-demarcated islands and strands, which appeared to be raised from the basal cell layer of the overlying epidermis and invaded into the underlying connective tissue (). The histopathologic evaluation of the resected bone showed secondary osteomyelitis due to the extensive ulcer. The clinical diagnosis of BCC was confirmed. Surgical resection was planned for the lesio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old female known case of rheumatoid arthritis affecting both knees presented to our clinic complaining of severe right knee stiffness post TKA 4-years-ago done in an outside facility ( and ). She lives in a rural community and was on hydroxychloroquine, but her disease was active as she was not compliant to her medication. On physical examinations, the right knee was larger in size compared to the left knee without joint effusion. Range of motion was zero on flexion, −10° in extension. Standing knee X-ray showed HO around the prosthesis (). Computed tomography (CT) demonstrated extensive HO with implants fixed in place (). Revision surgery and replacement of the prostheses was considered to restore function.\nThe old medial parapatellar approach was utilized. The medial and lateral gutters were completely released up to the posteromedial corner. When the knee was too stiff to be mobilized further, the patellar tendon was found to be severely contracted and shortened with patella baja deformity. A tibial tubercle osteotomy was needed for adequate exposure. Osteotomy fragment measured 6 cm with 1.5 cm thickness, after which we became able to flex the knee. The components were completely engulfed by capsular heterotopic bone (). Using osteotomes and burrs, the tibial and the femoral components were slowly visualized. Both components were found to be well fixed. Carful removal of the posterior heterotopic bone was done with a bone curette, which finally allowed for component removal. Intraoperative culture samples were taken as routine measure for revision surgeries. RT-Plus modular rotating hinge knee system (Smith & Nephew, Memphis, TN, USA) was used. The procedure was started with reaming the tibia up to size 12 mm. It was sized to be size four. Proximal drilling and rasping were done, and posterior offset stem was used.\nAfter that, reaming of the femur was carried out reaching size 14 mm, giving a good"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male with a history of intravenous (IV) drug abuse presented to the hospital with acute onset back pain. The patient had a 10-year history of chronic back pain as well as a history of cervical radiculopathy, for which he underwent anterior cervical discectomy and fusion 6 years ago. The patient stated that his back pain had been worsening over the past 3 weeks. The patient presented to the emergency room several times in the last couple of weeks prior to admission. His back pain was presumed to be related to his previous history, and he was discharged home on opioid analgesics.\nOn admission, the patient reported severe squeezing back pain extending from his lower to middle back. The pain was described by the patient as a 10/10 in intensity with radiation to his buttocks. The pain was not relieved by lying down and was aggravated by activity. The patient did not exhibit any lower extremity weakness, numbness, or bladder/bowel dysfunction, and he denied any fevers or night sweats. On physical examination, palpation of the spine revealed diffuse tenderness. Straight leg raising test was negative.\nIn the ED plain X-ray of the lumbosacral spine revealed degenerative changes of the lumbosacral spine but no evidence of infection, malignancy, or fracture (see ). The patient was sent to the inpatient ward for observation with an initial diagnosis of chronic back pain.\nInitial laboratory findings revealed a mildly elevated white blood cell count at 12,000 and anemia with hemoglobin at 9.5. Erythrocyte sedimentation rate was found to be 92. With these laboratory abnormalities and persistent symptoms, magnetic resonance imaging (MRI) was done to further evaluate the back pain. MRI examination of the lumbosacral spine revealed osteomyelitis with discitis at T10-T11 level with some retropulsion of both vertebral bodies causing mass effect on the spinal cord (see ). The patient was immediately started on IV dexamethasone, and he underwent CT-guided aspiration of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old man was diagnosed with pulmonary adenocarcinoma, then treated with chemotherapy. The cancer metastasized, and the patient was diagnosed with end-stage lung cancer. Cancer pain was treated with oral opioid therapy. Metastasis of the cancer caused obstructive jaundice and cholangitis, and the patient experienced septic shock. The attending physician performed emergent endoscopic biliary stent placement, in order to treat obstructive jaundice. The patient was medicated with continuous infusion of noradrenaline (0.2 μg/kg/min) through a peripheral vein, in order to maintain blood pressure. He underwent repeated placement of peripheral venous catheters, such that it became difficult to identify adequate peripheral veins for placement and maintenance of indwelling catheters. In the context of this treatment, the patient's congestive heart failure continued, which caused ascites and edema of the lower extremities.\nThe patient experienced orthopnea and could not sleep at night. The attending physician requested that the anesthesiologists secure a reliable venous line. The anesthesiologists checked the patient's groin and thighs; they excluded the femoral vein as a candidate for central venous access due to massive edema of the thighs. The anesthesiologists attempted to allow the patient to assume the supine or reverse Trendelenburg position; however, these positions caused worsening of the patient's dyspnea. The patient could solely tolerate the sitting position. The anesthesiologists then discontinued attempts to catheterize via the internal jugular and subclavian veins, because of the risk of air embolism during central venous catheterization of the patient in the sitting position.\nThe right subclavian vein was suspected to exhibit narrowing, based on computed tomography scan images (Fig. ). Thus, the anesthesiologists chose the left arm for insertion of a PICC, and found that the medial brachial vein exhibited sufficient size (diameter 4 mm) to place a PICC"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur case was a 70-days old male child that has presented with respiratory distress and cyanosis following breastfeeding. Physical examination was normal except the tachypnea, subcostal retraction.\nThe infant's arterial oxygen saturation was 92% at room air. The patient has admitted with initial diagnosis of pneumonia and subsequently an antibiotic therapy has initiated. Initial laboratory investigations were normal ().\nA chest radiography has shown an opacity in the lower part of the left lung. A computerized tomography (CT) of the thorax has revealed a well-defined heterogeneously enhancing mass measuring 45 mm × 40 mm in the lower lobe of the left lung ( and ). There was no pleural effusion. Differential diagnoses has proposed by radiological service has included pulmonary sequestration and congenital adenomatoid malformation.\nThe exploration has revealed a mass measuring 50 mm × 40 mm × 20 mm, involving the lower lobe of the left lung, having a solid appearance. The mass has resected via the left lower lobectomy. There was no spread to the chest wall. After installing chest tube, infant has supported through mechanical ventilation during the post-operative period and has discharged from Pediatric Intensive Care Unit after 4 days with no further problems with respiratory distress.\nMacroscopic examination has consisted of a lung lob measuring 50 × 40 × 20 mm. Cross-section shown a gray-white well circumscribed soft to firm mass with irregular brown border. Histological examination of tissue sections has revealed proliferation of neoplastic cells in lung tissue ().\nThere was atypical proliferation of spindled to fusiform cells have arranged in interlacing long fascicules. The neoplastic cells has shown little pleomorphism, scanty cytoplasm with indistinct cell borders and have separated by interwoven collagen fibers and have arranged in a parallel fashion. Occasioned mitotic were were present (1-2 HPF). The tumor has contained areas of hemorrhage and necrosis.\nThere"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-year-old boy with no pathological history accidentally fell from the top of an approximately 3 m climbing pole and injured his right extended elbow and wrist joint. Due to pain and deformity in the right elbow and wrist joints, he visited our hospital. Swelling and a dinner fork deformity of the right wrist joint and pronounced swelling of the right elbow joint were observed. No skin damage was observed. No findings of nerve injury or arterial injury were obtained in the right upper limb. Radiography revealed lateral dislocation of the radial head, a fracture of the proximal ulnar metaphysis, and mild bending deformation at the fracture site. In addition, fractures of the distal radius and ulna, as well as dorsal displacement of the distal fragment, were seen (). Thus, the patient was diagnosed with Bado type III Monteggia injury with ipsilateral fracture of the distal radius and ulna.\nManual reduction under nerve block was attempted on the day of injury. However, because it was difficult to maintain the reduction of the radial head, as shown in , open reduction and percutaneous procedures were performed under general anesthesia. A Kirschner wire was inserted, percutaneously, from the olecranon into the ulnar diaphysis. When the Kirschner wire was in place, the dislocation of the radial head immediately showed good reduction. Further, open reduction and fixation of the fractured distal radius and ulna were performed with Kirschner wires (). A long-arm cast was used for external fixation with the elbow in 90° flexion and the forearm in an intermediate position.\nTwo weeks after surgery, callus formation at the fractured bone was observed. Therefore, the cast was removed, and range of motion (ROM) exercises of the elbow and wrist joints were initiated. Since bone union was achieved at 6 weeks postsurgery, the Kirschner wires were removed. Pain, ROM limitation, and lateral instability were not observed in the elbow or wrist joints at 3 months after surgery. Addition"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old woman was presented to the hospital without prior colorectal cancer screening. Physical examination was significant for Virchow's node (Troisier's sign). Colonoscopy revealed innumerable uniform polyps most heavily concentrated in the cecum. Biopsy revealed mantle cell lymphoma. A 78-year-old woman with history of hypertension and hyperlipidemia presents to the surgical clinic for colonoscopy. Upon review of systems, patient reports dysphagia. Her physical examination was remarkable for a soft nontender anterior cervical lymphadenopathy, and a left supraclavicular lymph node enlargement (Virchow's node; Troisier's sign). Upper endoscopy and colonoscopy were scheduled within the next week. Upper endoscopy revealed a partially occluding oropharyngeal submucosal lesion. There were no signs of ulceration or any mucosal involvement. Some polyps were observed within the esophagus, but the stomach and duodenum were unremarkable. Colonoscopy revealed numerous polyps were increasing in quantity from the transverse colon to the cecum. On colonoscopic inspection, polyps were uniform in size and shape resembling a polyposis syndrome. Multiple biopsies were obtained in the cecum, and ascending and transverse colon, and then sent to pathology. Initial pathology report returned with the polyps as atypical lymphocytic infiltrate, which was later identified to be mantle cell lymphoma. Outside of the lymphatic system, mantle cell lymphoma is seen as a multiple lymphomatous polyposis, or lymphomatous intestinal polyposis. Its detection and identification are of utmost importance due to the aggressive nature of the disease. This is a patient who presented with a physical examination concerning for malignancy, which was later confirmed via biopsies in the colon and in a cervical lymph node. Mantle cell lymphoma is known as a late-presenting aggressive cancer. Outside of the lymphatic system, it can present as lymphomatous intestinal polyposis or multiple lymphomatous polyp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old woman with an unremarkable medical history visited our hospital after she accidently swallowed a tuna bone at supper. She complained of mild chest discomfort with slight pain. Chest radiography revealed no abnormal findings and she was permitted to go home at night (A, B). The next morning, she revisited the hospital with deterioration of chest discomfort and a slight fever of 37.4 °C. Non-contrast chest computed tomography (CT) revealed an impacted large fish bone with a length of 35 mm lying across the middle third of the thoracic esophagus and accompanied by local mediastinitis (C, D). She was immediately referred to a larger hospital, where she underwent contrast-enhanced chest CT scan that revealed penetration into the right inferior pulmonary vein caused by the fish bone (A, B). The bone protruded more than 10 mm from the vessel wall inside the pulmonary vein, accompanied by a small amount of free air. Blood tests revealed an abnormally elevated white blood cell (WBC) count of 11,400/μL and elevated C-reactive protein (CRP) level of 20.45 mg/dL. Although the pulmonary vein is a low-pressure system, endoscopic removal may result in a lethal intractable bleeding that would require an emergent cardiovascular surgery. Thus, endoscopic removal of the fish bone was performed in the operating room under general anesthesia (C, D) with cardiovascular surgical standby for a possible urgent surgery with a right thoracotomy approach.\nThe impacted fish bone was successfully removed endoscopically without massive bleeding. A follow-up chest CT scan was performed just after the endoscopic removal that confirmed the absence of mediastinal hematoma. The patient was carefully managed in the emergency ward not to overlook possible sudden changes of the general condition. Oral feeding was prohibited until the follow-up of chest CT scan and endoscopic inspection planned in the next week. To treat the mediastinitis, 3 g/day of intravenous meropenem was initiated. Feve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male with a history of hyperlipidemia and seizure disorder presented to an outside hospital following a breakthrough seizure, where he was incidentally also found to have punctate areas of acute cerebral infarcts in multiple vascular territories. Additional workup revealed the presence of a left atrial thrombus and newly diagnosed atrial fibrillation. He was ultimately discharged to home on apixaban. The patient then re-presented a month later for evaluation of transient diplopia, expressive aphasia, daily right temporal headaches, and right facial and left leg weakness. MRI of the brain showed new areas of diffusion restriction in the left cerebellar hemisphere and left medial occipital lobe (Figure ). CTA showed no signs of carotid occlusion or stenosis. The etiology of his multifocal strokes was thought to be related to his newly diagnosed atrial fibrillation and left atrial thrombus.\nThe patient was then transferred to our hospital for further evaluation. His initial NIH stroke scale was 8 (primary deficits were including unilateral facial palsy, bilateral lower extremity pronator drift and ataxia). Stroke labs, including lipid panel and hemoglobin A1C, were unremarkable. MRI of the brain with contrast showed a new infarct in the splenium of the corpus callosum in addition to prominent generalized meningeal enhancement (Figure ). MRI of the spine with contrast showed possible meningeal enhancement as well as punctate areas of encephalomalacia in the C3-4, C7, and T3 spinal levels. A bedside LP revealed a mildly elevated opening pressure of 24 cm H20, lymphocytic pleocytosis (WBC 150 K/cumm, 61% lymphocytes), protein 170 mg/dl, hypoglycorrhachia of 15 mg/dl, and presence of cryptococcal antigen. Other notable CSF labs included the presence of 11 oligoclonal bands. He was diagnosed with cryptococcal meningoencephalitis and started on a four-week course of amphotericin B and flucytosine. A repeat LP after several days of treatment showed a normal open"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old woman, gravida 2, para 1, had undergone aortic valve replacement (mechanical) for aortic regurgitation at the age of 10 years. Since then, she had been receiving anticoagulation with warfarin, 5 mg/day. During the previous pregnancy, she received a combination of warfarin and heparin for anticoagulation, and the pregnancy and delivery were uneventful for both mother and infant. As with the previous pregnancy, oral administration of warfarin was switched to continuous intravenous infusion of heparin in the fifth week of gestation. In the 12 weeks of gestation, oral administration of warfarin was resumed at a dose of 3 mg/day, and then, the dose was increased to 4.5 mg/day. The activated partial thromboplastin time (APTT) was maintained between 50 and 60 sec during heparin use, and prothrombin time by international normalized ratio (PT/INR) was maintained between 1.5 and 2.0 during oral administration of warfarin. On the fifth day of the 31 week of gestation, ultrasonography revealed mild enlargement of the left lateral ventricle of the fetus, measuring 1.0 cm, and it was found to have further enlarged to 1.5 cm on the fifth day of the 33 weeks of gestation (Fig.). Magnetic resonance imaging (MRI) performed on the first day of the 35 week of gestation revealed bilateral intracranial subdural hematoma in the fetus, and the left ventricle was found to have enlarged due to compression by the hematoma (Fig.). We determined that the fetal intracranial subdural hematoma had been caused by fetal intracranial hemorrhage associated with warfarin administration to the mother. On the same day, warfarin was discontinued and replaced with continuous intravenous infusion of heparin. Cardiotocography (CTG) showed that the fetal conditions were favorable and no anemia was observed based on the measurement of middle cerebral artery peak systolic velocity (MCA-PSV). On the second day of the 36 weeks of gestation, the mother underwent elective induction of delivery with ox"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA medically fit and well 13-year 11-month-old male was referred to the oral and maxillofacial surgery department at Alder Hey Children’s Hospital in Liverpool in regard to an intra-oral swelling of the right palatal region (Fig. ). An incisional biopsy was initially reported as a pleomorphic adenoma of the premolar region. Subsequently, a CT scan showed no significant bony abnormality, and a wide local excision was carried out with the application of a surgical palatal dressing plate. Histopathology of this resected tissue appeared to show tumour of intermediate malignant grade at the base of the specimen.\nFurther investigations undertaken to stage the tumour included a repeat CT scan which presented no evidence of significant bony involvement or erosion. An MRI scan showed no significant asymmetry or signal abnormality in the region of the hard palate, and there was no evidence of loco-regional metastasis of this tumour.\nFollowing a discussion of the craniofacial multidisciplinary team and numerous paediatric pathologists, a diagnosis of intermediate-grade sarcoma of the oral mucosa and hard palate was re-affirmed. A partial right-sided maxillectomy was planned to gain adequate tumour clearance, and prior to surgery, the patient attended for dental impressions and counselling regarding the procedures involved, together with instructions regarding the obturator prosthesis.\nA low-level right-sided standard hemi-maxillectomy was carried out via an intra-oral approach with preservation of the pterygoid plates (December 2013). The anterior alveolar cut was undertaken through the right lateral incisor socket following the extraction of this tooth in order to maximise the bone support on the maxillary central incisor abutment tooth. The residual zygomatic body on the right side was exposed, and two 37-mm zygomatic oncology implants (Southern Implants Ltd, South Africa) (Fig. ) were placed with excellent stability, ensuring that the prosthetic heads were positioned beneath"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male with a past medical history of coronary artery disease, cardiac stent, COPD, HTN, and dyslipidemia presented as a referral for left testicular teratoma and primary bladder leiomyoma. Prior to presenting to our facility, he underwent left radical orchiectomy, and hernia repair due to enlarging left testicle, had a transurethral resection of bladder tumor (TURBT) due to hematuria, and underwent PSA screening. Pathology determined the testicular mass to be a pT1 teratoma without lymphovascular invasion, PSA was found to be elevated (was 4.2 in 2014, now 4.39), and the 40 g of bladder tumor resected during the TURBT was found to be a leiomyoma of the bladder showing no sarcomatoid differentiation. A CT scan was performed which was notable for bilateral pelvic adenopathy with lymph nodes greater than 2 cm and an interaortocaval lymph node of approximately 1.2 cm. Additionally, outside CT scan with IV contrast of abdomen pelvis showed large 6 cm heterogeneous soft tissue mass within the posterior left aspect of the bladder (). The mass was causing complete obstruction of the left ureterovesical junction (UVJ), which resulted in severe left sided hydronephrosis and hydroureter. Although the CT findings were highly concerning for metastatic process, the TURBT specimen did not support the diagnosis of metastatic disease from a bladder primary as it had returned leiomyoma of bladder without sarcomatoid elements. The disparity between imaging findings and pathology results prompted confirmatory testing on both the initial testicular mass and the TURBT specimens. After discussion at multidisciplinary GU tumor board, the consensus recommendation was for CT-guided lymph node biopsy, repeat transurethral resection of bladder tumor, and decompression of the left upper tract via ureteral stent, or nephrostomy. The patient underwent rigid cystourethroscopy, monopolar transurethral resection of bladder tumor (large >5 cm) and monopolar transurethral resection of pro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 42-year-old man who presented to the emergency department with a complaint of abdominal pain and diarrhea for 3 days. The abdominal pain started in the periumbilical region and was shifted to the right lower quadrant of the abdomen. The pain started gradually and had been progressing in severity. He described the pain as a stabbing in nature. It was exacerbated by movement and food intake. The pain was partially relieved by oral analgesic medications like paracetamol. The pain was associated with low-grade fever and decreased appetite. The patient also complained of diarrhea with five bowel motions/day. The stools were watery with no mucus or blood. He reported that diarrhea developed after he received an oral antibiotic therapy (cefuroxime) for a recent upper respiratory tract infection.\nThe past medical history of the patient was remarkable for diabetes mellitus that was well-controlled with oral antidiabetic agents. He did not undergo any previous abdominal surgeries. He had a smoking history of 15 pack-years. He had never drunk alcohol before. He worked as a taxi driver. The family history was unremarkable for any inherited gastrointestinal disorders.\nUpon examination, the patient appeared sick. He was not pale, jaundiced, or cyanosed. Vital signs revealed tachycardia (115 bpm), low-grade fever (37.5℃), normal respiratory rate (14 bpm), and maintained blood pressure (122/80 mmHg). The oxygen saturation was 99% on room air. Abdominal examination revealed a soft abdomen with diffuse tenderness. However, the tenderness was more pronounced in the right iliac fossa with a positive rebound sign. Further, the Rovsing sign was positive. Initial laboratory investigation revealed elevated leukocyte count and elevated inflammatory markers, including erythrocyte sedimentation rate and C-reactive protein. The renal and hepatic profiles were within the normal limits (Table ).\nIn light of the aforementioned clinical information, the patient was diagnos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old woman was found unresponsive near a snowy mountain trail in winter. On that day, the outside air temperature ranged from − 2.0 to 1.0 °C. When emergency medical services arrived on the scene, they found that the patient was in cardiac arrest and in asystole. It was noticed that she also had mandibular rigidity. On the way to the hospital, emergency medical service staff were unable to insert an oral airway device for ventilation because the mandibular rigidity prevented sufficient mouth opening. The chest was compressible. CPR was performed with manual chest compression and bag valve mask ventilation ratio of 30:2 during transportation. When she was admitted to the hospital, 52 min had passed since she was discovered. She remained in cardiac arrest with an asystolic cardiac rhythm. Her initial core temperature was 22 °C measured by bladder thermistor. Her mandibular rigidity remained, and neck mobility was also restricted. Both elbows and knees could be passively bent with resistance and the chest wall was not stiff. We were concerned that postmortem changes (i.e., rigor mortis) had begun. We tried to force open her mouth for intubation and found that it could be slightly opened. Although this was insufficient to visualize the vocal cords with a conventional laryngoscope because of the impossibility of controlling it, we were able to insert an “Airway scope™” video laryngoscope, which allowed successful intubation. Although the patient was in cardiac arrest due to severe accidental hypothermia, which indicated an enhanced possibility of successful resuscitation, the mandibular rigidity connected, along with the supposition of rigor mortis initiation made us believe that it would be difficult to resuscitate successfully. However, her initial blood gas analysis revealed that her serum potassium level was 5.4 mmol/L (Table ). We decided to use veno-arterial ECMO to generate effective systemic perfusion and to rewarm the patient. After ECMO initiated, her"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 35-year-old man—who operated a jackhammer. He appeared at the Emergency and Accidents Department with constant and intense pain in the lower left limb, moderate ipsilateral paresis in the ankle, foot, and toes, and coldness. He had suffered these symptoms for around 48 hours. In addition, he had suffered from an irregular fever (not measured using a thermometer) for two weeks with oropharyngeal discomfort and spontaneous pain in the groin and left lower quadrant which increased with time. He did not mention any previous trauma but when pressed recalled hyperpulsatility beneath the inguinal ligament at least a year before. He did not consult a physician as the problem did not appear to bother him.\nHis medical history included a cerebral venous thrombosis (left transverse and sigmoid sinus thrombosis) which was attributed to mastoiditis in 2006, resulting in occasional attacks of epilepsy being treated successfully with oxcarbazepine. He was a smoker with no known allergies.\nA physical examination revealed feverishness, a generally good physical condition, normal thorax and abdomen features, and an expansive throbbing mass below the inguinal ligament and left minor pelvis. The absence of femoral and infrainguinal pulses was obvious as well as severe and acute ischemic symptoms. The other limbs were found normal.\nA blood test discovered leukocytosis (16 × 103/microliter) and neutrophilia (N = 80.4%) with a hemoglobin value of 13 g/dL. In a CT scan we observed a saccular aneurysm with a transversal diameter of 45 mm located in the left external iliac artery with no sign of rupture. This was associated with a short occlusion in the bifurcation between the femoral and profunda arteries (). A deep venous thrombosis in the iliofemoral area was found. There was no evidence of aneurysms or malformations in other abdominal organs.\nThe patient underwent urgent surgery under general anesthesia. During the surgery, we decided first to perform"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy with leucoderma was admitted to our service reporting pain while chewing, bulging in the left mandibular angle and aesthetic discomfort because of face asymmetry, but no relevant clinical facts existed.\nPhysical examination revealed a facial asymmetry, a palpable mass in the angle region of left mandibular, pain, limitation of oral opening and bulging in region of teeth 36 and 37, tooth 38 was lacking. The diagnosis exam, the panoramic radiographic and computed tomography of the face showed suggestive images of injury involving the body and left mandibular ascending ramus ( to ).\nPatient’s familiar medical history did not show significant data. Reconstruction possibilities were discussed with patient and his family including the use of autogenous bone grafting of iliac crest and/or off-label use of rhBMP-2. Advantages and disadvantages of both possibilities were presented and patient and family decided for rhBMP-2 off-label. After evaluation of surgical risk and treatment of teeth 36 and 37 canals had are done, the patient underwent surgery in a hospital environment under general anesthesia and nasotracheal intubation. We performed an incision with extension of mandibular ascending ramus to vestibular region to first lower left molar, being elevated the mucoperiosteal graft, therefore achieving a partial exposition of the injury. An osteotomy was need using a 701 drill for higher exposure of the injury (). The dissection was simple because the tumor was encapsulated ().\nRecipient site was prepared and, by using the bone grafting technique, the rhBMP-2 was prepared associated with Bio-Oss® (Geistlich Pharma AG, Wolhusen, Switzerland) and fairly adapted to surgical site with subsequent adaptation of titanium mesh 1.0 system that promoted a mechanical barrier. A plate 2.0 system was used on external oblique line to obtain higher stability ( and ).\nA polyglactin 910 wire suture was used in deep plans and on the mucosa. Material obtained was forwarded f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA right-handed, bilingual 54-year-old woman was admitted at the emergency department for a generalized tonic clonic seizure sustained by a primitive brain tumor located between the posterior part of the superior and middle temporal gyri and the anterior part of the angular gyrus in the left hemisphere. The lesion did not enhance after contrast medium administration and it was hypometabolic at 18F-fluorodeoxyglucose PET/MRI. The functional MRI (fMRI) confirmed that the lesion was located in the dominant hemisphere (). Due to the anxiety of the patient, mostly related to the diagnosis of brain tumor, the fMRI was performed testing only her mother tongue, i.e., Romanian. Interictal EEG showed an irritative activity in left centro–parietal derivations.\nConcerning the social and work surrounding the patient had been living in Italy for 17 years with her family, perfectly integrated in the social context, working as a housekeeper. Previously, she had 13 years of education, graduating in a vocational school in her home country.\nThe patient underwent a comprehensive battery of standardized neuropsychological tests performed in Italian, in order to evaluate the impact of the tumor on cognitive functions. A standardized evaluation of Romanian language was not executable because native language versions of the tests were not available and because none of the team spoke Romanian. The assessment was composed of tests covering different cognitive domains. The Oxford Cognitive Screen [,], a brief screening instrument composed of tasks on language, visual attention, spatial neglect, praxis abilities, visual and verbal memory, calculation, number reading and executive functions. Specific tests were also administered to better evaluate different cognitive functions. The Prose Memory Test (immediate and delayed recall) and Interference Memory test [] were used as a measure of verbal memory. Forward and backward digit span and the Corsi block-tapping test were administered to measure s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32 years old previously healthy fair-skinned male originally noted that a mole on his left calf began to change in 2006. He consulted a doctor and the mole was excised. A pathologic diagnosis of melanoma was made. A sentinel node dissection was carried out, and was negative for metastatic disease. In 2007, the patient noted enlargement of left inguinal lymph nodes, and small melanocytic lesions on the skin of his left leg. He was treated with interferon alpha under a clinical trial at a regional cancer hospital, with reduction of the nodes and resolution of the skin metastases. Interferon was stopped after 9 mo due to side effects.\nThe patient remained well until 2010, when a new left leg skin metastasis appeared. This was surgically excised. In late 2011, another new cutaneous metastasis was identified on the left leg, within the scar from the original melanoma surgery. This was biopsied and a diagnosis of recurrent melanoma was confirmed. He was then treated with wide excision and skin graft.\nIn March 2012, the patient was diagnosed with a recurrence within the left leg skin graft. This was excised and a new skin graft procedure was performed. Pathology revealed positive margins of the excised metastasis, so a re-excision was performed, again with positive margins. At the same time, needle biopsy of a left inguinal lymph node confirmed the presence of BRAF-positive metastatic melanoma. A Computed tomography (CT) scan performed in Mar 2012 revealed no evidence of distant metastases. The largest left inguinal node was 8mm in diameter, which was reported as “insignificant by size criteria” (Figure ).\nIn April 2012, the patient consulted a naturopathic doctor (Shainhouse) and began therapy with the following oral natural anti-cancer agents: Active hexose correlated compound or AHCC (mushroom extract)[], dandelion root[], curcumin[], and astragalus root[]. Parenteral therapy was also started, which consisted of intravenous vitamin C twice"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-year-old girl was referred with a long-standing history of over a year of intermittent vomiting, abdominal pain, and progressive abdominal distension. She was born at term following an uneventful pregnancy and normal antenatal ultrasonography. On clinical examination, she had very marked abdominal distension and a visible and palpable diffuse mass occupying her entire abdomen. She was initially investigated with an abdominal and pelvic ultrasonography which demonstrated a large multilocular fluid filled cystic mass occupying most of her abdomen from the left upper quadrant to her pelvis and extending across the lateral aspect of her abdomen and lying anterior to her bladder. A CT scan of her abdomen and pelvis confirmed a 27 cm × 20 cm × 14 cm multilocular mass extending from the left upper quadrant to her left iliac fossa, with bowel loops invaginating in between, causing mass effect on the rest of the her abdominal contents including her IVC (). She underwent a laparoscopic near total excision of her abdominal cyst. At laparoscopy, the cyst was seen to be enveloping the entire small bowel mesentery, in close relation to the bowel wall. In the portion of the cyst within the root of the mesentery, where it was difficult to achieve complete excision without compromising the vascularity of the bowel, a partial excision was done with electrocauterization of the residual mucosal lining. The operative time was 50 minutes, with no intraoperative complications or need for conversion to an open procedure. She made a good recovery following her surgery with no postoperative complications and was discharged home after 24 hours. Histological examination of the excised specimen revealed a cystic lymphangioma. At 6-month follow-up she continues to remain clinically well with no symptoms. A repeat abdominal ultrasonography suggested a small 2 cm recurrent cyst, which was well localized with the small bowel mesentery, with no mass effect. She continues to remain on regular fol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38 -year-old gravida 2 para 1pregnant woman was referred to our prenatal clinic for a survey at 18 weeks of gestation due to twin pregnancy with the discordant amniotic fluid amount. Sonographic examination revealed polyhydramnios with a maximum vertical pocket (MVP) of 12 cm in the recipient fetus’s sac and another stuck twin fetus showing an absence of end-diastolic velocity of umbilical artery (UA) Doppler flow and thus a stage III TTTS was diagnosed. After consultation with the family about treatment options including amnioreduction and laser therapy, the patient chose to receive fetoscope-guided laser therapy. Under local anesthesia and following procedures as previously described [], ten intertwin anastomoses (six donor artery to recipient vein anastomoses and four recipient vein to donor artery anastomoses) were coagulated with 10 ~ 15 W Diode laser power with Solomen technique. The postoperative course was uncomplicated and the UA Doppler returned to normal in donor twin after the surgery.\nTen days after the laser surgery, high-level ultrasound was done at the previous hospital that referred the case. Both fetuses had their amniotic fluid returning to normal, but incidentally they found both eyeballs of the donor twin were opaque, while the recipient’s were clear. (Fig. ) Therefore, discordant congenital cataract was suspected in the donor twin. At the gestational age of 23 weeks, fetal magnetic resonance imaging (MRI) was arranged to evaluate the central nervous system for both fetuses and to rule out if the donor twin had other associated anomalies; no additional information was gathered about the donor twin. At the gestational age of 27 weeks, sonography still revealed opacity over donor twin eyeballs. (Fig. ) The pregnancy was completed at gestational age 37 weeks by cesarean delivery indicated by malpresentation, resulting in the birth of two male babies, both babies weighing 2460 g each. Ten days after delivery by examination under anesthesia, the sl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old woman came to Seoul National University Dental Hospital complaining of intermittent stinging pain in her right cheek. Previously, she had visited a local dental clinic due to intermittent pain in the past 6 months. The vitality test of upper-right teeth had been performed. Even though the teeth had been vital, she had received endodontic treatment on the upper-right second premolar due to worsening pain. Then, she was referred to the Department of Oral and Maxillofacial Radiology at our hospital when she complained of new sharpening pain on the right side of her face after two or three days.\nThere were no clinically abnormal findings in physical and oral examinations. The patient only had a history of orthognathic surgery on both the maxilla and the mandible performed about 21 years prior to this visit. Panoramic and Waters' radiographs revealed increased haziness and dome-shaped homogeneous radiopacities in the lower regions of both maxillary sinuses (). Endodontic retreatment was performed on the upper-right second premolar because it was thought that radiologically, the origins of the pain were not in the maxillary sinuses but in the teeth, resulting in only a temporary reduction of pain that later intensified.\nComputed tomography (CT) was performed for finding other origins of the pain, and low-attenuation lesions were detected in both maxillary sinuses. The lesions measured approximately 36mm×27mm×20 mm in the right maxillary sinus, and 30mm×21mm×25 mm in the left maxillary sinus. The margins were undulated, while corticated discontinuously. The lesions extended slightly below the floor of both nasal sinuses. No internal calcifications were present. Postoperative signs including antral wall thickening, sclerotic change, and loss of continuity of the cortical antral wall lining, were not observed on the CT images. Furthermore, there were no characteristic features of distinct expansion or bone destruction of soft tissue (). The lesions were eventua"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73 year old female with stage IV hormone-sensitive breast cancer to bone presented with rash on the face and arms. She presented twelve years prior with a large right breast mass. She was treated with modified radical mastectomy revealing multifocal invasive lobular carcinoma with 25 of 25 lymph nodes involved with immunohistochemistry staining revealing ER-positivity, PR-positivity, and HER2-negativity. Staging workup revealed bone metastases and she was treated with anastrozole and zolendronic acid. After eight years, progression of osseous metastatic disease was noted and anastrozole was switched to exemestane 25 mg daily. Eighteen months later, progression in the bones occurred and she was treated with investigational orteronel 400 mg twice daily. Two years later, progression in the bone was noted and she initiated fulvestrant 500 mg intramuscular every month. After one year, progression was again noted in the bone, along with increased CA27-19 tumor marker which reached 358 U/ml. Fulvestrant was discontinued and patient was started on capecitabine 2500 mg twice daily for 14 days on and 7 days off for 21-day cycle at the beginning of summer. The patient had minimal symptoms, remained active, and spent much of the summer months out of doors. After 3 cycles, she developed a mild rash on the face, arms, but the tumor marker fell to 256 U/ml. Therapy was continued and after two additional cycles the rash worsened as the tumor marker continued to decline and imaging showed sclerosis of bony metastases, suggestive of healing. The rash appeared in a photo-distributed pattern but the patient was uncertain if the rash was worsened by sun exposure.\nThe rash was initially described as scattered macules and papules with thin raised plaques that were mildly pruritic on her cheeks and forearms. After the rash became more severe, capecitabine was held and she was referred to dermatology. Other medications at the time were zolendronic acid 4 mg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man presented with a 1-month history of abdominal pain. His previous medical and familial histories were unremarkable. Unenhanced transverse CT scan of the abdomen revealed an ill defined, lobulated mass that measured about 13 × 12 × 7 cm in size and it appeared as a heterogeneously low attenuated mass with numerous areas of coarse calcification. It was located in the left side of the retroperitoneal space and involved the body and tail of the pancreas (). Contrast-enhanced CT was performed after mechanical injection of 130 cc of nonionic iopromide (300 mg/ml of iodine) into the antecubital vein at a rate of 2.65 ml/sec. After initiating infusion of contrast material, we used scanning delays of 30 seconds before starting to obtain the arterial phase images. Imaging in the portal venous phase was performed after a scanning delay of 70 seconds from the initiation of infusion of contrast material. On the contrast-enhanced transverse CT scan obtained during the portal venous phase, subtle enhancement was noted in only the periphery of the mass and most of the mass remained without enhancement (). The contrast-enhanced coronal reformatted image showed the ill defined necrotic low attenuated mass with obliteration of the splenic vein by the mass, and there was the development of multiple collateral veins (). Portal venography via the celiac axis also showed tumor invasion to the splenic vein (). The patient underwent exploratory laparotomy and mass excision was done. The specimen was revealed to be a large, firm, fixed hypervascular mass arising from the pancreas, and it occupied the left upper quadrant of the abdomen. A large multilobulated mass that measured 15 cm in maximum diameter was located in the body and tail of the pancreas, and it was attached to the spleen and transverse colon (). Microscopically, the chondroid zone was surrounded by proliferation of undifferentiated cells with abrupt transition (). The pathological diagnosis was extraskeletal me"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a woman in her 50s who presented to the emergency department (ED) with a two-day history of colicky abdominal pain in the mid-epigastrium and right lower quadrant associated with nausea, emesis, distention, and obstipation. She had a past medical history of hypertension and major depressive disorder treated with losartan and citalopram, respectively; and regarding her surgical history, she did not have any prior abdominal operation. She did not have symptoms or a history of biliary pathology.\nOn physical examination, her abdomen was distended and tympanitic, but nontender. Laboratory analysis revealed a normal white blood cell count and hemoglobin. Serum electrolytes were indicative of mild volume depletion.\nShe subsequently underwent a CT scan of the abdomen and pelvis which showed a distal small bowel obstruction with a transition point at a 2.9 cm round intraluminal structure with central calcification (Figure ). There was no evidence of small bowel ischemia or perforation. The patient did not have radiopaque cholelithiasis or imaging findings of cholecystoenteric fistula (Figure ,B). Upon review of prior imaging, screening CT colonography from six years prior for cancer screening purposes showed a similar, but smaller intraluminal structure associated with the terminal ileum (Figure ).\nThe differential diagnosis included teratoma or other benign or malignant mass, ingested foreign body, and gallstone ileus. While most surgeons hearing the history would suspect gallstone ileus, especially in patients with known biliary pathology, lack of visible cholecystoenteric fistula or inflammatory changes in the right upper quadrant precluded this diagnosis. The patient was a reliable historian and denied a history of unusual foreign body ingestion. While the imaging phenotype of a central calcification and concentric radiolucent material was reminiscent of a mature teratoma, this pathology arising in the small bowel of a middle-aged patient would be very unu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe last case is a 74-year-old retired premutation male carrier who is diagnosed with FXTAS and has 91 CGG repeats. This individual has a history of significant ataxia, which began when he was 62 years of age. Initially he started using a cane consistently (67 years old) and then began using a walker (70 years old) before progressing to a wheelchair (73 years old). Over the past 5 years he has suffered several falls that have necessitated surgery, including a Le Fort fracture of the skull, a fractured wrist, a fractured pelvis, and a fractured ankle. He mentioned that he has had some neuropathy symptoms such as pain in his fingertips, but this was after fracturing his wrist. He also has some partial back pain but denies any overall chronic pain. Towards the end of the day, he complains of dizzy spells and becomes tired and subsequently is more prone to falling.\nHe has a history of kidney stones and nasal polyps, which were removed. His cardiovascular history is significant and includes a myocardial infarction at age 48 after 30 years of smoking. After he underwent a quadruple bypass heart surgery, he stopped smoking and began to treat his high blood pressure with antihypertensives (Terazosin 10 mg in the morning, then alternating with 5 mg every other day). Other medications include simvastatin for hypercholesterolemia and a combined fluticasone furoate and vilanterol inhaler for maintenance of chronic obstructive pulmonary disease. At age 64, he started experiencing memory deficits and complained of anxiety, moodiness, and irritability. These symptoms were managed with memantine and venlafaxine. However, he experienced moderate side effects, including dizziness and more problems with his balance, resulting in cessation of the treatment within a year.\nOn examination, he was found to have a controlled blood pressure and a normal heart rate. His BMI was found to be 33. Neurological examination revealed anisocoria,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15 year old boy presented to orthopedic clinic with a 2 week history of urinary retention, back pain, bilateral leg numbness and weakness, lumbar pain exacerbated by movement, sweat and fever. He had received conservative medical treatment with a diagnosis of low back pain but there was no response to analgesic and medical treatment. He had also referred to urologist due to his urinary retention. Ultra-sonograohy of bladder and kidneys detected no abnormal finding. He was then discharged after urinary catheterization with an unexplained diagnosis of urinary retention. His lower back pain was exacerbated and severe neurological deficit was also added to his clinical picture. He also developed difficulty in weight bearing and walking. His past medical history was not significant. He denied any previous trauma, spinal surgery, or immunodeficiency. He was not taking any medication. In physical examination, he presented with blood pressure of 100/80 mmHg, pulse rate of 100 pulse/minute and a body temperature of 38.5º C. Hematologic examination revealed a white blood cell count of 18600 /µl (neutrophil 70%), an erythrocyte sedimentation rate (ESR) of 68 mm/hr and a C reactive protein 3-plus positive.\nOn physical examination, there was a tenderness over the left side of lumbar vertebrae and on the left and right sides of para-lumbar region. Neurological examination showed hyperactive deep tendon reflexes, muscle weakness (3/5), and decreased pin prick sensation in the right leg. Rectal tone and sensation were normal but there was a perineal numbness.\nRadiologic imaging showed no significant evidence (). On magnetic resonance imaging (MRI) scan that were taken at the time of admission there were abnormal signal intensity at right paraspinal muscles of L2 and L3 level. The lesion was extended to the posterior aspect of thecal sac and its extra-dural mass effect caused canal stenosis and cauda equina compression to anterior wall of the canal. Radiologist recommended emergen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old man with no noticeable past medical history was hospitalized for widespread abdominal pain and vomiting at our emergency surgical unit. Three weeks before he had been involved in a motor vehicle accident and was admitted with a diagnosis of blunt thoracic and abdominal trauma; the treatment was conservative, and the patient was discharged after 7 days from hospitalization without need for blood transfusion. Our examination revealed moderate abdominal distention with pronounced tenderness in the lower quadrants, and blood examination showed only mild leucocytosis. An abdominal X-ray showed soft bowel distension with air–fluid levels. A computed tomography (CT) scan was then performed, which showed some calcifications within the mesentery root (), gastric dilatation, distension with multiple air–fluid levels of the small bowel. In the right iliac fossa, there was an ileal loop with frankly thickened walls and signs of parietal suffering at a full-to-empty passage. Free fluid was sparsely evident in all the recesses of the abdominal cavity.\nMoreover, several apparently hyperplastic-reactive nodes were present along the mesentery root. Calcifications were not present at a previous CT scan performed in another hospital after the trauma hospitalization. After informed consent the patient was prepared for surgery, and initially a laparoscopic approach was hypothesized but not allowed due to a severe desaturation episode during the intubation. During the exploratory laparotomy, we identified a bulky and hardened mass of the small bowel arising within the mesenteric root and retracting the visceral peritoneum, with a frank malignant appearance. Consequently, a wide resection of the involved intestinal tract with the relevant mesenteric root was performed. Another similar small thickened nodule was removed from the peritoneum of the left iliac fossa. The postoperative course was regular, and the patient was discharged after 5 days in complete wellness and restor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy Caucasian 28-year old female was referred to our dental clinic with a continuous dull pain in the left mandibular region, which had started after initiation of root canal treatment on the first molar by her general dentist about two weeks before. Upon clinical examination, a localized inflammation overlying the buccal mucosa in furcal region of the tooth #36 became evident which was tender on palpation. The tooth had no tenderness on percussion and no mobility. Careful periodontal probing showed a pocket depth within the normal range (<3 mm). Radiographic examination revealed overextended endodontic access cavity preparation and extensive destruction of pulp-chamber floor ().\nIn the radiography a small piece of amalgam was evident in the apical extend of the perforation which is believed to have separated from the previous amalgam restoration of the tooth. The location of this small piece was an indicator of wide destruction of the interradicular bone during the preparation of the access cavity ().\nThe possible treatment options, including tooth extraction with/without replacement, tooth hemisection and non-surgical perforation repair with subsequent continuing of the root canal therapy (RCT) and coronal restoration were explained for the patient. The patient preferred the option of saving the tooth via a non-surgical endodontic treatment and furcal perforation repair with CEM cement. She also read and signed an informed consent.\nBefore the start of the treatment, mouth rinse with 0.2% chlorhexidine rinse (Behsa Co., Tehran, Iran) was carried out in order to control the oral microbial flora. After administering local anesthesia (2% lidocaine with 1:80000 adrenalin; Daroupakhsh, Tehran, Iran) and proper tooth isolation, the temporary restorative material was removed with a slight correction in the outlines of access cavity and then all canal orifices were located. The cavity and perforation site were copiously irrigated with full concentration of sodium hyp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old male patient reported to the outpatient department of the authors' institution with the complaint of pain and swelling in the lower front tooth region for 15 days. The patient gave a history of extraction 1 month back due to loosened teeth following which he noticed a soft-tissue overgrowth in his mandibular anterior tooth region. The patient had the habit of bidi smoking for 30 years. Extraoral examination did not reveal any significant findings. He also experienced dull pain associated with this overgrowth. The submandibular and submental lymph nodes on the ipsilateral side were palpable.\nOn inspection, a soft nodular growth measuring about approximately 5 cm × 3 cm × 2 cm was seen on the mandibular anterior region. The lesion was pinkish white in color and ulceroproliferative in nature. The lesion was extending labiolingually from labial attached gingiva to lingual attached gingiva and mesiodistally from mandibular left canine to mandibular right first premolar region []. The growth was tender and firm in consistency. Based on clinical findings, a provisional diagnosis of aggressive inflammatory lesion with a differential diagnosis of granulomatous lesion and carcinoma of gingiva was made. No significant findings were noticed in an orthopantomogram. After routine hematological investigations, an incisional biopsy was performed. The tissue specimen was routinely fixed and processed. The H- and E-stained sections showed dysplastic epithelium invading into the connective tissue stroma. Invaded epithelial cells were in the form of nests, islands, and sheets composed of basaloid cells showing hyperchromatic large nuclei and indistinct cytoplasm [Figures and ]. Areas of comedonecrosis were seen in between the sheets of cells []. Frequent mitotic figures were also evident. The stroma also showed numerous blood vessels with areas of hemorrhage. Based on the histopathological findings, a diagnosis of BSCC with differential diagnosis of adenoid cystic carcino"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-years-old Japanese man presented with a tumor in the right temple and underwent resection of the tumor at a medical college hospital in 1979. The histological diagnosis was hemangiopericytoma. Thereafter, he demonstrated local recurrence many times, underwent resection 5 times and embolization was performed 2 times. Despite these treatments, this tumor relapsed in the temple again and was treated by irradiation (total 61.8 Gy) in November 2002. However, the tumor appeared to persist and multiple lung metastases were detected. After 4 months, he consulted our hospital for their treatment. On the first medical examination at our hospital, we evaluated the skull base tumor with MRI (Figure ) and lung metastasis with chest-CT. Because lung metastasis remained stable, we performed Choline-PET and compared findings to those of FDG-PET. Choline accumulated in the tip of the right temporal lobe (SUV max 4.0) but FDG-PET could not detect in the tumor because it accumulated strongly throughout the whole brain without demonstrating the tumor (Figure ). In addition to PET study, angiography via the right external carotid artery demonstrated the lesion strongly (Figure ). Based on these examinations, we diagnosed this lesion as residual hemangiopericytoma. Then he underwent resection of the residual skull base tumor in February 2004. First, we incised the coronary line at the front of the head, and tried to approach this tumor via right temporal craniotomy without facial incision. We resected completely the tumor together with a part of dura because of dural invasion. The tumor showed diffuse invasion of tissue around the mass lesion. We reconstructed the skull base by galeal flap. In addition, we plugged the dead space after tumor resection with abdominal fat tissue (Figure ). There were no complications postoperatively. This tumor demonstrated abundant blood vessels and was composed of round or spindle-shaped cells, including dilated staghorn-shaped vessels (Figure ). Imm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman presented to the accident and emergency department after sustaining a fall while on holiday. She complained of pain and reduced range of movement in her left shoulder. Her past medical history included hypertension atrial fibrillation, for which she took aspirin 75 mg once a day. She had previously undergone a thyroidectomy in 2000 for hyperthyroidism. She was otherwise fit and well with no known drug allergies.\nOn examination her left arm was bruised and painful when movements were attempted. Her distal neurovascular status of the affected limb was normal with no deficit detected. Plain film radiographs of her left shoulder demonstrated a minimally displaced and impacted fracture of her proximal humerus (as shown in ). After discussion with the orthopaedic registrar on call she was placed in a collar and cuff and sent home to attend the next available fracture clinic.\nWhen she was reviewed in the following fracture clinic it was noted that she had developed a swelling and erythema on the left side of her neck in the distribution of her external jugular vein (as shown in ). It was also found that the collar and cuff had been applied rather tightly. She was referred to the on call ENT registrar who made a diagnosis of thrombophlebitis of her external jugular vein. Further questioning did not reveal a history of further thrombotic events. The ENT registrar felt the erythema may be developing cellulitis and so started the patient on antibiotics (flucloxacillin 500 mg four times a day for 5 days) and placed her in a better fitting sling. The fracture was deemed suitable for nonsurgical management with regular clinical and radiological follow-up. As she was only on holiday in the region, further follow-up was arranged for two weeks in her local hospital.\nTwo days later, she represented to the accident and emergency department with pain and gross pitting oedema in her left arm. A Doppler scan demonstrated near complete occlusion of the left subclavian"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old male reported with a chief complaint of unesthetic appearance of the face due to depression in the lip region on the left side of the face. Extra orally, two scars and a prominent depression in lower lip region were noticeable on the left side of the face. On intraoral examination, mandibular anterior and premolar teeth were missing and a bony defect (12 mm × 19 mm) with flabby tissue at the base was present at the respective region []. The complete case history of the patient was taken, which revealed that the patient had undergone treatment for comminuted mandibular fracture in symphseal-parasymphyseal region on the left side of face 3 years back. This segment of the mandible along with five teeth (mandibular anteriors and premolars) was removed during open reduction of the fracture followed by placement of titanium reconstruction plate. The intraoral closure of the defect was done by placing the temporal flap over the defect. The relative positions of the two mandibular segments and the reconstruction plate could be clearly appreciated on orthopantogram []. The tissues in the defect region were 12 mm below the cervical margins of the adjacent teeth, attributing it as a Siebert's Class III defect []. The various treatment modalities were thoroughly explained to the patient. Considering the reluctance for the surgical procedure and economic status of the patient a modification of Andrews bridge was chosen as the treatment option. The modification planned was to replace the costlier prefabricated bar and sleeve attachment of conventional Andrews system with two small disc shaped magnets. The advantages and disadvantages were clearly explained to the patient and informed consent was taken. The step by step procedure is as follows:\nDiagnostic impressions were made and casts were prepared The selected abutment teeth (41, 36) were prepared for metal ceramic restorations. The gingival retraction was done using gingival retraction cord (Ultrapak) and putty w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old multiparous woman presented to us with complaints of pain in the abdomen of 6 months duration. She underwent laparoscopy for a pelvic mass 3 years before her present complaints. There was a 10 cm × 9 cm mass from the Pouch of Douglas extending into both broad ligaments. Laparoscopic myomectomy was done. The fibroid was degenerated. The specimen was retrieved by morcellation. The specimen weighed 620 g. She was asymptomatic for 3 years and presented to us with abdominal pain and fibroids detected on ultrasonography.\nClinical examination revealed a bulky uterus with a mass in the pouch of Douglas. Ultrasound revealed a mass of 6 × 5cm in the Pouch of Douglas and a 7 × 6 cm mass in the right lumbar region near the right kidney but separate from it. She did not have any complaints pertaining to the right lumbar mass.\nLaparoscopy was done with four ports, one primary supraumbilical and three accessory ports, two on the left and one on right side. Laparoscopy revealed a bulky uterus with small fibroids []. There was a 6 × 5 cm degenerated pelvic mass extending bilaterally in the broad ligament. On surveying the upper abdomen, she had a 7 × 6 cm mass engulfed completely by the omentum [].\nWe proceeded with total laparoscopic hysterectomy with excision of the pelvic mass. The lumbar mass was dissected carefully from the omentum with the harmonic ultracision [] and ensuring that it did not arise from the bowel or from any other structure. The uterus, pelvic mass and the right lumbar mass [] were retrieved vaginally. The vaginal vault was closed with interrupted No.1 delayed absorbable sutures. The uterus and the pelvic mass weighed 300 g. The lumbar mass weighed 80g.\nThe specimen was sent for histopathology. The pelvic mass and the right lumbar mass were reported as leiomyoma. The patient has an unremarkable postoperative period and is asymptomatic till"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male presented with a gradual onset of left-sided hemiplegia and weight loss of 14 kg over a period of ~4 weeks. His past medical history included COPD, hypertension and chronic hyponatraemia. There was no history of immunocompromise however he was malnourished. Of note, there was no history of foreign travel, intravenous drug use or household pets however the patient had undergone four dental fillings in the preceding 12 months. Neurological examination indicated MRC grade 2/5 power throughout the left upper and lower limbs with increased tone. The patient was apyrexic with a CRP of 68 mg/L.\nA CT brain revealed a right frontal mass lesion with surrounding oedema which was concerning for malignancy when taken in conjunction with the weight loss. Investigations for a primary tumour were negative including a CT of the chest, abdomen and pelvis in addition to upper GI endoscopy. Tumour markers did not reveal any abnormality. Additional testing for immunocompromise including HIV was negative and no primary source of infection was identified. A subsequent MRI brain revealed a total of five ring-enhancing lesions with vasogenic oedema distributed throughout both cerebral hemispheres with the largest measuring >2 cm (Fig. ).\nCommencement of dexamethasone (8 mg twice-daily) initially resulted in a good clinical response. Image-guided excision of the right frontal abscess was undertaken and culture results identified Nocardia farcinica. Despite appropriate treatment with intravenous linezolid combined with imipenem and the subsequent addition of co-trimoxazole, repeat imaging demonstrated a continued increase in size of the remaining abscesses. Two further operations were performed over a 4-week period in addition to ongoing anti-microbial therapy. Resection of all abscesses was achieved through right frontal, right parietal, left parieto-occipital and left temporal craniotomies. Microbiological analysis identified Enterococcus faecium in a second abscess and v"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61 year-old Caucasian woman was referred to our colorectal clinic with an 18-year history of severe intermittent anal pain and constipation. She described experiencing intermittent anal spasms lasting around 15 minutes. These episodes were worse when sitting down for longer than 45 minutes or when lying in bed. The frequency of these anal spasms was increasing with time and occurring every hour at night at the time of presentation. Her constipation symptoms constituted experiencing difficulty in defecation and a sensation of incomplete evacuation. She had no response to amitriptyline or topical diltiazem. Her past medical history was unremarkable apart from four normal vaginal deliveries. Her sister had colorectal cancer diagnosed at the age of 49 and had previously been treated for an undiagnosed anal sphincter problem. There was no other relevant history of note.\nShe initially underwent a flexible sigmoidoscopy and magnetic resonance imaging (MRI) of her perineum. The endoscopy was reported as normal, whereas the MRI showed edema of the IAS. She subsequently had an endoanal ultrasound which confirmed that her IAS was abnormally thick and greater than 5 mm (Fig. ). Anal manometry revealed that although resting and squeeze pressures were within normal limits there were periods of a significant increase in anal resting pressure lasting longer than 2 minutes (Fig. ). Pressures during this period were in excess of 200 mmHg which settled spontaneously. These pressures were even higher than the maximum recorded squeeze pressure (Fig. ).\nShe had an examination of the anal canal under anesthetic which showed a very prominent sphincter complex. She also received Botox injections (Dysport™) at the 3 and 9 o’clock positions of the IAS which led to no subsequent resolution of her symptoms. She then underwent a lateral internal anal sphincterotomy by dividing half of the length (1 cm) of the IAS on the left lateral aspect. A biopsy of the IAS taken at the time of surgery was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9 year old girl had come to the Department of Pedodontics and Preventive dentistry, Thai Moogambigai Dental College and Hospital, with the chief complaint of multiple swellings in the lower lip that were present for the past 6 months. The patient gives a history of the swellings being small at first with a slow enlargement. The habit of lip biting was also confirmed by the parents. Clinically three enlargements, on the lower labial mucosa, one in the left side and two in the right side, were noticed []. Two of the lesions appeared as an elevated sessile nodule with a smooth surface measuring 4 mm in diameter [Marking F in ]. One of the lesions appeared as a raised, circumscribed vesicle also measuring 4 mm in diameter [Marking M in ], with a bluish translucent cast. No submental or submandibular lymph nodes were palpable. Considering the history and clinical findings, a differential diagnosis of irritation fibroma and mucocele was noted.\nManagement of the lesions included both surgical and preventive aspects pertaining to the presenting condition. Surgical excision was [] done under local anesthesia revealing multiple cystic mass in relation to the region of the mucocele and a single mass in each of the region which contained the fibroma. The mucocele had inadvertently ruptured, considering the size, during excision due to which the contents could not be preserved. Suturing of the surgical site as done and post-operative instruction was given. The patient was advised lip bumper for management of the lip biting habit, the suspected cause for the lesions. The specimens [] excised were sent to the Department of Oral and Maxillofacial Pathology for confirmation of the diagnosis. hotomicrograph of fibroma reveals the surface showing shortening of stratified squamous epithelium and interlacing collagenous fibers []. Photomicrograph of the mucocele [] revealed a cyst-like cavity with eosinophilic coagulum, infiltrated by dense"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male with known stage IV sarcomatoid renal cell carcinoma presented to the emergency department (ED) complaining of shortness of breath; his vital signs were unremarkable with stable oxygen saturation, and his physical examination had been normal. Because of the high suspicion of pulmonary embolism related to his risk factors, a CT scan of the chest with IV contrast was done, which had shown bilateral segmental and sub-segmental PE and a cardiac mass in the right ventricle that is consistent with known renal cell carcinoma as shown in Figure . There was no right ventricular (RV) strain on CT or transthoracic echo, and troponin and B-type natriuretic peptide (BNP) had been normal. Given that he was stable, a decision was made to start him on therapeutic anticoagulation with low molecular weight heparin with close follow-up.\nSix months later, he presented to the ED with worsening shortness of breath. A CT scan was repeated at that time, showing an increased clot burden in the pulmonary arteries at segmental and sub-segmental levels but now with evidence of new RV strain on CT despite him being on a therapeutic dose of anticoagulation. It was thought that this was not related to hypercoagulability, but instead, these were tumor emboli related to his cardiac metastasis.\nCardiothoracic surgery was consulted, and as recommended, cardiac MRI was done to see if the cardiac metastasis could be removed surgically. Cardiac MRI showed a large right ventricular mass attached to the endocardium on the RV septal aspect and the anterior aspect of the RV outflow tract (RVOT); the mass was highly mobile and prolapsing into the pulmonary artery in real-time view (Figures -).\nSurgical option was considered because the mass was near the RVOT and was prolapsing into the pulmonary arteries. It was feared that massive tumor embolization could happen later on, leading to a high-risk pulmonary embolism and cardiac arrest. The patient also had good functional status despite havi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68 year old man presented with a five month history of progressive dysphagia and weight loss of 5 kg. An adenocarcinoma arising in Barrett's epithelium in the lower third of the esophagus was diagnosed, and staging including CT-PET and endoscopic ultrasound suggested clinical T3N1 M0 staging. He was treated with a standard regimen of neoadjuvant chemoradiotherapy prior to esophagectomy []. At surgery, extensive fibrosis was evident, and an en-bloc resection was performed including thoracic duct, part of pericardium, and mediastinal lymph node dissection including complete clearance of the sub-carinal nodes, and a cervical hand-sewn anastomosis was fashioned. Pathology revealed a ypT3N1 tumor, with clear margins, and 7 of 30 glands involved by tumor.\nOn day four postoperatively he had a neutrophil leucocytosis of 15 × 109/L and evidence of left basal consolidation. This persisted despite antibiotics, and a CT of thorax demonstrated no other abnormalities. He was managed on the ward, and his FiO2 varied from 0.4 to 0.6. Aspiration pneumonia was considered possible, and his nasogastric tube was left in situ. His neck wound was dry with no signs of inflammation or leakage. On day 14 the nasogastric drainage bag dramatically filled with air, and this persisted throughout the day and succeeding days, but without deterioration in respiratory function or evidence of progressive sepsis. A fiberoptic bronchoscopy was performed on day 16 which demonstrated bubbling at a gastro-bronchial fistula in the posterior aspect of the left main bronchus (Fig. ). An endoscopy revealed a healthy gastric tube but a tiny area of granulation tissue in the anterior portion of the anastomosis, the assumed site of fistula communication. A CT scan of the thorax demonstrated air in the mediastinum and the gastric conduit (Fig. )\nHe was managed conservatively with antibiotics, enteral nutrition via a jejunostomy, and non-invasive respiratory support in the form of humidified oxygen via face mask"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old man was referred to the Conservative Clinic for the management of the discoloration of a previous root canal treatment for tooth 22. The patient claimed to have had a history of trauma during his teenage years, and the tooth had multiple episodes of pain and swelling. The lesion healed after the completion of root canal treatment which was almost 5 years back. However, for the last few months, the tooth started to cause discomfort with a slight pain during biting or chewing. He also noticed that it became darker and blackish in color. The patient otherwise was cleared from any medical illness, and his health condition was fit and healthy. During an intraoral examination, tooth 22 showed dark discoloration and was tender to palpation and percussion. A 1 mm × 1 mm soft tissue swelling was located at the palatal site of the tooth. Thermal test and electronic pulp test indicated a positive response of the adjacent teeth 21 and 23. Periapical radiograph showed that tooth 22 had a well-condensed root canal filling; however, the gutta percha was overextended and there was periapical lesion at the area (). Cone Beam Computed Tomography (CBCT) revealed that the size of the lesion was approximately 2 mm × 2 mm (). The provisional diagnosis was a failure root canal-treated tooth with chronic apical periodontitis and discolored tooth. After discussion and explanation, the patient agreed for nonsurgical retreatment to remove the infection and extruded gutta percha, thus eliminating and healing the apical periodontitis before undergoing an internal bleaching. The patient was also aware of the possibility of periapical surgery as a complementary approach to resolve the pathology if the conventional retreatment failed to succeed.\nDuring retreatment, a Dental Operating Microscope (Zeiss OPMI ® pico, Germany) was used to enhance illumination and magnification to reach the apical root and assess the extruded gutta percha. The gutta percha was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old woman presented with a headache and was found to have a sinusitis-related headache pretreated with antibiotics. On admission, she was found to have random venous glucose of 33 mm/L and glycated hemoglobin (HbA1C) of 13.1%. (Table ). She had a significant family history of diabetes, and her father was diagnosed to have diabetes mellitus (DM) before the age of 40. Her weight at baseline was 48 kgs, with a calculated body mass index of 18.5. Detailed history revealed that she did have mild polyuria and polydipsia with the onset of sinusitis-related symptoms. Her vitals were stable, and the initial physical examination was unremarkable. She was started on oral hypoglycaemic agents on admission but soon failed despite adequate doses and was diagnosed with type 1 diabetes mellitus. She was continued on her antibiotics for the treatment of sinusitis and commenced on insulin glargine 16 units at night, glulisine five units three times before meals, and metformin. She was discharged promptly after three days as she recovered from her sinusitis and was competent with the self-administration of insulin.\nOn Day 4, she was readmitted, as she developed generalized swelling. It started off with lower limb swelling and progressed to develop discomfort over her groin and lower abdominal area due to swelling. This swelling swiftly progressed to involve the upper limbs, abdomen, and torso the following day. She remained ambulant and did her usual activities and was compliant with her medications. She was not taking any other herbs or over-the-counter medicines when she went home. Her vitals were stable and her weight increased to 55 kgs by this time. Physical examination revealed a generalized edematous woman with marked pitting edema extending over all four limbs and face. Her heart sounds were dual and lung sounds were clear. The examination of her abdomen was unremarkable, apart from the soft tissue swelling. The examination did not reveal a shifting"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA sixty-one-year-old man with a significant two-year past medical history of bilateral lower extremity weakness and a left parasellar meningioma presented with anorexia, intermittent dysphagia, and early satiety with intermittent nausea, vomiting, and diarrhea from which he had been suffering for the past three months. During this time, he experienced a 20-pound unintentional weight loss. He was not taking any medications known to cause peripheral neuropathy; additionally, he reported a 20 pack/year smoking history and denied alcohol or illicit substance use.\nPrior to admission, in January 2016, he had undergone extensive workup for similar symptoms of abdominal pain, nausea, vomiting, and dysphagia. The resulting workup included a CT of the chest, abdomen, and pelvis that demonstrated a fatty infiltrative change in the liver and a kidney, ureter, and bladder X-ray that showed a nonobstructive abdominal gas pattern with no dilated bowel loops or masses identified. An esophagogastroduodenoscopy done in March 2016 demonstrated dysphagia likely secondary to underlying neurologic issues, along with a small hiatal hernia, and an MRI that June revealed an unchanged left middle cranial fossa mass consistent with meningioma.\nUpon presentation in July 2016, our patient reported bilateral lower extremity pain present over the past six months, which had been attributed to distal axonal motor neuropathy by electromyogram and nerve conduction studies by his outpatient neurologist. He characterized his pain as alternating between throbbing or shooting up his legs, and that he had been started on pregabalin six months prior with some amelioration of his symptoms. Oxcarbazepine had been recently added to his medication, with some results. He also reported weakness in both his feet since receiving radiation therapy for meningioma two years prior, requiring the use of a walker to ambulate.\nIn the emergency department, his creatinine was elevated to 1.31 mg/dL from a baseline of 0.9 m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old right-handed male initially presented to the University of Washington Movement Disorders Clinic in March of 2015. Informed written consent was obtained from the patient for the purpose of video-taping and case study publication. He attributed his HT to a fall in 2010, although he also had HIV infections and HIV-related neurological issues such as progressive multifocal leukoencephalopathy and toxoplasmosis. Although the cause of his lesions is unclear, given the location of the lesions, their appearance and the patient’s history of HIV, we surmise that they are the possible result of HIV-related vasculopathy associated with CNS toxoplasmosis. His career was in construction, and the onset of his neurological symptoms was associated with a fall through a roof in 2010. His immediate neurological status post-fall remains unknown; however, he reported the onset of multiple subsequent neurological deficits over the following three to four months, including tremor, seizures, gait impairments, left spastic hemiparesis and dysarthria. Subsequent MRI indicated the presence of bilateral thalamic lesions with the left lesion being substantially larger than the right. He first noted tremors of the left ring-finger, which spread throughout his left arm, then gradually involved his right arm. His right arm tremor represented the most active component of is Holmes tremor and displayed components of resting, postural and kinetic tremors. In addition to arm tremor he demonstrated low frequency tremors of the neck and chin. Consistent with the asymmetry of his thalamic lesions, his tremor was more severe on the right-body compared to his left, whereas rigidity symptoms displayed similar severity in bilateral upper and lower extremities. His tremors were refractory to medications including levodopa, propranolol, gabapentin, topiramate and primidone. Although he found some tremor improvement from baclofen 80 mg per day, this was associated with an exacerbation of his seizu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female presented to our clinic with progressive painful swelling and restricted movement of the right thumb for a duration of 4 months. Radiographs revealed an expansile osteolytic lesion involving the entire length of the first metacarpal bone (). The MRI demonstrated irregular expansion of the tumor breaking through the cortex. Extension of the tumor into the surrounding soft tissue and around first carpometacarpal joint was observed (). The pathological findings from the core needle biopsy were consistent with the GCT of bone ().\nThe en bloc resection was performed. The first metacarpal and the trapezium were excised, and the defect was temporarily bridged with bone cement. Six months later, a repeat MRI revealed no evidence of tumor recurrence. After a discussion with the patient regarding the reconstructive planning, she disallowed any option of using her autogenous bone grafts. A surgical treatment with patient-specific prosthesis was subsequently offered. A computed tomography scan of the patient's left metacarpal was done and used as a mirror image to create the custom mold by an Electron Beam Melting 3D printing technique. This mold was subsequently used to cast the entire titanium prosthesis. Multiple holes were designed in the proximal and distal portions of the prosthesis for the ligament reconstruction and temporary fixation ().\nIntraoperatively, an incision was made over the dorsal aspect of the thumb metacarpophalangeal (MCP) joint, coursed along the radial insertion of the thenar muscles, curving ulnarly along the distal wrist crease, and extending longitudinally over the flexor carpi radialis (FCR) and palmaris longus (PL) tendon. The superficial branches of the radial nerve and artery were identified and protected. The biomembrane encapsulating the cement spacer was incised longitudinally. Once exposed, the cement spacer was removed and replaced by the titanium prosthesis. The ligament reconstruction was performed (). The collateral l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn anuric 60-year-old woman with diabetic nephropathy had been treated for four months by continuous ambulatory peritoneal dialysis (CAPD) with four daily exchanges and 2.0 L fill volume. She had a history of coronary artery disease with an anterior myocardial infarction seven months prior to the start of CAPD, followed by severe congestive heart failure with an ejection fraction of 23%. Her dry weight, documented one month after the start of CAPD by absence of both edema and hypertension, was 41.2 kg. Her height was 149 cm. She had not been seen by her CAPD providers for three months because of transportation difficulties when she was admitted with grand mal seizures followed by coma. One week prior to this admission, she communicated by telephone call with one provider. At that time, she reported total body swelling, moderate dyspnea and a body weight exceeding 70 kg. She was advised to use exclusively hypertonic dextrose (4.25%) CAPD dialysate and add two exchanges per day with short (1 hour) dwell times. Information obtained from relatives revealed that in the two days prior to this admission she had omitted her insulin dose because of anorexia and greatly decreased food intake.\nOn admission, she was comatose with a blood pressure of 180/74 mm Hg, regular pulse rhythm with a rate of 110 beats per minute, and temperature of 36.5 degrees Celsius. Her weight was 63.6 kg. Remarkable findings on physical examination included anasarca detected even in her scalp, a ventricular gallop, and crackles in both lung fields. Chest X-ray confirmed the presence of pulmonary edema and electrocardiogram was unchanged from recent tracings, which were consistent with old transmural myocardial infarction. Laboratory tests on admission revealed extreme hyperglycemia, severe hypertonicity, hypokalemia and respiratory acidosis.\nOver the next 30 hours, she received insulin boluses and had frequent (every 2-4 hours) determinations of serum glucose and potassium concentrations. Serum gluc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old male laborer presented at our institution with complaints of pain, swelling, and stiffness of the knee of a one-year duration and a sinus over the anterior aspect of the proximal leg. The patient was riding a vehicle involved in a road traffic accident about six years ago in which he sustained an injury to the left thigh. The thigh became painful, swollen, and deformed after the accident. The patient was unable to bear weight on the limb. There was no associated wound. He was taken to a hospital in which the attending doctor had diagnosed a fracture of the left femur after radiological investigation. He was treated by open reduction and intramedullary K-nail insertion six years ago. He had visited the same operating surgeon for follow-up care for the past five years for the complaint of pain, pus discharge, and stiffness of the knee. He was treated conservatively for the same.\nOn examination at presentation to our institute, he was averagely built, walked with a limp, and supported with one axillary crutch. The left knee was moderately swollen, the overlying skin had blackish discoloration, with an active pus-discharging sinus over the anterior aspect of the tibial tuberosity (Figure ). The sinus was discharging turbid purulent fluid. The knee was tender, swollen, but not fluctuant with a reduced range of motion of about 10-20 degrees. There was a healed longitudinal surgical scar on the lateral aspect of the left thigh measuring 10 cm and another healed scar over the superior aspect of the left buttock measuring 4 cm. There was no tenderness or abnormal movement at the fracture site in the left thigh. There was a limb length discrepancy of 6 cm, the left lower limb shorter than the right. No previous radiographs were available for review. Current radiographs were showing distal migration of the K-nail across the knee joint (Figure ).\nA 5-cm long anterior midline incision was given over"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman (gravida 2, para 1) was referred to our hospital due to placenta previa at gestational week 31. Her medical history was unremarkable, and her previous pregnancy was an uncomplicated, normal vaginal delivery at gestational week 38. Her current pregnancy was uncomplicated except for the placenta previa. She denied abnormal genital bleeding before the current pregnancy. Cervical cytology performed during early pregnancy was negative for intraepithelial lesions. Vaginal ultrasonography revealed total placenta previa and one lacuna (Fig. a). Magnetic resonance imaging (MRI) at gestational week 31 revealed total placenta previa and loss of the myometrium between the placenta and bladder wall (Fig. b). Other MRI findings of PAS such as uterine bulging, heterogenous placenta, and T2 dark band were not observed. Based on these findings, we suspected PAS, and an emergency cesarean delivery was performed owing to antepartum bleeding (approximately 100 mL) at gestational week 35. An abdominal midline incision was made, and a healthy male infant weighing 2274 g (− 0.42 SD) was delivered with Apgar scores of 8 and 9, at 1 and 5 min, respectively. The placenta was not delivered within 30 min after fetal delivery, thus requiring hysterectomy for PAS. Estimated blood loss was 1000 mL. The postoperative course was uneventful, and the patient and baby were discharged on the 8th postoperative day.\nPart of the chorion and placenta were adhered to the uterus (Fig. a). The resected uterus was divided to 7 specimens in order to perform macroscopic and histopathological analyses. The surgical specimen showed a white polyp measuring 2 cm, which parted from the uterine fundus and the lower uterine segment (Fig. b). Histopathological examination of the tumor involving the lower uterine segment revealed endometrioid adenocarcinoma (Grade 1), with < 50% myometrial invasion and positive expression of estrogen and progesterone receptors, in addition to PAS (Fig. a and b). Notab"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 5-month-old male child presented with recurrent pneumonia. The apex beat was in the right parasternal area, and there was no air entry on the right hemithorax. The skiagram showed an opaque right hemithorax. A contrast-enhanced computed tomography scan revealed a small collapsed right lung being supplied by the pulmonary artery and drained by the pulmonary vein []. The right-sided main bronchus was not identifiable.\nA contrast esophagogram showed prompt delineation of the right bronchial subdivisions. A communication of the lung with esophagus was established at the junction of middle and lower one-third of the intrathoracic esophagus [].\nThe child underwent an exploratory thoracotomy. The preoperative findings were confirmed. The bilobed lung was nonaerated and had a liver-like consistency []. There was a direct communication between the esophagus and the lung across a short bronchial stump [].\nThe communication was taken down, and the defect in the esophagus was repaired with interrupted 5-0 Polyglactin sutures over a 10 Fr nasogastric tube. The child made an uneventful recovery. The histopathological examination demonstrated the presence of respiratory epithelium and confirmed the diagnosis of EL. The child is currently thriving well and is asymptomatic after 18 months of the operation.\nMost of these patients have other associated congenital malformations, mainly esophageal atresia or cardiac anomalies.[] It closely mimics pulmonary sequestration (PS) radiologically; however in PS, blood supply is of systemic origin unlike the pulmonary artery in EL as in our case. Being a rare anomaly, a close index of suspicion is necessary for diagnosis. A history of recurrent pneumonia and relevant radiological studies should clinch the diagnosis in the majority of such cases. The clinical images provided are expected to help understand the abnormal anatomy and surgical repair in EL. Management is excision of the involved lobes along with the abnormally communicating bronch"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old male patient sought treatment due to “repeated cough and sputum for one year and aggravation with chest tightness for one week.” Chest computed tomography (CT) in a local hospital revealed encapsulated effusion in the right thoracic cavity. Chest-enhanced CT after admission revealed a space-occupying lesion in the right chest. The pathological diagnosis according to percutaneous lung biopsy was a solitary fibrous tumor. Preoperative three-dimensional reconstruction showed that the blood supply to the tumor originated from the arteries and veins of the right lower lobe (Fig. ). After complete preoperative preparation, the patient underwent resection of the tumor with single-operation-incision thoracoscopy. Incision selection is one cm for the endoscope port (at the midaxillary line of the seventh intercostal space) and two cm for the operation port (at the preaxillary line of the fifth intercostal space). Intraoperative exploration revealed that the tumor had two tumor pedicles (Fig. ), and both were located in the right lower lobe. The tumor pedicles were intraoperatively separated using a linear stapling device. Because the specimen was large and the surface was smooth, bagging the specimen by the traditional method was difficult; therefore, the specimen was bagged by adjusting the operating table. The detailed procedure was as follows: First, the operating table was arranged with the head at a lower position, and the specimen bag was inserted into the thoracic cavity. Then, the operating table was adjusted such that the head was at a higher position to enable loading of the specimen into the specimen bag by gravity. Due to the large size of the specimen, extracting the specimen by the traditional method was difficult. Therefore, a special method named “pulling carrot” was applied to remove the specimen (Fig. ). The specific procedure was as follows. (1) The operation port was extended to five cm. (2) Several drawstrings were intermittently sewn at th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old man presented with recurrent cough following pyrethroids spraying in an enclosed area for eradication of flea. Twenty four hours after the beginning of symptoms he admitted in first medical center and partially treated for 2 days with impression of respiratory poisoning. He discharged seemingly healthy, so that he could walk and breathe normally at the time of discharge. The same night symptoms recurred and he referred to second medical center and admitted for one and a half day and underwent indeterminate treatment. Four days after beginning of symptoms the patient referred to our tertiary university hospital with complaints of ptosis and dyspnea. Within 5-6 days of admission limb weakness, dysphagia, dysarthria, blurred vision, diplopia, tremor and respiratory distress added to previous symptoms. The patient was admitted to the ICU, intubated and mechanical ventilated. There was no history of diarrhea or respiratory infection in preceding 4 weeks.\nIn first physical examination the Blood pressure was 110/80, Temperature = 37.4, Respiratory rate = 16, Pulse rate = 80. He was conscious aware, obey and oriented. The pupils were of normal size and reactive. There was no evidence of gaze preference and nistagmus. The ophthalmoscopic examination was normal. Cranial nerves were intact and no gaze palsy was detected. In sensory examination, there was no stocking and gloving sensory loss and no sensory level. The position and vibration sensation was intact. In motor exam, there was no hypotonia or spasticity and rigidity, without any evidences of abnormal movements.\nDeep tendon reflexes were 2+/and symmetric in upper and lower limbs and a reduced manual muscle force of 4/5 on the Medical Research Council (MRC) grading was detected symmetrically in upper limbs.\nElectrocardiogram, chest X-ray and brain MRI were normal. No botulinium neurotoxin was detected in serum or feces. Lumbar puncture revealed normal CSF analysis without cytoalbuminemic dissociation.\nIn fi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old man presented with pain on the right side of the neck and odynophagia that occurred at trauma 7 days before presentation. At that time, the patient had experienced a stairway slip and fall, with his philtrum striking against the edge of the stairs and causing a 3.5 cm laceration of the labial mucosa of the upper lip, which was duly sutured. There was no loss of consciousness and no damage to the teeth.\nDespite complete healing of the injury site, there was no improvement in cervical pain and odynophagia. When the patient's mouth was opened >3.1 cm, or when a straw was used for the intake of semifluidic formula, the patient experienced pain on the upper part of the hyoid bone and near the mastoid process; this was not accompanied by a cracking sound. The degree of pain was classified as 6 on the visual analog scale (VAS) of 0 to 10, where 0 equals no pain and 10 equals unbearable pain. There was no discomfort on the left side of the neck and no restriction of horizontal head movement.\nDuring physical examination, firm calcified lesions were palpated in both tonsils, as well as between the hyoid bone and submandibular gland on both sides of the neck. Pain was elicited by pressing the lesions on the right side of the neck, but not by pressure stimulation of the lesions on both tonsils or on the left side of the neck.\nThe patient was diagnosed with diabetes and hypertension, chronic kidney disease, arrhythmia, heart failure, and gout; he was prescribed medications for each of these conditions. The patient had undergone percutaneous coronary intervention and coil embolization of a cerebral aneurysm 4 months and 6 months before presentation, respectively. There was no history of head and neck surgery.\nComputed tomography (CT) revealed complete ossification of the bilateral SHC. A fracture line was observed in the ampullary area on the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old, white woman with a history of alcohol abuse, presented to the accident and emergency department with a 4-hour history of an acutely ischaemic right upper limb with motor and sensory deficit. A hard tender, pulsatile mass was palpable in the right subclavian area with significant bruising; there was a palpable right subclavian pulse with no pulses distal to this. X-ray revealed a fracture of the surgical neck of the right humerus with the humeral head abducted and externally rotated, while the humeral shaft was displaced medially (Fig. ).\nTen weeks previously, she had presented with a fracture of the surgical neck of the right humerus following a fall whilst under the influence of alcohol. On that occasion, sensory and motor function of the limb had been recorded to be fully intact by the medical staff in Accident and Emergency and there had been a full complement of pulses. Given she had no neuro-vascular deficit in the affected limb, the vascular surgeons were not involved initially. Under guidance of the orthopaedic surgeons, she had been treated conservatively with a collar and cuff due to her age and history of current alcohol abuse. She was to have been followed up fortnightly in the orthopaedic fracture clinic – but failed to attend after her second visit. She had no neuro-vascular deficit on follow-up. She denied any further falls or trauma to the right upper limb.\nThe acute nature of the current presentation together with neurological compromise prompted classification as category-II acute limb ischaemia (Society for Vascular Surgery/International Society for Cardiovascular Surgery classification) [] and urgent angiography was performed with a view to revascularisation. This revealed a pseudoaneurysm of the third part of the right axillary artery with complete occlusion of the right brachial artery distal to this (Fig. ).\nOperative treatment was undertaken with initial exposure and control of the subclavian artery above the clavicle (Fig. )."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 62-year-old male with a past medical history of liver cirrhosis secondary to hepatitis C, tobacco use, and post-stent coronary artery disease, who initially came to the hospital for elective left and right heart catheterization as a pre-transplant evaluation. Physical examination showed abdominal distension and diffuse tenderness with the presence of prominent superficial abdominal veins. A computed tomography (CT) scan of the abdomen with contrast was obtained immediately. The CT showed an occlusive thrombus of the IVC extending from the renal veins to the level of the cavoatrial junction. Thrombus was also observed in the portal vein, and multiple subcutaneous varicosities were found. Initially, a plan was made to start the patient on anticoagulation, but because of the patient’s history of advanced cirrhosis, large esophageal varices on recent endoscopy, and thrombocytopenia, we concluded that the patient was not a candidate for anticoagulation. Given that the patient had significant abdominal distention with pain that did not improve even after therapeutic paracentesis; we inserted a stent in the IVC to relieve the patient’s pain as a palliative procedure to improve his quality of life.\nRight internal jugular (IJ) and right femoral vein accesses were obtained for the procedure. A 6F pigtail diagnostic catheter was advanced from the right IJ to the right atrium, and contrast was injected into the right atrium that showed an occluded IVC at the junction of the right atrium. Another pigtail catheter was advanced through the right femoral vein and an inferior venogram was performed that showed the IVC was 100% occluded 2 cm above the renal veins (Figures , ).\nA Glidewire advantage was advanced through the right femoral vein but was unable to cross the 100% occluded IVC. Then, a 7-French Swan-Ganz catheter was tried and was successfully advanced through the IVC all the way to the right atrium. A Swan wire was inserted through the Swan-Ganz catheter."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old farmer was referred to us 7 hours after he had met with a high-velocity road traffic accident. He was resuscitated as per the ATLS protocol at the hospital where he was initially treated and when he arrived at the casualty department of our hospital, he was conscious and all his vital parameters were within normal limits. He also gave the history that he was under treatment for segmental myoclonus which was characterised by semirhythmic involuntary muscle contractions.\nHis radiographs showed a left-sided posterior acetabular wall fracture (AO type 6 2 A1). He also had an ipsilateral femoral neck fracture with the femoral head displaced anteriorly (Figures and ) and also an associated middle-third fracture of the shaft of the femur (). He also had an extra-articular distal femur fracture on the opposite side (AO type 3 3 A1). On arrival, his serum lactate level was 1.9 mmol/l indicating that he had been adequately resuscitated.\nHe was taken for definitive surgery 9 hours after arrival. The patient was positioned in the lateral position and a posterolateral approach was planned to address the acetabular and femoral head fractures. Upon dissection, the femoral head () was found to have buttonholed and displaced anteriorly through the capsule which was found to be torn. The posterior wall of the acetabulum was addressed using two contoured reconstruction plates (). Using the trochanteric flip osteotomy, better access to the femoral neck was achieved and the femoral head was reduced anatomically and secured with K-wires. Then the femoral shaft fracture was reduced by opening the fracture site and held with a clamp. The femoral head fracture and the shaft fracture were fixed with an antegrade femoral nail with two screws securing the femoral head (Figures and ). The flip osteotomy was fixed using a tension band wire and the joint was reduced. The torn capsule was sutured. Closure was done in layers. The operating time was 4"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 71-year-old woman referred to our outpatients department with an actively draining fistula on her right shoulder.\nHer present history goes back to nearly 18 months prior to presentation when she underwent an arthroscopic rotator cuff repair with anchor suture of the supraspinatus muscle, at an outside center. In her immediate post-operative course, she explains a wound infection that necessitated an arthroscopic debridement and antibiotic therapy. Upon failure, she had an open articular lavage and debridement, with no avail. And finally, 9 months before her visit, she was submitted to another open revision and anchor suture removal. She failed to provide detailed reports and bacterial cultures for further studies. At the time of her first visit to our clinics, the patient was afebrile, with a preserved general state. Shoulder examination was difficult due to extreme pain, and anteriorly, along the surgical scar, we could observe a 1-cm sinus tract. Analytical workup showed no significant leukocytosis or inflammatory markers, except for an ESR of 53 mm/h. Shoulder X-ray revealed an irregular humeral head, with a bone defect on its greater tuberosity, which could correspond to the previous suture insertion (Fig. ). Also, the deltoid muscle shadow was effaced, in accordance with a generalized local muscular atrophy. A subsequent CT-scan confirmed a marked glenohumeral joint destruction, with a loss of the spherical humeral head morphology, a narrowed articular space, and a flattened articular surface. We could also detect irregular trabecular morphology of the humeral head and some marginal proliferative changes (Fig. ). Magnetic imagery demonstrated an important and generalized synovial inflammatory proliferation as well as contrast-enhancing joint effusion. There was an alteration of the bone signal of the scapula and most importantly, of the proximal humerus, suggestive of chronic and active osteomyelitis. The rotator cuff muscles showed mar"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45 year-old woman of Caucasian origin presented to the surgeon with a 6-month history of light pain in the upper third of the abdominal wall. In her medical history, the patient had undergone surgery for tonsillectomy, appendectomy and carpal tunnel syndrome and was suffering from arterial hypertension and thyroid disease, treated with ACE inhibitor and levothyroxine sodium.\nUltrasonography (10 MHz probe), performed in May 2013, showed a 20 mm oval formation localized in the right rectus abdominis muscle with inhomogeneous echogenicity and internal vascular signals.\nComputed Tomography (CT) scan with contrast, performed in August 2013, showed inhomogeneous solid nodule with maximum transverse diameter of about 16 mm and a longitudinal extension of 30 mm localized in the right rectus abdominis muscle and characterized by moderate contrast enhancement, without clear demarcation on the profile and light anterior extension in the intra-abdominal adipose tissue.\nContrast magnetic resonance imaging, performed in October 2013, displayed a 20 mm oval formation, localized in the right rectus abdominis muscle, hypointense in sequences T1-T2-weighted, homogeneously hyperdense in the late phase with subcutaneous outer profile and intra-abdominal inner profile, without signs of infiltration of the underlying peritoneum (Fig. ).\nPhysical examination revealed an oval shaped swelling, motionless on the surface and deep levels, with hard consistency and slightly irregular margins.\nAt superficial palpation there were no signs of pain; deep palpation evoked moderate soreness at the epigastrium.\nIn November 2013, the patient underwent to surgical removal of the lesion: surgical access through midline incision of epigastric region showed a not perfectly round hard mass, with adherence zone to the fibers of the right rectus muscle; en block excision was performed with the simultaneous removal of subcutaneous tissue, muscle fascia and parietal peritoneum. No early complication occurred."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old man with recently diagnosed diabetes was involved in a road traffic accident in March 2018. He was the driver of a mini-van which collided with a lorry. He sustained a right hip posterior dislocation and a right acetabular fracture for which he underwent fixation. He also sustained a right foot open lisfranc dislocation with fractures of all 3 cuneiforms and cuboid. He underwent external fixation for his right foot and subsequently midfoot arthrodesis (). Intraoperative cultures were negative and the open wound was eventually covered with an anterolateral thigh flap.\nThe patient subsequently had 3 readmissions for flap infection. The first admission occurred 4 months after injury. Initial wound swab grew methicillin-resistant Staphylococcus aureus (MRSA). During the wound debridement, there was a sinus over the flap with purulent discharge. The medial cuneiform screws were exposed and the medial cuneiform was unstable. The medial cuneiform was excised with removal of the exposed screws and a cement spacer was inserted. Intraoperative cultures were negative for bacterial growth. An infectious disease consult was made and the patient was started on intravenous vancomycin 1000 mg q12hrly for a total of 6 weeks duration.\nThe patient was readmitted for the second time 5 months after injury. Seropurulent discharge was noted during wound debridement and intraoperative cultures were again negative for bacterial growth. Decision was made to continue with intravenous vancomycin after consultation with infectious disease specialists.\nThe patient was readmitted 6 months after injury with new abscesses noted over his foot flap. He underwent debridement and seropurulent discharge was again noted in the wound. Intraoperative cultures grew Mycobacterium fortuitum (sensitivities as shown in ). His antibiotics was switched to IV cefoxitin 2g q6hrly, PO clarithromycin 500 mg OM and PO doxycycline 100 mg BD for 6 weeks.\nThe patient is still on follow-up at the time of wri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a woman in her 56 years old who had initially consulted our hospital in November 1996, at the onset of leukoplakia. The patient’s major complaint was the appearance of leukoplakic lesions corresponding to left side first and second molar equivalent to palate gingiva. The patient had been previously diagnosed with uterine polyps. Her family history was unremarkable. The patient was examined at our department in late November 1996, following a referral from her local dentist, who detected white lesions on the left palate during dental treatment in mid-November of the same year. The patient was diagnosed with leukoplakia, and the palatal leukoplakia was resected through an excisional biopsy in December of the same year. The patient was subsequently followed up on an outpatient basis. In May 2006, white lesions were observed on the left buccal mucosa and the patient was diagnosed with dysplasia. The condition was treated with another surgical resection, and the patient was followed up as an outpatient. In December 2008, a leukoplakic superficial tumor appeared at left side lower canine, the first premolar equivalency department buccal marginal gingiva.\nThe patient had moderate physique and was well-nourished, and no swelling of the cervical lymph nodes was observed. Leukoderma and erosion were observed at left side lower canine, the first premolar equivalency department buccal marginal gingiva. (Figure upper).\nPanoramic radiography findings did not reveal any resorption of the lower jaw. Computed tomography (CT) findings did not indicate any clear destruction of the lower left jaw or lymph node enlargement, which could be suggestive of metastasis to the neck.\nThe clinical diagnosis for the patient was tumor of lower left gingiva. In January 2009, the patient underwent an excisional biopsy, with resection of the lower left gingiva tumor. Pathological analysis revealed well-differentiated SCC of more than 20 mm (pT2). No swelling of the cervical lymph node"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 88-year-old woman with a history of type II diabetes mellitus, chronic deep venous thrombosis (DVT) of right femoral vein, and atrial fibrillation on coumadin presented to her primary care physician (PCP) with right lower leg extremity swelling, erythema, and pain. A week prior to presentation, there was development of a sore on her right posterior ankle that began to crust over. The patient's leg became increasingly edematous, painful, warm, and erythematous throughout the week. Her primary care physician prescribed cephalexin for 10 days followed by doxycycline for four days. She continued to have progression of her symptoms while on these antibiotics (). She then developed intermittent purulent drainage from the sore behind the ankle concurrently with severe pain radiating down the leg (). She was then hospitalized and assessed for a deep soft tissue infection, abscess, and deep vein thrombosis. Cefazolin was given with subsequent improvement in the degree of erythema, though she continued to endorse significant pain. As the erythema receded to the mid-shin, the patient had persistent scattered papules and macules along the upper calf (). Blood cultures were negative and over the course of her illness, she remained afebrile without night sweats or chills. Laboratory workup revealed an elevated CRP (11.4 mg/L), which was felt to be secondary to an active infection. At presentation, a complete blood count with differential was within normal limits (white blood cell count 6.0 thousand cells/μL). On hospital day 3, she underwent a CT lower extremity with contrast due to continued pain, which was significant for diffuse heterogeneity in the calf muscle, notably a 1.8 × 1.3 × 3.8 cm lesion in the gastrocnemius without evidence of a drainable fluid collection or air within the soft tissue. The leading differential at this time was myositis with phlegmon leading to persistent pain and continued erythema and edema. She proceeded to have a skin biopsy for culture"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18 year old male fell from roof of a moving truck. The truck was moving at low speed and he fell on muddy floor from a height of approximately 12 feet and sustained impact over abdomen. He was admitted in Nepalgunj medical college where contrast enhanced computed tomography of abdomen showed grade III liver injury. He was managed conservatively with bed rest, 12 units of blood transfusion then discharged. He presented 15 days later to Alka Hospital emergency department with complaints of pain abdomen, excessive tiredness and vomiting of blood. His vitals in the emergency were pulse 100/min, blood pressure 90/60 mmHg, respiratory rate 20/min and temperature 99 degree F. Contrast enhanced computed tomography of abdomen was done which showed pseudoaneurysm of right hepatic artery with ruptured hematoma in segments VI, VII and VIII of liver (Figs. and ). Clot was present in the pelvis and lesser sac. Haemoglobin was 8 g/dL.\nPatient was immediately transferred to intensive care unit and started on intravenous fluid, antibiotics. Blood transfusion was started but the patient became hemodynamically unstable. Patient was transferred to operation theatre and exploratory laparotomy was done. Intraoperative finding was approximately three litres of clot and blood in lesser sac and pelvis with approximately 5 cm laceration in segments VII and VIII of liver. Bleeding from the liver surface was controlled with gel foam packing, surgicell application. Drains were kept in Morrison’s pouch and pelvis. Five units of packed cell and two units of fresh frozen plasma was transfused intraoperatively. The pseudoaneurysm couldn’t be clipped intraoperatively due to the difficult location and hemodynamic instability of the patient. Postoperatively patient was transferred to intensive care unit. Patient was transfused with two units of blood postoperatively. Patient was transferred to the general ward on third postoperative day. Patient was discharged on eighth postoperative day.\nOn the 15"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old Japanese woman underwent a medical examination for health check reasons at her local hospital. An ultrasound scan revealed a uterine myoma-like lesion, 5.9 cm in diameter. The patient revisited the hospital 12-months later for a follow-up examination. In that time, the lesion had increased to approximately twice its size. The patient was referred to our clinic for a detailed examination. At the first internal examination, the body of the uterus was enlarged to the size of a newborn head; cervical and vaginal discharge was unremarkable. The adnexa were not palpable on both sides. The patient’s blood test results were normal. Transvaginal ultrasonography detected an isoechoic solid mass with an ill-defined boundary between the lesion and the uterus (Fig. ). A tumor, 110 × 90 × 80 mm in size, was revealed in the right pelvic cavity by magnetic resonance imaging. The tumor exhibited a slightly lobular pattern with smooth margins. The internal mass had a density similar to that of myometrium on abdominal, T1-weighted magnetic resonance imaging and a low density on T2-weighted magnetic resonance imaging in the horizontal plane (Fig. ). Several flow void regions (a bridging vascular sign) were detected between the lesion and the uterus. These findings suggested a subserous myoma. However, the continuity of the lesion and the uterus was unclear. Since we were unable to identify the right ovary, a fibroma/thecoma of the right ovary was considered as a differential diagnosis (Fig. ). The left ovary did not exhibit any abnormalities. At this point, a preliminary clinical diagnosis of subserous myoma was made and a laparoscopic myomectomy was planned. The laparoscopic findings demonstrated a 10-cm right ovarian mass without intra-abdominal adhesion or rupture of the tumor. The uterus and left appendages were normal in size (Fig. ). A laparoscopic right adnexectomy was subsequently performed. The ascitic fluid was serous, and the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old female of the Marshallese origin presented to the emergency department with complaints of nausea; nonbloody, nonbilious vomiting; and abdominal pain []. The patient denied any recent fevers, and no rash was reported. Review of systems was notable for the left ear drainage. Immunization status was unknown, and she was not reported to have been previously treated for any significant illness, though the history was limited by the patient's custodial circumstances. She lived in a small house in rural North Carolina with 21 other Marshallese immigrants and was cared for by relatives who had assumed care for her at the time of her immigration five years before.\nExamination during the initial hospital visit revealed dehydration and acute otitis media with rupture of the tympanic membrane. Laboratory results revealed leukocytosis, prerenal azotemia, elevated liver enzymes, and mildly elevated lipase (). Computed tomography (CT) showed scattered focal pulmonary infiltrates, splenomegaly, and a markedly distended stomach without an obvious focus of mechanical obstruction (). Cytomegalovirus and Epstein–Barr virus serology were requested with results suggesting prior exposure. She was admitted with a presumptive diagnosis of gastroparesis secondary to a nonspecific viral infection and possible mild pancreatitis. An NG tube was placed resulting in high volume output. Her symptoms gradually improved over several days with IV fluid support and bowel rest; her NG was successfully removed, and she was discharged home tolerating a regular diet.\nTwo days after discharge, the patient returned with recurrence of her prior symptoms. The patient appeared acutely ill with dehydration. On lung exam, scattered crackles were noted. She was also noted to have diffuse small nodular lesions most apparent on her hands, feet, lower legs, and face (). An advocate placed with the family reported her concern for additional symptoms of chronic weight loss and productive cough with postt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2 year old male child with a history of recurrent projectile non-bilious vomiting, since 4 weeks after birth, was referred for a barium meal study to rule out pyloric stenosis or gastro-oesophageal reflux disease. The patient experienced persistent hunger and was always underweight. The results of a full blood count test were within normal limits. A barium examination localised the stomach in the right upper quadrant of the abdomen, on the same side as the liver ().\nSubsequent images revealed a distended stomach with indented gastric antrum, narrowed pylorus and delayed emptying suggestive of partial pyloric stenosis ().\nComplementary ultrasound examination localised the spleen (which showed no abnormality) and two other structures with the same appearance as the spleen in the right upper quadrant adjacent to the right kidney (). The suspicion of other abnormalities and congenital transpositions of other organs lead to suggestions for other radiological procedures. Although MRI scan is the standard reference for definitive diagnosis of organ transposition, the procedure was, however, not performed owing to breakdown of the MRI equipment at that time. Hence a CT abdominal scan was undertaken with parental consent.\nThe CT scan confirmed the normal position of the internal viscera of the thorax and the abdomen, except the stomach and the spleen. The CT scan showed a dilated stomach on the right posterior to the liver and partial pyloric stenosis. The pyloric canal appeared elongated, and the whole pylorus was thickened. In addition, the spleen and the other structures with similar appearance as the spleen (suggesting multiple spleens) were found at the right side of the patient adjacent to the right kidney (). A surgical correction of the partial pyloric stenosis further confirmed the anomaly.\nA post-operative MRI scan performed 5 months later confirmed the anomaly as described above (–). The procedure was a free-breathing MRI scan as parental consent was without sed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old female patient with diabetes mellitus presented to the emergency department with the complaints of a painful swelling over the right lower abdominal pain for 4 days. It was insidious in onset and was associated with fever, nausea and reduced appetite. She did not have jaundice and hematemesis. However, she gave history of intermittent constipation with occasional bleeding per rectum (PR), abdominal discomfort and sense of incomplete evacuation after defecation for past 6 months. She had undergone an open laparoscopic cholecystectomy 1 year ago for symptomatic gall stone disease and her postoperative period was uneventful. She also gave history of significant weight loss for past 4 months.\nOn her physical examination, she was pale and malnourished. She was afebrile, tachycardia and tachypnea were present, and she was in acute distress due to pain. On examination of the abdomen, there was a tender fluctuant area over the right lower abdomen, predominantly in the subcutaneous and muscular plane. It measured around 6 × 8 cm with the erythema of the skin and surrounding induration (). There was no sinus or discharge from the skin. The rest of the abdomen was soft and nontender. On rectal examination, there was normal tone and finger stained with stool with no palpable mass noted. Laboratory investigation revealed an elevated white blood cell count of 16.5 (normal range 4.0–10.8 × 103 per liter) with neutrophils, hemoglobin was below normal limit of 7 mg/dl (normal range 12–16 g/dl) and albumin 2.6 (normal range 3.4–4.8 g/dl). The level of carcinoembryonic antigen was highly elevated.\nAfter resuscitation with intravenous fluids, administration of broad-spectrum intravenous antibiotics and intravenous analgesics, a contrast-enhanced computed tomography (CECT) scan was done to further characterize the lesion. CECT of abdomen showed large abscess extending from the subcutaneous and intermuscular planes over the right iliac fossa and breaching the peritoneum. It"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47 year-old man was admitted to our emergency department after a motorcycle accident with his right hip in a fixed position of 90° flexion, 90° abduction and externally rotation. The patient had a history of hitting an electric pole with his right thigh with abduction force during collision. The patient complained of severe pain during movement of his right hip joint. His vital signs were stable. There were no neurovascular deficits in the injured limb. An anteroposterior radiograph revealed an inferior, obturator-type dislocation of the right hip joint (). Computed tomography (CT) scan was performed before any manipulation to evaluate any associated injury. There was no additional damage to the femoral head, acetabulum or trochanteric area (). After appropriate consultations, manipulation under anesthesia was taken.\nGeneral anesthesia was administered with patient in supine position. The dislocation was reduced as per the recommended techniques. We applied continuous traction in line with femur with gentle flexion and lateral push was given on the inner thigh with the pelvis stabilized by an assistant. However, this was unsuccessful. The hip was then internal rotated and adducted. Forceful resistance was abruptly reduced with audible \"clunk\" and we checked stability and range of motion of the hip. Reduction of the hip joint was confirmed under fluoroscopy and skin traction was applied for maintenance. Post-reduction CT was taken in order to confirm the congruent reduction. Although the post-reduction X-ray had shown minimal contour change of the greater trochanter (), post-reduction CT scan revealed the fracture of the greater trochanter (). The authors considered the possibility of further displacement of the greater trochanter, because the fracture gap was more than 2 mm on CT image. The fracture of the trochanter was then fixed through the incision under fluoroscopy control with cannulated screws and washers (). The patient was discharged with advice for stric"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old man presented with progressive left eyelid swelling that started four weeks previously. His medical history included proximal gastrectomy because of a moderately differentiated gastric adenocarcinoma five years previously. The tumor cells expressed cytoplasmic cytokeratin- 7 (CK7) but not cytokeratin-20 (CK20). The eyelid swelling improved with prednisone administration. However, leg weakness and swelling developed one week prior, and the patient was consequently transferred to the oncology department of our hospital with a suspected spinal or vertebral metastasis. Orbital magnetic resonance imaging (MRI) revealed exophthalmos and a T2-weighted high-signal-intensity lesion accompanying fatty stranding on the preseptal and septal areas. The lesion was mostly enhanced and spread to the extraconal area; the inferior rectus muscle was also thickened without any definite mass. There was no specific finding showing an acute infarct on brain MRI. The overall imaging findings were suggestive of preseptal and septal cellulitis. Therefore, teicoplanin and ceftriaxone were administered because of concern about the potential for clinical complications of orbital cellulitis including visual disturbances and central nervous system manifestations.\nUpon physical examination at our clinic, the patient presented with localized relatively ill-demarcated erythematous swelling and indurations at the left upper and lower eyelid (). Histopathological examination revealed diffuse infiltration with tumor cells that formed strands or clusters between the collagen bundles throughout the upper dermis (). The infiltrating tumor cells were round and polygonal and of variable size. Cytoplasm was eosinophilic, while the nuclei of the tumor cells were pleomorphic with conspicuous nucleoli with mitotic figures. Signet ring cells with intracytoplasmic mucinous vacuoles that exhibited nuclei laterally were also observed. Immunohistochemical staining showed the tumor cells expressed cytop"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old woman with hypertension, dyslipidemia and morbid obesity (43 kg/m2) status-post gastric bypass surgery over ten years prior to presentation was admitted for evaluation of an upper gastrointestinal bleed. Postoperatively following gastric bypass surgery, the patient became hemodynamically unstable and developed acute kidney injury. Although her renal function improved, the underlying etiology of her postoperative complications remained unknown. An abnormal electrocardiogram noted several years later suggested a prior myocardial infarction, retrospectively hypothesized incurred perioperatively. The abnormal electrocardiogram prompted invasive coronary angiography which showed no evidence of obstructive coronary artery disease. During the current admission for upper gastrointestinal bleeding, an abdominal CT scan with intravenous contrast serendipitously revealed a filling defect in the left ventricular apex. Transthoracic echocardiography confirmed the presence of a large, heterogeneous apical mass and additionally showed midventricular hypertrophy measuring 20 mm in the interventricular septum, resulting in systolic apposition of the midventricular segments ().\nContrast-enhanced continuous wave Doppler revealed paradoxic diastolic flow from the apex toward the base as well as a systolic midcavity gradient of 41 mmHg (). Cardiovascular MRI (CMR) was recommended for further evaluation of left ventricular structure, function and tissue characterization.\nCMR revealed a mildly dilated left ventricle (end diastolic volume index 99 mL/m2) with midcavity hypertrophy (maximal wall thickness 20 mm in the interventricular septum), a measured ejection fraction of 65% and an aneurysmal apex ().\nApposition of the midventricular segments in systole effectively resulted in separate apical and basal chambers (). The aneurysmal apical segments contained a large (24 × 20 mm) mass with peripheral enhancement and a hypointense core on late gadolinium enhancement imaging con"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.\nAt age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.\nSix months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.\nA clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.\nShe was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.\nMagnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAt the end of 2008, a 54-year-old Japanese man was referred to our hospital because a liver mass had been discovered by ultrasonographic examination. Enhanced computed tomography (CT) revealed a large liver tumor 15 cm in diameter extending from the left lobe to the anterior segment of the right lobe, which was enhanced in the arterial phase and washed out in the equilibrium phase, which is typical of HCC (Figure ). The left branch of the portal vein was not identified as being involved in the tumor. Extrahepatic metastasis was not observed. The patient was in good health, and his Eastern Cooperative Oncology Group performance status was 0. He had never smoked cigarettes, drunk alcohol, or been diagnosed as obese or diabetic. Laboratory data demonstrated normal liver function and he had no evidence of past or persistent hepatitis B virus or hepatitis C virus infection. Elevations of alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) levels were observed: AFP level 119 ng/ml (normal range < 10); DCP level 158,000 mAU/ml (normal range < 40). His Child-Pugh score was A 5, and the tumor stage was Barcelona Clinic Liver Cancer stage C. According to the clinical practice guidelines for HCC [], surgical resection was considered because of normal underlying liver, although it was accompanied by vascular invasion. Subsequently, an extended left lobectomy was performed, and complete resection of the tumorous area was achieved. The pathological examination confirmed a moderate differentiated HCC with portal vein invasion of the left branch, and the underlying liver tissues were normal.\nEight months after the resection, recurrence of multiple lung metastases was detected on a follow-up periodical CT scan. Intrahepatic recurrence was not observed. The patient was initially treated with sorafenib at 800 mg per day. Two weeks later, a grade-2, hand-foot skin reaction occurred and a dose reduction of 400 mg per day was made. After two months, follow-up"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().\nThe patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was tre"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old male patient from an urban area of Kashmir (Asian) visited the Department of General Medicine of our institute with the chief complaints of severe lower-abdominal pain for the past eight months. The patient also complained of severe constipation, nausea, vomiting, anorexia, loss of appetite, abdominal cramps, incontinence of faeces and weight loss during the past four months. He experienced profuse bleeding from the rectum for the last month. Initial interviews with the patient revealed that the he was a heavy smoker and frequent user of noon-chai (Salt tea), meat and pickles. On examination the patient was found to be anemic. Digital rectal examination revealed an ulcero-infiltrative lesion with restricted mobility about 4 cm from the anal verge on the left lateral wall. A colonoscopy confirmed the rectal examination and biopsies taken at the time of the colonoscopy revealed squamous cell carcinoma (SCC) of basal cell type in the first histopathological examination. The report was re-confirmed by a second independent pathologist. A Contrast-Enhanced Computed Tomography (CECT) of the chest, abdomen and pelvis was also done but no lesions were found in any other site than the rectum. The lesion was without any fat stranding or lymphadenopathy. Furthermore, following the provisional diagnosis, the patient was referred to the Department of General Surgery for radical treatment, where he underwent LAR of the rectum using the standard technique of mesorectal excision (Figure ). The continuity of the gut was restored by a circular stapler for low colorectal anastomosis with formation of a colonic pouch. The colonic pouch takes over the function of rectal reservoir which is lost after excision of the middle and lower rectum. Microscopic examination of the resected lesion demonstrated a 2.5 cm × 3 cm SCC tumor of the rectum infiltrating the serosa. The margins of the excised tissue were found to be free of the tumor. However, four regional lymph nodes were als"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur case is a 6-year-old boy who sustained direct minor trauma to the left forehead. He was playing at home with his sister and swirling in a circular fashion when he slipped and hit his forehead against the ground. The following day, he reported blurring of vision in the left eye and his parents noticed a white left pupil. Twenty-four hours following the incident, examination of the right eye was normal and the left eye had hand motion vision. Intumescent cataract was evident by slit-lamp examination (). The cornea was clear, the anterior chamber was deep and quiet, the pupil was round and reactive, and the anterior lens capsule was intact. Intraocular pressure measured 14 mmHg in the right eye and 16 mmHg in the left eye. Gonioscopy revealed a normal angle without angle recession. The media opacity precluded exam of the posterior segment. B-scan revealed a flat retina, quiet vitreous, and a breached posterior capsule centrally (). Computerized tomography scan of brain was negative for skull fracture or intracranial bleed. Since the patient was in the amblyogenic age, cataract surgery was performed within hours of presentation.\nSurgery was started with trypan blue staining of anterior capsule, anterior circular capsulorhexis, and avoiding hydrodissection to prevent expansion of PCR. Slow aspiration of lens matter with the phacoemulsification probe was performed under low settings of bottle height, irrigation, and aspiration. After aspiration of two-thirds of the lens content, a very large, oval-shaped central posterior capsular rent was exposed (). Anterior vitrectomy was performed, followed by cortex aspiration with the vitrector. Although one-piece foldable intraocular lens implantation in the capsular bag was initially thought feasible, the intraocular lens had a tendency to dislodge into the vitreous cavity, necessitating subsequent fixation in the sulcus without further optic capture (). Intracameral carbachol was applied at the end of the surgery. One week po"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 86-year-old white English man was referred to the surgical clinic in September 2007 for melaena and weight loss. He was anaemic on physical examination with no other clinical findings. He had a history of a left pneumonectomy in 1985 for a squamous cell carcinoma of the lung, Chronic Obstructive Airway Disease, Benign Prostatic Hypertrophy and diverticulosis. His Haemoglobin was 6.0 gm/L.\nAbdominal CT () showed an apple-core stenosing tumour in the proximal transverse colon and a 2 cm intra-luminal lesion in the mid-ascending colon. He underwent a radical right hemicolectomy in November 2007. Macroscopic examination of the specimen revealed a 50 mm × 45 mm circumferential tumour in the large bowel, and invading the full thickness of the wall. The tumour was present at the serosal surface, and was situated 40 mm from the distal resection margin and 160 mm from the proximal resection margin. Other findings included full thickness (probably incisional) defect, 30 mm in maximum diameter that lied 80 mm proximal to the tumour and adjacent to a 24 mm sessile polyp (). The background mucosa showed six polyps in total, measuring between 4 mm and 25 mm, and the largest lied 60 mm from the proximal resection margin. The terminal ileum was sliced through the wall at approximately 40 mm from the proximal end and was attached to the rest of the ileum by a strand of ileal tissue only. Microscopy showed moderately differentiated adenocarcinoma (,). The tumour had an infiltrating growth pattern with minimal lymphocytic infiltration at the advancing edge. The tumour was present at the serosa (pT4). An area suspicious of extramural lymphovascular invasion was also seen. The largest polyp was a severely dysplastic tubulovillous adenoma. The rest of the polyps were moderately dysplastic tubulovillous and tubular adenomas. One other hyperplastic polyp was also identified. Thirteen lymph nodes were identified and none of them showed metastatic deposits. All those findings confirmed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 2-year-old boy from Russian republic of Ingushetia. Both parents and younger sibling (female) were asymptomatic. Family history is not burdened. Parents may be related, as the mother of the child and the grandmother (father's line) are from neighboring villages of Malgobek region of Ingushetia.\nThe patient is the first child of healthy parents. Pregnancy proceeded against the background of gestosis in the first and second trimester, threats of interruption for a period of 12 weeks, anemia, and lack of hydration. The child was born as a result of fast unassisted childbirth. His birth weight was 3570 g and height was 55 cm. Apgar scores were 6/7. Early motor development slightly delays: He attained head holding at 3 months, sitting without support at 6 months, by the year the boy got up and walked with support. From the age of 8 months, the baby had a weight loss of 2 kg for 2 months with episodes of repeated vomiting. At the age of 1 year 2 months against a background of acute respiratory viral infection, there was a regress in development—the boy stopped walking. Subsequently, rachitic skeletal changes, an increase in the volume of the abdomen appeared, and a loss of motor skills progressed. Magnetic resonance imaging (MRI) of brain revealed a mildly expressed leukopathy in white matter of parietal lobes. Proteinuria and glucosuria appeared at the age of 1 year 8 months.\nAt the age of 2 years 2 months, he was admitted to Russian children's clinical hospital with psychomotor retardation and treatment resistance. On physical examination, he was observed to have a pronounced delay in psychomotor development (he did not get up, walk, crawl; he could only keep his head and turn over). Neurological examination revealed muscular hypotrophy, tendency to hypotension in axial musculature, and uniform decrease in tendon reflexes from hands and feet. MRI of brain revealed subat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old Japanese woman noticed a tender lump in her right breast. She immediately went to a breast clinic to get a breast cancer screening. She had no family history of breast and ovarian cancer. After a month, she was referred to our institution with suspicion of metaplastic breast carcinoma with a core needle biopsy at the breast clinic. Physical examination revealed a hard, tender, and 25-mm mass in the upper outer quadrant of her right breast and a palpable lymph node in her right axilla. Mammography indicated an indistinct mass on the mediolateral oblique view and the craniocaudal view. Ultrasound (US) showed an 18 × 16-mm, irregular-shaped, and hypoechoic mass with a suspicion of a spread to the nipple inside the duct (Fig. a) and several swollen lymph nodes in levels I to II (Fig. b). Magnetic resonance imaging (MRI) detected enhancement of a 17 × 17-mm indistinct mass surrounded with a non-mass enhanced segmental lesion toward the nipple side spreading a maximum of 74-mm range, which had no interaction with the chest bone, muscles, and breast skin, in the right breast tissue (Fig. ). Invasive carcinoma with multiple axillary lymph node metastases was strongly suspected on clinical examination and imaging. Histological evaluation of the biopsy for the mass revealed a tumor with the growth of oval and spindle-shaped cells and multinucleated giant cells, the infiltrating lymphocyte into the breast tissue, and hyalinization in the stroma. The multinucleated giant cells stained positively for CD68. A part of the oval and spindle mononuclear cells stained weakly positive for CD68. These tumor cells stained negatively for estrogen receptor (ER), progesterone receptor (PgR), and human epidermal growth factor receptor 2 (HER2). There was a focal hemorrhage without necrosis. Few non-epithelial atypical cells were observed in the breast duct, but no atypical epithelial cells consistent with breast cancer were detected. GCT of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 11-year-old girl was presented to the National University of Malaysia (UKM) Paediatric Dental Clinic with a referral for further management of pulp necrosis of an immature lower right second premolar (tooth 45), secondary to the fractured tubercle of dens evaginatus. Two weeks earlier, she had treatment at a general dental clinic for pain related to tooth 45. Tooth 45 had spontaneous and lingering pain following cold and thermal stimuli. The tooth was diagnosed to have symptomatic irreversible pulpitis, and root canal therapy was initiated. The canal was accessed, and pulp extirpation performed before the placement of intracanal nonsetting calcium hydroxide by the general dental practitioner (GDP).\nAt the time of current assessment, her tooth-related symptoms had completely resolved. General oral examination showed the presence of generalised mild gingivitis with a basic periodontal examination (BPE) score of 1 in all sextants. The patient's oral hygiene was fair with a plaque score of 30%. The patient is still in her mixed dentition with the presence of the primary maxillary canines. Her upper dental arch was well aligned, and mild crowding of anterior teeth was noted in the lower arch. Tooth 45 has an occlusal glass ionomer dressing of the access cavity made for the pulp extirpation earlier by the GDP (). Cold and electric pulp sensibility testings showed positive responses to all fully erupted premolars indicative of tooth vitality expect for tooth 45. Tooth 45 also has slight tenderness to percussion. Periapical radiograph of tooth 45 showed an immature root with convergent open apex and small periapical radiolucency. The pulp space of tooth 45 is of an even width from the coronal to the apical portion (). Based on the assessments, tooth 45 was diagnosed with pulp necrosis secondary to fractured dens evaginatus and symptomatic apical periodontitis.\nOn the day of initial assessment, tooth 45 was isolated with rubber dam after infiltration of local anaes"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old white female patient was admitted to the emergency department of our hospital with symptoms of acute intestinal obstruction, first noted 48 hours before (colicky abdominal pain, vomiting, and abdominal distention). The patient was tetraplegic due to Friedreich's disease diagnosed 25 years ago and was hospitalized permanently in a center for chronic disorders.\nUpon physical examination, a prominent abdominal mass distorting her trunk shape was noted. In palpation, the abdomen had considerable distension with diffuse tenderness and moderate rebound tenderness. Despite the distension in the upper abdomen, a huge tumor could easily be palpated occupying mainly the lower abdomen.\nThe neurological examination revealed good responsiveness of the patient, quadriplegia, loss of tendon reflexes, and positive Babinski sign bilaterally. She was then referred for cardiac evaluation, where mitral insufficiency and left ventricular hypertrophy were found.\nThe white blood cell count was 18,100/μL with 79.1% neutrophils, which was further elevated the second day; urea was found 51 mg/dL and γGT 54 mU/mL. The rest of the blood tests were normal.\nThe most possible diagnosis was intestinal obstruction probably due to the tumor. An abdominal computed tomography was performed, which revealed a huge intra-abdominal mass originating most possibly from the right cornu of the uterus (Figures , , ).\nAn emergency exploratory laparotomy followed with a midline incision.\nAfter the peritoneal cavity was opened an enormous circumscribed mass measuring 29.5 × 22 × 12 cm was revealed displacing the bowel to the abdominal periphery. The mass originated from the right cornu of the uterus. After lysis of the adhesions between the tumor and the greater omentum, the tumor was excised () and the right uterine cornu was ligated with a nonabsorbable suture. Inspection of the small intestine revealed a stenotic area in its central portion due to an adhesion with the omentum. The adhesion was ta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old man with no previous history of illness was diagnosed with stage I papillary thyroid cancer, tall-cell variant and underwent total thyroidectomy. Two years later, he developed lymph-node and multiple lung metastases and underwent additional neck dissection and radioactive iodine treatment, thyroid-stimulating hormone-suppressive therapy and sorafenib and lenvatinib therapies; unfortunately, he developed resistance to these therapies. Seven years later, the cervical tumour was observed during regular follow-up to have gradually increased in size and additional neck dissection was scheduled. However, the lesion was judged to be inoperable because of its rapid growth just before surgery and radiation therapy began 1 week later. At the first visit to our department, the patient’s left cervical lymph-node metastasis had markedly increased to 13 cm maximum diameter and the tumour had grown circumferentially around the common carotid artery (CA). The patient was referred to our department for palliative EBRT to reduce exudates and bleeding.\nCT scan showed lymph-node metastases not only in the left neck but also in the axilla and mediastinum, which squeezed the superior vena cava (). Many small lung metastases were also observed. The patient had good performance status, had no dysphagia that could lead to aspiration pneumonia, had no complications that increased the risk of adverse event from high-dose irradiation and had no other life-threatening distant metastatic lesions; therefore, we presented high-dose IMRT as an alternative to standard palliative irradiation. Although this case presented with a huge cervical mass, fiber–optic investigation of the pharynx showed no airway narrowing and no symptoms of facial oedema, suggesting that emergency irradiation was not indicated. That is, 1 week of IMRT treatment was considered acceptable. The purpose of this treatment was to prevent fatal airway obstruction and to prolong patient survival by maintaining tumour s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old, a male who is an auto driver by profession presented with a relapse of alcohol dependence. The patient was treated for alcohol dependence in a private hospital, and he was abstinent for last 4 years till 2 months before. He also a complaint of hearing voices for the 4 months but it did not disturb him much. Patient complaint of excessive anxiety and restlessness 2 months ago following the demise of his relative. He started consuming alcohol and within 4 days he developed tremor, insomnia, craving for alcohol which qualified him for a relapsed episode. He was admitted to hospital and detoxified. During the stay, complaint of hearing of voices getting more prominent following deaddiction treatment. After the admission, he complaint of hearing multiple people talking among themselves about him. He used to talk back to them but could never control it. He also used to get irritated on silly matters and cry like a helpless boy with an expression of suicidal ideation to get relief from the agony of hearing derogatory voices. He continued to be abstinent from alcohol after 2 weeks of discharge, but the hearing of voices got worsened which was quite unexpected even in the presence of olanzapine 20 mg and quetiapine 25 mg. His cognition was well preserved with Mini-Mental State Examination score of 27. Due to the atypical course of illness, we sought a neurological consultation, who suggested for magnetic resonance imaging (MRI) brain and electroencephalogram (EEG). Out of our surprise, MRI report revealed the presence of an arachnoid cyst in right middle cranial fossa compressing temporal lobe. EEG did not reveal any paroxysmal discharge. Other investigations such as total and differential count, blood sugar, thyroid function, urine routine, liver and renal function tests were within normal range. Hence, neurosurgical consultation was asked for. They suggested mannitol to reduce intracranial pressure and phenytoin to prevent focal seizure. Surgical interventio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old gentleman, the clerk by occupation, presented to us in the OPD with pain in the lower half of posterolateral aspect of left thigh travelling down the lateral aspect of leg till ankle since 3 months. The pain was insidious in onset and gradually progressive, worse since a month. He had worsening of pain on taking a few steps and needed to sit after walking 50 m. He did not have any pain when sitting or lying down. He complained of mild paresthesias in left lateral aspect of leg on walking. He did not complain of numbness. There were no symptoms in the right lower limb. He did not have any back pain. There was no history of recent more than usual physical activity or trauma. For the last 1-month he was being treated by a local doctor as L5 radiculopathy. He was on oral non-steroidal anti-inflammatory drugs and pregabalin, with temporary and partial relief. Magnetic resonance imaging (MRI) (Figs. and ) ordered by the same local doctor, due to resistant symptoms, showed diffuse disc bulge at L4-5 and lateral recess stenosis. He was later given transforaminal nerve root block at his local center with no relief. He had taken a course of injectable vitamin D3 without prior estimation of its serum levels. He was finally referred to our center for surgical L4-5 root decompression. On clinical examination at our center, the patient had tenderness at the lateral aspect of proximal left leg. There was a pain on compression, bringing the fibula closer to tibia. The left knee had a varus deformity (). Knee joint examination revealed medial joint line tenderness and crepitus on a range of motion testing. There was no joint laxity and the knee range of motion was full. The patient had an antalgic gait. The spine and neurological examination was within normal limits. There was no thickening of the common peroneal nerve at the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a three-year-old Caucasian girl with ASD, focusing on her PEH (Table ). She was born after 41-weeks gestation via caesarean section and had an Apgar score of 9/10. A birth weight of 3.85 kg, head circumference of 37 cm and length at birth of 50 cm were recorded. No dyschromias or malformations were found. Our patient's growth and karyotype were otherwise normal. She was breastfed until the age of nine weeks. By five months, she was able to hold her head steady and erect, and was able to walk on her own at 15 months of age. Our patient currently walks on her tiptoes and began this when she first started walking. On examination, our patient had normal growth and anthropometric data. Her muscle tone was moderately decreased, widespread and symmetric, with normal osteotendinous nerve reflexes. Acquisition and delayed maturation of language was observed. Sensory perception and attention were thought to be normal until 12 months of age. Subsequently, her parents noticed that our patient did not respond to their calls and seemed isolated with introverted behavior. Our patient was not communicative and was consistently unresponsive to the calling of her name. In addition, she did not interact with other children and presented with restricted interest and repetitive stereotypical behavior. Our patient did not show imitative or projective play. In terms of education, starting at two years of age she was schooled with additional support from an early learning program. Brain magnetic resonance imaging (MRI) scans appeared normal. Our patient was diagnosed with pervasive developmental disorder of the autistic spectrum and moderate mental retardation.\nThe 32-year-old mother and 36-year-old father lived on the second floor of a 14-year-old building in Puente Tocinos, Murcia. The mother had given birth to a healthy boy six years earlier. In the current case, the pregnancy was not planned. During the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old male chronic smoker with medical history significant for chronic obstructive pulmonary disease was admitted for imaging guided biopsy of a 1.2 cm left lower lobe lung nodule found recently on a computed tomography (CT) scan of the chest. The nodule was highly suspicious for primary lung malignancy. The patient was placed in a prone position and lung parenchyma in the posterior lateral left chest was visualized. Under CT guidance, a 19-gauge guide was advanced into the left lower lobe and two separate 20-gauge core biopsy specimens were obtained from the mass. There was no hemorrhage or immediate post procedure complication. However, towards the end of the procedure, the patient started complaining of sudden onset of chest pain and became unconscious. No palpable pulses were identified. A code blue was called and cardiopulmonary resuscitation was begun according to Advanced Cardiovascular Life Support guidelines. The patient subsequently demonstrated ventricular fibrillation which responded to defibrillation shock and epinephrine. The patient had three cycles of chest compressions, one dose of epinephrine, and a shock of 200 J. He was successfully resuscitated and intubated for mechanical ventilation. A CT scan of the chest was obtained immediately after the resuscitation and it demonstrated development of a small anechoic area in the left cardiac ventricle consistent with air embolus (Figure ).\nThe vital signs recorded at the time were as follows: blood pressure of 130/80 mmHg, pulse rate of 90 beats per minute, respiratory rate of 18 breaths per minute, and normal oxygen saturation of 92% on room air. The patient was admitted to the intensive care unit. Bedside transthoracic echocardiogram (TTE) did not reveal evidence of an air embolus. Additionally, no cardiac wall motion abnormalities were noted. The patient remained hemodynamically stable for 24 hours, and he was successfully weaned off from the mechanical ventilator next day and discharged home i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old male visited our clinic complaining of right knee pain and restriction in ROM of the right knee, especially in flexion. He had undergone a patellectomy on the right knee for a gunshot injury 45 years ago, and knee pain and limitation of ROM worsened gradually since 10 years ago. He did not respond to conservative treatment, had progressive reduction in the ambulatory capability and was barely able to climb a single flight of stairs at presentation to our clinic.\nClinical examination of the right knee revealed a transverse surgical scar with a varus knee alignment of 3°, 0° to 15° of active ROM, and severe ankylosis. There was no collateral ligament laxity and both the anterior drawer and Lachman tests were negative. There was no posterior sag and no extension lag. Plain radiographs showed severe bi-compartmental osteoarthritis ().\nTKA was performed through an anterior midline longitudinal skin incision, which was perpendicular to the previous patellectomy scar. Arthrotomy was made medial to the scar tissue of the previously excised patella, and extensile rectus snip was performed for adequate exposure and knee joint flexion (). All other ligaments were normal. We performed intra-articular adhesiolysis and synovectomy for hypertrophied soft tissue, and added 2° more tibial posterior slope to achieve greater ROM. Upon achieving balanced gaps and neutral mechanical alignment, press fit condylar posterior stabilized total knee prosthesis (DePuy Mitek Inc., Raynham, MA, USA) was inserted. The tibial and femoral components were fixed with cement.\nQuadriceps femoris strengthening exercises were initiated immediately after surgery. From the 2nd postoperative day, active ROM exercises of the knee joint were performed with passive ROM exercises using controlled passive motion devices to facilitate rapid ROM recovery. Weight-bearing ambulation was allowed after suture removal at 2 week after surgery. Postoperative recovery was good and he achieved satisfactory am"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old man presented with a 19-year history of bilateral, slowly progressive, painful swelling of the Achilles tendon and a 1-year history of hypesthesia over the right sole without any trauma. The patient had no history of cataract or epilepsy, although he did have chronic diarrhea and had attended a special school due to learning disabilities.\nPhysical examination found a huge ovoid mass in bilateral Achilles tendons (). The patient experienced no pain during rest or ankle motion. Muscle strength was normal, except for mild weakness in both ankles. A sensory test revealed that the patient had decreased sensation in both feet, especially to light touch. The deep tendon reflex was increased in both lower extremities. Babinski sign and ankle clonus were positive on both sides. Magnetic resonance imaging (MRI) of the ankle showed fusiform thickening of the Achilles tendon and an enlarged tibial nerve (). The patient was mentally alert and he scored 25 points in the Mini-Mental State Examination with a very low IQ of 52 points.\nUltrasonography showed diffusely enlarged peripheral nerves in the lower limbs, upper limbs, and C5–C7 nerve roots. We also performed ultrasonographic evaluation of the peripheral nerves in a normal male subject of similar age and anthropometry. Cross-sectional areas (CSA) of the peripheral nerves were measured as shown in . Significantly larger CSA values were found in the patient with CTX than in the normal subject, for the posterior tibial nerve behind the medial malleolus and for the median nerve at both the wrist and the elbow, like the other peripheral nerves ().\nNerve conduction studies showed decreased sensory conduction velocity of the ulnar nerve on both sides (right, 43.7 m/s; left, 46.0 m/s) and decreased motor conduction velocity of the peroneal nerve (right, 37 m/s; left, 38.2 m/s). The posterior tibial nerve somatosensory evoked potential test (SEP) showed no response, while the median nerve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old male presented in our emergency department complaining sudden, severe dizziness and left ptosis of an hour's duration. On admission, his symptoms gradually worsened, showing left-side facial palsy, severe dysarthria, and left-limb ataxia. He was on oral anticoagulation with a daily aspirin since he had a mechanical aortic valve replaced more than a year previously. However, his international normalization ratio (INR) on admission turned out to be only 1.4.\nSubsequent, acute stroke MR imaging showed occlusion of the basilar artery with a focal infarction in the left superior cerebellar artery territory (). Systemic tissue plasminogen activator (Actylase, Boehringer Ingelheim, Germany) was given at a dose of 0.6 mg/kg as the patient was still within the time window of intravenous thrombolytic therapy. Because the patient did not show any symptomatic improvement, our endovascular treatment team was called in per our institutional acute stroke bridging therapy protocol.\nRight vertebral angiogram showed a typical pattern of BAO. The lesion showed antegrade flow directly after placement of the SFR (). However, the f irst retrieval was unsuccessful and only showed a slight change in the shape of the filling defect. The pattern repeated during several, following trials. Eventually, the clot migrated further distally into the left posterior cerebral artery ().\nAt the time of the final device retrieval, we obtained a control angiogram while the device was still in the midportion of the basilar trunk (). We were able to retract the filling defect proximally into the mid portion of the basilar trunk. However, it was attached at the distal tip of the device. Eventually we could pull down the device to the distal vertebral artery (VA) level proximal to the ipsilateral posterior inferior cerebellar artery (PICA) origin.\nOn the control angiogram we noted that half of the filling defect had migrated into the right PCA and half of it was still within the device mesh"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old man with no history of skin cancer presented to the outpatient dermatology clinic for a scalp lesion of three weeks duration. He reported rapid lesion growth, but no change in the overall appearance nor any associated symptoms. Examination revealed a mobile, round, exophytic nodule with overlying ulceration and hemorrhagic crust, approximately 1.5 cm in diameter (Figure ). Given a high clinical suspicion of malignancy, the lesion was excised three weeks following the initial visit using a fusiform (elliptical) incision with 1 cm margins. The lesion immediately prior to the procedure is seen in Figure .\nA histopathologic examination of an excisional biopsy of the cutaneous lesion revealed a proliferation of spindle and pleomorphic tumor cells, which flattened the overlying epidermis (Figure ) and extended to the subcutaneous tissue (Figure ). The tumor cells were large and polygonal and contained eosinophilic cytoplasm. They expressed diffuse CD10 positivity (Figure ) and focal CD68 positivity. The tumor cells were negative for p40 and SOX10, excluding the possibility of sarcomatoid carcinoma and melanoma, respectively. The histopathologic findings were found to be consistent with invasive pleomorphic dermal sarcoma. The tumor measured 3.3 cm at the largest dimension, and tumor cells were found to be present at the surgical margin. There was no evidence of lymphovascular or perineural invasion.\nA surgical, wide, local excision was planned. Preparatory computed tomography (CT) imaging revealed an approximately 3.9 cm focus of enhancement with central ulceration in the soft tissue of the posterior scalp and confirmed a lack of bony erosion in the underlying calvarium. No metastatic adenopathy was appreciated. Figure demonstrates the scalp vertex prior to surgery. A wide local excision was performed using a 2 cm margin around the remaining tumor for a 7.5 cm area of planned excision. The repair utilized a 7x3.5 cm full-thickness skin graft from the left up"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old female patient of Indian origin reported to the out-patient department with a chief complaint of a painful swelling in the right posterior mandible of 6 months duration. The swelling was insidious in onset and had progressed slowly to cause facial asymmetry along with mild parasthesia. On examination, there was a diffuse hard swelling on the right side of face with smooth margins extending anteroposteriorly from anterior border of the masseter muscle to the posterior border of the ramus and superoinferiorly from tragus to the inferior border of the mandible []. The skin overlying the swelling was normal in appearance with no rise in local temperature and there was no associated cervical lymphadenopathy. Intraorally there was bicortical expansion in the posterior region of the right mandible with a firm, tender soft-tissue mass posterior to the second molar. The mucosa overlying the lesion was erythematous and the third molar was clinically absent. There was no other apparent abnormality in the oral cavity except for missing maxillary third molar on the right side. The hematological parameters of the patient were within normal range. An orthopantomograph was advised and it revealed a large unilocular lesion in the ramus of the right mandible extending supero-inferiorly from the superior border of the ramus, involving the coronoid process, to the inferior border of the mandible, leaving a thin rim of bone inferiorly. Postero-anteriorly the lesion extended from posterior border of the ramus up to the body of the mandible distal to the second molar and involving the entire width and the anterior border of the ramus []. Based on the clinical and radiographic findings a provisional diagnosis of ameloblastoma was made with other benign/malignant odontogenic neoplasm, keratocystic odontogenic tumor, calcifying cystic odontogenic tumor or any other intraosseous neoplasm being kept as differential diagnosis. Fine needle aspiration (FNA) was performed, which yiel"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male was referred from a primary care facility for the management of dentoalveolar fracture involving the left maxillary tuberosity during attempted extraction of maxillary left first molar. He had no known medical problems and no known allergies.\nUpon examination, he presented with facial asymmetry with swelling occurring on his left face. The swelling was diffuse and slightly tender to palpation, involving the entire left buccal region from zygomatic arch to the border of the mandible. There was no limitation of mouth opening and no deviation of the mandible upon opening and closing of the mouth.\nIntraorally, there was a mobile fracture segment seen on his left maxilla involving the left maxillary first, second, third molar and maxillary tuberosity. The segment was extremely mobile and extruded preventing full occlusion of his teeth. The maxillary left second premolar was firm. The maxillary left first molar had a large occlusal caries which extends subgingivally and was reported to be tender to percussion prior to the attempted extraction. There was a small laceration wound on the buccal gingiva adjacent to the upper left first molar measuring about 6 mm (Figure ).\nAs the diagnosis as well as the extent of the dentoalveolar fracture was able to be determined clinically, no radiographical examination was done for this patient.\nAs the patient was a young healthy male, and the maxillary second and third molar that was involved in the maxillary tuberosity fracture was sound, the authors decided on a conservative approach to reduce and stabilize the fractured segment followed by transalveolar extraction of the unrestorable maxillary first molar at a later date. As the patient was seen toward the end of the working day, the fracture was first stabilized using eyelet wiring and an appointment was set for the following day.\nDuring his next appointment, closed reduction and fixation was achieved using upper and lower arch bars with intermaxillary fixation (I"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old asymptomatic female, G1P0, with a history of curettage, is presented to the Department of Gynecology and Obstetrics for termination of pregnancy. Her last menstrual period was 17 weeks and 2 days ago. Abdominal ultrasound revealed a clear gestational sac (GS), fetus with heartbeat and placenta previa. Abdominal ultrasound also showed the GS at a distance from the cavity, with a compressed myometrium between the two of them (). The patient received a MRI examination, showing an enlarged uterus of 13.0 cm ×11.7 cm × 7.9 cm, because of pieces of evidence. The MRI demonstrated a foetus with clear organs (), and compressed the lower uterine segment (). The GS was not connected with the uterine cavity and endometrium, but embedded into the myometrium in the right posterior wall of the uterine. A linear hypointensity of the junction zone was observed between the GS and the uterine cavity on T2weighted image ().\nThis result is likely to be placenta implantation as the myometrium cannot be separated from the placenta. The patient was at risk of the uterine rupture and life- threatening haemorrhage. Emergent management should be performed. Performing uterine artery embolization (UAE) and interventional therapy is inadvisable because of the obstructing myometrium between the cervix and placenta. Employing a surgical exploration of the abdomen was decided that was undertaken under temporary balloon occlusion of the abdominal aorta to reduce the loss of blood. The balloon was placed in the abdominal aorta between the opening of renal artery and iliac artery just before the operation. If the area of the focal damage was heavy, the subtotal hysterectomy or hysterectomy was needed. Otherwise, clinicians can perform excision by laparotomy and hysteroplasty. Given the age of patient, clinicians did their best to perform hysteroplasty instead of hysterectomy. The intramural ectopic GS in the second trimester was successfully excluded without life-threatening haemorrhage"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Caucasian, Greek man presented to the out-patient clinic of KAT hospital complaining of weakness and limited range of motion of his right shoulder. He had noticed, over the past two months, that abduction and elevation of the joint had gradually become limited while he was carrying his newborn child in a baby basket. He denied any neck or shoulder pain and could not recall a specific precipitating traumatic event or any recent episode of respiratory infection. However, he reported that his job was a heavy manual one, requiring lifting and carrying heavy objects on his shoulders. Our patient had no significant medical history.\nPhysical examination revealed a winged scapula and asymmetry of his shoulders, with right shoulder depression (Figure ). He was unable to abduct his right arm above 80° in the frontal or scapular plane while his forward elevation was slightly reduced. His passive range of motion was comparable to the normal left side. Scapular winging was marked during abduction and disappeared in forward elevation, while it was only slightly evident at rest (Figure ). Furthermore, there was a marked wasting of his right trapezius muscle with decreased shrugging of the affected shoulder. Both wasting and weakness were not observed in the ipsilateral sternocleidomastoid muscle, and a neurological examination did not reveal other cranial nerve deficits. No brachial plexus neurological signs were detected. Our patient's rotator cuff was judged to be intact.\nResults of his complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum biochemistry were all normal. The initial X-rays of his right shoulder region were unremarkable. Computed tomography (CT) of the shoulder girdle of our patient revealed significant diffuse trapezius muscle wasting (Figure ). Magnetic resonance imaging (MRI) of his cervical spine, right shoulder joint and skull base identified no pathology except mild atrophy of his right sternocleidomasto"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old previously health boy initially presented with intermittent headache, fever, and cough for few months. He was seen by his pediatrician and symptoms were thought to be infectious in nature. His headaches and fevers persisted for several weeks despite supportive management with hydration and antipyretics. Two months after initial presentation, he was seen by a neurologist for his headaches. He was diagnosed with migraine like headaches and given a course of steroids with minimal improvement. Later, he developed neck lymph nodes swelling and nausea/vomiting. His mother noticed that he had lost weight (3 kg) and fatigue, and the neck lesions increased in size and number. Three months after initial presentation, he was admitted to the hospital and physical exam revealed multilevel neck lymphadenopathy (in range of 1-2 cm), significant splenomegaly, and swelling in both lower extremities. Labs demonstrated significant anemia with a hemoglobin of 6 g/dL. MRI of the abdomen showed significant, small bilateral pleural effusions, splenomegaly of 19 cm and multiple retroperitoneal nodes. A left cervical lymph node excisional biopsy was done.\nA small cervical lymph node was received in pathology department, measuring 1.2 cm × 1.2 cm × 0.2 cm. A portion of the lymph node was sent for flow cytometric analysis as routine lymphoma protocol. A result of flow cytometry was noncontributory; no aberrant lymphoid population identified.\nHistologic sections of the lymph node revealed entirely effaced nodal architecture with lymphoid infiltrated and focal sclerosis (Figure ). No residual germinal center meshwork was revealed by CD23 stain. There were scattered atypical large lymphoid cells in the background of small reactive lymphocytes and histiocytes. These neoplastic cells were medium to large size with pleomorphic morphologic features. Many of them showed moderate or abundant cytoplasm; some of them showed binucleate or multinucleate with prominent eosinophilic nucleoli t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old male was referred to Emory Eye Center in June 2010 for herpetic stromal keratitis in the left eye. His past ocular history was notable for central retinal vein occlusion (CRVO) in the left eye 3 years earlier. He underwent multiple intravitreal injections of bevacizumab and triamcinolone for the treatment of CRVO-associated macular edema. He subsequently developed a suspected herpetic keratouveitis resulting in a dense central stromal scar and visual acuity of count fingers despite aggressive topical and oral antiviral therapy.\nThe patient underwent penetrating keratoplasty (PK) with extra-capsular cataract extraction and intraocular lens placement in July 2010. Pathologic examination of the corneal transplant showed microsporidial organisms. Visual acuity improved to 20/80 with use of rigid gas permeable contact lens, and the graft remained clear until March of 2013 when the patient presented with signs and symptoms of early graft rejection. Topical corticosteroids were utilized with no improvement, so repeat PK was performed in October 2014. Pathologic examination of the repeat PK specimen again showed microsporidia despite the absence of intraocular inflammation, hypopyon, or any other signs of clinical infection.\nFive weeks post-operatively, the patient presented with new onset floaters that had been present for 2 weeks. Visual acuity was light perception, and intraocular pressure was 17 mmHg. Anterior segment examination showed trace haze at the cornea graft-host interface, 1+ anterior chamber cells, a normal iris with a round and reactive pupil, and a well-positioned posterior chamber intraocular lens. There was no view of the posterior pole. B-scan ultrasound showed a presumed vitreous hemorrhage. The patient was lost to follow-up and presented again on post-operative week 9. Examination showed keratic precipitates, trace anterior chamber cell, and neovascularization of the iris. There was no view of the posterior segment due to a dense yellow o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of 83-year-old male with previous cerebrovascular disease, coronary artery bypass surgery, and prostate cancer. He was diagnosed with smear positive pulmonary TB. He received anti-TB 4-drug combination (HREZ). After 2 months of treatment, the patient sputum was converted to negative smear, but he was suffering from progressive dyspnea on exertion with a Medical Research Council (MRC) Dyspnea Scale grade 5 []. On the physical examination, wheezing was demonstrated on chest auscultation and O2 saturation was 96% in room air. Methylprednisolone sodium succinate 80 mg/day for one week followed by oral prednisolone 40 mg/day was administered for relief of dyspnea, but they were not effective. Chest X-ray demonstrated narrowing of distal trachea and minimal infiltrations in left lower lobe. Chest CT revealed stenosis of distal trachea and left main bronchus; the stenotic part in distal trachea was 5 mm in diameter at the narrowest portion and 30 mm in length. Additionally, the stenosis in left main bronchus was 3 mm in diameter and 33 mm in length (). The pulmonary function test indicated a reduction in the percent predicted FEV1 (49.8%). He was referred to Nagoya Medical Center to perform pulmonary intervention. Under general anesthesia, rigid and flexible bronchoscopies were used to perform balloon dilatation under fluoroscopic guidance for both distal trachea and left main bronchus. Tracheobronchial stenosis was of fibrostenotic type. Through the instrument channel of flexible bronchoscope, a controlled radial expansion balloon (Boston Scientific, Boston, MA, USA) was inserted into distal trachea. The diameters used were calculated from the CT taken before the procedure and modified by the real situation at the site. It was inflated to size of 7 mm in diameter for 2 minutes (min) once, 8 mm for 2 min once, 10 mm for 2 min twice, and lastly 12 mm for 4 min twice. Then the balloon was inserted in the left main bronchus and infl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old male presented to the outpatient department with a history of low backache for the past one year, associated with typical claudication symptoms, left-sided unilateral numbness, and paresthesia of the foot. He gave no history of radicular pain, but he complained of progressive reduction in claudication distance. He had experienced a sudden deterioration in gait along with urinary incontinence, following a trivial traumatic fall, one week before presentation. There was no history of constitutional features. On examination, he had a bilateral high-stepping gait due to foot drop. Symmetrical weakness of both the L4 and L5 roots (MRC grade 0/5) and partial weakness of the S1 root (MRC grade 3/5) was noted with nondermatomal sensory disturbances. Deep tendon reflexes of the lower limbs were absent bilaterally. Though anal tone was normal, saddle anesthesia was present. Postvoidal ultrasonogram of the urinary bladder revealed a residual urine volume of 250 ml, thus confirming a neurogenic bladder.\nPlain radiography of the lumbar spine did not show any gross feature of instability and was inconclusive (). Magnetic resonance imaging (MRI) of the lumbar spine revealed a solitary intraspinal posterior epidural lesion of 1.8 × 1.5 × 0.5 cm at the L2-L3 level with heterogeneous signal intensities and adjacent epidural fatty hypertrophy contributing to severe canal stenosis (3 mm). The cauda equina was severely compressed and was almost not visible (). Owing to the heterogeneous signal intensities, computerized topography (CT) was performed which revealed the presence of an osseous lesion attached to the right L2 inferior articular process causing severe secondary canal stenosis (). Considering the recent-onset neurological deficit, the patient was advised surgical decompression and excision biopsy at the earliest. The patient was positioned prone on a Relton Hall frame under general anesthesia. A standard midline posterior approach was employed and L2 and L3 lamina"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old African American man was initially sent to our emergency room to evaluate a possible head trauma after a witnessed fall. He complained of frequent falls and leg weakness for 3–4 months. The weakness appeared to be progressive and persistent without episodic worsening. He had to use a cane to compensate but was still able to ambulate. His family members also endorsed cognitive defects over the past few months before admission. These impairments consisted mainly of apathy and withdrawal from social interactions; he used to be fully independent but now stayed at home most of the time. His medical history was only significant for alcohol abuse (three to four cans of beer and red wine daily for 2 years), and his family history was unremarkable.\nPhysical examinations showed an age-appropriate, alert, and oriented man. He was able to engage in conversations with a paucity of speech and flat affect; he also made eye contact and followed all commands during our evaluations.\nThere was bilateral weakness with spasticity in all lower extremity muscle groups. The deep tendon reflex was hypoactive with an upward response of the plantar reflex on the left side. He also had a wide-based unsteady gait and poor limb coordination. The remainder of the neurological examination and a general examination were unremarkable.\nInitial brain computed tomography (CT) in our emergency room demonstrated a mass lesion occupying the left caudate and extending into his frontal lobe (Fig. ). A brain MRI showed bilateral and symmetric hyperintense signals in the corpus callosum, periventricular white matter, and internal capsule (Fig. ) with an axial fluid-attenuated inversion recovery (FLAIR) sequence with gadolinium enhancement (Fig. ). A cervical spine MRI was negative for cord compression and abnormal signals.\nRoutine blood tests, as well as human immunodeficiency virus (HIV), syphilis, and thyroid function tests, were unremarkable, and his serum vitamin B12 level was borderline (28"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old man presented to us with chronic, progressive midline low back pain associated with right lower extremity radiculopathy. The patient described the pain as radiating and achy. On the physical exam, the patient had decreased sensation in the lateral aspect of the right lower extremity. Radiological findings demonstrated multilevel central stenosis and neuroforaminal narrowing with a degenerative scoliotic deformity of the lumbar spine (Figures , ). A conservative trial for up to a year with physical therapy, chiropractic and interventional pain modalities provided partial and short-lasting relief. As the pain continued to progress, the patient decided to proceed with surgery.\nVarious surgical options were considered. Eventually the patient underwent an ALIF at the L3-S1 levels using a retroperitoneal approach followed by a T10-pelvis posterior spinal fusion and a right L4-L5 laminotomy and decompression in two stages (Figure ). The post-operative course was complicated by abdominal distention that occurred on post-operative day eight. Computed tomography (CT) scan of the abdomen and pelvis demonstrated a large collection of retroperitoneal fluid measuring 11 x 9 x 22 cm in the left pelvis and left flank area with mass effect on the left kidney and ureter causing hydronephrosis (Figure ). After a consult with the general surgery team and the approach surgeon, the patient underwent ultrasound-guided drainage of fluid with temporary drain placement.\nThe fluid was serosangionous in nature with a high output of greater than 1500 cc/day. Fluid gram stain showed no organisms and cultures also revealed no growth. He was discharged home with the drain in place for a total of 22 days after which the drain was discontinued upon clinic follow-up. The lymphocele recurred four days after the drain was removed, and the patient presented back to the emergency room with recurrence of abdominal distension. A new drain was placed again in the fluid collection, and was fina"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe encountered a 69-year-old man who had localized right pleural metastases after undergoing nephrectomy in September 2017 for right RCC (8.0 × 7.0 × 7.0 cm), clinical stage 3, clear cell type histology, grade 2 (, A–2C). The tumor was histologically solid, with hemorrhage, necrosis, scarring, and pseudocapsule formation, and infiltrated into the renal parenchyma. The tumor spread to the right renal vein, but no infiltration into the inferior vena cava was observed. He didn't receive adjuvant chemotherapy following the nephrectomy. Postoperatively, he did not present with any symptoms and received regular follow-up with chest and abdominal computed tomography (CT) every three months. There were no confirmed recurrence and metastasis until March 2020, when he visited our hospital complaining of right chest pain and dyspnea. At this time, CT scan revealed right pleural effusion and multiple pleural masses (C and D). There were no abnormal radiologic findings in the other organs. He had no smoking history, no past medical history, and no asbestos exposure. We suspected the following possibilities: metastasis from RCC, malignant pleural mesothelioma, and synovial sarcoma. For investigation and diagnosis, we performed two pleural effusion tests before surgery, but both cytological results were class I. After one month, there were no new abnormal radiologic findings, but we confirmed that the tumors obviously grew on CT (E and F). Finally, we performed intrathoracic tumor resection under general anesthesia and diagnosed histologically as pleural metastasis from clear cell type RCC (D–F). Thoracoscopy showed multiple reddish, soft, bleeding encapsulated tumors (). The pleural fluid cytology had no malignant cells. A total of eight bleeding tumors were completely resected, with the largest measuring 5.0 × 3.8 × 2.2 cm. This case is currently being treated for pembrolizumab plus axitinib, which has been reported to be superior to sunitinib in overall survival and progression"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old female patient presented to our emergency department with complaints of shortness of breath and chest pain. Her medical history was unremarkable. On her physical examination, arterial blood pressure was 125/70 mmHg, heart rate was 86 beats per minute, and respiratory rate was 16 breaths per minute. Cardiac and pulmonary auscultation was normal. Cardiac enzymes, biochemical analysis, and complete blood count were normal except for eosinophilia. Posterior-anterior chest radiograph showed normal pulmonary appearance; however, a hyperdense mass with regular contours, measuring 5 cm in diameter, was detected in the apical aspect of the left ventricle. Electrocardiographic (ECG) findings were unremarkable. A transthoracic echocardiogram (TTE) showed a cystic mass lesion located in the pericardium adjacent to the left ventricle. Thoracic CT and MRI were performed for differential diagnosis of the cardiac mass. Her CT showed a 5 x 6 cm cystic lesion with well-defined borders in the pericardium adjacent to the left ventricle (). On MRI, a cystic lesion adjacent to the posterior aspect of the left ventricle was observed; the lesion was hyperintense on axial T2-weighted images, hypointense on axial and coronal T1-weighted images, and did not show contrast enhancement on postcontrast coronal T1-weighted images (). The diagnosis was verified by an indirect hemagglutination test performed to the patient who had been considered to have a cardiac hydatid cyst. Abdominal ultrasonographic evaluation revealed no other cystic lesion either in the liver or other abdominal organs. Under the light of these findings, the patient was scheduled for surgery with the diagnosis of cardiac hydatid cyst. The mediastinum was accessed through left anterolateral thoracotomy. Accessing to the left mediastinal area, a solitary cystic lesion with a well-defined border was visualized in the pericardium adjacent to the left ventricle. The lesion was aspirated via puncture. Because the cyst"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old man was transferred to our emergency department from a local orthopedic clinic due to abdominal pain and vomiting for 6 days. The patient had been admitted to a local clinic for 6 days following surgery for fracture of his wrist joint. Epigastric pain developed and the patient underwent esophagoduodenoscopy, which led to a diagnosis of acute peptic ulcer. Use of ulcer medication, including a proton pump inhibitor, did not result in symptom improvement, and so the patient was transferred. His vital signs were stable and he showed mild epigastric tenderness on physical examination. Laboratory parameters revealed electrolyte imbalance and dehydration with a potassium level of 2.9 mmol/l, chloride level of 87 mmol/l, blood urea nitrogen level of 46.9 mg/dl and creatinine level of 1.40 mg/dl. Chest X-ray () and computed tomography (CT) scan () showed herniation of the gastric body and antrum through the left diaphragm with organo-axial volvulus and obstruction at the pylorus level. To identify the cause of herniation, we rechecked his medical history and found that he had fallen a height of 5 m 15 months prior. The CT scan at that time () revealed a small defect of the left diaphragm without herniation, which we had missed. The patient’s symptoms improved after insertion of a nasogastric tube and hydration. The patient then underwent a laparoscopic examination (). The patient was placed supine in the reverse Trendelenburg position with the surgeon on the right side of the patient. A total of 4 ports were used: one 10 mm port at the umbilicus for the 30-degree rigid scope, one 12 mm and one 5 mm port at the right midcostal for working port and one 5 mm port at the left anterior axillary line for liver retraction. The gastric body and omentum were herniated through the defect in the left diaphragm. We reduced the herniated omentum and stomach using ultrasonic shear because a part"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old man was admitted to a local hospital for transient (10 min) left limb numbness when he rested on the sofa. Magnetic resonance angiography revealed that the right ICA was occluded from its origin to the intracranial segment. The patient reported taking aspirin, clopidogrel and atorvastatin, and was referred to the authors' center 2 weeks later. Physical examination revealed no obvious positive findings. Although a 2-month history of diabetes was recorded, there was no history of hypertension, hyperlipidemia, or smoking.\nThe initial CDFI was performed on day 1 of hospitalization, which revealed a patent right ICA with normal blood flow velocity (). However, CTA on day 2 indicated that the right ICA was occluded (). A repeat CDFI scan on day 4 of hospitalization revealed a hypoechoic mass [thickness 2.8 mm (suspected thrombus)] was attached to the anterior wall of the initial segment of the right ICA (). Magnetic resonance imaging (MRI) was performed on day 6; T1-weighted imaging showed that the intracranial segment of the right ICA was invisible, indicating that the right ICA was occluded (). However, digital subtraction angiography (DSA) performed on the same day revealed that the right ICA was normal, with no significant stenosis in any segment ().\nCDFI findings were consistent with those of DSA, but nevertheless inconsistent with CTA and MRI. It was not advisable for clinicians to make a definitive diagnosis pertaining to the vascular lesions of the patient. Given the generally good condition of the patient and no significant discomfort, he continued taking aspirin 100 mg/day, clopidogrel 75 mg/day, and atorvastatin 20 mg/day after discharge. Follow-up CDFI 1 and 3 months after discharge did not detect the hypoechoic mass that was attached to the anterior wall of the initial segment of the right ICA, and complete patency and normal blood flow velocity were apparently restored.\nFive months later, however, the patient was re-admitted to the authors'"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old male was referred to the surgical outpatient department with a 2-month history of altered bowel habit. Abdominal examination and digital rectal examination in the outpatient clinic were unremarkable.\nThe laboratory studies, full blood count and biochemistry were normal. A colonoscopy study identified four abnormal lesions, two of which were colonic subcentimetre polyps. More distally in the mid-rectum, at 15 cm from the anal verge, there was a sizeable, villous polypoidal lesion, which was proved on biopsy to be a tubulovillous adenoma (TVA) showing low-grade dysplasia. More proximally in the distal sigmoid colon at 25 cm there was a segment of a malignant-looking lesion associated with a stricture (). However, biopsy samples from this region showed hyperplastic colonic mucosa showing lamina propria fibrosis and mild chronic active inflammation with separate pieces of granulation tissue and ulcer slough but no evidence of malignancy.\nAs per local protocol for malignant-appearing lesions on endoscopy, a staging CT scan was arranged on the basis of the colonoscopy appearances to facilitate the cancer pathway. This demonstrated, at the site of the presumed malignancy in the distal sigmoid colon, a 7 cm segment of circumferential thickening on a background of diverticulosis (). This was associated with a few subcentimetre locoregional and inferior mesenteric lymph nodes. There was no suggestion of malignancy elsewhere; so the proposed CT staging was T2/3 N1 M0.\nAlthough the 5 cm rectal TVA could explain the patient’s symptoms it was felt at the multidisciplinary team discussion that either lesion could be responsible for the patient’s symptoms. Despite the lack of malignant cells from the biopsy samples the surgical team were still concerned about a potential sigmoid colon malignancy from the endoscopy and CT appearances. It was felt that the colonoscopy sampling was not truly representative of the malignant appearing sigmoid colon lesion seen at colonosco"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old female presented to our clinic in July 1996 with progressively decreased visual acuity and pain in both eyes that had begun 12 years prior. Her visual acuity was counting fingers at a distance of 50 cm from the right eye, while that of the left eye was 0.06. Corneal stromal edema and Descemet's folds were found in both eyes (). Corneal opacity was involved in all layers of the cornea, and epithelial bullas were found in the center of the right cornea. Lens, vitreous, and fundus were normal. The patient had neither a personal medical history nor familial history of eye disease. We performed penetrating keratoplasty in the right eye without a precise diagnosis. Visual acuity was maintained at 0.2 during the first few months after surgery.\nVisual acuity proceeded to decrease, and ocular pain recurred four years after the first surgery. Right eye visual acuity was hand motion, and slit-lamp biomicroscopy showed recurrence of epithelial edema and stromal opacity (). In July 2005, the patient underwent a second penetrating keratoplasty in the right eye due to recurrent corneal opacity and neovascularization in the cornea. Despite mild corneal opacity and corneal edema, visual acuity was maintained at 0.08 during the first two years after the second surgery.\nA third penetrating keratoplasty was performed on the right eye in July 2008, due to worsened corneal opacity and visual acuity decrease to 0.02 (). Total serum protein level, which had remained at a normal level until 2008, was elevated to 10.4 g/dL after preoperative evaluation. Electrophoresis revealed elevated M protein in the serum (2.72 g/dL) and urine (29.3 mg/dL). Immunofixation electrophoresis showed elevated kappa light chains. Bone marrow smears depicted a plasma cell concentration of 2.4%, and there were no morphological abnormalities. The patient was diagnosed with type IgG-kappa MGUS and was transferred to the hemato-oncology department for further examination.\nIn the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male with a history of alcoholism and radiation treatment (total dose of 57.6 Gy) for early-stage vocal cord cancer 16 months earlier was referred to us with radiographic detection of a pulmonary nodule in the right lower lobe. Endobronchial biopsy of the pulmonary nodule revealed the diagnosis of squamous cell carcinoma. Positron emission tomography/computed tomography (CT) revealed accumulation in the pulmonary nodule, but no other lesion was suggestive of metastasis. The tumor was diagnosed as a primary lung cancer, clinical stage IA1 (T1aN0M0), or metastatic pulmonary tumor, and video-assisted thoracoscopic right lower lobectomy with lymph node dissection was performed. Level 8 and 9 lymph nodes were not enlarged; therefore, lymph node dissection of these nodal station was not performed (Fig. a), while the level 7 lymph nodes were dissected. There was no direct injury of the esophagus, and no apparent esophageal damage was visualized on magnified video endoscopic images (Fig. b). The operation was uneventful. The patient was able to resume oral intake from the day after the surgery.\nThe patient tended to need to make a strong effort to cough, with swallowing and expectoration having become difficult, presumably due to the radiation therapy given to the larynx. Three days after the operation, the patient developed severe sudden pain in the right shoulder with high fever (39.6 °C). Findings of the chest X-ray obtained with a portable apparatus showed a few infiltrative shadows in the right lung field, and blood examination revealed no findings that were not compatible with the postoperative status of the patient. The patient was started on intravenous antibiotic administration. Absence of air leakage through the chest tube was confirmed, and the chest tube was removed 4 days after the operation. However, a plain chest X-ray revealed increased infiltrative opacities in the right lung field, and the patient developed a right pneumothorax 5 days after t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old right-hand dominant female presented to our orthopedic department with tolerable pain in upper back associated with “clunking” during active movements of right shoulder. The parents also had noticed an abnormal prominence in the right scapular region. She developed gradual symptoms over a 6 month period before her presentation with no antecedent history of trauma and constitutional symptoms. Other siblings and parents were normal.\nPhysical examination revealed a nontender palpable mass at superior border near medial angle of scapula. A grating sensation, both palpable and audible, was produced during active shoulder range of motion. Vertebral border of right scapula was more prominent than left (). The winging of scapula was noticed even at rest which did not increase as the patient did push against the wall. There were no signs of infection or inflammation. A bony mass was felt over the superomedial angle of the right scapula, which was minimally tender and corresponded to the area from where the crepitus arose. The upper extremity and shoulder girdle muscles were neurologically intact. Laboratory investigations were within normal limits.\nRadiographs showed a large bony tumor arising from superior border close to angulus superior scapulae and directed toward the thorax (). Computed tomography scan images revealed a pedunculated bony mass measuring 5.3×3.0×1.5 cm attached to ventral surface of superior border of scapula by a small stalk (-). Magnetic resonance imaging revealed this mass was extending anteriorly against the ribs and had a characteristic mushroom-shaped appearance with no obvious soft tissue component. A diagnosis of ventral scapular exostosis is made and patient was offered for surgical treatment in view of her complaints and cosmetic concern. Wide, open excision is the treatment of choice; however, there are recent reports of arthroscopic excision [, , , , ].\nThe patient was treated with excision of osteochondroma in prone position und"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old healthy nulliparous female presented to a regional hospital in Australia in spontaneous labour at 39 weeks and 4 days of gestation. Her pregnancy was otherwise uncomplicated and she had no medical and surgical history of note.\nThe patient presented to the hospital with a cervical dilation of 4 cm. Her first stage of labour lasted 1 hr and 45 minutes and her second stage lasted 1 hr and 16 minutes, respectively. Analgesic treatment in the first stage included nitrogen oxide as required and 10 mg of intramuscular morphine. Analgesic used in the second stage was only nitrous oxide as required. An episiotomy was performed at delivery. She delivered a live born infant weighing 3690 g with APGAR scores of 9 and 10. The 3rd stage lasted 15 minutes with delivery of an intact placenta.\nAfter delivery, she further requested nitrous oxide and had 10 mls of 1.0% lignocaine infiltrated into the perineum for an episiotomy repair.\nApproximately 2 hours postpartum, the patient started complaining of sudden onset dyspnea and lower chest tightness. Her GCS was 15 at this time and her vital signs were oxygen saturation >95% on room air with a respiratory rate of 18 breaths per minute, pulse of 85 beats per minute, BP 130/78, and a temperature 37.2°C.\nPhysical examination at the time revealed swelling in the neck and jaw line and palpable crepitus in the anterior chest wall, neck, and jaw, consistent with subcutaneous emphysema.\nInitial management included observation and pulse oximetry, as she was clinically stable and able to have a conversation without increase in chest pain or decrease in oxygen saturation.\nSubsequently a chest X-ray (CXR) was obtained which demonstrated pneumomediastinum with air tracking superiorly into the pericardiac spaces (). Following telephone consultation with a cardiothoracic team at our major tertiary referral center, a computed tomography (CT) contrast study was ordered as recommended. CT"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old male patient presented to the skin out-patient department with history of a huge progressively increasing swelling over the back of the scalp [] and multiple black nodules at various parts of the body. According to patient same kind of lesions were present over the trunk at birth, which were surgically removed when he was 4-year-old. The lesion over the scalp started at the age of 6-7 years and the truncal lesions developed gradually since then. On examination, there was a single bosselated irregular non-tender skin colored swelling of 15 cm × 20 cm with deep folds over the occipital region extending toward the nape of the neck. There were certain areas of depigmentation [ along with blue streaks over the swelling. The surface of the skin was hairless, the skin over the swelling was non-pinchable and the swelling was immobile. There was no skin erosion, dermatitis, infection, odor or tenderness.\nThere were multiple hyperpigmented nodules distributed over different areas of the body such as mandible, flanks, abdomen [], front and back of both thighs, right knee joint, lower leg [], right sole and over volar aspect of first and second finger of the left hand []. The size of the nodules ranged from 0.5 cm × 1 cm to 1.5 cm × 2.5 cm. The nodules were blackish brown in color surface was smooth and hairless. They were asymptomatic and non-tender on palpation. Nails and mucous membrane examination were within normal limits. He had normal intelligence (the full-scale intelligence quotient was 97) and he had no psychiatric problem. Examination of the neurological, ophthalmological and other systems was normal. Laboratory results, including venereal disease research laboratory test, serology for human immunodeficiency virus, growth hormone and thyroid function, were all negative or normal. A punch biopsy from the scalp lesion and an excision biopsy from the nodule over the body was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman presented with pain in her chest wall for two months, and had no significant medical history, such as trauma, infection, or tumor. The pain was located in the left lower chest in a band-like pattern overlapping the T10 dermatome. The pain was intermittent and occurred several times a day, continuing for 10–20 min each episode and alleviated when lying down. The pain was considered to be intercostal neuralgia.\nTo identify the cause of the neuralgia, we performed MRI, which revealed multiple cysts at the T9–T11 nerve roots bilaterally (Fig. ). No other causal abnormality for the chest wall pain was found other than the cysts. The interior of the cysts showed similar intensity to the CSF on imaging. The largest cyst was at the level of the left T10 vertebra and had a linear shadow that suggested the presence of nerve root fibers. Computed tomography (CT) with myelography was also performed to study CSF communication between the thecal sac and the cysts. After 10 mL of 240 mg I/mL iodinated contrast medium (Omnipaque 240, Daiichi Sankyo, Inc., Japan) was injected into the thecal sac at L4/5 in the lateral recumbent position, the first CT image was taken immediately (left and middle columns of Fig. ), and revealed multiple cysts from T6–L2, including small cysts. The cysts were enhanced by the contrast medium and most showed the same intensity as that of the thecal sac at the corresponding level; however, the largest cyst at left T10 and another at left T9 showed much higher concentrations of the contrast medium. Three hours after the injection, the intensities of the cysts and the thecal sac were equal on the second CT (right column of Fig. ). The next day, another CT examination showed no detectable contrast enhancement. Based on these findings, we suggested a diagnosis of multiple perineural cysts.\nThe patient was treated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6 years old male child born by full term vaginal delivery with a birth weight of 2.25 kg, presented with a huge asymptomatic swelling over the left lateral chest wall since 6 years. Mother noticed a small asymptomatic lump on back of the left shoulder at 1 month of age, which gradually progressed to present size of around 20 cm × 20 cm × 17 cm. Child was asymptomatic and had grown well with a weight of 15.6 kg without any other swellings or syndromes. His systemic and general physical examination was normal. The giant ellipsoidal non tender well demarcated swelling, having soft to firm in consistency with slight mobility was located on the left lateral thoracoabdominal wall extending superiorly from the left axilla to left upper half of lateral abdominal wall inferiorly, posteriorly 2 cm off the spine and extending anteriorly to anterior axillary line ( and ()). Chest X-ray showed ground glass opacity over left thoracoabdominal wall (); ultrasonogrpahy showed ill defined heteroechoic mass in left lateral thoraco abdominal wall in the subcutaneous plane 21 cm × 18 cm × 16 cm without any internal vascularity, calcification or necrosis. Computer enhanced chest tomography revealed a well encapsulated giant lipoma with multiple septations without calcifications, necrosis or rib/intra pleural extension over the left lateral thoracoabdominal wall, having an average of 165.87 Hounsfield units (HU) with an area occupying an average area of 108.17 sqcm ( and (); ).\nRadical excision of the mass was done under general anaesthesia without prior biopsy. Intra operatively the mass was located below the muscular plane, just above the rib cage not infiltrating into the ribs, intercostals muscles or pleura; could be easily excised along with its capsule intact uneventfully (). Muscles were closed after keeping a drain. Post operatively feeds were started same day and drain removed next day. Mass weighted 1.5 kg with histology showing mature"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe first patient is a 7-year-old Palestinian girl from the Arab community in Israel; she was born to non-consanguineous parents after a full-term pregnancy by normal delivery with a normal birth weight of 3.1 kg. According to her parents she had normal development until the age of 1 year. At this age she was hospitalized because of a generalized tonic-clonic convulsion during febrile disease. She was discharged with the diagnosis of simple febrile convulsions. A few months later she had recurrent episodes of febrile convulsions. She underwent an EEG recording, which was normal. At the age of 2 years she had several attacks of non-febrile generalized tonic-clonic seizures; every attack lasted for 3 to 7 minutes followed by 10 to 15 minutes of a postictal state. Another interictal EEG after sleep deprivation and photic stimulation was normal. Furthermore, karyotype testing and brain magnetic resonance imaging (MRI) were carried out when she was 2-years old and found to be normal. She also underwent cerebrospinal fluid examination for protein, glucose, lactate levels and cell count, yielding normal results. Routine metabolic screening was normal. Ophthalmologic and hearing examinations were normal. She was further followed by our pediatric neurology and child development clinic. Her examination revealed no dysmorphic features and no visceral enlargement. She showed mild motor and cognitive delay but could stand and walk with support, and could speak up to 15 words with good communication abilities. Her neurologic examination revealed normal tone and normal tendon reflexes of her lower and upper limbs. Babinski sign was normal. Her cranial nerves, sensory perception and cerebellar function were normal. For the seizures she was treated with valproic acid and topiramate, with good response. She attended special education kindergarten, with speech therapy and occupational therapy. At the most recent examination, at the age of 7 years, she had normal intelligence and atten"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73 y/o man with no smoking history and a diagnosis of RA was referred to the pulmonary clinic for multiple pulmonary nodules in a peri-lymphatic pattern (). Patient was noted to have progressive pulmonary nodules that have been increasing in size ().\nHis rheumatologist planned to start him on TNF-alpha inhibitors for his RA and wanted to evaluate for infections and malignant causes prior to proceeding with the treatment. He was asymptomatic and denied any respiratory complaints. At the time of presentation, he was being treated with leflunomide, hydroxychloroquine and sulfasalazine. Pt is a Navy veteran with exposure to asbestos while he was in the Navy. Following his discharge from the Navy, he worked 10 years overseeing production of plastic and metal parts for guided radar systems. He then transitioned to working in residential construction, hanging, siding and replacing windows. He also worked on restoring brick on old houses by stripping off paint for about 5 years.\nPulmonary function test (PFT) revealed mild obstructive ventilator defect with FEV1/FVC 66%, FEV1 of 3.13L, 94% predicted. He underwent bronchoscopy with transbronchial biopsies of the right upper lobe nodules. Pathology revealed a necrotic tissue () with central silica crystals visualized under polarized light which was consistent with silico-anthracotic nodules. The biopsies were negative for malignancy. There was no evidence of infection on bronchoalveolar lavage. His AFB and fungal cultures were also negative.\nThree years following his biopsy, the patient presented with lower extremity edema and dyspnea on exertion. He was found to have worsening renal failure with subsequent renal biopsy showing a mixture of minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). The staining was negative for amyloid and no silica deposits were identified. He also underwent right heart catheterization that showed mild pulmonary hypertension with mean PAP of 33. CT chest did not show worsen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA thirty-one-year-old male presented with a six-month history of right shoulder pain with insidious onset after repetitive work-related shoulder exercises and movements. The patient was a nonsmoker with a BMI of 28. He had a history of Hashimoto thyroiditis and a right shoulder rotator cuff tear repaired arthroscopically in 1997. Upon physical examination, the patient had full strength of FPL, FDP, and the intrinsic muscles of the hand and pain with resisted external rotation as well as tenderness with palpation over the bicep tendon. MRI revealed significant fluid collection in the bicipital groove surrounding the long head of the biceps tendon and a subchondral lesion in the greater tuberosity of the humerus suggestive of a cyst. The patient was diagnosed with biceps tenosynovitis and a superior labrum tear with shoulder impingement. Surgery was scheduled after the patient failed conservative treatment options including physical therapy and corticosteroid injections having no significant improvement in his symptoms. On the day of surgery, the patient was given a preoperative, ultrasound-guided, interscalene nerve block with 25 mL of 0.5% ropivacaine administered with a 21 gauge, 90 mm, echogenic short bevel needle. Next, the patient underwent induction of general endotracheal anesthesia. The patient was placed in the lateral decubitus position with the head in a neutral position, and a boom was used to apply 15 pounds of traction throughout the arthroscopic procedure. Glenohumeral debridement and a subacromial bursectomy were performed arthroscopically. The weighted traction was then released and an open subpectoral long head biceps tenodesis was performed. The total case time was exactly 2 hours.\nThe patient returned to clinic twelve days postoperatively with symptoms consistent with AIN palsy of the right hand along with median nerve involvement at the level of the wrist. He was unable to flex the MCP or IP joints of the thumb or index finger, but flexion of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old male underwent a tissue-matched renal allograft transplant for end-stage renal failure secondary to hypertension and primary antiphospholipid syndrome. Primary antiphospholipid syndrome was diagnosed 2 years prior to renal transplantation when he developed recurrent episodes of thrombosis of the arteriovenous fistula and neck veins, for which he was started on warfarin. Anticoagulation was optimized prior to surgery by withholding warfarin 5 days before surgery while bridging with heparin. During the early postoperative period (first postoperative week), he developed a peri-renal hematoma (ultrasonography 13 cm × 7 cm). Noncontrast computed tomography scan detected a homogenous fluid collection posterior to the transplanted kidney which extended superiorly up to the right subhepatic area and inferiorly into the pelvis, displacing the bladder to the left (Figure ). Anticoagulation was then withheld and he recovered over the next few days with normalization of serum creatinine and urine output. Prior to discharge, his urethral catheter and ureteric stent were removed and warfarin was restarted.\nThree weeks after the surgery, he presented with reduced urine output and progressive abdominal distension associated with pain and fever. Ultrasound scan revealed a large perigraft collection. Resuscitation and urgent exploration revealed a viable graft with a large urinoma posterior to the kidney. A possible anastomotic leak was suspected and a passive external drain was placed to allow adequate drainage of urine and healing of the anastomotic site. However, the conservative approach failed and there was no reduction in the drain output. Therefore, surgical exploration and definitive reconstruction were planned.\nSurgical exploration revealed an allograft vascular pedicle in the inferolateral aspect of the graft with a completely sloughed off allograft ureter (Figure ). Sloughed part of the allograft ureter was excised up to the pelviureteric junction where the g"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old man accidentally fell at home and was admitted to our hospital. The patient was hospitalized with several problems such as multiple metastases of prostate cancer, chronic heart failure, emphysema, impaired renal function, and biliary stent placement due to idiopathic biliary stenosis. While no fracture was identified, the patient complained of lower back pain and was unable to move. As a consequence, he was hospitalized for the purpose of pain management. On the third day of hospitalization, the patient developed a fever of 38.2°C, and his laboratory data showed high levels of WBC count and CRP. While the source of infection was not identified, a urinary tract infection was suspected because he had purulent urine from previous examination and no symptom of respiratory tract infection. The patient underwent treatment with CMZ 1 g every 12 hrs. Three days after therapy initiation, the fever declined and the laboratory data of the inflammatory response normalized. Although blood culture was negative, we decided to treat according to sepsis because he was frail. We, therefore, planned to administer CMZ for 14 days. During the treatment course, the patient did not develop fever and had a healthy appetite.\nOn the morning of the 14th day of hospitalization, the patient complained of a sudden difficulty in breathing. His peripheral artery oxygen saturation decreased to 74%. No fever, coughing, or sputum was identified. A chest computed tomography (CT) scan was performed, showing the presence of ground glass shadows bilaterally (). While the blood work demonstrated the absence of an inflammatory response, Hb decreased by 1.5 g/dL from the previous day. The BNP value was 103 pg/dL, similar to that at initial hospitalization. Because hemostasis of the blood sampling site was difficult, additional laboratory tests were performed. These showed a marked prolongation of PT-INR (). In the evening, his value of Hb dropped from 6.8 to 5.5 g/dl in six hours. We doubted"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old female presented to our outpatient department with low back pain that had persisted for few years. The patient experienced severe left lower extremity pain for several weeks with no history of trauma. The pain limited her walk to <10 m in a stretch. She had no history of previous spinal surgery. The patient was treated at a local hospital with oral analgesics. However, intermittent claudication and pain persisted. The motor examination did not reveal any weakness; however, there was hypoesthesia in the S1 dermatome. Plain radiographs revealed degenerative Meyerding Grade I spondylolisthesis at L5-S1 () []. Subsequent magnetic resonance imaging done revealed an associated prolapsed intervertebral disc and lumbar canal stenosis ( and ). She was given a trial of caudal epidural steroid injections for symptomatic relief. The patient did not improve, and hence, surgical intervention in the form of bilateral pedicle screw fixation with interbody cage was planned. The patient underwent posterior decompression through left- sided laminotomy followed by pedicle screw fixation on the right side. Screws were inserted in the pedicle of L5-S1. An optimal hold of the screw in the left pedicle of L5 could not be achieved due to the poor quality of bone; hence, intraoperatively, the plan was revised from bilateral to unilateral pedicle screw fixation. Further, a transforaminal interbody cage was inserted. Optimal placement of the implant and the reduction was confirmed intraoperatively under C-arm (). The patient was given a lumbosacral corset, and physiotherapy was initiated from the 2nd post-operative day. The patient’s leg pain decreased immediately after surgery, and ambulation was started 3 days later ( and ). The patient started complaining of severe pain on the 8th post-operative day, for which she was treated with oral analgesics. X-ray done on the next day revealed loosening of the rod from the L5 pedicle screw, with back out of the insert screw (). The patie"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 20-year-old Somalian man, who presented with an inversion injury of his ankle, sustained during a fall downstairs. He had subsequent pain in the foot and difficulty walking. The history on admission was limited due to language difficulties, but he felt otherwise generally well.\nExamination demonstrated tenderness over the base of the 1st and 5th metatarsals, cuboid and navicular, with swelling of the dorsal lateral aspect of the right foot. Ankle movements were normal, although limited by pain. There was warmth of the overlying skin, but no rash was seen. No abnormalities were detected in other joints, and systemic examination was normal with no lymphadenopathy or fever and unremarkable respiratory, cardiovascular and abdominal examinations. He had a slightly raised CRP of 10, normal ESR of 10, and an x-ray of the right foot and ankle showed abnormal lucent lesions at the base of the 3rd, 4th and 5th metatarsals but no recent fracture ().\nFurther history was finally obtained through an interpreter. The patient had come to the UK 2 years previously, but had sustained trauma to his foot during a road traffic accident in Somalia about 4 years previously. Following this he had persistent foot pain and a non-healing wound. He had not sought medical attention until 2 years later when he had presented to an orthopaedic outpatient clinic. An x-ray performed on this occasion demonstrated deformities at the bases of the lateral four metatarsal bones and of the lateral cuneiform bone. These deformities were well corticated and attributed to old fractures. He reported no contacts with TB and on direct questioning had no respiratory symptoms, fevers, night sweats or weight loss, and no other past medical history. Although bloods revealed a concomitant hepatitis B infection, an HIV test was negative.\nAn MRI scan showed prominent bone marrow oedema with destruction of the navicular, medial and lateral and cuneiform bones ()."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 40-year-old man developed daily headaches and was referred to an ophthalmologist when these were complicated by visual blurring. Fundoscopic exam revealed papilledema, prompting imaging studies. Head CT and MRI scans demonstrated a 5-cm partially calcified, partially enhancing right frontoparietal mass with extension into the splenium of the corpus callosum. There was associated cerebral edema and mass effect with compression of the right lateral ventricle. On the day of the MRI, the patient developed left sided weakness and had a seizure. The patient subsequently underwent a craniotomy with resection of the contrast enhancing component and a portion of the non-enhancing component. Adjuvant therapy included 12 cycles of temozolomide chemotherapy, but this had to be discontinued after the 12th cycle due to severe rash. The last MRI scan performed 4.9 years after initial presentation showed stable disease with residual non-enhancing tumor and otherwise, the patient is doing well.\nThe pathologic findings in case 3 were nearly identical to those of case 2, except that there was a greater degree of intermingling between the two elements and the zones of infarct-like necrosis within the oligodendroglial component were larger. Synaptophysin staining revealed strong cytoplasmic and Golgi pattern positivity in dysmorphic ganglion cells, while only rare oligodendroglial cells showed cytoplasmic reactivity. There was extensive GFAP positivity with most positive cells showing morphologic features of gliofibrillary oligodendrocytes. However, irregular cells with elongate processes were also seen, suggesting a minor astrocytic component. Both components were Neu-N negative. The CD34 stain highlighted endothelial cells only; tumor cells were negative. The Ki-67 labeling index was low to moderate, focally reaching a maximal staining of 15% in the oligodendroglial component; it was <1% in GGLF. FISH analysis revealed chromosome 19q deletion in both components, while chromosome"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61 year old Caucasian man presented to our Accident and Emergency unit with a day history of right iliac fossa pain associated with fever and rigors. The appetite was reduced but no nausea or vomiting. The pain was said to be constant and sharp in nature and exacerbated by movement and stretching. He denies any history of a recent altered bowel habit or urinary symptoms. The only significant past medical history were renal calculi and well controlled asthma.\nPhysical examination revealed mild dehydration and normal vital signs. His abdomen was full with tenderness in the right iliac fossa and associated with guarding and local peritonitis. Blood investigations showed haemoglobin level of 14.0 g/dl, total white blood cell count of 22.4 with neutrophilia of 20.0, platelet count of 326, C-reactive protein of 36 and normal electrolytes, urea, amylase and liver function tests.\nThe initial diagnosis of acute appendicitis was entertained and patient was prepared and consented for an open appendicectomy. The findings at operation included a 4 cm by 5 cm pericaecal abscess mass adjacent to the anterior tenia coli. Within the abscess mass was a perforated anterior caecal diverticulum with necrotic wall. There was a polypoid mass within the wall of the caecum. The appendix was macroscopically normal with no evidence of acute inflammation. There was a suspicion of a perforated caecal tumour. He then underwent a right hemicolectomy with an ileo-transverse anastomosis through a medial extension of the appendicectomy wound.\nThe histology of the right hemicolectomy specimen macroscopically showed an inflamed and perforated solitary caecal diverticulum with abscess formation and an isolated caecal pedunculated polyp. Microscopically no dysplasia or malignancy within the caecal diverticulum and the polyp was a tubulovillous adenoma with low grade dysplasia. The caecal diverticulum lacked mucularis propria and therefore was considered to be acquired [Figures and ].\nHis postoperative"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old Caucasian male with a 10-year history of tophaceous gout in his knees bilaterally, treated with allopurinol, was admitted with a 3-week history of swelling, pain, and drainage from his left knee. His symptoms began after an acute traumatic injury to the left lateral knee, in which he suffered a small cut with a break in the skin. Before the injury, the patient was asymptomatic and denied any pain, bleeding, or skin breakdown to the bilateral knees. On physical examination, the patient had a large, tennis ball-sized mass over his left knee anterior to the patella and patellar tendon, with a second irregularly shaped firm mass inferior to this (). There were multiple areas of skin breakdown over the large mass overlying the patient’s left knee, which was draining purulent and sanguineous fluid that appeared to be gouty tophaceous material. There was no surrounding erythema. Over the right anterior knee, there were two large, firm masses (). The superior mass was tennis ball sized and the inferior mass was smaller and irregularly shaped. There was thinning of the overlying skin, which remained intact. He denied any pain to the right knee. The patient’s examination was also remarkable for a 3×3 cm, firm, mobile, non-tender, soft tissue mass over the proximal right olecranon. He denied any pain or limited range of motion or function secondary to this mass. His medical history consisted of gout, diabetes mellitus, and hypercholesterolemia. The patient reported a distant history of a similar mass being resected from his right knee. His surgical history also included removal of the left knee bursa and carpal tunnel release. He denied any smoking or illicit drug use but endorsed social alcohol use. He had an average build with a body mass index of 26.9. The patient was started on intravenous antibiotics and imaging studies were performed.\nPlain radiographs of the bilateral knees revealed large soft"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old male patient with coronary artery disease status post coronary stent placement was found to have a lung nodule on the chest radiograph at that time. The patient underwent a computed tomography (CT) scan, and bronchoscopy, and was found to have a 9 mm fatty endobronchial lesion in the bronchus intermedius above the middle lobe with 2 cm extraluminal fatty lesion into the right hilum. An endobronchial ultrasound with biopsy of the mass was performed, which showed benign bronchial epithelial cells. Since endobronchial resection of the mass would lead to a large defect in the right bronchus intermedius, the decision was made to perform robotic-assisted resection of the lesion (Video ).\nWe used the Da Vinci Xi robot to perform resection of the endobronchial lesion and hilar mass with right lower lobe superior segmentectomy to remove the lesion. The patient had a “five on a dice” port placement for the operation [, ]. First, we performed the right lower lobe superior segmentectomy to obtain adequate exposure of the hilar mass. We mobilized the superior segmental branch of pulmonary artery and superior segmental branch of the right lower lobe going to the inferior pulmonary vein and divided them with the vascular robot stapler. We divided the superior segmental branch of right lower lobe bronchus with the robot blue load stapler. We used indocyanine green angiography to define the borders of the superior segment of the right lower lobe, which was divided using the robot blue load stapler. This provided access to the hilar fatty tumor, which allowed for removal of the hilar mass and subsequent resection of endobronchial lesion with scissors. The frozen section on both lesions was negative for malignancy. We confirmed complete resection with intraoperative bronchoscopy that also showed a large opening in the airway.\nIn order to reconstruct the airway, we placed two 3-0 vicryl stay sutures at the proximal and distal ends of the airway and placed the suture throu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year old woman was referred in January of 2009 to our pulmonary hypertension unit. She presented with a six-month history of dyspnea on major exertion without dizziness, syncope or chest pain. Her prior medical evaluation revealed PH and a PA aneurysm. At examination the patient was found to have a palpable systolic impulse within the second left anterior intercostal space, a grade 3/6 systolic murmur and a 2/6 diastolic murmur at the lower and upper left sternal border, respectively. Her chest radiography showed cardiomegaly and dilation of the main pulmonary artery and its branches (Figure ).\nSecondary causes for PH were excluded according to the protocol described in the PH guidelines of the European Society of Cardiology []. A transthoracic echocardiography demonstrated a dilated right atrium and a dilated, hypertrophied right ventricle with severe systolic dysfunction (TAPSE 13), mild tricuspid regurgitation with PH (pulmonary artery systolic pressure, 80 mmHg), an aneurysmally dilated main PA (76 mm) and right (56 mm) and left (35 mm) PA branches and severe pulmonary regurgitation. The left sided-chambers were normal. A posterior and lateral moderate pericardium effusion could be seen. NT-proBNP was 1746 pg/mL.\nA right cardiac catheterization showed a mean PA pressure of 61 mmHg with a cardiac output of 3.2 L/min. After vasoreactivity testing with intravenous epoprostenol, carried out on April of 2009, mean PA pressure dropped to 39 mmHg and concomitantly the cardiac output increased to 4.7 L/min. Calcium channel blockers were initiated, with excellent hemodynamic response and normalization of NT-proBNP values after five months of treatment.\nThe control right cardiac catheterization after 20 months of follow-up showed a mean PA pressure of 26 mmHg with a cardiac output of 5.54 L/min. Regardless of the near normalization of right cardiac pressures and the improvement of right ventricle function the patient maintained a severe pulmonary regurgitation (Figur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old man presented to the Department of Periodontology, Government College of Dentistry, Indore, with the chief complaint of severe ulceration in the mouth, sore throat, and low-grade fever for 4 weeks and skin lesions on his hands and back.\nIntraoral examination revealed the presence of chronic ulcerative lesion on the buccal mucosa, gingiva, corner of the mouth, and palatal mucosa with subsequent disruption and necrosis of buccal mucosa and advanced bone loss involving all teeth []. The lesions were indurated, painful to touch, and covered with gray pseudomembrane accompanied by bilateral submandibular lymphadenopathy. Multiple firm, dark pigmented papules (<1 cm) were present on the dorsal surface of hands, forearms, and back [].\nThe patient gave a history of sore throat and hoarseness in voice for 6 months and chronic low-grade fever for 4 weeks. The patient was tested HIV seronegative.\nThe initial lesions mimicked necrotizing ulcerative periodontitis, for which he was prescribed amoxicillin (500 mg) and metronidazole (400 mg) thrice daily for 7 days. Lesions were swabbed with cotton pellet dipped in H2O2 to remove pseudomembrane; oral hygiene instructions were reinforced, and the patient was recalled after 3 days [].\nThe patient presented a significant improvement, following which the patient underwent staged, nonsurgical, quadrant-wise scaling, and root planing over a 2-week period. There was an initial reduction in inflammation during the treatment phase, but the palatal soft tissues in relation to maxillary posterior teeth remained intensely inflamed with bilateral disruption of the buccal mucosa showing no significant improvement [].\nAn incisional biopsy of the affected area was done, which demonstrated the presence of epithelioid cell granulomas in the connective tissue with multiple histiocytes that formed multinucleated giant cells. The cytoplasm of histiocytes demonstrated small round, oval basophilic bodies surrounded by clear halo, which is c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n58-year-old woman was referred by her General Practitioner to the Emergency Department with a one-week history of a moderately painful irreducible lump in her right groin, associated with nausea and vomiting. She did not have any urinary or bowel symptoms. She last opened her bowel earlier that day. She was known previously to have a spontaneously reducible lump in the right groin suggestive of a hernia.\nThe patient's medical history included hypercholesterolaemia treated with statins, menopausal symptoms treated with hormone replacement therapy, and pending investigation of a liver lesion. She had no known allergies.\nOn assessment the patient was in painful distress, she was tachycardic but otherwise her vital signs were stable. Her abdomen was soft and nontender; there was a palpable, nonerythematous lump in the right groin which was tender to touch and irreducible. The patient had marginally raised amylase of 57 iu/L and C-reactive protein (CRP) of 19 mg/L; her full blood count and renal and liver function tests were within normal limits.\nThe patient had an abdominal radiograph which was unremarkable. A groin ultrasound scan showed an approximately 5.2 × 2.7 cm cystic abnormality with a small communication with the abdominal cavity, suggestive of a femoral hernia.\nPatient then had an abdominal CT scan with oral and intravenous contrast (). This was reported as a right sided femoral hernia and the caecum and the ileocaecal junction were in close proximity to the hernial orifice. A tubular structure was seen in the hernial sac which did not take up the oral contrast; this was reported as an appendix in a femoral hernia.\nThe patient was taken to the operating theatre for an emergency right sided exploration and hernia repair under general anaesthesia. An infrainguinal transverse incision was made over the lump and the hernial sac was dissected free. The sac was opened revealing a congested appendix and ca"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient discussed herein is a 60-year-old male who presented to the surgical oncology clinic with a one-year history of intermittent abdominal pain. He was previously evaluated by gastroenterology at an outside institution and had undergone a CT scan and an endoscopic ultrasound (EUS). This imaging revealed an approximately 4.5 cm mass between the duodenal bulb and the head of the pancreas with both solid and cystic components. A biopsy was performed during the EUS, but a tissue diagnosis could not be made.\nAt the time of our initial interview, the patient reported persistence of his abdominal pain as well as 15 pounds of weight loss over the preceding three months. He was otherwise asymptomatic. He admitted to occasional smoking and alcohol use. His family history was negative for GI malignancy. On exam, he was noted to be anicteric and nonjaundiced. Abdominal exam was normal aside from a reducible nontender 3 cm umbilical hernia.\nAfter the patient's office visit, an MRI was performed for better characterization of the previously identified mass. This showed a 4.4 cm predominantly solid mass in the bulb and second portion of the duodenum with extension into the pancreatoduodenal groove as well as fluid in the right pararenal and paraduodenal spaces (Figures and ). A repeat endoscopy with EUS was performed. Endoscopy showed a nodular, edematous, friable mass in the first portion of the duodenum causing mild stricture of the lumen (). EUS revealed a slightly nodular, ill-defined, hypoechoic and heterogeneous submucosal mass in the medial wall of the first portion of the duodenum extending into the duodenal sweep and causing mild stricture. The duodenal wall was thickened with loss of demarcation between layers (). Repeat biopsy and fine needle aspiration (FNA) of the mass taken at the time of EUS revealed only duodenal mucosa with dilated lymphatic channels and prominent lymphoid follicles.\nGiven the remaining diagnostic uncertainty, the patient was discussed in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 32-year-old man who presented to the emergency department with a complaint of lower abdominal pain for one week. His pain was persistent throughout the day and was stabbing in nature. He scored the pain as 7 out of 10 in intensity. It was associated with fever, nausea, and vomiting. There was no history of change in bowel motions or urinary symptoms. His past medical history was remarkable for a peptic ulcer disease. He had not undergone any surgical procedure previously. He was a non-smoker and did not drink alcohol. The family history was non-contributory. Of note, the patient did not have a history of diabetes mellitus, chronic steroid therapy, or any immunodeficiency disorders.\nOn examination, the patient looked tired and his vital signs revealed a low-grade fever and tachycardia. Abdominal examination showed tenderness in the lower abdomen with evidence of suprapubic mass. No overlying skin changes were noted. The abdomen was soft and lax with no signs of guarding or rigidity. Laboratory investigation revealed a leukocyte count of 14,200/𝜇L and erythrocyte sedimentation rate of 23 mm/hr. Other biochemical investigations, including renal and liver function tests, were within normal limits.\nAn abdominal ultrasound examination of the patient revealed a spheric collection with poorly defined borders. Subsequently, an abdominal CT scan was performed, which demonstrated a soft tissue mass adjacent to the anterior abdominal wall with an upward track to the umbilicus (Figures , ). Based on the clinical and radiological features, he was diagnosed as having a urachal abscess. A cystourethrogram was performed and revealed no communication with the bladder.\nThe culture from the obtained specimen of the abscess revealed growth of Staphylococcus aureus. The patient was administered a broad-spectrum intravenous antibiotic therapy, which resulted in clinical improvement with the resolution of the fever. He was then prepared for laparotomy, which confirmed the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old woman presented in 1994 to the ophthalmology department with sustained episodes of flashes affecting the vision in both eyes. She was morbidly obese weighing 140 kg and a smoker. On examination, her optic discs and fundi were normal, but she was noted to have a transient drop in her visual acuity that normalized over a few days. For the on-going troublesome migrainous phenomenon, she was referred to neurology where she reported episodes of blurred vision, paraesthesia in the left lower jaw, left arm and leg. She was experiencing monthly right-sided headaches, associated with photophobia, which resolved within 24 hours. Examination was normal with no evidence of focal neurological deficit. Multiple sclerosis was considered as a diagnosis but later deemed unlikely. She was thought to have complicated migraine, and she was discharged. In 1998, she was re-referred to the neurology department with intermittent tingling on both sides of her body. This was accompanied by a sensation of imbalance. She had some short lasting visual obscuration. Neurological examination was normal. A magnetic resonance imaging (MRI) of the brain was organized but could not be performed due to morbid obesity. In 2002, she presented to the emergency eye department with bilateral granulomatous uveitis. Retinal fundoscopy revealed multifocal retinal periphlebitis. The optic discs appeared healthy, and there was no retinal cystoid macular oedema. Blood tests showed a normal ANA, antiphospholipid screen, full blood count, an ESR of 28 mm/hour and the presence of an atypical ANCA. The ANCA prompted a referral to the rheumatology department. An MRI of the brain showed lesions that involved the deep white matter (Fig. ). Over the next few years, she was monitored in a combined rheumatology–neurology clinic. Neurological examination remained normal. A Lumbar Puncture (LP) was not performed due to the body habitus. Visual evoked potentials were normal. Between 2002 and 2004, she had episod"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 57-year-old male who complained of weakness and pain in the lower extremities, as well as urinary retention. He had undergone transnasal surgery for ACTH-producing pituitary tumor in 1998. He subsequently experienced repeated episodes of residual tumor growth and underwent multiple sessions of tumor resection and radiotherapy. He developed urinary bladder dysfunction and pain/weakness in the lower extremities without a known cause. With gradual worsening of symptoms, the patient presented to our department on referral in 2009. On admission the physical examination revealed that the femoral nerve stretch test was positive only on the right side, and the straight leg-raising test was positive at 10 degrees for both legs. In the manual muscle test, reduced muscle strength was observed in the left gastrocnemius muscle and left extensor hallucis longus muscle, and a marked decrease in perception was noted in the L4, L5, and S1 regions on both sides. A urethral catheter was in place due to urinary retention. Neurological findings suggested damage to the cauda equina at L4 and lower levels. ACTH level was high at 356.8 pg/mL (). On magnetic resonance imaging (MRI), the signal intensity of the lesion was intermediate on T1-weighted images, low to intermediate on T2-weighted images and intermediate with partially high-intensity areas on short-inversion-time inversion recovery images. On a gadolinium-enhanced image, a neoplastic lesion was observed, whose content was slightly and irregularly enhanced by the contrast medium (). Given a diagnosis of cauda equina syndrome caused by a tumor in the cauda equina, laminectomy at L3-S2 followed by tumor removal was performed. The tumor was identified as an elastic, hard and clearly bordered mass entangled in several cauda equina nerves and encapsulated by a thin membrane. The tumor was detached from the nerves and as much of it was removed as possible. Two tumor masses were excised ().\nOn histopathology, H&"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old male patient, from Peru, with no relevant medical history, presented in September 2019 with a history of back pain, weight loss of about 5 kg, early feeling of fullness and night sweating of 8 months of evolution. His physical examination revealed a mobile mass without defined margins, located 12 cm from his left ribcage. The results of his routine haematology and biochemistry laboratory blood tests revealed moderate anaemia with a haemoglobin of 9.0 g/L and hyperkalaemia with a serum potassium of 5.8 mmol/L.\nHe had computed tomography (CT) scan of abdomen which showed a left renal mass of heterogeneous density of 19 × 12 × 9 cm, which had defined borders and contours and which was not associated with any nodal or vascular involvement (). Kidney cancer presumptive diagnosis was considered.\nIn October 2019, he underwent a surgery (left radical nephrectomy plus para-aortic lymphadenectomy), and during the procedure he was noted to have a left kidney dependent tumour that measured 20 × 19 cm with associated hilar and para-aortic lymph nodes.\nMacroscopy pathology examination of the specimen was reported to have identified a left renal tumour that measured 23 × 12 × 10 cm which was noted to have a solid component, and which was soft in consistency, and which was light brown in colour and which contained areas of myxoid and haemorrhagic necrosis of 30% and 10%, respectively (). Microscopy pathology examination of the specimen detected a cell proliferation of tumour cells that were arranged in a storiform pattern which infiltrated the renal sinus, capsule and the perirenal fat, with pleomorphic nuclei and high mitotic index (). These findings were reported to be consistent with an undifferentiated liposarcoma of high histological grade, with 35 mitoses per ten high-power field (35/10 high-power field mitoses) and 30% of necrosis.\nThere was no evidence of metastatic spread to the Gerota’s fascia, renal pelvis, adrenal glands as well as there was no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old female patient who was still breastfeeding 10 months after her first natural delivery visited our outpatient clinic because of a left intertrochanteric fracture caused by falling from standing height. Before her pregnancy, the patient had no hypertension, diabetes mellitus, or other chronic diseases. She had no history of long-term drug use, smoking, or alcohol intake. She had not had any operations, did not suffer from hip or femur trauma, and had no family history of osteoporosis or hip fracture. During her pregnancy, the patient had no preeclampsia, eclampsia, gestational hyperthyroidism, or other metabolic diseases. She had no history of chronic diarrhea and never used glucocorticoids, heparin, or other drugs. Calcium 600 mg and vitamin D3 700 IU were supplemented every day during pregnancy, but she discontinued taking calcium and vitamin D after delivery. The patient had never complained about lower back or transient hip pain or a decrease in self-awareness of height during pregnancy and lactation. The patient experienced pain in the left hip after a fall, and could not stand on her left leg. At a physical examination, shortening deformity at the left leg was found, the range of motion in the left hip was restricted because of pain, and there was localized tenderness with palpation on the left hip. Percussion pain in the left lower limb was positive, but there was no tenderness in the spinal process in the thoracolumbar region and paravertebral muscles. Hip radiography () showed a left intertrochanteric fracture. Although the patient never complained about low back pain, magnetic resonance imaging of the thoracic and lumbar spine identified a new compression fracture in the L1 vertebra with marrow edema (). Laboratory test results are shown in . Serum calcium and parathyroid hormone concentrations were in the normal range, and 25-hydroxyvitamin D3 and albumin concentrations were low. BMD was measured with DXA, which showed a reduction in density i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old man was admitted to the emergency department with right upper quadrant pain and jaundice. Though gallbladder could not be demonstrated optimally, the ultrasonographic examination revealed an increase in gallbladder wall thickness but it was contracted. Dilatation of intra and extrahepatic bile duct was detected. As a result, 64-detector multidetector computed tomography (MDCT) was performed since we could not evaluate gallbladder and choledochus optimally with ultrasound. In MDCT, gallbladder was contracted and could not be demonstrated clearly. The enlargement of choledochus and multiple choledochus stones were determined. For a better evaluation of the biliary stones, T2 weighted (T2W) MRCP (NCE-MRCP) was performed. T2W images showed multiple stones in ductus choledochus and intrahepatic bile ducts. A 15×20 mm cystic lesion including thin septa was demonstrated at the head of pancreas at periampullary region (). There was no relationship between cystic lesion and pancreatic duct. Gadoxetic-acid enhanced MRCP (CE-MRCP) was performed at the same session to examine the bile duct obstruction and to evaluate the pancreatic cystic lesion (). A slight enhancement was detected at the wall and septi of the cystic lesion in CE-MRCP. There was no relationship between cyst and choledochus or pancreatic duct. There was no obstruction in the biliary tract as well. The transition of contrast material to the lumen of gallbladder was not seen at either early or late phase images. The patient was planned to undergo the surgical treatment according to these findings.\nAt surgical exploration, the size of gallbladder was significantly reduced. There were fibrotic adhesions between gallbladder, liver and transverse colon. Cholecystectomy was done; the pancreatic cystic lesion was aspirated and excised, as well. The histopathologic examination revealed a moderately differentiated adenocarcinoma of gallbladder with positive surgical margins and the pancreatic lesion was rep"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old man presented to the orthopedics department with progressive right wrist pain. He sustained a blunt injury caused by assault 3 days ago and initially evaluated in the emergency department. Radiographs of the wrist were obtained, and he was diagnosed with wrist sprain. He was prescribed with nonsteroidal anti-inflammatory and muscle relaxants drugs, and a volar short arm splint was applied. He was referred to the orthopedics clinics when his pain did not respond to treatment. The splint was removed, and inspection showed wrist edema along with loss of the dorsal ulnar styloid prominence ().\nThe wrist was tender to palpation, and the ulnar styloid process was not palpable at the dorsal aspect of the joint. He had mildly limited dorsiflexion and palmar flexion, and no forearm rotation. His previous X-rays, obtained 3 days ago in the emergency department, revealed an obvious UVD ().\nClosed reduction was attempted under local anesthesia, however failed due to extreme pain. A computerized tomography (CT) was taken for possible locked dislocation. Axial views and volume-rendered images of the DRUJ revealed volar dislocation of the ulnar head engaged with the sigmoid notch ().\nThe patient was taken to the operating room and under general anesthesia, the ulnar head was reduced by forceful pronation. The DRUJ was stable during passive forearm rotation. A long arm cast was applied with the forearm in semi-prone position and kept for 3 weeks. Magnetic resonance imaging (MRI) was obtained to inspect possible injuries to the stabilizing soft tissues and showed incomplete triangular fibrocartilage complex (TFCC) tear and bone impaction injury caused by engagement of the ulnar head to the sigmoid notch (). The cast was removed at the 3 weeks, and rehabilitation was initiated. The 3-stage wrist rehabilitation program was prescribed for the patient: Progression to each stage was guided by pain response. The stages of rehabilitation were described as pain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old Thai girl was born via cesarean section due to premature rupture of the membrane with a birth weight of 2500 g. She is the first child of a consanguineous (second-degree relatives) couple. Both parents are healthy and have never had fractures. During her first year of life, she had delayed motor development and growth failure. At one year of age, she could not sit by herself and weighed 7.5 kg (< 3rd centile). She presented to our hospital at 14 months of age with fractures of both femora without a history of significant trauma. She was found to have ptosis of both eyes with normal teeth but no blue sclerae. She was small for her age. Her weight was 7.8 kg (3rd centile) and her length was 68 cm (< 3rd centile). Skeletal survey showed diffuse osteopenia, multiple healed fractures of the right humoral shaft, both tibiae and fibulae. Spine radiograph showed flattening and indentation of vertebral bodies (Fig. ). A diagnosis of OI was made and intravenous bisphosphonate therapy (pamidronate 1 mg/kg/dose for 3 days) was initiated and given every 3 months. However, she sustained 1–2 long bone fractures per year from minor trauma. She required multiple corrective osteotomies to correct her deformities. At the last follow-up, she was 14 years old, weighing 20 kg. She could not walk due to her long bone deformity (Fig. ). Remarkably, although she was in a special education class due to physical disabilities, her cognition was appropriate for age. She could talk fluently and do mathematics properly.\nPrenatally, her younger sister was found to have a dilated fourth ventricle by an ultrasonography. She was born at term via cesarean section because of previous cesarean section and was diagnosed with hydrocephalus at birth. At 4 months of age, she had her first fracture without a history of a significant trauma, leading"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59 year-old Caucasian female with past medical history of migraines, presented to our emergency department as a transfer from another facility for further management of a non-ST elevation myocardial infarction. In the emergency room she presented with notable anterolateral T wave inversions on ECG as well as elevated troponin I of 2.5 ng/mL (reference range: 0.000–0.039 ng/mL). vThe patient was having continued chest pain at time of arrival and stated that she experienced her first acute episode of chest pain 1 day earlier, occurring at her home, while at rest. She stated that earlier in the day she was experiencing a migraine and took her home medication of Treximet 85/500 mg with good relief of her symptoms. The patient stated that she occasionally gets migraines and on occasion uses Treximet to relieve her symptoms, however has not had to take the medication in quite some time. The patient claimed that a few hours after her migraine had resolved she began to experience non-radiating, left sided, substernal chest pressure with associated paresthesia in the lower extremities and some non-descriptive nausea. This prompted her to seek medical attention at a local urgent care facility. She was seen and assessed by a physician and had an ECG performed which demonstrated no significant issues so she was discharged home with an antacid and told to follow up with her primary physician as an outpatient. The patient stated that the chest pain never really dissipated however she went to sleep that night without issues. The next morning, she woke up with continued chest pressure, yet, decreased in quality from the previous day. She went to work that day and while talking to her coworkers she immediately felt worsening of her chest pressure and was taken to a local hospital, without catheterization capabilities, where she was noted to have new ECG changes and elevated troponins. Upon transfer to our facility she was given 325 mg of aspirin by mouth and started on"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man was admitted to our hospital for the treatment of a rectal tumor found incidentally by rectal examination. The tumor, about 3 cm in diameter, was located on the right side of the lower rectum 3 cm above the anal verge. The pathological analysis of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) indicated that the rectal cancer invaded into the muscularis propria without distant metastases and that lateral pelvic lymph node (LPLN) was not enlarged with a maximum long-axis diameter <3 mm. The most important problem was that the patient had a huge benign prostatic hypertrophy, the size of which was 85 × 80 × 70 mm (Fig. a–c). To achieve complete TME with negative CRM, a hybrid transabdominal-transanal approach for ISR was conducted.\nFirst, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old right-handed woman with no prior history of neurological symptoms was referred to our hospital with chief complaints of aphasia and headaches and no sign of both extremities weakness. These symptoms had developed suddenly 1 week before she was admitted to the hospital. CT images revealed intracerebral haemorrhage (maximum 3.5 cm in diameter) in the left frontal lobe (Figures and ).\nCerebral angiography revealed a contralateral unruptured aneurysm in the M1 region (not shown). On the basis of the preoperative MRI findings (Figures and ), the patient was diagnosed with intracerebral haemorrhage (ICH) caused by cerebral cavernous malformation. We recommended surgical intervention since the lesion was symptomatic and we thought that there would be a future risk of rebleeding. A preoperative 3D fusion image was then constructed to simulate surgical procedures (Figures –). From the results of the preoperative simulation, we determined that a straight skin incision and small craniotomy behind the hairline would be enough to remove the hematoma (). Using the simulated 3D image, Broca's area (the inferior frontal gyrus) was identified to be caudal to the hematoma cavity (). This information led the surgical team to avoid contact with the caudal wall of the hematoma cavity so that Broca's area was not damaged.\nThe patient underwent craniotomy under general anaesthesia 1 week after the onset of haemorrhage. A straight skin incision was made behind the hairline, and a bone flap was removed to reveal the preoperatively targeted sulcus (). A cross-shaped opening was made in the dura () followed by a large opening in the arachnoid membrane over and inside the targeted sulcus (). Inside the sulcus, a gyrus flattened by the hematoma was observed as indicated in the preoperative simulation. A minimal corticotomy (4 mm) was then made on the gyrus to reach the hematoma (). Most of the hematoma was liquid and was easily removed by suction; however, detachment of the solid"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case presents a 20-year-old German female patient diagnosed with a chronic wound infection caused by MFC following a traffic accident in Vietnam (see Fig. for a timeline). The patient was travelling through Vietnam when she was involved in a motorbike accident in February 2019. She was taken to the emergency department of a hospital in Hanoi where she presented with a large wound on the right leg. At the time of admission, she was complaining of severe pain in her back and right foreleg, as well as headache and nausea. The patient reported no other pre-existing medical conditions. Radiograph of the lower leg did not show any signs of fracture, and cranio-encephalic traumatic lesions were excluded in the cranial computed tomography (CT) scan. However, a lumbosacral spine CT scan revealed stable fractures of the thoracic vertebrae (T4 / 5). The patient underwent surgical debridement and suture of the leg wound the next day (see Fig. a for a representative photograph) and was treated with metronidazole and ceftriaxone over four days. She was discharged eight days after admission, transported to Germany and immediately admitted to a local hospital. At that time, her right lower leg was swollen, but lacked signs of surgical site infection. The patient was discharged three days afterwards, and dressing changes were subsequently performed in an outpatient-setting by her general practitioner and in local hospitals. Approximately five weeks after the accident, wound inflammation was observed for the first time, with redness and warmth around the suture site and dehiscent areas of the wound edges. However, no signs of systemic infection such as fever, increased leukocyte count, or C-reactive protein levels were apparent. Three days later, she was re-admitted to a local hospital with the diagnosis of wound infection. Surgeons described purulent exudate and a subcutaneous firm tumor measuring 2 × 4 cm in size (Fig. b) with spontaneous drainage (Fig. c). The patient was dis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 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 ).\nAs a result of this decreased angle, an abrupt collapse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old female with history of Protein C deficiency and recent right thoracic outlet decompression surgery and first right first rib resection 3 weeks prior presented to an internal medicine clinic with dyspnea on exertion of one day duration. The patient was in good health up until 8 months before presentation when she developed recurrent transient ichemic attacks (TIAs). She underwent extensive evaluation at several hospitals and eventually was found to have thoracic outlet syndrome of the left upper extremity and possible thrombus at the subclavian artery. She successfully underwent left-sided thoracic outlet decompression and left first rib resection 7 months prior to presentation. Her post-op period was complicated by a subocclusive left external iliac deep vein thrombosis (DVT), and she was treated with apixaban. She recovered over the next several months and continued anticoagulation for her prior TIAsand DVT in the setting of Protein C deficiency. Two months prior to presentation, she developed right arm symptoms consistent with thoracic artery outlet syndrome on the contralateral side. She ultimately underwent thoracic outlet decompression surgery and right first rib resection 3 weeks prior to presentation, only missing full anticoagulation for 2 days. She was recovering as expected until she began to notice dyspnea on exertion 1 day prior to presentation.\nHer vitals were within normal limits. Her physical exam was notable for decreased breath sounds and dullness to percussion in the right lung base. To evaluate her complaints further, a Cardiac Limited Ultrasound Exam (CLUE) was performed with the phased array probe and revealed the right hemidiaphragm had decreased movement compared to the left hemidiaphragm with a normal CLUE exam otherwise ( and ; Supplement Videos 1 and 2) [].\nLabwork including troponin was normal, and electrocardigram revealed a new right bundle branch block but no evidence of ischemia. CT angiography of the chest was pursued du"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy, 10-year-old boy was admitted to pediatric dentistry clinic for the management of crowding associated with a large tooth present in the upper jaw. On intraoral examination, the patient's chief complaint was confirmed by the presence of a misaligned maxillary right central incisor. The tooth had a talon cusp-like enamel projection on the labial aspect of the crown and had a large mesiodistal dimension. Owing to the patient's gagging reflex, a proper radiographic examination of the incisor could not be made. However, the occlusal and periapical radiographs were highly suggestive of a large pulp chamber, and even of the possibility of a fused tooth. The occlusal radiograph also indicated an unerupted supernumerary incisor located on the contralateral side between the central and lateral incisors. The supernumerary incisor had a well-shaped crown and showed advanced root formation with incomplete apical closure ().\nAmong possible treatment options, esthetic reduction of the crown in both the proximal and labial aspects was considered unfavorable due to the presence of a large pulp chamber. Extraction of the tooth and consequent orthodontic correction were also discarded as a treatment alternative, since orthodontic movement of the supernumerary tooth over the midline could result in resorption of the alveolar bone. Finally, the use of the contralateral supernumerary incisor as a replacement for the existing large incisor was considered the best treatment option, since both the radiographic crown dimensions and presence of the immature apex favored the possibility for autotransplantation. The patient and his parents were informed about the treatment options and their possible outcomes. The patient showed up four months later, approving the treatment plan of autotransplantation. During the time, the supernumerary incisor erupted into the crowded maxillary arch in a rotated fashion (). Extraction of the large incisor and autotransplantation of the supernumerary t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51 year old man presented to our outpatient department with an increasing swelling in the right distal upper arm. He reported about local pain without radiation. The patient´s medical history was without previous infections, surgeries or other diseases. The mass in the arm presented solid and relocatable. The examination showed full strength in all upper extremity muscles, especially in the forearm flexors, in M. pronator, M. abductor pollicis brevis, M. flexor pollcis brevis, M. opponens pollcis and Mm. lumbricales I and II. No sensory loss in the upper arm, the forearm, the palm and dorsum of the hand and the fingers could be found.\nMRI of the upper arm showed a spindle-shaped homogeneously contrast enhancing mass. It was located some centimeters above the crook of the arm within the medial sulcus bicipitalis. In the imaging it showed a relationship to the median nerve main branch of the forearm or seemed to originate from part of its fibres, respectively. Its diameter was about 11 × 4 centimeters (). The primary diagnosis from the radiologist was schwannoma.\nSurgical extirpation was indicated and performed. In its middle part the exposed tumour had a smooth capsule which was opened (). In its equator the surface had a good boundary to the surrounding tissue (). It did not extend to the muscles or tendons. In its distal and especially in its proximal ending the tumour showed a more infiltrative growth (). A feeding fascicle could be identified and was cut after ensuring by electric stimulation that it had no motor function. But with the intention to set no damage at the main nerve trunk approximately twenty percent residual tumour was left ().\nThe postoperative course was uneventful. The patient suffered a light hypesthesia in the forearm. This did not match to the supply territory of the median nerve which is the palmar hand. It rather corresponded to another skin nerve, possibly damaged by the approach. There was no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19 year old nulliparous, British Caucasian woman was admitted with a sudden onset of right iliac fossa pain. Urine pregnancy test was negative. This pain was sharp and stabbing in nature with no radiation. There was no associated vomiting or fever. She denied any urinary urgency, frequency or dysuria and her bowels were normal. On examination there was minimal guarding and no rebound tenderness. No distension was seen and bowel sounds were heard. Transvaginal pelvic ultrasound demonstrated two small simple cysts within the right ovary. She was managed conservatively with analgesics only and the pain resolved within 24 hours. Following this acute episode she developed intermittent pelvic pain. Her subsequent scan showed 9.8 × 4.5 cm complex cystic mass in right adnexa with features suggestive of a dermoid cyst with no colour flow on Doppler examination. Interestingly her CA 125 was markedly elevated at 657; CEA, ∝ FP, HCG, white cell count (WCC) and CRP were all within normal limits. Her periods were regular and she was using condoms for contraception. She was in a new relationship and they had been together for the last 4 months.\nPast medical history included well controlled asthma, a negative laparotomy at the age of seven for abdominal pain but no previous pelvic infections. Pelvic examination revealed a normal size uterus with a right adnexal mass which appeared fixed to the pelvic side wall.\nA subsequent CT scan one week later suggested a right adnexal dermoid cyst 5.4 × 4.8 cm with abnormal soft tissue 3.0 × 2.6 cm deep to right rectus muscle and abnormal irregular soft tissue along pelvic side wall extending from left common iliac bifurcation to left adnexa and an enlarged 10 mm precaval lymph node was also seen. These features were thought to be highly suspicious of malignancy during the case review at the Gynaecology oncology Multidisciplinary Team (MDT) meeting.\nA further CA 125 level was measured pre-operatively and had fall"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old female patient with Down syndrome (weight 35 kg, height 135 cm) was referred to the department of dental anesthesia for behavioral management. Behavioral management was difficult because of her congenital heart condition, and uncooperativeness due to intellectual disability and dental phobia. Her chief complaints were pulp exposure, necrotic change, and pus discharge in the right mandibular first molar. Meanwhile, a root canal procedure was planned with a pediatric dentist.\nThe patient was given birth by normal spontaneous vaginal delivery with birth weight of 3.0 kg, and was diagnosed with chromosome 47XX + 21 Down syndrome. Immediately upon birth, she was also diagnosed with ventricular septal defect, for which she underwent regular examinations without any surgical intervention. At age 5, cardiac catheterization found severe pulmonary hypertension, based on which a diagnosis of ES was made ().\nEchocardiography results indicated bidirectional shunt due to large perimembranous ventricular septal defect, resulting in severe pulmonary hypertension. A chest radiograph showed no significant interval changes, while laboratory test results showed hemoglobin and hematocrit level of 14.2 g/dl and 41.2%, respectively. Other laboratory findings were unremarkable.\nPreoperative physical examination results showed blood pressure of 110/70 mmHg, heart rate of 100 beats/min, and oxygen saturation of 91%. Her physical activity was identified as NYHA (New York Heart Association) class II, meaning mild symptoms (mild shortness of breath and/or angina, and slight limitation during ordinary activity). A pediatric cardiologist recommended avoiding general anesthesia since it could threaten her life, and instead, recommended the use of antibiotics (bacterial endocarditis) and lidocaine without epinephrine, prevention of air embolism, and prevention of an increase in PVR during anesthesia and recovery period.\nA pediatric dentist had planned to perform root canal treatment o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old male patient presented after a motorcycle accident with fractures of the left distal radius, left fifth metacarpus, left tibial plateau, and left second and third metatarsi, as well as wounds on the anterior surface of the left tibia and the dorsal surface of the left foot. The patient underwent emergency surgery to repair the lacerated extensor tendons in his left foot and injured dorsalis pedis artery was ligated. He underwent another operation three days after admission to repair his left distal radius fracture and metatarsal fractures. In the third week, the left tibia plateau fracture was fixed with a hybrid Ilizarov ring and monolateral Schanz screws to tibial shaft and the necrotic tissue was debrided. Extensive necrotic lesions formed in the wounds on the dorsum of the patient’s left foot and his anterior tibia. Empirical treatment with tigecycline and ciprofloxacin was initiated based on a diagnosis of complicated skin/soft tissue infection. Tissue cultures were obtained from the wound on the fifth day of antibiotic therapy. Due to the persistence of extensive necrosis after nine days of antibiotherapy, tigecycline and ciprofloxacin were replaced with imipenem and teicoplanin. On the same day, wound debridement was performed in the operating room and tissue culture samples were obtained intraoperatively. A. flavus growth was observed in the initial tissue culture, and A. flavus and A. fumigatus growth was observed in the tissue cultures obtained intraoperatively. Based on the diagnosis of PCA, intravenous voriconazole at a loading dose of 6 mg/kg twice daily and maintenance dose of 4 mg/kg twice daily was added to the patient’s treatment. Debridement was repeated after 10 days and tissue cultures were obtained. Tissue culture was again positive for A. flavus. VAC treatment was started after a second debridement. No growth was observed in tissue cultures obtained on day 10 and day 17 of antifungal therapy. The wounds turned to healthy granulati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old man presented with a long history of groin pain for several years. There was no history of trauma or injury to groin. The pain exacerbated by walking and prolonged sitting. Since last few months his pain had increased with loss of movement at the hip. Physical examination revealed slight asymmetry in the region of the iliac bone compared with the contralateral side, with no signs of inflammation or palpable mass. Hip range of motion was decreased with flexion limited to 90°, and abduction of 15°. Patient walked with Trendelenburg gait possibly because of pain. Conventional radiographs of the hip () revealed the presence of a bony protuberance at the right anterior inferior iliac spine, several centimeters in length close to the right acetabulum, with no signs ofjoint degeneration. Suspecting a giant osteochondroma which could be in the process of malignant transformation we performed a magnetic resonance imaging (MRI) which showed the existence of a bone tumor with benign appearance, but excluding the osteochondroma as a diagnostic possibility, because there was no peripheral cartilage. Subsequently a CT scan () revealed a bony lesion (6 cm long and 3 cm thick) with a well-defined cortical bone and a heterogeneous zone in the junction with the ilium suggesting a pseudo- articulation. With these studies we could establish the diagnosis of pelvic digit instead of an osteochondroma.\nInitially, non-steroidal anti-inflammatory medications were prescribed with no symptomatic improvement. Surgical excision of the pelvic rib was planned with consent of the patient. Anterior approach to the hip (Smith-Petersen) was used. Tensor fascia latae and gluteus minimus required to be partially detached to completely expose the ‘rib’ till the base. The ‘rib’ was resected from its base and samples send for histopathology (). Histopathological examination showed the presence of corticomedullary structure similar to a rib, with no accompanying cartilage; this finding was co"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old nondiabetic male presented to us with history of chest pain of 3-hour duration two days ago, associated with vomiting and one episode of syncope. For these complaints, he had been evaluated at a local hospital and diagnosed as acute inferior wall with posterior wall MI with atrioventricular (AV) dissociation, for which he was managed medically, and transvenous right ventricular apical temporary pacing was done. Due to persistent hypotension and recurrent rest pain, the patient was referred to us on the third day of the index event. His presentation ECG at our centre showed evidence of inferior wall MI with 2 : 1 AV block (). Echocardiogram showed hypokinesia in the left circumflex (LCx) territory, with an ejection fraction of 50% and moderate mitral regurgitation. Pacing threshold was normal and remained so throughout the observation period. In view of postinfarction angina, hypotension, and persistent AV block, the patient was taken up for coronary angiography with an intent to revascularise. His coronary angiography showed a left dominant circulation with 90% stenosis in proximal segment of left circumflex artery and 70% stenosis in the middle segment of the left anterior descending (LAD) artery. The LCx was balloon dilated followed by deployment of a drug eluting stent; the LAD was planned for a staged procedure. The angioplasty was uneventful and the patient was shifted to ICCU.\nAfter four hours of percutaneous coronary intervention (PCI), the patient suddenly developed palpitations and ECG showed monomorphic ventricular tachycardia (). He was managed with 150 J biphasic DC cardioversion followed by intravenous amiodarone bolus and infusion, considering it to be secondary VT. The serum electrolytes were within normal limits. There were multiple hemodynamically significant episodes of both monomorphic () and polymorphic VT () over the next few hours. Significant ischemia was effectively ruled out by a check angiography that showed patent LCx stent w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old woman injured her right ankle joint after falling from a bicycle in January 2013. One week later, ORIF was performed at the initial emergency hospital. One month postoperatively, the patient was permitted to walk with weight-bearing but was unable to do so due to sustained ankle pain on the lateral and posterior aspect. After follow-up, including rehabilitation for 7 months, all screws were removed under the assumption that bone union had been obtained. However, ankle pain remained and the patient still could not walk with weight-bearing and was referred to our hospital in December 2013.\nOn initial plain radiographs, Weber type B and Lauge-Hansen classification SE type stage 4 fractures were revealed (). The medial and lateral malleoli were fixed using Acutrak 2 screws (Acumed, Hillsboro, OR) at the time of initial operation in February 2013 (). After the removal of those screws, a medial clear space was opened (). Computed tomography at our hospital revealed bone union of the posterior and medial malleoli but malunion of the lateral malleolus ().\nAnkle arthrodesis is considered one form of salvage when a long time has elapsed since the first operation. However, reconstructive osteotomy was selected in this case because of the young age of the patient and the relatively smooth joint surface on radiography. In this case, shortening of the fibula because of posterolateral rotation of the distal fragment and widening of the ankle fork because of concomitant syndesmotic injury was present. As a result, the surgical plan involved fibular osteotomy through the initial fracture plane with fibular lengthening and internal rotation of the distal fragment until the ankle fork had been reconstructed anatomically. In addition, syndesmotic stabilization was planned by screw fixation.\nWe also evaluated preoperative foot function before reconstructive osteotomy using the self-administered foot evaluation questionnaire (SAFE-Q) () []. Despite poor results, ankle range"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur proband is a 43-year-old male of northern European descent who initially presented with acute onset left leg cramping pain that lasted for several days. The pain was associated with numbness in his left leg and nausea. His past medical history was significant for mitral valve prolapse, aortic root dilation umbilical hernia left anterior cruciate ligament (ACL) rupture, and severe myopia corrected with LASIK surgery. Family history revealed rheumatic heart disease in his mother, necessitating mitral valve repair due to mitral valve prolapse with severe regurgitation. Upon examination, his popliteal arterial pulses were 4+ bilateral, bounding. His height was 196 cm, with an increased arm span-height ratio of 1.07. He had a mild pectus carinatum deformity, mild scoliosis positive wrist and thumb sign, pes planus, and mild skin striae. A Doppler ultrasound was performed by his primary care physician (PCP), which ruled out deep venous thrombosis (DVT); however, it revealed a large left popliteal artery aneurysm with thrombus that measured 6.3 × 3.1 × 3.4 cm. He underwent a CT angiogram that showed normal abdominal aorta as well as common iliac arteries. However it showed bilateral popliteal artery aneurysms measuring 3.6 × 4 cm in the left side and 3 × 2.8 cm in the right side (). After repairing of his left popliteal artery aneurysm with bovine carotid interposition via posterior approach, he was sent for cardiac and genetic evaluations. He underwent a MRI exam of the heart with and without intravenous gadolinium contrast administration () which showed mild bileaflet mitral valve prolapse and aortic root dilation (measuring 46 mm at the level of the sinuses of Valsalva). The patient has been prescribed metoprolol tartrate and losartan to control his aortic root disease and was to undergo elective aortic repair when the aortic dimension becomes near to or reaches 50 mm. A diagnosis of Marfan syndrome was made based on the revised Ghent criteria as the proband had aor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 47-year-old male police officer who sought care at a consulting office and had been the victim of a perforating firearm wound to the right infraclavicular region 7 months prior to presentation. At the time of wounding he had been treated conservatively.\nThe patient complained of exertional dyspnea and considerable edema and pain in the right arm. He had brought the results of a chest tomography conducted some weeks before which showed considerable dilatation of the right subclavian vein and the cervical veins of the right upper limb.\nPhysical examination revealed significant edema of the right upper limb, with pain on palpation and holosystolic murmur in the topography of the right pulmonary apex. Right radial, ulnar, and brachial pulses were all reduced in comparison with those of the contralateral limb.\nTwo weeks after this consultation, the patient presented at an emergency room with exacerbation of the dyspnea, symptomatic ventricular tachycardia, and frequent premature ventricular contractions and was admitted to the hospital.\nSupplementary cardiac tests were then conducted. The echocardiogram showed dilatation of the left cardiac chambers and an ejection fraction of 63%. Myocardial scintigraphy showed signs of dilated cardiomyopathy.\nAfter clinical and cardiac stabilization, the patient underwent arteriography of the right upper limb, which showed a large arteriovenous fistula between the right subclavian vessels and a pseudoaneurysm of the subclavian artery ( ).\nThe treatment chosen was endovascular repair under local anesthesia with sedation. The technique employed was via puncture of the right common femoral artery with a 7F introducer and puncture of the right brachial artery with a 5F introducer. The subclavian artery was catheterized via the brachial access and the guidewire was snared and a through-and-through system constructed via the femoral access, due to difficulty in advancing the guidewire via the subclavian artery. The injury w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32 year-old woman with a history of hypothyroidism and pre-eclampsia initially presented to an outside hospital with acute onset dense left hemiplegia, right gaze preference, and left-sided neglect. Her initial National Institute of Health Stroke Scale (NIHSS) was 14 and she had an admission Glasgow Coma Scale (GCS) of 10. A computed tomography (CT) angiogram of her neck revealed complete occlusion of the right cervical internal carotid artery (ICA). She was outside the time window for intravenous thrombolysis; however, she underwent mechanical thrombectomy using a stent retreiver device and aspiration (Penumbra System®, Alameda, CA). Immediately after the procedure, there was a successful restoration of the blood flow to the distal ICA, proximal middle cerebral artery (MCA), and to the anterior cerebral artery (ACA), with residual distal M2 occlusion. She was intubated for the procedure and was extubated in the following days. Her left-sided weakness persisted and a repeat CTA showed re-occlusion of the right cervical ICA. No further intervention was done and she was treated with aspirin and statin for secondary stroke prophylaxis. The stroke was deemed cryptogenic after work-up for a potential source was negative including an echocardiogram which demonstrated a normal ejection fraction, normal left atrial size, and negative bubble study. A workup for prothrombotic and hypercoagulable states were negative as well. Magnetic resonance imaging (MRI) of the brain was done which showed a large area of diffusion restriction with corresponding decreased apparent diffusion coefficient (ADC) and T2 hyperintensity in the right frontal, parietal, temporal lobes and in the basal ganglia with areas of hypointensities on gradient echo sequencing, which suggested infarction in these areas with some areas of hemorrhagic conversion (Figure ).\nSubsequently, she was discharged to an inpatient rehabilitation center. While at the rehabilitation center, about four weeks after her stro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old Caucasian woman who had no medical history presented with a headache of 2 months’ duration in August 2012. There was a family history of malignancies. She had no psychosocial history. She did not take any medications. She was a housewife. She lived with her husband and three children in a flat in the city center of Istanbul. She never smoked tobacco and did not consume alcohol. Her vital signs were stable with blood pressure 110/70 mmHg, pulse rate 82/minute, and temperature 36.5 °C. On neurological examination, there was a limitation of temporal movement in her right eye. There were no signs of paresthesia or hypoesthesia. A general examination showed no other abnormality. Brain MRI showed 34 mm × 10 mm and 20 mm × 19 mm masses in her clivus. She was operated on and a pathology examination showed chordoma. Postoperative stereotactic radiotherapy to clivus at a total dose of 24 Gray in one fraction with gamma-knife was performed. In March 2014, she had a recurrence in her clivus and then she underwent another operation. A pathology examination revealed chordoma. She presented with diplopia for 1 month in January 2015. Brain MRI detected a recurrent mass in her clivus and invasion to the pons. She was treated with external cranial radiotherapy for palliative intent. She received a total of 30 Gray to recurrent mass in ten fractions during 10 days. In March 2015, a residual mass in her clivus was seen in MRI. She was started on daily 400 mg of imatinib in April 2015. The best response to imatinib was stable disease. Overall, imatinib was well tolerated; she reported periorbital edema, grade 1 skin rash on her legs, and nausea grade 2. She complained of visual loss in her left eye in May 2017. Brain MRI confirmed progressive disease (Fig. ). Imatinib was stopped and sunitinib 37.5 mg per day was started in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 37-year-old male with a past medical history of essential hypertension and hyperlipidemia who was transferred to our hospital for further ongoing care for colitis and hematochezia in settings of possible bleeding disorder. The patient was initially presented to another hospital with a one-week history of diffuse abdominal pain, bloating, and a three-day history of bright red blood per rectum. He also reported multiple episodes of vomiting and one episode of gross hematuria. The patient also reported a six-month history of fatigue, generalized body weakness, cold intolerance, swelling in his arms and legs, easy bruising, and unintentional weight loss of 20 pounds over six months duration. In October 2020, he had an episode of profuse gum bleeding after a dental procedure, and he has been currently being worked up by hematology as an outpatient for von Willebrand disease (VWD) versus hemophilia. He had a remote history of proteinuria and was following by nephrology outpatient, but a biopsy was not pursued in the setting of bleeding disorder workup. We were consulted as he was found to have nephrotic range proteinuria with a 24 hr urine protein of 4.61 gm.\nOn examination, he was afebrile with a blood pressure of 105/64, tachycardia with a heart rate of 112, and normal oxygen saturation on room air. He was in no acute distress. His cardiac and pulmonary exam was unremarkable. Abdominal examination revealed mild diffuse tenderness and dullness on percussion. He had +2 non-pitting edema in the lower extremities. The skin was dry, and no rash was noted. Ultrasound abdomen was done, which showed hepatomegaly with findings of portal hypertension with the slow flow in the main portal veins, recanalized umbilical vein, pericholecystic edema, reversal flow within the splenic vein at pancreas, splenic siderosis, splenic varices, and moderate ascites.\nLaboratory workup (Table ) revealed acute kidney injury ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Caucasian man presented with intermittent upper abdominal pain, nausea and bloating for the previous 12 months. There was no history of fever, jaundice, pale stools or dark urine. His past medical history included a Billroth II gastrectomy and Roux-en-Y reconstruction for peptic ulcer disease 11 years earlier. On examination, he was haemodynamically stable and afebrile. Abdominal examination was unremarkable. Laboratory tests, including liver function tests and inflammatory markers were all normal. Transabdominal ultrasound examination revealed gallstones and intra- and extrahepatic biliary dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful. Magnetic resonance cholangiopancreatogram (MRCP) and computed tomography (CT) confirmed gallstones within the gallbladder and biliary dilatation to the level of the ampulla, and demonstrated a 4 × 3 cm low density filling defect in the second part of the duodenum (Figure ).\nAfter he was admitted to a specialist centre, endoscopic ultrasonography and repeat ERCP were attempted but failed due to inability to cannulate the duodenal limb of the Roux-en-Y. Two hours after the procedure he developed severe, generalized abdominal pain and hypotension. This raised the possibility of iatrogenic intestinal perforation. However, it was decided to proceed directly to laparotomy rather than repeat imaging, since it was apparent that surgical exploration would be required in the event of unsuccessful ERCP. During the operation, there was no evidence of intestinal perforation. A 3.5 cm gallstone was found proximal to a stricture in the second part of the duodenum. There was no evidence of a cholecystoduodenal fistula. The duodenal papilla and pancreas were normal. The common bile duct, which was dilated due to extrinsic compression by the intraduodenal gallstone, was explored and found to be normal, and contained no stones. The gallstone in the duodenum was extracted via a duodenotomy, the duodenal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 63-year-old Hispanic woman with a history of peptic ulcer disease with dyspepsia and was treated with a proton pump inhibitor (PPI). She was diagnosed with Helicobacter pylori infection and received a triple drug therapy. Subsequently she experienced weight loss of approximately 14 kg over 2 months (BMI = 18.4; previous weight 64 kg, BMI = 23.5), and her dyspepsia did not improve. Colonoscopy and esophagogastroduodenoscopy (EGD) were performed and revealed a 4 cm pyloric ulcer and 70% pyloric stenosis; biopsies were taken at the time of the EGD. The biopsy demonstrated adenocarcinoma in signet ring cells. She was referred to the General Ignacio Zaragoza Regional Hospital Surgery Department for further evaluation. Social history was significant for an 18-pack-year smoking history. Her family history was significant for first-degree relatives with a history of cancer: one with bladder carcinoma and the other with prostate carcinoma. Her physical examination was within normal limits. Laboratory tests demonstrated normal hemoglobin and hematocrit levels, normal liver enzymes, and normal renal function; however, urinalysis was significant for both proteinuria and hematuria, and her blood type is A positive. Carbohydrate antigen (CA)125 and CA19-9 were normal. Her chest X-ray was normal for her age. A computed tomography (CT) scan of her abdomen and pelvis showed a tumor in her left kidney of approximately 140 × 97 × 85 mm with homogeneous enhancement in its upper pole. No distant metastases were evident. Surgical intervention with an exploratory laparotomy was undertaken, where a partial gastrectomy was performed with gastrojejunal anastomosis with omega of Braun reconstruction and left radical nephrectomy. Interoperative cryosections were evaluated by pathology. She had an estimated blood loss of 850 cc, with an estimated surgical time of 210 minutes. The postsurgical course was without complications. The histopathological report describes the left kidn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old female patient with a history of bronchial asthma of two-year duration came to our hospital for evaluation of uncontrolled asthma. Since her diagnosis, she was started on short acting β-agonists followed by inhaled steroids.\nNot long after, long acting β-agonists and Montelukast were added to the treatment because of persistent asthma consisting of a persistent cough, shortness of breath and wheezes that were not responding to the treatment previously prescribed. She also was prescribed steroids as needed for relapses which happened frequently.\nShe sought help by multiple pulmonologists and internists, because it was interfering with her life activities, who prescribed her the same treatment and would put her on oral steroids which would improve the patient's condition partially but not completely.\nFrequent exacerbations were noticed but since she was already taking the maximal optimal dose for asthma medications, nothing else could be done.\nIn our hospital, the patient was reevaluated with a detailed history focusing on the place of residence, degree of ventilation of her house (which was well ventilated) and exposure to allergens and animals at home. There was nothing of significant value with no allergen exposure, no history of NSAIDs or β-blockers use and no heart burn. She did however mention a brownish colored sputum with a plug like consistency and multiple courses of antibiotics.\nShe also mentioned that her husband is an avid smoker but not in front of her and her past medical and surgical history was unremarkable despite the asthma. She affirmed to be compliant with her medication but still suffering from frequent exacerbations that were partially relived by oral or IV steroids.\nThis led to the suspicion of allergic bronchopulmonary aspergillosis and thus further investigations were done which included:\nA chest-CT scan that showed atelectatic bands. Blood and sputum samples that showed increased IgE levels (450 kU/L), increased eosinophils cou"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old female with a pertinent history of essential hypertension, anxiety, and hypothyroidism presented with acute-onset abdominal pain. The pain described the typical characteristics of pancreatitis, with sharp mid-gastric pain radiating towards the back, without any significant relieving factors, accompanied by unremitting nausea and vomiting. The patient did not have any recent history of smoking, drinking, or any recreational drug use. Her home medications included losartan, Synthroid, Xanax, and bupropion.\nClinical history did not yield any relevant information, apart from the fact that the patient had presented with similar acute symptoms of pancreatitis approximately four weeks prior to this episode. She was conservatively managed with intravenous fluids and pain control with the resolution of symptoms. The patient was investigated for common causes of pancreatitis, including ultrasound and computed tomography (CT) of the abdomen, lipid profile, drug screen, and hepatitis panel. The workup to rule out the common causes of pancreatitis was negative.\nThe patient subsequently improved and was discharged home to be followed by the gastroenterology for further investigations, including magnetic resonance imaging (MRI) of the abdomen and immunoglobulin (IgG4) levels, to rule out uncommon causes of pancreatitis. Of note, before discharge home, she was resumed on losartan at the same dose.\nIn this admission, the patient presented with similar complains and the repeat CT abdomen with intravenous (IV) contrast redemonstrated acute pancreatic inflammation with mild peri-pancreatic fluid accumulation without any evidence of necrosis and ductal dilatation (Figure ). The ultrasound of the abdomen was also repeated, which did not yield any evidence of cholelithiasis and the common bile duct measured 4 mm in size. The patient was evaluated by gastroenterology and was managed symptomatically. MRI the abdomen did not demonstrate intra or extrahepatic biliary ductal path"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old man visited the gastroenterologist because he had been suffering from iron deficiency anaemia without obvious blood loss for a few months. Apart from intermittent pain in the right upper abdominal region, there were no other symptoms. His weight remained constant and he did not lose his appetite. Defecation was regular, once a day. His medical record consisted of diabetes mellitus type II, hypertension, impaired renal function and an ear operation many years before. He had no history of gastrointestinal problems. Family history revealed two brothers who had died of colorectal cancer at old age. With a body mass index of 28 he was overweight. Examination of the abdomen did not reveal any unusual findings. No abnormality was palpated during digital rectal examination. A complete blood count revealed anaemia (Hb 6.7 mmol/l) and iron deficiency (9 µmol/l).\nThe patient underwent colonoscopy. Diverticulosis was seen in the sigmoid. Three polyps were removed during the colonoscopy. A bleeding tumour was found in the ascending colon, 80 cm from the anal sphincter. Definitive pathology revealed an adenocarcinoma in the ascending colon. An abdominal CT scan confirmed the presence of a process in the ascending colon. It also showed a liver lesion with a diameter of 9 mm, suspicious of liver metastasis. The CT scan did not reveal any other unusual findings. Ultrasonography of the upper abdomen confirmed a liver lesion, with a diameter of 13 mm, suspicious of liver metastasis with an atypical hepatic haemangioma in the differential diagnosis. MRI scan showed a liver lesion in segment V, suspicious of liver metastasis.\nThe patient underwent simultaneous right hemicolectomy and wedge resection of the liver lesion. During perioperative inspection of the upper abdomen, a gallbladder deformity was seen (fig. ). The fundus of the gallbladder was folded like a cap. The patient underwent cholecystectomy to make the wedge resection of the liver metastasis in segment V easi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-years-old male during an ordinary visit for drug prescription due to his chronic health problems, described his complaints (voice alteration, dysphagia and saliva drooling progressively worsening during the last few weeks) and his general physician referred him for an E.N.T. evaluation. The lack of any pain sensation was the reason for the delay of seeing a physician. His medical history was significant for severe benign prostatic hyperplasia, hypertension and chronic obstructive pulmonary disease. He was heavy tobacco smoker until recently. No history of alcohol intake was referred.\nClinical examination of the oral cavity revealed an oversized pigmented soft mass arising from the left half of his hard palate involving the soft palate and the ipsilateral palatine tonsil causing partial obstruction of the oral cavity and the oropharynx (Figure ). Some pigmented macules of various sizes were also noted growing at the periphery of the tumor. During neck palpation a 2 × 3 cm firm mobile non-tender mass was palpated at the left upper jugular region. A punch biopsy of the oral mass was performed.\nA complete blood cell count, biochemical profile, and urinalysis were ordered without significant findings. A chest x ray was normal.\nHistological examination of the specimen demonstrated extensive infiltration of the ulcerated mucosa by neoplastic predominantly epithelioid cells, in a solid, nested, trabecular or alveolar pattern. The cells were round to oval, having prominent eosinophilic nucleoli and atypical mitotic figures. In areas with intact surface epithelium was identified continuity of the tumor with the epithelium. There were also brown pigment deposition and neoplastic giant cells (figure ).\nA computer tomography with contrast revealed pathologically enlarged cervical lymph nodes of the left neck. Signs of infiltration of the ipsilateral medial pterygoid muscle were also observed (figure ).\nWork up for distant metastases (CT scan of chest, brain and abdomen plus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 48 year old male presented to our surgical out-patient service complaining of a 3 month history of progressively worsening dysphagia for solids with associated regurgitation and unintentional weight loss of 14 kg. Physical examination was unremarkable and there was no evidence of organomegaly or lymphadenopathy. Subsequent oesophagoscopy revealed a large polypoid pigmented lesion at 30 cm. The lesion did not impede the passage of the scope. Multiple biopsies were taken. Two pigmented cutaneous lesions (no sinister features present in either lesion) were also excised – histology showed benign lesions. No evidence of melanoma was found.\nA staging CT scan of his thorax, abdomen and pelvis showed a well-defined eccentric mass in the mid-lower oesophagus. There was no apparent local invasion or regional lymphadenopathy.\nWhole body FDG PET/CT body scan confirmed the mass in the oesophagus with increased uptake in a high abdominal pre-aortic and high right paratracheal node consistent with metastasis. (see figure ).\nBiopsy results from the oesophagoscopy showed an infiltrating malignant tumour with prominent nucleoli and cells prominent in the submucosa and also in the basal layer of the squamous mucosa. S100 stain was positive. Features were consistent with malignant melanoma. The features that confirmed the primary nature of the neoplasm were the junctional change, multi-pleomorphic spindle shaped cells with prominent nucleoli and some lymphocytic infiltrate. (see figures &).\nThe absence of cutaneous, ocular, or mucosal melanoma elsewhere also supported a diagnosis of primary rather than secondary melanoma.\nHe underwent a three stage oesophagectomy with mediastinal lymphadenectomy. Seven of the twenty six lymph nodes were postitive for melanoma, including the two nodes highlighted by the FDG-PET scan. The remainder of his post-operative stay was unremarkable and he was discharged home.\nHe underwent a course of immunomodulatory therapy, consisting of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.\nA punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).\nEven though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old man with no history of skin cancer presented to the outpatient dermatology clinic for a scalp lesion of three weeks duration. He reported rapid lesion growth, but no change in the overall appearance nor any associated symptoms. Examination revealed a mobile, round, exophytic nodule with overlying ulceration and hemorrhagic crust, approximately 1.5 cm in diameter (Figure ). Given a high clinical suspicion of malignancy, the lesion was excised three weeks following the initial visit using a fusiform (elliptical) incision with 1 cm margins. The lesion immediately prior to the procedure is seen in Figure .\nA histopathologic examination of an excisional biopsy of the cutaneous lesion revealed a proliferation of spindle and pleomorphic tumor cells, which flattened the overlying epidermis (Figure ) and extended to the subcutaneous tissue (Figure ). The tumor cells were large and polygonal and contained eosinophilic cytoplasm. They expressed diffuse CD10 positivity (Figure ) and focal CD68 positivity. The tumor cells were negative for p40 and SOX10, excluding the possibility of sarcomatoid carcinoma and melanoma, respectively. The histopathologic findings were found to be consistent with invasive pleomorphic dermal sarcoma. The tumor measured 3.3 cm at the largest dimension, and tumor cells were found to be present at the surgical margin. There was no evidence of lymphovascular or perineural invasion.\nA surgical, wide, local excision was planned. Preparatory computed tomography (CT) imaging revealed an approximately 3.9 cm focus of enhancement with central ulceration in the soft tissue of the posterior scalp and confirmed a lack of bony erosion in the underlying calvarium. No metastatic adenopathy was appreciated. Figure demonstrates the scalp vertex prior to surgery. A wide local excision was performed using a 2 cm margin around the remaining tumor for a 7.5 cm area of planned excision. The repair utilized a 7x3.5 cm full-thickness skin graft from the left up"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old female with renal failure secondary to adult polycystic kidney disease had repeatedly refused the formation of an AV fistula for haemodialysis due to severe needle phobia. She was commenced on peritoneal dialysis in 2008, which became inadequate as a result of membrane failure in 2010. She was commenced on haemodialysis via twin tunnelled Tesio® (Medcomp, PA, USA) lines inserted via a left internal jugular approach having had temporary right internal jugular access previously.\nShe was referred to the vascular surgery unit with the line in situ for 2 years following a failed attempt to remove the malfunctioning venous limb of the catheter on the renal unit. A chest X-ray showed the tip of the catheter at the level of the right atrium (Fig. ). Following discussion at the multi-disciplinary meeting, the decision was made to attempt removal of the line by a combined endovascular and surgical approach under general anaesthesia.\nUnder general anaesthesia, a cut down was performed onto the left internal jugular vein at the entry point of the catheter. The fibrin sheath was incised and traction on the catheter failed to release it. Simultaneous traction and snaring of the catheter tip via a femoral venous approach was failed. A hydrophilic guide-wire was passed through the catheter and out of a side hole of the line, which was then snared in the right atrium. Synchronous traction was applied to both ends of the line via the snare and the external portion of the line, but the line could not be freed. Balloon angioplasty within the lumen of the line was performed in order to attempt splitting of the surrounding fibrin sheath. Furthermore, upon traction of the external portion of the line, the unusual finding of a palpable transmitted pulse via the catheter was noted. In order to investigate this further, a trans-oesophageal echocardiogram was performed intra-operatively. This showed the proximal portion of the line passing through the tricuspid valve, with its t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman with an intractable pain radiating over the left chest, suggestive of intercostal neuralgia, was referred to our spine center for further evaluation and management. Five weeks earlier, she experienced a ground-level fall, causing severe back pain. According to the initial evaluation conducted elsewhere, she was diagnosed as having OVF of the T10 vertebral body and managed conservatively with a brace and pain medication for one month. Her chief complaint gradually changed from bilateral back pain to an aching pain extending to the left thorax before her first visit to our hospital. What is noteworthy about the history of this case is that 8 years previously, she had had a painful OVF of the T12 vertebral body at the age of 79 years, which was treated with vertebroplasty using hydroxyapatite (HA) blocks and posterior pedicle screw instrumentation followed by iliac bone graft fusion from T11 to L1 at another hospital [].\nOn clinical examination at our hospital, the patient had no neurologic deficits, complaining of nothing but reporting a position-dependent severe chest pain on the left side, which intensified when sitting up from a supine position. Imaging studies revealed neither rib fractures nor abnormal findings of the chest cavity as a possible cause of the chest pain.\nOn the plain radiographs of the thoracic spine (), the anteroposterior (AP) views and the lateral views taken in the supine position showed the IVC within the T10 collapsed vertebral body as a gas-like radiolucent area, which disappeared on the lateral view obtained in the sitting position (i.e., the opening-closing phenomenon) most likely indicating an OVF of nonneoplastic and noninfectious origin [, ]. The lateral radiograph in the sitting position also demonstrated that the fracture line extended through the posterior fusion mass bone, grafted 8 years ago, indicating a potentially unstable flexion-distraction injury. Close observation of the AP radiograph obtained in the sup"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old male was referred to the endocrine surgery team with hypercalcemia and a history of several years of kidney stones. He had first been diagnosed with elevated serum calcium ∼6months prior to his visit in the endocrine surgery clinic but had experienced recurrent problems with nephrolithiasis for several years prior to this. He underwent three lithotripsy procedures and multiple urologic stent placements during this time. Additional symptoms included severe fatigue, weakness and joint pain. Aside from his nephrolithiasis and subsequent renal failure, the patient was otherwise healthy, with no medication use, no allergies, and no history of tobacco or alcohol use.\nSix months prior to our evaluation, at another hospital, the patient underwent failed neck exploration for primary hyperparathyroidism. Pre-operative imaging suggested a right inferior parathyroid adenoma, but bilateral neck exploration including a right thyroid lobectomy was unsuccessful. The initial operation was complicated by transient bilateral vocal cord palsies. The patient was evaluated by an otolaryngologist, and his weak voice and vocal cord palsies resolved without any further intervention.\nHis hypercalcemia persisted and the patient continued to suffer from nephrolithiasis. Despite his multiple urologic interventions, he developed renal failure with a creatinine peaking at 13.5 and requiring temporary dialysis. Parathyroid imaging, including sestamibi/SPECT scan as well as MRI/MRA of the neck and chest suggested an ectopic parathyroid adenoma in the aortopulmonary window (Fig. ). Following consultation with cardiothoracic surgery, the patient underwent a minimally invasive thoracic approach to the mediastinum, followed by conversion to a left posterolateral thoracotomy. Neither approach located the suspected mediastinal adenoma. A median sternotomy was then performed. The entire thymus and all mediastinal fatty tissues were removed without evidence of any abnormality. Finally, the pe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old, Australian Caucasian man who was a national competing power lifter was referred to our specialist sports clinic 8 weeks after experiencing sudden intractable pain in his left knee, accompanied by a loud popping sound, whilst leg pressing 300 kg. Weight bearing and extension of his left leg were subsequently limited as a result of pain. Prior to attending our clinic, he had been managed non-operatively by his General Practitioner and a Physiotherapist, who had provided him with a knee brace for support. Despite this, he suffered continued pain and weakness, but denied any locking, giving way or instability.\nHe was a non-smoker, with no past medical problems and expressly denied using systemic steroids. He had not previously experienced any knee problems. Clinical examination revealed left quadriceps wasting in comparison to the contra-lateral leg with a palpable gap over the superior-lateral aspect of his patella. Knee flexion, in particular squatting, evoked pain and accentuated the gap. This also further demarcated the prominent, retracted vastus lateralis muscle belly (). A normal range of active movement was retained; however power in extension was diminished in comparison with the other leg. There was no extension lag and no clinical evidence of ligamentous or meniscal pathology within the knee joint.\nBlood tests showed no evidence of haematological or metabolic abnormality.\nAnterior-posterior, lateral and skyline patella radiographs of the knee showed no diagnostic irregularity and no evidence of femoral trochlea dysplasia or variation in patella height or tilt. MRI demonstrated a complete and isolated avulsion of the vastus lateralis component of the quadriceps tendon in the osteotendinous region at its patella insertion (). The patient was keen for operative intervention as he had already undertaken a course of unsuccessful conservative therapy and was anxious to expedite his return to training.\nIntra-operative findings confirmed an avulsion of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old female patient presented to the emergency department complaining of severe pain and redness in both eyes.\nThe patient had a clear medical record. She mentioned that she is a regular contact lens user due to myopia and had never experienced problems with her eyes. She had been wearing soft contact lenses for the last six years on a daily wear basis for eight hours per day, seven days per week and used OptiFree Express (Alcon, Fort Worth, Texas) as a disinfecting solution. She claimed to never wear her contact lenses overnight. The patient also mentioned that she had recently switched to a different contact lens disinfecting solution. She started to use Renu fresh multipurpose solution (Bausch & Lomb, Rochester, New York) based on the recommendation of her optician. Finally she mentioned that her lenses, suitable for use for one month, were not used for more than one week, and that the pair currently in use were in fine condition.\nBest corrected visual acuity was 20/20 on both eyes despite the fact that a sense of blurred vision was reported.\nSlit-lamp examination revealed two infiltrates, approximately 1,5 mm in size, at 4 and 7 o'clock in the inferior part of the cornea in the right eye and five smaller infiltrates in the superior half of the left cornea. The infiltrates appeared to extend to the middle stroma. Furthermore, conjunctival redness and moderate anterior chamber inflammation were observed in both eyes.\nRegarding management, the appropriate guidelines were applied [].\nImmediately, prior to any action, the infected contact lenses and a specimen of the disinfecting solution were taken and sent in for culture [].\nInitially, although the patient was informed of her condition and advised to follow the appropriate treatment in her own house, she demonstrated significant anxiety about the way she should administer the medication and subsequently was advised to remain in the clinic for treatment."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man presented with left hip pain and intermittent low grade fever, as well as occasional yellowish drainage from a sinus tract at the surgical incision of a cementless THA performed 4 years before at another hospital. Patient's past medical history was also significant for a 2-vessel coronary artery bypass graft (CABG), performed one year prior to the current presentation. Prior use of steroids, a previous state of immunosuppression, or recent travel was not reported. The patient reported multiple prior hospital admissions due to drainage, allegedly attributed to a superficial infection and suppressed multiple times with multiple courses of per os and/or intravenous antibiotics including vancomycin, clindamycin, ciprofloxacin and cotrimoxazole, only to recur a few months after each episode and antibiotics regimen. Anteroposterior (AP) pelvis, AP and lateral hip radiographs as well as laboratory findings were consistent with PJI, as well as heterotopic ossification adjacent to the left hip joint (Fig. ). Preoperative cultures collected with wound swabs showed Staphylococcus hominis and Staphylococcus capitis isolates of debatable clinical significance; cultures of synovial fluid aspiration were negative. With the assumptive diagnosis of PJI and septic loosening of the implants a joint decision was obtained for a staged THA revision.\nThe patient was scheduled for the first stage THA revision 4 weeks after cessation of any antibiotics. Through a posterior hip approach, the femoral component was removed via a Paprosky-style extended proximal femoral osteotomy . Next, the acetabular cup and supporting screw were removed (Fig. ). Eight tissue samples were obtained from the bone, joint capsule and femoral canal for cultures, and the implants were sent for sonication. We routinely use sonication to identify bacteria in the biofilm on explanted implants, as this method has been found to be significantly more sensitive than tissue biopsy, while maintaining almos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female patient presented with cough and mild dyspnea to the outpatient department. She had a history of being diagnosed with pulmonary tuberculosis 7 years ago, which she had completely recovered after 6 months of antituberculosis drug regimen. There was no other notable history. Dullness and decreased breathing sound at the left side was noted after auscultation. Complete blood count revealed no abnormal finding, and no acid-fast bacilli was discovered on the sputum culture test. Plain chest radiography showed giant bulla in the left lung and subsegmental consolidation in the left lower lung field. Chest computed tomography (CT) scan revealed the left upper lobe of the lung being replaced by bullae of various sizes, and subsegmental consolidation had broad contacted with bullae at the lingular segment of the left upper lobe (). The right lung showed no abnormality. The patient's pulmonary function test signified moderate obstructive respiratory failure. Wedge resection of the left lung using video-assisted thoracoscopy was performed under the preoperative diagnoses of giant bullae and pulmonary emphysema. During operation, the left lower lobe was found to be severely compressed by the bullae. Gross examination of the wedge resected lung was 15 × 9 × 4 cm in size with dilated giant bullae (). Spongiform emphysema was observed at the cut surface, and there were partial solid changes and fibrotic progression. Examination of the solidified sites by light microscope indicated general emphysematous changes with destruction of the alveolar wall in addition to numerous tissues replaced by structures similar to the chorionic villi. The villous structure was adjacent to, or in some cases adhered to, the destroyed alveolar wall and interlobular septa. Immunohistochemical staining of the epithelium lining the villous structure was partly positive for thyroid transcription factor-1, and the interstitial cells at the core was positive for CD-10, D2-40 and vimentin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old male was referred to his ophthalmologist regarding the complaint of sudden blurriness of vision in his right eye. He was diagnosed five months ago with a case of ENKTCL, nasal type, stage IV-B with testicular and central nervous system involvement with 23% natural killer (NK) cells on cerebrospinal fluid (CSF) flow cytometry. He was on an active therapeutic plan consisting of cycles of chemotherapy (i.e., SMILE protocol: dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide), to which there was a complete response in the form of negative flow cytometry and computed tomography (CT) of the chest, abdomen, and pelvis. Five months after the initial diagnosis, prior to the fourth cycle of treatment, a complaint of blurriness of right eye vision was made. Brain CT was done aiming to rule out ocular involvement, which turned out to be unremarkable. At the time of the complaint, visual acuity was 20/30 -2 in the right eye as opposed to 20/20 in the left eye. The right eye showed relative afferent pupillary defect. Extraocular muscle movements were competent in both eyes. On examination of the anterior chamber, +1 cells were visualized in the right eye only. On dilated fundus examination, there was vitritis in the right eye which obscured the vision. Left eye examination was insignificant. B scan ocular ultrasonography revealed retinal detachment in the right eye. An optic CT revealed vitritis in the right eye; an impression of disease infiltration of the eye was made. The therapeutic plan was a diagnostic vitrectomy followed by systemic therapy. A pars plana vitrectomy was made and the vitreous specimen was sampled revealing the presence of 10% viable lymphoid cells expressing CD2 and CD56 on immunohistochemistry stain. An orbital magnetic resonance imaging (MRI) was ordered revealing evidence of an enhancing retinal lesion centered on the optic disc with diffuse restriction consistent with lymphomatous infiltration; minimal proptosis of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man with severe chronic obstructive pulmonary disease (COPD) presented with a feeling of fatigue, weight loss, and reduced physical activities. He was diagnosed with COPD at the age of 69 years and had retired from work the following year. His smoking history included 40 cigarettes per day between the age of 14 and 69 years; his airflow limitation was classified as severe by the Global initiative for Chronic Obstructive Lung Disease; and a chest computed tomography (CT) scan showed severe emphysema. He had started long-term oxygen therapy at the age of 72 years and is currently inhaling 3 L/min of oxygen. Medical and family histories were otherwise unremarkable. Cardiac ultrasound excluded comorbid congestive heart failure or pulmonary hypertension, and CT pulmonary arteriography also excluded chronic pulmonary thromboembolism. As the patient had a history of acute exacerbations of COPD more than twice a year with extreme respiratory symptoms, he was prescribed a combination of inhaled long-acting antimuscarinic antagonist, long-acting beta2-agonist, corticosteroid, and oral carbocysteine, ambroxol, and theophylline. He reported symptoms of dyspnea on exertion, depression and anxiety, and a decrease in physical activity. He also experienced anorexia with a weight loss of more than 5 kg in a year, and no other possible causes of weight loss, such as tuberculosis and malignant tumor, were observed. Therefore, in addition to respiratory pharmacotherapy, we prescribed an antianxiety drug and provided nutritional supplement therapy, patient education, and pulmonary rehabilitation. However, the patient's mental and physical symptoms did not improve after 4 months. Furthermore, he exhibited deterioration in activities of daily living as well as physical and mental weakness; hospital visits were difficult and therefore, he considered home care. Persistent weight loss, poor endurance and energy, and low physical activity levels led to the diagnosis of physical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man with known cervical canal stenosis due to ossification of the cervical posterior longitudinal ligament was transferred to an emergency room soon after a falling accident. The patient was alert and had complete tetraplegia, sensory deficits below the C4 cervical sensory level, and progressive restrictive respiratory failure that required assisted ventilation, and, eventually, a tracheostomy. Cervical spine magnetic resonance imaging showed cervical cord compression that was worse at the C3–C4 intervertebral level, and an intramedullary high signal at C3 and C4 vertebral levels, and the patient was managed conservatively. During the conventional weaning process of trials of intermittent spontaneous breathing in the ICU, an unexpected cardiac arrest made both the patient and medical staff reluctant to proceed with further weaning. Fifty-eight days after cervical cord injury, the patient was transferred to our hospital for further rehabilitation. He was fully conscious and received pressure-support mechanical ventilation with back-up rates of 16 breaths. He had total tetraplegia below shoulder girdle muscles with a preserved sensation from C2 to C3 on both sides, and a urinary obstruction. The limbs and trunk were stiff with contracture, and muscle stretch reflexes of the limbs were abolished. Neurological level of injury was C3 according to the ISNCSCI, with a total sensory score of four. There was no sensory sacral sparing, while the deep anal pressure was preserved, and the American Spinal Injury Association scale graded B. Chest roentgenogram and computerized tomography showed bilateral, widespread atelectasis. The patient occasionally showed signs of pulmonary infection. Intensive pulmonary care and rehabilitation, including physical support for expectoration, mechanically assisted removal of tracheal secretions (CoughAssist E70®, Philips Japan, Tokyo), ventilator muscle training, and management of the spasticity of the abdominal wall, resulted i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old female presented to the ENT department with a short history of severe breathlessness and stridor for 7 days with no history of hemoptysis, chest pain, or change in voice. She gave a history of being operated for uterine fibroids 2 months ago following which she had developed disseminated intravascular coagulation and septicaemia, for which she remained intubated and ventilated for 20 days. Indirect laryngoscopy showed normal vocal cords. Fibreoptic bronchoscopic examination under local anesthesia (performed in a reclining position) preoperatively revealed a tracheal stenosis and computerized tomographic scan (CT) confirmed it to be at the level of lower border of T3. The length of the narrowed segment was 8 mm with an anteroposterior diameter of 0.53 cm []. A diagnosis of tracheal stenosis following prolonged endotracheal intubation was made and anticipating the need for CPB during surgery, the patient was referred to the CTVS department for tracheal resection and end-to-end anastomosis.\nPhysical examination revealed severe respiratory distress. The respiratory rate was 35--40/min, patient had stridor, and was unable to lie supine. She was somewhat comfortable at a reclining position of 60--70°. There was no swelling in the neck, she had an adequate mouth opening with a Mallampati grade I. All routine hematological and biochemical laboratory tests were within normal limits. Arterial blood gas analysis (ABG) was also acceptable with oxygen saturation of 90% and respiratory alkalosis when breathing room air. Institution of CPB via femoral route under local anesthesia was considered necessary, but was not executed due to technical difficulty posed by the patient not being able to lie supine. Hence, as in the first patient, it was planned to perform sternotomy in the reclining position using inhalational anesthetics. A thoracic epidural catheter was inserted before anesthetic induction in the sitting position at the level of T3--T4 (0.2% of ropivacaine wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old girl was referred to Mofid Children’s Hospital with a large necrotic ulcer on his left upper chest, and generalized lymphadenopathy since two months ago ().\nThe ulcer was begun with a small pruritic papule on the left upper chest, enlarged and extended to the neck, and then ulcerated.\nShe had a history of toxoplasmosis presenting with cervical lymphadenopathy, and positive IgM and IgG anti-toxoplasma antibodies, at least 10 months before this ulcer appearance. An excisional biopsy was performed at that time, with result of preserved nodal architecture, follicular hyperplasia and no malignant cells and positive PCR for Toxoplasma gondii infection, so, she underwent following up until the skin ulcer appeared, and then, she was referred for more extensive work up.\nOn physical examination she had a large necrotic ulcer (20 × 10 Cm) with a noma appearance on the chest, and a hyperpigmented plaque (2 × 1 cm) on the abdomen, along with generalized lymphadenopathy and mild splenomegaly.\nAfter debridement of the chest wall ulcer and biopsies of abdominal skin and cervical lymph node, she was treated with ceftriaxone and clindamycin.\nSeveral aerobic and anaerobic microorganisms such as Staphylococcus saprophyticus, Lactobacillus spp., enterococci spp., Staphylococcus aureus and Peptococus niger were isolated from the ulcer culture.\nFurther investigation showed normal bone survey and bone marrow aspiration.\nThoracic computed tomography (CT) without contrast revealed a large lobulated mass in the left anterior chest wall, with extension to the axillary area and several cervical and left supra clavicular lymphadenopathies. (The CT scan was not available in this article). Abdominal and pelvic CT scan revealed mildly enlarged spleen and para-aortic lymphadenopathies.\nCT scan of the neck showed multiple extensive adenopathies predominantly in the left side of the neck and significant soft tissue swelling of the lower neck and chest wall. Brain CT scan was normal.\nRouti"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a 60-year-old right-handed man with past medical history of relapsing-remitting multiple sclerosis diagnosed 20 years ago with prior beta interferon treatment for 8 years and with chronic left residual hemiparesis who presented to the emergency room after experiencing generalized weakness followed by a fall to the ground with apparent loss of consciousness. While the patient reported no loss of consciousness, he did not have memory of the events surrounding the fall. EMS was called and patient was airlifted to the nearest percutaneous intervention-capable center after the ECG showed a ST segment elevation in the leads V1 to V3, so the ST segment elevation myocardial infarction (STEMI) alert was activated. In the emergency department, the patient was without chest pain. Upon further questioning, he denied any family history of heart disease including no cardiomyopathy, heart failure, arrhythmias, or premature or sudden cardiac death. Vitals demonstrated mild tachycardia to 105 beats per minute and a temperature of 38 degrees Celsius, and labs revealed a negative troponin level. Ultimately, the ST segment elevation myocardial infarction (STEMI) alert was cancelled due to the high clinical suspicion of the type 1 Brugada pattern in a syncopal patient with anteroseptal ST elevations without chest pain. Workup for the febrile episode revealed positive serology for influenza B. Oseltamivir was started and the patient completed 5 days of treatment. The patient was no longer febrile and his tachycardia had resolved, but he continued to show a persistent type 1 Brugada pattern on the ECG during the entire hospitalization course as seen below (). The patient subsequently went for a transthoracic echocardiogram which demonstrated a normal left and right ventricular function and no structural abnormalities. He also underwent coronary angiography, which revealed nonobstructive coronary artery disease.\nUltimately, the primary concern was to elucidate, whether the patient'"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 88-year-old male presented in the outpatient surgical setting with a chief complaint of a right groin bulge that had been present for 6 weeks. He had sharp pain initially when he first developed the abnormality but had been asymptomatic ever since. He did not recall any inciting factors. He was concerned that a previously repaired right inguinal hernia had recurred from its original tissue repair in 1977. Details of the original right inguinal hernia repair were unknown to the patient, other than no implantation of mesh occurred. On physical examination, a 3 cm × 3 cm firm, nontender mass was palpable in the right groin just lateral to the pubic tubercle. A computed tomography scan of the abdomen and pelvis was performed to elucidate the cause of the mass in his groin (Figs. , , and ). The imaging was relevant for a right inguinal hernia with the appendix present within the sac. Preoperative laboratory testing revealed a white blood cell count of 4.7 × 109/L. The patient elected to proceed with surgical intervention for hernia repair.\nThe patient presented to the hospital setting for his elective right inguinal hernia repair. A classic oblique incision was made in the right groin using the anterior superior iliac spine and pubic tubercle as landmarks. The external oblique aponeurosis was opened and the hernia isolated and examined. The hernia was noted to be comprised of an extremely hard and dense amount of omentum that had a chronic, scarred appearance. The base of the appendix could be seen exiting the internal inguinal ring, but the densely adhered omentum prevented reduction of the appendix back into the peritoneal cavity. Initially, there was no indication to perform an appendectomy at the time of the procedure if the appendix could be successfully reduced into the abdominal cavity. However, the chronic appearing adhesions in the area prevented this step. In order to reduce the appendix at that point, a relaxing incision was then made in the typical transve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old Caucasian man was admitted for an elective balloon aortic valvuloplasty for critical aortic stenosis. He had a significant cardiac history including congestive cardiac failure, permanent pacemaker and mitral valve replacement and was on subsequent long-term warfarin anticoagulation. Interestingly, he had a prior left ICS from a spontaneous iliolumbar branch artery bleed that was treated with embolization and fasciotomy from which he made a complete recovery.\nDuring this admission, balloon aortic valvuloplasty was attempted with right femoral artery access obtained via a right groin puncture; unfortunately, the patient became hemodynamically unstable and the procedure was abandoned. Two weeks later, the patient started complaining of severe pain in the right hip. Examination revealed extensive bruising overlying the right groin and decreased hip flexion on the right side with diminished power in the L3–S1 myotomes. Additionally, there was patchy loss of sensation to the anterior right thigh and the dorsum of the right foot. A Doppler ultrasound of the right groin was performed which revealed a 2 cm false aneurysm in the right groin medial to the right common femoral artery. A non-contrast computed tomography (CT) scan was also performed which revealed areas of mesenteric stranding in the right iliac fossa with an enlarged right iliacus muscle measuring 7 × 6.5 cm. The iliacus muscle demonstrated subtle low-attenuation areas in keeping with an iliacus hematoma (Fig. a and b).\nUltrasound guided thrombin injection was performed to treat the pseudoaneurysm. A follow-up CT angiogram demonstrated successful thrombosis of the right CFA pseudoaneurysm and a stable iliacus hematoma with no active iliac arterial extravasation. The patient was taken to the operating theater for an iliacus fasciotomy and hematoma evacuation.\nOn exposure, the retroperitoneal layer was reflected medially and the neurovascular structures were identified and protected. The right iliac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old primigavida with 29.3 weeks of gestation was admitted in our institute for termination of pregnancy, as her routine anomalous ultrasonogram (USG) done at a primary center revealed defective development of spine, atrial septal defect (ASD), aplasia of the right kidney, and encephalocele. The mother's routine blood and biochemical investigations were within normal limits. She was not a known diabetic or hypertensive and had a history of nonconsanguineous marriage. She gave a history of iron and folic acid tablets supplementation. A repeat USG done at our institute confirmed the above-mentioned anomalies. In view of multiple nonviable anomalies, with the informed consent of the parents, the pregnancy was terminated and abortus was sent for pathological examination.\nAt autopsy it was a fetus of ambiguous genitalia, weighed 900 g. The head was enlarged, severely retroflexed, and there was no neck. Head was seen directly resting on the chest and mandibular skin in continuous with chest skin surface. The ears were low set [] and the vertebral column was short and irregular. There was an omphalocele with partly covered membrane containing liver, bladder, and intestine as contents. Lower limbs showed bilateral clubfoot. There was overgrowth of upper limbs compared with lower limbs []. Posteriorly the skin of the scalp was thick and extended up to lumbar region [] Radiograph of the abortus revealed hyperextension of the neck with occiput touching the cervicodorsal vertebra with soft tissue continuation on the dorsal aspect of the neck. Cervical and thoracic vertebra showed defective block vertebra with thoracolumbar lordosis suggestive of iniencephaly []. Autopsy of the fetus revealed two lobes in the right lung with hypoplasia of both the lungs []. Cardia showed ASD [Figure and ]. There was an accessory spleen in the greater omentum []. Both the testes were seen in the inguinal canal. On opening the cranial cavity, there was defect in the development"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old African–American male presented with a gunshot wound through the left face and neck. On exam the patient was noted to be pulseless and apneic. After resuscitation, initiation of a mass transfusion protocol and return of spontaneous circulation, the patient was GCS 11 (E4V1TM6) and was noted to have no movement in any extremities. A computed tomographic (CT) cervical spine scan and CT angiography of the neck revealed a bullet trajectory through the left C2–3 facet with fractured c3 posterior elements and a bullet fragment at the C3 level, a left vertebral artery dissection, and left internal and external carotid artery transections (). The patient underwent an emergent tracheostomy, neck exploration, left ICA/ECA ligation and partial wound closure. This was followed by endovascular embolization of the left vertebral artery. The patient was noted to have serosanginous drainage from the neck wound consistent with a CSF leak. After an unsuccessful trail of conservative management, a lumbar drain was placed and confirmed with fluoroscopic guidance without CSF egress. A magnetic resonance imaging (MRI) scan of the cervical spine was obtained which demonstrated a pronounced CSF fistula and a complete obstruction of the CSF space at the C3–6 levels ().\nAn EVD was placed in the intensive care unit after informed consent was obtained. The EVD was placed under sterile conditions using local anesthesia consisting of lidocaine with 1% epinepherine and mild conscious sedation consisting of 5 mg of diazepam, and 2 mg of morphine. Ten milliliter of CSF was drained every hour. The EVD was exchanged on Day 14 as customary at our institution due minimal but persistent CSF leak. CSF diversion was continued for a total of 25 days due to the large size of the wound and the initial partial closure. The external drain was removed after a successful 48-hour clamp trial. There were no complications associated with the csf diversion. The patient remained free of CSF"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old Japanese man with a history of distal partial gastrectomy for gastric cancer 10 years earlier was admitted for surgical treatment of intrathoracic esophageal cancer (T3, N2, M0, stage III). He underwent subtotal esophagectomy with three-field lymph node dissection and removal of the remnant stomach with the abdominal lymph nodes. The alimentary continuity was reconstructed with a pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. Anastomosis of the esophagus and jejunum was carried out instrumentally with a circular stapler. A postoperative enteral contrast examination showed smooth passage and no deformity of the reconstructed jejunum. The patient was discharged about 4 weeks postoperatively. About 6 months after the esophagectomy, the patient was readmitted to our hospital because of abdominal discomfort and vomiting. His vital signs were stable and unremarkable. He was thin, with a body mass index of 18.6 kg/m2. Physical examination revealed that the pedicled jejunum through the antethoracic space was markedly dilated and the abdomen was soft and flat (Fig. ). Laboratory data showed only leukocytosis with no other remarkable findings. A chest roentgenogram revealed an increased cardiothoracic ratio of 70%, and an enteral contrast study showed a bird’s beak deformity. The swallowed barium remained static in the reconstructed jejunum. Computed tomography of the thoracoabdominal region showed the reconstructed jejunum within the pericardium anterior to the heart (Fig. ). We diagnosed the patient with IPDH after esophagectomy and performed an emergency laparotomy. Upon opening the abdominal cavity, we found that the reconstructed jejunum had herniated into the pericardium through an approximately 4-cm-diameter diaphragmatic defect without a hernia sac (Fig. ). The herniation was easily reduced, and t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female known case of hypertension and diabetes on treatment had undergone bilateral total knee replacement in 2002. The patient was treated with oral bisphosphonate therapy for osteoporosis, 70mg alendronate once a week orally from 2003 to 2007 (4 years) and then from 2009 to 2013 (4 years). The patient presented to the hospital in January 2013 with pain in the right side of the jaw and pain during mastication since 6 months. From her history, clinical examination and radiological findings she was diagnosed to have osteonecrosis of her right posterior body mandible (). This was treated by way of sequestrectomy and saucerization in January 2013 () and stoppage of Alendronate. There was no history of the patient having any dental procedure while on alendronate. In March 2013, she was admitted with complaints of pain and swelling over the right thigh following a history of trivial fall, and after clinical examination and history taking, X-rays were done which showed an atypical right displaced subtrochanteric fracture through the focally thickened lateral cortex of proximal femur (). The fracture was managed surgically with proximal femoral nailing (). The knee replacement was unrelated to the sub-trochanteric fracture. For the subtrochanteric fracture of femur, regular follow-ups were done postoperatively with serial X-rays. Blood investigations were done, and serum calcium was 9.5mg/dl, and serum Vitamin D3 was 20ng/ml which was optimized with 6,00,000 IU of intramuscular Vitamin D3 and maintained by oral Vitamin D3 medications. At 3 months, the fracture was in delayed union (), and hence, the patient was started on injection Teriparatide 20mcg subcutaneous for a period of 18 months. The patient was kept non-weight bearing. The 6 months X-ray showed further progression in fracture healing (), and the patient was allowed partial weight bearing. In October 2013, 10 months after stopping Alendronate, she again came with the complaint of pain in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old female arrived to the emergency room after experiencing a ground-level fall. The initial physical examination revealed that the patient had a left upper limb abduction 4/5 weakness with mild C5 dermatome hypoesthesia. Vitals were found to be stable, and other than a previously diagnosed essential tremor, the patient was found in her usual state of health. Initial neck computed tomography (CT) revealed a C5 fracture involving the body, left traverse process and transverse foramen, and mild anterolisthesis as well as C6 left transverse process comminuted fracture. Neck CT angiography revealed slight contrast extravasation at C6 transverse process region with normal vascular reconstitution above and below the injury level. Cervical spine magnetic resonance imaging disclosed a C4-5 disc bulging with concomitant T2 cord hyperintensity and soft tissue enhancement which in the setting of acute trauma was believed to correlate with spinal cord contusion and an associated ligamentous injury [].\nDue to the high suspicion of instability, the patient was admitted for emergency spinal stabilization surgery. Soon after admission, the patient's hemodynamic status was compromised due to an unstable supraventricular tachycardia that required aggressive medical management and prevented from pursuing surgical stabilization due to the high cardiac risk associated. The patient's family was oriented regarding the related risks and at that time family refused surgical treatment.\nSoon after the patient's recovery, she was discharged home with a rigid cervical orthosis for conservative management and was subsequently followed in sequential outpatient visits. The patient's clinical course was marked by deterioration of the left upper limb weakness, mainly abduction and handgrip as well as anesthesia. Follow-up imaging revealed worsening of C4-5 anterolisthesis due to vertebral subluxation []. After proper medical and cardiac risk assessment, a decision was made to admit the pa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25 year old female was diagnosed of CVID in 2006 (at age of 18) with initial presentation of recurrent episodes of bacterial sinusitis and outbreaks of genital herpes. Laboratory work revealed hypogammaglobulinemia with poor antibody responses to both polysaccharide and protein antigens. She was found to have IL-2-Inducible T-cell kinase (ITK) mutation, which is potentially involved in the pathogenesis of her CVID. She was started on IVIG and has been receiving it every month.\nThe patient has additional history of type 1 diabetes diagnosed at 18 months of age, for which she has been depending on insulin, as well as immune thrombocytopenia purpura (ITP) diagnosed at age of 11. She had multiple episodes of recurrent thrombocytopenia managed with IVIG and corticosteroids. In 2002, at the age of 14, she was hospitalized with a presentation of fever and pain, and found to have lymphadenopathy, lymphopenia, neutropenia, and thrombocytopenia. An extensive infectious workup was negative. She had bone marrow biopsy, which was unremarkable with the exception of findings consistent with cytopenias. She ultimately underwent a splenectomy and lymph node resection in 2002. Lymph node and spleen pathology revealed noncaseating granuloma. After the splenectomy, her fevers and pain resolved. Her blood counts have remained relatively normal since splenectomy.\nIn June 2013 when she was 25 year old, she presented with left flank pain and fever. A CT scan showed diffuse lymphadenopathy in chest, abdomen, and pelvis with the largest node measuring 4.7 × 2.9 cm in the mid abdomen. A biopsy of left peri-aortic lymph node showed non-necrotizing granulomatous inflammation. Extensive infectious disease and rheumatology workup were all negative. She was started with prednisone 60 mg daily for 7 days before being tapered down, with clinical improvement. In September 2013, she was hospitalized again with abdominal pain and fever. A PET scan was done and showed extensive hypermetabolic lymphade"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 85-year-old female with known history of anxiety disorder, coronary artery disease, diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident (CVA) and chronic anemia was sent to the emergency department by the family for acute encephalopathy. Patient was diagnosed with a UTI 3 weeks prior to presenting to the emergency department and finished a course of antibiotics but was still feeling weak. Hence, a chest x-ray was done by the primary care provider during the follow- up appointment which showed findings concerning for pneumonia and a CT of the chest was done along with a SARS-CoV-2 PCR test. Patient had a positive SARS-CoV-2 PCR test 2 days prior to presenting to the emergency department. Patient had mild cognitive impairment at baseline as noted by the family and was currently being worked up by the primary care provider as an outpatient. According to the patient’s daughter, they were able to notice some personality changes going on for at least 4 to 5 months prior to her admission. Patient was alert and awake but was not oriented to time, place, person and situation. She was not in any acute cardiorespiratory distress. She denied to have fever, chills, chest pain, chest pressure, shortness of breath, abdominal pain, nausea, recent changes in bowel or bladder habits. She was only able to recall her first name and could not recall her last name or date of birth. A thorough investigation was done in the emergency department and laboratory work up of note showed hyponatremia, hyperglycemia, elevated CRP,elevated erythrocyte sedimentation rate (ESR),elevated procalcitonin, microcytosis with hypochromia with mild anemia and thrombocytosis and elevated D-dimer (Table ).\nUrinalysis was done in the emergency department which did not indicate an infection. CT of the head without contrast showed no acute intracranial process, cortical atrophy and mild chronic small vessel white matter ischemic disease; old infarct in the right posterior"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old woman was admitted with acute onset of short-term memory loss, intermittent headaches, dizzy spells and an obvious change in personality which had progressed over a ten day period. Intermittent vomiting, confusion and unsteadiness were also reported. These symptoms worsened over the three days prior to admission. Her past medical history included an episode of herpes simplex virus infection about one month earlier. A non-smoker, she consumed alcohol in moderation.\nOn examination, she had disorientation of time and place and her mini mental score was found to be 2/10. Confusion with nominal aphasia was also noted. She was apyrexial. Cardiovascular, respiratory and gastrointestinal system examination was unremarkable. Neurological examination showed normal power and tone in both arms and legs with normal symmetrical deep tendon reflexes. Her gait, coordination, cranial nerve and fundus examination were normal.\nInvestigations revealed a normal full blood count and unremarkable routine biochemical tests and inflammatory markers. Contrast enhanced CT of the brain showed low attenuation areas adjacent to the anterior ends of both thalami. Appearances were reported as an unusual form of cerebral infarctions and it was suggested that other pathology could not be ruled out.\nExamination of CSF revealed isolated lymphocytosis. Glucose and protein were normal. Polymerase Chain Reaction (PCR) tests for herpes simplex virus and varicella zoster were negative.\nElectroencephalogram (EEG) recordings showed intermittent low frequency activity suggesting focal abnormality of cortical function, probably associated with a vascular or structural lesion but no clear evidence of encephalitis or epileptiform activity. On MRI scan (Figure ) of the head there were bilateral symmetrical lesions in both thalami giving high signal changes on the T2 weighted and proton density images. In addition there were asymmetrical multiple high signal areas on T2 weighted images in both cerebe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a 40-year-old male with a history of chronic back pain and a recent, acute progression of bilateral lower extremity paresthesias and weakness. Over a seven-day period prior to presentation, the patient experienced a sudden onset of bilateral leg numbness, with no history of trauma or another precipitating event. The right leg was affected more severely than the left, traveling primarily in a distribution down the lateral leg into the dorsum of the foot and great toe. He eventually began having a shooting pain in this same distribution. He also reported a progressive weakness with bilateral ankle and toe dorsiflexion and five days duration of perineal numbness and mild urinary retention. On exam, he was unable to dorsiflex his ankles or great toes against gravity and had reduced sensation in the lateral aspect of both lower legs and the dorsum of bilateral feet. The patient’s Achilles reflexes were also diminished bilaterally, though reflexes were present and brisk at the knee. It is also pertinent that no upper motor neuron signs were present.\nMagnetic resonance imaging (MRI) of the lumbar spine revealed a somewhat heterogeneous, but predominately T2-weighted, hyperintense mass in the left lateral and dorsal epidural spaces (Figure ). There was significant lumbar stenosis present at the level of L4-5 secondary to the mass, with the rightward displacement of the thecal sac. There was no clear connection to the adjacent facet joint although the dorsal mass did seem to be contiguous with the dorsal aspect of the L4-5 disc (Figure ).\nDue to the acute onset of symptoms, as well as the severity of neurologic involvement, the patient was taken to surgery for exploration and removal of the epidural mass. An L4-5 laminectomy was performed, which revealed a very large dorsally migrated disc fragment that erupted as soon as the ligamentum flavum was removed. The large mass, which was displacing the thecal sac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a clinical case report of a 34-years-old pregnant woman with a single gestation. An omphalocele enclosing mixed intestinal and hepatic content was diagnosed at 12th week (). Nuchal translucency (NT) was normal, and no other associated malformations were observed. Parents were counseled regarding ultrasound findings. A genetic study was performed including karyotype, 60K Array-CGH, and methylation-sensitive multiplex ligation probe analysis to analyze the presence of epigenetic and genetic changes related to BeckwithWiedemann Syndrome (BWS), all of them being negative. Parents were informed of the results, as well as the impossibility of ruling out BWS completely despite the negativity of the genetic study, since this disorder is caused by epigenetic defects and there are up to 20% of cases whose diagnosis is clinical and therefore postnatal. After counseling, the patient decided to continue with gestation. The 20th week anomaly scan showed no associated malformations, except a slight upward and leftward heart displacement due to diaphragm elevation. Cardiac function and ductal venosus flow were normal throughout gestation and the heart was structurally normal. At 21st week, the omphalocele content became only hepatic (). Ultrasound controls were scheduled every 4 weeks to rule out the early onset of fetal growth restriction, as well as other disorders. At 37th week the estimated bag size was 51 × 56 mm (). At 38.3 weeks, the patient was admitted because of mild but regular contractions. At 38.4 weeks, a caesarean section was performed with the coordination of the Obstetrics, Neonatology, Anesthesiology, and Pediatric Surgery teams. The newborn weighed 3540 g, Apgar Test 9-10, and pH 7.32 (). A thermal bag covering the whole baby's body was placed immediately after the birth to maintain body heat and reduce the risk of infection (). The baby was admitted in the Neonatal Ward for management and surgical preparation in the first hours, starting parenteral nu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old Caucasian male, with a past medical history significant for tobacco abuse (41 pack-years), presented with shortness of breath accompanied by chest and back pain for two months. Blood workup showed a WBC count of 68,400 cells/µL, with an AEC of 27,360 cells/µL. A computed tomography (CT) pulmonary angiogram was performed, as he was hypoxic, and revealed a 3.6-cm speculated mass within the anterior right upper lobe, partially invading the anterior chest wall. It also revealed mediastinal and hilar adenopathy, an extensive osseous lesion (including compression fracture at T7), and a small pericardial effusion (Figure ). A CT of the abdomen and pelvis with contrast was performed and revealed a diffuse metastatic disease involving the liver, adrenal glands, spleen, and the bones. Magnetic resonance imaging (MRI) of the thoracic spine did not reveal spinal cord compression, but it did show the compression fracture at T7 and multilevel thoracic spondylosis. An MRI of the brain revealed a 5-mm lesion in the left occipital lobe, without edema or mass effect.\nThe hematology-oncology team was consulted for an evaluation of the metastatic disease and the eosinophilia. A core needle biopsy was obtained from a liver lesion and the result came back as poorly differentiated adenocarcinoma of the lung (cytokeratin 7, TTF1, and napsin-A were positive, while cytokeratin 2 and CDX2 were negative). Given his functional status, the decision was made to hold on systemic therapy and start on palliative radiation to the spine for pain control. The plan was to complete radiation sessions and then evaluate his functional status before starting systemic therapy.\nHe continued to have a high WBC count during the admission (Figure ). Therefore, a bone marrow biopsy was performed to rule out a hematologic malignancy and it revealed metastatic adenocarcinoma of the lung with no evidence of a myeloproliferative disorder. The flow cytometry from the bone marrow showed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old female with a past medical history significant for polyarteritis nodosa on immunosuppression with Azathioprine presented to the neurosurgery clinic with progressive right lower extremity shooting pain, numbness and tingling over the past six months. On physical examination, she had trace weakness in right lower extremity dorsiflexion as well as right foot eversion with diminished vibratory and pin-prick sensation in her bilateral lower extremities. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine with and without contrast was obtained which demonstrated a cystic lesion in the conus medullaris spanning the thoracic 11 to thoracic 12 levels (Figure ). This cystic lesion was first identified nine years prior in 2011 (Figure ). At the time of initial imaging in 2011, the patient did not have any neurologic complaints nor did she have any appreciable neurologic deficits on physical examination. A dedicated MRI of the thoracolumbar spine was obtained in 2011 due to an indeterminate finding observed in the conus medullaris on abdominal MRI for workup of abdominal pain. At the time of initial identification in 2011, due to the lack of neurologic symptoms and neurologic deficits, the cystic mass was determined to be an incidental finding with no further intervention pursued. On MRI thoracic spine with and without contrast at the time of her subsequent presentation in 2020, she was found to have interval enlargement (Figure ) of the previously imaged conus medullaris cystic mass (Figure ) which had enlarged over the course of the past nine years. Electromyography (EMG) and nerve conduction velocities (NCV) were obtained with normal results, making a peripheral neurologic process such as neuropathy or radiculopathy less likely. Based on the interval increase in the size of the conus medullaris lesion in the setting of normal EMG and NCV, it was felt the etiology of her current symptomatology and neurologic examination findings were related to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2006, a 25-year-old man, who had sustained a complete left brachial plexus injury with cervical root avulsion and subclavian artery lesion in a motorcycle accident, came to our attention. An exposed distal humeral shaft fracture at the level of the elbow with median and ulnar nerve transection was also identified.\nThe patient was treated in an emergency department with humeral fracture stabilization (Synthes locking compression plate; Synthes, West Chester, PA, USA) and revascularization of the left arm. In July 2006 he underwent surgery of the brachial plexus lesion, with nerve transfers of the distal spinal accessory to axillary nerve and the phrenic to musculocutaneous nerve. Unfortunately he did not show any sign of recovery of the motor function in the left upper limb, and in August 2008 a functional transfer of a gracilis free flap to brachial biceps and a wrist arthrodesis were performed. Over the last 6 years the patient has undergone surgery 3 times and has followed a rehabilitation program.\nFrom the outset, the patient has been treated by searching for symmetry in orthostatic posture. The Global Postural Rehabilitation technique has been used thus far in the course of rehabilitation. Three times per week the patient sustains passive mobilization of each upper limb joint to maintain articular suppleness and prevent stiffness. During the session, the physiotherapist also administers sensitive stimulation to maintain afferent channels.\nAt all times the patient wears splints to place the distal extremity in an intrinsic position for correct articular and muscle length. The whole upper limb is supported by a sling. Postural control, splinting, mobilization, and sensibility rehabilitation have all been included in the rehabilitation program.\nSince 2007 the patient has suffered from neuropathic pain (NP) involving the ulnar side of the forearm, the proximal third of the forearm, and the thumb in both radial (dorsal) and median (volar) regions.\nFrom the out"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.\nPatient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old male patient presented with febrile sensation and anterior chest wall pain with an erythematous ulcerative plaque in the right parasternal area that had become aggravated over a month despite antibiotic treatment prescribed at a local clinic. A swab culture was done, which led to the identification of Citrobacter koseri. The patient was admitted to the general ward for further workup and initiated on intravenous (IV) ciprofloxacin (400 mg every 12 hours).\nThe patient had undergone right upper lobectomy and thymectomy 35 years ago via posterolateral thoracotomy followed by adjuvant radiotherapy. A chest computed tomography scan revealed chronic empyema with a right apical calcified sac with an air-fluid level and chest wall abscess, for which continuity to the pleural space could not be excluded ().\nAn elliptical skin incision was made around the fistula orifice at the second and third intercostal spaces (ICSs) along the right side of the sternum at the costosternal junction. After removing the infected bony chest wall, we entered the empyema cavity and evacuated the pus and necrotic materials. A sump drainage tube was inserted into the cavity for subsequent irrigation and drainage.\nTreatment with IV antibiotics was continued, and daily chest tube irrigation with 1 L of taurolidine-mixed purified water was performed for local infection control. Subsequently, a pleural fluid culture study was performed every 5 days, and no bacterial growth was observed. However, the patient remained febrile for 36 days after the initial operation; thus, we delayed the second stage of the operation. After discontinuing the irrigation using the chemical agent, the patient was afebrile and in a suitable condition for thoracomyoplasty. The first stage of the operation included full thoracotomy and resection of the second to fifth ribs. The thoracic cavity was entered and inspected through the fourth ICS periosteal bed. Severe visceral pleural adhesion to the chest wall was s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48 year old male patient presented to the emergency department with a one hour history of epigastric pain, vomiting and profuse sweating. The patient's medical history was significant for long standing hypertension and chronic heavy cigarette smoking as well as recurrent attacks of chest pains related mainly to exertion and relieved by rest.\nClinical examination revealed an obese restless patient with a blood pressure of 90/60 bilaterally and a regular pulse at 110 beats per minute. The jugular veins were congested with a venous pressure of 15 mmHg above the sternal angle and positive Kussmaul's sign. Cardiac examination revealed normal first and second heart sounds and an S3 gallop but no murmurs or pericardial rub. Chest examination revealed bilaterally equal air entry with normal vesicular breathing and no rhonchi or crepitations.\nElectrocardiogram was performed in the emergency room and revealed Q waves and ST segment elevation in the inferior leads as well as tall R wave and ST segment depression in lead V2 as shown in figure . Right chest leads showed ST segment elevation in lead V3R and V4R as shown in figure . The clinical picture together with electrocardiographic finding suggested a diagnosis of acute transmural infero-posterior associated with right ventricular myocardial infarction.\nImmediately after admission to the emergency room, the patient's conscious level ran a downhill course and he went into deep coma with a GCS of 3/15 and pinpoint pupils. A computed tomography of the brain was performed and revealed no abnormalities. This deterioration was presumed to be due to acute ischemic stroke not yet evident in the initial CT scan. Taking into consideration this sudden worsening of his conscious level and a calculated NIHSS score (National Institute of Health Stroke Scale) of >25 indicating a massive cerebral infarction, it was decided not to administer thrombolytic therapy. We also decided not to undergo primary percutaneous transluminal coronary ang"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old, white male of Greek origin, was admitted in our hospital in December 2008 in order to be treated for a large mass located in the head of the pancreas. The patient had been originally subjected to a routine blood check up, which revealed mildly elevated transaminase levels. He was then referred for an abdominal U/S and eventually for a CT scan on an outpatient basis. Both revealed a large, well circumscribed mass of 6.8 cm in diameter, which seemed to be in direct contact with the head of the pancreas and the inferior vena cava (Figure ). A subsequent MRI of the abdomen showed the mass to measure about 7.3 cm, to have irregular borders and to be located posterolaterally to the pancreatic head. The inferior vena cava was located directly behind the mass, and seemed to be slightly displaced by the tumor. The portal vein was located directly above the mass. Both these vessels did not appear to be directly invaded by the mass.\nEndoscopic ultrasound scan was performed which allowed FNA of the mass. The cytology revealed cells morphologically and immunogistologically indicative of a neuroendocrine pancreatic neoplasm. Subsequently, the patient was referred to our hospital for further surgical and possible antiproliferative therapy.\nOn physical examination the patient was found to manifest periodic choreo - athetosic movements that had appeared in the 3 months that preceded the diagnosis of his pancreatic tumor, to together with polyarthralgia of his limbs’ large joints. The rest of his neurological clinical examination as well as an MRI of the brain were normal. Serum amylase, bilirubin and transaminase levels and all serum tumor markers were within normal range.\nThe patient underwent surgical resection of the tumor by means of a modified Whipple’s procedure and Roux-n-Y reconstruction of the gastrointestinal tract (Figure ). His recovery was uneventful and he was discharged from the hospital 10 days after the operation.\nPathological examination of the s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man presented with an incidental right renal mass after magnetic resonance cholangiopancreatography (MRCP) for investigation of abnormal results of liver function tests (LFTs), which suggested an obstructed biliary tree. The patient had undergone OLT in 2000 after extensive preoperative investigations for cryptogenic liver cirrhosis including serology and radiology. Post-OLT histopathology showed that the native liver had nodules of varying sizes consistent with cirrhosis with no evidence of carcinoma. The patient was started on immunosuppressive therapy with tacrolimus, which was subsequently changed to sirolimus in 2005, and he was followed up quarterly by the liver transplant service at our center.\nOn routine follow-up, the patient was found to have obstructive (cholestatic) LFT results in late 2009. An MRCP was performed and a diagnosis of choledocholithiasis was made, but incidentally a right renal mass was also found. No biliary tree obstruction or liver lesions were noted on this scan. A triple-phase computed tomographic (CT) scan of his abdomen and pelvis further confirmed the presence of a lobulated enhancing mass (55 mm×45 mm in diameter) in the right upper pole extending into the perinephric fat and abutting the right hemidiaphragm () but with a clear plane between the liver and the mass. Again, the hepatobiliary system had no lesions present. He was otherwise asymptomatic with all staging negative for metastatic disease. His case was reviewed at a multidisciplinary meeting where consensus dictated that the mass was likely to represent a primary renal tumor that should be resected. Partial nephrectomy was offered but declined by the patient.\nThe patient underwent a right open radical nephrectomy via a flank approach and resection of part of the hemidiaphragm requiring repair with a synthetic mesh (Gore-Tex patch). There were no obvious liver lesions on careful inspection and palpation. The procedure resulted in 500 mL of blood loss and no pe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male Japanese patient presented to our clinic with an inability to extend his left knee. He had injured his left knee during a jump while playing handball and sustained an avulsion fracture of the tibial tubercle Open reduction and cannulated screw fixation for the tibial plateau fracture had been performed at another institution 10 months before he visited our hospital. However, the rupture of the patellar tendon had been missed during the initial emergency treatment. He complained of patellar dislocation, an inability to run, and difficulty in walking up and down stairs. An examination indicated that his left patella had migrated proximally and was higher than the right (Figure \n). There was evidence of quadriceps wasting, and a palpable gap below the patella was noted. The range of movement was from 0 to 130°; however, there was no active knee extension. The preoperative Lysholm knee-score\n[] was 65 points. Both plain radiography and computed tomography with three-dimensional reconstruction confirmed that there was massive ectopic calcification along the patellar tendon and severe patella alta (Insall-Salvati index, 1.6) (Figure \n). Magnetic resonance imaging indicated the absence of continuity in the patellar tendon and an irregularity in the tibial tuberosity.\nDuring surgery, two-thirds of the patellar tendon mass was found to have been replaced by bone. The bony mass, which was 5.5 × 3.0 × 2.0 cm in size, was removed. Rupture of the patellar tendon from the inferior pole of the patella was identified during the operation. The semitendinosus and gracilis tendons were used to reconstruct the patellar tendon, as described. The ruptured patellar tendon remnant was sutured to strengthen the reconstruction, and the course of rehabilitation proceeded, as described. His knee functions gradually returned to normal, and no pain was reported. He was able to resume his sports activities 6 months after surgery and returned to full training 8 months after surg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old boy presented to THP with a history of fever for 2 days along with headache, arthralgia and myalgia. He did not complain of abdominal pain and did not have bleeding manifestations or any other warning symptoms. On examination, blood pressure was 110/70 mmHg and pulse rate was 100 beat per minute and capillary refilling time was less than 2 s. The abdomen was soft and non-tender and there was no free fluid. Lung fields were clear on respiratory system examination. Rest of the examination was normal. His NS-1 was positive and the PCR appeared as DEN 2 serotype. The patient was managed as having dengue fever. He continued to have fever spikes for 4 days following admission. On the 5th day following admission, he developed postural dizziness, vomiting and heavy diarrhoea. On examination, he was febrile, dehydrated, flushed and had warm peripheries. Blood pressure was 90/60 mmHg, pulse rate was 130 beats per minute and a capillary refilling time of 2 s. Ultrasound examination of abdomen revealed free fluid in the hepato-renal pouch with increased gall bladder wall thickness. He was clinically diagnosed as having DHF complicated with septic shock and gastroenteritis. He was taken to HDU and critical phase monitoring commenced. His c-reactive protein was high 112 mg/dl. Broad-spectrum intravenous antibiotics (ceftriaxone and metronidazole) were started cover the sepsis after taking blood and urine cultures. Within about 1 h, the patient deteriorated significantly and continued to have vomiting and diarrhoea. Blood pressure dropped to 60/30 mmHg and the pulse rate increased to 120 beats/min. Several fluid boluses were given including normal saline and IV Dextran 40. The haematocrit value dropped from 36 to 30 and patient went into decompensated shock with no urine output. He needed continuous transfusion of whole blood amounting to 9 pints over 20 h to maintain blood pressure and urine output. However, there were no obvious bleeding sites."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of EA, a 77-year-old Filipino female, diabetic, hypertensive with a history of coronary artery disease who underwent percutaneous coronary angioplasty of the right coronary artery (RCA) in 2000. One week prior to consult, she complained of occasional chest heaviness aggravated by effort and worsening shortness of breath. She was admitted in the wards and initially managed as a case of acute coronary syndrome and community-acquired pneumonia. Pertinent physical examination findings included the following: BP 100/60 mm Hg, cardiac rate of 77 beats per minute (bpm), respiratory rate of 22 cycles per minute, no neck vein engorgement, bibasal rales, with a systolic ejection murmur heard over the lower left sternal border with no radiation to the carotids. The 12-lead electrocardiography showed sinus rhythm, normal axis, with left atrial abnormality, and LV hypertrophy with secondary ST-T wave abnormalities; chest radiography revealed enlarged heart with LV prominence with mild congestion. Two-dimensional transthoracic echocardiogram was done which showed markedly thickened walls of the left ventricle ( and ) with a peak instantaneous continuous wave Doppler gradient across the basal LV segment of 194 mm Hg, and concentric LV remodeling with segmental wall motion abnormality with preserved systolic function and presence of SAM of the mitral valve with an LV ejection fraction of 57% by Simpson’s. Surgical myectomy was advised but she refused any surgical treatment. ASA was then the treatment option.\nOn the second hospital day, she underwent coronary angiogram which showed patent stent on the RCA with absence of a major septal perforator branch of the LAD artery (). shows how a normal major septal perforator appears on angiogram as it originates from the proximal LAD. This was taken from another patient, a 52-year-old female []. Septal ablation was deferred and she was referred to electrophysiology for evaluation. On the third day, electrophysiologic/ventricu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old male patient presented with a one-week history of bloody otorrhea from the right side. In the past 34 years, the patient had undergone four surgeries to remove the masses from his right parotid gland. Histopathologic examinations performed after the first three surgeries indicated the presence of benign pleomorphic adenomas. The latest surgery was performed nine months ago to remove a 3.3 cm mass from the parotid gland. Following this surgery however, a histopathologic examination revealed a true malignant mixed tumor (carcinosarcoma) composed of poorly differentiated carcinoma and osteosarcoma. Immunohistochemical studies were positive for P53, Ki67, and vimentin, weakly positive for cytokeratin, and negative for Actin and the S100 protein. The patient was given adjuvant radiotherapy after the latest surgery and was doing well except for symptoms associated with irradiation.\nThe patient underwent a follow-up high-resolution CT scan of the temporal bone for the presented symptoms and showed extensive opacification of the right mastoid air cells, posterior petrous bone, middle ear, and the external auditory canal. The imaging appearance raised the suspicion of a recurrent tumor. Excisional biopsy of the external auditory canal mass was performed and confirmed the diagnosis of a recurrent true malignant mixed tumor.\nDuring this hospitalization, a chest radiograph indicated the presence of patchy opacities in his left lower lung field () not seen in previous chest radiographs; this warranted a CT scan for further characterization. A CT scan of the chest showed parenchymal consolidation with some amorphous calcifications (); hence, the possibilities of fungal infection or granulomatous disease were considered initially. This patient had no fever and did not report associated symptoms of infectious or inflammatory respiratory tract diseases; therefore, a CT-guided biopsy of the pulmonary lesion was performed because of the concern of atypical pulmonary meta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old female without significant past medical history presented to the clinic after the results of a routine mammogram revealed the continued presence of a small mass in her right breast. A mammogram dated 3 years prior detected this mass and reported it as small and benign, located inferior to an implant of her right breast. The more recent mammogram findings reported no change in size. The patient was asymptomatic and denied previous history of cancer and no family history of breast cancer, or other malignancies. She denied weight loss, fever, night sweats, or change in appetite. However, she did report mild discomfort with self-palpation to her lower right breast. Her breast implants were placed 28 years ago in Argentina for cosmetic reasons and have not since been revised. Additionally, she reported a long history of smoking tobacco daily.\nTo rule out malignancy, an ultrasound was performed and confirmed the presence of an elongated nodular density benign in appearance. The mass had multiple areas of hyperechoic densities within it and was located at the 8 o'clock position 10 cm from the right nipple. The size was measured to be 3.4 × 1.3 × 3.2 cm, with no evidence of shadowing or implant rupture reported (). The impression of the ultrasound was the presence of a hamartoma, a benign lesion of the breast that corresponded with previous mammogram results. Despite recommendations for a follow-up mammogram at a later date, the patient was referred by her primary care provider for fine-needle biopsy and samples were sent for evaluation.\nBiopsy samples were sent to pathology for analysis using histology, immunohistochemistry, and FISH studies. Histologic sections of the core biopsy fragments showed malignant lymphoma of diffuse pattern. The tumor cells were large in size with anaplastic and focally spindled morphology. Additionally, there were increased mitotic figures and cellular apoptosis. Immunohistochemistry revealed lymphoma cells positive for CD20, PAX5"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman with a medical history of hypertension, chronic obstructive pulmonary disease, osteoarthritis of knees, chronic smoker, and cocaine abuser presented to the emergency department with complaints of painful body rash which appeared within some hours after smoking cocaine. The rash first appeared on her right arm, followed by rash on the right thigh, left thigh, and left arm. This rash was associated with a burning pain, ten out of ten in intensity without radiation and mostly located on her right arm and right thigh. There was no skin peeling or purulent discharge noted. She denied having any oral or genital mucosal ulcer. She denied any physical injury, fall, pruritus, gastrointestinal symptoms, genitourinary symptoms, fever, chills, chest pain, dyspnea, headache, blurring of vision, dizziness or urinary symptoms. She denied any other systemic complaint. Her home medications include amlodipine, albuterol inhaler as needed, and acetaminophen as needed. She has never been prescribed any anticoagulant including warfarin.\nAlthough she has been smoking cocaine for more than 20 years, the first episode of skin rash post cocaine use did not occur until 3 years ago. At that time, the rash also occurred on bilateral legs and she was admitted to a local hospital. She underwent skin biopsy and it revealed vasculitis with fibrin-platelet thrombi consistent with levamisole-induced vasculitis. She was counseled to stop using cocaine and was treated with intravenous steroid followed by tapered dose of prednisone. The next episode of similar rash lesions of bilateral legs developed in 2014 after smoking cocaine and she again responded to steroids treatment. Six days prior admission to our hospital, she used a larger amount of cocaine than usual (200 dollar-worth). She denied any allergy to cold weather, food, or medications.\nInitial vital signs included a temperature of 98°F, pulse rate 98 beats/min, respiratory rate 18 breaths/min, blood pressure 105/72 mmHg, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2007, a 71-year-old woman was diagnosed with DM because of heliotropic rash over the upper eyelids, edema and erythema at the face and the upper extremities, skeletal muscle pain, and progressive weakness of the proximal muscles of her upper and lower limbs. Laboratory tests showed significant elevation of creatine kinase (3.7 times the normal levels) and anti-Jo1 antibodies positivity. Electromyography findings indicated myositis of the proximal muscles, and the muscle biopsy showed perimysial inflammation. She had been a heavy smoker until the age of fifty (more than 20 cigarettes per day), not addicted to alcohol, and she had a history of hypertensive cardiomyopathy. The patient was treated with systemic steroid therapy with good control of muscle pain and weakness and partial remission of skin rash. In July 2008, she was diagnosed with a carcinoma of the right colon with locoregional lymph node involvement and three liver metastases, all localized in the left lobe. Tumor genetic evaluation showed the presence of the BRAF V600E mutation. She underwent right hemicolectomy, subsequent systemic neoadjuvant chemotherapy with oxaliplatin and capecitabine (XELOX regimen) for 4 cycles with significant shrinkage of liver nodules and, in February 2009, resection of hepatic metastases. Systemic chemotherapy with the same agents was administered for additional 4 cycles after radical hepatectomy. A complete remission of clinical and laboratory signs of DM was also observed upon liver surgery.\nThe patient had a relapse-free survival of 7 months, until September 2009, when a computed tomography (CT) scan revealed multiple lung metastases. A parallel recurrence of facial erythema, skeletal muscle pain, and weakness of the proximal muscles was observed. Laboratory tests exhibited also elevation of creatine kinase levels and anti-Jo1 antibodies. A 2nd line chemotherapy with 5-fluorouracil, folinic acid, and irinotecan (FOLFIRI regimen) was administered for 5 months with co"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male, prior to his presentation at our clinical setting, was diagnosed with an osteosarcoma in his left fibula. At the time of the diagnosis, he presented with a painful and progressively enlarging mass over the left ankle which restricted any weight bearing on the affected leg. A contrast-enhanced magnetic resonance imaging (MRI) scan of the lower extremities revealed a well-defined multicystic mass arising from the distal metaphyseal region of the left fibula (Figure ).\nThe mass was subjected to a core needle biopsy and subsequent histological evaluation of the biopsy specimen revealed a collection of hypercellular, spindle polygonal cells with an abundance of osteoclastic giant cells; which provided the tissue diagnosis of an osteosarcoma. Following this diagnosis, the patient presented to our clinical setting for further management. He underwent surgical excision of the tumor followed by the placement of a vascularized fibular bone graft. Following the surgery, the patient was provided with a total of 32 cycles of adjuvant chemotherapy with cisplatin, methotrexate, and leucovorin. He subsequently went into remission. After six months, he presented again with complaints of resurfaced pain in his left leg. A bone scan was performed due to the suspicion of tumor recurrence, which revealed an intense and irregular uptake in the distal segment of the left leg; confirming the reemergence of his primary pathology. The bone scan also showed areas of bony metastasis (evidenced by multiple areas of moderate tracer uptake) in the left maxilla, left parietal bone of the skull and greater trochanter of the left femur (figure ).\nFurther assessment with a contrast-enhanced high-resolution computed tomography (HRCT) scan of the lungs revealed multiple soft tissue nodules of differing sizes in both lungs. Some of these nodules were pleural-based and some showed internal cavitations (with the largest in the right upper lobe measuring 1.8 cm in diameter), which were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14 years old girl was brought to our pediatric emergency unit because of severe hypocromic microcytic anemia detected by her primary care physician who had required blood tests to investigate the cause of reported asthenia and weight loss. Her mother reported that the patient had experienced early satiety and abdominal pain for several months. No history of fever or trauma as well as no dysuria, gross hematuria or recent travel abroad. Reported regular menstrual cycles until 2 months before admission.\nWith regards to the past medical history, a neurosurgical intervention for cranial meningocele of the bregmatic region at the age of 6 years and laparoscopic cholecystectomy for gallstones at the age of 13 years have been reported. At the time of cholecystectomy, hemoglobin was normal as well as hemoglobin electrophoresis. Initially, parents denied that their daughter had any history of eating disorder such as PICA, though alopecia was reported.\nAt physical examination: anorexic habitus, pulse rate of 88 beats/min, respiratory rate of 28/min, very pale skin and mucosae, no evident bleeding nor icterus. Her abdomen was rigid under palpation with a non- compressible mass in the left upper quadrant.\nLaboratory tests, including erythrocyte morphology, confirmed a severe IDA, with normal Serum electrolytes, amylase, thyroid and liver function tests and vitamin B6, B12 and folate at the lower range of norm. Fecal occult blood test was positive.\nAbdominal ultrasound (US) showed perihepatic free fluid and mild splenomegaly (10.5 cm diameter) and computed tomography (CT) scan reported severe gastric dilatation due to organic matter accumulation. The mass completely filled the gastric fundus and antrum and extended into duodenum. Also, small bowel dilatation and air-fluid levels were present (Fig. ). A gastric bezoar was therefore suspected.\nAfter appropriate transfusion of erythrocytes and plasma, endoscopist evaluation was requested. In the light of the large size of the mas"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 34-year-old female who presented to the ED with a one-day history of severe right breast pain with a mass. The patient noted a pea sized mass four months ago. Attributing the mass to her menstrual cycle, she did not seek medical attention until this ED encounter. The patient is not currently on birth control but has taken oral contraceptives in the past. She has never been pregnant and is a nonsmoker with no family history of breast or ovarian cancer. She has no history of breast surgery and menarche was at 13 years old. On exam, there was a palpable, dominant mass in the right breast at the 12 o'clock position measuring 4 cm by 2.5 cm in greatest dimension. The mass was mobile and there was no induration, drainage, fluctuance, erythema skin dimpling, nipple retraction, nipple discharge, peau d'orange, palpable lymphadenopathy in the bilateral axilla(s), lymphedema of the bilateral arm, or palpable masses in the left breast. The ED physician attempted to aspirate and drain the mass, which was unsuccessful. She was then given Motrin and clindamycin for suspected abscess and told to follow up at a breast center for imaging. No imaging was done in the ED. Three weeks later the patient was seen at a breast health and imaging center and completed a mammogram, ultrasound, and biopsy.\nMammogram demonstrated an irregular mass measuring 29 mm in longest dimension at 12 o'clock at a distance of 7 cm from the nipple at the site of palpable mass (Figure and Figure ). Coarse heterogeneous calcifications were noted in the mass. The breast was heterogeneously dense which may have lowered the sensitivity of mammography.\nRight breast ultrasound demonstrated a solid mass measuring 29 x 17 x 28 mm at the site of the clinically palpable mass at 12 o'clock at a distance of 7 cm from the nipple (Figure and Figure ). The characteristics of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-month-old girl was referred to a tertiary eye hospital for management of her left microphthalmos. She was born at 37 weeks by caesarean section weighing 1.26 kg following a complicated pregnancy. Her mother had experienced moderate reflux and recurrent gastritis as well as one episode of gastroenteritis during the tenth week of pregnancy; she did not suffer infection or nutritional deficiency. There was no history of medication use during pregnancy. The mother was monitored intensively during the third trimester for intrauterine growth retardation. The patient spent 3 weeks of the post-natal period in a special care baby unit for weight gain, requiring minimal respiratory support and an incubator for 3 days.\nAt term corrected age, her left eye appeared microphthalmic with an unusual fundal appearance, whilst her right eye appeared normal. Three months later, she was not showing any reproducible fix and follow responses with either eye, she had a reduced gaze preference to the left, but no abnormal eye movements were noted. There was an afferent pupil defect of the microphthalmic left eye with minimal pupil constriction to light. Both corneas and lenses were clear; irides were brown and well pigmented. Her skin and fundus were also appropriately pigmented. Her left eye appeared clinically microphthalmic with a microcornea as the central horizontal corneal diameter measured 7.5 mm (reference range of 9.0–10.5 mm []).\nDilated fundus examination of the left eye revealed a large nasal chorio-retinal coloboma, a rudimentary ‘optic nerve head' and no discernible macular reflex or foveal pit. The right eye appeared structurally normal with a healthy disc, normal macular appearance, and normal horizontal corneal diameter.\nUnexpectedly, the ultrasound b-scan measured an axial length of 15.3 mm right eye and 15.7 mm left eye. This was supported by the MRI of the brain and orbits (Fig. ), which showed a longer globe length of the left compared to the right"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman (gravida 1, para 1, and abortion 1) was referred due to the pelvic mass which was found by the transvaginal ultrasound in private clinic. Transvaginal ultrasound demonstrated a large irregularly marginated solid mass in the pelvic cavity. She denied the abdominal bloating and the pain except for the vaginal discharge. Her appetite, bowel and urinary function were normal with no recent weight loss. The medical history was unremarkable; there was no history of the abdominal surgery, gynecologic disorders, and family history was not notable. On the physical examination, there was no palpable mass in the abdomen and the cervix appeared normal. Laboratory tests, including tumor markers (CA-125, CEA, and CA-19-9) were within the normal range. Pelvic computed tomography (CT) revealed a 12×9 cm2, lobulated and well-enhanced mass (). Expected origin was the left ovary and the patient was underwent laparoscopic surgery. On the laparoscopy, the uterus and both sides of adnexa were appeared normal. The tumor was not originated from ovary and located in the presacral retroperitoneal space. The tumor was bluish-colored, and adhered densely to the adjacent tissues. The surface of tumor was fragile to bleed easily during dissection (). Since the mass was large and fixed with adjacent tissue, the mass was removed with several pieces. The frozen section biopsy (FSB) was conducted with those pieces. The FSB test result revealed the stromal tumor which cannot be excluded the chance of malignancy. We decided to the laparotomy considering result of FSB. After midline incision, the whole abdomen, including appendix, liver, and diaphragm, were explored carefully and revealed no other abnormalities. Tumor was adhered to the sigmoid colon on the right side of the pelvis and to the iliac vessels and the ovary on the left side of the pelvis. During the sharp dissection around tumor, the left internal iliac vein was injured. It caused fatally massive hemorrhage"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old woman presented with multiple episodes of recurrent upper abdominal pain associated with retching and vomiting. All episodes were treated at home with intramuscular metoclopramide, not requiring hospitalization. Her clinical examination noted only mild tenderness on upper abdominal examination. Haematological and biochemical profiling was performed, as were plain abdominal X-ray and abdominal sonography, and all were normal. She also underwent an endoscopic examination of the upper digestive tract, which revealed a suspected stomach rotation. Following this, the patient ingested a barium meal that showed an organo-axial rotation of this organ, confirming the presence of a volvulus. The patient was treated with nasogastric drainage, intravenous fluids and proton pump inhibitors. She was offered definitive surgical treatment for her condition by laparoscopic gastropexy.\nLaparoscopy was performed under general endotracheal anaesthesia. A carboperitoneum of 12 to 14 mmHg was created through umbilical Veress needle insertion. A number 10 trocar was placed here for camera passage. A number 10 trocar was inserted in the right iliac fossa and a number 5 trocar was inserted in the left iliac fossa. A great number of peritoneal adhesions were found on examination of the abdominal cavity. No macroscopic diaphragmatic defect was found. A laxity of gastrocolic and gastrophrenic ligaments was found, associated with a medium-grade gastrectasis.\nThe major curve was approached by making an opening into the gastrocolic omentum, which was divided from the antrum to the fundus and skeletonised using an ultracision harmonic scalpel. Four Ethibond 2/0 seromuscular sutures were later placed, using the trocar ports to introduce the strands. The sutures were placed on the anterior wall of the stomach (two near the fundus on the major and lesser curve side and two on the gastric body on the major and lesser curve side). The needles were cut off, retrieved and both ends of the s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n62-year-old woman with medical history significant for aortic stenosis and chronic atrial fibrillation presented to the emergency department with fatigue and progressively worsening shortness of breath with minimal exertion. She was asymptomatic at rest and denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, leg swelling, presyncope, or syncope. She was incidentally found to have a systolic murmur during her pregnancy 20 years prior to this presentation. Notably, she had been offered aortic valve replacement in the past but declined.\nVital signs were normal with blood pressure of 110/60 mmHg, pulse rate of 79/min, temperature of 97.2°F, and respiratory rate of 16 breaths/min with normal oxygen saturation of 100% on ambient air. Physical examination was significant for irregularly irregular heart rhythm, and ejection systolic murmur was loudest in the aortic area with radiation to the carotids. Her lungs were clear to auscultation, and no pedal edema was noted. Electrocardiogram revealed atrial fibrillation with voltage criteria for left ventricular hypertrophy. Her most recent transthoracic echocardiogram revealed a thickened calcified aortic valve with decreased excursion with 4.6 m/s velocity suggesting a peak of 86 mmHg and mean of 36 mmHg suggestive of severe aortic stenosis. No other significant valvular abnormalities noted. Cardiac catheterization revealed widely patent coronary arteries.\nBased on the presence of worsening symptoms and the risk of sudden cardiac death, the decision was made to proceed with surgical aortic valve replacement. Given her history of chronic atrial fibrillation, she was also planned for left atrial appendage exclusion and Cox Maze IV procedure simultaneously with the aortic valve replacement. Intraoperative transesophageal echocardiogram revealed quadricuspid aortic valves confirmed during surgical exploration (). The native stenotic quadricuspid aortic valve leaflets were excised, and a 21 mm Saint Jude Medical Trifecta val"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old primigravida was referred to our tertiary care hospital with a suspicion of either a chorioangioma of the placenta or a placental teratoma on the second-trimester anomaly scan performed from a secondary care hospital. The patient had no known comorbidities apart from being diagnosed with pregnancy-induced hypertension. The conception was planned and was not assisted by any interventional or medical means. There was no history of congenital anomalies in the family or of twin pregnancies. Ultrasonography at our institution revealed a single intrauterine fetus, corresponding to 27 weeks and two days of gestation, displaying a normal interval growth from the previous ultrasound. The presence of a multiloculated cystic mass with septations and calcifications was also noted. This mass was devoid of any vascularity (Figure ).\nOn color Doppler examination, no vascularity was noted and the mass, reported as measuring 104 x 53 mm, appeared as arising from the anterior wall of the uterus. The differential diagnosis of placental teratoma, chorioangioma, hemorrhagic placental degeneration, or degenerating fibroid was considered. A repeat scan in the third trimester revealed the same findings.\nAt 36 weeks and five days of gestation, the patient gave birth, via C-section, to a fetus with good Apgar scores (9/1, 9/5). A second congenitally malformed fetus was also delivered, which was devoid of cephalic end structures. Only the feet and lower limbs of the fetus were discernable (Figure ). A single placenta measuring 515 grams was also delivered, containing two umbilical cords. The patient was discharged in a stable condition on the sixth day of admission.\nA histopathological examination of the placenta revealed placental discs measuring up to 19.5 x 14 x 4 cm. The placental membrane measured 30 x 16 cm, with two umbilical cords. The separately lying fetus showed gross malformation with the absence of the head and both upper limbs. However, both lower limbs were partia"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old Caucasian male with past medical history positive only for diverticulitis with a resultant sigmoidectomy presented to a pain management specialist with progressively worsening bilateral low back, buttock, and radicular leg pain, weakness, and numbness for five weeks after falling from an 8 ft. ladder onto concrete. At the time of the fall, no notable injury was sustained and the patient reported only minimal low back pain without radiculopathy. Over the next several days, the patient began to experience numbness and weakness of the bilateral lower extremities. Evaluation in the ER, which included a hip X-ray and MRI of the lumbar spine (seen in ), revealed only mild lumbar facet arthropathy and moderate left neural foraminal stenosis at L3-L4 without any concomitant hip or spine fracture.\nFollowing discharge, the patient reported worsening low back pain and bilateral lower extremity weakness in both L5 and S1 distributions. Several weeks after the initial fall, the patient was referred to pain management where he was evaluated and eventually underwent a radionuclide bone scan. This revealed mildly increased uptake at L5/S1 but was suspected to be a result of facet osteoarthritis. The patient denied any fever at this time, constitutional symptoms, or recent illness. Review of symptoms and physical exam were unremarkable aside from mild paraspinal tenderness and lumbosacral radiculopathy. The rest of the patient's neurologic exam was normal. The patient was instructed to follow up in one week's time. At the return visit, he reported continued worsening of symptoms with no relief. At this point in time, the patient mentioned that he had been experiencing shaking chills at night. Other review of symptoms and physical exam remained unchanged, and the patient was noted to be afebrile. A CT scan () and subsequent MRI of the lumbar spine () were conducted which revealed extensive findings of discitis/osteomyelitis at L5–S1 as well as an epidural abscess result"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old female patient with a past medical history of chronic obstructive pulmonary disease, hypertension, hyperlipidemia who presented to our emergency room (ER) due to worsening of respiratory distress. Four days prior to admission, the patient was hospitalized for management of community acquired pneumonia and upper gastrointestinal (GI) bleed and was later discharged to a rehab center. During a physical therapy session at the rehab facility, the patient developed severe shortness of breath and was found to be hypoxic with an oxygen saturation (SpO2) of 75%, she was placed on a nasal cannula. Presenting vitals in the ER showed a blood pressure of 152/83 mmHg, pulse 137 bpm, respiratory rate of 18/min and SpO2 97% on a 15 litre nonrebreather, and the patient was found to be COVID-19 positive using the RT-PCR test. Initial computed tomography (CT) of the chest pulmonary embolism protocol found multiple small bilateral pulmonary emboli as well as elevated right ventricular to left ventricular ratio of 1.4 indicating right heart strain (). The patient was noted to have expressive aphasia and left sided flaccid paralysis, and an initial CT scan of the head without intravenous (IV) contrast showed no evidence of acute intracranial abnormality. A magnetic resonance imaging (MRI) of the head with and without gadavist intravenous (IV) contrast () done later on Day 1 found a large acute right middle cerebral artery (MCA) territory infarct. The patient was started empirically on IV dexamethasone, antibiotic therapy, aspirin, atorvastatin, and therapeutic enoxaparin. On Day 2, a CT angiography of the head and neck with IV contrast showed an abrupt vessel cut off of the right internal carotid artery at the level of the supraclinoid right ICA, and nonvisualization of the distal right internal carotid artery as well as the right M1 due to a non-occlusive thrombus ().\nThe patient was transferred to an acute care facility, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year-old girl presented at the Emergency Department for SCH following a distortion of the right arm occurred in horse fall. She was admitted 1 h after the event complaining of severe pain, swelling arm, and numbness of the fingers. At physical examination, the hand was hypothermic and pulses were not palpable. Vascular examination showed good capillary refill but no flow at arterial Doppler ultrasound scan was detected. An X-ray documented a Gartland IIIB fracture (). The patient underwent a closed reduction of the fracture and percutaneous pin fixation. At the end of the procedure, the arterial pulses did not reappear. To rule out any vascular injury, arterial Doppler ultrasound was performed demonstrating brachial artery interruption at the fracture level associated with an intramural hematoma; an external hematoma compressing the artery, that could have been drained cutting lacertus fibrosus, was not identified.\nWith a percutaneous right common femoral arterial approach, digital subtraction angiography (DSA) was performed, showing occlusion of the distal brachial artery, with recanalization of the ulnar and radial arteries immediately below the bifurcation (). The occlusion was crossed with two 0.014ʺ guide wires positioned in the ulnar and radial arteries, respectively, to protect the bifurcation. A 3 × 28 mm BVS (Absorb; Abbott Vascular, Lakeside Drive, Santa Clara, CA) was released in the distal brachial artery (), followed by remodeling with a non-compliant 2.5 × 20 mm balloon catheter to solve residual in-stent stenosis (). The final angiography confirmed correct positioning and patency of the stent with restoration of distal flow (). The stenotic part was interpreted as a spasm of the artery and we decided to not treat it. At the postoperative ultrasound scan, the stenotic part was not detected anymore. A regular sphygmic pulse appeared on radial and ulnar arteries.\nThe arm was maintained with a 130° posterior splint for 40 days after surgery, to avoid"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-month-old male child was referred to our service with a history of membrane formation on the upper and lower palpebral conjunctiva of both eyes since 2 months after birth. Hemophilus influenzae was cultured from the conjunctival smear. Examination under general anesthesia revealed firmly thickened, sessile membrane and papillomatous lesion on the upper and lower tarsal conjunctiva in both eyes []. There was no involvement of the bulbar conjunctiva and cornea in both eyes, and the membranes and papillomatous lesions were excised. Postoperatively, the patient was treated with corticosteroid and antibiotic eye drops. Histological examination of the membrane was suggestive of LC []. Three months after the surgery, membrane and papillomatous lesion recurrence was noted in both eyes. The patient was started with CsA 2% drops in olive oil, four times daily. Local tolerability was excellent. The patient complained of a mild burning and sensation of a foreign body in the eye for a few minutes after application of the CsA drop. Excision of the membranes together with amniotic membrane (AM) transplantation for conjunctival reconstruction was decided upon. Before surgery, the ethics committee of our department approved the treatment, and the family provided written informed consent. The human AM was prepared according to Tseng et al.'s method.[] The new membrane and papillomatous lesion were excised under general anesthesia. The AM epithelium was secured up to the conjunctival edge at the mucocutaneous junction and the fornices with 8-0 polyglactin sutures in both upper and lower tarsal conjunctiva []. Two months postoperatively, the AM had dissolved. Topical application of CsA 2% four times daily was continued for 6 months. The patient was examined monthly for the first 6 months and then quarterly by the same ophthalmologist. At the end of 40 months follow-up, the membrane had resolved, leaving moderate residual conjunctival scarring on the upper and lower conjunctiva in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old Nigerian female with hemoglobin SS presented to a community hospital with a two-day history of left-sided headache and expressive aphasia. Her past medical history was notable for painful crises that occurred approximately once every 5 months and were managed at home with oral analgesics. Physical examination was remarkable for mild pallor and a severe expressive aphasia. She was transfused 2 units of packed red blood cells. The initial CT was normal, although an MRI showed an acute ischemic stroke in the distribution of the left middle cerebral artery. She was transferred to the Johns Hopkins Hospital for further evaluation and management. A complete blood count showed a hemoglobin of 9.9 g/dL, hematocrit of 27.4%, and reticulocyte count of 9.3%. Shortly after admission, she underwent an automated exchange transfusion to achieve a hemoglobin S concentration of 30%. The percent of hemoglobin S after the procedure was 17.0%.\nA transthoracic echocardiogram and bubble study with agitated saline showed bidirectional flow consistent with a PFO. A CT angiogram showed evidence of moyamoya disease. Chronic hypertransfusion therapy was recommended, although the patient did not return for transfusion therapy. She was also placed on daily oral aspirin and folate.\nFour months after the first stroke, the patient was readmitted with complaints of general malaise, weakness, intermittent confusion, and slurred speech noted four days before presentation. Physical examination was notable for a right facial droop, dysarthria, and a deviation of the tongue to the right. A complete blood count showed a hemoglobin of 11.5 g/dL, hematocrit of 32.5%, and reticulocyte count of 4.8%. The percent of hemoglobin S at presentation was 89.4%. She underwent another exchange transfusion to achieve a hemoglobin S of 30%. The day after the exchange transfusion, a doppler ultrasound of the lower extremities was performed to determine if a thrombus was present that could have provided a s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male patient with a history of neck pain and numbness of extremities for 6 years presented with hypoesthesia below the inguinal plane. The right upper extremity numbness was heavier than the left. The abovementioned symptoms were aggravated for 1 year resulting in a walking disorder. The patient required crutches when walking, and the maximum distance that he could walk was 50 m. Physical examination showed grade III strength of each muscle in both upper extremities, grade II grip strength, and grade IV strength of each muscle in both lower extremities. Bilateral Hoffman tests were positive, whereas the tendon reflex of both lower extremities was hyperactive. Magnetic resonance imaging (MRI) of the cervical vertebra showed that abnormal odontoid in the occipitocervical junction area and severe surrounding hydrops. The atlantoaxial instability resulted in mild AAD, as detected via computed tomography (CT), and the spinal cord was compressed by the posterior atlas arch (Fig. ).\nAfter failure of conservative treatment, we decided to perform surgical treatment on the patient to address the walking disorder. Preoperatively, we performed cervical CT angiography (CTA) to evaluate the relationship between the important blood vessels and bone in the cervical area. At the same time, 3D CT of the cervical region was performed to make a 3D print model of the patient's occipitocervical area (Fig. ). We simulated the depth and angle of cervical screw insertion according to the 3D print model, and finally determined the most suitable cervical screw for the patient. After adequate preoperative preparation, we performed posterior-only occipitocervical fusion combined with intraoperative 3D navigation system.\nAfter induction of general anesthesia, the patient was placed in a prone position. The vertebrae were exposed through an approximately 25-cm longitudinal midline skin incision from the occipital tuberosity to the spinous process of C6. The skin, subcutaneous tissue"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old female was transferred from a peripheral hospital 10 days after an elective lower uterine section caesarean section for a breech presentation for which she had an epidural anaesthetic. She presented to her general practitioner with a 2-day history of increasing right leg weakness. She was referred to her local hospital where she presented as no longer able to walk. Her examination demonstrated 0/5 power in right ankle flexion, extension, eversion and inversion with increased tone. Her cranial nerve examination was normal as was her tone and reflexes. An urgent MRI of the spine was undertaken that revealed no evidence of epidural collection or neural compression. She subsequently underwent a CT scan of the brain that demonstrated a dural-based lobulated, heavily calcified left parafalcine mass associated with extensive oedema consistent with a meningioma (). The bulk of the calcification was at the periphery of the lesion with relative sparing of the central elements. 8-mg dexamethasone was administered intravenously prior to transfer to a tertiary centre where an MRI of the brain was undertaken. This showed a left extra-axial parafalcine mass compressing the pre- and postcentral gyri and abutting the paracentral lobule. It was isointense to cortex on T2 weighted images with hypointense peripheral component corresponding to areas of calcification. The mass demonstrated peripheral enhancement and an enhancing dural tail. There was no evidence of restricted diffusion. Overall, it was felt most likely to be a meningioma with some atypical features. She underwent a left frontoparietal craniotomy and resection of the lesion. Histology demonstrated a meningothelial meningioma, WHO grade I with focal areas of necrosis and features, raising the possibility of embolization-related changes. She recovered well and was discharged home after brief inpatient rehabilitation. At her 4-month review, she was walking with 5/5 power in hip and knee flexion and extension an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old female had been suffering from dry cough, myalgia, and arthralgia since 2013 and was diagnosed as DM (Table ). Her symptoms were abated by combination treatment using prednisolone and tacrolimus. However, the cough, pyrexia, and arthralgia recurred due to the exacerbation of DM. The patient was admitted to our hospital for further checkup and treatment. Laboratory data showed that her white blood cell count and C-reactive protein levels were elevated. Her serum carcinoembryonic antigen and carbohydrate antigen 19-9 were not elevated (Table ). Enhanced computed tomography showed a 20-mm low-density tumor with a gradual enhancement in segment 4 of the liver (Fig. ). Ultrasonography showed a 20-mm tumor in segment 4 of the liver (Fig. ). In magnetic resonance imaging (MRI), the tumor had a weak signal intensity on T1-weighted images and a strong signal intensity on T2-weighted and diffusion-weighted images. In the dynamic study of MRI, enhancement of the edge of the tumor was gradually increased from the early to the late phase (Fig. ). Following the diagnosis of ICC in segment 4 of the liver, hepatic medial segmentectomy and cholecystectomy were performed. In the resected specimen, macroscopic findings consisted of a solid hepatic tumor with the diameter of 35 × 25 × 21 mm (Fig. ). The pathological diagnosis was moderately differentiated adenocarcinoma with vascular invasions and without lymph node metastasis (pStage III). The tumor consists of cells with coarse chromatin (Fig. ). Many of the tumors have tube formation and immunohistological findings of intrahepatic ICC and moderately differentiated adenocarcinoma with CK7 (+), CK 19 (+), and CK 20 (–) (Fig. ). The patient made a satisfactory recovery with no postoperative complications and was transferred to the Department of the Internal Medicine to treat DM with tacrolimus 5 mg/day and prednisone 20 mg/day. The patient was discharged on postoperative day 23. Since this case was a high-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man accidentally hurt his head while cutting trees 3 months ago, followed by loss of consciousness and bleeding in the bilateral nasal and external auditory canal. He scored 7 on the Glasgow coma scale (GCS). CT examination revealed extensive subarachnoid hemorrhage, skull base fracture, intracranial pneumatosis, and double lung contusion. The patient was treated conservatively after admission. Physical examination showed 5-mm dilation in the left pupil, along with an absence of pupillary light reflex to direct and indirect light sources. The right pupil was dilated by 3 mm, and pupillary light reflex was slower than normal. Furthermore, bilateral eye movements could not be examined, and the bilateral eyelid and conjunctival edema were not obvious. On the 13th day of hospitalization, there was a marked improvement in the patient’s consciousness; he could automatically blink and was able to easily follow simple instructions. Consequently, we noted a swelling in the patient’s right eyelid, along with conjunctival congestion, edema, and exophthalmos. The eyes seemed to pulsate on touch and auscultation revealed vascular murmur. The patient presented with drooping of the left eyelid, dilation of the pupils, and loss of direct and indirect pupillary light reflex. Although he was able to perceive light, and there were no edema or congestion present on the conjunctiva, he was unable to move his eyeball (Fig. A, B).\nSymptoms of his right eye were obvious and those of his left oculomotor nerve palsy appeared on admission. Therefore, we suspected that the patient had a CCF on the right side and a left oculomotor nerve injury associated with skull base fracture. Subsequently, we performed a CTA examination on the patient’s head and surprisingly observed that the contrast agent had extravasated from the cavernous segment of the bilateral internal carotid artery. Three-dimensional imaging revealed that the bilateral internal carotid arteries were swollen and irregu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 28-year-old man treated with maintenance hemodialysis since 1998 because of ESKD of an unknown etiology discovered in 1997. Renal biopsy was not performed as both kidneys were small at presentation. Neither self nor family history of urolithiasis or renal disease was reported. In 1999, the patient received a living-related kidney transplant. The donor was his 51-year-old mother, who had a good health with no medical history or physical abnormality at the pretransplantation check-up. Immunosuppression treatment composed of ATG for 10 days, cyclosporin, corticosteroids, and azathioprine. Because of persistent anuria after surgery, duplex ultrasound examination was performed and showed no blood flow in the graft vein. Surgical exploration 6 h after graft found a pleated graft vein and it was corrected. Graft biopsies were performed at the same time. It showed a normal histological appearance with no features of rejection. Twenty-five days after transplantation, urine output improved despite persistent graft dysfunction with a SCr of 700 μmol/l. A second allograft biopsy, performed at day 33, failed to show any features consistent with acute or chronic rejection. Subsequently, graft magnetic resonance imaging examination suggested partial cortical necrosis. However, graft function improved (SCr decreased to 500 μmol/L) and he was free of dialysis. Five months later, the patient was hospitalized because of increment of SCr to 950 μmol/L, while urine flow was maintained at about 1.5 l/24 h. Ultrasound examination of the graft and duplex ultrasound examination of renal vessels were normal. Cyclosporin monitoring was at the therapeutic range. Acute rejection was suspected and treatment with 3 methyl-prednisolone pulses was instituted empirically without a satisfactory response. A third allograft biopsy was performed and showed mild chronic tubule-interstitial changes with CaOx crystal deposits within the interstitium and lumena of the renal tubules. Re-exa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOn November 25, 2011, a 94 yr-old woman was referred for the management of erythematous to violaceous patches with bullae on dorsum of left foot. She repeatedly hit her left foot in which intravenous line was situated with the opposite side for days. She had a various underlying disease including Alzheimer's dementia, angina pectoris, type 2 diabetes, hypertension, chronic kidney disease (stage IV) and was in a bed ridden state. Because of the poor oral intake and noncompliance to the Levin-tube, the percutaneous endoscopic gastrostomy tube had been inserted on her abdomen and only minimal amount of nutrition was maintained.\nDespite of the daily simple dressing and intermittent debridement about 2 weeks, the status of the wound was deteriorated and advanced to painful ulcerative patches with eschar and granulation tissues (). The results of the bacterial culture and gram stain were negative.\nAutologous PRP were prepared for the alternative management of her worsening wound. 12 mL peripheral autologous blood was obtained and collected into tubes containing acid-citrate-dextrose solution formula (ACD-A) anticoagulant. The citrated blood was centrifuged for 7 min at 2,500 rpm. Subsequently, the yellow plasma (containing buffy coat with platelets) was separated from other components. The upper 3 to 4 mL plasma called platelet poor plasma was removed by micropipette. The remnant PRP was extracted by sleeve filter and mixed with CaCl2. Finally, The CaCl2-activated PRP was topically applied to the ulcerative wound.\nThe patient underwent a total of 7 PRP treatments over a span of 8 weeks (performed twice a week until 5th treatment and then weekly until 7th treatment). As described above, these treatments involved topically application of activated PRP as well as packing of the wound with aseptic film for the sustained effect of growth factors. The film was removed on next day and the top layer was covered with hydrofoam dressing material until subsequent PRP treatment.\nOver"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old boy presented to the emergency department (ED) one day after sustaining a closed right forearm fracture due to a fall. He was admitted in another hospital the day prior, where he underwent closed reduction and received an above-elbow slab. He was referred to our hospital due to the inability of the former to achieve a good reduction. Examination at our ED revealed intact vascularity and nerve function. No signs of compartment syndrome were evident in the form of excessive pain or tense swelling. Radiography showed malreduction (). Re-reduction and casting were successfully performed (). Assessment of the ulnar nerve post-reduction was not possible as the boy was uncooperative due to pain. The patient was discharged and scheduled for a follow-up visit in the outpatient clinic 2 days later. The visit was rescheduled, and he was seen 7 days after discharge.\nAt the follow-up visit in the clinic, the patient still complained of sharp pain. Physical examination showed no swelling suggestive of compartment syndrome, pulses and capillary filling were normal, and median and radial nerves were intact; however, signs of ulnar nerve palsy in the form of decreased sensation in the little finger and weak abduction and adduction of the fingers were present. Radiography showed loss of reduction. Redisplacement could be explained by the fact that the patient was 10 years old, and as described by the study by Bowman et al stating that reduction of both bone forearm fractures in children 10 years and older are more likely to fail. The patient was admitted and closed reduction with percutaneous ESIN under general anesthesia was performed. Two 2.5-mm elastic nails were used, retrogradely for the radius and anterogradely for the ulna. The postoperative radiograph is shown in .\nNo improvement in the patient’s sensory or motor deficit was seen after the surgery. As there were no available radiologists with experience in musculoskeletal ultrasonography in our hospital, and an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male patient, not known to have any medical illness, was brought to the emergency room by his wife and daughter due to decreased oral intake since three days. The decreased oral intake was associated with vomiting. The patient had a normal state of health until 2 months prior to his visit, when he started to develop changes in his behavior. According to his wife, the patient became more aggressive, had reduced sleep, had stopped going to work, and became isolated. He also had hallucinations and episodes of short-term memory loss. The above symptoms were accompanied by generalized body weakness, mainly in the lower limbs. The body weakness was associated with pain; the patient became wheelchair-bound. During the last two months, the patient visited many physicians, but no definite diagnosis was determined. He was examined by a psychiatrist and was diagnosed with organic mood disorder. He was prescribed quetiapine (antipsychotic), mirtazapine (antidepressant), and lamotrigine (mood stabilizer). However, according to his wife, he showed no improvements after taking the medications.\nThree months prior to his visit, the patient was admitted by the gastroenterology team due to biliary obstruction and endoscopic retrograde cholangiopancreatography (ERCP) was performed; biliary stricture was observed and he underwent stent insertion. At this time, he was also found to have a focal hepatic lesion. He did not have any past psychiatric history, a history suggestive of diabetes mellitus, autoimmune diseases, or any past gastric or ileal surgeries. He had a brief history of alcohol consumption but had stopped drinking 20 years ago. He was not a vegetarian. His daily diet was predominantly carbohydrate-rich and contained adequate animal protein.\nAn initial examination indicated pale mucous membranes, but no jaundice. The patient was conscious, but disoriented to place, time, and person. He said irrelevant words, was unable to comprehend others, and had bouts of cryi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old previously healthy female was transferred from an outside hospital for a second opinion for a liver transplant. She first noticed fatigue, weakness, and abdominal swelling three months prior to her admission at the outside hospital. CT of the abdomen with contrast showed cirrhosis and multiple masses with arterial enhancement in her liver. She underwent a liver biopsy. Pathology was reported as a low-grade vascular tumor. She presented to a larger academic center where she underwent an exploratory laparotomy with open liver biopsy to further investigate the liver lesions. There was no visual evidence of omental spread. The pathology was reviewed by multiple tertiary centers specializing in hepatic malignancies and was reported as a low-grade vascular lesion, which was likely small vessel neoplasm. After denial for LT secondary to an unknown low-grade vascular tumor, she presented to our medical center. MRI of the liver showed multiple enhancing liver masses (Figure ). Oncology was consulted and she was diagnosed with benign liver vascular tumors with an overall favorable prognosis.\nShe was listed for liver transplant with a model for end-stage liver disease-sodium (MELD-Na) score of 25. The patient had normal renal function prior to her admission with a creatinine level of 0.79 mg/dL, which increased to 3.3 mg/dL after her admission which was thought to be secondary to hepatorenal syndrome (HRS) type I. Her creatinine level did not improve despite medical management and hemodialysis (HD) was initiated prior to transfer to the University Medical Center. She continued on HD for approximately 10 weeks prior to her LT and was listed for combined liver and kidney transplant.\nShe underwent an orthotopic liver transplant 10 weeks after presenting to the UNMC. Microscopic evaluation of the tumor cells showed positive immunohistochemical staining for the ETS-related gene and was negative for human herpesvirus-8. A Ki-67 labeling index of the solid areas was app"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis was a 68-year-old man in whom medical checkup revealed pelvic lymphadenopathy; his PSA level was 3.92 ng/mL. Prostate biopsy was performed, and prostate cancer with a Gleason score of 3 + 4 = 7 was detected in 4 out of 10 biopsy sites (right: 1/5, left: 3/5). MRI also revealed a mass (38 × 31 mm in diameter) in the left pelvis. Because lymph node metastasis of prostate cancer could not be ruled out, endocrine therapy with bicalutamide and leuprorelin was started. Although his PSA level decreased to 0.248 ng/mL, the mass in the left pelvis remained unchanged and was unlikely to have metastasized from the prostate cancer. Pelvic MRI findings revealed a well-circumscribed mass on the ventral side of the left piriformis muscle measuring 38 × 31 mm in diameter (Fig. ).\nThe prostate and the left pelvic tumor were resected under robotic assistance. As with case 1, the patient was placed in a 25-degree head-down tilt, ports were placed according to the usual procedure of RARP. Surgery was performed via a transperitoneal approach and pelvic tumor was resected by robot-assisted surgery (Fig. ). No large nerve was observed in the proximity of the tumor unlike those observed in case 1. After prostatectomy and right and left lymphadenectomy were subsequently performed under robotic assistance, surgery was completed. The operative time was 4 h and 45 min. The console time for the left pelvic tumor was 1 h and 38 min and that for the prostate was 1 h and 57 min. Blood loss was 100 mL; no other intraoperative complications were observed.\nHistopathological findings were consistent with schwannoma. There were no malignant features (Fig. ). In the prostate, the glandular epithelial components were markedly atrophic, and mild lymphocytic infiltration and fibrosis were observed, but without residual tumor cells. The histological therapeutic effect was grade 3b (no residual cancer cells were seen after hormonal therapy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old Japanese woman on renal dialysis had a 4-month history of tinnitus and hearing loss. Computed tomography (CT) showed a high-density 35-mm diameter tumor in the pineal region and obstructive hydrocephalus []. The tumor was heterogeneously hyperintense on T1-weighted magnetic resonance imaging (MRI) scans and low- and iso-mixed intense on T2-weighted images. On T2* images, it contained very low intensity areas suggestive of hemorrhagic components []. No other intracranial lesions including lesions underlying her acoustic symptoms were identified. Her chronic renal failure ruled out enhanced imaging studies. On the basis of our neuroimaging findings, we made a preoperative diagnosis of pineal parenchymal tumor with hemorrhagic components and melanoma.\nWe used the left occipital transtentorial approach with the patient in the three-quarter prone position.[] To reduce occipital lobe retraction, an operated side-down approach was used. The incision extended from the inion along the midline and then was curved in a horseshoe fashion back behind the ear. The craniotomy was performed to visualize the transverse and sagittal sinuses through extent in the operative field by rongeur or airdrill. Then, a catheter was placed in the left lateral ventricle. The dura mater was opened with two triangular flaps based on the superior sagittal sinus and the transverse sinus. The incision of the tentorium was made at an angle of 15° to the straight sinus, starting from a point, 15 mm lateral and 15 mm anterior to the junction of straight and transverse sinus, extending upto the tentorial free edge, and then the lateral flap was reflected laterally. After the dense arachnoid over the quadrigeminal cistern was opened, a dark red, easily bleeding solid tumor was found in the pineal region []. We successfully dissected the feeders arising from posterior choroidal arteries, removed the tumor subtotally. After 2 weeks later from first operation, endoscopic third ventriculostomy w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe discuss a 59-year-old female who presented for planned PICC insertion for chemotherapy administration. Her medical history consisted of sigmoid adenocarcinoma with a Hartmann’s procedure the month before and subsequently commencing chemotherapy a week before. She was a non-smoker and had no familial history of coagulation disorders.\nThe PICC line was inserted into the right arm under ultrasound guidance, without any immediate concerns noted during the procedure. An X-ray revealed the PICC tip to be in a satisfactory position, but potentially a little too deep (). There were no symptoms of chest discomfort or palpitations.\nApproximately an hour later, she developed symptoms of pain and weakness to her left arm (the opposite side). Her arm was clinically assessed as cool to touch with a delayed capillary refill with pulses absent. A computed tomography angiogram (CTA) of her left arm was arranged which revealed an abrupt stop in the left axillary artery ( and ) with reconstitution of the vessels in the antecubital fossa. She was taken to theatre for a brachial embolectomy to re-establish blood flow to her acutely ischaemic arm.\nBrachial access was obtained over the antecubital fossa, the brachial artery was controlled and incised. Proximal embolectomy with balloon catheter retrieved a long segment of thrombus, with resulting good inflow and back bleeding. Post-operatively she was commenced on therapeutic low molecular weight heparin (LMWH).\nShe was subsequently worked up for a cause for this limb threatening pathology. Echocardiogram revealed unremarkable cardiac valves without evidence of an embolic source. A bubble study was also performed which showed no evidence of right to left shunt or patent foramen ovale. Histology confirmed recent blood clot without organization. At follow up she had a good radial pulse and her LMWH was switched to rivaroxaban.\nPICC lines are generally considered safe, with delayed complications including occlusion, accidental withdrawal,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old man was evaluated in the emergency room (ER) of our hospital for complains of dizziness and near syncope while walking home earlier that day. He had started feeling generalized weakness and fatigue after he underwent neck surgery for a tonsillar lesion at another hospital 6 months earlier. He also reported unintentional weight loss of 20 pounds over 6 months along with loss of appetite. He denied any loss of consciousness, palpitation, shortness of breath, chest pain, hearing difficulty, headache, vision changes, nausea, vomiting, diaphoresis or fever. He had human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) with a CD4 count of less than 20. He was non-adherent to the anti-retroviral therapy. He also had chronic obstructive pulmonary disease and was using albuterol and steroid inhalers. His social history was significant for active cocaine abuse. He reported smoking one pack of cigarette per day for more than 35 years. Family history was significant for prostate cancer in father. His surgical records from the previous hospitalizations were obtained and revealed robotic resection of the left tonsil lesion and selective neck dissection 3 months prior with biopsy results showing left tonsillar SCC, P16+, stage T1N3M0. He did not receive any radiation or chemotherapy.\nIn the ER, his vitals were recorded as: pulse of 75 beats/min, blood pressure 125/75 mm Hg with no orthostatic hypotension, respiratory rate of 16 breaths/min and oxygen saturation of 98% on room air. His physical exam was significant for severe cachexia with body mass index (BMI) of 19. Conjunctival pallor was noted. His neck exam showed staples on left side with a clean wound site. He was also noted to have left second toe swelling and tenderness with clammy extremities and adequate pulsations bilaterally. A computed tomography (CT) scan of head was done to evaluate dizziness and near syncope that showed old ischemic changes. Initial electrocardiogram"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur work is a single case report and has been reported in line with the SCARE criteria [].\nA 50-year-old man complained of a painless slow swelling in the left cheek, which had increased in size in the last four months, tobacco smoking, and alcohol intake for 15 years, without any chemical exposure. There was no history of local trauma, radiotherapy, HPV infections, or family history of malignancy. He was referred to our department's consultation for specialized care. No other personal or family history was raised during the patient interrogation.\nClinical examination showed painless swelling in the left cheek, a 3 × 3 cm mass presenting with irregular borders ().\nThere were no palpable neck lymph nodes on the left side.\nA biopsy of surgical material was performed, showing a well-differentiated squamous cell carcinoma.\nThe definitive diagnosis of malignancy was made; metastatic investigations were performed, including chest radiography, abdominal echography, PET scan. The results of these exams were normal.\nThe computed tomography (CT) was performed and revealed a 4 × 4 cm mass along the cheek, and the alveolar bone was eroded.\nBased on the positive medical history and clinical examination, surgery was indicated and performed by the chief professor of our department who has 15 years of operative experience. The surgical procedure had the aim of the restoration of the anatomic landmarks after a large excision of the tumor and reconstruction of full-thickness cheek defect with a deltopectoral flap under general anesthesia. (, , ).\nDuration of surgery: 120 min; estimation of blood loss: 350 ml; duration of hospital stay: 4 days.\nThe patient received amoxicillin/clavulanic acid 1g twice daily and antalgics for 8 days.\nPost-operative histopathology confirmed SCC proliferation ().\nThe multidisciplinary team deciding on the treatment options included surgeons, oncologists, radiotherapists, ENT surgeons, radiologists. The decision was made to treat the patient with the surg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old woman sustained a slip-down injury while performing daily work. She was diagnosed with a three-part fracture of the surgical neck of the right humerus. The glenohumeral joint showed grade 4 osteoarthritis on the glenoid articular surface and humeral head, with a lot of osteophytes. The fractured shoulder joint had an irreparable massive rotator cuff tear involving the subscapularis, supraspinatus, and infraspinatus and showed fat degeneration (Goutallier classification grade 4). We decided to perform RTSA on posttrauma day 5. She was placed in the beach-chair position and operated on under general anesthesia with associated local interscalene block. A deltopectoral approach was used and the fractured greater and lesser tuberosities were retracted to allow for the removal of the head of the humerus for wider exposure of the glenoid. The supraspinatus tendon and the long head of the biceps were divided. The glenoid baseplate was implanted flush to the inferior, anterior, and posterior rims of the glenoid with an inferior inclination of approximately 10° and was secured using 4 lag screws inserted though the glenoid. We inserted the hemisphere and confirmed the stability of the implant. The humeral component was inserted using intramedullary cement in 5° retroversion. We inserted a 6-mm polyethylene bearing after trial reduction. The fractured tuberosities were then sutured to each other and around the neck of the prosthesis in their anatomical position. After the operation, the shoulder was immobilized for 2 days and remained in an ultra-sling for 3 weeks postoperatively before passive ROM was started. Active, active assisted, and isometric exercises were started at 6 weeks, with progression to strengthening exercises at 12 weeks. The shoulder had a dislocation of the glenohumeral joint on postoperative day 7 and she experienced a sharp pain and limited motion. Plain radiographs revealed anterior dislocation of the humerus and polyethylene bearing. We re"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old right-handed paratrooper was presented to the orthopedic emergency department because he fell on his outstretched right hand after having attempted a wrong landing technique. The accident took place in the island of Rodos where he received first aids and was then transported to our hospital for further treatment.\nOn physical examination, there was swelling and pain over the dorsum of the hand. Despite the swelling, it was feasible to notice deformity and to palpate the characteristic step-off created by the bases of the metacarpals. Active movement of the wrist and the fingers was limited while the patient was unwilling to cooperate due to pain. Neurovascular assessment revealed both a strong palpable radial pulse and a lively capillary refill while sensation of the hand was normal.\nPlain radiographs (a dorsopalmar and an oblique view) of the right hand showed complete dorsal dislocation of the three ulnar CMC joints (). In order to achieve a better assessment of the injured joint surfaces, an additional CT scan of the right hand was conducted. The latter not only confirmed the diagnosis but also revealed a bony fragment at the base of the fifth metacarpal that originated from the hamate (Figures and ).\nAt the emergency department, closed reduction was attempted by applying longitudinal traction to the involved digits with pressure over the bases of the dislocated metacarpals. After that, the wrist was immobilized with a plaster. Three days later, the patient was operated under general anaesthesia in supine position. The surgical treatment chosen was open reduction and internal fixation (ORIF). Two longitudinal incisions were made over the second and fourth web spaces addressing adjacent respective joints. At this point, it is of note that when the subcutaneous hematoma was evacuated and the extensor tendons were retraced with the surrounding loose connective tissues, we noticed that our initial closed reduction which took place in the emergency room h"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWritten informed consent was obtained from the patient for her anonymized information to be published in this article.\nA 46-year-old female dental hygienist with no history of rheumatoid arthritis or trauma presented with metatarsalgia of the right foot. She was diagnosed with interdigital neuroma at a nearby hospital and received a local steroid injection on the plantar aspect of the second web space. The use of an insole was also prescribed. For 2 years thereafter, steroid injections were administered to treat any exacerbation of the metatarsalgia (10 injections of triamcinolone and one of betamethasone were administered). At 1 year after the primary injection, the second and third toes became bent and developed swelling, especially at the third MTP joint; she was subsequently referred to our department.\nPhysical findings indicated flexible hammertoe deformities of the second and third toes. The ranges of motion of the right second and third toe MTP joints at extension were 90° and 70°, respectively, whereas the corresponding ranges at flexion were both 0°. The ranges of motion in the proximal interphalangeal joints at extension were −30° and −60° in the second and third toes, respectively; the corresponding ranges at flexion were 70° and 90°, respectively.\nThe initial non-weight-bearing radiographs revealed no dislocation or arthritic changes in the second and third MTP joints (). After 2 years, dorsal dislocations of these joints were noted on a lateral radiograph (). Although no bone cyst or sclerosis was observed on the dorsoplantar radiograph, mild hallux valgus deformity was found. Magnetic resonance imaging revealed synovial fluid retention in the second and third MTP joints, and the plantar plates of both joints were ruptured from the proximal phalanx and retracted under the metatarsal head ().\nSurgery was performed for the second and third MTP joints and the hallux valgus deformity. The plantar plate disappeared, and the flexor digitorum tendon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman presented with rapidly progressing, asymptomatic skin lesions on the chest followed by similar nodules over the occipital and left parietal area of her scalp. She had a significant loss of weight of 6 kg over the last 6 months. General examination revealed a firm left supraclavicular lymph node. Cutaneous examination revealed the presence of multiple tender nodules with a soft, rubbery consistency with overlying superficial telangiectasia scattered on the scalp [], face [], upper chest [], and lower back, varying in size from 0.5 cm × 0.5 cm to 2 cm × 2 cm.\nThe differential diagnoses considered based on her clinical presentation were cutaneous lymphoma, cutaneous metastases, and histiocytosis. Her blood investigations were within normal limits. A skin biopsy from one of the nodules showed hyperkeratosis with prominence of the granular layer. The dermis was infiltrated by a tumor composed predominantly of loose clusters of round cells with eccentrically placed, hyperchromatic nuclei, and abundant amounts of cytoplasm containing neutral mucin [Figures –]. On immunohistochemistry, the cells were pancytokeratin positive. A diagnosis of metastatic poorly differentiated signet cell carcinoma was made based on the histopathological findings. A gastroscopy-guided biopsy done from the gastric mucosa showed poorly differentiated signet cell-type adenocarcinoma. A computed tomography scan and positron emission tomography scan done showed thickening of the cecal wall and omentum with enlarged para-aortic lymph nodes. An explorative laparotomy was done, which showed an obstructive growth in the short segment of the ascending colon with extensive nodal involvement. She was diagnosed to have a synchronous adenocarcinoma of the stomach and cecum. A palliative ileotransverse anastomosis was done. She was started on chemotherapy. She however did not show any response to first-, second-, and third-line of chemotherapeutic drugs. After 6 months of being on chemother"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male presented to an outside institution in 2015 for evaluation of slowly enlarging bilateral cervical lymphadenopathy, parotid swelling, and night sweats. Medical history was significant for melanoma removed from the bridge of his nose in 2015, and active smoking for over 40 years.\nDuring his initial workup at the OSH, computed tomography (CT) imaging showed multiple enlarged bilateral parotid lesions, scattered enlarged level I and II nodes, and upper mediastinal lymph nodes. He underwent ultrasound-guided fine needle aspiration (FNA) and core needle biopsy of a large left neck lymph node measuring 4.0 × 1.9 cm. Cytology was consistent with WT. Additionally, a level IA neck dissection was performed. Pathology revealed WT and no evidence of malignancy or lymphoma. Six-month follow-up imaging showed stable appearance of the bilateral parotid masses and cervical lymph nodes; however, there was interval enlargement of right upper mediastinal paratracheal lymph nodes.\nHe relocated in September 2016 and transitioned care to our institution. Thoracic surgery performed endoscopic bronchial ultrasound and transbronchial biopsies of the right paratracheal node. Cytopathology revealed absence of malignant cells. Flow cytometry was negative for lymphoma. He elected for close surveillance with serial imaging in lieu of mediastinoscopy. Six-month follow up imaging showed stable size of the mediastinal lymph nodes and slight enlargement of a left neck lymph node () and he was subsequently referred to the Department of Otolaryngology.\nPhysical examination revealed bilateral enlarged parotid glands and bulky cervical lymphadenopathy slightly larger on the right. Facial nerve function was intact bilaterally. The patient was counseled on smoking cessation. He was discussed at our multidisciplinary tumor board. Given the progression of cervical disease, he underwent level II lymph node dissection with removal of a large nodal conglomerate and culture of cystic contents."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old man was involved in a motor vehicle accident resulting in an isolated fracture of the right mid femur. The patient was awake and had a Glasgow Coma Scale (GCS) of 15 at admission to the emergency department. The patient was examined and stabilized according to the advanced trauma life support (ATLS) principles. Whole-body computerized tomography did not show any head injury. There were multiple displaced costal fractures on the right side with lung contusion and minimal pneumothorax that did not need drainage.\nThe patient was admitted to the intensive care unit (ICU) while waiting for surgical stabilization of the fracture. During the 6-hour preoperative stay in the ICU, the patient was stable and awake. The patient was operated upon in general anesthesia. Intramedullary insertion of a femur nail was attempted but was quite difficult to achieve. A great deal of manipulation and drilling was required in order to insert a 400 mm nail. The patient was stable peroperatively.\nThree hours later he was transported back to the ICU, still intubated and on 0.5 fraction inspired oxygen (FiO2). A wake-up test was performed at arrival to the ICU, and the patient seemed to be awake but suffered from pain. The patient deteriorated during the next 6 hours. He developed a high fever, and his oxygen saturation decreased. A new chest X-ray showed 2.5 cm pneumothorax that was drained successfully, but saturation continued to decrease during the next 6 hours. His oxygen demand increased ending up at 0.9 FiO2. A decision was made to increase sedation and apply a higher positive end expiratory pressure. In addition the patient was turned into a prone position.\nThe patient was kept sedated during the next 24 hours, and the FiO2 was decreased to 0.4. Moderate hypercapnia was tolerated (7.5–8.5 kPa). A wake-up test was not performed while the patient was in the prone position but the patient's pupils were examined"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn August 2013, a 63-year-old woman presented with a gradual onset of decreased exercise tolerance, dyspnea, and a heavy feeling in the chest. Otherwise she was in good health with no relevant concomitant diseases. She denied fever, hemoptysis, weight loss, or other constitutional symptoms. There was no drug, alcohol, or nicotine abuse. She took no medication and there was no recent surgery or trauma. On physical examination we found a decreased breath sound over the right hemithorax and dullness to percussion at the right side of the thorax. There were no signs of peripheral oedema or ascites. She did not have any peripheral lymphadenopathy or enlarged spleen and liver. Laboratory values were normal for a white blood cell count of 5.9 × 109/L, a hematocrit of 44%, and a platelet count of 192 × 109/L. Her creatinine was within normal range and albumin was 42 g/L, with a total protein of 76 g/dL. Furthermore lactate dehydrogenase and tests for glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and bilirubin were all normal. The posteroanterior chest radiograph on admission confirmed a large right pleural effusion (). On admission, the effusion was drained showing a turbid and milky white appearance. Biochemical tests on the fluid showed a high triglyceride content (79 mmol/L) in the form of chylomicrons with cholesterol levels as low as 4.6 mmol/L. Further cytological analysis showed the presence of lymphocytosis but no malignant cells. Flow cytometry confirmed the absence of B-cell or T-cell lymphoma. Further imaging with PET-CT was initiated searching for the underlying disease. This revealed a PET positive bulky intraperitoneal tumour around the abdominal aorta and pancreas extending to the pelvic inlet (). There was a heterogeneous contrast enhancement and clear encasement of nearby arteries and veins. No enlarged mediastinal lymph nodes or suspect gynaecological malignancy was seen. In our case, the disruption occurred"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-years-old man with past medical history significant for mild mental retardation, obsessive compulsive disorder, and attention deficit hyperactivity disorder was admitted to our service after falling at his workplace after rising from a chair. It was a witnessed fall. Patient collapsed after rising from his chair after eating lunch at work. There was no urinary of fecal incontinence, no tongue biting, no jerky movements, and no loss of consciousness. There was no confusion or altered mental status afterwards.\nHowever, interestingly, the patient was tachycardic from 120 s to 140 s on presentation and was also noted to have orthostatic hypotension, despite IV hydration in the ED. Of note, patient's intake has always been good and rather he enjoys drinking plenty of fluids. The review of systems was negative, and the patient did not have any other signs or symptoms concerning any infection. Physical exam was significant only for mildly dilated pupils.\nElectrocardiogram (ECG) revealed sinus tachycardia, with no ST changes, and QTc interval was noted to be within the normal limits. Echocardiography showed a normal left ventricular size with mild hypertrophy with a low normal systolic function (ejection fraction of 50–55%). Segmental LV function was normal. Right ventricular size and function were normal, and no valvular abnormalities were noted. A head CT done in the emergency department also did not reveal any masses or lesions, and there were no fractures or hematomas. Thyroid studies were also within normal limits.\nAs per the patient's parent, who has been taking care of him for the past 26 years, the patient has never had these symptoms. The patient apparently has been on atomoxetine (Strattera; Eli Lilly and Company), for the last 6 years without any problems. When asked about any new changes or additions to his medications, the patient was recently started on fluoxetine (Prozac) couple of months ago to help him with the “tic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male was referred to the spinal team with a presentation of becoming “off legs” with progressive difficulty in walking. He had a prior history of vertebral PD, diagnosed 11 years ago, but had reported no symptoms of back pain in the interim.\nIn the recent months, he had started developing paraesthesia in both lower limbs, with progressive leg weakness and difficulty walking.\nThere was no bowel or bladder involvement. His past medical history included chronic kidney disease, Type II diabetes mellitus and vitamin D deficiency. He was also noted to be human leukocyte antigen B27 positive.\nClinical examination revealed a rigid thoracic kyphosis and spastic paraparesis. Lower limb power was globally reduced to Medical Research Council grade 4/5. Altered sensation to fine touch was demonstrated below the level of T7.\nSubsequent investigations included whole-spine MRI and CT. This demonstrated the features of AS with multilevel syndesmophytes and interspinous ligament calcification. There was cortical thickening, sclerosis and vertebral squaring of T10, consistent with the known history of PD. However, in addition, there was contiguous spread of the pagetic changes across the diffusely ankylosed thoracic segments (). The combination of these pathologies produced a marked kyphotic deformity, with extensive bony expansion of the pagetic thoracic spine that resulted in significant central canal stenosis ().\nAn MRI confirmed the extent of canal stenosis and cord compromise, with intramedullary T2 hyperintensity extending from the cervicothoracic junction to T11 (). There was sparing of the lumbar segments, with a normal appearance of the distal cord and conus ().\nFollowing discussion at our regional spinal multidisciplinary team, it was decided that surgical decompression would likely result in poor outcome, given the extent and severity of the disease. Multiple infusions of zoledronate were administered, in addition to three courses of calcitonin, in an attempt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old female with a past medical history of hypertension and diabetes was admitted with COVID-19 bronchopneumonia. Her hospital course has been complicated by respiratory failure requiring mechanical ventilation, septic shock requiring norepinephrine. During the admission, she was bradycardic in the 50s in sinus rhythm. Her heart rate dropped down to 30 for a short time of about six seconds. The rhythm strip showed AV dissociation consistent with complete heart block, as shown in Figure .\nThe bradycardia episode did not last long enough to obtain 12 lead EKG. She was then back in sinus rhythm. Her transthoracic echocardiography was unremarkable with normal ejection fraction and no segmental wall motion abnormality, brain natriuretic peptide (BNP) within normal limits, troponin I elevated up to 50 ng/ml. Troponin elevation was attributed to demand-mediated myocardial ischemia.\nThe decision was made to follow up, given that the complete heart block was for a short time and did not recur. The patient was not on any medication or sedation that can cause bradycardia and was oxygenating well on the ventilator. The next day she had pulseless electrical activity (PEA) cardiac arrest related to complete heart block, and return of spontaneous circulation (ROSC) was achieved after three minutes, and a temporary trans-venous pacemaker was placed, and she was paced most of the time because of persistent bradycardia and complete heart block. Later, when her condition improved and she was extubated, her heart rate started recovering gradually. At first, she was in junctional tachycardia, as shown in Figure , and there were no further bradycardia episodes.\nShe remained in hospital because of poor physical condition and need for rehabilitation placement, and all that time, she was on continuous telemetry. One week later, she was back in sinus rhythm, as shown in Figure . the temporary pacemaker was removed, and she was discharged on a ZIO monitor for two weeks with no furthe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old man presented at the Neurology consultation with a six-week history of a severe, strictly left orbitotemporal headache, with a frequency of three attacks per week, occasionally more than one at the same day. Most of them occurred in the first half of the night, waking him up, and lasted between thirty minutes and one hour. He used to take ibuprofen as acute treatment, with unsatisfactory response, since he did not notice a significant difference between treated and untreated attacks in terms of duration and pain intensity. To relief the pain, he used to open the window to get some fresh air. The headache was always associated with ipsilateral conjunctival injection and lacrimation. Pain triggers were not identified by the patient. He had no personal or familial history of headaches. His medical history was remarkable for hypertension and asthma, with a past surgical history including septoplasty and bilateral middle turbinectomy and uncinectomy due to nasal respiratory insufficiency. By the time of medical evaluation he was asymptomatic and neurological exploration was unremarkable. The clinical picture was suggestive of a CH and the patient was medicated with verapamil 120 mg daily. A MRI scan was performed, which revealed a sphenoid sinus mucocele, without secure expansion of the sinus. Two weeks later the patient came to the Emergency Department with complaints of horizontal diplopia that he noted when he woke up in that morning. He maintained the headache attacks, with similar characteristics, despite prophylactic therapy. Neurological examination revealed left eye adduction palsy and ptosis. A brain CT scan was performed and excluded lesions other than the mucocele. Paranasal sinus MRI revealed molding of the medial wall of left cavernous sinus by the sphenoid mass (). A paranasal sinus CT scan was also performed to allow for a better characterization of the lesion, showing sclerosis and interruption of the roof and posterior wall of the left sphe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old man presented with progressive hearing loss in the right ear and vertigo for the past 6 months and facial numbness and unsteady gait for the past 15 days. Upon physical examination, he was found to have right ear sensory hearing loss, ataxia, diminished sensation in the right face (supplied by the third branch of the trigeminal nerve), and high frequency hearing loss in the right ear, as revealed by brain stem auditory evoked potential examination. MRI examination revealed a lesion in the CPA with solid and cystic components, which compressed the brain stem and the cerebellum. The anterior portion of the lesion was solid and showed signs of cystic changes, whereas the posterior portion of the lesion was cystic. The solid component of the lesion showed hyper- and isointensity on T1WI images and mixed hyper- and hypointensity on T2WI images, and it was significantly enhanced after contrast administration. The size of the solid component of the lesion was about 2.2 cm × 2.2 cm × 2.3 cm (Figure ). Surgery was performed via a right suboccipital retrosigmoid approach, and intraoperative monitoring of cranial nerves was conducted. The lesion was revealed to be red, well margined, firm, vascular, anteriorly solid with cystic changes, and adherent to the brain stem and the cerebellar hemisphere, the trigeminal nerve, and facial and acoustic nerves. Following separation of the lesion from adjacent nerves and tissues along the border of the lesion under microscopy, the lesion was totally resected in a partitioning manner. The xanthochromic fluid in the back of the lesion was drained during surgery. The patient recovered well after surgery and presenting symptoms were significantly relieved. Postoperative CT scans demonstrated that the lesion was completely resected (Figure ). The histopathological features of the lesion were consistent with a CM (Figure ). At 1-year follow-up, this patient's symptoms at presentation had resolved."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old female was referred from an ENT specialist practitioner to the ENT-department due to multiple enlarged cervical lymph nodes located bilaterally and an involuntary weight loss of 10 kilograms over the last 6 months. There was no significant previous medical history. Fine needle aspiration biopsy (FNAB) suggested lymphoma and subsequent histological examination of an excised lymph node between level two and three from the left side of the neck confirmed the diagnosis of mantle cell lymphoma (MCL). PET-CT and bone marrow examination further demonstrated bone marrow involvement. Accordingly, the lymphoma was staged as Ann Arbor IVB and AJCC stage IV. The patient received eight series of R-CHOP followed by a scheduled 2-year-period of maintenance therapy with rituximab. Twelve months into maintenance therapy the patient developed a tender swelling of the right submandibular- and left sublingual gland. On clinical examination, a one-centimeter process with normal overlying mucosa was found in the left sublingual gland () along with a similar process in the right submandibular gland. Ultrasound of the left sublingual- and right submandibular gland revealed two hyperechoic one-centimeter tumors. Further examination and ultrasound of the neck revealed no enlarged lymph nodes. A magnetic resonance imaging (MRI) of the head and neck was performed (). PET-CT revealed a process of the sigmoid colon, but the bone marrow examination showed no signs of infiltration. MCL relapse was confirmed by subsequent excision and histological examination of the sublingual- and submandibular gland, as well as histological examination of a biopsy specimen taken from the sigmoid colon via colonoscopy. Histological examination of the excised sublingual gland showed salivary gland tissue infiltrated by lymphoid tumor cells appearing as blastoid cells with multiple membrane bound nucleoli (). Mitotic figures were seen in several of these cells. Immunohistochemistry showed positive reac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old male with repeated episodes of forehead swelling was referred to our department. He had no history of sinus surgery but had undergone microsurgical aneurysm clipping at the age of 47. He did not have diabetes or other immunocompromising disorders. Axial computed tomography demonstrated an intracranial metal-density spot, indicating the site of previous clipping (). The posterior wall of the left frontal sinus was deformed as a result of the previous neurosurgery (). The left middle meatus was opacified with homogeneous density (). The left frontal sinus had heterogeneous opacity including a high-density spot. Three-dimensional reconstruction showed the postoperative change of the frontal bone ().\nSurgery was performed under general anesthesia. The mucosa of the frontal recess was edematous and obstructed the drainage pathway of the frontal sinus. Total removal of the anterior ethmoid cells revealed the frontal sinus ostium, but this ostium was too narrow to introduce any instrument into the frontal sinus (). Therefore, the EMLP was performed. The bilateral frontal sinuses were opened and the frontal beak and intersinus septum were drilled out. The left frontal sinus was filled with cheesy brown material (). Most of the material could be removed with curved instruments and flexible suction devices, but a portion of the material was located in the fissure of the bone. Even meticulous lavage with saline and extensive adjustment of flexible instruments failed to remove all of the remnant material (). Therefore, a small skin incision was made at the eyebrow and the frontal wall of the frontal sinus was trephined. Through this direct and close approach, the entire remainder of the material could be removed (). We preserved the mucosa of the frontal sinus to prevent postoperative scarring at the surgery site. The nasal cavity was packed with Sorbsan (calcium alginate) []. Histological examination revealed that the purulent material was formed by mixed bacteri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male was admitted to an outside institution with lethargy, weight loss of 30 kg, and severe unexplained anemia (hemoglobin 4.5 g/dL; hematocrit 15%). The patient felt better after transfusion of 4 units of packed red blood cells, and gastroscopy performed at the time revealed a healed duodenal ulcer and erosive gastritis.\nWhen he lost his medical insurance, he was discharged and advised to have further workup performed elsewhere. During a difficult colonoscopy at a charity clinic, a large tumor was found in his right colon that precluded passage of the scope to the cecum (see ). Biopsy confirmed an infiltrating adenocarcinoma. Polyps in the sigmoid and transverse colon were also removed and found to be tubular adenomata. The patient was then referred to our institution, a safety-net hospital, where a CT scan was performed. The imaging demonstrated a 5 × 5 cm mass in the mesentery with spiculated calcifications, as well as an additional mass near the ileocecal valve that had the appearance of an intussusception (see ). Malrotation was not suspected, although later review of the imaging with a specialized CT radiologist demonstrated inversion of the normal SMA to SMV configuration (see ). Malrotation was not suspected. The liver was free of metastases. His past medical history included no prior surgery.\nA laparoscopic right hemicolectomy was scheduled and commenced with introduction of a 10 mm optical trocar and two 5 mm ports. Upon entry, most of the small bowel was found plastered to the right flank, and the right colon was not visible. The left colon was visualized, but even after releasing adhesive bands holding the small bowel to the right side and mobilizing these loops to the left of midline, the ascending colon was not visible. It was decided that laparotomy was required to elucidate the findings. The abdomen was entered through a midline incision, and after mobilizing and packing off the small bowel to the left, the right paracolic gut"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38 year-old male ophthalmologist was seen at the Ophthalmic Accident and Emergency Department with a five-hour history of a right watery red eye. He had been exposed to several conjunctivitis patients during the preceding few days, whilst working at the same department.\nAn initial diagnosis of probable viral conjunctivitis was made, and the patient was prescribed chloramphenicol eye drops. Conjunctival swabs were taken and sent to the microbiology laboratory for analysis. A day later the conjunctivitis had become bilateral and purulent. Several hours after the conjunctivitis became bilateral the patient also developed a sore throat. The previous swab cultures isolated Streptococcus pneumoniae as the infective pathogen. Three days later, the patient noticed tenderness and swelling of the proximal interphalangeal joint of the index finger in the left hand, which became progressively more swollen and tender over the next couple of days. The patient had become febrile; however, there were neither chills nor rigors. He was prescribed oral amoxicillin 500 mg TID and flucloxacillin 500 mg QID, in the belief this was septic arthritis.\nTwo days after the swelling started he was seen by a rheumatologist, who made a diagnosis of reactive arthritis. The patient was fully investigated (see following text and Table ). Plain X-ray showed a little soft tissue swelling over the proximal interphalangeal joint of the left index finger. The patient was negative for antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), anti-DNA antibodies and antinuclear antibodies; complement factors C3 and C4 were within the reference range. No pathogen could be grown in blood culture and joint aspiration (performed by the rheumatologist) yielded no synovial fluid. The patient was HLA-B27 negative. A firm diagnosis of reactive arthritis as a sequel to pneumococcal conjunctivitis was made. Anti-inflammatory drugs resolved the swelling and pain within 48 hours. The conjunctivitis had a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old male nursing student presented to the emergency department with complaints of retrosternal pain and dyspnoea for one day. The patient also complained that he could feel some air passing through the tissues below the skin in the neck. The patient had a history of throat pain and intermittent cough for three days and a history of ingestion of hot water a day before the presentation. He denied any history of trauma to the neck or any strenuous activity over the past one week. His other medical history was unremarkable. He had no addictions and not undergone any surgeries in the past.\nPhysical examination revealed a healthy-looking young man with tachypnoea. His pulse rate was 112 beats/min and blood pressure was 120/70 mmHg, his respiratory rate was 24/min. Crepitations were felt in the neck region extending up to the left nipple over the chest. The breath sounds and heart sounds were normal. Other systemic examinations were within normal limits.\nLaboratory values (complete blood count, renal function test, electrolytes) and arterial blood gas were within normal limits. His electrocardiogram (ECG) was normal. X-ray neck and chest showed pneumomediastinum and subcutaneous emphysema (Figures -). Laryngoscopic examination did not reveal any mucosal lesion or foreign body. Computed tomographic scan of the head, neck and chest with oral gastrograffin was done which was suggestive of pneumomediastinum (Figures -). There was no evidence of any oesophageal perforation, pneumothorax, pleural disease and lung pathology. Upper gastrointestinal endoscopy and bronchoscopy was also normal. The patient was admitted and managed conservatively. He was given oxygen by mask, analgesics, cough suppressants, and steroid nebulisation. His symptoms settled with conservative management in three days and hence the patient was discharged. The patient was followed up for six months and there was no recurrence of symptoms. Chest X-ray was repeated after three and six months and ther"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 8-year-old female child was noted have a growth on her right iris. The asymptomatic lesion was followed for 3 months and demonstrated slight enlargement, leading to suspicion of JXG. She was referred for diagnosis and management.\nOn examination, visual acuity was 20/20 in each eye and intraocular pressures were normal. The only abnormal ocular finding was a minimally pigmented, vascular iris mass, measuring 6.0 mm in diameter and 2 mm in thickness, located in the nasal aspect of the iris []. Gonioscopy and ultrasound biomicroscopy revealed that the lesion was confined to the iris with no extension or seeding into the angle or ciliary body. Fluorescein angiography revealed intense vascularity confined to the mass and not involving the surrounding normal iris []. Our differential diagnosis included amelanotic iris melanoma versus JXG.\nFNAB was performed for diagnostic purposes. Using an operating microscope, a 27-gauge needle was passed through the clear cornea 1 mm from the limbus and directed into the tumor with aspiration using standard technique.[] Cytopathology revealed atypical cells with spindle morphology, ovoid nuclei, and prominent central nucleoli, which were immunoreactive for melanocytic markers melan-A and HMB45, consistent with spindle B malignant melanoma cells [].\nBased on the cytopathological diagnosis of melanoma, basal sector iridectomy was performed. Histopathology revealed an amelanotic neoplasm, composed predominantly of spindle B melanoma cells and few cells with intermediate morphology between spindle B and epithelioid melanoma. There was one mitotic figure per 40 high-power fields []. There was minimal invasion into the trabecular meshwork and base of the pars plicata. The tumor appeared to be completely removed. The tumor was classified as pT2a based on the American Joint Committee on Cancer classification (8th edition).[]\nOne week after surgery, the visual acuity was 20/40, and 6 months later, it remained 20/25. Local and systemic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old, para 5, postmenopausal black African woman who was human immunodeficiency virus (HIV)-negative presented to our casualty department with a 5-year history of progressive abdominal swelling. Five years prior to presenting, which was 1 year before she reached menopause, she had noticed that her abdomen was gradually distending. Her symptoms were associated with constipation, feeling of incomplete rectal emptying, early satiety, vomiting, and urinary frequency and urgency. She did not have any chronic illnesses and had a negative personal and family history of ovarian, uterine, bowel, and breast cancers. She was not receiving any medication prior to this presentation. She had delivered five children by cesarean section, and they were all alive and well. She lived in a rural area and was a subsistence farmer. She did not smoke and did not drink alcohol.\nShe had ascitic taps three times in 1 week at a district hospital before referral to a higher-level hospital because of recurrent reaccumulation of ascites. A transabdominal ultrasound scan (USS) showed generalized ascites with a thick fluid with septa, as well as bilateral mild hydroureter and hydronephrosis. Again, the ascites was drained twice. One month later, she underwent computed tomography (CT), which showed a large predominantly cystic lesion that occupied almost the entire abdominal and pelvic cavities, which were distended, causing a marked mass effect on surrounding organs and bowel. The lesion had areas of internal septation predominantly on the right flank with no features of metastatic disease. Tumor markers measured during this admission are shown in Table .\nThe patient was referred to a tertiary hospital but only went 5 years later. Upon admission, she had marked temporal wasting, with bilateral pitting lower limb edema extending to her sacrum. She had a normal breast examination. Her blood pressure was elevated at 167/93 mmHg, with tachycardia of 150 beats/min. Her body temperature was 36."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old right-handed white woman with no significant medical history was diagnosed as having MS in 2013 at age 22 and experienced ongoing radiologic activity on both glatiramer acetate and dimethyl fumarate. She transitioned to natalizumab in July 2014 to stabilize disease activity, and her JCV antibody index was positive at 3.58 prior to starting natalizumab. She became clinically and radiologically stable with the initiation of natalizumab until November 2016 when a surveillance MRI of her brain showed asymmetric confluent non-enhancing hyperintensities in the bilateral subcortical precentral gyri consistent with PML (Fig. , ). Cerebral spinal fluid (CSF) showed quantitative polymerase chain reaction (PCR) for JCV of 15 copies/ml, and other CSF studies were within normal limits. A diagnosis of PML was made based on the compatible neuroimaging findings along with the presence of JCV DNA in the CSF. Natalizumab was discontinued after 27 total treatments. Our patient was asymptomatic at the time of PML diagnosis, and she was highly functioning with an Expanded Disability Status Scale (EDSS) of 0. A decision was made to defer plasmapheresis at the time of diagnosis given her high functional status, subtle radiological change, and low viral titer. She was treated with orally administered mefloquine loading dose followed by 250 mg weekly and mirtazapine 15 mg daily.\nRepeat MRI at 2 months following diagnosis showed no changes in her brain lesions. She remained asymptomatic until 3 months after diagnosis when she noticed mild dysmetria of her left hand that progressed to a tremor. The following month a repeat brain MRI revealed a few small enhancing lesions in her left frontal lobe suggestive of IRIS (Fig. , ). The hyperintensities in the bilateral precentral gyri remained stable. Imaging of her cervical spine revealed a new non-enhancing cord lesion. She was then treated for 5 days with intravenously administered immunoglobulin and restarted on glatiramer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old female presented with pain in the lower back radiating to the right leg. Her symptoms first developed three years ago. When she walked for 10 minutes, her pain was aggravated and accompanied by numbness with a cramping sensation in the right leg. There was no weakness or sensory changes. No abnormal signs were seen on physical examination. For three years, she had been treated with oral medication and three sets of epidural steroid injections. The effect of the third epidural steroid injection did not last for more than one month. Moreover, PEA with the Racz catheter did not effectively reduce her pain level. The patient continued to complain of pain with a score of 8 on the NRS and she could not walk for more than ten minutes. His functional score on the ODI was 64. Her lumbar MRI revealed central disc extrusion at the L4-5 level with central canal stenosis, and bilateral L5 nerve root compression.\nWe planned PEA and decompression with the inflatable balloon neuroplasty catheter, and prepared as described above. A caudal epidurogram showed a filling defect from the central epidural space at the L4-5 level to both L5 intervertebral foramina (especially the preganglionic area). Gentle adhesiolysis of the preganglionic area at the right L5 level by intermittent balloon inflation was performed as described above, and the preganglionic spread of contrast medium was confirmed. At the end of the procedure, a Perifix epidural catheter was left at the target site through the balloon catheter lumen. After test injection of 1 ml of lidocaine, 6 ml of a mixture of 1% lidocaine and 1,500 IU hyaluronidase was administered through the Perifix catheter. After 10 to 15 minutes of monitoring, another 4 ml of a mixture of 10% hypertonic saline and 20 mg triamcinolone was injected through the catheter. The Perifix catheter was left in place for a 2-day drug injection. The catheter was then removed on"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old Hispanic gravida 3, para 2-0-0-2 at 32 weeks of gestation presented to an outside hospital with a 3-day history of worsening chest pain, dyspnea, orthopnea, and shoulder pain. She was previously in good health without comorbid medical issues. Initial work-up at the outside hospital included a computed tomography (CT), which was significant for a large pericardial effusion with no evidence of pulmonary embolism (). She was transferred to our institution for further management.\nOn arrival, the patient was uncomfortable and leaning forward, with a blood pressure of 127/80 mmHg, pulse of 124 beats per minute, respirations of 24 times per minute, and an oxygen saturation of 97%. She appeared in distress. There was tachycardia and distant heart sounds on physical examination, but no jugular venous distension noted. Laboratory evaluation revealed no significant abnormalities. Arterial blood gas analysis demonstrated a mixed metabolic and respiratory acidosis. Cardiac ischemia markers were negative. An electrocardiogram (ECG) demonstrated sinus tachycardia and electrical alternans.\nA transthoracic echocardiogram showed a large pericardial effusion with tamponade physiology and a left ventricular ejection fraction of 50% (). The patient had worsening chest pain and discomfort. The obstetric team performed fetal monitoring which demonstrated no abnormalities. A multidisciplinary team met at the patient's bedside and consisted of maternal fetal medicine (MFM), cardiothoracic surgery, neonatology, cardiac anesthesia, and cardiology specialists.\nIt was decided that surgical pericardial window and drainage with drain placement was the most appropriate treatment because the majority of the pericardial effusion was posterior and would not be amenable to percutaneous drainage. The patient received a dose of betamethasone for fetal benefit, and underwent an uncomplicated pericardial window and drainage under general anesthesia with standard monitoring and continuous fet"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old male presented to the emergency with the chief complaints of recurrent postprandial epigastric pain for three days. On scrutiny of previous records, it was discovered that this was his third hospitalization for the same complaint. On all three occasions, the patient reported that his complaints were triggered after fasting for religious reasons. He had also undergone a gastroduodenoscopy three months back revealing gastric erosions for which he had been prescribed omeprazole. At the time of the admission, this was the only drug he had been taking. No history of previous abdominal surgery was noted. On examination, apart from tachycardia, other vitals were stable. The abdomen was distended but tenderness could not be elicited. On digital rectal examination, there was rectal ballooning without any soiling of the examining finger. All hematological investigations were within normal limits and an ultrasound of the abdomen was also normal. The abdominal radiograph showed multiple air fluid levels suggestive of intestinal obstruction. A computed tomography of the abdomen was also suggestive of subacute intestinal obstruction. The patient was started on intravenous fluids and a nasogastric tube was inserted. Twelve hours later, the patient underwent an exploratory laparotomy for worsening abdominal pain, signs of peritonitis and non-resolving small bowel obstruction. On opening the abdomen, the ileum had twisted along its mesenteric axis in the clockwise direction (Figure ).\nMild distention of the stomach and proximal ileal loops was noted. The large bowel distal to the site of twisting was collapsed. No perforation or band was found. The volvulus was untwisted, and a line of rotation was seen. No fixation of the twisted segemnt was done. The bowel was slightly discoloured, but viable and started to return to its normal colour and shine (Figure ).\nThe patient was given 100% oxygen and the bowel was covered with warm moist sponges till the serosa returned to i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.\nHe first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.\nThe results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment cha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male subject visited the Department of Periodontics, The Oxford Dental College and Hospital, Bangalore complaining of bleeding gums following brushing and painless swelling in the left posterior area of the hard palate since 6 months. His medical and family history was noncontributory and was in good physical condition. The extraoral examination was unremarkable. No other abnormality was found.\nOral hygiene status of the subject was satisfactory. Intraoral examination showed the presence of swelling in the left posterior area of the hard palate of approximately 2 cm × 1 cm in size and color similar to that of palatal mucosa with slight bluish hue in the center of the lesion with a presence of sinus opening []. On palpation, the lesion was nontender and firm in consistency around the borders and soft at the center of the lesion. There was purulent discharge through the sinus tract.\nElectrical pulp vitality test results were positive. To track the sinus tract, intraoral periapical radiograph was taken with gutta-percha point placed through the sinus opening. The gutta-percha point extended till the apex of mesial root of a maxillary first molar. There were no signs of alveolar bone resorption in the panoramic, periapical, and occlusal radiographs. The floor of the maxillary sinus appeared intact. Complete hemogram showed all the parameters within the normal range. Computed tomography peripheral nerve sheath reported soft tissue density on the left side of palate causing smooth bony indentation [].\nInitially, the differential diagnosis of the swelling was made as periodontal abscess, palatal region vascular malformations such as hemangioma, mucocele, sialometaplasia, pleomorphic adenoma, adenoid cystic carcinoma, MEC, and adenosquamous carcinoma.\nIncisional biopsy was done to establish a definitive diagnosis, to assign a histological grade and prescribe adequate therapy. On histopathological examination, H and E staining showed three groups of cells, name"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase D (Insomnia): A 19-year-old female was asked to take EPI reading by her physician (who is associated with Life in Yoga Institute) because she was seriously overweight at 278 lbs with 5' 6' height (body mass index = 44.9) and in suboptimal health condition. Her chief complaint was inability to sleep at night – and even when she falls asleep, she never had sound sleep and barely slept for two hours each night.\nEPI showed very low C in all organ systems and the lowest was the nervous system at 0.5. Consistent with the protocol, we have developed, the exercise for the weakest system – nervous system – was recommended. After 6 restrictive throat breaths for vagal stimulation she began to feel better and being new to the practice found it difficult to do more. There was much improvement in C for epiphysis (pineal gland and melatonin) and nervous System []. She continued doing this practice three times a day with around 20 breaths each time, with the last session every night before going to sleep, and thereafter, she has had no problem of insomnia and has experienced higher level of wellness.\nThe readings also showed substantial increase in Pituitary C, but she had no weight loss. The puzzle is resolved by looking at the 33% increased E (reduced coherence) for Pituitary.\ncomparing C (communication energy), IA (total energy), and E (entropy) for the two cases explains more than the weight loss phenomenon.\nEndocrine versus nervous system drivers – Case C diabetic is narrowly endocrine-related to metabolic elements indicated by pituitary and pancreases activation – the drop in E is much larger than drop in IA while C is in normal zone ensuring increased coherent energy. However, Case D's problem of insomnia is primarily nervous system driven where C and IA increase and E drops ensuring increased coherence. Milder impact in coherence"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a healthy 53-year-old male with an unremarkable medical or surgical history, who has a 6-month history of progressive neck pain that radiates to his right and left shoulders. The patients’ pain, which was alleviated by analgesia and physiotherapy, increased when he lay flat or on his left side. His neurological examination, including a cranial nerves exam, indicated normal findings. There was no history of trauma or sinus disease.\nImaging of the cervical spine and brain was performed. The brain magnetic resonance imaging (MRI) [] showed a well-defined mildly expansile bone lesion in the clivus with low T1 and high T2 signal intensity with nearly complete suppression of signal intensity on fluid attenuated inversion recovery. No contrast enhancement or solid tissue was identified. There is a mild posterior expansion of the clivus, which caused effacement of the prepontine cistern, mild collapse of the clivus, and relatively acute angulation of the clivus canal angle. Surgery was discussed to perform a biopsy and reach a diagnosis.\nThe patient underwent transnasal endoscopic resection of the clival lesion in collaboration with the ear, nose, and throat team using neuronavigation. The superior margin of the clival lesion was identified by neuronavigation, and then trepination of the anterior portion of the clivus was performed using a high-speed drill []. A gush of clear colorless fluid leaked under high-pressure. Direct communication was detected between the subarachnoid space and the cyst through a dural defect. The cyst wall was a direct continuation of the arachnoid membrane. Specimens were taken from the bone, cyst wall, and cavity and were sent for analysis. The intraoperative fresh frozen section was inconclusive. A fat graft was obtained from the thigh, placed in the cystic bony cavity and supported by a synthetic plate and septal flap. There were no intraoperative complications, and the patient was transferred to the recovery room in stable condition f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old woman working as a clerical staff, requiring daily commuting by crowded trains, was suffering from left knee pain for last 6 years. Her difficulty in walking had worsened since last 6 months and did not respond to nonsurgical management. She was bedridden for 2 months before she presented to us. She also had a history of intermittent rectal bleeding.\nOn examination, there were cutaneous and soft tissue hemangiomas alongwith varicose veins throughout the affected left lower extremity from hip to toes, mainly on the gluteal region, posterior thigh, popliteal fossa, calf and foot [Figure -]. There were no visible salmon patches or portwine stains. Left lower extremity was not significantly enlarged compared to right lower extremity. There were no lesions over the anterior aspect of left knee. There was a 10° valgus alignment of the knee []. She had a flexion deformity of 20° with further flexion up to 40°. The movements were very painful in the available range of motion (ROM). The knee society pain score was 29 and her functional score was 0. There was no true leg length discrepancy. Dorsalis pedis and posterior tibial pulsations were palpable. The distal neurological status was normal. The right knee had full range of movements with no pain or deformity. There were no vascular lesions in right lower extremity. Bilateral hip examination was normal.\nRadiographs [] showed severe degenerative tricompartmental arthritis in the left knee joint with bone loss from the lateral femoral condyle and the lateral tibial plateau. There was subchondral sclerosis and osteophyte formation. Phleboliths in the vascular malformations were noticed on the X-rays.\nMagnetic resonance imaging and magnetic resonance venogram [] of the left lower limb with pelvis showed vascular malformation; mostly multifocal hemangiomas involving superficial and deep soft tissues of the entire left lower limb, pelvic region, rectum and left femur. There were no communications between the superfi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old, white Caucasian man was presented to our hospital emergency department with one-month history of jaundice, pruritus, acholic feces, dark urine, unintentional weight loss, and worsening pain in the lumbar region. On the date of admission the urine was light yellow and the patient reported that feces were of normal color and consistence. He denied alcohol or illegal drug use and had no travel history within the last 10 years. He reported jaundice and pruritus progressing for one month prior to admission. He denied having pain, nausea, vomiting, or elevated temperature during the whole month. Pain in the lumbar region was progressing during the last 2 years, due to PCa metastasis. Patient had metastatic PCa and underwent palliative hormonal therapy in ambulatory settings; he also had moderate aortic stenosis found by echocardiography and angina pectoris of class II according to the classification system by Canadian Cardiovascular Society. In year 2016, metastatic process involving the lumbar spinal and thoracic region was diagnosed using skeletal scintigraphy. Starting from year 2016 he received androgen deprivation therapy in outpatient settings and testosterone level was controlled in conjugation with PSA. Testosterone remained at castrate level.\nDuring physical examination, yellow skin, scratch marks on the back and thorax due to pruritus, and aortic murmur were revealed.\nBlood tests indicated that the patient had cholestasis, elevated alanine aminotransferase, elevated aspartate transaminase, elevated gamma-glutamyl transferase, and elevated bilirubin (). Infectious disease such as hepatitis C and hepatitis B was excluded using testing for antibodies. Autoimmune causes were also excluded; anti-mitochondrial antibody, anti-glycoprotein antibody-210, and anti-sp100 antibodies, IgA and IgM, were all negative. Alpha-fetoprotein was also negative. Alkaline phosphatase (ALP) was significantly elevated; thus isoenzyme of bone origin ALP2 was determined to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman (158 cm, 72 kg), at 37 + 1 weeks of gestational age was scheduled for caesarean delivery. The patient had previously received caesarean delivery because of preeclampsia. In this pregnancy, the patient had been diagnosed with pregnancy-induced hypertension and was prescribed aspirin 100 mg once a day for prevention of preeclampsia for 12 to 36 weeks. Blood pressure was not well controlled during the week leading up to surgery and was associated with overall discomfort. Therefore, the surgery was performed 2 weeks earlier than the planned date. A preoperative laboratory test, including Na+, K+, Ca2+, and Mg2+, and chest radiography were all within the normal range, and electrocardiography showed sinus tachycardia.\nIn the operating room, the patient was monitored with three-lead electrocardiography, pulse oximetry, and non-invasive blood pressure monitoring. The initial blood pressure and heart rate were 140/80 mmHg and 122 beats per minute (bpm), respectively. Peripheral oxygen saturation was 99%, with 2 L/minute of oxygen supplied via nasal prongs. Before induction of anaesthesia, the patient had rapid, shallow breaths and appeared to be extremely anxious. However, considering effects on the foetus, no anxiolytics were used, and only verbal comment was provided. Spinal anaesthesia was performed in the left lateral position at the third and fourth lumbar intervertebral space with a 25-gauge needle. After free flow of cerebrospinal fluid was identified, 11 mg of hyperbaric bupivacaine was slowly administered intrathecally.\nThe patient was then placed in the supine position, and initial sensory blockade was assessed by the perception of cold sensation using an alcohol-soaked sponge and by detecting pain. Before this could be completed, the patient presented with sudden onset of convulsions in the face and bilateral upper extremities for approximately 5 seconds. She also showed a slightly decreased mentality, but did not lose consciousness. At that ti"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman presented to a local hospital with a history of recurrent urinary urgency and dysuria and without macroscopic hematuria for 1 month. Urinalysis revealed leukocyturia (133/HP) and hematuria (25/HP). The patient was sexually active and was initially diagnosed with uncomplicated urinary infection. The patient received norfloxacin for 1 week. However, the symptoms remained unrelieved, and she was consulted for further examinations in the local hospital. As urinary ultrasound indicated thickening of the bladder anterior wall, further an abdominal contrast-enhanced computed tomography (CT) was carried out, through which more lesions were found, and malignant changes were highly suspicious (Fig. a). The cystoscopy from the primary hospital identified extensive basal mass in the bladder walls and the histological results of tissue biopsy revealed non-invasive urothelial carcinoma. Radical cystectomy was recommended by the provincial hospital owing to the extensive involvement of the bladder.\nThe patient considered the possibility of radical cystectomy to be devastating and presented at our hospital for consultation. A review of the patient's medical history revealed that the patient had undergone a Chinese IUD (Copper-bearing) placement 11 years ago after the birth of her first child. However, she became pregnant and underwent a painless induced abortion 3 months later, and the routine gynecological sonography revealed no IUD. After the following 2 accidental pregnancies, she underwent another IUD placement which worked well. Considering the above-mentioned history, our CT scanning revealed that a portion of one of the two implanted IUDs had migrated beyond the right uterus wall and was adjacent to the bladder (Fig. b). To verify the pathological diagnosis, diagnostic transurethral resection was performed (Fig. c, d), including the right, top, and trigone bladder wall, whereas histological examinations reported granuloma of the bladder right and top wall"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old man who works in a rubber factory developed reddish-colored lesions over the inner aspect of the left forearm, left elbow and outer aspect of the left arm, which were raised above the surface of the skin and were nonitchy and painless and associated with diminution of sensation []. The patient was diagnosed leprosy and was on regular treatment for the past 3 months. Six days before admission, he developed paresthesia (pin and needle sensation) in the left hand followed by the right hand and subsequently in both the lower limbs within 1 day. On the 2nd day of illness, he needed support to stand from the sitting position and started dragging his left feet while walking. After 1 more day, he buckles his knee while walking and could walk only with support of one person and also developed weakness of the upper limb on the next day. He could not comb his hair and could not grip a glass of water. On presentation, he was unable to get up from lying to sitting position and unable to turn side to side in bed. There was no cranial nerve abnormality and no bladder or bowel complaints. There was no history of recent cough or loose stools before the illness. No new skin lesions have appeared, but there was development of inflammation in the existing skin lesion.\nOn examination, he had hypoesthetic patch on the above-mentioned sites with bilateral thickened and tender ulnar and common peroneal nerve. Cranial nerves were normal. Power in the upper limb was Medical Research Council (MRC) grade 3/5 both proximally and distally with a hand grip of 5%–10%. Power in the lower limb was MRC grade 2/5 proximally and 4/5 distally. Deep tendon reflexes were absent globally. Sensation was decreased (pain, touch, temperature) around 60% on the patch and vibration was impaired at toes bilaterally.\nOn investigations, he had hemoglobin of 14.23 g/dl,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15–30 min after every meal. The full blood count, serum biochemistry values, and C-reactive protein level were within normal ranges. Additionally, arterial gas analysis was normal. Abdominal plain radiography showed free air between the liver and diaphragm, and PI (Fig. ). Abdominal computed tomography showed severe calcification of the SMA origin; SMA peripheral flow was reserved (Fig. ). Computed tomography (CT) revealed bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum (Fig. ).\nSince the patient did not have peritonitis, a conservative approach was performed. She was managed in the condition of intensive care unit, due to fears of the potential for acute mesenteric ischemia due to mesenteric artery occlusion or non-occlusive mesenteric ischemia. She was managed for bowel obstruction, which included fasting and intravenous fluid administration. She received heparin infusion to prevent SMA occlusion and maintain collateral flow. During admission, she reported abdominal pain relief. Seven days after admission, abdominal plain radiography showed improvement in PI and pneumoperitoneum; therefore, she was permitted to begin drinking fluids. There was no evidence of recurrent abdominal pain after the fluid consumption, so she was allowed to eat solid food.\nAngiography was planned to relieve the postprandial abdominal pain. The findings showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery (Fig. , ). ET, namely stenting to the SMA and common hepatic artery, was performed. The SMA trunk was engaged with a 6F Parent Plus 60 guiding catheter (Medikit, Tokyo, Japan) from the left brachial artery. Initially, 8000 units of heparin was infused, and additional heparin was added to keep the activated whole blood clott"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of 40-year-old male patient with a colloid cyst in the third ventricle. The patient was admitted at Clinic of Radiology, with symptoms of headache and episodes of vomit. In clinical examination patient had symptoms of brain tumor. He was treated for depression since 2017. A year ago he underwent a MRI head scan, where dilation of lateral ventricle was seen as sign of early hydrocephalus.\nThe MRI scan demonstrated a cyst in foramen of Monro region with typical signal intensities in the cystic formation that confirmed the diagnosis of colloid cyst (). In MRI images, they present as homogeneously to heterogeneously hypointense or hyperintense masses in T1 and T2 weighted acquisitions. The outstanding characteristic is a sharply outlined round or ovoid mass in the anterior and superior third ventricle, near or at the foramen of Monro region. Hydrocephalus is observed in most patients4. After diagnosis the patients was recommended to consult with a Neurosurgeon for intervention. The patient underwent surgical intervention and the cyst was removed. Similar findings were revealed also on histopathological examination (, Panels a, b, c, d, e and f). After the intervention the patient did post-operative MRI exam control as recommended where it was evidenced successful tumoral extraction while the histopathologic results described findings compatible with colloid cyst Fig2.\nA colloid cyst can be removed with a craniotomy. A craniotomy is a surgery where an incision is made in the scalp, and part of the skull is removed for the duration of the surgery then the skull is put back in place.\nOn the T1-weighted images, the lesion showed a central signal intensity slightly higher than that of the surrounding brain with a mildly hypointense rim (, Panel a). On proton density–weighted images, the colloid cyst was of homogeneous signal intensity, and on T2-weighted images, it showed a central region of hypointensity surrounded by a rim of relative hyperintensity (simi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPresenting concerns\nThis is a case of a 22-year-old white female who presented at 34 weeks with preterm premature rupture of membranes. She had a history of two prior cesarean deliveries. A left ovarian tumor, not noted during the course of her current pregnancy, was noted on cesarean delivery.\nCurrent pregnancy\nWhen she presented with preterm premature rupture of membranes, repeat cesarean section was performed again. At the time of surgery, another 8 cm mass on her left ovary was diagnosed intraoperatively. This mass was not diagnosed prior to surgery. A second trimester ultrasound was performed that did not show any ovarian cyst. During the surgery, the mass appeared tan with punctate focal hemorrhage. The mass was unable to be separated from her left fallopian tube, so the mass, the left fallopian tube and part of the left ovary were all removed. We were able to leave a small amount of residual ovarian tissue. Pathologic description noted a multiloculated and cystic mass with clear mucinous fluid consistent with mature cystic teratoma (Figure ). Her postoperative course was uncomplicated.\nPrevious pregnancy\nHer antecedent pregnancy was complicated by right ovarian torsion at 13 weeks secondary to an ovarian tumor. A right salpingo-oophorectomy was performed. The right ovary was sent to pathology and noted to be infarcted with no viable tissue from the mass to make a definitive diagnosis (Figure ). During that same surgery, an 8 cm, irregularly shaped mass with a focally hemorrhagic surface was noted on the left ovary. A left ovarian cystectomy was performed, and final pathology showed a benign mucinous cystadenoma (Figure ). At the time of cesarean in the same pregnancy, a metachronous mucinous cystadenoma was noted on her left ovary; cystectomy and partial left oophorectomy were performed.\nFollow-up and outcomes\nFollowing her third cesarean delivery, this patient was surprised to learn that she had developed another ovarian cyst in pregnancy necessitating remov"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old male presented with dull aching pain and gradually progressive swelling over the left scapular region since five months. Pain was aggravated on shoulder movement and on lying supine. He had no fever. Physical examination revealed a swelling of 3 X 3 cm which was located in the left supraspinous region. The swelling was warm and tender with soft cystic consistency. There was no discharging sinus. Terminal range of motion was restricted with pain especially during the last 15° of abduction.\nHis blood investigations were unremarkable with ESR of 15 mm/hr. Anteroposterior radiograph of left shoulder revealed a well defined, 4 X 3 cm osteolytic lesion at the superomedial aspect of body of scapula, with surrounding sclerosis []. The lateral radiograph showed increased soft tissue shadow in the superior aspect of scapula. His chest radiograph was normal. Since appearance was similar to a bone tumor, differentiation was important and work up on same lines was planned. Whole body bone scan showed abnormal increase in tracer uptake in the body of scapula with the rest of the skeleton being normal. Computer tomography (CT) showed erosions involving the supero-medial aspect of the body of scapula and along the base of the spinous process of scapula [ and ]. Magnetic resonance imaging (MRI) scan revealed a well- defined lobulated lesion []. It showed high signal on T2W and low signal on T1W images. Central T2W hypointensity was also seen. There was a soft tissue component extending posteriorly into the subcutaneous tissue. The left shoulder joint was normal. The differential diagnosis were chronic infection probably tuberculosis, Eosiniphilic granuloma or tumourous conditions. A CT guided biopsy was done Tissue and fluid were sent for cultures and histopathology. Biopsy revealed granulomas composed of epithelioid cells, lymphocytes and a few multinucleate giant cells suggestive of tuberculosis. Culture from Lowenstein Jensen medium showed acid fast bacilli after"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old African man presented with an 8-year history of left upper limb pain. The pain was so severe that he was unable to sleep at night. He complained of almost incessant pain and paresthesia from the left side of his neck, and along his entire left upper limb. Touching him anywhere on his limb and neck would elicit a burning pain that radiated along his entire upper extremity. There was no antecedent history of trauma, and he did not have any features of neurofibromatosis type 1.\nOn further probing, he reported that the pain had initially started from the tip of his left middle fingertip. Over time, the pain had grown worse, and extended to involve the entire limb.\nThe pain was aggravated by cold weather, lifting of heavy weights with his left hand and direct pressure or trauma to his left middle finger. It was relieved by rubber band tourniquet (self-applied) and by rubbing either side of his finger on a rough cloth or other rough surface. During the 8-year period, he was managed for multiple different diagnoses including neurogenic pain, neuroma, gout and thoracic outlet syndrome. He underwent multiple diagnostic tests including computed tomography (CT) scan and magnetic resonance imaging (MRI) imaging of his spine and brachial plexus. He had a total of 12 stellate ganglion blocks administered over the 8 years without a resolution of symptoms.\nOn examination, he had neck tenderness along the brachial plexus roots, and along his entire left upper limb. His left middle finger was visibly thickened and dry, with exquisite tenderness over the entire pulp, precluding further examination.\nA diagnosis of chronic regional pain syndrome (CRPS), most likely secondary to a glomus tumor, was made. Previous MRI images were inconclusive, and we did not see the need to get new ones. We proposed an exploration of his left middle fingertip, and informed him that the finding and excision of a glomus tumor would"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old female sought for treatment in our hospital due to pain mass in the left parotid gland. The lesion was symptomatic and had been present about 6 months with a recent rapid increase in size. The patient reported no prior surgeries.\nUpon examination, there was a 3.5 × 3.0 × 1.5 cm medium texture, unclear boundary, immobile, and pain mass, but the facial nerve function was intact. There was no palpable lymphadenopathy. The remaining oral cavity and head and neck examinations were normality.\nA large mass sized 35 × 30 × 15 mm in the left parotid gland was identified on MRI (Fat suppressed T2-weighted images showed mild hyperintensity, T1-weighted images showed hyperintensity). The mass was heterogeneous and had an unclear margin, so MRI suggested the mass could be a malignant tumor.\nAt surgery, we remove the tumor to the biopsy, and then the lesion was considered as a malignant neoplasm. The tumor was not invaded to adjacent tissues, so the patient subsequently underwent extensive resection of the tumor with a safety margin of 1 cm under general anesthesia. Then the tumor was sent for histopathological and immunohistochemistry analysis to confirm the histogenetic origin of the lesion. There were 2 different components including typical EMC and high-grade carcinoma in the lesion. The EMC component includes the inner layer of duct consisted of cuboidal epithelial cells and the outer layer consisted of clear myoepithelial cells. They present various tumor cells, which arrange in trabecular, tubular, or islands. The high-grade transformation component was composing of intensive spindle cells with increased nuclear pleomorphism, mitotic activity, prominent nucleolus and acidophilic cytoplasm. The large amount of spindle cells arranged in fascicular clusters (Fig. ). Immunohistochemical examination indicated that the EMC component was diffusely positive to CK. The tumor cells of the EMC were only positive for CD117 in the duct, and the outer myoepithelial cells w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-day-old full term female baby, delivered at a peripheral hospital, was brought with continuous frothing of saliva from the mouth, refusal of feeds and a progressive respiratory distress since birth. No records were available regarding the initial resuscitation of the baby and whether a nasogastric tube was passed at birth to assess esophageal patency. She was seen at three different hospitals where a diagnosis of esophageal atresia was made before she reached our center for further management.\nOn examination, the baby was a sick-looking full-term female neonate having severe tachypnea with persistent white froth in mouth. No chest wall retractions or central cyanosis was noted. Heart rate was 162 beats per minute and respiratory rate was 54 per minute. Auscultation of the chest revealed equal air entry on both sides with coarse crepitations. Insertion of a red rubber tube through the mouth revealed obstruction at 10cms from the mouth was noted. Chest roentgenogram with the red rubber tube in situ demonstrated the tube lying at the level of the third thoracic vertebrae with presence of air in the stomach. Echocardiographic examination was normal. A clinical diagnosis of esophageal atresia with distal tracheo-esophageal fistula (Vogt type III) was made. She was stabilized by low-pressure continuous upper pouch suction, oxygen, antibiotics and chest physiotherapy.\nThe patient was taken up for a right postero-lateral thoracotomy. On exploration, the esophagus was found to be in continuity with no evidence of esophageal atresia. Careful palpation of the esophagus revealed a hard mass in the upper esophagus. Longitudinal esophagotomy over the mass showed multiple foreign bodies (beetle nuts pieces) and they were meticulously removed (Fig. 1). After removal of beetle nut pieces, a nasogastric tube could easily be passed into the stomach from the mouth. Esophagus was repaired over the nasogastric tube and chest was closed after putting an intercostal drain. Post-operati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old woman presented with a 2-week history of progressive lower limb weakness and bilateral numbness from her hips to her toes. Her primary care physician referred her for physical therapy, which did not improve her strength. Her symptoms continued to worsen until she became bed bound and presented to the hospital 2 months after the initial onset of symptoms. Her past medical history included stage IIIC ovarian adenocarcinoma 17 months prior to presentation. At that time, her Ca 125 level was 1612 units/mL. She received 6 cycles of neoadjuvant chemotherapy with carboplatin and Taxol, followed by exploratory laparotomy, bilateral salpingoopherectomy, splenectomy (due to concerning lesions in the spleen), and 3 cycles of chemotherapy. Two subsequent abdominal computed tomography (CT) scans showed no evidence of recurrence and Ca 125 levels had decreased to normal.\nOn exam she had left lower extremity weakness; 2/5 in both hip and knee flexion and extension, 4/5 in dorsiflexion and plantar flexion. Right lower extremity strength was 0/5 in both hip and knee flexion and extension, and 3/5 in dorsiflexion and plantar flexion. Ca 125 levels were normal. Cerebrospinal fluid analysis indicated nonspecific inflammatory changes and no sign of infection. Spinal magnetic resonance imaging (MRI) showed an intramedullary lesion at T11-T12 (). Positron emission tomography CT revealed focally increased FDG avidity at T11-T12. A laminectomy and biopsy of the lesion were performed; pathology indicated metastatic ovarian cancer ().\nThe patient received high-dose corticosteroid therapy for 1 week after her presentation. She was discharged to a rehabilitation facility and underwent outpatient radiation therapy with 30 Gy in 10 fractions of 300 cGy each, from T7 to L1. She tolerated the treatment well and gained slight improvement in sensation and weakness, but was unable to ambulate. She received a subsequent 6 cycles of chemotherapy with Taxol and carboplatin. On completion of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.\nTo obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.\nThe right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ult"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 68-year-old lady with a past medical history significant for hypertension, hyperlipidemia, and hypothyroidism who presented with complaints of lower abdominal pain, diarrhea, and bright red blood per rectum. She was a retired medical assistant who had quit smoking 3-4 weeks prior to presentation after having smoked half pack a day for 30 years. Her home medications included lisinopril, simvastatin, aspirin, levothyroxine, and calcium and vitamin D supplementation. Her review of systems was positive for mild intermittent dry cough for the past 1.5 months. She denied fever, chills, weight loss, productive cough, hemoptysis, night sweats, and changes in urinary habits. She had unlimited exercise tolerance. Her physical examination in the emergency department was unremarkable except for mild tenderness to palpation over the lower abdomen. A computed tomography (CT) scan of the abdomen showed sigmoid and distal ascending colon colitis and incidentally identified a right hilar mass. The mass was in the superior segment of the right lower lobe and extended throughout the lower lobe along the pulmonary vessels (). The central part of the mass was enhancing with hypodensity noted peripherally suggestive of necrosis. The dominant portion of the mass measured up to 6 cm transverse × 3.4 cm antero-posterior. The tracheobronchial tree was found to be patent. An additional irregular, pleural based mass in the superior segment of the right lower lobe was also identified which measured 3.9 cm transverse × 1.5 cm anteroposterior. An additional pleural nodularity was noted in the inferior portion of the right lower lobe. These findings were highly suggestive of a right lower lobe malignancy. There was no significant mediastinal, axillary, or hilar adenopathy noted except for a subcarinal (9 mm in short axis) and paratracheal lymph node (5 mm in short axis). She underwent bronchoscopy which showed a friable exophytic endobronchial mass in the right lower lobe at 1 cm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year old female patient was admitted to our hospital with complaints of intermittent dysphagia and chest pain for 1 year. She had symptoms on the lower substernal area when swallowing a large amount of water, which were accompanied by chest pain. Chest pain was a sharp and non-radiating and was relieved by transports of swallowed water to the stomach. These symptoms only occurred when guzzling water and not by taking a sip of water or eating. The temperature of water did not show any correlation with her symptoms. Her past history was unremarkable. There was no family history of similar symptoms. She was of normal body weight and had no abnormalities on chest and abdominal physical examination.\nEndoscopy of the upper digestive tract was performed in other hospitals, but there were no abnormal mucosal lesions. Then she was referred to our hospital for further investigation on dysphagia and chest pain. The barium esophagogram showed no abnormalities. 24 hour esophageal impedance-pH monitoring was performed and there were no pathologic regurgitation.\nHRM was performed to access the esophageal motility (). On sitting position, 14 times of water swallowing in total was performed. The interval between each swallow was 30 seconds. The patient swallowed 5 mL of water from the first swallow to the seventh swallow, 10 mL from the eighth swallow to the 10th swallow, 15 mL on the 11th swallow, 20 mL on the 12th swallow and 50 mL on the 13th swallow. On the 14th swallow she tried to drink 100 mL water, but could swallow only 25 mL. She did not have symptoms from the first to the 10th swallow, but started to complain chest pain and dysphasia when swallowing more than 15 mL. The more water she swallowed, the worse her symptoms got. She complained the most severe symptoms when swallowing 50 mL of water. Rapid propagated pressurizations were observed at the second, fourth, sixth and seventh swallows, in which pressurization front velocity was measured as 19."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old man presented to his primary care physician’s office with haematuria of one-month duration. He also reported a 10–15 lb weight loss over the preceding 4–6 weeks. A review of symptoms was positive for anorexia and lower-back pain for the preceding two months. Urinalysis confirmed the presence of haematuria without evidence of any infectious process. A computed tomography (CT) scan of the abdomen and pelvis revealed a left renal mass (measuring 13 cm in diameter) with imaging characteristics suggestive of primary RCC (). The workup for metastatic diseases with magnetic resonance imaging (MRI) of the brain, CT of the chest, and a bone scan was negative. The patient was evaluated by urology and was scheduled for nephrectomy but had to return to the hospital a week sooner than scheduled because of symptoms of right-flank pain, worsening back pain, and progressive weakness of both legs. The lower-extremity weakness started a week prior to presentation and progressively got worse, resulting in the inability to walk. The weakness was associated with urinary incontinence. The rest of the review of symptoms was negative.\nThe past medical history was significant for hypertension. He denied any significant family history. His personal history was significant for a 15 to 20 pack per year history of smoking.\nOn physical examination, the patient had tenderness in the lower back and over the right costovertebral angle. Motor power was 5/5 in both upper extremities, 3/5 in the left lower extremity, and 2/5 in the right lower extremity, in both the proximal and distal muscle groups. The gait could not be tested because of the patient’s inability to stand up. There was decreased anal sphincter tone, and sensation was impaired in the perineal region. There was no evidence of meningimus, and the cranial nerve examination was normal.\nMRI of the spine demonstrated nodular enhancement of the spinal cord with diffuse leptomeningeal involvement along"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68 year-old-male patient was involved in a motorcycle accident. He presented to our emergency department with diffuse swelling and severe pain over the left knee and over the left ankle. No evidence of other skeletal injury was reported at the clinical examination. Both a radiographic examination and a CT scan revealed a left tibial fracture (Schatzker type VI) with a depression of the lateral-posterolateral side. A medial and posteromedial involvement of the tibial plateau was found, associated with a non-displaced fracture of the peroneal malleolus (, , , ). The fracture of the tibial plateau involved all columns (lateral, medial, posterior), as previously described by Luo. A long leg partial splint - was applied and limb elevation was recommended until surgery. A 3D reconstruction of the knee was done for a more accurate investigation of the fracture and an in-depth preoperative planning (, , ).\nThe fracture of the proximal tibia consisted in a split depressed lateral condyle with a posterior-lateral involvement. Medial plateau fracture was more complex, as the posterior-medial involvement was more extended in the medial side. The patient was operated seven days later to the admission, as a detailed cardiologic examination was requested by the anesthesiologist before surgery.\nThe patient was placed onto an orthopedic transparent bed in supine position to facilitate fluoroscopy and without using a pneumatic tourniquet. Cephazoline (2 gr iv bolus) was administered 30 minutes prior to skin incision as antibiotic prophylaxis.\nThe knee was externally rotated and flexed about 30 degrees and a posteromedial approach was firstly made. Incision was made posterior to the superficial medial collateral ligament. The fascia was identified and incised, the space between pes anserinus and the medial gastrocnemius was developed. Under direct visualization, the posterior fragment of the posterior medial column was reduced and stabilized in an anti-glide way with a 3.5 mm T-plat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old man without any underlying diseases had suffered from left side weakness and clonic–tonic seizures for 12 days. Computed tomography (CT) of the patient's head revealed a hypodensed mass with the size of 3 × 3 × 2.4 cm of the right temporal lobe. He was then admitted, and the magnetic resonance imaging (MRI) of his brain showed cystic astrocytoma in the right parietal lobe without midline shifting. A craniotomy was performed, and the pathology showed astrocytoma (World Health Organization (WHO) grade III). After operation, he received 2-dimensional conformal RT with a total dose of 45 Gy in 25 fractions to the whole brain. Mild skin erythematous change was noted after the completion of RT.\nDuring a regular follow-up of 14 years after postoperative adjuvant RT, a small red nodule was noted at the patient's right scalp. The size of the nodule increased overtime and the color eventually turned to black within a year. This gray-colored skin papule with a diameter of 2.5 cm has an ulcerative center. He received skin tumor excision at the age of 42. The skin tumor was totally removed with an adequate margin. The pathology revealed BCC. The morphology of the tumor featured basaloid cells which extended into the dermis with elongated nuclei and little cytoplasm. The peripheral cell layer of the tumor masses showed a palisade arrangement of the nuclei (Fig. ). No skin tumor recurrence has been noted to date.\nTwo years later, the patient developed headache, left side weakness with unsteady gait at the age of 44. His brain MRI revealed a huge cystic lesion with fluid-fluid level in the patient's right frontal lobe. There were hemorrhage, perifocal edema, mass effect causing mild midline shift. Second craniotomy was performed, and there was presence of microvascular of festoons gliosis, microcalcification and tiny foci of necrosis in the specimen, which favored the diagnosis of glioblastoma (WHO grade IV)."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a fifty-six-year-old man who initially complained of swelling in his left external ear canal. Over the previous year, he had gradually experienced severe left trigeminal neuralgia, which was occasionally accompanied by a sensation of ear fullness. On physical examination, the lesion was a solitary nodule, with a maximum diameter of 1.6 cm. The lesion was a tender, smooth, firm swelling nodule that was skin-colored with a wide base, and it had not ulcerated the left external auditory canal, which was covered with intact skin. The lesion occluded the ear canal and obstructed the view of the tympanic membrane. The patient’s hearing in this ear was slightly affected. There was no sign of regional or distant metastasis on examination before surgery. The remaining clinical imaging examinations, including head, neck and cranial nerve examinations, were normal. Routine laboratory test results, including those of liver function, kidney function, total electrolyte levels, coagulation function and complete blood counts, remained within normal limits. A high-resolution positron emission tomography (PET)-computed tomography (CT) scan of the whole body demonstrated the fluorodeoxyglucose (FDG)-avid mass described above (maximum standard uptake volume (SUVmax 2.6), while no involvement of the bony canal walls was identified (). The patient had a history of being physically fit and did not have a personal or family history of skin tumors. Taken together, the results demonstrated that the patient had no evidence of local positive lymph nodes or distant metastases, and the lesion was limited to the external auditory canal. The patient underwent wide excision of the lesion with clear margins under general anesthesia. The postoperative course was normal and uneventful. The patient was followed up over a period of 6 months, and no evidence of local recurrence or systemic metastasis was clinically observed. The patient was instructed to report for follow-up after another"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Caucasian female patient was referred to our department for further work-up of painful cutaneous lesions (Fig. ) and several masses within her liver.\nEight weeks prior, she had observed an erythematous nodule on her right chest. Subsequently, similar cutaneous lesions had developed on her arms and legs, and later also on her buttocks and back. She did not report any abdominal complaints. Outpatient treatment with topical and systemic steroids based on a suspicion of erythema nodosum (EN) did not yield substantial effect.\nFour weeks prior, several liver lesions had been detected by ultrasound and were interpreted as metastases of a previously treated breast cancer. Additional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) had been carried out (Fig. ) and confirmed the liver lesions.\nAs the nodules on her skin continued to spread and became increasingly painful, she was presented to the Department of Dermatology in our clinic. There, another attempt of steroids and an intensified local therapy resulted in no improvement of her clinical condition. Due to raising inflammatory parameters a work-up for possible infectious causes and an antibiotic therapy with piperacillin/tazobactam, and later with meropenem were initiated. A colonoscopy revealed two small polyps, which were completely removed. Pancreatic enzymes were markedly elevated. A punch biopsy of one of the skin lesions was obtained showing a lobular necrotizing panniculitis with “ghost cells” compatible with pancreatic panniculitis (Fig. ). CT, MRI and repeated ultrasound examinations (Fig. ) did not reveal any pathological findings in the pancreas. In contrast enhanced CT multiple sharply-bounded liver lesions were visualized in both liver lobes. Compared with the CT obtained during outpatient care, the lesions had progressed in size and measured from 1 cm to 6 cm. The perfusion pattern was non-hypervascular and the density was hypointense, partly comparable with the den"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe first patient was a 24-year-old African American female with past medical history of congenital Human Immunodeficiency Virus (HIV) infection, compliant with antiretroviral therapy (ART) with a CD4 count of 275, recently diagnosed endometriosis, and childhood asthma. She was admitted to the hospital for an elective dilatation and curettage procedure. She was seen postprocedure by pulmonary medicine for acute onset of shortness of breath. She was noted to be in mild respiratory distress with oxygen saturation of 96% on 4 liters of oxygen via nasal cannula but, otherwise, had a normal exam. She improved after receiving nebulized albuterol. Upon further questioning, the patient revealed that she was diagnosed with asthma as a child. She was treated with various inhaled and nebulized medications throughout her childhood. During early adolescence, she required home oxygen for about 1-2 years. She had multiple hospitalizations for presumed asthma exacerbation during her childhood and teenage years. She did not recall having a pulmonary function test or any imaging of the chest. She had never been placed on noninvasive or invasive mechanical ventilation. Over the last 5-6 years, she had no hospitalizations for shortness of breath. She did not use oxygen at home. She had a desk job as a receptionist in a doctor's office so was able to perform her duties without experiencing any respiratory distress. However, she did get short of breath after walking 3 blocks and after climbing 1 flight of stairs. She used an albuterol inhaler which she said brought only mild relief of her symptoms. She had never smoked cigarettes or any other illicit drugs. However, she was exposed to second-hand smoke as her grandmother and several of her friends smoked in her presence.\nHer hemoglobin on presentation was 8.9 g/dL, stable as compared to previous levels. She had a normal white blood cell, platelet count, and renal function. A liver function test was normal except for a low albumin level o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-year-old boy presented with complaints of pain and swelling over the right forearm since 4 months. Examination revealed a 10 cm × 5 cm bony hard mass arising from the diaphysis of the ulna. Elbow and wrist range of movements were normal, pronation and supination were restricted due to pain, no distal neurovascular deficiency was noted. The plain radiograph of the forearm in two perpendicular planes revealed a permeative destructive lesion with a wide zone of transition involving the middle and lower third ulna with periosteal reaction and cortical breach []. Magnetic resonance imaging (MRI) revealed the involvement of almost the entire ulna except for the proximal part sparing the olecranon and articular surface (T1-weighted images). It was associated with a large soft tissue component with the displacement of ulnar vessels (T2-weighted images) [ and ].\nThe clinico-radiological diagnosis of Ewings sarcoma was confirmed histopathologically with core needle biopsy. The patient was staged with computed tomography of the chest, a bone scan and multiple-site bone marrow aspiration, which did not reveal metastasis. The patient was evaluated in a multidisciplinary clinic and was started on multi-agent chemotherapy. He was reassessed after induction chemotherapy with plain radiography and an MRI of the forearm for planning local treatment []. The MRI revealed a substantial decrease in the soft tissue component of the disease. Local treatment options (limb salvage surgery with complex reconstruction vs definitive radiotherapy) were discussed with the patient and attendants, who opted for surgical treatment.\nA limb salvage surgical procedure was planned with wide excision of the ulna except the proximal 2 cm, which includes partial articular surface as this was uninvolved by the disease. This ensured a narrow 1 cm tumor-free margin proximally. Reconstruction was planned with medialization of the radius with its proximal articular surface to this retained fragment creati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 14-year-old male patient had normal birth and developmental milestones. He has no family history of dystonia or other movement disorders. At the age of 7, the first symptom of dystonia appeared as clumsiness of the hands; when he started to attend elementary school, he experienced difficulty with schoolwork because of an abnormal handgrip during writing. He was also noted to have difficulty playing with small objects such as building blocks or certain musical instruments such as a flute or piano. At first, the condition progressed very slowly. At the age of 10, the patient’s father became aware that his son’s hand clumsiness was not correlated with his age and development, and sought medical help. The boy visited a rehabilitation clinic for the hand clumsiness and underwent a series of rehabilitation treatments without obvious improvement. He also visited a pediatric neurologist for evaluation, but the brain magnetic resonance imaging (MRI) examination revealed only a parapineal arachnoid cyst, and no specific diagnosis was made at that time. However, when the patient was 11 years old, scoliosis appeared that mainly involved the thoracic and lumbar regions of the spine and abnormal posture, which rapidly deteriorated in the following 6 months. His gait and stance became severely impeded due to the severity of the scoliosis. He visited orthopedic doctors at the local hospital and received various medications, botulinum toxin injection, a back brace, and different types of physical therapy based on an initial suspicion of adult idiopathic scoliosis. None of these treatments were effective for the scoliosis. Muscle biopsy was performed but the results were normal. He was finally referred to a pediatric neurologist (WTL) at our center. Levodopa was given as a trial but had no effect. Laboratory biochemical tests showed no abnormalities and medication-induced and acquired dystonia were excluded. Genetic testing with a dystonia panel by next-generation sequencing reve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old man presented to our institute with an enlarging, painless, nodular mass in the right upper lid that began 4 months prior with rapid increase in size over the last 3 months. The mass became significantly prominent over the last month prior to presentation resulting in discomfort, ulceration, and bleeding on manipulation. Physical examination revealed a solitary mass in the middle third of the right upper eyelid, overhanging the lid margin that was 9 mm × 12 mm in size, pinkish, firm, fleshy with small-dilated blood vessels on the surface with central ulceration and crusting []. The mass was underlying the right upper lid skin extending beyond the lash line without invading the palpebral conjunctiva. It was firm to hard in consistency and tender to the touch and did not appear to extend to the deeper underlying tissues. There was no regional aurical, cervical, or submandibular lymphadenopathy. The remainder of the ocular and general physical examination including examinations of the liver and lungs was normal. Basal cell carcinoma or squamous cell carcinoma was suspected on the basis of the clinical examination. A biopsy was sent to the pathology service.\nA complete, wide excision of the nodular mass with a 3 mm clear margin of healthy surrounding tissue was performed along with primary closure []. The pathology service identified malignant nodular hidradenoma, a rare eccrine sweat gland tumor (described below). At the last visit, 6 months after excision, there was no recurrence of the lesion. The patient was subsequently lost to follow up.\nThe specimen submitted to the pathology department comprised of a nodular mass 1.5 cm in diameter. The cut surface was yellowish with few cavities.\nHistopathologic examination revealed a tumor in the dermis with surrounding fibrous capsule. Two types of tumor cells were noted with predominance of one cell-type which was polyhedral to round in configuration with round to oval nuclei and prominent nucleoli surrounded b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old woman of African descent with NF1 presented to our clinic complaining of chronic pain, depression, and anxiety. She was diagnosed with NF1 at puberty but had reported symptoms since childhood. She was unaware of a family history of similar conditions. She has Lisch nodules on her iris bilaterally and 10 café-au-lait patches across her body. The patient also has numerous subcutaneous neurofibromas on her face (plainly visible and causing some facial disfigurement) and in several regions of her body. These caused her chronic, intermittent, sharp pain of varying intensity but averaging 6/10 on the 10-point pain scale. She has tried many OTC pain medications with limited benefits. She has had over 20 surgical resections and multiple laser treatments for the neurofibromas with limited success as they often recurred after treatment. She reports pain from both the treatment and the tumors themselves. The neurofibroma tumors have also caused her cosmetic issues. She reports being withdrawn, stressed, and anxious, especially in social situations when she feels that people are staring at her. She reports low energy and had lost interest in most activities. Furthermore, she reports that her condition has interfered with finding employment and leading a normal life. She states that her mood is low, and she has frequent crying episodes. Her general practitioner (GP) has prescribed multiple antidepressants that were not tolerated due to the side effects. Consistent with NF1 common symptoms, she reports having migraine headaches. She averages around 15 episodes per month varying in intensity between 5/10 and 10/10. She has reportedly used OTC pain medications for the migraines unsuccessfully.\nCBD oil has no established dosing guidelines or maximum doses, except in psychosis (800 mg) and seizure disorders (2,500 mg or 25 - 50 mg/kg) []. Dosing is highly individualized and relies to a great extent on titration. The general approach to initiation is to \"st"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old African American female presented to the emergency department (ED) with a new onset of dizziness, difficulty walking, and low blood pressure. Her past medical history was significant for hypercholesterolemia, hypertension, and a recent urinary tract infection. She smoked tobacco but used neither alcohol nor illegal drugs. There was no history of asbestos exposure or recent viral illness. Physical examination was unremarkable. Lab work was performed and showed normal results, so the patient was released. The following day, she returned to the ED once again, and reported that her symptoms had escalated significantly. Soon thereafter the patient developed multiple organ failure with subsequent cardiac arrest, passing into pulseless electrical activity, and her death was pronounced. The initial significant autopsy finding was the discovery of approximately one liter of blood within the pericardial cavity. The pericardial sac was focally adhesed to the surface of the heart. The pericardial surface of the heart was markedly granular and thickened. An area on the pericardium of the anterior left ventricle was focally disrupted without frank tearing or laceration and blood was observed to ooze through this defect. Gross photographs were not taken due to the initial impression of classic pericarditis. The remainder of the postmortem examination was negative for grossly suspicious malignancy, including pleural, pulmonary and lymphoreticular involvement. No abdominal or pelvic pathology was identified. In particular, there was no omental or peritoneal caking, and no ovarian, renal, or hepatic masses were identified. Microscopic examination of tissue sections taken from the epicardium revealed dense lymphocytic infiltrates admixed with numerous neoplastic, polygonal cells with abundant cytoplasm and enlarged, irregular nuclei containing conspicuous nucleoli. Some of these tumor cell clusters formed gland-like formations and papillary structures (Figure ). Abundant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy, grade 9 student, presented in neurosurgery clinic with complaints of backache and left leg numbness. According to the patient’s father, his symptoms started three months prior when he developed pain in the lower back. Symptoms were gradual in onset, continuous and progressively increasing in intensity from moderate to severe. The pain was worse at night and was relieved by taking paracetamol (acetaminophen). It was also associated with weakness in the lower limbs, with a left-sided predominance. A week prior to presentation, the patient developed urinary retention and constipation. His birth and family histories were insignificant. Vaccination and developmental milestones were up to date. General physical exam was unremarkable. Systemic examination revealed decreased power in the lower limbs, bilaterally positive straight leg response and absent plantar reflexes.\nConsidering the presenting complaints and examination findings, the patient was admitted for further workup. Magnetic resonance imaging (MRI) of the whole spine was performed which revealed an intramedullary lesion extending from T8 to L1 vertebrae involving the conus. The maximum dimension of the lesion was 138 mm (Figure ). A decompression laminectomy for excision of space occupying lesion was performed. The resected specimen was sent for histopathological review, where the diagnosis of glioblastoma multiforme was established (Figures , ).\nImmediate post-operative MRI of thoracic and lumbar spine demonstrated post-surgical changes along with hemorrhage at the site of surgery with cord edema (Figure ). MRI brain showed no metastatic disease. Post-operatively, the patient had noticeably reduced sensation and power in the lower limbs, making him bedbound. Physical rehabilitation was then instituted which improved his condition slightly to the extent that he could be mobilized using a wheelchair.\nThe case was further discussed in site-specific multidisciplinary team meeting, where the conse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old ex-smoker with type 2 diabetes (70 pack-years) man was transferred to the Otorhinolaryngology after being seen in the Pulmonology Department with a progressive gradual increase in hoarseness of voice for a duration of 6 months, shortness of breath exacerbated by exertion and when lying flat had choking attacks, which occurred with liquids only, weight loss and recent hemoptysis with no history of fever, dysphagia, pain, or tuberculosis exposure. Afterwards, pleural effusion drainage was done by the Pulmonology Department to relieve the symptoms and he was sent for cytology. Surprisingly, the lung computed tomography (CT) only showed a large left pleural effusion at the time with complete left lung collapse, no obstructive mass was present, and no signs of any lesion was reported (). Meanwhile, the pleural effusion cytology showed atypical cells, vacuolated cytoplasm, and prominent nucleoli in a background of macrophages, lymphocytes and blood with suspicion of malignancy. Six weeks later, another pleural tap for a recurrent pleural effusion was performed with the pleural fluid cytology being negative for tumor cells. After complete full body workup, the Pulmonary Department discovered a thyroid nodule and transferred the case to the Otorhinolaryngology with a provisional diagnosis of thyroid nodule due to the progressiveness of hoarseness of voice with lung metastasis.\nOn head and neck examination, the tongue was deviated to the right with no other abnormalities found and no lymphadenopathy. A laryngoscopy showed a mobile left vocal cord and an immobile right vocal cord in the paramedian position with excessive pooling of hypopharyngeal secretions, most extensively in the right pyriform fossa. Further investigation of the thyroid showed a normal thyroid function tests (TFT) while a neck CT showed a right vocal cord paralysis with a right thyroid nodule about 1.5 cm () and an upper mediastinal lymph node enlargement at the right tracheoesophageal groove"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old male with no known medical history developed sudden onset chest pain, dyspnea, and a sensation of fullness in his throat. He was transported to the emergency room where he was found to be hypotensive (82/54 mmHg), bradycardic (40 beats/min), and tachypneic (26 breaths/min). His oxygen saturation was normal, and he was awake and alert and exhibited no neurologic deficits. His electrocardiogram showed normal sinus rhythm without acute ST-T wave changes, and his troponin T was normal. Given the concern for pulmonary embolism, a computed tomography (CT) scan with contrast was obtained. The CT scan revealed acute type A dissection arising from the aortic root and extending to the left iliac system. The left coronary ostium, all three great vessels, the celiac trunk, superior mesenteric artery, and left renal artery appeared to be involved. He was scheduled for emergent aortic reconstruction with deep hypothermic circulatory arrest.\nThe patient underwent induction of general anesthesia with tracheal intubation. Transesophageal echocardiography (TOE) was subsequently performed, which confirmed the presence of a dissection flap in the ascending aorta []. The flap was observed to prolapse across the aortic valve into the LV outflow tract during diastole [ and Online ]. Remarkably, there was no aortic valve insufficiency [], the LV wall motion was normal, and there was no hemopericardium. Following sternotomy and opening of the pericardium, heavy bleeding through the aortic wall was encountered. Cardiopulmonary bypass (CPB) via femoral cannulation was initiated, and the patient was cooled to 18°C. During 37 min of circulatory arrest, the ascending aorta and inside curve of the aortic arch were excised and replaced with vascular graft (hemiarch). The aortic valve and root were replaced with a valved conduit, and the coronary buttons were implanted into the conduit. After the anastomosis of the valved conduit to the hemiarch graft, the patient was separated from C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old man with a major complaint of painful mass at the lower calf was referred to our institution. Pain and swelling in his left lower leg started to develop 2 weeks prior to his presentation to our clinic and progressively worsened, eventually rendering him unable to walk. While he denied any trauma to that leg, he had been taking aspirin 100 mg, amlodipine 5 mg, candesartan cilexetil 8 mg per day for 7 years to control his hypertension, and had a history of several times of injections in the left knee for 1 year because of osteoarthritis.\nPhysical examination showed severe calf swelling with tenderness; however, no local heat or redness was observed (). The patient's body temperature was 36.8℃, his dorsalis pedis artery and posterior tibial artery pulses were strong at the level of ankle and foot, and the neurological findings were normal. Knee joint line tenderness and 10° of flexion contracture were observed in the left knee. The left knee score was 51 points.\nThe patient's blood parameters were normal: white blood cell (WBC) was 8,450, C-reactive protein (CRP) was 0.49, and coagulation parameters and autoimmune parameters were normal. But platelet aggregation function assay was delayed. A plain X-ray of the left leg revealed Kellgren-Lawrence grade 4 osteoarthritis of the knee joint and increased soft tissue density along the medial aspect of the proximal lower leg (). Computed tomography angiography (CTA) showed a large mass along the subfascial layer in the medial aspect of the gastrocnemius, and no evidence of deep venous thrombosis. MRI revealed a large mass extending distally along the subfascia in the superficial aspect of the medial gastrocnemius with muscle compression. The mass measuring 13×5×3 cm showed a low-intermediate signal intensity on T1-weighted images and an intermediate-high signal intensity on T2-weighted images. These MRI findings suggested the presence of a hematoma and the inhomogeneity"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn August 2010, a 29-year-old African American female who was 16 weeks pregnant presented to her primary care physician complaining of a fever of 103 degrees Fahrenheit, chills, pleuritic chest pain, shortness of breath and a non-productive cough for 2 days. Her pregnancy had been complicated by thyrotoxicosis and hyperemesis gravidarum requiring the placement of a peripherally inserted central venous catheter for total parenteral nutrition (TPN). The catheter had been placed approximately 11 days prior to the onset of her symptoms and she had received TPN since that time. The patient had no other significant medical history and was born in the United States with no recent travel or unusual food exposures. She did not smoke tobacco, drink alcohol or use illicit drugs. She was sexually active with a single male partner and had no history of sexually transmitted diseases. Her only sick contact was her father who had recently been treated for cellulitis. Her immunization history was unknown.\nThe patient was initially given a 5-day course of azithromycin. No laboratory studies or cultures were performed at the time. Three days later she returned to the emergency department of a community hospital complaining of persistent symptoms and mild vaginal spotting. She continued to have fevers, chills, pleuritic chest pain and dyspnea that had improved minimally with azithromycin.\nA chest x-ray revealed diffuse, peripherally located reticulonodular infiltrates in both lung fields. Laboratory testing demonstrated an elevated white blood cell count (15,800 cells per cubic millimeter). The automated differential showed 90% neutrophils and 6% bands. A complete metabolic panel was within normal limits. Her albumin, a general marker of nutritional status, was within normal range. The patient was admitted to the hospital. Two sets of blood cultures, both peripheral and from her central venous catheter, were drawn at the time of admission. Both sets had bacterial growth (at 44 and 30 h"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe proband was a 34 year-old right-handed man. From the age of 26 years, involuntary movements of the bilateral lower limbs, associated with dysarthria, grinding teeth and drooling, appeared and gradually worsened. At 31, he suffered from epileptic seizures, which were considered to be generalized tonic-clonic seizure, but antiepileptic drugs had never been administered. One year later, involuntary movements spread to his upper limbs and orofacial automatisms including abnormal tic-like facial movements, tongue protrusion and biting his lips appeared. Then he was treated with haloperidol (2 mg three times a day) and baclofen (10 mg three times a day) for 2 years for his choreic and dystonic problems, but he responded poorly to drug treatments. At age of 34, his involuntary movements gradually spread to his whole body and epileptic seizures increased in frequency. Since the disease onset, the patient had never suffer from psychiatric problems. Neurological examination revealed poor muscle tone and absent deep tendon reflexes in all limbs. Additionally, right positive babinski sign was elicited. Laboratory data revealed elevated creatine kinase level in the peripheral blood. Acanthocytes were found in 4% of cells on the peripheral blood smear test. Doppler ultrasound examination revealed splenomegaly. Brain magnetic resonance imaging (MRI) showed progressive, symmetrical, mild atrophy of the caudate heads (Figure ). His 24-h continuous electroencephalography (EEG) showed generalized asynchronous theta and epileptiform activity, which mostly originated from the right temporal lobe. A nerve conduction study showed a polyneuropathy, which revealed the right peroneal nerve, right median nerve and bilateral ulnar nerves were partly damaged. His score of Mini Mental Status Examination (MMSE) was 27. The father of the proband did not show any neurological abnormalities and died from pneumonia at 65 years old (Figure ). The mother of the proband (II-3), a 65-year-old woman,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male with body mass index of 42 kg/m2 was referred for management of bilateral asymptomatic nephrolithiasis. His family history was significant for nephrolithiasis in his brother and sister. He had passed five calcium oxalate stones since the age of 30 years. He was a smoker with no other medical history.\nThe initial abdominal plain X-ray (kidney, ureter, and bladder radiograph [KUB]) showed a left lower pole calcification and a 1.5 cm calcification on the iliac crest (). A noncontrast CT of the abdomen and pelvis revealed a 1.8 cm right midureteral stone (1288 HU) with proximal hydroureteronephrosis, a thin right renal cortex, two right lower pole stones 5 mm each (). In addition, a dilated tubular structure measuring 9 × 4.3 cm connected to the cecum and containing a few dependent calcifications was described. This was thought to be an appendiceal mucocele compressing the right mid ureter below the midureteral stone (). On renal scintigraphy, the right kidney was obstructed and contributed to 32% of the global renal function. After a failed attempt of extracorporeal shockwave lithotripsy, right retrograde flexible ureteroscopy (URS) was performed, which revealed a tortuous right distal ureter up to the midureteral stone that was impacted on an inflammatory stricture. In the presence of the stricture and of a tortuous ureter, we thought it was not safe to proceed with laser lithotripsy because of increased risk of ureteral trauma. An indwelling ureteral stent was placed and the patient was brought back for second-look URS and laser lithotripsy. During the second URS 4 weeks later, the impacted midureteral stone was accessed with a semirigid ureteroscope, and the stone was fragmented with Holmium laser energy (1 J, 10 Hz) and the fragments were removed using a zero-tip basket. At this point, a mucous plug was found in the dilated tortuous proximal ureter. A ureteral access sheath was placed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male presented to the ambulatory surgery center for a scheduled right sided C6 - C7 interlaminar epidural steroid injection. The patient had been dealing with neck pain for the last few years, with decreased range of motion predominantly on extension, positive Spurling’s sign on the right side, decreased sensation to light touch in the C6 - C7 nerve distribution, and normal reflexes that were elicited on physical examination. He had minimal relief with medication, including NSAIDs and tramadol, and physical therapy. MRI of the cervical spine showed a posterior disc osteophyte complex that was causing mild to moderate spinal canal stenosis with severe right and moderate to severe left neural foraminal narrowing. The radiologic findings along with the positive physical exam findings were evidence that the patient could potentially benefit from a cervical epidural block.\nAfter informed consent was obtained, the patient was placed on the fluoroscopy table in the prone position with the neck in the neutral position. The right C6 - C7 epidural space was identified using fluoroscopy and a 22-gauge, 3.5 inch Tuohy was advanced to the epidural space using loss of resistance technique. Isovue contrast was used for needle localization and after confirmation of the presence of the contrast in the epidural space (), 10 mg of dexamethasone and 2 mL of preservative free 1% lidocaine were injected.\nThe patient was then taken from the OR to the post anesthesia care unit (PACU) for observation. About five minutes after arrival into the PACU, the patient was noted to be anxious and hypertensive, with the systolic pressure running in the 180s mmHg and the diastolic pressure in the 100s mmHg. The patient was normotensive prior to the procedure with a blood pressure of 134/82 mmHg. In addition to the elevated blood pressure, the patient reported that he was unable to swallow and was having a subjective sensation of dizziness, and concurrent horizontal nystagmus. All other v"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old Caucasian man with severe chronic thromboembolic pulmonary hypertension and progressive decline to New York Heart Association (NYHA) functional class IV was admitted to our intensive care unit (ICU) because of respiratory failure and need for mechanical ventilation. His medical history included repeated episodes of deep vein thrombosis and two episodes of pulmonary embolism despite adequate anticoagulant therapy. Upon completion of the pulmonary hypertension investigation, his pulmonary thromboembolic disease was considered non-operable and was treated with bosentan and inhaled iloprost. Following the initiation of mechanical ventilation he was switched to intravenous iloprost and three months later our patient demonstrated a significant hemodynamic improvement, allowing him to undergo PEA. Details on his hemodynamic status and management are described elsewhere [].\nDuring his hospitalization, our patient had two episodes of ICU-acquired microbial and fungal infections including a catheter related candidaemia due to Candida albicans and Staphylococcus epidermidis (isolated from the catheter tip of a left internal jugular central venous catheter, treated with caspofungin for 15 days and linezolid 600 mg twice a day for 14 days), and an episode of ventilator-associated pneumonia (VAP) due to Acinetobacter baumannii treated according to the detected antimicrobial susceptibilities with imipenem (1 g every six hours) and colistin (3 × 106U every eight hours).\nImmediately prior to PEA, our patient was given 1 g of vancomycin as surgical prophylaxis with the induction of anesthesia. During the first post-operative week he was febrile without an apparent site of infection and received antibiotic treatment according to the surveillance cultures. On the eighth post-operative day an exudate drained automatically from the surgical wound; cultures grown in Sabouraud dextrose agar revealed a fast-growing isolate with cottony texture identified as Aspergillus spp. Mi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female patient presented to us with a 6-year-old history of pain in the right little fingertip. She took treatment at multiple places and only got transient relief before she was referred from the primary care center for further evaluation. The onset was insidious and there was no history of injury, smoking, diabetes, peripheral vascular, and cardiovascular disorder. There was no visible swelling but localized pain and tenderness over the volar aspect of distal phalanx of the little finger. The neurovascular status was intact in the affected upper extremity. There was also the history of pain increasing on cold temperature, when a fan or air conditioner is on and during winters, On palpation, pinpoint tenderness was noted when the volar pulp was given pressure with a blunt pin. The nails were normal without any pain or discoloration. The patient had normal radiographs and patient was referred for magnetic resonance imaging (MRI) of the finger. The MRI revealed a 14 × 3.5 mm altered signal intensity lesion in the soft tissue of the distal phalanx on the volar aspect best seen on sagittal T1-weighted images as T1 hyperintense lesion with heterogeneous hypointensity on fat suppression []. The lesion was closely abutting the distal phalanx cortex but without any cortical breach noted. The MRI was suggestive of glomus tumor and the excision biopsy was planned. The volar midline incision centered over the lesion was made under aseptic preparation and finger tourniquet, A glistening bluish-colored soft tissue lesion was found and that was removed en bloc with careful dissection []. Hemostasis was achieved and the wound closed after ensuring the excision of the lesion in its entirety so that to decrease chances of recurrence. The specimen was sent for biopsy and diagnosis of glomus tumor was concluded []. The postoperative period and the follow-up was uneventful and there was a marked improvement in clinical parameters with a marked reduction in the presurgery"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old nondiabetic male, presented with two chronic nonhealing ulcers of six months duration, one on the posterior part of left lower leg, measuring 3.3 × 1.8 cm with a fibrinous base and a second cutaneous ulcer on the anterior part of right leg, measuring 3.0 × 2.0 cm with a fibrinous base []. The patient reported a sensation of tightness in and around the ulcer sites with increasing severity. Both ulcers had thick nonhealing edges with a punched out appearance. The patient had been administered previously with various medications, including various types of antibiotics for six months with no improvement in the healing of the ulcers. He was on Tab. methotrexate 15 mg once-a-week for seronegative rheumatoid arthritis from past 10 years. He had no history of psoriasis at any time. He underwent complete blood investigations, which showed no pancytopenia or any other significant hematological abnormality. Culture and sensitivity tests from ulcer sites were repeatedly sterile for bacteria and fungi. Venous and arterial doppler studies of both lower limbs were done to exclude peripheral vascular disease and were normal. In view of underlying rheumatoid arthritis, a biopsy of both the ulcers was performed. There was no histopathological evidence of vasculitis or granulomatous lesions []. After extensively reviewing the clinical and investigational findings, it was found that the appearance and characteristics of the ulcers resembled those of methotrexate-induced ulcer previously reported in the literature. After a detailed discussion with the patient, methotrexate was stopped and the ulcerated lesion was closely monitored. Also, the patient was monitored for any exacerbation of rheumatoid arthritis. Two weeks after withdrawal of methotrexate, the ulcer showed definite signs of healing and by six weeks it was almost complete healed []. No other significant adjunctive wound healing measures were given. There was no exacerbation of symptoms of rheumatoid arthritis. S"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old man from the Indian Subcontinent experienced right sided, painless, sudden visual loss. He presented on the same day and his best-corrected visual acuity (BCVA) was 6/60 in the right eye and 6/6 in the left. His anterior segment examination was unremarkable and his intraocular pressure was 17 OD and 15 OS. On fundoscopy, we found a recent cilioretinal artery occlusion on the right and a normal left fundus. White retinal oedema was present along the artery course leading into the fovea. No thrombi were seen within the artery lumen. The optic discs were healthy bilaterally and there were no other peripheral retinal or vascular lesions. No signs of inflammation were found in the anterior or posterior chamber.\nHe had normal eye movements and a neurological examination did not reveal any other signs of stroke. The patient was otherwise well with no other medical history. He was not taking any regular medication and there was no significant family history. He admitted to smoking cannabis three times earlier in the day, before his vision loss. He denied the use of tobacco and informed us that this was his first use of Skunk cannabis. He also denied using any other illicit substance, most pertinently, cocaine.\nOn general examination, his blood pressure, heart rate, and ECG were within normal limits. His full blood count, kidney, liver, and thyroid function tests were normal. Furthermore, inflammatory markers, glycosylated haemoglobin, plasma homocysteine, lipid panel, coagulation screen, and serum protein electrophoresis were also normal. His blood tests did not reveal any signs of dehydration.\nThe fundus photograph of the right eye showed neuroretinal thickening along the route of the cilioretinal artery (), while the left eye showed normal retinal layers. An optical coherence tomography (OCT) scan confirmed neuroretinal thickening in the distribution of the cilioretinal artery of the right eye (). He was treated with topical beta-blockers (timolol), prostagl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old right-hand-dominant and otherwise healthy female student presented with a pain in the right upper scapular region that increased with shoulder motion and resting in the supine position. She reported that a painless snap in her back had occurred during sports activity 11 years previously and had disappeared 2 years later after discontinuing sports activity. The pain in the right upper scapular region had appeared 3 months earlier during continuous inputting to her personal computer and had rapidly worsened. She presented at a nearby hospital because the pain was generated during activities of daily life and prevented her from sleeping in the supine position. A physician suspected a malignant bone tumor based on radiographic and magnetic resonance imaging (MRI) findings and referred the patient to our hospital.\nThe patient had no relevant family or medical history. The right shoulder was slightly lower than the contralateral shoulder. There were no neurological deficits in the right shoulder or arm. There was winging of the right scapula with the arm at the side. An upper interval between the spine and the medial scapular border was widened by 70%, but the lower one was not (). There was no atrophy of the back muscle, and contraction of the trapezius was normal. The muscle bellies of the short rotators and rotator cuff were not tender and were without defects. The limitations of the active ranges of motion were 10° for total elevation, 15° for external rotation, and two vertebrae for internal rotation. Horizontal adduction was not limited with moderate pain beyond 100°. The empty can test generated upper scapular pain. No deformity or osseous tumor was palpable in the large joints, pelvis, or ribcage. Radiographs revealed a bone mass extruding from the ventral side of the superomedial scapular angle; no abnormality was depicted in the large joints. Computed tomography showed a mushroom-shaped osseous tumor composed of a cortex continuous with the scapula"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 32-year-old otherwise healthy female who was admitted to a tertiary care center with unexplained hypoglycemia and altered mental status. She was in her usual state of health until one month prior to hospitalization when she presented with morning drowsiness and loss of appetite. Due to the gradual worsening of symptoms, she was brought to the Emergency Department for further evaluation.\nUpon admission, the patient was found to have a glucose level of 35 mg/dL. She had recurrent episodes of hypoglycemia despite numerous intravenous glucose infusions which led to a work up for a possible pancreatic tumor. An ultrasound of the abdomen was performed showing several liver nodules along with a large pancreatic mass measuring up to 10.7 cm in the largest diameter (not shown). Computerized tomography (CT) scan of the abdomen was performed confirming the sonographic findings. The patient underwent a liver biopsy. Histopathology and immunohistochemistry results were consistent with low-grade neuroendocrine neoplasia (positive stain for chromogranin A) (). Insulin and C-peptide levels are depicted in .\nThe patient received continuous intravenous glucose because of recurrent episodes of hypoglycemia throughout the hospital stay (). Glucagon and hydrochlorothiazide failed to elevate glucose levels.\nOctreoscan was performed showing a high uptake in focal areas of the liver, left lower quadrant of the abdomen, and cervicothoracic area ().\nSandostatin LAR 30 mg IM was started on hospital stay day 43 on an every 28 days basis. The patient received 2 infusions of radiolabeled somatostatin analog lutetium (177LU) 8 weeks apart beginning on hospital day 56. By the second administration of the radiopharmaceutical, Octreoscan SPECT/CT had already shown objective metabolic and radiologic response to treatment (Figures and ). Serum glucose levels started to rise by hospital stay day 60 (). Intravenous glucose infusion was titrated progressively down onwards. The patient w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old Indian male patient presented to a tertiary centre in Melbourne with 3 months of progressive dysphagia, which significantly worsened over the 3 weeks prior to admission. He was admitted under the upper gastrointestinal surgical unit for further evaluation and consideration of an elective Heller myotomy.\nThe patient presented with the primary complaint of dysphagia; unable to tolerate any solids or liquids without regurgitating it back up. The vomit contained undigested food with no apparent features of haematemesis such as coffee ground appearance. The patient did however complain of mild epigastric pain while vomiting. This dysphagia was accompanied by substantial weight loss of 5 kg over the preceding 2 weeks. He denied any associated fever, cough or other coryzal symptoms. He also denied symptoms of bowel obstruction such as new constipation or significant abdominal distension.\nThe patient had a recent presentation to another large metropolitan hospital due to aspiration pneumonia in October 2017. During that admission, he was investigated for dysphagia. A barium swallow test revealed the following features: ‘bird beak’ appearance, marked distal oesophageal dilation with abnormal peristalsis and tertiary peristaltic waves; however, subsequent oesophageal manometry (lower oesophageal sphincter basal pressure: 8.9 mm Hg, residual pressure: 9.3 mm Hg, upper oesophageal sphincter basal pressure: 48.9 mm Hg, residual pressure: 7.5 mm Hg) was not typical of achalasia. He consequently underwent a gastroscopy, which showed oesophageal dilation and gastritis. The patient was given the diagnosis of achalasia and managed conservatively at that stage and was referred to the upper gastrointestinal surgical unit at Monash Medical Centre for surgical management of achalasia.\nHis medical history includes a previous Heller myotomy at the age of 17 and neurofibromatosis. The indication for the Heller myotomy remains unclear as it was completed overseas with no record"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 54-year-old woman presented with a 1-year history of a large smooth plaque on the scalp with associated alopecia (Fig. ). The lesion was tender, had slowly increased in size and had not been treated prior to the visit. She had no other symptoms, organomegaly or lymphadenopathy. Excisional biopsy was performed, which revealed a lobular infiltrate of atypical lymphocytes (Fig. ) predominantly expressing CD8 and displaying rimming of adipocytes (Fig. ). The immunoperoxidase workup also showed moderately dense dermal and subcutaneous lymphocytes expressing CD4, a minority of lymphocytes expressing CD56 and an elevated Ki-67 labeling rate with rimming around adipocytes. There were associated necrosis and sclerosis of fatty lobules and increased dermal and subcutaneous mucin. Bacterial and fungal cultures and stains were negative. There also was superficial perivascular and perifollicular mixed lymphocytic infiltrate with vacuolar alteration of the basal layer of the epidermis and follicular epithelium. A diagnosis of SPTCL was made by the dermatopathology unit at a large, academic medical center, based upon the clinical, histologic and immunohistochemical studies. T-cell gene rearrangement studies were not performed on the original biopsy, and the tissue was no longer available for subsequent testing. Some of the histologic features described might also have suggested lupus profundus. The patient was referred to the oncologist and treated with radiotherapy with complete resolution of the lesion and hair regrowth.\nFour years later the patient returned to her original dermatology clinic with new multiple firm, tender and enlarging subcutaneous nodules on the upper back, left shoulder, left forearm and both shins (Fig. ). Based on the patient's prior history and the clinical appearance of the lesions, the differential diagnosis included recurrent SPTCL, as well as traumatic panniculitis, lupus profundus and erythema nodosum. Punch biopsies of the two lesions were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis patient was a generally healthy 62-year-old male with a left lobe complex nodule within a nontoxic multinodular goiter that had been enlarging for approximately 3 years. In 2015, the patient had a FNAB reported as benign, BC II. Because of continued growth, he had a second FNA biopsy approximately six months later reported as a Hürthle cell neoplasm or suspicious for a Hürthle cell neoplasm, BC IV with Oncocytic / Hürthle cells dispersed mostly singly and in small fragments in a background of lysed blood. CKAE1/AE3, TTF-1, and thyroglobulin immunostains were positive (). Molecular testing with ThyroSeq® v2 revealed an absence of gene mutations or fusions but overexpression of the MET gene with an uncertain increased risk of malignancy. After repeat ultrasound imaging, the nodule had grown from 4.9 to 6.0 cm over the course of 1 year. He was euthyroid with negative anti-thyroid antibodies. There was no family history of thyroid cancer or known radiation exposures in his youth. He had no obstructive symptoms despite the size of the mass and denied shortness of breath, dysphagia, neck pain, neck pressure, or recent voice changes. His weight had been stable and appetite good. His past medical history was significant for a retinal detachment, hypertension, and inguinal hernia with a surgical history limited to eye surgery and hernia repair. He denied tobacco or alcohol use. On exam, the patient had an enlarged, firm thyroid gland with the left thyroid lobe causing significant tracheal deviation to the right. A neck CT scan demonstrated a markedly enlarged left thyroid lobe (7.2 cm in sagittal height) causing significant rightward tracheal deviation, minimal tracheal compression, and slight early substernal extension (). He had multiple opinions from both endocrinologists and surgeons with various recommendations from left thyroid lobectomy to total thyroidectomy. The patient had initially contemplated a hemithyroidectomy due to concerns for voice impairment that cou"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old man presented to the general surgical team with a one-week history of constant right iliac fossa pain radiating to his back. He did not report any other concerning symptoms - weight loss or change in bowel habit. Previous clinic letters indicated he had intermittent colicky right iliac fossa pain 6 years prior, which was investigated with a CT abdomen and no abnormality was detected. His past medical history included hypertension and human immunodeficiency virus (HIV) stage 3, which is the most severe stage of HIV infection where individuals are most immunocompromised []. He was taking antiviral medication for his HIV with a good CD4 count. His past surgical history included bilateral inguinal hernia repair. He denied any family history of malignancies.\nThe bed-side abdominal examination demonstrated a soft abdomen with tenderness and guarding in the right iliac fossa, and no masses were palpable. Biochemistry revealed an elevated white cell count of 10.02 × 109/L and a C-reactive protein of 133.7 mg/dL, and the remainder of his blood results were unremarkable.\nCT abdomen and pelvis with contrast revealed an appendiceal abscess (Figure ). This finding was discussed at the local X-ray multidisciplinary team (MDT) meeting, where a decision was made to manage it conservatively with broad-spectrum antibiotics and CT-guided drainage. This improved his symptoms substantially and was discharged two days later with a drain in-situ which was to be reviewed as an outpatient. Cytology from the drainage did not reveal any malignant cells.\nFollowing his discharge, he was further investigated with an outpatient colonoscopy, which revealed a caecal lesion and biopsy showed a high-grade dysplasia. A repeat CT scan still demonstrated a para appendiceal collection, which had improved.\nIn view of these findings he was referred to Basingstoke Hospital, a tertiary centre. He was reviewed at Basingstoke and a decision was made for him to undergo cytoreductive surgery. Subse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 54-year-old Caucasian male with a past medical history significant for chronic lower back pain for 15 years and basal cell carcinoma, who initially presented with a left sided inguinal mass associated with mild discomfort (). The patient was diagnosed with an indirect inguinal hernia which was repaired robotically using Progrip mesh at an outside community hospital. Intraoperatively, the surgeon noted what appeared to be a large cord “lipoma,” as well as hematoma that was attributed to attempted reduction, and incarcerated sigmoid colon through the defect. The mass was not sent for pathology and was assumed to be a simple lipoma. At 4.5 months postoperatively, the patient returned with a left sided groin fluid collection ().\nAscribing this to postoperative seroma, a 15 French Blake drain was placed with removal of 1 L of serosanguinous fluid without evidence of infection. This fluid was not sent to pathology. Drain placement was complicated by cellulitis 1 week later which resolved with IV antibiotics. Two weeks following drain placement it was removed as the fluid had resolved. At 7 months postoperatively, the patient again noted recurrent fluid collection in the left inguinal site. A follow up CT scan of the abdomen/pelvis with contrast demonstrated a large left sided retroperitoneal seroma with fluid that extended into the left inguinal canal in addition to a new retroperitoneal fluid collection ( and ()). Additionally, a new right sided retroperitoneal fluid collection was noted well away from the original postoperative bed. Bilateral drains were again placed with evacuation of 1140 mL of hematoma. Cytology of the fluid revealed mononuclear mesothelial, monocytic, and histiocytic cells and culture was negative for microbial organisms.\nThe treating medical team felt that the patient’s symptoms were most consistent with mesh complications, and the patient underwent explantation of the mesh. Intraoperatively, fluid was noted to extend below the mes"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old male, 168 cm tall and weighing 71 kg, with a traumatic right rotator cuff injury, was scheduled for arthroscopic reconstruction surgery under general anesthesia. This patient had a history of diabetes mellitus and was taking oral hypoglycemic agents and insulin. For several years, he experienced recurrent episodes of severe left ocular pain and increased IOP, which later resolved. On close ophthalmic examination, he was diagnosed with Posner-Schlossman syndrome. There was mild epithelial edema of the cornea with a few keratic precipitates, and his cup/disc ratio was 0.5 with no visual field change. During the acute crisis period, the measured IOP in his left eye was above 30 mmHg and the IOP in his right eye was 13 mmHg. His symptoms were relieved after applying eye drops containing dorzolamide, a carbonic anhydrase inhibitor, and prednisolone acetate, but frequently recurred. Three weeks before his scheduled surgery, the IOP in his left eye rose again and he became extremely anxious about the operation. After consultation with an ophthalmologist, we decided to measure the patient's IOP intraoperatively using portable tonometry, and obtained informed consent from the patient for this perioperative risk.\nPreoperative laboratory findings, including hemoglobin concentration, liver function and coagulation tests, and arterial blood gas analysis, were normal, as were chest X-rays. The patient had a left axis deviation and an incomplete right fascicular block on electrocardiography and a mild restrictive pattern on pulmonary function test without any significant symptoms. In the morning of the day of surgery, the patient received 7.5 mg of midazolam per os. Before entering the operating room, his vital signs were stable, with a blood pressure of 133/75 mmHg, a heart rate of 82 beats per min, and an oxygen saturation of 99%. Two drops of 0.5% proparacaine hydrochloride were applied to each eye, and IOP was measured by portable tonometry (Tono-Pen Avia, Ametek"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 83-year-old woman presented with acute and progressive weakness of the right-hand extensors with painless swelling in the proximal part of the right forearm. Interestingly, she noticed that weakness after a fall on the outstretched left hand leading to fracture of left distal radius. She was treated conservatively in a cast. Six weeks later, and during routine follow-up, she mentioned that she noticed her right-hand weakness only when she started to use it excessively. She denied any injury to her right-hand or elbow. Examination revealed a swelling 3 × 3 cm in the antero-lateral aspect of the right forearm in the region of supinator muscle. The swelling was soft in consistency and decreased in size on flexion with supination of the forearm indicating that the lump was deep to the brachioradialis muscle. Extension of the metacarpophalangeal joints of all fingers in her right-hand was weakened. Also, there was slight weakness in the wrist joint extension. There was no sensory deficit in any of the dermatomes of the hand or the forearm.\nRadiographs of the right elbow showed soft-tissue density closely related to the proximal radius with normal bone appearance. Electromyography of the posterior interosseous nerve and muscles demonstrated active denervation, but nevertheless there were 1 or 2 recruited motor units confirming continuity of these motor fibres. Magnetic resonance imaging (MRI) of the right forearm revealed a multilobulated mass with hypointensity signal on a T1-weighted sequence which is pathognomonic of a lipoma. The precise anatomical location was in the lateral and anterior aspects of the right radius neck and extending distally for about 3 cm as shown in Figures and . The lesion was explored through anterior approach under general anaesthesia. The radial nerve and its two branches were identified. PIN was traced distally to the level of the proximal margin of volar supinator muscle (arcade of Frohse). There was focal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 18-year-old, right-hand dominant male college freshman was referred to our clinic for evaluation of recurrent right shoulder dislocations. He had no history of connective tissue disorder and was otherwise healthy. His first dislocation event occurred 2 years prior while rock climbing and simply reaching forward and laterally to his right. No significant causative trauma was reported in association. He sought no medical treatment as the shoulder was reduced on sight. The patient reported that the dislocations were becoming more frequent and the most recent event occurred while practicing Jiu Jitsu, again while simply reaching without significant forces. Dislocations continued to occur despite rehabilitation exercises. On physical exam, he was noted to have no significant muscle atrophy or scapular dyskinesis. Notable on examination, he was found to have anterior apprehension, a positive inferior sulcus sign (compared to the uninvolved limb), and a mild posterior instability to load shift testing. On observation, the patient also showed signs of a minimal right upper extremity hemimelia despite the fact that this was his dominant arm and that he was a recreational athlete. Most apparent, his right hand was minimally, although noticeably, smaller than left, a finding not previously reported in unilateral congenital absence of the LHB tendon. His preoperative DASH score was 29.55. Magnetic Resonance Imaging (MRI) without contrast of the affected shoulder indicated an anterior Bankart type labral lesion, small nonengaging Hill-Sachs lesion, and most atypically nonvisualization of the biceps tendon () and absence of the bicipital groove ().\nArthroscopic shoulder stabilization was recommended and an anterior and posterior capsular shift with anterior Bankart repair were performed (). The posterior capsular shift was added to the stabilization procedure due to assessment of subtle multidirectional type instability. The rotator interval was not closed as this was felt t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular regio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old woman with a chief complaint of hematochezia and anorexia that had been present for one month was admitted to the hospital. Physical examination and blood test results revealed nothing of note except for an elevated carcinoembryonic antigen of 24.7 ng/mL. Colonoscopy revealed that a type 1 tumor, i.e., a polypoid-type tumor, was located in the sigmoid colon, and an elevated lesion with redness was located in the appendiceal orifice (). The tumor was biopsied and diagnosed with well-differentiated tubular adenocarcinoma, which was suspicious of primary sigmoid colon cancer. The elevated lesion in the appendiceal orifice had redness on its top surface, but biopsy was not performed there because it was not suspected to be malignant due to the apparently normal mucosa. A computed tomography (CT) scan showed, however, an appendiceal mass that involved the sigmoid colon () and was located adjacent to the right ureter, suggesting an appendiceal cancer invading the sigmoid colon. The preoperative diagnosis was appendiceal cancer with a clinical stage of T4bN0M0, stage IIC, according to the TNM classification, the Union for International Cancer Control (UICC) 8th edition.\nIleocecal resection with extended lymphadenectomy and en bloc resection of the sigmoid colon was performed through a lower abdominal midline incision after the insertion of a ureteral stent. The appendiceal tumor involved the sigmoid colon and the terminal ileum. The ileocecal part was mobilized from the retroperitoneum, keeping the right ureter intact. The ileum was divided proximal to the involved part with a linear stapler. The ileocolic vessels were ligated at their origins, and the extended D3 lymph node dissection was performed. The ascending colon and then the sigmoid colon proximal to the invaded part were divided with a linear stapler. The ileocecal part which included the tumor and the involved sigmoid colon was resected in total after the rectum was divided. The pericolic lymph node"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 65-year-old female patient admitted to the Cardiac Surgery Department in Wroclaw in January 2018 with severe mitral regurgitation (MR) and the history of ischemic heart disease, after elective percutaneous coronary intervention of the circumflex branch of left coronary artery with two drug-eluting stents (DES) implantation 4 years earlier. Furthermore, the patient diagnosed with many chronic conditions, such as metabolic syndrome, obesity with BMI 33 and gastroesophageal reflux disease. Currently, with an exercise dyspnoea for about 2 years, intensifying in recent weeks, she was hospitalized in the Cardiology Department for further diagnostics. The transthoracic echocardiography (TTE) revealed non dilated left ventricle with a normal systolic ejection fraction of 60%, and no evidence of segmental wall motion abnormalities, severe MR with the prolapse of the A2 segment and systolic restriction of the posterior leaflet. Colour Doppler showed a highly distinctive eccentric turbulent jet directed towards the lateral wall and the base of the left atrium with ERO 0.6cm2 and regurgitant volume of 60 ml. Additionally, in the performed coronary angiography, hemodynamically significant narrowing was found in the area of the previously implanted DES. The patient was then consulted by the cardiac surgeon and qualified for surgery. After admission to the Cardiac Surgery Department, as part of the pre-operative preparation, TTE was again performed, in which the severe MR was confirmed and no pathological structures in the right atrium were described. Due to the unclear image in the right pulmonary field, described by the radiologist in the chest X-ray (Fig. ), diagnostics was extended by performing a computed tomography of the chest, which excluded the presence of pathological shadow in the lung parenchyma. There was no referral to the atrial septum in the CT report. The patient was scheduled for mitral valve repair surgery and coronary artery bypass grafti"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman underwent transurethral resection of bladder tumor (TURBT) at our institute in 2004; her pathological diagnosis was a high-grade UC with adenocarcinomatous differentiation (pT2a, G2>G3). Radical cystectomy was conducted. Only carcinoma in situ (CIS) was found in the surgical specimen, and the surgical margin was negative. There was no cancer cell infiltration in the resected uterus or anterior wall of the vagina, and no lymph node involvement was detected. The patient developed continuous pain and bleeding from the residual vagina in 2010, and a tumor was found in the residual vagina; magnetic resonance imaging (MRI) showed it to be located on the anterior wall (). A biopsy of the tumor revealed a pathological diagnosis of adenocarcinoma (). Computed tomography (CT) and bone scintigraphy revealed no metastasis. Based on a preoperative diagnosis of a primary adenocarcinoma occurring on the residual vagina, tumor resection was performed (). The sigmoid colon was partially resected as it was strongly adherent to the tumor. On pathological examination, adenocarcinoma and SCC were detected (); on immunohistochemistry, sections of the tumor were positive for the SCC markers CD56, chromogranin A, and synaptophysin and were negative for the urothelial carcinoma markers GATA-3, p63, uroplakin, thrombomodulin, and 34βE12. We then reexamined the original TURBT specimen and confirmed the presence of SCC (). Adenocarcinoma and SCC were mostly present in the superficial layer of the TURBT specimen, while high-grade UC was found in the deeper layers where muscle invasion was present. Based on these findings, the tumor was diagnosed as a recurring bladder tumor. Local recurrence and pelvic bone metastasis were detected via MRI 3 months after the patient underwent surgical resection of the vaginal recurrence, whereupon she underwent radiation therapy (52 Gy, 26 fractions). She developed ileus in January 2011 and underwent release surgery. Subsequently, multiple l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman (G4,P2), at the 15th gestational week of twin-pregnancy following IVF-embryo transfer, was found to have a solid adrenal mass on a regular checkup. MRI revealed a 11×7.5 cm right suprarenal hypervascular mass with mixed signal intensity in T2-weighted images (). The diagnosis of PC was confirmed by laboratory analysis (). The patient had no genetic testing and her family history was not indicative of any hereditary disease. She had two previous vaginal deliveries (14 and 11 years ago) and a history of one abortus at 10-week gestation two years earlier. The patient confirmed that she had no symptoms relating to PC in her previous deliveries. She had no genetic testing and her family history was not indicative of hereditary disease. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. Perinatological ultrasonography revealed normal morphology of dichorionic and diamniotic male and female fetuses.\nA multidisciplinary team consisting of urologists, anesthesiologists, endocrinologist, and obstetricians focused on the therapeutic approach. The patient did not receive any medical treatment for alpha or beta blockade preoperatively. She underwent laparotomy with a subcostal incision and transperitoneal tumor resection at 17 weeks of gestation (). During surgery blood pressure (BP) was stabilized with phentolamine and esmolol, with occasional bouts of brief hypertensive periods up to 240 mm Hg systolic pressure. A hypervascular mass with fragile large veins was dissected free of the upper pole of the right kidney, between the vena cava and the lower border of the liver. The estimated blood loss was 1100 ml. The patient was transfused with 3 units of erythrocyte suspensions. The postoperative period was uneventful and she remained hemodynamically stable. Histopathological examinations were in accordance with a PC.\nShe had a norma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old man presented with the complaint of painful swelling in the right lower limb for 5 months. Also, he noted a serous discharge from the scar of the previous surgery, over the last 5 months. His medical history included an internal fixation with a metal rod implant for femoral fracture treatment (). Roughly two months after the initial symptoms, the implant was removed (). The computed tomography (CT) detected a huge right proximal thigh lesion as well as multiple soft tissue lesions. These soft tissue lesions included the subcutaneous tissue of the face and abdominal wall, left perinephric and posterior pararenal space, left gluteal region, right second rib, and the right iliac bone. The Magnetic resonance imaging (MRI) scan of the right thigh showed an ill-defined, lobulated, expansile, intramedullary lytic lesion, which involved the metaphyseal and diaphyseal region of the femur. It also showed thickening and multi-focal breach of the cortex with associated extraosseous soft tissue component involving the skeletal muscle tissue. The positron emission tomography (PET) showed increased FDG avid uptake in the right thigh, nodal and extranodal tissue, intramuscular and subcutaneous region, renal, bowel, skeletal, omental, and peritoneal region, indicating the possibility of a disseminated malignancy ().\nA biopsy of the femoral lytic region was performed, and the patient underwent a prophylactic internal fixation of the right femur with nails.\nThe biopsy’s histology revealed large, atypical cells in solid sheets with a round to oval irregular nuclei and nuclear indentations (). The chromatin was coarse to vesicular with prominent nucleoli and moderate basophilic to eosinophilic cytoplasm. Amidst these large cells, the characteristic hallmark cells with kidney-shaped nuclei were also present. Mitotic activity was brisk. These neoplastic cells were invading and replacing the surrounding bone trabeculae, indicated by dead bony fragments, collection of giant os"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe a case of a 40-year-old female nurse who presented in May 2003 with an 18-month history of pain in the left thumb. Clinical examination showed soft-tissue swelling around the left thumb metacarpal. Radiographs showed an expansile lesion occupying most of the metacarpal with periosteal reaction and cortical destruction. MR scan () showed extensive destruction with expansion of the shaft of the first metacarpal of the left hand, associated with a soft-tissue mass and an extraosseous component, primarily on the dorsal aspect. On T\n1 weighted images, the lesion was of low signal; on fluid-sensitive sequences, the lesion showed high signal with a thin and irregular septae. Following contrast medium administration, inhomogeneous, multilobulated, peripheral enhancement of the lesion was noted but also areas of non-enhancement predominated centrally, consistent with a cartilaginous lesion.\nThe CT scan () demonstrated a lytic lesion involving virtually the entire shaft of the first metacarpal of the left hand and reaching the subchondral bone plate at both ends. The lesion demonstrated a significant expansion of the bone with small areas of punctuate calcification, significant thinning of the cortex circumferentially and a breach in the cortex with some new bone formation on the dorsal aspect. Some soft-tissue swelling was also seen. There was no evidence of pulmonary metastases on the CT scan () at initial diagnosis.\nAn open biopsy was performed in June 2003, the histology of which revealed a grade II chondrosarcoma with evidence of spread beyond the cortex into the periosteum. Vascular invasion was not identified. 1 month later, under general anaesthesia, a first ray amputation was performed with disarticulation of the thumb at the trapezioscaphoid joint. A tourniquet was used at the time of the surgery to exsanguinate the limb. Macroscopic examination revealed an expansion of the metacarpal bone due to a chondroid tumour measuring 35 × 25 mm, which eroded thro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA five-year-old boy weighing 11 kg, was brought to a public tertiary care hospital in Karachi, Pakistan by his parents. His chief complaints were described as a diffuse rash over the body, swelling of the head and bulging of both eyes as well as swelling of the gums. These symptoms were progressive and relapsing, with the rash being present since the past 18 months and having extended to a breakout over the head, neck, back, chest and perineum over the last month and the swelling and bulging having progressed over the past year.\nAccording to his mother, the child had been in absolute good health until the age of two years, when he developed a spontaneous fracture of his right clavicle. The family was counseled and told the fracture would heal without any intervention. At two-and-a-half-years of age, the family sought a dental consult for a spontaneously broken tooth which was described to them as a developmental problem of the mandible. Further on, at three years of age, the child developed an infected oral ulcer, a severe swelling of his gums and had two episodes of a yellowish ear discharge for which he underwent drainage. His bodily rash made its first appearance six months after that, at 3.5 years of age, presenting as yellow lesions with pus filled discharge over the head, palms, soles and genital area - albeit, healing afterwards. The swelling of the right side of the head and bulging of both eyes started at the age of four years, with the proptosis gradually progressing to its current state upon presentation and associated with dimness of vision in the right eye. The child had previously been misdiagnosed as a case of Papillon-Lefevre syndrome (rare ectodermal dysplasia characterized by palmoplantar keratoderma associated with early onset periodontitis) two years ago and prescribed fluconazole, but to no avail. He was the third offspring of a consanguineous marriage,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old female, with a BMI of 33.9, was transferred to our hospital from an outside facility with a diagnosis of a failed left hip prosthesis. The implant had fractured in the area of the femoral neck adjacent to the modular head ().\nThe patient had undergone left total hip arthroplasty twelve years prior to presentation for osteoarthritis. The femoral component was a cemented Exactech Opteon stem, size 2, with a 28 mm, +5 mm femoral head. The acetabular component was a 54 mm Duraloc cup with an Enduron polyethylene liner (DePuy Inc., Warsaw, IN). The patient had a total knee arthroplasty performed in the ipsilateral extremity three years prior to the total hip arthroplasty also for osteoarthritis. Three months after the total hip arthroplasty, the patient developed a Staphylococcus epidermidis periprosthetic infection in her knee and underwent exchange arthroplasty later that same year. Only the total knee implant had been affected and revised, whereas the total hip implant was unaffected. The patient subsequently underwent successful rehabilitation and had been an independent community ambulator thereafter.\nUpon presentation, the patient denied shortness of breath, chest pain, fevers, chills, night sweats, or recent travel. Five month prior to presentation, the patient had dental work with appropriate antibiotic prophylaxis. The critical event most likely occurred several days prior to presentation when the patient slipped and fell in the bathroom. Plain radiographs revealed a fracture of the femoral component at the area of the femoral neck adjacent to the modular head (). The stem appeared well seated with no evidence of infection, loosening, malalignment, or periprosthetic fracture. Examination and imaging of the ipsilateral knee were unremarkable.\nSurgery was subsequently planned for component retrieval and revision arthroplasty. Under general anesthesia, the patient was placed in the lateral decubitus position. The previous incision was opened, the sub"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old married male presented to our clinic with complaints of few confluent and mildly itchy blisters on the glans penis for one day. The blisters had appeared a day after having protected sexual intercourse with his wife. There was mild fever along with the specified symptoms. On further questioning the patient recalled that he had three similar episodes at the same site about one, two and four months ago. For these he did not seek medical attention since they healed spontaneously without any sequela. On further query, the patient correlated all four episodes of penile blistering with prior intake of an oral sex stimulant medication that he had procured over the counter (OTC).\nOn examination, skin colored blisters of different sizes were noted on the glans penis [] covering an area of 3 cm × 2 cm. The blisters stood on a slightly erythematous base and few of the blisters had coalesced to form larger ones. On palpation the lesion was non-indurated but mildly tender. Rest of the mucocutaneous examination was normal. There was no local or generalized lymphadenopathy. Systemic examination was non-contributory and tests for VDRL, herpes simplex (1 and 2) and human immunodeficiency virus (1 and 2) were negative. We advised a biopsy of the area which the patient declined. Based on the history and clinical findings, we made a diagnosis of fixed drug reaction. The patient furnished a sample of the suspected medicine and also brought his wife for history taking and examination. We prescribed a low potent topical steroid and told him to avoid using the medicine in future.\nAfter one week, the lesions had healed without any residual pigmentation. We found that the medicine contained 10 mg of tadalafil along with herbal ingredients. Patch test over the healed area with the medicine (containing both the taldenafil as well as the herbal ingredients) was negative. The patient declined an oral challenge test. The Naran"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14 year-old female presented with a year's history of painless enlargement of the right parotid gland and one week's history of facial asymmetry. Physical examination revealed a firm mass 2 × 3 cm in diameter in the region of the parotid gland as well as right facial nerve paralysis. The mass was fixed with palpation as was a palpable right cervical lymph node. She had a normal body temperature and normal complete blood count, erythrocyte sedimentation rate, and blood chemistry.\nWe investigated the possibility of other diseases that could cause a swelling in the parotid gland: granulomatous infections such as mycobacterial diseases and autoimmune disorders. The results were negative.\nMagnetic resonance imaging (MRI) showed an enlargement of the right parotid gland with evidence of multiple cystic masses involving both the superficial and deep portions of the gland.\nFine-needle aspiration (FNA) biopsy was used for diagnosis. Cytopathological examination suggested ACC with the finding of large globules of the extracellular matrix, partially surrounded by basaloid tumour cells but lacking characteristic globules.\nA radical parotidectomy and modified radical neck dissection with spinal accessory nerve preservation was planned under general anesthesia. A preauricular incision that curved under the ear lobule was made in extension with the neck dissection incision. A skin subcutaneous flap was raised over the parotid until the distal branches of the facial nerve were seen to exit the gland. The mandibular, buccal, and zygomatic branches were incised and tagged with fine silk sutures for later grafting []. As the main trunk was considered to be encased by the tumour, a mastoidectomy was performed, to identify the main trunk of the facial nerve, increase the length of the proximal nerve stump for grafting, and also to provide adequate surgical margin.[] Once the main trunk was identified, extensive resection was performed to remove the parotid neoplasm. Frozen sections fr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old Italian girl was referred by her pediatrician because of a retained deciduous canine in her right mandible. During an earlier visit to the pediatrician, the doctor, considering the age of the patient, asked her about the exchange of deciduous teeth, and she reported that the tooth had not yet changed. She was not alarmed, neither was her mother, but the pediatrician insisted that the tooth would probably have already dropped. The pediatrician therefore encouraged her to contact her dentist.\nThe girl was in good health, and her dental and medical history was unremarkable with only the usual childhood maladies.\nAn extraoral clinical examination disclosed a symmetrical face with balanced vertical thirds.She shows a dental-skeletal class I with normal mandibular divergence, with no bad habits, and her cephalometric values are all normal; even her lower and upper incisors are normal-inclined. Her profile is standard for Italian people. An intraoral examination revealed that her dental midlines were concordant with each other and with her face, and no mandibular shift was detected on closure. Except for some lower incisor crowding the overall occlusion was fair with acceptable overjet and overbite. Her clinical periodontal parameters were normal. A radiographic examination revealed that the mandibular right canine was in an oblique position with its crown tip near the apex of the lower right first incisor root (Figure ). An occlusal radiograph confirmed that the crown of the impacted canine was vestibular (Figure ). The canine angulation to the midline was 55° (Figure ). This value suggested a very difficult problem, which might not be orthodontically treatable. After careful evaluation of this case, in view of the age of the patient, the clinical decision was to treat this impacted tooth orthodontically. Full mouth orthodontic treatment was suggested.\nIt was our goal to treat this case with a non-extraction orthodontic approach using upper and lower jaw app"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old male patient presented at our emergency room after a traffic accident and the brain computed tomography (CT) scan indicated an incidental arachnoid cyst on posterior fossa. At that time, the patient complained only of facial abrasions and the left knee pain, but not of headache or visual disturbance. In eight months, however, he revisited our Department of Ophthalmology to check the decreased visual acuity, visual field defect, and headache. On the ophthalmologic examination, bilateral papilledema (), decreased visual acuity, and visual field defect () were found. After the transfer to the Department of Neurosurgery, we rechecked brain CT scans (). The diameter of the patient's arachnoid cyst did not change compared to the previous CT scans; however, the slightly enlarged third ventricle was compressing the optic chiasm and the suprasellar area. Since visual complications were expected, we recommended an emergency operation. However, the patient refused the operation for personal reasons. One week later, he came back to the hospital with nearly complete visual loss. His right eye was completely blind, whereas his left eye recognized only light ().\nOn that day, he underwent an emergency operation. A conventional suboccipital craniectomy was performed on the patient lying on the operating table in the prone position. After the dural incision, the arachnoid cyst was exposed and cystic fluid was expelled. Arachnoid membrane was carefully dissected and the arachnoid cyst was fenestrated to cisterna magna for connecting with the cerebrospinal fluid (CSF) flows. Arachnoid membrane which covering the foramen of magendie was also fenestrated and the CSF flows was running properly (). Excluding the brain tumor, the collected membrane was sent to the pathologic laboratory. In high power field microscopy under the hematoxylin and eosin stain, the cystic membrane was composed by membranous fibrocollagenous tissues without tumor cells. Finally, the patient was diagn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn December 2011, a 69-year-old male patient was admitted to our institution for the evaluation of further therapeutic options of metastatic malignant melanoma. Previously, in March 2009, the diagnosis of an ulcerated nodular solid malignant melanoma of the left cheek (thickness 30 mm, Clark level 5) with infiltration of the left parotid gland had been made. The neoplastic cells carried wild-type B-RAF alleles, but an oncogenic mutation in exon 2 of the N-RAS gene was found. The past medical history was unremarkable except for hypertension, for which antihypertensive combination therapy was given. In March 2009, the patient underwent surgical excision and neck dissection, during which a total of 16 lymph nodes were removed, which histologically did not show any signs of tumor invasion at that time. Subsequently, however, in October 2009, a soft tissue metastasis developed at the base of the resection area, which was treated with local irradiation over a course of 2 months. In December 2010, another subcutaneous metastasis was found above the left base of the mandible, which was surgically resected. Histopathological analysis showed clear resection margins.\nAdjuvant immunotherapy with 3 million units of interferon-α thrice weekly was initiated in January 2011 but terminated in May 2011, when increasing serum concentrations of the tumor marker S100 indicated disease progression under therapy. Moreover, by this time, the patient had developed numbness and weakness of the right arm and left leg. A CT scan revealed newly developed lung metastases and lymph node metastases in the right hilar region as well as below the carina, and an MRI scan showed 2 new brain metastases – one in the left frontal region and another one in the area of the head of the right caudate nucleus.\nAfter a course of stereotactic irradiation (7 × 5 Gy, i.e. a cumulative dose of 35 Gy), another MRI scan performed in December 2011 showed regression of the left frontal brain metastasis and constant si"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA twenty-five-year-old woman presented at our Institute with three months history of cough with scanty expectoration, progressive dyspnoea and chest pain. She migrated from Nepal to India along with her husband and was working as a part-time domestic helper. There was no history of diabetes, hypertension, or any other significant disease. She had weight loss by 4 kg over the last three months, presently weighing 40 kg. She had dyspnoea at rest, respiratory rate 28/min, and pulse rate 120/min. She had wide spread crackles over bilateral lung fields. No significant cardiovascular system or ECG finding was observed. No cause of chronic alveolar edema could be elicited. There was no clinical evidence of any gynecological involvement. No BCG scar was seen and she could not recall any BCG vaccination. Her complete blood count, routine biochemical tests including blood sugar and urinalysis were within normal limits. Her serum was non-reactive for HIV-antigens on two different occasions. Chest radiograph revealed bilateral diffuse alveolar opacities having irregular fluffy margins with a pattern of coalescence and presenting in butterfly distribution. The blunting of right CP angle was also seen []. The tuberculin test read at 48 h showed an induration of 28 mm. The microbiological evaluation of her sputum showed no pathogen. CT scan of thorax [] was also suggestive of alveolar opacities, showing the air-bronchogram within alveolar opacities and presence of right pleural effusion. Thoracentesis and the evaluation of pleural fluid showed exudative effusion but leading to no further differentiation. The various differential diagnoses considered [] were individually evaluated for by using fiberoptic bronchoscopy, detailed systemic history, thorough clinical examination and appropriate relevant investigations. The BAL specimen and brush specimen obtained through the fiberoptic bronchoscope were negative for any malignant cells and bacterial, mycobacterial or fungal infection us"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old male presented to the emergency room with complaints of central abdominal pain for the past eight to nine hours and multiple episodes of vomiting. The pain was cramping, located in the central abdominal area. The pain occurred every one to two hours and each episode lasted 15-20 minutes. The pain was associated with episodes of bilious vomiting that provided partial relief. His last bowel movement was two days ago. The patient had been experiencing multiple such episodes for the past two years. No history suggestive of tuberculosis was present. The patient had no previous abdominal surgery. The patient’s blood pressure was 114/82 mm of Hg. The patient’s pulse rate was 92 beats per minute. The systemic examination was unremarkable. The upper abdomen was distended. The abdomen was soft and no tenderness was present. No free fluid was present. Exaggerated bowel sounds were heard. Rectal examination was normal. Abdominal x-rays revealed dilated jejunal loops with abnormal air-fluid levels and no air in the colon.\nThe patient was admitted with a provisional diagnosis of acute intestinal obstruction and was managed with nasogastric decompression and fluids. The pain resolved the next day as did the distension. Patient moved bowels subsequently. The nasogastric output was 800 - 1,000 cc in 24 hours with bilious contents. The patient was allowed liquids gradually and started tolerating semisolids well. Urgent contrast-enhanced computed tomography (CECT) abdomen was done and revealed the duodenojejunal (DJ) flexure to be lying on the right side and not crossing over to the left, small bowel loops in the right half of the abdomen, lack of visualisation of the caecum in the right lower abdomen (Figure ), and reversed superior mesenteric artery and vein in relation with the vein lying to the left of the artery (Figure ). A barium contrast study was done and revealed the DJ flexure was limited to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old female presented to our polyclinic with increasing pain in the left upper quadrant in the previous month. She had been treated for hypertension and had a hysterectomy 7 years ago due to a myoma. The patient had quit smoking 3 years earlier and was taking alprazolam 0.5 mg/day for an anxiety disorder. A physical examination revealed minimal sensitivity of the left upper quadrant upon deep palpation and an incision scar from the gynaecologic surgery. Nothing else of note was detected. The patient's body mass index was 32.5 kg/m2, and laboratory measurements were within the normal range. Endoscopy and a colonoscopy conducted to determine the cause of pain revealed no pathological findings. An ultrasonic evaluation revealed no evidence of an aneurysm. However, magnetic resonance imaging (MRI) was conducted due to the presence of a hyperechoic lesion (53 × 39 mm in size) in the right lobe of the subcapsular area of the liver. The MRI study revealed a 35 mm diameter hemangioma in the liver segment 8 and a 40 mm aneurysm with a thrombus in the splenic artery of the pancreas tail region (). Tortuosity of the splenic artery, which had a proximal diameter of 1 cm, was detected. In angiographic multislice computed tomography (CT), minimal aneurysmatic dilatation was detected in the celiac truncus in the midsegment of the splenic artery, in addition to saccular aneurysmal dilatation, 50% thrombosed and in the size of 45 × 40 × 39 mm adjacent to the pancreas. A long segment of the splenic artery transection extended from the distal aneurysm to the splenic hilus ().\nFollowing a consultation with the interventional cardiovascular department, an endovascular intervention was planned for the treatment of the aneurysm. Endovascular interventions made from the femoral region were inconclusive because of extreme angulation of the truncus celiacus, aneurysmal dilatation of the trunk, and tortuosity of the splenic artery. The patient was informed about the surgical procedur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn December 1999, a 64-year-old man underwent a cemented left total knee arthroplasty using a sigma PFC posterior cruciate retaining total knee prosthesis (DePuy Orthopaedics, Warsaw, IN, USA) for degenerative changes in relation to osteoarthritis using a medial parapatellar approach in a different centre. The patient recovered uneventfully and was doing well. In July 2009, the patient presented to us with a history of sudden onset pain and locking of the left knee since the preceding three months. There was no history of trauma and since was mobilising with difficulty using crutches. The patient weighed 89 kgs and had no other medical comorbidities. Clinical examination revealed a severe antalgic gait and a significant amount of rocking with metal on metal noise in 20 degrees flexion. Passive movements ranged from 0 to 90 degrees. At that moment, the knee was quiescent. AP and lateral radiographs (Figures , , and ) of the left knee revealed a fracture of the posterior condyle of the femoral prosthesis with rotation and evidence of further loosening. Given the patients symptoms and the radiographic evidence, a decision to perform a revision of the total knee arthroplasty was made after a fully informed written consent.\nRevision surgery was performed as an elective procedure in August 2009 revealing the broken prosthesis (Figures and ). A TC3 RP PFC revision prosthesis was used with a medial parapatellar approach. A size 4 tibial prosthesis with a 53 mm sleeve and 12∗75 mm stem and a size 4 femur with 31 mm sleeve and 14∗75 mm stem along with femoral metallic augments and a 12.5 mm RP insert were used. Intraoperative range of motion was from 0 to 120 degrees and the procedure was uneventful. The patient recovered well and was mobilised with touch weight bearing for 6 weeks. Checking the X-ray revealed a satisfactory prosthesis and the patient was discharged on the 8th postoperative day. Follow-up at 6-week and 6-month period revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old Asian woman was referred to our department for a renal angiogram following 8 months of uncontrolled hypertension despite receiving medications. Initially, the patient presented with severe headache and fatigue. She had no history of smoking or drinking alcohol, was not diabetic, and had no history of diabetes in her family. She had no history of atherosclerosis. Apart from high blood pressure, the result of her physical examination was unremarkable; her general, cardiovascular system, respiratory system, and abdominal examinations were unremarkable. Neurological examination on admission showed that the patient was alert, attentive, and oriented. Her speech was clear and fluent with good repetition, comprehension, and naming. She recalled 3/3 objects at 5 min. All of her cranial nerves were intact. Motor examination revealed no pronator drift of outstretched arms. Her muscle bulk and tone were normal. Her strength was full bilaterally. Her reflexes and sensory were both intact. Her coordination and gait were normal. Laboratory investigations revealed normal complete blood count, serum cholesterol, lipid profile, and renal function (serum creatinine 119 μmol/L). Her left kidney size was normal with measurement of 9.6 cm by 4.8 cm. Renal Doppler ultrasound confirmed renal artery stenosis with renal resistive index of 0.58. The percentage of renal artery stenosis in the two branches of the left renal artery was 70% and 75%, respectively , before the first balloon angioplasty; after the first balloon angioplasty, these percentages remained the same. After the second ballooning and stenting procedure, revascularization was achieved. The patient had been attending a hypertension clinic and receiving antihypertensive drugs for the past 8 months on a regular basis under close observation. Despite this treatment and care, her blood pressure remained high at 175/110 mmHg, which the attending doctor concluded to be uncontrolled blood pressure. Initial imaging indi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old female with a past medical history of stage IV NSCLC with metastatic disease to the bones and liver presented with lower extremity edema. She reported 2 weeks of swelling that initially began around her eyes and face that then progressed inferiorly to her abdomen and lower extremities. She had gained 12 pounds over a similar time frame and noted new, progressively worsening hematuria with frothy urine. She denied fever or recent illness, although she had endorse dyspnea with dry cough and orthopnea. She also had a new erythematous maculopapular rash on her face over her eyelids, cheeks, and nose. She had received her first cycle of ipilimumab for the treatment of her lung cancer 4 weeks prior.\nShe was diagnosed with NSCLC approximately 2 years prior and completed 6 cycles of carboplatin, pemetrexed, and pembrolizumab with good initial response to therapy, followed by maintenance therapy with pemetrexed and pembrolizumab and progression of disease. Her treatment course was complicated by primary adrenal insufficiency secondary to pembrolizumab use, for which she was initially treated with pulse steroids (1 year prior to current presentation) and remained on oral prednisone (5 mg by mouth daily). She had not received pembrolizumab for 3 months prior to her current presentation. Her other medical history included hypertension, gastroesophageal reflux disease, and osteoporosis. She continued to smoke approximately 1 pack of cigarettes per day.\nOn physical examination, her temperature was 37.1°C, blood pressure was 192/104 mm Hg, heart rate was 73 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 94% on room air. She appeared to be in no acute distress and did not have evidence of jugular venous distention, though did have faint rales at the bases of the lungs, bilaterally. Her cardiovascular exam was unremarkable. Her abdominal exam did not have a fluid wave. She had 1+"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe publication of case information and materials was approved by the Institutional Review Board of The Gachon University Gil Medical Center (GAIRB2015-197).\nA 31-year-old male patient visited our hospital with symptoms of recurrent rib fractures in the absence of physical trauma, increased body hair, and central obesity. His evaluation showed Cushing’s syndrome with bilateral adrenal cortical thickening, three calcified lesions on the left testis, and a pigmented skin lesion on the buttock. The patient and his sister had resection for familial cardiac myxomas 5 years ago, but did not have any other symptoms at that point; they were the subject of a previous case report []. The patient was diagnosed with Carney complex, and bilateral adrenalectomy and resection of the pigmented skin lesion were performed. A needle biopsy was done for the testicular tumor to preserve patient fertility.\nThe cardiac myxomas resected 5 years ago were located in both the right atrium and the ventricle, with sizes of 6.0 × 3.5 cm and 0.9 × 0.5 cm, respectively. The resected specimens were composed of hyperemic gelatinous soft tissue (). Histologically, they showed fusiform to stellate cells with a moderate amount of eosinophilic cytoplasm embedded within the myxoid stroma (). The patient was found to have a mutation in the protein kinase A type I-a regulatory subunit (PRKAR1A) gene when he had the resection of his cardiac myxoma [].\nThe bilateral adrenalectomy specimen showed multiple dark to light brown nodules measuring up to 1.2 × 1.2 cm throughout the cortex (). Histologically, the nodules were composed of cells resembling those of normal zona reticularis and contained dark brown pigments (). The histological features were consistent with those of PPNAD.\nThe resected skin showed dumbbell-shaped intradermal melanocytic proliferation with heavy pigmentation resembling blue nevus (), but with epithelioid melanocytes (). The cells were positive for S-100 protein () and human melanoma blac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old male, with Crouzon syndrome phenotype, visited the emergency department of a tertiary referral center, reporting multiple episodes of epistaxis in the past few days. The patient also reported nasal obstruction and impaired nasal breathing for the previous several months. Rest of the medical history was free. On clinical examination, a polypoid lesion protruding from the right nostril was noted. In addition, asymmetry of the face and projection of the ipsilateral canine fossa were evident.\nComputed tomography of the paranasal sinuses showed an inhomogeneous soft-tissue mass, which completely occupied the right nasal cavity, maxillary sinus, and anterior and posterior ethmoidal cells. The lesion produced extensive bone remodeling of the right maxillary sinus with complete absence of its anterior wall, as well as erosion of the posterior wall and entry of the lesion in the pterygopalatine fossa. There was also erosion of the ipsilateral lower as well as median orbital wall, and entry of the lesion in the orbital cavity. Despite its large size, the lesion seemed to be well defined without invasive characteristics (Figures –).\nRoutine laboratory tests were within normal range. Preoperative maxillofacial consultation excluded pathology of odontogenic origin. The patient underwent a biopsy under local anesthesia, and the findings showed nonspecific inflammation. Open surgery under general anesthesia was undertaken via lateral rhinotomy and medial maxillectomy (). The maxillary sinus mucosa was completely replaced by inflammatory tissue simulating a benign mass. This mass was readily mobilized and dissected free from surrounding tissues within the orbit and pterygopalatine fossa, as no macroscopic invasion of any neighboring structures was noted. Histopathological examination revealed typical nasal polyposis with mixed population of eosinophils, neutrophils, and macrophages, with no evidence of fungal invasion (Figures –). Antibiotic and corticosteroid treatme"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old Caucasian male sustained diaphyseal fractures of the left radius and ulna three months prior to the presentation in focus. The fractures were managed surgically with closed reduction and 3.0 mm intramedullary elastic nailing of the ulna and open reduction and internal fixation (ORIF) of the radius with a 3.5 mm dynamic compression plate (DCP). Follow-up at two months confirmed satisfactory progress and radiological evidence of the union. The patient was scheduled for elective removal of the elastic nail at three months.\nOne week prior to metalwork removal the patient tripped and fell onto his outstretched left hand. He presented with severe clinical deformity of the forearm and severe distal neurovascular deficit (Figure ). The hand was pale with an absent radial pulse, prolonged capillary refill time (CRT) and no digital signal on pulse oximetry. Furthermore, both sensory numbness and motor weakness in the distributions of both median and ulna nerves were noted.\nEmergent closed reduction in the emergency department was only partially successful in restoring alignment, with restoration of the CRT but persistent neurological deficit. Post-reduction radiographs revealed persistent angular deformity of sixty degrees. Re-fracture of the ulna with plastic deformation of the flexible nail was again noted, as was a periprosthetic fracture at the distal margin of the radial plate (Figure ).\nIn view of the persisting neurological deficit, the patient was taken to the operating theater expediently. Further attempts at closed manipulation under general anesthesia were unsuccessful. The IM nail- though deformed- was intact allowing successful removal via the routine method from the proximal ulna entry point; however, satisfactory reduction could still not be gained. The radius was approached through the previous volar approach and re-plated, ensuring use of a longer 3.5 mm DCP to account for the previous screw holes. The ulna was then approached directly and inter"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male presented to the oral oncology outpatient department with a swelling over the right side of the mandible of one month's duration. A comprehensive history was taken, and the patient revealed a history of extraction of multiple teeth on the same side, after which the swelling started insidiously. It was soon accompanied by intermittent episodes of pain, which was of a pricking nature and radiated upwards along the jaw and to the ear on the same side. The patient was prescribed analgesics and anti-inflammatory medications, which provided temporary pain relief but there was no decrease in the swelling. The patient also complained of excessive salivation for two weeks. The patient had a habit of smoking 10 - 15 cigarettes a day for more than 25 years with occasional alcohol consumption. There was a negative history of chewing tobacco in any form.\nClinical examination revealed a bony hard swelling of the right side of the mandible, approximately 5 x 4 cm in maximum dimension, extending from the angle of the mandible to 2 cm short of the midline. The swelling was tender on palpation, with defined edges, and was fixed over the bone. No crackling or crepitus was elicited and the overlying skin was unremarkable. However, paraesthesia of the skin over the ipsilateral chin and lower lip was elicited.\nOn intraoral examination, no abnormality of the oral mucosa was detected and the patient was edentulous. Tenderness was elicited on palpating the alveolar mucosa on the right side, up to the retromolar region. The neck was palpated; however, no significant cervical nodes were found. An orthopantomogram was taken which showed a large radiolucency with irregular borders extending from the lower right canine region to the right angle of the mandible (Figure ).\nClinical findings and previous biopsy reports were correlated and the diagnosis was inconclusive. The lesion was provisionally diagnosed as an intraosseous malignancy of the mandible. The oral pathologist sugg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old Caucasian man with a four-year history of left hand pain, dysesthesia and weakness that progressed over the subsequent year to involve the left upper extremity presented to our clinic. He was initially diagnosed with Raynaud’s disease and treated with nifedipine. His pain continued to worsen and later progressed to involve bilateral upper extremities all the way up to the elbows. Over the subsequent two to three years he developed progressive right upper extremity as well as bilateral lower extremity weakness. Neurologic examination revealed quadriparesis and impaired sensation to all modalities over bilateral upper extremities up to the elbows and bilateral lower extremities up to a few inches below the waistline.\nHe underwent a magnetic resonance imaging (MRI) of the brain and cervical spine which showed a 2.7 × 1.1 × 1.5cm avidly enhancing intramedullary lesion at C2-C4 with a cervical cord syrinx, marked cord edema and expansion, extending from the medulla through T3. He was taken to the operating room and an attempt at surgical resection was unsuccessful due to the lack of a defined surgical plane and the high vascularity of the tumor mass. A biopsy was performed which confirmed the diagnosis of hemangioblastoma. The syrinx was not entered or drained during this procedure. The patient refused testing for von Hippel-Lindau disease but no other hemangioblastomas were seen on whole neuraxis scanning and fundoscopic examination. Postoperatively he continued to deteriorate to the extent that he became wheelchair bound. Oral dexamethasone (16mg daily) was initiated approximately one week postoperatively because of increasing arm weakness and he showed minimal improvement. The improvement was short-lived and dexamethasone was subsequently tapered over the ensuing two to three weeks.\nBevacizumab was started after obtaining appropriate informed consent. The patient was given a 10mg/kg infusion every two weeks (initially for two cycles) and an MRI of the ce"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a nineteen year old male with a motorcycle accident, admitted to the emergencies complaining about a mild pain at the base of the neck. No other serious injuries were present despite of the severity of the crash.\nA free medical history was reported. Clinical examination confirmed patient's stable respiratory and hemodynamic condition, the lower cervical pain as well as the absence of any neurological deficit. X-ray examination demonstrated a small fracture at the anterior superior surface of the C7 vertebrae indicative of a combination of flexion-destruction forces applied during the accident.\nDynamic cervical spine x-rays were indicative of instability and CT-scan 3D analysis, performed to evaluate x-ray findings, confirmed the presence of the fracture and the anterior subluxation at the C6–C7 level.\nConservative treatment with Halo-vest, x-ray evaluation of the reduction and a new neurological examination were performed, figure . Patient was discharged from the hospital with instructions to visit the outpatients department according to treatment schedule.\nDespite of our instructions, the patient neglected visiting regularly the outpatient department and presented three months later to the emergencies complaining of mild headaches and fatigue.\nClinical examination revealed mild redness and edema of the skin as well as pin loosening and irritation at the point of pin insertion. GCS was estimated at 15/15 and no neurological deficit was detected. Lateral and anteroposterior X-rays were normal. Blood count presented an increased amount of WBCs, mainly neutrophils. Pins were tightened and patient was instructed to visit the clinic the following day for new blood and radiologic exams.\nThe following day, the patient was admitted in our clinic. New blood counts and x-rays were performed and samples were taken from the area of pin insertion with minimal incision and were sent to the Microbiology Department. Due to the lack of definite diagnosis, furt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year old female presented to the surgical clinic with pain and swelling in the left gluteal region. The swelling had gradually increased in size over 4 months. The pain was radiating to the left lower limb and associated with numbness. The patient had been involved in a road traffic accident two years earlier and had suffered a left acetabular fracture, which had been treated conservatively.\nPhysical examination revealed a large tender swelling in the left gluteal area simulating an abscess. However, pulsation was observed over the swelling that raised the suspicion of a vascular lesion. Therefore, contrast enhanced computed tomography (CT) was done before trying any intervention. The scan demonstrated a large pseudoaneurysm originating from the left superior gluteal artery measuring 6.4 × 5.8 × 3.4 cm with a small intra-pelvic component and large extra-pelvic component in the gluteal area []. This lesion appeared as a contrast-filled structure in direct communication with the superior gluteal artery. Its two components were communicating in the region of greater sciatic notch.\nMagnetic resonance imaging (MRI) was also performed for better assessment of this vascular swelling and any surrounding hematoma. The aneurysm demonstrated mixed signal intensities; with rounded central signal-void area representing the patent lumen, and a peripheral thick rim of high signal intensity on T1-weighted and low signal intensity on T2-weighted images denoting a thrombus/hematoma []. In addition, the signal void lumen showed some flow artifacts.\nThe patient was referred for endovascular treatment.Digital subtraction angiography (DSA) and transcatheter embolization were done in the same session. The aneurysm was approached by puncturing the right femoral artery and occluded by placing four coils and gelfoam in the feeding vessels [].\nRepeated CT angiography after 1 week confirmed exclusion of the aneurysm with only a residual hematoma in the area [Figure and ]. Patient had an u"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a nine-year-old, previously healthy boy, presenting to the emergency department of a tertiary care hospital with complaints of severe frontal headache for the last two weeks but more for the last two days. Headache was associated with nausea, vomiting, photophobia, and pain in both eyes. There was no history of fever, jerking movements, or trauma. The child had no past medical or surgical history. He achieved all developmental milestones normally and was doing well at school. His examination revealed a fully conscious and oriented child with a heart rate of 77 per minute and blood pressure of 159/112 mm Hg. Power was 5/5 on both sides, all cranial nerves were intact, and no sensory loss was observed. There were no meningeal signs but there was right side papilledema. The rest of the exam was normal. His blood investigations, including blood glucose, full blood count, serum creatinine, and electrolytes, were normal. MRI of the brain was done, after initial symptomatic management. MRI showed left temporal, extra-axial collection measuring 5.40 × 4.10 cm of CSF-like intensity compatible with arachnoid cyst and bilateral frontoparietal subdural enlargement compatible with subdural hygroma ().\nWithin an hour of ED admission the child's frequency of vomiting increased along with mild drowsiness. At that point Cushing's reflex was positive with heart rate was 64/minute and blood pressure of 177/110 mm Hg. The child was referred to the neurosurgery team and the subdural hygromas were drained through bilateral frontal burr holes. Left temporal arachnoid cyst was partially drained through left temporal craniotomy. A left subdural-peritoneal shunt was placed for drainage of any future collection. Drained CSF was xanthochromic and negative for malignant cells. CSF culture showed no growth. Histopathology of cyst confirmed radiological diagnosis of arachnoid cyst. Final diagnosis of left temporal arachnoid cyst with spontaneous subdural hygroma was made as t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nInformed consent was obtained from the individual participant in the study.\nA 35-year-old man (body weight: 100 kg) was admitted to our center complaining of headache and chest discomfort. Physical examination revealed high blood pressure (184/88 mm Hg) in the right arm and weak lower extremity and left arm pulses. Echocardiography and computed tomography (CT) angiography demonstrated an aortic arch coarctation with a minimal diameter of 5 mm. The coarctation was located between the left common carotid artery and the LSA, with a large collateral circulation and a large biloculated calcified aneurysm just distal to the coarctation. The LSA arose from the upper locule of the aneurysm with an upper-to-lower flow direction (Fig. A and B). Coronary angiography and CT cerebral angiography are unremarkable.\nAnatomical surgical aortoplasty or percutaneous transluminal aortoplasty for the complex lesion between the aortic arch and descending aorta would be a difficult as well as high-risk procedure. Therefore, the team decided to treat the patient via a 2-stage hybrid approach, with extra-anatomic bypass grafting performed first, followed by subsequent transluminal occlusion of the aneurysmal orifice several months later.\nThe first-stage procedure was performed under general anesthesia via a left thoracotomy without cardiopulmonary bypass or deep hypothermic circulatory arrest. A bypass between the ascending aorta and the descending aorta was established using a 16-mm Gore-Tex tube. Arterial ligation was performed at the aorta just proximal to the coarctation, at the descending aorta distal to the aneurysm, and at the origin of the LSA. Postoperative recovery was uneventful, with a decreased blood pressure difference between the right arm and lower limbs (preoperative and postoperative systolic blood pressure difference is 46 and 8 mm Hg, respectively). The patient was discharged 8 days after the operation in good condition.\nSix months later, the patient was readmitted for t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46 years old housewife presented with left knee pain of ten months’ duration without significant trauma. She had been treated elsewhere as septic arthritis of the left knee based on the radiological features of severe bone defect of the medical condyle of the left tibia. There was neither history nor clinical appearance suggestive of septic arthritis of the left knee. Results of investigations did not support the diagnosis of infection of her left knee. There was genu varus deformity of her left knee, and she walked with an antalgic gait, occasionally requiring a walking frame for long-distance walking. She had never been hospitalised before. She was given two trials of oral antibiotics empirically but to no avail. Due to the persistent pain that had not resolved with nonsteroidal anti-inflammatory therapy and antibiotics, she was referred to our orthopaedic department.\nAt our centre, we found there was muscular weakness in the lower extremities. Movement of the left knee was painful with limited range of movement of 0° to 90°. The skin in the affected knee was normal without signs of infection, vascular abnormalities or oedema. Peripheral pulses in the left lower limb were normal. The varus deformity of left knee was passively correctable. Radiograph of her left knee showed no progressive changes of the bone defect compared to the bone defect ten months previously. () Laboratory studies including haematological tests revealed no evidence of metabolic, neoplastic, immunological or infectious aetiology. She was then scheduled for total knee replacement for her left knee, six months later.\nHowever, while awaiting elective surgery, three months after presenting to our centre, she returned with complaint of right hip pain of three weeks duration. The right lower limb was shorter by two centimetres compared to the left lower limb. There was no history of trauma or infection. Radiograph of the right hip revealed complete osteolysis of the femoral head, though a radiogra"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn eight-year-old girl presented to the clinic suffering from tenderness and bleeding from a vast necrotic sacro-gluteal mass. She had small pigmentation at this region since birth but it was asymptomatic and diagnosed as a naevus. However, at the age of eight years, the lesion aggressively progressed and became painful and haemorrhagic. No family history was significant. The patient went to a dermatologist who prescribed local steroids without any benefits. The lesion continued to become larger and more painful. No signs of puberty were present at time of presentation and no trauma other than sitting for long periods during school was reported.\nCurrently, the lesion became around 12 cm at the longer diameter and 10 at the shorter one with irregular episodes of mild bleeding which prevented the patient from her normal life. Current physical examination found a murmur on auscultation over the mass and Doppler ultrasonography showed a fast and high-flow lesion which speculated to be AVM. Magnetic resonance imaging (MRI) showed non-capsulated superficial soft tissue mass in the sacro-gluteal region. The mass was large and measured approximately (12*10*4) cm. It consisted primarily within the skin and subcutaneous fat in the retro sacro-gluteal region and encased the coccyx. There was no extension to the pelvis or to the spinal canal. The mass was heterogeneous in signal intensity with numerous dark flow voids. Contrast enhanced images showed multiple enhancing abnormal blood vessels. It was consistent with an arteriovenous malformation (AVM). Otherwise, the pelvic structures were within normal limits (). Brain MRI was normal, and no medications were used to treat the lesion.\nThe patient had financial difficulties and the surgery and embolization was postponed for another six months. During the six months, the lesion grew rapidly and became necrotic with occasionally heavy haemorrhage. Haemoglobin (Hb) reached as low as (5 g/dl) and the mass reached (15*15*2 cm) in size"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26 year-old man attended our ophthalmic ward in April 2017 with intermittent bleeding of the right eye, from which there was also strong odor. The patient was a heavy smoker but had no other underlying conditions. He had no history of drug-use. From his medical history it was noted that the patient had undergone a right ophthalmectomy 24 years previously due to retinoblastoma, and implantation of an artificial right eyeball in 2014 (timeline shown in Additional file ).\nOn admission, his pulse rate was between 80 and 100 beats/min. His body temperature and respiratory rate were both normal. Physical examination showed narrow conjunctival sac in right eye and the exposure of ocular prosthesis, which was discharging a yellow-green secretion along with a strong odor. The visual acuity of left eye was 0.3, and the intraocular pressure was 15 mmHg. All other characteristics of the left eye were normal. A auscultation did not show any abnormality in the lungs, and no signs of carotid murmur were found. Interestingly, laboratory investigations did not reveal abnormal inflammatory markers such as leukocytosis or any increase in neutrophils or C-reaction protein. According to clinical and laboratory investigations, infectious endocarditis was not suspected. The patient had no history of other immunosuppressive conditions, except smoking and a retinoblastoma 24 years previously. The patient did not report any direct contact with animals; however, he did work in a clothing factory so would have been contact with wool and cowhide for one month of the year. Three months had elapsed between the patient last coming into contact with wool and cowhide and the appearance of clinical symptoms. Considering the results of these investigations, partial artificial eye infection, especially anaerobic organism infection, was suspected.\nImaging workups were completed, which included chest x-ray, transthoracic echocardiography and eye magnetic resonance imaging. As shown in Fig. , eye magnet"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old male presented for consideration of vertebral augmentation due to diagnosis of stage IV, metastatic prostate adenocarcinoma, and worsening back pain. Lupron therapy was initiated at diagnosis four months prior. Docetaxel treatment was planned for six cycles but was subsequently stopped after the first cycle secondary to side effects. No radiation therapy was previously given. PSA level was 120.73 at diagnosis and 0.6 before radiofrequency ablation.\nAt the first appointment, the patient reported mild back pain and required a walker but was able to ambulate without difficulty. He did have pain upon palpation of the thoracolumbar junctional level. He did not have any neurologic deficit at presentation. Computed tomography (CT) scans showed 40% compression deformity of T12. Magnetic resonance imaging (MRI) showed pathologic involvement of T12 and L1 and metastatic involvement of the epidural component, resulting in 40% spinal canal stenosis (Figure ). At this time, vertebral augmentation was recommended although it was believed the epidural component would not be addressed and Radiation Oncology would need to be consulted. In a short period of two months, the patient’s condition deteriorated where he was wheelchair bound due to severe pain, not controlled with NSAIDS or opioids. In addition, repeat studies showed further tumor infiltration involving T11, prompting augmentation of T11, in addition to T12 and L1.\nThe procedure was performed under monitored anesthesia care (MAC) and fluoroscopic guided imaging. Under this image guidance, 10-gauge introducer needles were advanced into the T11, T12, and L1 vertebral levels using a bilateral transpedicular approach (Figure ). A drill and osteotome were used to create cavities at the anterior aspect of the vertebral bodies. Bilateral 17-gauge bipolar radiofrequency probes were advanced into the vertebral cavities and simultaneous application of radiofrequency energy was performed as part of the protocol for volu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old woman was admitted to the ICU with acute respiratory distress and circulation insufficiency. Besides a history of Waldenstrom’s macroglobulinemia that had not required active treatment, she had no history of health problems, infections or recent hospitalisations. She was a lifelong non-smoker, lived in a rural home with her husband, and handled firewood for home heating. Four days prior to admission the patient noted fever, chills, dyspnoea with dry cough and diarrhoea. On the day of admission, these symptoms were more severe, and an ambulance had been called because of syncope. Her ability to oxygenate deteriorated progressively during the first hospital day, and she was intubated and mechanically ventilated.\nChest X-ray on admission showed bilateral diffuse lung infiltrates and signs of interstitial oedema. Large bilateral pleural effusions were noted, and >1000 ml were drained. Echocardiographic examination identified normal left ventricular wall motion, and no signs of structural abnormalities or of pulmonary hypertension. Thin-cut CT images of the lungs on the third ICU day showed diffuse bilateral alveolar and interstitial infiltrates with dependent consolidation (Fig. ). The clinical course during the first seven days was dominated by respiratory insufficiency requiring maximal ventilatory support with high levels of inspired oxygen, as well as circulatory shock requiring treatment with vasopressor and inotropic infusions. Other important clinical aspects included coagulopathy with diffusely spread petechiae, progression of renal failure with anuria requiring dialysis, and elevated levels of LDH (Table ). She was treated presumptively for bacterial pneumonia and sepsis with a series of broad spectrum antibiotics and corticosteroids, without apparent response.\nHantavirus infection was verified with the detection of PUUV RNA in plasma (630,000 copies/ml) on the day of admission, while IgM and IgG were negative. Seroconversion with positive IgM and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man with a history of chronic obstructive pulmonary disease, cerebral vascular accident, necrotizing pancreatitis complicated by pseudocyst requiring splenectomy and heart failure with preserved ejection fraction was transferred to our hospital following one month of treatment for pneumonia. He was a distant alcoholic but had since gone through rehabilitation and admitted to drinking one time per week and smoking four cigarettes a day. He had previously presented to his primary care physician with fever and malaise and was diagnosed with community-acquired pneumonia. He was treated with five days of azithromycin. He continued to worsen, and was admitted to an outside hospital with hypoxemia and right lower lobe pneumonia for which he was started empirically on vancomycin and piperacillin-tazobactam. His hospital course was complicated by respiratory failure requiring intubation for three days and a recurrent exudative right lung loculated effusion that required decortication and placement of a catheter that remained in place for two weeks. All blood and pleural fluid cultures were negative.\nOn transfer to our hospital for physical rehabilitation, the patient complained of mild shortness of breath. He denied hemoptysis, chest pain, orthopnea, nausea, chills or night sweats. Physical exam was significant for bilateral rhonchi with signs of consolidation in the right lower lobe. His labs were notable for a white blood cell count (WBC) of 17,000 cells/mcl with 87% neutrophils, and a chest radiograph revealed a right middle lobe infiltrate. He was continued on intravenous (IV) vancomycin and piperacillin-tazobactam at admission. Over the next two days his WBC climbed to 21,000 cells/mcl. Computed tomography scan of the chest revealed a right-sided empyema with extensive bilateral airspace disease consistent with severe pneumonia. A new chest tube was placed, which drained dark brown exudative fluid with gram-positive cocci on gram stain. The fluid was cultu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old non-hypertensive diabetic male, farmer by profession, presented with complaints of blackish discoloration of distal part of the left foot for 15 days predominantly involving four small toes. He had similar blackish discoloration of left great toe for last one month, which was amputated 15 days back in a local hospital. He also complained of ulcerative wound over the distal part of left foot and amputated great toe (Figure ). He was diagnosed as a case of uncontrolled type-2 diabetes mellitus with poor glycemic control on irregular oral hypoglycemics for five years. He had a history of claudication pain in lower limbs for the last one year, which gradually progresses to pain even at rest and loss of sensation of digits for the last three months. He is a chronic smoker and alcoholic for the past 20 years. There was no history of fever, pus discharge from the distal lower limb, chest pain, blurring of vision, blackouts, or abdominal pain.\nOn clinical examination, there were no signs of pallor, icterus, pedal edema, lymphadenopathy, clubbing, or cyanosis with random blood glucose of 344 mg/dl. Extensive ulceration and necrosis were present over the ankle, heel, and great toe region of left lower limb along with blackish discoloration of second to fifth toes. The peripheral arterial pulses were not palpable in all major peripheral arteries of both lower limbs. Computed tomograghy (CT) angiogram of lower limbs showed high-grade occlusion and luminal narrowing in almost all major arteries of both lower limbs. The provisional diagnosis was made as bilateral lower limb peripheral vascular disease due to uncontrolled diabetes mellitus. The patient was planned for above-knee amputation of left lower limb.\nThe patient had developed few episodes of mild grade fever, for which automated blood culture was collected and sent to the microbiology laboratory. The bottle was loaded in BacT/Alert Virtuo system ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15 year old male patient presented with a chief complaint of swelling in the mandibular anterior region for 20 days. There was moderate swelling in the chin area, which was nontender and had firm consistency with ambiguous margins. There was no history of trauma and he also had no complaint of fluid, blood, or pus discharge from the swelling. There was no relevant medical history of any disease, especially endocrinal disturbances. He was physically and mentally healthy and not under any medication.\nOn clinical (extraoral) examination, the swelling existed in the lower third of the face extending from the right to the left parasymphyseal region. Superiorly, the swelling was obliterating the mentolabial sulcus and up to the lower border of the mandible. The overlying skin was normal in color and texture but was stretched. The margins of the swelling were diffuse. On a profile view, there was a slight prognathic appearance []. On palpation, the swelling was firm, nontender, and with a normal temperature.\nIntraoral examination revealed an oval, nontender, and firm swelling, measuring 7 cm × 5 cm in size, which was extending from the right second premolar to the left first premolar with buccal and lingual cortical plates expansion. Superiorly, the swelling was at the level of the gingival margins of the anterior teeth. There was no restriction in tongue movements or difficulty in swallowing. The overlying mucosa was nonadherent and with normal color and texture. Severe mesial tilting of all four incisors and mild mesial displacement of left canine and first premolar along with the two right premolars was noticed. The patient had retained his right deciduous canine. No caries was detected. All four anterior teeth were nontender on percussion with Grade I mobility. All findings of inspection were confirmed by palpation.\nMandibular occlusal radiograph revealed a well-circumscribed unilocular radiolucency with radio-opaque border extending from the right second molar to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old, gravida 0 woman presented to the gynecological emergency room with complaint of severe, constant low abdominal pain (VAS 8). She denied any radiation of pain, fever, chills, nausea, or vomiting. No urinary symptoms, vaginal discharge, or bleeding were presented. She was in middle cycle and was not taking any contraceptive. She reported dysmenorrhea and painful intercourse the last year such as Chlamydia infection ten years earlier.\nThree days before, the patient experienced sudden onset of severe, right lower quadrant pain and presented to the emergency surgical department where she was treated for suspect renal colic and urine infection. The pain recurred the next day and became continued. One year ago, the patient was admitted to surgical department for renal colic and during her hospitalization a CT scan was performed and showed an elongated cystic mass on the right adnexa.\nOn physical examination, focal tenderness was presented in the right lower quadrant. On pelvic examination, right ovarian tenderness was noted and there was no cervical motion tenderness. Complete blood count and urinalysis were normal, CRP was 47, and urine pregnancy test was negative. Endocervical swabs were obtained and were negative.\nSonography examination showed a normal uterus and a normal left ovary. A small amount of simple free fluid was present within the Douglas pouch. A cystic mass measuring 8 × 4 × 3.5 cm was thought to arise from the right adnexa or ovary. Carefully examination demonstrated that the tubular cystic structure was separated from the ovary and was presenting two ecographic features: the first one was a fusiform, thick-walled cystic mass resembling a hydrosalpinx and the second one had the appearance of a cyst containing blood. Differential diagnosis included isolated torsion of Fallopian tube, paraovarian cyst, hydrosalpinx associated with tube-ovarian abscess, or endometrioma. CT examination did not add useful information; the mass was similar at the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 34-year-old gravida II para l woman, with a gestational age of 26 + 3 weeks at admission, who had a relatively healthy 4-year-old child with her 40-year-old husband of non-consanguineous marriage. She had been on injectable contraception for 2 years and had regular menses for 6 months before the pregnancy. She had antenatal care at a local health center and was vaccinated with tetanus toxoid once and supplemented with iron for 3 months. She was screened for retroviral infection, hepatitis, and syphilis and it was documented nonreactive. She had no anatomic scan at early gestation. She came to Felege Hiwot Referral Hospital with the chief complaint of severe and persistent headache of a day’s duration which was occipital in location associated with blurred vision and generalized body swelling of 1 week’s duration. She had no other danger signs in pregnancy. Her past gynecologic history, medical history, and surgical history were uneventful. She is Amhara by ethnicity. She had no known family history of hereditary or chromosomal disorders.\nHer blood pressure at admission was 180/120 mmHg and pulse rate was 84 beats per minute; her respiratory rate was 22 breaths per minute and she was afebrile. She had pink conjunctiva and non icteric sclera, 24 weeks-sized gravid uterus, no abdominal tenderness, no organomegaly, no sign of fluid collection in her abdomen, and the fetal heart beat was positive. She had no vaginal bleeding or discharge. She had pedal and pretibial edema. She was conscious and oriented to person, place, and time. Her deep tendon reflex was +2 and her motor and sensory examinations showed no motor or sensory problems. Other parts of systemic examinations were normal.\nHer hypertension was controlled with intravenously administered hydralazine 5 mg two doses at our emergency department. In her complete blood count her white blood cells were 7300 cells/micL,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male not known to have any chronic medical illness, presented complaining of epigastric and left upper quadrant pain for 1 month, associated with intermittent nausea and vomiting, and aggravated by fatty meals, with no other associated symptoms. He had frequent visits to the emergency department where he was managed with analgesia and antacids with mild symptomatic improvement. Clinical examination was unremarkable with no evidence of jaundice or abdominal tenderness. His blood test results showed a normal complete blood count, kidney function, and liver function. Chest X Ray revealed dextrocardia with stomach fundic gas shadow on Right side (). Abdominal ultrasonography revealed transpositioning of the solid organs with a left sided liver and gallbladder with a solitary stone and mild wall thickening. We elected to perform a Magnetic Resonance Cholangiopancreatography to delineate the anatomy and to rule out any anomalies within the biliary tree. It confirmed the previously noted findings, showed no evident anomaly within the biliary tree, and confirmed the diagnosis of situs inversus totalis (, ). The patient was Scheduled for an elective laparoscopic cholecystectomy.\nThe Operating room equipment arrangement was adjusted as Mirror Image of Routine Laparoscopic cholecystectomy (). The Monitor was placed on left side of the patient. The surgeon with the camera assistant were on right side of the patient and the first assistant was on left side of the patient. The abdomen was scrubbed and draped in the standard aseptic technique. The first infraumbilical 11 mm trocar introduced and pneumoperitoneum induced using the open technique. Three 5 mm trocars were placed, at the xiphisternum which was used for the surgeon’s left hand, at the left midclavicular line 2 cm below the costal margin which was used as working port for the surgeon’s right hand and at left anterior axillary line 5 cm from the costal margin which was used for retraction of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8 days old male neonate was born to an Asian mother through vaginal delivery at 37 weeks of gestation, weighed 2,380 g, and had APGAR scores of 9 and 10 at 1 and 5 min, respectively. He was admitted to our hospital with a 2 days history of fever of up to 39°C but did not have respiratory or gastrointestinal symptoms. The infant's family denied any medical history and TB contact. His physical examination at admission documented smooth respiration, clear breathing sound, and no hepatosplenomegaly. The complete blood count indicated a total white blood cell count of 17,500/μL with 69% neutrophils, 20% lymphocytes, 9% monocytes, and 2% eosinophils. The C-reactive protein level was 7.3 mg/dL. The findings of the cerebrospinal fluid (CSF) analysis were normal. Bacterial cultures of the blood, urine, and CSF were negative. Intravenous antibiotics, namely cefotaxime and ampicillin, were administered after admission on the basis of suspicion of neonatal fever. Despite the administration of the antimicrobial combination therapy, the fever persisted and the neonate developed abdominal distension when he was 12 days old. Abdominal radiography exhibited nonspecific dilated bowel loops. Because no improvement in the condition of the patient was observed after changing antibiotics, infection caused by some virus and other atypical pathogen, including Mycobacterium tuberculosis, was considered. Tests for herpes simplex virus, Epstein–Barr virus, cytomegalovirus, hepatitis B virus, rubella, Chlamydia trachomatis, and Toxoplasma gondii were all negative. The repeat C-reactive protein level was elevated to 14.4 mg/dL. Coagulopathy with 323.7 μg/mL of abnormal fibrin degradation product and more than 20 mg/L of D-dimer were also noted. Antibiotics were switched to vancomycin and ceftazidime empirically. Chest radiography displayed only increased right lung field infiltration when the infant was 12 days old (), and chest computed tomography (CT) imaging exhibited a large amount of ri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old Bosnian male with an unremarkable health history was originally seen in early October 2015 at a walk-in medical clinic after he noticed a change in his voice for 3 weeks. The patient had no smoking history, no prior occupational exposures, was an infrequent social drinker and worked as an assistant manager at a convenience store. Initially he thought the hoarseness was secondary to an upper respiratory tract infection and surprisingly did not notice the neck mass until it was pointed out to him (Fig. ). The physician who examined him at the time felt a large mass in the left anterior portion of the neck and followed up with a neck ultrasound. The neck ultrasound was unremarkable revealing a homogeneous thyroid gland with no solid or cystic soft tissue masses along with normal appearing lymph nodes on both sides of the neck.\nTwo days later he presented to the emergency department because of increasing hoarseness and mild dysphagia. The department of Otolaryngology Head and Neck Surgery was consulted. At the time of consultation, the patient appeared to be in no airway distress and had normal vital signs. On physical examination, a palpable mass was felt on the left side of the neck. The rest of the head and neck examination was unremarkable. Laboratory investigations were ordered and included CBC, serum ionized calcium, thyroid stimulating hormone, free T4 and T3 and calcitonin. These laboratory findings were all within normal limits with the exception of a slightly elevated T3 level. Direct fiberoptic nasopharyngolaryngoscopy was performed and revealed a supraglottic mass involving the left vocal cord causing immobility (Fig. ). The mass appeared to be submucosal in nature and did not affect the right vocal cord. He was then admitted for observation and further workup for diagnostic purposes.\nA CT scan with contrast was performed and showed a 5 × 5.7 cm laryngeal mass centered on the left thyroid cartilage, which was completely destroyed (Fig. ). It di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old female with a past medical history significant for hypertension and chronic renal insufficiency treated without hemodialysis presented to the emergency department with moderate to severe headaches associated with bilateral visual disturbances. The onset was nine days prior to presentation and was described as a right frontal headache with gradual loss of vision in the right eye, followed by vision changes in the left eye. She reported seeing only hand movement with the right eye, and finger counting only with the left eye. She also had neck pain, chest pain, numbness in both hands, and mild shortness of breath, but denied any other symptoms. Specifically, she denied fever, chills, recent injury, numbness, weakness, or undergoing any spinal procedure. She also acknowledged she went to a hospital out of state a few days prior to the presentation where was evaluated for a “stroke” and confirmed she did not have one and received a CT scan of the brain. On the day of presentation, she noted her left-sided vision was getting worse, so she decided to get a second opinion. Her mother was noted to have had similar symptoms when she was 28 and was diagnosed with a “stroke,” and had received spinal taps.\nOn physical examination, the patient was found to be morbidly obese with a body mass index (BMI) of 38. Her initial vital signs were blood pressure 196/141 mmHg, pulse 80 beats per minute, respirations 16 breaths per minute, temperature of 36.8° C, and oxygen saturation of 98% on room air. She could not read the top line of the eye chart. The vision in her right eye was grossly reduced to hand waving only. She had light perception, an afferent pupillary defect, and abducens nerve palsy. The left eye vision was grossly reduced to finger counting only. Extraocular movements were intact. There was a mild proptosis. The pupil was mildly dilated and sluggish"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-year-old healthy boy underwent an office-based surgical circumcision by his physician. During the procedure, profound bleeding was observed that was not controlled by applying direct pressure. The physician attempted to control the bleeding by multiple deep suturing; the bleeding was stopped successfully and the patient was discharged home. During the postoperative period, the child had progressive painful and difficult voiding with only few drops of urine after straining. During this period the child was prescribed painkillers for his discomfort and no additional evaluation was done. After about a week he was referred to a district hospital with fever (temperature=38.1C), agitation, vomiting, urinary retention, and significant abdominal distension. Abdominal examination showed decreased bowel sounds, dull percussion, and severe guarding. Urgent abdominopelvic ultrasound revealed large volume of free fluid in the abdomen and pelvis, with small amount of urine in the bladder. The initial lab tests also showed leukocytosis with left shift and increased blood creatinine and blood urea nitrogen. Catheterization with a 6-Fr feeding tube failed because it did not pass beyond the subcoronal urethra. The patient underwent emergency midline laparotomy with the diagnosis of acute abdomen and the fluid was drained. A small intraperitoneal bladder rupture was noticed at the dome of bladder. The gastrointestinal tract was inspected precisely and was intact. The diagnosis of intraperitoneal bladder rupture with urinary ascites was made probably due to near-total urethral obstruction. The rupture site was repaired in two layers and a suprapubic cystostomy catheter was fixed.\nTwo months later, the patient was referred to our center for further evaluation and treatment. Antegrade voiding cystourethrography (VCUG) was performed via the suprapubic catheter that showed terminal urethral obstruction (). Urethroscopy was attempted under general anesthesia that failed due to complete"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old male construction worker fell off a ladder sustaining a type A4 fracture of the L2 vertebra. On admission, there were no neurological deficits except for painful paresthesias in both lower limbs, right over left. No signs or symptoms of cauda equina compromise.\nAfter an initial X-ray investigation of the spine that showed the L2 fracture, computed tomography (CT) imaging, and magnetic resonance imaging of the lumbar spine were performed.\nThese investigations revealed a type A4 fracture with the involvement of both cranial and caudal endplates as well as interruption of the posterior wall. The spinal canal was severely stenosed just below the level of the conus [Figures and - and ].\nConsidering the segmental kyphosis and the severe canal narrowing as well as the need for early mobilization for maintenance of muscle trophism and performance, we listed the patient for surgery by pedicle screw and rod fixation.\nUnder general anesthesia and muscle relaxation, the patient was positioned prone on two separate silicone-foam blocks, one of semi-cylindrical shape under the mid-upper chest and the other of wedge shape under the upper thighs and pelvis. In between these two supports, the abdomen is completely free which not only allows for better ventilation and reduced venous pressure but is also crucial in permitting the maximum amount of positional lordosis. Subsequently, and still, before sterile draping, a fluoroscopy C-arm was brought in to identify the fracture in the lateral projection. Two operators would now hold the patient at both ankles and under the armpits and apply simultaneous traction in the craniocaudal directions []. Traction force is applied at maximum intensity for 3–5 s after which a lateral image is performed to check for any reduction. If no or only little reduction is visible on the fluoroscopy image, the procedure is repeated a couple of times with the attempt to hold the simultaneous traction some seconds more.\nWith this"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19 year old male with no previous history of heart disease was admitted with rest dyspnoea, found to be due to acute heart failure. He had felt fatigued with progressive limitation of exercise tolerance over the preceding 3 months. Symptoms were exacerbated by an upper respiratory tract infection one month before hospitalization. The patient was treated with antibiotics without noticeable improvement. The patient's mother had died suddenly at the age of 44 with a dilated cardiomyopathy of unknown cause for which she had had a pacemaker implanted.\nOn admission, the patient was cachectic with a body mass index of 17 and in poor general condition, with rest dyspnoea, tachypnoea of 30/minute and tachycardia of 130/minute. His liver was enlarged, there was evidence of pulmonary oedema and a systolic murmur, maximal at the apex.\nBlood analysis showed elevated liver enzymes (aspartate aminotransferase 192 units/L; alanine aminotransferase 400 u/L and creatine kinase 510 u/L) and mildly elevated Troponin I and C-reactive protein levels. Chest X-ray confirmed pulmonary oedema and showed an enlarged heart shadow. Sinus tachycardia and left bundle branch block with QRS duration >200 ms were present on electrocardiogram.\nEchocardiography on admission revealed significantly enlarged left ventricle and both atria, severe hypertrophy of both ventricles muscle without left ventricular outflow tract (LVOT) obstruction. Moderate tricuspid and severe mitral valve insufficiency, decreased left ventricular (LV) ejection fraction to 30% with global hypokinesis were observed.\nThe patient was referred for cardiovascular magnetic resonance (CMR), which was performed on a 1.5 T system with 4 element torso coil. Oxygen was supplied by mask throughout the study at a flow rate of 3 l/min. Function was assessed with steady state free precession (SSFP) sequence in short axis slices covering the ventricles and in 4-chamber, 2-chamber and LVOT orientations. Perfusion was assessed at rest only in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old Brazilian woman presented to our Surgery Department of Oral and Maxillofacial Surgery for evaluation of cystic lesions in her teeth 13 and 15 and a swelling on her right maxilla (Fig. ). In her anamnesis, she reported that she had already had endodontic treatment for her teeth 13 and 15 without regression of the lesion. Her teeth 14 and 24 had been previously removed for orthodontic treatment. A radiographic and computed tomography (CT) examination showed a radiolucent lesion, diffuse, of approximately 20 mm, involving the teeth 13 and 15. The initial diagnosis was inflammatory periapical cyst (Fig. ).\nShe underwent preoperative laboratory tests and an excisional biopsy of the lesion was undertaken under general anesthesia. The choice of the use general anesthesia was due to the size of the lesion and possibility of enucleation without removal of the teeth involved. The collected material was sent for pathological examination. The result was compatible with CGCL (Figs. and ), which differed from our diagnostic hypothesis. After the definitive diagnosis, she was advised to carry out regular monitoring because of the risk of recurrence.\nShe self-monitored for a period of 10 months; she then presented again with a complaint of swelling on the site, but without the presence of pain. A new CT scan was requested and indicated recurrence of the lesion, which now involved the region’s incisor, canine, and premolar (Fig. ). New laboratory tests were carried out: alkaline phosphatase, calcium, phosphorus, and parathyroid hormone (PTH). We ruled out the possibility of the lesion being compatible with Brown tumor of hyperparathyroidism. A possible loss of the four dental elements involved was not ruled out.\nWe proposed new treatment with intralesional corticosteroid injections to our patient in an attempt to reduce the lesion for a future enucleation. She was given a drug application schedule: nine applications in the affected regions with intervals of 15 days bet"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old male patient presented to hospital, complaining of volume growth of the tongue with numbness for the past 1 month before consultation. The patient reported a long-term smoking and drinking habit.\nThis study was conducted with the approval of Medical Ethics Committee of Chongqing Cancer Hospital, and was performed in accordance with the ethical standards of the Helsinki Declaration. Written informed consents for his data and images to be used for our study and publication were obtained from patient before operation.\nOn intraoral clinical examination and palpation, an obvious smooth firm mass of about 2 cm in diameter on the mobile tongue with the same color as that of the surrounding mucosa was observed without other oral lesions. The cervical lymph nodes were not swollen on palpation. A biopsy was carried out and histopathological analysis demonstrated tissues formed by adenoid cystic carcinoma. Computed tomography (CT) of the head and neck enhanced scanning revealed an ill-defined measuring 23 mm × 19 mm high density mass with altered enhanced signal entities involving the anterior 2/3rd of the tongue. There was no obvious abnormality in the adjacent mandibular bone. No obvious enlarged lymph nodes were seen in both sides of the neck (Fig. ). The doppler ultrasound indicated that the submental and bilateral submandibular lymph nodes were all reactive.\nThe patient was positioned supine and then general anesthesia was given through nasal intubation. Incision was placed over the anteriorly till 2/3rd of tongue after emptying cervical lymph nodes at levels I–III ipsilateral to the tumor, and then the anterolateral femoral free flap (ALFT) was used to repair the defect of tongue and preserve the swallowing and speech function. During the intervention, a preventive tracheotomy was carried out to ensure breathing (Fig. ).\nA histopathological examination defined ACC with a cribriform pattern. As is typically observed in ACC, the present case was positive for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old Asian man was referred to the ER of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. He had no known medical illnesses and was well until the evening prior to presentation, at which time he developed obvious right-sided chest pain radiating to his ipsilateral shoulder with persistent chest tightness. This tightness was described as sticking in nature, significantly worse on deep inspiration and with movement, and relieved by leaning forward or lying down. There was an associated dry cough but no hemoptysis. There was no history of trauma, injury, difficulty in breathing, or palpitations. He was tall and thin and described himself as otherwise quite healthy. He had never previously been admitted to a hospital. He reported no significant chronic medical history, such as primary hypertension, any type of heart disease, disturbed microcirculation, peripheral neuropathy, diabetes mellitus, an impaired immune system, malignancies, leukemia, the long-term administration of corticosteroids, liver cirrhosis, renal failure, urinary tract infection, or hemodialysis. He also reported no history of infection, such as tuberculosis, any type of hepatitis, or acquired immunodeficiency syndrome (AIDS). There was no prior history of traumas, blood transfusions, surgical procedures, or other serious events in his medical history. He had not lived in an epidemic area and had no history of toxin or radioactive exposure. He denied a personal or family history of bleeding diathesis but reported a 10-year history of smoking 8–10 cigarettes per day. He was an office worker by occupation. He had experienced similar symptoms on one occasion 4 years previously. No abnormalities were detected at that time, and his symptoms resolved.\nA physical examination (PE) revealed a young man who was awake and alert but in mild to moderate painful distress. His respiratory rate was 22–26 breaths/minute with an oxygen satur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a 54-year-old African American man with DPA with an unusual location of his initial tumor and whose management required further assessment of metastasis and need of addressing a lateral positive margin. The patient initially presented to clinic in 2012 with complaints of a six-year history of a bump on his left ankle. The patient described the bump as a non-painful mass that had been steadily enlarging over the past several years. There was no history of ulceration, redness, or discharge from the site and the patient denied any constitutional symptoms. On physical exam, the patient had a skin mass approximately 0.5 cm in diameter on the lateral dorsum of his right foot. The mass was freely mobile, non-erythematous, and smooth. At the time of his initial presentation, he expressed interest in surgical removal of the mass. The patient was lost to follow up prior to his surgery and presented to the clinic again in 2014 with the same complaint and indicated that the mass had now grown in size. The patient again denied any constitutional symptoms. The patient underwent excisional biopsy of this lesion. Pathological examination of this specimen demonstrated a 2.0×1.7×1.5 cm circumscribed unencapsulated dermal-based mass with a homogenous tan cut surface. Microscopically, the lesion proved to be an adenocarcinoma with ductal differentiation and predominantly cribriform pattern. Occasional mitotic figures and foci of comedo-like necrosis were present. The histologic findings were diagnostic of DPA (). The cauterized lateral margin was positive for tumor. Given the natural history associated with this diagnosis and the positive surgical margin, colonoscopy and positron emission tomography (PET) were ordered. Colonoscopy was negative for malignancy. There was no history of physical findings suggestive of thyroid or breast malignancy. PET demonstrated a focus of intense activity in the right iliopsoas muscle neighboring the right femoral neck that was thought"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old female patient presented to our institution with symptoms of melena and presyncope. Her medical history included a cholecystectomy and a combined splenectomy and partial pancreatectomy (carried out due to idiopathic thrombocytopenic purpura without postoperative complications of note). An endoscopy was performed, which demonstrated gastroesophageal varices with a large esophageal varix and bleeding gastric varices (Fig. a). Her religious denomination was that of a Jehovah's Witness, and she declined blood transfusion. Given the active bleed and limited conservative treatment options, the varices were treated via cyanoacrylate injection with successful hemostasis.\nHowever, shortly after the procedure, she was found to be obtunded with neurological deficits, and an immediate noncontrast CT brain and CT cerebral angiogram demonstrated small, scattered bilateral hyperdensities correlating with glue emboli (Fig. b). The patient did recover neurologically despite a follow-up magnetic resonance imaging confirming multiple subacute infarcts.\nThis embolic ischemic stroke prompted evaluation for a right to left vascular shunt. Initially, an echocardiogram with an agitated saline contrast bubble study was performed, which did not demonstrate a patent foramen ovale.\nEndoscopic ultrasound was performed, which demonstrated an extensive gastroesophageal variceal matrix but could not identify a specific vascular shunt. Contrast-enhanced CT of the thorax and abdomen was then performed, which demonstrated a PPVA connecting a large paraesophageal varix to the left inferior pulmonary vein (Fig. c). This study also demonstrated a diminutive right branch of the portal vein, although the main portal vein was normal in appearance.\nThe patient continued to experience symptomatic anemia requiring iron transfusions and erythropoietin. A decision was made to perform transhepatic portal venography with the aim of definitive identification of the PPVA and potential subsequent coil"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 2-year-old boy presented at the emergency department of a local hospital with persistent pain and oral blood loss after an unwitnessed fall. Immediately afterwards, he was found crying with only the base of a toothbrush in his hand. The head of the previously intact toothbrush was missing. During initial inspection of the oral cavity, the bleeding had stopped and no abnormalities were seen by the otolaryngologist. Although the parents repeatedly expressed their concern about their son's persisting abnormal behavior and the still missing head of the toothbrush, the patient was discharged with instructions to return to the hospital in case of a fever and/or recurrent blood loss. That same night, the boy started vomiting fresh blood and was taken to the hospital by ambulance. Again the bleeding had stopped spontaneously but the persistent character of the blood loss initiated a reinspection of the oronasopharynx under general anesthesia by an otolaryngologist. This revealed the missing head of the toothbrush () lodged horizontally in the lateral walls of the nasopharynx with its sharp end embedded in the left lateral pharyngeal wall. It was removed without problems, making a small lesion visible in the left pharyngeal wall. The patient was successfully extubated and transferred to the pediatric ward.\nSeveral hours afterwards however, he started vomiting large amounts of blood again, rapidly leading to progressive lethargy, tachycardia, and severe hypotension. Because of life-threatening hypovolemic shock with a hemoglobin level of 2.9 mmol/L, large amounts of intravenous saline and an unmatched blood transfusion were given. Crash reintubation followed, and during a second reinspection of the oro- and nasopharynx the bleeding again had stopped spontaneously. The site of the previous blood loss could not be identified. A Bellocq tampon was left in place and given the hemodynamic instability, and the still unknown origin of the massive bleeding the pa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man was referred to our clinic with severe bilateral ectropion. In 2015, an abdominal mass was detected in the left lobe of the patient’s liver during his follow-up. The mass was biopsied and pathologically diagnosed as cholangiocellular carcinoma for which he was maintained on treatment with capecitabine, 500mg daily, after the completion of gemcitabine and cisplatin combination regimen. At the end of the 3rd month of capecitabine treatment, the patient noticed increased tenderness and progressive bilateral ectropion in addition to upper lid shortening, hyperpigmentation, and cutaneous sclerosis around the head and neck region. He was consulted to the dermatology department for further assessment, and an incisional skin biopsy was planned. Biopsy results showed nonspecific findings with areas of interstitial granulomatous dermatitis accompanied by elastophagocytosis. These findings without the evidence of any previous periorbital surgery were considered as an adverse effect of the capecitabine treatment. The patient was followed up by the dermatology and ophthalmology departments, and as he had no corneal abrasion and visual problems, he was managed medically with topical Vaseline and clobetasol propionate cream (0.05%), moxifloxacin antibiotic eye drops, and artificial tears for ocular symptoms. Capecitabine was stopped in the 5th month of treatment because of severe bilateral corneal erosion in addition to the progression of lower lid retraction during follow-up. His upper lid shortness did not change, whereas the corneal erosion and lower lid ectropion did not resolve and continued to progress; therefore, he was referred to the plastic and reconstructive surgery department 1 month after the capecitabine treatment was stopped. Physical examination revealed bilateral lower lid ectropion, bilateral vertical shortening of the upper eyelids, and lagophthalmos []. During the 1-month drug-free period leading up to the surgical procedure, the patient’s fin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old gentleman presented with a 2-year history of progressive left nasal obstruction. There was no associated dysgeusia or hyposomnia or anosmia. He was a lifelong non-smoker and was not known to have allergies to medications or an atopic type of rhinosinusitis. He did not have any other significant medical or surgical history and no genetic history of nasal pathologies.\nOn examination, he had severely reduced left nasal airflow. Anterior rhinoscopy revealed a large fleshy tumour in the left nasal cavity, which was not papillomatous or vascular (). Nasendoscopic examination showed a large tumour of solid and polypoidal components. It occluded the posterior nasal choanae, filling the inferior aspect of the nose. Visualized from the right nostril, the tumour prolapsed into the postnasal space. There was no contact bleeding. The right nasal passage appeared normal. The nasopharyngeal vault and the remainder of the upper airway appeared normal. He did not have otitis media with effusion in the left ear and there was no palpable cervical lymphadenopathy. Pre-operative imaging was ordered to determine the extent of the lesion ().\nTreatment was local excision under general anaesthetic. The tumour was attached to the lateral wall of the nose at the level of the middle turbinate and was removed in its entirety excision. There was minimal bleeding and the nasal passage looked otherwise normal. Middle meatal antrostomy revealed scant mucus in the antrum, but the mucosa appeared normal. The perioperative course was uneventful, and the patient was discharged home on the sameday.\nThe resected mass was a grey polypoidal tissue with spicules of bone measuring 36 × 33 × 18 mm.\nHistological examination revealed the mass was lined with ciliated respiratory epithelium, which invaginated into the core of the polyp, forming glandular and cystic structures. There was focal calcification within the cysts. There was a component of bland sero-mucinous glands in lobular"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old male with a past medical history significant for a coronary artery bypass grafting 10 years prior presented with 3 weeks of persistent left epigastric pain. He denied dyspnea or chest pain. On exam, he was hemodynamically stable, in no apparent distress, and no audible murmur. EKG showed Q wave on the inferior leads suggest ing old myocardial infarct, which was unchanged from a previous EKG performed 3 months prior. A complete series of cardiac enzymes ruled out acute myocardial infarction. Because of the previous coronary bypass surgery and his atypical symptom, the patient underwent cardiac catheterization which showed patent grafts (left internal mammary artery to the left anterior descending artery and saphenous vein graft to the obtuse marginal artery) and intact right coronary system. Left ventriculography was not performed at that time. Transthoracic echocardiography showed severely decreased left ventricular function. Because of persistent pain in the left epigastric area to the left flank, a contrast CT scan was obtained to role out intraabdominal pathology. The 16 slice spiral CT scan with intravenous contrast demonstrated a large LV pseudoaneurysm (Fig. ). There was no other intraabdominal lesion was observed. Left ventriculogram was subsequently performed and confirmed the LV pseudoaneurysm (Fig. ).\nThe patient was then scheduled for resection of the LV pseudoaneurysm. After dissection of the anterior wall of the heart, further dissection of the lateral and posterior wall of the heart was performed under cardiopulmonary bypass because of dense adhesion. The LV pseudoaneurysm was located in the posterolateral wall of the LV (Fig. ), adherent to the posterior pericardium. After complete immobilization of the LV, the pseudoaneurysm was opened under aortic cross clamp. The wall of the pseudoaneurysm was thin and filled with clots. The neck of the pseudoaneurysm was identified and closed with a Gore-Tex patch. The ventriculotomy was then closed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old female with a past medical history of severe allergy-induced asthma and chronic nasal drip presented to the clinic with worsening cough and chest tightness for 10 days and was treated for bronchitis with steroids and antibiotics. She then presented to the emergency department with severe and acutely worsening shortness of breath, sudden onset pleuritic chest pain, and sharp radiating pain between both shoulder blades with deep inspiration. At time of presentation, the patient was afebrile with vital signs within the normal limits. Lab work was insignificant with negative leukocyte count and negative cardiac enzymes. A chest X-ray demonstrated an abnormal right cardiomediastinal silhouette with large opacity over the right mediastinum adjacent to the right atrial border. A follow-up CT scan revealed a large right-sided mass adjacent to the right atrium and extending into the right chest measuring 5.1 cm × 9 cm × 4.3 cm (). Her last imaging study was a fluoroscopy study 10 years ago that showed no indications for a mediastinal mass. An echocardiogram revealed a normal ejection fraction (55–59%), no wall motion abnormalities, and a cyst near the right atrium. The patient had continued pleuritic chest pain and difficulty breathing and the decision was made to perform video-assisted thoracoscopic surgery (VATS) for pericardial cyst removal. The patient underwent general anesthesia with a 37 French left-sided double-lumen tube. Standard ASA monitors were applied. Two large-bore peripheral IVs and an arterial line were placed for continuous blood pressure monitoring. Intraoperatively, a large cystic lesion was adherent to the pericardium (). There was no solid component and no obvious communication with the pericardium. Part of the cyst wall was left on the phrenic nerve to preserve it. The patient tolerated the procedure well, had no postoperative complications, and was discharged home on postoperative day number two. The final pathology report revealed beni"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA female patient aged 51 years reported with severe, throbbing pain in left upper first premolar, that is, 24, since three days. The pain was aggravated on chewing and lingered on for few hours after removal of stimulus. There was history of sensitivity to cold beverages. The patient could recall episodes of similar pain with the same tooth for the past two years which was only temporarily relieved with desensitising tooth paste.\nOn clinical examination, no caries was detected nor restoration was present but a very faint craze line could be seen on the distal marginal ridge extending onto the distal proximal surface of 24 (). The extent of the craze line could not be determined. The tooth was tender on percussion, it did not exhibit mobility, and the fracture could not be separated using wedging forces. Periodontal probing depths were normal. Electric pulp test revealed immediate response. Radiograph did not confirm the fracture line or reveal any significant findings (). The patient was given a choice of using cone beam computed tomography (CBCT) to determine the extent of fracture and the prognosis of the tooth. She was explained the benefits and also assured that radiation exposure would be kept as minimal as possible. An informed consent was obtained from the patient. Cone beam computed tomography (Vatech, PaX-Reve 3D plus, pulse type generator, 5 × 5 cm field of view (FOV) and 0.08 mm voxel size) was used to determine the relative depth of fracture apically and the proximity of fracture to the pulp (Figures and ). The fracture line was found to extend mesiodistally involving lingual pulp horn and apically it did not extend below the level of alveolar bone. Prognosis was considered to be favourable. Root canal treatment followed by crown restoration was then decided as most appropriate treatment plan. The suspicion of fracture extending to deeper aspects of root, coupled with acute symptoms of pain in the patient prompted the usage of CBCT for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old woman presented with a chief complaint of abdominal, back and neck pain. She had developed polymyositis 12 years previously and started taking prednisolone (controlled at 11 mg/day at the visit). She was also taking oral medication for hypertension.\nLower abdominal pain appeared a day after upper gastrointestinal angiography with barium contrast agent. Subsequently, she experienced gradual abdominal, back and neck pain. Chest and abdominal computed tomography (CT) showed mediastinal emphysema and free air in the abdominal cavity. She was referred to our hospital for suspicion of an oesophageal rupture.\nThe patient’s height was 152 cm, body weight was 41 kg, body temperature was 39.4 °C, blood pressure was 160/99 mmHg, and pulse rate was 140 times/minute. Her abdomen was markedly bloated with an overall rebound tenderness.\nOn chest and abdominal CT, free gas was observed in the entire abdominal cavity (), and extensive emphysema was also observed in the retroperitoneum (). In addition, it was observed from the mediastinum to both sides of the necks ().\nColon perforation was suspected from the abdominal findings and the finding of free gas in the abdominal cavity. Although emergency surgery was planned, the perforation site could not be identified on the image. In addition, a diagnosis of oesophageal rupture could not be ruled out because of atypical findings of colon perforation, such as pneumomediastinum. Therefore, after general anaesthesia, upper gastrointestinal endoscopy was performed for the purpose of diagnosis and operative decision. Because there was no obvious perforation in the oesophagus, oesophageal rupture was ruled out, and a laparotomy approach was used.\nWhen the abdominal midline incision was performed, extensive emphysema was observed throughout the mesentery (). There was no stool-like ascites in the abdominal cavity, and a small amount of cloudy ascites was observed in the pelvis. When the serosa of the sigmoid colon, where emphysema"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male with myelodysplastic syndrome treated with double cord allogeneic blood stem cell transplant 34 months ago complicated with chronic GVHD-related glomerular nephropathy, adrenal insufficiency, and end-stage renal disease on hemodialysis presented to clinic after 2 weeks of joint pain. Physical exam revealed normal strength, and he was treated with nonsteroidal anti-inflammatory therapy. Four days later, he developed worsening joint pain, lower extremity calf pain, and hoarse voice. Examination at this time was notable for 3/5 strength in his lower extremities. He was admitted to the hospital and treated with 50 mg intravenous hydrocortisone every 12 hours for three days and intravenous fluids for a suspected postviral myositis. His symptoms resolved, and he was discharged home.\nFive days afterwards, he was readmitted to a different hospital for dysphagia and concern of aspiration pneumonia. A gastric tube was placed, he was treated with intravenous ceftriaxone and metronidazole, and he was sent to a rehabilitation facility. Of note, he was not treated with a quinolone or aminoglycoside antibiotic. Another four days later, he presented to our hospital with worsening pneumonia. At this time, physical exam revealed decreased proximal muscle and grip strength, weak palate elevation, diplopia upon prolonged upward gaze, and 3/5 strength in lower extremities. He did not exhibit muscle fatigue from repetitive use. Initial evaluation for this patient was unremarkable for brain or cranial nerve lesions, motor neuron disease, neuromuscular junction disorders (NMJ), or other myopathies (). He was treated with stress-dose steroids (50 mg methylprednisolone every six hours) for concern of myositis, antibiotics, and other supportive measures. Four days after this admission, the antiacetylcholine receptor (AChR) antibody (Ab) panel revealed elevated ACR binding and modulating antibodies correlating with diagnosis of myasthenia gravis. Titers for AChR binding Ab w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old woman with a 6-month history of swelling in the left floor of her mouth was referred to our institution. Although she experienced slight difficulty in swallowing, she did not experience pain or tongue paralysis. Her medical and family histories were unremarkable.\nIntraoral examination revealed a well-defined 3.5 × 3 × 2 cm-sized solid, spherical submucosal nodule adjacent to the sublingual gland; the nodule was covered with light bluish smooth mucus (Fig. ). The patient experienced slight pain when pressure was applied to the tumor. Mobility and sensory functions of the tongue were normal, and no lymphadenopathy in the submandibular region was detected on palpation. All relevant laboratory test results were normal. Enhanced computed tomography revealed a 2.8 × 1.8 × 2.1 cm-sized well-defined, solid, heterogeneous nodule that did not appear to involve the mandible (Fig. ). In addition, a three-dimensionally reconstructed image showed a nodular lesion occupying the left floor of the mouth with abundant blood flow (Fig. ). No enlarged lymph nodes were found in the submental or submandibular regions.\nThe initial clinical impression was a benign salivary gland tumor, dermoid cyst, or benign connective tissue neoplasm. The patient was scheduled for surgery via an intraoral approach. First, an elliptical incision was made around the periphery of the sublingual gland through only the oral mucosa, and a full-thickness tissue flap was prepared along the lingual aspect of the sublingual gland. After the sublingual gland was freed from its surrounding tissue with blunt dissection, a well-circumscribed tumor without capsular extension was found beneath the body of the sublingual gland and located above the submandibular gland duct and lingual nerve. The submandibular gland duct and lingual nerve were carefully freed from the tumor surface, and the complete tumor was excised along with the sublingual gland (Fig. ). The tissue sample was fixed with 10% formalin and s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old male presented in June 1995 with left hip pain for 2-month duration. The patient was a high school student, and he had this pain on and off which was tolerable. At that time, he was active with his high school extracurricular activities. But he went to see his general practitioner as the pain was disturbing his school activities for 1 month. He took oral analgesia for the pain, and he came to our hospital as the pain worsened the last 10 days. There were no constitutional symptoms and no history of trauma.\nOn physical examination, the range of motion of the left hip was reduced due to pain. There was no lymphadenopathy or neurovascular deficit. The plain radiograph showed osteolytic lesion over the superior aspect neck of left femur with scalloping of medullary canal (). CT scan reported a 4 cm destruction involving the metaphysis and neck of left femur with calcification and joint effusion and no sequestrum (). MRI findings revealed a 4 cm well-circumscribed eccentric mass at neck of femur with abnormal marrow signals (). The erythrocyte sedimentation rate (ESR) was slightly elevated (40 mm for the 1st hour), and the C-reactive protein (CRP) and total white cell count level were within normal range. Based on the history, clinical examination, and imaging, a diagnosis of benign bone tumor involving the neck of left femur was made.\nOn anterior exploration of left hip joint, the capsule was intact; we opened up the capsule to reach the lesion. There was friable bone tissue of 4 × 3 cm over the anterior cortex of neck of femur which was breached, but the other cortices were intact. Curettage and autologous iliac crest bone grafting was carried out, as the frozen section confirmed the diagnosis of EG. Two cannulated screws were used to pin the neck of left femur prophylactically against pathological fracture. The histopathologic examination revealed a mixed cellular infiltrate consisting of eosinophilic polymorphs with plasma cells and Langerhans histiocyt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old healthy female underwent colonoscopy in the context of a positive fecal immunohistochemistry test (FIT) of 77 ng/mL. Her medical history was only significant for a remote caesarean section. Her family history was significant for her father having colonic polyps at the age of 70. The patient also endorsed occasional NSAID use. The patient had used Bi-Peglyte solution for bowel preparation.\nThe patient was sedated before and during the procedure with a total of 3 mg of midazolam and 100 mcg of fentanyl. CO2 was used to insufflate the colon. The colon was quite tortuous and required repositioning of the patient on to her back and right side. Application of counter pressure was also used to reach the cecum. Bowel preparation was suboptimal, and fecal material clogged the endoscope numerous times. Extensive lavage and suction were required during withdrawal. A 1.2 cm pedunculated polyp in the descending colon was injected with methylene blue and completely removed as 2 pieces by hot snare polypectomy. Withdrawal time was 15 minutes. Overall, the patient tolerated the procedure well. Pathology of the polyp demonstrated a tubulovillous adenoma with low-grade dysplasia.\nThe patient subsequently presented to the emergency department (ED) 2 days after colonoscopy with severe abdominal pain but no bleeding or diarrhea. Initial bloodwork was unremarkable other than an elevated lactate of 5. A CT abdomen with IV contrast demonstrated diffuse large bowel thickening with severe involvement of the sigmoid and small volume of pelvic ascites (). There was no hemoperitoneum, pneumoperitoneum, or bowel obstruction. The patient underwent an urgent flexible sigmoidoscopy. Starting at the rectosigmoid junction, there were patchy, dusky areas of mucosa with submucosal swelling and erythema but no frank ulcerations (). The endoscope was only advanced to the midsigmoid, and biopsies were not taken due to the fear of inducing more complications. The proximal extent of the change"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case report of a 57-year old female patient with a history of left nephrectomy due to clear cell RCC in December 2008. The patient was in favorable prognostic categories according to Motzer et al. The patient had no family history of malignant neoplasm and no history of chronic diseases. Due to metastatic disease (metastases in lungs), interferon immunotherapy was used as a first line therapy. The best response to treatment was partial regression according to RECIST criteria (version 1.0). After 11 months immunotherapy was stopped due to the disease progression – enlargement of existing lesions. In April 2010 the patient was qualified to 2nd line therapy with a tyrosine kinase inhibitor (sorafenib). The patient received a total of 8 chemotherapy courses. The response to treatment was stable disease according to RECIST criteria. In December 2010, due to the disease progression – appearance of new focal lesions in the liver, the patient was qualified to 3rd line therapy using a selective mTOR inhibitor (everolimus). Marked toxicity was observed during the therapy – anemia grade 3 according to CTC AE that required transfusion of packed red blood cells. The treatment was stopped after 13 courses in January 2012 due to the disease progression – appearance of new lesions in lungs, left adrenal gland and the skeletal system. The patient underwent palliative radiotherapy on the tumor site, 11th rib in January 2012, and then in June 2012 on central nervous system (CNS) area due to focal lesions located in the right parietal and temporal lobes and in the right cerebellar hemisphere. In May 2012 the patient started a 4th line therapy, axitinib at a dose of 5 mg twice daily. Partial response to treatment was achieved. The treatment was stopped in November 2012 due to the disease progression. The total time to progression was 37.5 months (). The patient died in December 2012. The total survival time from the disease diagnosis was 45 months.\nThe treatment was carried ou"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA. P., a 61-year-old woman, was taken to the emergency ward of the Tehran Heart Center, Iran, by her husband and son. On admission, she was suffering from dyspnea, and there was a sewing needle penetrating her chest. During the physical examination, the heart and lungs were normal. Emergency fluoroscopy, echocardiography and computed tomography (CT) scan were performed. The chest CT scan revealed that the needle had penetrated into the heart, and echocardiography demonstrated that the needle had ruptured the pericardium, but it had not entered the left ventricle. The patient underwent surgery 4 hours after admission, and the needle was removed successfully.\nAn interview with her family disclosed a history of major depressive disorder and pharmacological treatment. During the first 3 sessions of psychiatric counseling after the surgical operation, the patient denied a suicide attempt. She claimed that an accidental fall was the cause of her injury. On the 4th session, however, she admitted that the problem was not accidental, stating that she had attempted unplanned impulsive suicide by swallowing needles twice before, once 10 years and once a year previous to this. In both cases, she had been hospitalized for some days and discharged without any complications.\nThe patient had been suffering from major depressive disorder since the sudden death of her son, 10 years ago. During the previous 5 years, she had received different pharmacological treatments, namely clonazepam, alprazolam, venlafaxine, and Depakine, which were not followed through. No history of psychotherapy or electroconvulsive therapy was reported.\nThe patient reported having experienced auditory hallucinations during different periods of taking low-dose benzodiazepine pills. According to her family, during these periods, the patient had experienced disorientation, disturbed consciousness, distraction, and auditory hallucinations. Through these accounts we were guided toward the delirious picture of thos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old G4P0 lady of 28 of weeks gestation presented with sudden onset of chest pain, radiating to her jaw and back. Her vital signs were within normal limits, electrocardiogram showed normal sinus rhythm and her blood results were unremarkable, in particular cardiac enzymes were not elevated. She reported reduced fetal movements and was therefore transferred to a nearby maternity hospital.\nHer past obstetric history included stillborn twins of 27 weeks of gestation at the age of 16, which was attributed to considerable antenatal alcohol and drug use. Later in her early twenties she had two terminations.\nAntenatal care for this pregnancy was commenced with a general practitioner and was then referred to a midwifery practice at her request. At 20 weeks of gestation, morphology ultrasound showed a right hydronephrotic kidney in the fetus and she was referred for antenatal care at a tertiary hospital.\nAt the maternity hospital, she remained haemodynamically stable but she was found to have a faint indeterminate murmur and Troponin T was elevated to 0.04 (normal range < 0.02 μg/L). There was no radio-radio delay or radio-femoral delay bilaterally and she reported no shortness of breath. She complained of ongoing chest and back pain, which settled with analgesia. Cardiotocography (CTG) was normal but she was given corticosteroids in case of preterm birth.\nOvernight, the patient went into cardiogenic shock. Chest X-ray showed cardiomegaly, acute pulmonary oedema and a prominent descending aorta. An urgent transthoracic echocardiogram revealed a 6 cm aortic root dissection with occlusion of two out of three aortic branches.\nThe patient was resuscitated and transferred to the intensive care unit (ICU) of another tertiary hospital. She had an emergency lower segment caesarean section under general anaesthesia and a live male infant (1610 g) was delivered without complication. The neonate was transferred to the ICU for management of extreme prematurity. The cardiothorac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-year-old male child was referred to us for complaint of pain in abdomen. On enquiry, there was intermittent history of bilious vomiting since infancy. There was no previous history as regard to abdominal distension. However, there was occasional history of abdominal pain, which was relieved by medication. On examination, his abdomen was distended, but it was non-tender. The weight of the patient was 9 kg. Thus he had failed to thrive. His ultrasound (USG) of abdomen suggested some fluid filled cystic spaces. A computerized tomography (CT) scan of abdomen was advised for confirmation of the diagnosis.\nOn next day, just after CT abdomen, the patient suddenly developed severe abdominal pain. X-ray abdomen showed pneumoperitoneum. Clinically the patient looked septic. His pulse rate was 130/min with a feeble pulse. An urgent laparotomy was planned. After initial stabilization, the patient was explored under general anesthesia. On exploration, we noticed malrotation of the gut, which was associated with two turns of midgut volvulus. The midgut did not have any evidence of ischemia or gangrene. It was complete malrotation having cecum in left hypochondrium and narrow mesentery. Ladd's bands were also present. The peritoneal cavity was grossly contaminated with fecal fluid. The perforation site was about one foot proximal to ileocecal region. The perforation was at the mesenteric side, and it was associated with a soft mesenteric mass communicating with the normal bowel. The mass was about 10 cm in length. The perforation was just at the junction of the mesenteric mass and the normal bowel [].\nAfter performing the Ladd's procedure, attention was placed towards the perforation. On attempting to resect the mesenteric mass, we noticed two lumens in the bowel distal to the perforation site and single lumen proximal to that [Figures and ]. The duplication appeared to be having all the layers of the bowel wall. When an attempt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old Japanese woman presented with a 10-year history of left hip pain and 1-year history of left leg edema. The left leg edema was apparent particularly after long durations of standing, sitting, or walking. The patient had a history of hypertension, arteriosclerosis, and internal carotid artery constriction. We could feel pulses of the femoral and dorsal arteries well even when the leg edema appeared. Physical examination revealed limitation of the range of motion (ROM) of her left hip, with 80° flexion, 20° abduction, 15° adduction, 45° external rotation, and 5° internal rotation. Plain radiographs revealed advanced OA secondary to developmental dysplasia of the left hip. A huge osseous mass was also observed at the inferomedial portion of the femoral head (Figures and ). Based on a previous radiograph, we determined that this mass was absent 8 years ago (). Computed tomography (CT) images and magnetic resonance imaging (MRI) revealed compression of the femoral vessels by the mass (Figures –). On MRI, the intensity of the mass was almost similar to the surrounding bone marrow, with very high intensity at the surface on the short-tau inversion recovery (STIR) image (Figures –). The Japanese orthopaedic association (JOA) hip score [] was 54 points: 20 points in pain, 12 points in ROM, 10 points in gait, and 12 points in activity of daily life. We diagnosed the mass as a capital drop secondary to OA and performed total hip arthroplasty (THA) with resection of the mass. The mass was observed to be completely inside the articular capsule and there was minimal inflammation and adhesion between the mass and capsule. Cartilage tissue was observed on the surface of the mass (). THA was performed using a short tapered wedge stem with a 32 mm ceramic head (Microplasty, BIOMET, Warsaw, IN) and a 48 mm cementless cup with a polyethylene liner (Trident"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old male was found to have a left hypochondrial mass on physical examination following a trivial soft tissue injury. Ultrasound scan revealed a large retroperitoneal mass in the pancreatic tail region with a mild splenomegaly. No other abnormality was noted in the ultrasound scan. Contrast-enhanced computed topography (CT) of the abdomen showed a 10.3 × 7.6 × 10.3 cm size heterogeneous mass with mild contrast enhancement arising from the body and the tail of the pancreas with no calcifications (). Multiple vascular channels were seen around the lesion. Splenic vein was compressed and displaced by the mass with enlargement of the spleen. Mass effect had displaced the left kidney posteriorly. All other intra-abdominal viscera were normal. All haematological investigations were normal.\nHe underwent laparoscopic resection of distal pancreatic tumour en bloc with spleen. Patient was operated on in right lateral position with head-up tilt using five ports. shows the ports arrangement. Large tumour was noted originating from the body and tail of the pancreas with dilated veins surrounding the tumour. Patient also had a large spleen and an enlarged liver. Dissection was performed using ultrasound dissector and bipolar diathermy. Splenic artery divided between clips and splenic vein was ligated and clipped before dividing. Pancreas was divided just distal to the portal vein using bipolar diathermy and ultrasound dissector. The specimen () was delivered in a bag through a 7.5 cm incision.\nPostoperative period was uneventful and he was discharged on 4th postoperative day.\nHistology revealed a tumour predominantly composed of sheets of round to polygonal cells containing sharp cytoplasmic vacuolations and bland nuclei. The eosinophilic cytoplasm was seen as a rim in the periphery. Very occasional mitotic figures were present (). The focal pseudopapillae formation was also evident with vascular cores lined by neoplastic cells (). The stroma was highly vascular (). Ther"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old Sri Lankan Tamil male with a history of well-controlled type 2 diabetes mellitus and a goitre of 30 years presented with a painful enlargement of goitre on the left side for one month. He had progressively worsening difficulty in breathing with intermittent dysphagia for solids. He did not have any symptoms of local infiltration and was clinically euthyroid. Examination revealed a hard mass arising from the left thyroid lobe measuring 8 cm × 7 cm in size with gross tracheal deviation to the right side. In addition, there were two mobile lumps anterior to the mass in the subcutaneous tissue plane (). There was no retrosternal or retroclavicular extension on the left side. The right thyroid lobe was moderately enlarged and had multiple palpable nodules. There was no cervical lymphadenopathy. Ultrasound scan showed a large calcified left thyroid nodule and few superficial nodules. The outer surfaces of the nodules were delineated by an echogenic line suggestive of surface calcification. The internal echotexture of the nodules was not clearly appreciated due to artefacts from the surface calcifications. Right thyroid lobe showed only benign characteristics. Neck X-ray radiography showed a calcified left lobe with significant tracheal deviation to the opposite side (Figures and ). Thyroid stimulating hormone (TSH) and free thyroxine (T4) levels were within normal limits. Ultrasound-guided fine needle aspiration cytology (FNAC) showed scattered cyst macrophages, lymphocytes, and multinucleated giant cells in an eosinophilic background with scanty colloid. The features were compatible with a benign cyst (Thy 2).\nThe patient underwent a total thyroidectomy. Two confluent nodules were noted in the subcutaneous tissue plane extending through the deep fascia between the strap muscles to the calcified left lobe nodule. The deep fascia and strap muscles were thinned out and were adhered to the calcified left lobe (). Division of strap muscles on the left side was r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Forty five-year-old previously healthy female presented with complaints of swelling and pain in bilateral feet for eight years and history of recurrent episodes of multiple nodules over bilateral legs and feet, which burst to form ulcers for a period of seven years. There was no history of any preceding drug intake. There was no history of similar complaints in family members and no history suggestive of systemic illness. On examination, there was pitting pedal edema, multiple ulcers over bilateral lower limbs (one over medial malleolus of right foot and two over lateral aspect of the left foot) measuring about 1-2 cm in size, slightly tender, irregular margins, sloping edges, floor of the ulcers were covered with slough with erythema and hyperpigmentation of the surrounding skin. Multiple scars of previously healed wounds were present [Figure and ]. There was no palpable thrill or bruit, no clinical evidence of varicose veins and no significant lymphadenopathy. All the peripheral pulsations were well felt. Systemic examination was within normal limits. Routine investigations including complete blood counts, liver and renal function tests, urinalysis, chest radiographs were within normal limits. Enzyme linked immunosorbent assay (ELISA) for HIV 1 and 2 was non reactive. The result of Mantoux test was negative. Bleeding time, clotting time and prothrombin time were within normal limits. Color Doppler study of bilateral lower limbs was within normal limits. Based on the history and investigations, differential diagnosis of chromoblastomycosis, mycetoma, vasculitis and erythema induratum was kept. Histopathological examination of a biopsy sample from the edge of the lesion showed hyperplastic epidermis with an increased number of thick walled capillaries in the papillary, mid and reticular dermis. Moderate amount of hemosiderin deposits were seen around these vessels with perivascular lymphocytic infiltrate and mucin []. Based on the history, examination and histopat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old man was admitted to our clinic because of left knee pain. He had pulmonary tuberculosis at 6 years old. He presented pus-forming arthritis, which was presumably tuberculous arthritis, in the left knee after 2 years, with spontaneous remission after closure of the draining sinuses. Thereafter, no recurrent symptom of infection was observed. However, the deformity and growth disturbance progressed with the knee pain. He had limb lengthening and alignment correction for the leg length discrepancy and genu valgum. However, his left knee pain continued despite the deformity correction. Radiographs showed a fused knee with severe tricompartmental arthritis (Fig. ). Severe limitation in range of motion was observed on the left knee. We planned to perform one- or two-stage primary TKA depending on the presence of infection [].\nIntraoperatively, a large subchondral abscess was found in the lateral femoral condyle and lateral tibial plateau after takedown of the fusion (Fig. d). On the basis of the necrotizing inflammation with granuloma in the frozen-section biopsy, active tuberculosis was suspected. Aggressive debridement and curettage of the infected and necrotic bone and soft tissues were performed.. After bone cuts and soft tissue balancing to prepare for TKA, articulating cement spacers (vancomycin 4 g and streptomycin 2 g per 1 batch) were made intraoperatively and applied to the tibial and femoral sides in sequence using intraoperative cement molds with a previously described technique [, ] (Fig. ). Relative medial and lateral stabilities were confirmed intraoperatively after inserting the articulating cement spacers. The diagnosis of tuberculosis infection was confirmed by isolating Mycobacterium tuberculosis from cultures. We decided to delay the TKA for at least 6 to 9 months to allow the administration of antituberculous drugs []. Evaluation at 1-year follow-up revealed no recurrent infection after sufficient antituberculous drug treatment. Therefore"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old man referred to our department with a 7-week history of left hip limping, difficulty walking, and inability to bend forward. He had aided waddling gait and poor tolerance of weight bearing. There was no history of any major trauma. His vital signs were normal. The examination of the hip elicited an impaired restriction of flexion and both internal and external rotation, with a 2-cm shortening of the left leg. A Harris hip score of 65.5 was achieved by the patient. His distal neurovascular status was intact ().\nOther examinations showed poor secondary sexual characteristics with a Tanner’s pubertal and axillary stage of 2. He worked in an automobile repair shop and had normal social activities. A survey of his past medical history showed that at age of 17 years, blurred vision, meningeal signs, and abnormal secondary sexual development were noted; and after investigations, brain magnetic resonance imaging showed a lobulated intra- and suprasellar mass, 38 × 32 × 24 mm in diameter, with extension posteriorly into the interpeduncular cistern and extension superiorly and insinuation into the third ventricle. Consequently, in December 2001, he underwent brain surgery for craniopharyngioma. Ten years later, his previous symptoms recurred, and in April 2011, he underwent a second brain surgery for tumor recurrence. At the meantime, he had been followed up by an endocrine clinic.\nAccording to the patient’s past history, he was born full term with a birth weight of 3.5 kg and his early development was described as normal (menarche was at age of 14 years). Since that age, he had always weighed between 49 and 57 kg. During these years, he was under medical therapy for hormonal disorders. There was no history of delayed dental maturation, hyposmia, or a family history of delayed puberty. He had no midline defects. Complete pituitary evaluation is depicted in .\nIn 17"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female had a 2-year history of right hemifacial spasm. She had been treated with clonazepam and other alternative therapies with limited effect. She was admitted to our hospital for microvascular decompression surgery for her hemifacial spasm. Preoperative magnetic resonance imaging (MRI) with T2-based cisternography revealed attachment of her right posterior inferior cerebellar artery (PICA) to her facial nerve exit zone. We carried out microvascular decompression surgery with a lateral suboccipital approach and placed a sponge (polyurethane) between the PICA and the brainstem, fixing them with fibrin glue []. Her postoperative course was uneventful. Her hemifacial spasm disappeared completely 3 days after the decompression surgery. Postoperative MRI showed a PICA running course without attachment to the brainstem [].\nSix years after her surgery, she noticed a mild spasm in her superior orbicularis oculi muscle which spread to her prioral muscles and occasionally sustained a tonic state. She visited our department and underwent a MRI scan. T2-based cisternography showed a closed PICA running course compared with the MRI immediately after her initial surgery []. At this point, she was eager to undergo decompression surgery again, even if it was only for inspection. We carried out the second surgery with her informed consent.\nUsing a lateral suboccipital approach through the previous incision and craniotomy, we dissected the arachnoid adhesion and confirmed that the sponge placed in the first surgery between the offending artery and the brainstem was not dislocated. However, the sponge was degenerated. The structure of the sponge was fragile and easy to collapse. The honeycomb structure or bubbles in the sponge were not preserved []. We attempted to remove the sponge, but its adhesion to the lower cranial nerves was strong. We inserted Teflon between the sponge and the brainstem and moved the distal portion of the PICA to the dura of the petrous surface"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man was admitted to the department of the gastroenterology with complaints of odynophagia and dysphagia to solid foods for one month. He experienced worsening of dysphagia and he also reported otalgia for the last two days. His oral intake had decreased and he had preferred to consume liquids. As a result, he had lost 10 kg in a month. Fifteen days before the admission, the patient was assessed by several ENT outpatient clinics and was treated for pharyngitis with two different antibiotics. He had no history of smoking, alcohol consumption, or any other systemic diseases. During the questioning of the patient, he pointed out his neck region as the site of obstruction. On physical examination, he was afebrile with normal vital signs. However, the palpation of the neck was painful. The white blood cell count was 6,940/mm³, C-reactive protein was 51 mg/L, and erythrocyte sedimentation rate was 64 mm/hour. The standard barium swallow study was normal. The upper gastrointestinal endoscopy revealed normal findings except for erosive bulbitis. The etiology of dysphagia had not been identified by these tests and a computed tomography (CT) scan of the neck was performed. The CT scan demonstrated a 4 × 2.5 cm sized cystic lesion with minimal irregular border at the base of the tongue (). The patient was referred to the ENT department. On his ENT examination, there was a slight swelling at the base of the tongue. The larynx and the tonsils were normal. There were no signs of airway obstruction. The abscess at the base of the tongue was drained through the oral route by needle aspiration for five consecutive days. On the first day, a 15 cc purulent material was drained and the aspirated material was cultured. Coagulase-negative staphylococci were isolated from the culture media and the empirical treatment with ceftriaxone based on the antibiogram results was not changed. The patient was ordered to complete a 7- to 10-day"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second case was a 10-year-old girl who presented with abdominal pain and a weight loss of 2 kg over three months. Laboratory tests performed demonstrated persistently elevated CRP (22 and 24 mg/L), a fecal calprotectin of >300 µg/g. An abdominal ultrasound noted thickening of the terminal ileum with enlarged lymph nodes. A gastroscopy demonstrated thickened gastric folds with evidence for chronic inflammation in biopsies, but no ulcers; Helicobacter pylori was not present. A colonoscopy revealed aphthous ulcers in the transverse colon with linear and aphthous ulcers in the ascending colon, while the terminal ileum was reported as normal. Biopsies demonstrated chronic inflammation consistent with Crohn’s disease. An MRE demonstrated thickening and enhancement of the bowel wall in the distal ileum. Her pediatric Crohn’s disease activity index (PCDAI, remission defined as <10) upon presentation to our clinic was 30, consistent with moderately active disease. She refused medical therapy and was started on the CDED with PEN. After six weeks she was in clinical remission with normal CRP and had regained 1.3 kg. She performed the second phase of the induction diet and then the phase 3 maintenance diet. During the subsequent 12 months remained in clinical remission with normal CRP and fecal calprotectin. An MRE and colonoscopy were repeated between 12–15 months, both were completely normal at this time. She remained in sustained deep remission for three years, maintaining the diet with some difficulty as she struggled with adherence at times. During the ensuing summer she travelled abroad several times and did not adhere to the diet. Though she felt well her calprotectin increased from 16 to 300 µg/g. She regressed to the phase 1 induction diet for four weeks and then returned to the maintenance diet. Her calprotectin normalized and a subsequent ileocolonoscopy was completely normal.\nDr. Arie Levine: These two cases serve as examples of how dietary therapy with the CDED"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-month-old male infant, after an uncomplicated pregnancy and delivery, weighed 3000 g at birth; there were no complications during pregnancy and no family history. The infant had symptoms of mild respiratory distress for 2 months, without fever or cough. He was diagnosed with patent foramen ovale by echocardiography at the primary hospital and received no treatments. Later, the symptoms were aggravated, and his parents sought care, again at the primary hospital, 9 days later. Ultrasonography of the abdomen showed features suggestive of hemangioendothelioma of liver. The hospital suggested that to the infant should be transferred to our hospital for treatment.\nExamination revealed an irritable infant with cough, fever, breathlessness and cyanosis; the infant weighed 6.8 kg and was in respiratory distress with a relative ratio of approximately 130/min. The infant had multiple skin hemangiomas of varying sizes on the head, neck, right index finger, and right shank. His physical examination was remarkable for bilateral wheezy phlegm in both lung bases. The physical examination showed enlarged cardiac dullness, but there were no significant heart murmurs. Abdominal distention was noted. The liver was soft and located 8 cm below the costal margin at the right mid-clavicular line.\nEchocardiography showed right atrial and right ventricular dilatation with a thickened right ventricular anterior wall and interventricular septum. The normal structure of the cardiac chamber and continuous atrioventricular septum were observed. The infant was diagnosed as having severe pulmonary artery hypertension with mild tricuspid regurgitation and trivial mitral regurgitation. Ultrasonography of the abdomen showed densely hypodense lesions, increased volume of liver lobes, with a clear boundary and a maximum diameter of 4.1 cm. The liver lobes had a heterogeneous internal echo and enhanced peripheral echo. Visible blood vessels were observed in the hypodense lesions. There were only a fe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was an 11-year-old male with a past medical history positive for psoriasis that presented in December 2016 with a complaint of an enlarged lymph node on the right side of the neck of approximately 3 months’ duration. He was born in Vietnam, but adopted at a young age and raised in Michigan. Therefore, family history could not accurately be obtained. There was no history of any precipitating viral upper respiratory infection or any other inciting events. Over 3 months, there were no changes or fluctuation in size of the enlarged lymph node. There was no history of dysphagia, odynophagia, dysphonia, or otalgia. There was no history of weight loss or night sweats. In addition, there was no history of fever.\nThe patient had previously been evaluated by a primary care physician who trialed a course of antibiotics without any improvement or resolution of the neck mass. In addition, an ultrasound of the neck was obtained which demonstrated multiple large right-sided neck lymph nodes, with the largest measuring 2.7 cm. Multiple lymph nodes in the left neck, which measured approximately 1 cm, were noted as well. Epstein-Barr Virus (EBV) serology was also performed. Epstein-Barr Virus Capsid IgG was positive, EBV Capsid IgM was negative, EBV Early Antigen AB was positive, and EB Early Antigen AB was positive. These results indicated the patient was likely exposed to an EBV infection in the past, with no active or recent infection. A Monospot test was also completed and negative.\nOn clinical examination, the patient’s neck demonstrated palpable right-sided cervical lymphadenopathy, with a prominent 2-cm lymph node in level 5. It did not appear infectious, as there was no evidence of erythema, edema, or warmth. Other than this palpable lesion, the remainder of his otolaryngologic examination was unremarkable and the patient remained completely asymptomatic. No other infectious serology or workup was pursued.\nGiven"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 10 (Tables and ), a 76-year-old female, was referred to the department of neurology in July 2012 because of progressing cognitive decline over the last 12 months, loss of weight, nausea, gait disturbance and tremor. She was seen on May 2011 for the first time by a neurologist with a 3-month history of dull holocephalic headache who ordered a cranial magnetic resonance imaging (MRI) and diagnosed a tension-type headache and a depressive disorder. Treatment with an antidepressant (duloxetine) was started. The patient experienced no improvement and a second examination by another neurologist was undertaken 2 months later. Again no focal neurological signs could be detected. Due to the weight loss, an occult neoplasm was suspected but not detected during an extensive inpatient investigation at a medical department during February 2012; however, the MRI showed bilateral white matter lesions (WML) and an old lacunar lesion located at the left striatum, the latter was not seen in the previous MRI from May 2011. Since the patient also suffered from mild hypertension, vascular encephalopathy was thought to be the cause of the progressive cognitive decline. Extensive neurocognitive testing was carried out in a rehabilitation centre in May 2012 and disclosed a severe decline of attention, memory and executive functions corresponding to subcortical dementia (Fig. ). When the patient was seen for a further diagnostic work-up at the SMZ-Ost-Donauspital in July 2012, the weight was 47 kg and a weight loss of 20 kg was reported over the past year. The gait was insecure with postural instability and with a tendency to fall when turning around. Frontal signs were positive, the voice was quiet, the tonus was mildly elevated and showed a slight hesitancy (“Gegenhalten”), tendon reflexes were brisk, paresis and pyramidal signs missing. There were no signs of ataxia, but a mild bradykinesia. Action tremor was more distinct than a mild resting tremor."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur case was a 53-year-old man who received a deceased donor kidney transplant 16 years ago, which was presumably due to hypertension. He presented with redness, pain and swelling of his left arm. He reported no trauma but was trimming shrubs and plants one week earlier. He also complained of intermittent fever and chills. There was no significant animal contact or recent travels. He took cyclosporine and mycophenolate for immunosuppression but had no recent use of corticosteroids.\nEvaluation showed a temperature of 100.3 °F, heart rate of 99 beats/min, respiration of 20 cycles/min and blood pressure of 109/71 mmHg. Skin examination showed erythema, tenderness and swelling on the medial aspect of his left arm and forearm in a linear fashion (). There was also a wound on his left forearm, which was located distal to the sporotrichoid lesion, which he thought might have been due to an insect bite or an injury related to his recent gardening (). There was an old unused dialysis graft on the forearm, which appeared to be unaffected. There were no significant lymph node enlargement and the examination of the other systems was completely unremarkable.\nUltrasound imaging of the left arm showed hypoechoic, tubular type structures (the largest measuring 8 × 5 mm) in the subcutaneous fat, which is consistent with an abscess. Two views of the chest radiograph was normal.\nThe patient underwent incision and drainage of a long abscess tract, which measured approximately 35 cm. Frank purulent drainage was expressed from the tract and was sent for bacterial, fungal and mycobacterial cultures. In the meantime, the patient was started on empirical intravenous piperacillin/tazobactam and vancomycin while awaiting culture results. Sporotrichosis was considered as a strong differential but antifungal therapy was deferred until the culture results became available.\nSignificant laboratory findings include a white blood cell count of 12.2 × 109/L, blood urea nitrogen of 56 mg/"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA16-year-old boy sustained injury to left knee while playing. He had severe pain and swelling in the knee. He was not able to bear weight on affected limb. X-rays revealed displaced tibial spine fracture [, ]. He was treated in cast by orthopedic surgeon. Patient was not comfortable in the cast and came to us. It was a displaced fracture. We did MRI to rule out other injuries []. Patient was treated arthroscopically under spinal anesthesia in supine position.\nAnterolateral and anteromedial portals were used. Both the portals should be standard or slightly low as higher portal may put the scope above the fractured fragment and one may not be able to see the fracture clearly. Fractured fragment was clearly defined with the help of a shaver. It also involved significant portion of medial tibial platue [, ]. Fracture was reduced with the help of ACL zig and under C- Arm guidance, provisionally fixed with guide wire from superolateral portal taking care not to cross physis. As it was a large fragment, it did not sit completely from medial side so another wire was used from superomedial portal to fix medial side of fragment perpendicular to lateral wire, again without crossing the physis. Two 3.5 mm partially threaded cannulated screws (Zimmer) were directly used; 45mm from lateral side and 35mm from medial side []. Stability of the fragment was assessed with a probe and was found to be very stable []. Post-operatively, patient was given a knee brace []. Post-op X-rays showed proper position of both screws [, ]. He was allowed to walk full weight bearing with the knee brace and with support. Knee ROM from 0-90 was allowed for 2 weeks then 0-120 for next 2 weeks. After one month, he was allowed to walk without knee brace. At 6 months, patients was allowed to run. Now we have 8 months follow-up."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old woman with performance status 2 had right chest and left lumbar pain and was referred to our hospital for treatment. The computed tomography (CT) findings in the previous hospital showed some recurrent masses and metastatic tumors: 144 × 137 × 120 mm3 mass in the left abdomen to the pelvic cavity, a 50 × 43 mm2 mass on the right pelvic wall, a 52 × 47 mm2 mass on the ascending colon, and small metastatic masses on the diaphragm and bilateral lungs (). Serum carbohydrate antigen (CA)19-9 and CA125 levels were 3128 and 96.1 ng/mL, respectively. She had a previous history of 4 years’ treatment with paclitaxel and carboplatin, docetaxel and carboplatin, doxorubicin and cisplatin, medroxyprogesterone acetate, and paclitaxel-alone chemotherapies, as well as immunotherapy for the present recurrent tumors found 5 years after standard surgery for endometrioid adenocarcinoma G1 (Stage IB). Although she and her husband were informed by the former doctor and by us that palliative care would be appropriate, they desired another anti-cancer therapy. They were therefore told about daily oral administration of half-dose etoposide (25 mg/day) that had been reported in the 1990s in Japan. They provided written, informed consent to its administration, and the therapy was then started. Treatment for 4 months reduced serum tumor marker levels and relieved her pain; however, the therapy was discontinued at the end of the fourth month at her request because of mild to moderate stomachache, and serum tumor marker levels increased again. Therefore, the same treatment was quickly restarted. Serum CA19-9 and CA125 levels decreased dramatically to around 110 ng/mL and the normal range, respectively (), and CT showed shrinkage of the recurrent tumors (). She became cheerful with a good appetite and bowel habit, with slight lumbar pain. However, the tumor marker levels gradually increased in the 22nd month of treatment, and she again complained of lumbar pain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female with osteoarthritis of the right knee underwent Mako/Stryker robotic-assisted total knee arthroplasty. The patient's past medical history consisted of hypertension. No medical conditions predisposing the patient to a fracture were noted. A midvastus approach was used, and trackers were placed with unicortically inserted pins in the tibial shaft and femoral shaft for the robotic tracking system. The operation was performed without complication, and the tracking pins were removed manually at the conclusion of the case. Postoperative radiology reports noted proper positioning of prosthesis with no acute fracture.\nPhysical therapy was begun on postoperative day 1 with partial weight bearing with a front wheel walker with PT assistance and was able to walk the entire hospital corridor two times. Patient was discharged on postoperative day 2 with outpatient physical therapy arrangements. Patient had a satisfactory postoperative course.\nThe patient had an uncomplicated recovery until 6 weeks postoperatively when she was at work and sustained a ground level fall due to acute pain of the right thigh and her leg “giving out.” Patient was unable to bear weight on the extremity. She presented to the emergency department where she was found to have a complete, oblique fracture through the midshaft of the right femur (). On radiography, the femoral tracking pin site is clearly visible at the location of the fracture in the distal segment (). The patient was taken to the OR and underwent intramedullary nailing of the right femur with retention of right knee prosthesis hardware (). CT scan of right lower extremity confirmed evidence of a fracture through the prior surgery pin tracks. Following intramedullary nail placement, the patient had a normal postoperative course. Final films at 6 months showed a healed fracture with stable orthopedic hardware (). At this time, the patient was pain free, ambulating without issue, and elected to proceed with an as needed f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.\nHis vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man was admitted to the local hospital with left upper abdominal pain lasting 2 weeks. A gastroscopy showed a bulging gastric lesion in the antrum. However, the pathology was benign. The patient did not receive any treatment, and still had abdominal pain. Then, he was referred to the Second Affiliated Hospital of Xi’an Jiaotong University. Physical examination revealed no mucocutaneous pigmentation, no palpable masses in the abdomen, but left upper abdominal tenderness. The patient had no family history of polyps or tumors in the gastrointestinal tract. Laboratory tests were normal, and the tumor markers were within normal limits. Abdominal computed tomography revealed that the gastric wall in the antrum was thickened (Fig. ). A gastroscopy showed a giant and extensive bulging gastric lesion located on the greater curvature and posterior and anterior walls of the gastric antrum, involving three-quarters of the gastric wall. The mucosal surface of the lesion was smooth without erosion or ulcer. Magnifying endoscopy with narrow-band imaging showed the almost normal microvascular morphology of the lesion (Fig. ). Endoscopic ultrasonography was performed, showing a low-echo area in the muscularis mucosae and no invasion into the submucosal layer, without enlarged celiac lymph nodes (Fig. ). An endoscopic mucosal resection was performed, and a bigger specimen was sent for histopathological examination to confirm the diagnosis. The final pathology report indicated a hamartomatous polyp (Fig. ). After excluding PJS, a solitary Peutz–Jeghers-type hamartomatous polyp was diagnosed. Then, the patient underwent an ESD. The resected specimen was measured in 110 × 80 × 4 mm3 (Fig. ). We treated patients with acid suppression. The patient recovered quickly, without any complications. A gastroscopy on the fourth day after endoscopic surgery showed a large postoperative artificial ulcer (Fig. ). A gastroscopy on the 40th day after endoscopic surgery showed a narrow lu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur 23-year-old female patient with no significant past medical history presented to the hospital complaining of acute shortness of breath, abdominal pain, and severe left lower extremity pain. The patient was in her usual state of health until the evening of her symptoms, when she suddenly turned in her bed and began to experience numbness, tingling, and purplish discoloration of her left lower extremity. On arrival to the emergency department, the patient was in respiratory distress and had bilateral swelling of her lower extremities, the left side larger than the right. A bilateral lower extremity duplex ultrasound revealed a deep vein thrombosis (DVT) in the left lower extremity, the popliteal, and the femoral veins. In addition a CT of the chest utilizing our pulmonary embolism protocol delineated two pulmonary emboli in the first order pulmonary arteries and multiple segmental emboli located in the right upper and right lower lobes. She was subsequently started on a heparin drip.\nThe patient denied any tobacco use, recent immobilization, or travel. She reported the use of an estrogen vaginal delivery device (ethinyl estradiol vaginal ring) for the previous 6 months. Her hypercoagulable workup was revealing for heterozygosity at C677T for factor V Leiden. It should be noted that heterozygous carriers of FVL have been shown to have an overall 3- to 7-fold increased risk of venous thrombosis, while homozygotes to C677T have a 50- to 100-fold increased risk. []\nDue to the acute presentation of her venous thromboembolism, a left pelvic and lower extremity venous thrombectomy was performed. This was followed by stenting of a popliteal venous occlusion, and subsequent thrombolysis with tissue plasminogen activator. Surprisingly, a left lower extremity venogram revealed bilateral inferior vena cavas.\nIn our patient, the left-sided duplicated IVC and iliac veins were found to be thrombosed. This was marked by the stippled appearance of the duplicated left IVC vessel se"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old female with background history of heavy consumption of alcohol at younger age initially presented to us with an acute back pain at the lower thoracic and upper lumbar spines, which was associated with an acute onset of paraparesis with Medical Research Council (MRC) power of 1, paraesthesia and discomfort at voiding following a traumatic event during travelling on a speed boat to an island at a time of heavy waves season. The urgent magnetic resonance imaging (MRI) of the thoracolumbar spine disclosed an abnormal sizeable mixed hypo- and hyperintensed lesions on T1 and T2 [Figure –] at multiple spinal levels. Eccentrically, the lesions did not seem to cause compressive effect onto the spinal cord. The conservative management was opted after noting the harmless looking lesions on the MRI. Two weeks of regular analgesia and physiotherapy in neurointensive care were given, but the lower limbs weakness recovered partially to grade 3 with more intense pain at the back. She remained bed bound and was unable to urinate and therefore was catheterized. At the same time she started to complain of right subcostal and lower pelvic pain, which were tender; further investigation revealed two cystic lesions in the liver and her ovaries. Our initial provisional diagnosis was either a traumatic or vascular malformation-induced spinal hematoma, or spinal metastases. Nonetheless, history did not favor the second provisional diagnosis. Since the recovery was partial and the diagnosis was doubtful, we decided to proceed with laminectomy at lesional site of T9-T11.\nLaminectomy was completed from T9 to T11 and the intraoperative finding is shown in . The histopathological diagnosis was arachnoiditis. The surgery was uneventful and she was discharged home with regular follow-ups. One month after the spinal surgery, the abdominal and pelvic pain became more frequent and tenderness was noted mainly at pelvic area. She was operated endoscopically by the gynecologist and biopsy w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old Japanese man was admitted to our hospital. He had sustained a right femoral neck fracture at the age of 19 years. At that time, he underwent osteosynthesis for the femoral neck fracture. The details of his operation were unclear, but he had developed an infection of the operative wound. There was no record of bacteriological examination performed at that time. One year later, when the patient was 20 years of age, the infection had resolved, and he underwent hemiarthroplasty of the hip joint with a bipolar cup. There was no record of that operation or the amount of damage to the acetabular cartilage. He had no particular problems following the procedure and was still able to surf as a hobby. He noticed a leg-length discrepancy, but he did not seek medical attention because there was no pain.Twenty years later, at age forty, the patient was injured while surfing. He felt a strong pain in the right femoral region and had difficulty walking. He was transported by ambulance to a nearby hospital. The diagnosis was Vancouver type B2 peri-prosthetic fracture of the femur. However, because the prosthesis had migrated, there was a massive bone defect of the acetabular roof on the pelvic side (Figure \n) that had resulted in the leg-length discrepancy.The plan was to treat only the peri-prosthetic fracture because the hospital had no bone bank. The implant was removed using a posterolateral approach and an extended trochanteric osteotomy. He underwent a new hemiarthroplasty of the hip joint with a modular neck and long stem. He also underwent osteosynthesis of the femur using a plate and hook for trochanteric fixation (Figure \n). The femoral shaft fracture achieved bone union, and his walking ability recovered to his previous level.He was later admitted to our hospital for reconstruction of the acetabular roof. He did not complain of coxalgia; however, his physical examination showed that the leg-length discrepancy was approximately"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 1. A 14-year-old female patient was admitted to our emergency department with the complaints of hip pain and the inability to walk, which occurred after a minor fall, based on the patient history. There was no previous fracture in her medical history. However, family history of the patient showed a similar bone disease. Physical examination revealed pain with palpation as well as loss of hip range of motion. Ocular and neurological examination demonstrated bilateral loss of vision. Other systemic examinations showed normal vital findings. Laboratory test results were within normal limits, except mild anemia. Plain X-ray showed a mildly displaced fracture of the right femoral neck with a dense sclerotic line. Based on the patient history, physical examination findings, and laboratory and imaging test results, along with consultation remarks, the patient was diagnosed with osteopetrosis tarda and osteopetrotic femoral proximal fracture. Following closed reduction, a lateral straight mini-incision was performed under fluoroscopic visualization. Drilling was highly difficult and time-consuming, and one of the drill tips was bent. However, osteosynthesis was performed using two 4.5 mm spongious screws without any other complications. Fluoroscopic assessment revealed an adequate reduction and fixation. Based on the intraoperative examination, the range of motion of the hip was within normal limits. Bone specimens which were obtained by drilling and the intraoperative biopsy were sent for pathological examination. No perioperative complications were observed. In the postoperative period, there was no scar-related complication, either. The patient was referred to the rehabilitation program on the third postoperative day and sutures were removed at 12 days. She was mobilized without loading on the healing fracture, using a crutch at two weeks and with partial loading at six weeks. The histopathological examination confirmed the diagnosis of osteopetrosis. No complicatio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA six year old girl presented to the Orthopaedic department with a five day history of right hip pain, fevers and difficulty weight bearing. There was no history of trauma or any recent illness. The patient was of Somail origin but there was no recent history of travel or infectious contacts and no significant past medical history.\nOn examination she had a temperature of 39.5 degrees Celsius and the right hip was held in flexion, with localised anterior joint line tenderness. Both passive and active movements of her hip were painful and restricted. Examination of her left hip, knees and ankles was normal. Examination of her abdomen revealed mild tenderness in the right iliac fossa.\nBlood tests showed a neutrophilia with left shift and a raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Sickle cell screen was negative and initial pelvic x-rays were normal. She was diagnosed with hip septic arthritis and an open washout of the hip joint was performed. Two millilitres of blood stained fluid was aspirated and the patient was commenced on intravenous (IV) antibiotics. The following day the patient remained pyrexial and the CRP and ESR continued to be raised. A second open washout of the right hip was performed but no pus or fluid was aspirated.\nBlood and joint fluid cultures were subsequently positive for staphylococcus aureus. A magnetic resonance imaging (MRI) scan of the right hip was performed which showed collections of the right iliacus and distal iliopsoas, with abnormal marrow signal in the right iliac wing consistent with osteomyelitis ().\nThe patient was diagnosed with iliac osteomyelitis and transferred to Manchester Children’s Hospital were she underwent exploration of the right iliopsoas abscess. This revealed a large collection of pus and some necrotic muscle, which was thoroughly washed out and debrided.\nShe gradually made a recovery and was eventually discharged home after a total of 30 days. Oral antibiotics were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male with a past medical history of a neuroendocrine tumor (NET) of the left femur presented with progressive dyspnea, orthopnea, and lower extremity edema. Three years ago, the patient was found to have a mass on the left femur. Biopsy revealed poorly differentiated neuroendocrine carcinoma of unknown primary. He had undergone surgical resection of the left femoral tumor and above-knee amputation with adjuvant chemotherapy (cisplatin and etoposide) and radiation therapy. Routine surveillance imaging showed no evidence of malignancy. Chest computed tomographic (CT) and magnetic resonance imaging of the abdomen/pelvis with contrast were performed at three-month intervals for the first year followed by six-month intervals. The patient was in clinical remission for the last two years.\nOn physical exam, his blood pressure was 119/76 mmHg, heart rate was 104 beats per minute, respiratory rate was 22 breaths per minute, and jugular venous pressure was elevated. Grade III/VI systolic ejection murmur was present at the left sternal border and rales at the lung bases. Chest X-ray revealed cardiomegaly and bilateral pleural effusions. A transthoracic echocardiogram revealed a large mass measuring 8.10 X 6.54 cm within the right ventricle causing right ventricular outflow obstruction, and the left ventricular ejection fraction was 60-65% (Figure ). Cardiac magnetic resonance imaging confirmed the mass extending from the right ventricular free wall with compression of the left ventricle and dilated right atrium (Figure ). A positron emission tomographic/computed tomographic scan showed increased standardized uptake value activity of 9.3 in the right ventricular mass (Figure ). Cardiac biopsy of the right ventricular mass was consistent with metastatic neuroendocrine tumor (Figure ). The tumor cells were negative for synaptophysin and chromogranin A but positive for CDX2, a marker for neuroendocrine tumor of unknown primary []. In view of the tumor that caused impa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female visited with a complaint of gradually decreased visual acuity. At the first ophthalmological examination, the corrected best visual acuities in the right eye and the left eye were 1.0 and 0.4 respectively. Slit lamp examination revealed that there was no specific finding in the anterior segment, and the funduscopic finding of both eyes showed that cotton wool spots, macular edema and vascular tortuosity were present around the optic disc in the left eye (), but the right eyes was unremarkable except the suspected cotton wool spots near superotemporal arcade (). Fluorescein angiography revealed microaneurysms and macular edema in the left eye (), and right eye showed minimal microaneurysms without macular edema (). We found that the thickness of macula was increased when measured by optical coherent tomography (). Past medical history included modified radical mastectomy for right breast cancer 5 years ago. She had no medical history of diabetes, hypertension and systemic vascular disease and no evidence of abnormalities in laboratory finding.\nOne year before this visit, she was confirmed to have metastatic tumor on her right frontal lobe shown on MRI () which was taken after a sudden convulsion. And she had received radiation therapy of fractionated external irradiation to the whole brain (3,000 cGy/10fraction) for 2 weeks and local boost irradiation (1,200 cGy) After that, she was transferred to another hospital for gamma knife surgery on that lesion. Total dose of gamma knife surgery on the tumor bed was 40 Gy and the amount of irradiation for each eye was 0.2 Gy.\nImmediate intravitreal TA injection was performed for macular edema and two weeks later, the visual acuity was improved to 0.6. But the visual acuity was decreased to 0.3 again 3 months later, so we performed intravitreal TA injection again. Three months after the second injection, the fundus examination and optical coherent tomography revealed that retinal thickness was improved and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old male presented with left-sided headache after inadvertently colliding with a door and hitting the left side of his face. The patient's past medical history was significant for mechanical mitral valve on anticoagulation, HLA-B27 associated uveitis, and bilateral retinal detachments. Four years ago, he underwent prosthetic replacement of the right eye and silicone oil (SO) endotamponade on the left, however this maneuver was ultimately unsuccessful, and he had no vision in either eye at baseline. Physical exam was notable for an irregular and non-reactive left pupil with no light perception; clean prosthetic within the right orbit; and a small abrasion on the left forehead and nose with minimal ecchymosis. His neurological exam was otherwise unremarkable.\nThe patient's initial CT head was misinterpreted as favoring intracranial metastasis which led to further work up with MRI head, CT chest, abdomen and pelvis. He was found to have a 13 mm spiculated nodule in the right lower lobe of the lung with low uptake on a positron emission tomography scan that also revealed other nonspecific findings in the gastrointestinal tract.\nThe patient was admitted to the intensive care unit where his anticoagulation, warfarin with therapeutic level at the time of admission, was held for concern of intracranial hemorrhage. He underwent an esophagogastroduodenoscopy and colonoscopy given the abnormal positron emission tomography scan findings.\nHe was seen by multiple services. While there were initial plans to obtain a surgical biopsy of his lung nodule, image review with radiology led to a prone CT head which confirmed the mobile debris in the ventricular system was in fact SO. Supine CT head revealed new (compared to a prior imaging two years earlier performed when he was presented to an outside emergency room with dizziness) hyperdense nodules in the anti-dependent portions of the lateral ventricles. MRI head with and without contrast showed the hyperdense lesions in the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man presented at our hospital with pain and swelling on the outside of his right foot. Right foot was injured falling into the groove of 50 cm during the work. He did not remember how his foot was twisted. The lateral column of his right foot was shortened by approximately 6.5 mm on X-ray (). A computed tomography (CT) scan showed displacement of the joint surface between the cuboid and the fourth metatarsal, with a 3.5 mm depression observed in the range of the articular surface 3/4 (). There are no other fractures except the cuboid. We took MRI to find other injuries. MRI showed only cuboid fracture. And there were no injuries of other bones and ligaments. There were no tenderness points except the cuboid. Based on these findings, we diagnosed the patient with an isolated nutcracker fracture of the cuboid and planned to perform an open reduction and bone grafting.\nA lateral incision was made along the axis from the tip of the fibula to the tip of the fifth metatarsal. Next, we identified the Lisfranc joint using fluoroscopic guidance and made an incision in the joint capsule. Using a 1.9 mm arthroscope, we examined the Lisfranc joint () and noted that the cuboid articular surface between the cuboid and the fourth metatarsal was crushed (). Articular surface of metatarsal was kept with a little fibrillation. The articular capsule was opened widely, and the fracture site was identified using fluoroscopic guidance. A hole was created at the fracture site, and the depressed fragments were elevated using surgical instruments, until the regular joint line was restored. A bone biopsy needle was then used to fill in the large defect with artificial bone (). We used granular type OSferion® produced by OLYMPUS in Japan. We used about 2.0 g in the fracture site (). Finally, the articular capsule was resutured.\nThe patient's right leg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old woman presented to our department with signs and symptoms of multinodular goiter (MNG). Bulky hypertrophy of the thyroid gland at the anterior neck was determined by inspection. Larger nodules with regular margins were palpated in both lobes by physical examination. Serum thyroid-stimulating hormone and free thyroxine levels were normal by biochemical analysis. Thyroid ultrasound revealed multiple nodules in both lobes. Bigger nodules were a 50 x 36 x 40 mm hypoechoic solid nodule in the right lobe and a 33 x 25 x 37 mm isoechoic solid nodule in the left lobe. Fine needle aspiration from dominant nodules revealed benign cytology. The diagnosis was MNG. Total thyroidectomy under the guidance of IONM was planned as the surgical treatment. Informed consent was obtained from the patient.\nThe right thyroid lobe was partially mobilized after ligation of the middle thyroid vein. The carotid sheath was incised, and the right vagus nerve (VN) was located behind the carotid artery and the jugular vein. Direct stimulation of the VN with the stimulator probe at a standard distal point did not create a sound signal. The absence of a distal V1 (d-V1) signal revealed the early proximal separation of the inferior laryngeal nerve and eventual presence of the non-RLN. The carotid sheath incision was extended toward the cephalic direction. The right VN was proximally followed under the guidance of IONM with serial electrophysiological stimulation to identify the separation point of the inferior laryngeal nerve. A positive signal from a proximal point of stimulation (p-V1 = 648 µV) helped us to locate the separation point of the right inferior laryngeal nerve. Stimulation of the inferior nerve when first identified at the separation point posterior to the carotid artery created a positive sound signal and wave amplitude (R1 = 661 µV). Both lower and upper poles of the right lobe were carefully dissected, and the lobe was mobilized medially. The right non-RLN arising"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Caucasian male with past medical history of Pott's disease as a child, osteoarthritis of the right knee, and a right Baker's cyst presented to the Emergency department with complaints of worsening leg pain for two days and confusion for one day. At presentation, the patient was tachycardic. All other vital signs were within normal limits. His review of systems was remarkable for chronic knee pain for the last two years and right leg pain for the last three months and decreased appetite and weight loss over the course of four months. On physical examination, the patient was in moderate distress. He was alert and oriented to time, place, and person but had poor concentration. On musculoskeletal exam there was a diffuse area of swelling on the right lower extremity which was extremely tender to touch with minimal warmth and erythema. This was located posteromedially involving the calf and medial aspect of the leg. Knee joint was nonswollen, nontender, and without any erythema or warmth (). Laboratory data revealed leucocyte count 14.6 k/cumm, Hemoglobin 10.2 mg/dL, and hematocrit 30.4%. HIV testing was negative. His metabolic panel showed hyponatremia, 124 mEq, but was otherwise unremarkable. Leg MRI was performed. This showed a large heterogeneous fluid collection involving the subcutaneous soft tissues of the posterior medial right lower extremity measuring approximately 21.1 × 7.2 × 8.5 cm with marked mass effect on the gastrocnemius muscle. Heterogeneity of the distal femur including the femoral condyles, tibial plateau, and proximal fibular head was also visualized suggesting possible osteomyelitis as well (). The patient underwent surgical resection of the left Baker's cyst. Intraoperative findings included a thick, boggy synovium with dull and dusky appearing cartilage. Tissue and fluid stain revealed acid fast bacillus (AFB) in one of two samples which was later identified as MTB. On pathologic section, a granulomatous reaction with giant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman with a past medical history of treated stage III ovarian cancer presented with an asymptomatic new solitary left renal mass detected on surveillance imaging. Computed tomography (CT) of the abdomen and pelvis showed a 3.3 cm endophytic mass (RENAL nephrometry score 9P) [] in the upper pole of the left kidney suggestive of a cT1a primary RCC. There was no evidence of other synchronous lesions or metastases. Given the patient's prior history of ovarian cancer, we opted for a CT-guided renal mass biopsy. Under CT guidance, a three-core biopsy was performed using an 18-gauge needle over a coaxial sheath. Pathologic examination of the mass was consistent with RCC.\nGiven that the patient was asymptomatic and the uneventful nature of the renal mass biopsy, the lesion was not reimaged and we proceeded with transperitoneal RPN. After dissecting the renal hilum and overlying renal fat, a 12 mm laparoscopic drop-in ultrasound probe was used to evaluate the renal mass prior to resection. The mass was well visualized and there was no obvious perinephric hematoma noted. During sharp tumor resection, however, we encountered an intrarenal hematoma that was clearly outside of the tumor margin (). The hematoma had several small areas of pale yellow coloration that appeared to be organizing hematoma. Since this was consistent with recent biopsy, we completely suctioned the hematoma and performed a wide margin resection to completely remove the tumor and hematoma. The tumor pseudocapsule was not violated during the resection. The specimen was extracted via an EndoCatch bag, and was grossly confirmed to be an intact specimen on the back table. Final pathology confirmed a 4.5 cm Fuhrman Grade 3 Papillary RCC with negative margins and an adjacent organizing hematoma.\nFive months after the initial surgery, surveillance CT revealed a new 2.4 cm left renal mass, enlarged para-aortic lymph nodes, and several nodules present in the oment"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms (Fig. a) showed hemorrhage in the left temporal lobe, and the patient was admitted in our department with a clinically confirmed diagnosis of ��hemorrhage in the left temporal lobe”. The patient had a previous history of hypertension for more than 10 years, and was under medication to control and maintain the blood pressure to be around 130/80 mmHg. The patient denied the history of diabetes and had no bad habits, such as smoking and drinking alcohol. Physical examination at admission revealed that his body temperature was 36.2 °C and blood pressure was 196/119 mmHg. The patient was conscious and suffered from incomplete aphemia. Bilateral pupils were of the size and round, the diameter of pupils was 3 mm, and pupils were sensitive to light reflexes. Muscular strength of the limbs was about grade 4. Bilateral pathological signs were negative, and there was no significant abnormality noticed during nervous system examination. Head MRI conducted the next day after admission indicated no significant vascular malformations (Fig. b). General consultation evaluated that bleeding sites of the patient were slightly different from hypertensive intracerebral hemorrhage. The hematoma sites were close to the middle cerebral artery and the walking areas of its branches, mainly in the temporal lobes. Therefore, cerebral vascular hemorrhage and other causes could not be excluded, and head CTA was further suggested. Head CTA performed on 17th May 2017 showed that the patient suffered from intracerebral hematoma caused by aneurysm rupture at the M1 bifurcation of the left middle cerebral artery, without any significant subarachnoid hemo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 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.\nHe 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.\nThe 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"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old female patient presented to the emergency department with a sudden onset of left leg pain and oedema. She had a fever of 38 °C once a few days before. Physical evaluation revealed a swollen and painful left leg with reduced range of motion of the left hip and bumps palpated on the right tibia proximal metaphysis. No signs of arthritis, possible intestinal inflammation or skin changes were seen during physical evaluation. The patient’s blood pressure and urinary output were normal. After the emergency ultrasound exam revealed a diagnosis of femoral and pelvic deep vein thrombosis, she was admitted to the hospital. According to her parents, the patient had had no chronic diseases to date. They indicated that she had a foot fracture at the age of 8 years. There were no autoimmune or auto-inflammatory disorders in the patient’s family history.\nInitial investigations revealed high levels of inflammatory markers (CRP and ESR), and a severe microcytic anaemia as well as thrombocytosis, hypoalbuminemia and elevated fibrinogen concentration and D-dimer values (Table ). Suspecting an infectious cause, a urinalysis was performed, and haematuria and proteinuria were detected. Both blood and urine cultures were sterile. X-rays of the legs were done (Fig. ), showing sites of hyperostosis and sclerosis in the metaphysis of the right tibia along with a periosteal reaction, suggesting a possible osteomyelitis or oncological processes in the bones. As the diagnosis of acute osteomyelitis could not be disproved, broad-spectrum antibiotics were prescribed. However, the CRP level did not change significantly over the first few days, so other causes of acute thrombosis and inflammation were investigated. An abdominal ultrasound showed a giant, homogenous pelvic mass and hydronephrosis of the left kidney. Kidney function was quite abnormal as the creatinine level was 185 μmol/L and urinary protein excretion of 7 g over 24 h was detected. Within the next few days the patient’"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 47-year-old female who has been diagnosed with undifferentiated mucinous cervical adenocarcinoma a year and a half ago and had hysterectomy with salpingo-oophorectomy along with chemoradiation. She presented to the hospital with complaints of fatigue, nausea and reduced appetite for a week. Her examination revealed icterus and mild right upper quadrant tenderness but no ascites. She had no petechial rash and had no features of encephalopathy. Her initial workup revealed elevated liver enzymes with alanine transaminase (ALT) of 1891, aspartate transaminase (AST) of 600 and alkaline phosphatase (ALP) of 178. She had a total bilirubin level of 2.1 with the direct bilirubin of 1.9. Her electrolyte panel, renal parameters, and hemogram were normal.\nAt this point, we revisited history to inquire about the possibility of toxin or drug-induced hepatitis and viral hepatitis. She did not mention any recent addition of new medications. There is no recent acetaminophen intake or any other hepatotoxic medication. She does not consume any alcohol nor has she any history suggestive of a risk for viral hepatitis. Further workup included an ultrasound of the liver, viral hepatitis panel, and toxicology screening. Her viral hepatitis panel and the toxicology screening came back negative with normal serum acetaminophen levels. Ultrasound scan of the liver showed slight intrahepatic dilatation but normal common bile duct and no features of cholelithiasis. There was a 2.7-cm mass in the posterior segment of the right hepatic lobe and the same was confirmed in the CT scan (Figure ). Of note, there was hepatopetal blood flow seen during ultrasonography (USG)-Doppler and there were no features of portal vein thrombosis. The positron emission tomography (PET) scan which was done at this time revealed multiple new hypermetabolic metastatic lesions in the liver predominantly in the posterior right hepatic lobe (Figure ). There was increased hypermetabolic activity in the regi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn March 2015, a 41-year-old woman presented with a sudden headache associated with vomiting of gastric contents in the afternoon and was immediately sent to the hospital. She reported no coma, convulsions of the limbs, or inability to move. Her heart rate was 73 beats/min, blood pressure was 104/65 mm Hg, and her respiratory rate was 23 breaths/min. She was breathing ambient air with satisfactory air oxygen saturation. There were no lesions in the oropharynx, and her neck was supple. The lungs were clear, and her heart rate was regular, without any murmur. Physical and neurological examination at that time revealed no special abnormalities. Her medical history revealed a sulfanilamide allergy but no other diseases.\nThe emergent CT scan of her brain showed an occupying lesion about 4.9 × 4.3 cm in the left cerebellum accompanied by intracranial vascular bleeding. There was a destruction of occipital bone. The mass was noncalcified and slightly dense with severe peritumoral bleeding and edema (Fig. ). We did not perform MRI because of limited time and objective conditions.\nThe next day, this patient suddenly fell into a coma. We then performed an operation to excise the lesion, clear the intracranial hematoma, and performed ventricular drainage and tracheotomy. We used a transcortical approach to the left cerebellum. In the operation, we performed a left parietal craniotomy and made a Y-shaped incision in the dura under a microscope. We removed a 3 × 3 × 3 cm cystic lesion with poor dissection margins from the surrounding tissue and sent it for pathologic examination. The tumor was cystic and full of clear, yellow lipid matter, with attachments to the meninges and the occipital bone. The immediate postoperative course was uneventful.\nUnfortunately, a postoperative intracranial infection developed, and the patient presented with shivering and hyperpyrexia. The cerebrospinal fluid (CSF) tested positive for a Gram-positive bacterial infection and targeted antibiotic was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old male patient with chronic alcoholism and hepatitis B virus carrier was diagnosed with alcoholic liver cirrhosis and hepatocellular carcinoma (HCC) two years ago. Then, he received transcatheter arterial chemoembolization therapy three times and has been living without recurrence. The patient visited our emergency department with the symptoms of headache beginning 10 days prior and progressive left hemiparesis, altered mentality occurring two days prior. He was afebrile and his vital signs were stable. There were no leukocytosis and C-reactive protein (CRP) was 4.04 mg/L of blood. Upon a neurological examination, he was drowsy with disorientation and revealed decreased upper and lower extremities motor power to grade IV. DWI of the brain was performed because of suspicion of cerebral infarction. It showed a multi-lobulated cystic mass lesion and associated mild edema located in the right parieto-occipital lobe. We considered the possibility of a metastatic brain tumor at the first impression owing to negative diffusion restriction sign and a history of HCC. Contrast enhanced MRI combined with DWI revealed a multi-lobulated cystic rim-enhancing mass with surrounding edema and hypointensity in the cystic cavity on the DWI (). Stereotactic biopsy with aspiration was performed on the assumption of HCC multiple metastasis in the brain and the result revealed BA involving multiple bacterial colonies. However, because the bacteria was not cultured, an initial antimicrobial therapy was started on the basis of the standard empirical treatment that consists of vancomycin plus a third-generation cephalosporin and metronidazole. Despite the use of the above antimicrobial therapy, clinical deterioration with an increasing abscess size on cranial imaging () made further stereotactic aspiration and cultures including fungus, parasite and tuberculosis mycobacterium. The amount of vancomycin dosage was increased in order to increase the CSF concentration of vancomycin b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old woman was referred to our institute for further evaluation of a tongue mass. She had a 5-year history of pain involving the right lateral tongue edge, and the lesion had been diagnosed as lichen planus by incisional biopsy performed by her dentist. The disease was stable for a long time; however, the tongue pain suddenly worsened. Physical examination revealed an elastic, hard, 1.2 × 0.7 cm mass of the right tongue (Fig. ). There was no palpable lymphadenopathy in the head and neck area. The patient was being medically treated for hypertension and diabetes mellitus, both of which were well controlled. She denied using tobacco or alcohol but had been exposed to smoke from her family. She had no history of exposure to ionizing radiation or having undergone cancer chemotherapy. Regarding her family history, her younger brother had been treated for rectal cancer and liver metastasis.\nContrast-enhanced CT scans of the head and neck, chest, and liver were performed as a routine procedure in patients with oral cavity cancer. CT showed no lesions in the tongue, cervical lymph nodes, lungs, bone, or liver; however, three masses were detected in both breasts and the right kidney. Whole-body FDG-PET was performed to identify any other lesions; no other lesions were found. An upper gastrointestinal examination, indirect laryngoscopic examination, and bone scintigraphy revealed no abnormalities. The patient had no breast- or kidney-related signs or symptoms before we identified the masses. Fine-needle aspiration cytology was performed to confirm the diagnosis of the bilateral breast masses and revealed malignancy on both sides. Renal cancer was suspected based on the CT findings (Fig. , arrow). All four lesions were diagnosed as early-stage cancers at the initial presentation.\nWe removed the four tumors over three surgical procedures because the patient had diabetes mellitus. The patient underwent wide local excision of the tongue tumor. Histopathological examinati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old, previously healthy, African American man presented to an emergency department 45 minutes after the acute onset of left facial droop and right-sided weakness (Fig. ). A thorough history confirmed an episode 1-week prior, during which he developed sudden onset of dizziness associated with nausea and vomiting that resolved within hours. He denied any past medical or surgical history and was taking no medications. He has no family history of tumors. In the emergency room, his vital signs were within normal limits. His physical examination was significant for a left facial droop and right hemiparesis. Auscultation of his chest revealed a regular rate and rhythm with no appreciable murmur. No additional significant findings were noted. Stroke protocol was initiated. A chest X-ray was normal and an electrocardiogram showed normal sinus rhythm. A head computed tomography (CT) scan was negative for signs of intracranial hemorrhage. He was subsequently started on tissue plasminogen activator (tPA) therapy. Magnetic resonance imaging (MRI) of his brain demonstrated a right basal ganglia infarct and an old left cerebral infarct. A carotid ultrasound was negative. TTE demonstrated a 1 cm by 1 cm mass on the posterior leaflet of the mitral valve with a moderate mitral regurgitation In addition, TTE revealed a questionable mass on the left coronary cusp of the aortic valve. These findings were confirmed with TEE (Fig. ), which verified no sign of endocarditis and no atrial septal defect. A complete hypercoagulable workup was negative. Stroke protocol continued with the working diagnosis of cerebrovascular accident secondary to emboli from the mitral valve mass. Within 24 hours, he regained function of the right side of his body and had complete resolution of symptoms. He was diagnosed as having transient ischemic attack (TIA) and discussion was undertaken regarding surgical excision of his mitral valve mass.\nA median sternotomy was performed and cardiopulmonary bypa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 55-year-old male, employed as a manual laborer in Indian Railways. Patient presented in emergency with severe abdominal pain, multiple episodes of vomiting, abdominal distension, and obstipation. He had a history of recurrent attacks of colicky abdominal pain, nausea, and vomiting over the last 2 years. There was a history of hospitalization for occasional episodes of severe abdominal pain and distension and obstipation over this period. The frequency of these attacks had been progressively increasing over the last 2 years with the patient requiring weekly admission for the preceding two months before coming to our centre. There was history of loss of weight and appetite. There was no associated history of fever. There was no contributory past or family history. He was a chronic smoker of 80 packet years and a social alcoholic. He was investigated by CT scan of the abdomen and Thorax and MRI of the abdomen during his previous admissions and was diagnosed as a case of hiatus hernia with retroperitoneal fibrosis/diffuse lymphoproliferative disorder. CT chest showed nodularity indicative of infective pathology. However, these investigations were not available with the patient at the time of admission to our hospital. He was normotensive and afebrile but was having tachycardia and tachypnoea (pulse: 108/minute and respiratory rate: 22/minute). His nutritional status appeared adequate. His general physical examination was essentially normal.\nHis systemic examination of chest, CVS, and CNS revealed no obvious abnormality. On abdominal examination he had a distended abdomen with stretched umbilicus. There were no visible scars. Abdomen was diffusely tender and guarded with no palpable organomegaly. Examination of external genitalia, hernial orifices and renal angles revealed no abnormality. On a digital rectal examination the rectum was empty and ballooned. A provisional diagnosis of acute intestinal obstruction with impending strangulation was made and c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old male patient presented with pulsation of the skull and dizziness during bending down. Neurological examination revealed a dysdiadochokinesia on both sides, no further neurological deficits. The scalp was soft. A bone resistance was not palpable. Cranial magnetic resonance imaging (MRI) showed an extensive growing, contrast enhancing lesion expanding at the supra- and infratentorial convexity, infiltrating and destroying large parts of the skull, and infiltrating the skin (). CT scanning and 3D-reconstruction images stress out the massive destruction of the calvarian bone (Figures and ).\nA surgical procedure with the aim of complete tumor resection in a curative manner was not possible, so that a digital subtraction angiography (DSA) was done to identify the arterial blood supply of the tumor. The tumor was fed by branches of both internal and external carotid arteries and additionally by the right vertebral artery. The feeding branches were embolised to induce decrease of tumor size and growth. The patient was discharged and was followed closely in our out-patient department.\nTwo months later, the patient presented with progressive ataxia and dysarthria. On examination, we discovered circumscribed skin necrosis of the skull in consequence of embolization of the feeding arteries and the skin infiltration of the tumor. Despite previous embolization, MRI showed marked increase of the infratentorially localized tumor with cystic components with compression of the fourth ventricle and the brainstem. In consideration of the new findings, we resected parts of the tumor located in the posterior fossa and at the occipital convexity via an extended sub-occipital approach. During surgery, the tumor was located in the epidural space with diffuse infiltration of the bone and the skin. Histopathological work-up revealed an anaplastic meningioma WHO grade 3 with high cell density, tall polymorph nuclei and high mitotic rate with a high proliferation index of 60% ()."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old male with a history of right tibial shaft and lateral malleolus fractures following a fall injury underwent open reduction and internal fixation with a locking plate for the fibula fracture and minimally invasive percutaneous osteosynthesis for the tibial shaft fracture at another hospital. Postoperatively, the patient was followed up at our hospital for 1 year due to residential issues, and the removal of the plate was scheduled after confirmation of bone union. According to the previous hospital’s medical records, a 9-hole locking plate (APIS®, Gwangju, Republic of Korea) was used for the distal tibia, with three 5.0-mm locking screws for proximal fixation and six 3.5-mm locking screws for distal fixation. Under spinal anesthesia, a plate removal surgery was performed, following which the fibular plate was easily removed. However, five of the six distal locking screws were damaged, and they could not be removed with a screwdriver. This situation was explained to the patient during the operation, and we could confirm that the patient wanted to remove the plate irrespective of the amount of time required. At the time, a tourniquet was used for approximately 1 h, and screw removal was attempted using a conical extraction screw, but only one of the six screws could be removed. Previously proposed techniques requiring additional skin incisions were not considered because there were multiple damaged screws that could not be removed, these techniques would require extended amount of time for removal, and the surrounding soft tissues could be damaged. Hence, we decided to use a screw extractor (IRWIN®, Huntersville, NC, USA), a non-medical instrument, following sterilization with ethylene oxide. In brief, 6-mm drill bit of the extractor was used, four screw heads were drilled, the locking screws and locking plate were separated, and the plate was removed. Of the remaining four screws, one was removed using a vice grip; the remaining three screws"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old woman with past medical history of hypertension, hyperlipidemia, and hypothyroidism presented with chief complaint of worsening low right-sided back pain for one week. She had not had any trauma or injury to the area prior to onset of pain. She then developed right-sided leg weakness, right thigh numbness, and perianal numbness in a progressive fashion. She also reported urinary retention.\nOn further questioning, she reported numbness of chin on both sides which started two weeks prior. She did have a left molar tooth extraction one week prior to the onset of all symptoms, and did receive local anesthesia for that. However, she confirmed that the numbness of chin was present prior to tooth extraction as well.\nHer vital signs at the time of presentation were: blood pressure 124/58 mmHg, heart rate 89 beats/min, temperature 98.3°F, and respiratory rate 22 breaths/min with oxygen saturation of 95% on room air. Her physical exam was significant for tenderness to palpation of lower lumbar spine, decreased motor strength, and sensation of the right lower extremity. She also had decreased sensation to touch and pain around her lips and on chin bilaterally.\nLaboratory investigations at the time of presentation and on Day 4 and Day 5 are listed in Table .\nShe had a CT scan of lumbar spine without contrast which showed multilevel chronic changes without any acute pathology. She underwent a CT myelogram of the lumbar spine, which also did not show any acute pathology.\nShe then underwent MRI of the thoracic and lumbar spine with and without IV contrast, which showed extensive epidural and possibly subdural enhancement at multiple levels of canal. A lesion within the canal at L2 level was causing severe compression of the cauda equina just below the level of conus and extending into the right foramen at L2-3. These findings were highly suggestive of a neoplastic process (Figure ).\nThe patient was admitted to the hospital with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case involving a 76-year-old female patient who was first seen by her doctor for problems and discomfort with deglutition. Upon an objective examination, the thyroid gland appeared to be mildly enlarged (more on the right side of the neck) with a hard consistency, but mobile relative to the underlying tissues. The only comorbidity was a mental illness.\nAn ultrasound (US) of the neck was immediately performed and revealed a multinodular retrosternal goiter, for which the larger nodule in the right lobe presented with a diameter of approximately 6 cm and complete ring calcification. The goiter extended into the upper mediastinum and was lying on the aortic arch.\nDue to the goiter’s retrosternal configuration, we performed a CT scan of the neck and thorax. The scan showed the posterior dislocation of the epiaortic vessels and lateral dislocation and compression of the pharynx. The large nodule described previously based on US exhibited a mixed type of calcification; in fact, in the context of a large egg-shell calcification, multiple spots with microcalcifications were observed (A and B).\nGiven the notable dimensions of the goiter, its symptomatic disposition and the extreme calcification of the nodule, we chose to avoid an ultrasound-guided ago-biopsy due to the low probability of obtaining a good tissue sample and the consequent diagnosis, and in agreement with the patient’s endocrinologist, we decided to directly perform a standard thyroidectomy through a cervicotomy. The primary difficulty during the operation was the complete calcification of the entire right lobe, which was adherent to the trachea and vascular structures (A and B). However, no major bleeding or complications occurred during surgery.\nMacroscopically, the pathologist described a nodule with a weight of 130 g that was partially cavitated and extremely hard when cut (A and B).\nA microscopic histological examination excluded the presence of atypical cells and revealed nodular hyperplasia"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously well 87-year-old Caucasian woman living in a senior assisted care center presented to the neurology clinic with complaints of six months of slowly progressing left sided weakness. Initial difficulty in ambulating and using the stairs progressed to being wheelchair bound. Neurologic exam revealed diffuse 3/5 left sided weakness, left leg drift, and left facial droop. Brain magnetic resonance imaging (MRI) revealed a large confluent white matter T2-hyperintensity in the right frontal lobe with multifocal nodular enhancement of the left cerebral hemisphere (). Foci of enhancement were also identified in the cerebellum and leptomeninges. The radiologic differential diagnosis included vasculitis, lymphoma, and CNS sarcoidosis as the most probable causes of the multifocal disease process, with glial neoplasm, demyelination, and metastases considered less likely.\nAll sample analysis described below were performed on material obtained by brain biopsy as part of clinical care. All samples were obtained with appropriate consent.\nA biopsy of the mass was performed and revealed extensive parenchymal lakes and vascular and perivascular deposition of amorphous, amyloid like material (). Congo-red positive staining and apple-green birefringence (not shown) of the amorphous material upon polarization confirmed that the amorphous material was amyloid (). Also present in the resected tissue were a number of small intraparenchymal blood vessels with perivascular lymphoplasmacytic infiltrates (). The initial histologic differential diagnoses included cerebral amyloid angiopathy-inflammatory type (CAA-I) and lymphoma associated amyloidoma. To identify the underlying etiology of the amyloid accumulation, a number of additional analyses were performed.\nLiquid chromatography tandem mass spectroscopic analysis identified the amyloid as AL λ-type and not β amyloid or an amyloid associated with a hereditary amyloidosis. Further analysis of the perivascular lymphoid populations wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old male patient visited SMG-SNU Boramae Medical Center with exertional chest pain, which had been aggravated during the most recent 3 months. The initial electrocardiogram revealed sinus bradycardia with a heart rate of 50 beat per minute, and there was no ST segment elevation. The serum cardiac enzyme level was within the normal range, and there were no abnormal findings except mild functional mitral regurgitation in transthoracic echocardiography, which showed a left ventricular ejection fraction of 67% and no regional wall motion abnormality. Myocardial single-photon emission computed tomography showed a reversible perfusion decrease at the basal inferior wall. Preoperative coronary angiography showed 70% to 80% stenosis of the left anterior descending coronary artery (LAD), 90% stenosis of the proximal ramus artery, 50% stenosis of the proximal left circumflex artery, 95% stenosis of the distal right coronary artery, and 90% stenosis of the posterolateral branch artery (PLB). According to the patient’s past medical history, he had undergone right upper lobectomy for squamous lung cancer 3 years ago. In addition, arteriosclerosis obliterans of both the lower extremities had been treated medically for 6 years.\nDiagnosed with unstable angina with three-vessel disease, the patient underwent off-pump coronary artery bypass graft surgery (CABG). Under general anesthesia, an advanced venous access catheter and a Swan-Ganz (SG) catheter were inserted via the right internal jugular vein by the anesthesiologist. Several premature ventricular contractions (PVCs) occurred during the insertion of the SG catheter. We used the left internal mammary artery as a pedicled graft and anastomosed it to the mid-LAD. We also harvested the saphenous vein from the left lower leg and anastomosed it to the left internal mammary artery to make a Y-shaped composite graft. Subsequently, the vein graft was anastomosed to the ramus artery and PLB sequentially. During the operation,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old man with a 5-year history of gluten intolerance and bullous dermatosis had been treated for recurrent conjunctivitis. He came to us with progressive vision loss, photosensitivity, foreign body sensation, and burning sensation in both eyes. He presented bullous and papular lesions with erythematous base in periocular tissues, limbs, thorax (). Two years before, a previous diagnosis of dermatitis herpetiformis in another center was given and was treated with 50 mg per day of oral dapsone and 5 mg per day of oral prednisolone.\nThe visual acuity was light perception in each eye. Slit lamp examination showed dysfunctional meibomian glands, conjunctival hyperemia, subconjcuntival fibrosis, corneal superficial vascularization, and opacification with epithelial defects, and the rest of the anterior segment was difficult to evaluate (). The ocular ultrasound was unremarkable in both eyes. A histopathological examination of the skin biopsy revealed neutrophil alignment along basal membrane and subepidermal cleavage with inflammatory cells in the superficial dermis; immunofluorescence confirmed IgA deposits along the basal membrane ().\nWe decided to continue with dapsone and started him on a topical erythromycin ointment, lubricants, 50 mg per day of systemic prednisolone, 50 mg per day of sulfone, and 75 mg daily of azathioprine. A keratolimbal allograft transplantation was performed, with superficial keratectomy that underwent histopathological studies. We observed a complete destruction of Bowman's layer, replaced by fibrotic tissue with perforant vessels, and immunofluorescence studies confirmed IgA deposits over this area ().\nA monolayer of cryopreserved amniotic membrane was implanted in his right eye. We suggested immunoglobulin therapy, but the patient could not obtain the treatment. Four months after the surgery, a corneal melt was noted and eventually he needed two more amniotic membrane patches for immanent perforation. Unfortunately he persisted with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA three and a half month old female child being treated in another hospital was referred to us. This child had complaints of cough, coryza, fever, and respiratory distress since day 10 of life. The child was admitted in another hospital and was treated for pneumonia. Chest X-ray (CXR) at that time showed collapse consolidation of the apical segment and lower lobe of the right lung which was misread as lobar consolidations []. She was given intravenous antibiotics and was discharged. Subsequently, this child required four more readmissions and was suspected of having recurrent pneumonia. During this course, her blood investigations were essentially normal. Two-dimensional echo was normal. A cystic fibrosis screening was done which also was normal. This child was then referred to Lok Nayak Hospital, New Delhi. On examination, the child was alert, active with stable vitals. Blood investigations were essentially normal. Venous blood gas showed pH 7.2, PCO2 54, and BE 5.4. CXR showed hyperlucency in the right upper and middle zone with slight mediastinal shift to the left. An inhomogeneous opacity was noted in the right middle zone along with a thin linear opacity in the left hemithorax which led to the suspicion of right lobar emphysema []. Computed tomography (CT) scan was planned which showed collapse of apical and posterior segments of the right upper zone along with hyperinflation of the right middle lobe. Consolidation with subsegmental collapse was seen in the apical segment of both lower lungs []. A diagnosis of CLE was made. As the child was clinically stable, a decision to manage her conservatively was taken. However, on the 7th day of admission, the child's condition deteriorated with worsening respiratory distress and was unable to maintain saturation even with oxygen support. The child developed severe chest retractions. The child was then taken up to the emergency operation theatre for urgent thoracotomy and exploration. Right middle lobe was found emphysem"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male professional hockey player suffered a fall on ice during a game, which resulted in a flexion-external rotation injury to his left lower extremity. At the time, he felt a pop and developed immediate onset of the left knee pain. Plain films and magnetic resonance imaging (MRI) revealed anterior dislocation of the proximal tibiofibular joint (). The patient had subsequent spontaneous reduction while entering a car the following day. 3 days after injury, the patient had persistent the left knee pain and difficulty with the range of motion to terminal flexion and extension and presented to clinic. At presentation, the patient was unable to comfortably bear weight on the extremity. On examination, he had tenderness to palpation at the fibular head but no tenderness over the ankle. His left knee had a range of motion comfortably from 10 to 90° and full strength in all muscle groups, as well as intact sensation in all nerve distributions in the lower extremity. Initially, the patient elected for nonoperative treatment and was advised to remain non- weight- bearing for 1week followed by a repeat MRI. This study revealed a small amount of lateral subluxation of the left fibular head. At this point, the patient had persistent pain and difficulty with extension, and so elected to undergo surgical treatment. 12 days after injury, the patient underwent ORIF of the proximal tibiofibular joint. The joint was noted to be resting in a laterally subluxed position. It was manually reducible but unstable (). A single 3.5 mm cortical lag screw was inserted from the fibula to the tibia parallel to the knee joint, after which the joint remained anatomically reduced. Postoperatively, the patient remained non-weight-bearing with passive range of motion limitations for 4 weeks, after which weight-bearing and active range of motion were allowed. At 8 weeks, his physical examination included minimal edema about the head of the fibula; active range of motion from 0° to 135° wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man was followed up in our clinic for two years for early cervical myelopathy secondary to C3 to C5 stenosis. His medical history was significant for dialysis-dependent end-stage renal disease due to chronic allograft nephropathy despite cyclosporine therapy for a living-related donor kidney transplant. He suffered a previous myocardial infarction treated with percutaneous coronary intervention and sick sinus syndrome, which required a pacemaker that was removed due to a postoperative abscess. He survived squamous cell carcinoma of the parotid gland with lymphatic involvement that necessitated radical resection and radiation of the head, neck, and axilla. He was also diabetic. At the time of his initial presentation to our clinic, his symptoms included very slight loss of coordination in his left hand and a mild sense of imbalance. He could still ambulate and live independently and therefore did not wish to proceed with cervical decompression and fusion.\nHe was lost to follow-up but returned to our clinic two years later. At this time, he presented with loss of coordination in both hands and could no longer ambulate. As a result, he was no longer able to care for himself. He remained dialysis dependent and was oliguric, but not completely anuric. Repeat cervical MRI revealed worsening stenosis at C3-5 compared to the MRI scan performed two years earlier. At this point, he wished to proceed with surgery. As per standard protocol, he was given 1 gram of intravenous cefazolin immediately prior to incision. He underwent posterior C3-5 laminectomies and instrumented fusion with lateral mass fixation. In an attempt to preserve his remaining kidney function and reduce his risk of SSI, we applied 1 gram of vancomycin powder over the instrumentation and soft tissues of the surgical exposure. Although there were not any previous reports of intrawound application of vancomycin powder in patients on dialysis, we felt it was a justified treatment to minimize his ch"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nHere we present a 3-year-old girl, born from non-consanguineous parents after a normal pregnancy and cesarean delivery, hospitalized after 2 days of high fever, productive cough, clear nasal secretions and lack of appetite. One week before, she had suffered a non-febrile respiratory infection treated with azithromycin. She presented incomplete ocular albinism characterized by absence of pigmentation in the peripheral retina but had no history of serious recurrent infections or excessive bleeding. There was no family history of albinism or hypopigmentation, immunological or hematological alterations, or of deaths at an early age.\nDuring her evaluation, pancytopenia and oculocutaneous albinism were identified whilst chest x-rays (CXR) did not show significant alterations. Infectious diseases were ruled out by serological screening and direct observation in blood smears. Analysis for respiratory viruses was positive for adenovirus and respiratory syncytial virus (RSV). She showed normal psychomotor development and her vaccination schedule was up to date. Morphological studies were performed both on peripheral blood (PB) and bone marrow (BM) samples. Results for PB cells were consistent with CHS alterations. Hypercellular BM with increased levels of the granulocytic series and lower erythroid and lymphocytes series was also observed. In PB as in BM, purple inclusions were detected in both lymphocytes and all stages of the granulocytic series. Intense vacuolization, sometimes with a purple inclusion, was also seen in all cell types (). BM’s flow cytometry showed a normal immunophenotype, with an increase of immature myeloid cells (). NK cells showed defective granule exocytosis with low expression of CD107a on stimulated NK cells () and a slightly reduced cytotoxic capacity () evaluated by degranulation assay.\nDifferential diagnosis by cytogenetic analysis, including conventional karyotype by C-banding and FISH revealed a normal female karyotype (46,XX). Due to the clini"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old lady complained of recurrent paroxysmal tachycardia during physical exercise.\nThe tachycardia could be seen on an event recorder (Figure ). It was a narrow QRS tachycardia reaching a rate of 194 bpm.\nOn the base of the tracing, a presumptive diagnosis of typical slow-fast atrioventricular nodal tachycardia was done.\nMedical treatment consisted of sertraline and omeprazole.\nAn electrophysiological study was performed. Para-hissian ventricular pacing at baseline revealed absolutely no retrograde conduction (Figure ). Atrial pacing revealed an anterograde Wenckebach phenomenon at 700 ms atrial pacing cycle length and no anterograde nodal jump. After isoprenaline infusion (1 µg/min), retrograde dissociation persisted but at 2 µg/min one-to-one concentric retrograde conduction could be seen (Figure ). At 3 µg/min isoprenaline infusion, ventricular premature stimulation induced isolated narrow QRS ventricular echoes following progressive prolongation of the retrograde conduction by 65 ms with unchanged pattern of retrograde conduction. This suggested concealed retrograde block in the slow pathway with a slow-fast ventricular echo.\nAtrial pacing induced a double ventricular response, one through the fast nodal anterograde pathway and one through the anterograde slow pathway followed by one retrograde fast pathway echo and a second ventricular echo with retrograde block in the fast pathway (Figure ). A typical episode of slow-fast atrioventricular nodal reentrant tachycardia at 152 bpm could then be induced via the double-response mechanism (Figure ).\nThe atrial activation during tachycardia was identical as the one during ventricular pacing when retrograde conduction was present, and it was not possible to advance the atrial electrogram when a ventricular pacing impulse was delivered during the refractory period of the His confirming the mechanism of the tachycardia. Five cryoablation lesions were delivered on the triangle of Koch on sites with an A/V ratio <"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old man was injured by direct impact with a hockey puck over the left eye and underwent vitrectomy with combined phacofragmentation in our hospital. Two months after the surgery, his left eye exhibited retinal detachment in the form of rigid folds with a large number of proliferative membranes. The patient was young and could not maintain the prone position for long periods because of work obligations, so he refused treatments of SO tamponade and enucleation; he requested FCVB implantation. At that time, his BCVA results were light perception in the left eye and 10/10 in the right eye. His IOP results were 10 mmHg in the left eye and 16 mmHg in the right eye. Anterior segment examination showed large organic membranes on the iris, while the lens was entirely absent. Fundoscopy, fundus photography (), and B-scan ultrasound () examinations all showed extensive retinal detachment in the patient’s left eye. Therefore, the patient provided written informed consent to undergo SO-filled FCVB implantation in the left eye. The specific surgical treatment that the patient underwent is described in .\nOn the first day postoperatively, BCVA in the patient’s left eye remained light perception, while the IOP was 15 mmHg. Fundoscopy showed that the FCVB was appropriately positioned and the retina was attached. At 3 months postoperatively, the cornea was slightly opaque and exhibited keratic precipitates. The FCVB remained appropriately positioned with respect to the retina and showed a firm connection to the inner scleral wall; the IOP at the time was 10 mmHg. Topical corticosteroids were administered as anti-inflammatory therapy. At 9 months postoperatively, as shown in , persistent corneal opacity was evident with new-onset neovascularization and a thick anterior chamber exudative membrane; no other intraocular structures were visible. IOP in the patient’s left eye was 10 mmHg, while the BCVA remained light perception. B-scan ultrasound showed pseudo expansion of the ey"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old lady presented in the emergency room with swelling and pain of the right shoulder for the previous 4 days. She reported a minor trauma to her right shoulder a week previously, following which she developed swelling and pain, associated with high-grade fever. She was a known diabetic and had been receiving treatment with oral hypoglycaemic agents for the last 5 years.\nOn clinical examination, the patient was toxic, febrile, tachypnoeic and had tachycardia. On local examination there was a diffuse swelling involving the right shoulder, neck and anterior chest wall, and the overlying skin was inflamed. There was local rise in temperature with tenderness and marked induration. There was gross oedema involving the face and the patient had difficulty in breathing.\nContrast-enhanced computed tomography (CT) scan showed extensive cellulitis and thrombosis of the internal jugular vein and marked necrosis of the underlying muscles (Figs and ). The basic investigations revealed a haemoglobin level of 7.5 g/dl, a random plasma glucose level of 227 mg/dl and the fasting glucose level was 240 mg/dl.\nThe total count was elevated to 16 370 mm3 and arterial blood gas showed metabolic acidosis.\nThe patient was started on intravenous piperacillin tazobactam and was subsequently taken for emergency debridement of the wound on the right shoulder. During surgery, as the wound was being debrided, there was practically no bleeding (Fig. ). There was extensive necrosis involving the scapular, neck and facial muscles, although the subcutaneous tissue and the overlying skin looked apparently normal. The tissue was sent for histopathology and, to our surprise, it turned out to be positive for fungal elements. Examination showed acute on chronic inflammatory cell infiltrate, necrosis and splaying of muscle fibres. Many broad aseptate fungal elements morphologically resembling features of the zygomycetes group were seen (Fig. ). Special staining on periodic acid Schiff (PAS) stain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA caucasian, 69 y.o., nonsmoker and not consuming alcohol woman referred to our outpatient office seeking for an abdominal profile reshaping procedure. The patient suffered from hypertension and gastroesophageal reflux, both drug-treated. Her BMI was 25,6 and the anesthesiologist assigned her ASA II score.\nThe patient presented an 18-cm long linear scar on the left lateral side of her abdomen due to open kidney surgery performed 30 years before for renal stones removal and she did not complain any abdominal symptom at the time of the visit. Thus, trunk contour was characterized by both a bulge deformity of the left side and moderate subcutaneous adipose tissue excess with skin laxity of the inferior abdomen (, , ).\nAt the ultrasound investigation, the bulge revealed a portion of 0,7 cm of relaxed fascia underlying the existing scar with protrusion of fatty tissue through the gap, without any sign of intestinal loops involvement.\nThe patient was scheduled for flank bulge repair, liposuction and short scar abdominoplasty, which did not include umbilical transposition or recti abdominis muscles plication.\nSurgery was performed by a senior consultant specialist of our clinic with the patient under general anesthesia and placed on her right lateral decubitus with a sandbag gel positioner under her right flank. Through a direct skin incision traced along the existing scar we exposed the left bulge: no true adipose tissue hernia was encountered, but only abdominal wall deformity with absence of proper muscle fascia.\nA double plication of the left external oblique muscle was performed, after drug-induced muscle relaxation. Turned the patient in supine decubitus we focused on the lower abdomen performing two stab incisions medially to anterior superior iliac spines to infiltrate 800cc of tumescent solution []. Then liposuction was performed using a 4 mm blunt cannula and about 800cc of clear adipose tissue were removed without bleeding.\nA short scar abdominoplasty completed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old man presented with 4-month history of otorrhea and a rapidly growing mass on the external auditory canal and postauricular area after open cavity mastoidectomy at other hospital 5 months ago. He was otherwise healthy, with no significant medical history. He had received no previous radiotherapy. Physical examination revealed polypoid mass totally packed in external auditory canal and exophytic mass about 5×4 cm in postauricular area ().\nNo cervical lymph nodes were palpitated. No facial paralysis was present. The scalp and the remainder of the findings on otolaryngologic examination were within normal limits. Audiometry demonstrated a mixed hearing loss of 50 dB of bone conduction and 90 dB of air conduction hearing. Routine clinical laboratory data and a chest radiograph were normal. Two biopsies were performed. Histologic evaluation identified the lesion as a leiomyosarcoma with extensive necrosis.\nComputed tomography (CT) of the temporal bone demonstrated a mass in the middle ear cavity, with absence of almost the entire temporal bone due to previous operation and with destruction of a part of petrous bone. The inner ear structures were preserved ().\nMagnetic resonance imaging (MRI) indicated a mass expending to pterygoid muscles, posterior margin of mandible and middle and posterior cranial fossa dura. The lesion obstructed the external auditory canal and could not be demarcated with granulation tissue ().\nFor the en bloc excision of the mass, the clear margin was 1.5 cm or more. The auricle was sacrificed for the design of surgical incision with the discolorated skin.\nThe excisions of the temporal bone was conducted including the external auditory canal, the middle ear, the vestibular organ, middle and posterior fossa dura, and the partial petrous bone. The cochlear, the lateral sinus, and the jugular bulb remain intact (). For the preservation of facial nerve function, the delicate epineural dissection of facial nerve was performed from tympanic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male was admitted to our department complaining of pain and paresthesia in the left upper limb associated with massive swelling. He was a heavy smoker and had a past medical history remarkable for hypertension and bilateral polycystic kidney disease. The patient started hemodialysis in 2003 from a distal radiocephalic AVF on the left arm. After spontaneous fistula thrombosis 1 year later, a new radiocephalic AVF for hemodialysis was created on the right arm. In 2005, he received a successful cadaveric kidney transplant in the right iliac fossa and since then had been administered with immunosuppressive drugs (cyclosporine 20 mg and mycophenolate mofetil 2,000 mg daily) and corticosteroids (methylprednisolone 4 mg daily) to avoid renal rejection. The patient lamented a small swelling of the left arm persisting for 2 years, which in the last 4 months went through an important increase in size, associated with mild paresthetic symptoms.\nThe patient's past medical history was negative for injective drug abuse, upper-limb trauma, and brachial artery access for endovascular procedures.\nOn physical examination, he had a left arm circumference of 41 cm, compared to the contralateral arm of 26 cm, with a pulsing ovoid swelling on the medial aspect, 3 cm above the medial epicondyle at the level of the armpit (Fig ).\nThe mass resulted tight, pulsatile and incompressible, and painful on palpation along with mild distal edema. Bilaterally, the supraclavicular and axillary lymph nodes were not palpable. The right and left radial and ulnar pulses were both palpable. An ultrasound duplex scan of the left upper-limb arterial system revealed a giant true aneurysm of the brachial artery in presence of parietal thrombosis with turbulent flow seen along the vessel.\nThe patient underwent surgical treatment under general anesthesia. He was placed in the supine position with abducted left upper limb. An incision was made over the axilla, and the BAA was isolated with proximal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a 25 years old Malay girl with learning disability and no significant past medical history, who started noticing a sacral mass since August 2015. The mass was painless and gradually increasing in size. The family members of this patient brought her to a traditional healer. They did not seek any medical treatment until late 2017. By this time, the mass over the sacrum was extremely large. Family members claimed the mass was preventing the patient from lying down flat supine. The patient was also unable to ambulate for the past 2 years. Hence, she was bedbound most of the time. It was difficult for her to sit on the wheelchair. She also felt tired to move because the mass was quite heavy. The family members claimed when the patient was lying down flat, she had to flex her hips and knees to achieve a more comfortable position. In addition, she often slept either in prone position or in supine with multiple pillows below her body. The mother also claimed over the last 2 months, the patient’s body had been getting thinner despite her physical weight was increasing due to the increase in size of the sacral mass. The patient had been passing stool and urine in pampers. There was no past medical history and no family history of cancer. Socially, the patient lived with her mother and siblings. The mother was the main care taker. Her father passed away 10 years ago because of heart attack. The patient previously attended a special needs school, but she stopped going to school since 2015 after developing the sacral mass.\nThis patient was managed in the Southern Region referral centre for Orthopaedic Oncology in Malaysia. On clinical examination in the Orthopaedic Oncology ward, the patient appeared cachexic, she had slightly pale conjunctiva, but she was not dysmorphic. Vital signs were Blood Pressure 142/90, Pulse Rate 98 beats per minute and Temperature 37 degrees Celsius. There was a large mass 40 cm × 30 cm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old woman (gravida 2, para 2) was referred to our hospital complaining of a lower abdominal mass and pain. Her medical history was unremarkable. She was initially diagnosed with a uterine leiomyoma by transcervical needle biopsy. CT revealed a large heterogeneous tumor occupying the pelvic cavity and an intravascular tumor within the dilated left internal iliac and ovarian veins (Figures and ). Her preoperative cervical cytology results were negative for intraepithelial lesions and malignancy. The endometrial cytology and needle biopsy results were also negative. Thus, the preoperative diagnosis was IVL, with extension of the tumor into the left internal iliac and ovarian veins.\nIntraoperatively, multiple myomas were found within the uterine corpus and cervix, and the tumor extended to the parametrium and paracolpium. Detachment of the tumor from the left ureter and vaginal wall was very difficult. Intravenous tumors in the left internal iliac and ovarian veins could be palpated. The left internal iliac vein forming the common iliac vein was transected at the bifurcation region. In addition, TAH and bilateral salpingo-oophorectomy (BSO) were performed, resulting in the complete surgical resection of the tumor (operative time, 11 hours; blood loss, 8462 g). The resected uterus and adnexa weighed 897 g (Figures and ). There was no residual tumor detected in the venous resection stump.\nThe nodule resected from the uterus and the internal iliac and ovarian veins consisted of a proliferation of spindle cells. There was no nuclear atypia and the mitotic index was low. In addition, vessel endothelium cells and a vascular smooth muscle layer covered the IVL (Figures and ). The tumor cells stained positive for Alcian blue (pH = 2.5) and the staining disappeared after hyaluronidase digestion. However, compared to that in Case 1, the intensity of the staining was weaker and less diffuse (Figures and ). Similar findings for hyaluronan expression were obtained using th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Japanese man on PD presented with progressive worsening of abdominal pain and cloudy peritoneal fluid. He had high blood pressure, and he started continuous ambulatory peritoneal dialysis (CAPD) because of hypertensive nephrosclerosis 8 years previously. A PD catheter was primarily inserted at the right abdomen, but it was removed and inserted at the left abdomen because of exit site and tunnel infection 5 years previously. He had no past medical history of diabetes mellitus and major abdominal surgery. In the peritoneal equilibration test, his result was high. Bloody ascites was not evident. One year previously, he had been hospitalized for PD-associated peritonitis caused by touch contamination that was treated with intraperitoneal cephazoline and cephtazidime. Bowel adhesion was not noted 5 years previously; however, local bowel adhesions and agglomeration of the intestine were detected by computed tomography (CT) after the identification of PD-associated peritonitis (Fig. , ). The major findings of EPS, such as peritoneal thickening and calcification, were not noted on CT.\nOn physical examination, his blood pressure was 134/74 mmHg, pulse rate was 76 beats/min, and temperature was 99.7 ° F. He complained of severe pain in the right upper quadrant of the abdomen, and this area was tender on palpation. The exit site was clear. Laboratory tests revealed mild inflammation, with a white blood cell count of 10,100 /μL and C-reactive protein level of 0.9 mg/dL. The peritoneal fluid cell count was increased at 980 /mL. Based on these findings, PD-associated peritonitis was diagnosed. CT showed localized dilation of the intestine, which suggested adhesive small bowel obstruction (Fig. ). As we suspected that the peritonitis might be associated with bacterial translocation from the dilated intestine, he was advised to stop eating and was switched from CAPD to hemodialysis. Additionally, he was treated with intravenous vancomycin and cephtazidime. The PD cath"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40 year old lady with malignant metastatic paraganglioma was admitted electively to a medical ward for management of severe and incapacitating orthostatic hypotension.\nShe had been diagnosed at the age of 10 following unsuccessful treatment of suspected migraines. She had had symptoms of severe headaches and visual disturbances associated with sweating and vomiting, and had been treated with clonidine therapy. During a visit to her general practitioner, her blood pressure was noted to be unreadably high, and she was therefore immediately sent to hospital. In hospital, chest x-ray demonstrated a right-sided paravertebral opacity, and 24 hour urine collection revealed increased catecholamine levels. She underwent thoracotomy and tumour excision, and a diagnosis of extra-adrenal phaeochromocytoma was made. She was discharged from follow-up 3 years later.\nAt the age of 23, she became pregnant and had debilitating morning sickness and regular urinary tract infections. At 32 weeks' gestation, a 24 hour urine collection was performed and revealed increased catecholamines once again, at which point she was admitted to hospital. Investigations, including MIBG scanning, revealed recurrence of the paravertebral mass in her chest, and a deposit in the left scapula was also noted. She was started on oral labetalol at this point. She remained in hospital until the onset of labour at 38 weeks, at which point she underwent elective Caesarean section under general anaesthesia. 3 months post-partum, she commenced the first of five cycles of intravenous MIBG therapy, the duration of treatment lasting 2 ½ years in total.\nFollowing this treatment she remained well for the next 8 years, during which time she underwent premature menopause at age 25. At age 29, with the assistance of in-vitro fertilization, she gave birth to twins, this pregnancy being eventful only by the need for Caesarean section due to breech position and hysterectomy being necessary intra-operatively due to intra-pa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 67-year-old woman with relevant medical history of colon cancer treated with hemicolectomy, radiation, and chemotherapy 14 years ago without recurrence during the follow-up. The patient had several visits to the emergency room for immediate postprandial abdominal pain (especially epigastric and on upper quadrants) as well as nausea, vomiting, and significant weight loss during the last 18 months. Ultrasound demonstrated thrombosis of the inferior vena cava at epigastric level with an 80 × 30 mm thrombus. Computed tomography (CT scan) revealed a retroperitoneal heterogeneous soft tissue density mass that involved the infrarenal IVC without affecting the iliac veins of 8 × 4.6 cm in size and no evidence of metastatic disease (Figures and ). Celiac and mesenteric arteries were patent without stenosis. A biopsy of the tumor wall was conducted through a median laparotomy, because of technical difficulties by laparoscopic approach due to previous abdominal surgery and pericava localization of the tumor. As there was no definitive intraoperative diagnosis and the patient was not informed about the therapeutical procedure, tumor extirpation was postponed until pathology results were available and so the patient can be fully informed, as well. Pathologic study demonstrated a fusocellular stromal tumor, showing fascicles which intersect at 90°, histochemically and immunohistochemically concordant with IVC leiomyosarcoma (LMS).\nSurgical approach by transverse abdominal incision is done, and the retroperitoneal mass arising from segment I IVC was exposed through a Kocher maneuver and right colon mobilization from the renal to the iliac veins. Inflammatory tissue and fibrosis were found and dissected carefully to preserve the surrounding structures, especially both ureters and renal veins. Tumorectomy, resection and ligation of the infrarenal IVC, was made leaving the iliac veins patent (Figure ).\nThe specimen was composed of nine pieces, the principal of 7.5 ×"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old male of asthenic build presented with the complaint that fecal matter was coming out through an opening in the right iliac fossa region of his abdomen for the past 6 months. Initially, he had developed a swelling in the skin of the right iliac fossa over the scar of an appendectomy done 14 years back. The swelling had ruptured after 7-8 days, to discharge fecal matter mixed with pus. Within a week, the opening healed, but the swelling reappeared 7-8 days later, only to rupture again after a few days. This cycle of swelling followed by rupture was associated with evening rise of temperature. The fever was of moderate degree and was associated with the swelling stage only. His appetite was adequate and he was passing stools and urine normally.\nOn examination, the patient was moderately nourished and there were no features of anemia, hypoproteinemia, dehydration, or electrolyte disturbances. A 0.5 cm × 0.5 cm fistulous opening with fecal soiling was seen over the scar of a previous surgery in the right iliac fossa []. No mass could be palpated in the abdomen. The patient had no history of any other surgery or hospitalization. There was no history suggestive of any chronic disease such as TB, diabetes mellitus, or ischemic heart disease. Biopsy of the inflamed appendix and of an enlarged lymph node, taken at the time of the surgery done 14 years back, had not shown caseating granuloma but only nonspecific inflammatory reaction.\nWe took X-rays of the chest and abdomen, both of which were normal. Abdominal sonography revealed bowel-wall thickening in the ileocecal region and enlarged mesenteric lymph nodes, as well as a fistulous tract between the terminal ileum and the skin. A percutaneous fistulogram was obtained, which revealed a narrowing involving the ileocaecal junction and the terminal ileum, and a fistulous tract connecting the terminal ileum to the opening in the skin in the right iliac fossa []. Colonoscopy was performed and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old G4P2212 mother was referred to our institution for a fetal echocardiogram after a routine ultrasound raised concern for multiple congenital anomalies, including cardiac defects. The fetal ultrasound demonstrated the presence of an abnormal nuchal cord, left renal agenesis, rocker bottom feet, and possible omphalocele. Fetal echocardiography demonstrated a large atrial communication with right to left shunting, dilated right atrium, tricuspid atresia with a hypoplastic right ventricle, and pulmonary atresia with a hypoplastic pulmonary trunk. Branch pulmonary arteries appeared confluent and there was a moderate sized patent ductus arteriosus with left to right flow and subsequent flow reversal in the ductus venosus. Free fetal deoxyribonucleic acid (DNA) for trisomy 13, 18, and 21 was negative and amniocentesis demonstrated a normal 46XY karyotype and normal microarray. Maternal history was unremarkable with all negative serologies during pregnancy. Family history was significant for a first cousin with tricuspid atresia who had undergone Fontan palliation.\nThe male infant was born at 36 6/7 weeks gestational age at another institution with a birth weight of 2,150 grams. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Umbilical lines were placed and E type Prostaglandin was started before transport to our institution. The infant also required intubation due to respiratory distress before transport. Upon arrival to our institution, the infant underwent an echocardiogram, which demonstrated cardiac anatomy consistent with that noted on the fetal echocardiogram [Figures -]. Of note is the absence of the right atrioventricular connection, which is the essential feature of tricuspid atresia. The pulmonary trunk was thread-like, thus, leading to an effective absence of the ventriculo-arterial connection as well. Left ventricular function was normal and the coronary arteries had normal origin and distal course. Renal ultrasound demonstrated left re"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient presented as a 53 years old white male with anemia and fatigue. Previous history included no medications, distal left lower extremity venous thrombophlebitis 2 months prior, status post laparoscopic gastric Roux-en-Y bypass (for obesity and diabetes mellitus which had been untreated and resolved postoperatively) three years prior to presentation and a left ulnar nerve decompression nine years prior. Physical examination revealed no palpable lymphadenopathy, a fullness in the left upper quadrant and fecal occult blood positive stool. Laboratory studies showed a serum hemoglobin of 6 mg/dl. Computed tomography (CT) scan of the abdomen showed a 24 cm left upper quadrant mass with multiple liver lesions, splenomegaly and a 1 cm mass in the spleen (Fig. ). A laparoscopic liver biopsy was performed and histopathology was initially reported as hepatocellular carcinoma versus hepatoid carcinoma. One month later, serum hemoglobin was 4.4 mg/dl and gross melena was seen. Blood transfusions did not resolve the anemia. Serum albumin was decreased to 1.7 g/dl.\nThe patient underwent gastrectomy, splenectomy, distal pancreatectomy and resection of small bowel and a portion of colon that were adherent to the tumor mass. At the end of surgery, there was no gross tumor remaining except for the previously identified liver metastases. Pathology showed a tumor that originated in the pancreas with direct extension to the small bowel, colon, and stomach. The resected specimen weighed 3500 g and the spleen measured 14x7x10cm (Fig. ). On cut section, the spleen contained a 1.0 cm lesion consistent with a metastasis, which was then confirmed to be a metastatic lesion on histopathologic evaluation (Fig. ).\nThe final pathology report showed a pNET, well differentiated, stage T4N0M1 with 0/13 lymph nodes containing tumor. The lesion in the spleen was located near the edge of the spleen, but there was no direct invasion by the tumor mass (Figs. and ) grossly or histologically. Examin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe first case involved a 60-year-old woman with intracranial hemorrhage, hospitalized in our hospital in a stable neurological state. She had a history of a total arthroplasty of her right ischium 25 days ago and mild thrombocytopenia after the administration of low molecular weight heparin, which had been replaced by aspirin. On day 5, she developed acute respiratory failure with clinical signs of right heart failure, due to massive pulmonary embolism and deep venous thrombosis at the level of right iliac, femoral and popliteal veins. At that time, the platelet count was determined at 50.000/μL, disseminated intravascular coagulation was not present and all routine laboratory tests were within normal limits.\nIn view of thrombocytopenia after the administration of low molecular weight heparin and the thromboembolic events, HIT was clinically suspected. The diagnosis was confirmed three days later, by the positive enzyme immunoassay for antibodies to heparin-platelet factor 4 (Asserachrom HPIA, Diagnostica Stago). Antibody titers were determined on citrated plasma and results were expressed as percent of the absorbance measured at 450 nm with a positive control (1.900 optical density units), representing the value 100%. Antibody titers were estimated to be 87% (cut off for positive value 23%).\nDespite the increased risk of a recurrent intracranial hemorrhage, the presence of severe deep venous thrombosis on the ground of HIT immediated the administration of an alternative anticoagulant and fondaparinux sodium (Arixtra®, GlaxoSmithKline) was started subcutaneously in the dose of 7,5 mg daily. Given the severity of the patient's condition and her stabilized neurological status, we decided the administration of the highest recommended dose. Furthermore, the insertion of vena cava filter (Gunther, Tulip™, Cook USA) was decided for the prevention of new embolic events. The clinical status of the patients gradually improved and platelet count normalized 5 days after the i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old Caucasian male patient sought medical care complaining of a 4-month history of exertion dyspnea and edema of the lower limbs. His past medical history included hypertension and congestive heart failure, and although he had been abstinent for 1 year, he had previously smoked 75 packs/year. On physical examination he was hypotensive and cyanotic; his pulse was arrhythmic; he had edema of the lower limbs; he had bulging jugular veins when in the supine position; there were rales in the lower two-thirds of both lungs; and tender hepatomegaly was present. The electrocardiogram showed atrial fibrillation, and the echodopplercardiogram estimated the left ventricle ejection fraction of 63% (Teicholz), eccentric left ventricular hypertrophy, marked mitral insufficiency, and a left atrium of 85 mm. Pulmonary systolic pressure was estimated at 62 mmHg with marked tricuspid valve insufficiency. There were no valvular morphological abnormalities. He was hospitalized with the diagnosis of hypertensive cardiomyopathy and cor pulmonale.\nHe also complained of vision loss for 2 months accompanied by protrusion of the right eye globe. The ophthalmologic examination in the right eye revealed marked corneal deepithelization and edema, ocular protrusion, the absence of photomotor and consensual reflexes, and low visual acuity. The left eye was normal. Brain computed tomography and cranial magnetic resonance imaging (MRI) confirmed the presence of a neoplastic lesion infiltrating the paranasal sinuses and the frontal encephalic lobe (). A tumoral biopsy was scheduled, but the patient died before the procedure could be done because of a refractory cardiogenic shock.\nAutopsy findings included marked cardiomegaly with four-chamber dilation; the interventricular septum measured 18 mm, and the ventricular wall (posterior, anterior, and lateral) measured 15 mm. Radiological findings were confirmed at autopsy as a metastatic lesion most probably from an epithelial neoplasm of the e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 20-year-old male who presented at the medical service complaining of moderate to high intensity pain in the left flank. He described the pain as “stabbing” and stated that he had suffered from these pains since he was 6 years of age. They had initially been triggered by physical effort and had a frequency of one painful episode per week, but had become more recurrent, with sudden onset and without trigger factors (at rest) during the year preceding the consultation. He also reported an episode of macroscopic hematuria associated with pain one 1 week previously. He reported no other signs and no other complaints. He had no family history of nephropathy or hematuria. During physical examination he was lucid, well-oriented in space and time, with clear speech, good oxygenation, acyanotic, a heart rate of 84 bpm, blood pressure of 120 x 60 mmHg, and weight of 70 kg. Laboratory tests and initial clinical investigation were inconclusive. A computed tomography examination of the whole abdomen () revealed compression of the LRV between the aorta and spinal column and a dilated and tortuous LGV, with no pelvic varicose veins, confirming a diagnosis of posterior nutcracker syndrome. It was decided to manage the patient with clinical follow-up and he was medicated with diosmin-hesperidin and analgesics.\nAfter a succession of return visits for further evaluations, the patient reported that the pain had not improved and there had been further episodes of macroscopic hematuria. Abdominal angiotomography () was ordered, to provide a better view of the compression and the decision was taken to conduct a surgical intervention for venous revascularization, without using a stent. The procedure chosen was transposition of the LGV, which was transected distally and reimplanted at the inferior vena cava (IVC), with a left paramedian incision and extraperitoneal access. The postoperative period was uneventful, the patient reported improvement of the painful complaints an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old male patient presented in the Oral and Maxillofacial Surgery Service of the Federal University of Rio Grande do Norte for evaluation of a swelling on the alveolar ridge of the anterior mandible, which had been previously identified in routine radiographic examination with prosthesis purposes. During anamnesis, the patient reported to be hypertensive and diabetic, as well as having chronic heart disease. At the clinical examination, no volume could be observed in the anterior region of the mandible, and the patient reported no painful symptomatology.\nRadiographical examination revealed an unilocular and irregular radiolucent lesion, measuring approximately 3 cm in diameter (). Preoperative laboratory tests (hemogram, coagulogram, and blood glucose testing) were performed, as well as surgical risk and preanesthetic evaluation. Under the diagnostic hypothesis of residual cyst or another odontogenic lesion, the patient underwent surgery under general anesthesia in order to enucleate the lesion. In the transoperative period, in addition to surgical enucleation, a peripheral osteotomy and interposition of synthetic material for guided bone regeneration (Bio-OSS and Bio-Gide) were performed, considering the need for prosthetic rehabilitation of the patient. After the procedure, the specimen was sent to histopathological examination. Gross examination of the specimen revealed a firm and oval mass with cystic aspect, containing liquid in the interior (Figures and ). Microscopically, the hematoxylin and eosin (H and E) stained section showed a defined cystic lesion with a fibrous capsule and a lining of odontogenic epithelium (Figures –). The basal cells of the epithelial lining were mainly columnar and similar to ameloblasts and the overlying layers were loosely arranged, resembling the stellate reticulum of the enamel organ. Several amounts of ghost cells were found within the epithelial component and also in the capsule (). Extensive areas of eosinophilic ma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 83-year-old African American male patient presented with chronic cough for many years. He reported mild progressive dyspnea on exertion improving with rest. He denied hemoptysis or sputum production. He has been a resident of an assisted living facility for the past 17 years. He smoked 1/2 pack per day for 14 years and quit 40 years ago. He worked in the construction business, mainly demolishing buildings for more than 20 years, which led to significant exposure to construction dust and asbestos. He did not wear a mask as the use of protective gear was not mandatory at the time. The rest of the exposure history was negative for tuberculosis, pets, recent travel, or sick contacts. His past medical history was significant for right middle lobe and right lower lobe pneumonia 3 years ago successfully treated with antibiotics.\nA chest X-ray showed bilateral calcified pleural plaques and the presence of right middle lobe band like atelectasis. This prompted further workup with computed tomography (CT) of the chest showing calcified aorta, coronaries, mediastinal lymph nodes, calcified right upper lobe nodule suggestive of old granulomatous disease, right middle lobe ovoid opacity 3 × 2 cm, right upper lobe anterior segment bronchocele and stricture, right lower lobe and left lower lobe mild fibrosis (Figures and ). The above changes were stable for 3 years except for the new right middle lobe opacity. A positron emission tomography (PET) scan failed to demonstrate metabolic activity within the lesion. Pulmonary function tests showed forced expiratory volume for 1 second to slow vital capacity (FEV1/SVC) ratio of 69 (normal range 63–84), normal FEV1 and forced vital capacity (FVC), normal lung volumes, and moderate reduction in diffusing capacity for carbon monoxide (DLCO). His echocardiography showed normal right ventricular size and function with no tricuspid valve regurgitation.\nBronchoscopy was performed to further assess the new right middle lobe opacity and showed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nEmergency medical services (EMS) were called to the home of a four-year-old female with a history of intermittent asthma and recent outpatient diagnosis of pneumonia after found to be cyanotic, surrounded by emesis, and without apparent respirations. Cardiopulmonary resuscitation was initiated by EMS upon arrival for pulseless electrical activity, and after eight minutes the patient achieved return of spontaneous circulation. She was subsequently intubated without the need for induction medications and transported to the emergency department (ED). Upon arrival to the ED, an initial physical exam revealed an intubated, unresponsive child with markedly diminished lung sounds bilaterally without wheezing, and an oxygen saturation of 60% on 100% fraction of inspired oxygen (FiO2). Additionally, respiratory therapy reported extreme difficulty with ventilation. Initial bedside chest radiographs (CXR) () were obtained and showed evidence suggestive of bilateral pneumothoraces, which in conjunction with the patient’s clinical picture prompted bilateral chest tube placement. Both returned large volumes of serous fluid, although no blood or air.\nContinuation of the primary survey revealed tachycardia at 132 beats per minute with strong and regular peripheral pulses in all extremities. There was no jugular venous distention. The abdomen was soft without masses. A limited neurologic exam revealed bilateral sluggish pupils, with the right pupil at 6 millimeters (mm) and the left pupil at 3 mm. There were no obvious signs of trauma, and no dermatologic findings.\nAfter initial stabilization, collateral history was obtained from the mother who stated the patient had been feeling tired with intermittent fevers over the prior few days, which led to a diagnosis of mild viral pneumonia by her outpatient pediatrician. Per her electronic health record, this was based on the patient’s age, gradual onset of symptoms with non-toxic appearance, and non-focal pulmonary findings on auscultatio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old female patient was admitted because of a cystic mass on her left kidney. The cystic mass was incidentally identified during a routine health evaluation. There was no relevant past history. Results of the physical examination were unremarkable. Laboratory data, such as blood chemistry and urine analysis that included urine cytology, showed normal levels.\nThe computed tomography (CT) demonstrated a homogeneous cystic mass at the upper pole of the left kidney (). An irregularly shaped solid mass of 5 × 3cm was adjacent to the cystic mass on the renal hilar area. The solid mass showed irregular enhancement in the arterial phase (). To determine whether the solid mass was intrarenal or extrarenal, we used a retrograde pyelography that revealed a bifid left renal pelvis. We used radiological contrast media to visualize the pelvis and calices of the lower moiety. However, we did not visualize the upper moiety calyx (). Selective urine cytology of the upper moiety calyx was negative for malignancy. The patient underwent nephrectomy in order to remove the renal mass. A 5 × 3-cm protruding mass in the left renal hilum was found intraoperatively. En-bloc resection of the left kidney with the masses was performed.\nAccording to the pathologic examination, the kidney was 15.0 × 8.7 × 6.0cm and weighed 174g. The cystic lesion at the upper pole of the left kidney was a simple cyst. The renal pelvis of the upper moiety was blind-ended and was filled with a gray-white solid mass. The mass was 5 × 3cm and well-marginated. Moreover, portions of the mass showed a grayish mucoid appearance emerging (). Tumor necrosis was not identified in the solid mass. In the low power microscopic field, the mass arose from the smooth muscle layer of the renal pelvis (). Furthermore, the mass showed a few atypias of the nucleus, a few mitotic figures, and positive staining for smooth muscle-specific actin and for desmin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe case was a 13-month-old baby with 9.7 kg, which was 3.5 kg at birth, and second male child of a family habitant in a village in Ardabil, Iran. He was referred to the hospital because of undescended testis (UDT) with a testis in the abdomen and one inguinal canal that was detected by ultrasound. Because the case was infant, the family history was asked to examine the problem in more detail. Accordingly, there was UDT history in the family, where the baby’s old brother also underwent orchiopexy surgery 4 years ago for UDT. During the pregnancy, the progesterone was injected to the mother for Hemorrhage every day for a week. The pregnancy was healthy and the baby is born by cesarean section.\nBecause of complete similar appearance to testis as the images show, we did not perform biopsy fearing of primary testicular delicate perfusion impairment. The baby referred to our centre because of bilateral UDT and nonpalpable testicle on the right side. However, sonography revealed both testicles in the proximal inguinal canal. The scrotum was not grown, HCG therapy had been started by pediatrician, and Other clinical signs were typical.\nSurgical intervention was considered for the patient. Before surgery, four HCG 1200u injections were administered to the patient in four times at 1 month (one for per week) for testicular descent. However, the intervention did not completely resolve the problem, and there were no more diagnostic challenges. The patient underwent surgical procedure with general anaesthesia to diagnosis and as a final treatment stage. It was diagnosed that the testicles were on the left in the proximal inguinal canal and the sac hernia was ligated parallel to the inner ring. The left testis was a small component in the proximal without the epididymis. Two testes were closely connected in the lower part by a common epididymis, which all of them were situated in the left scrotum (Fig."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 33-year-old gravida 2 para 1 that was referred to our department after the first trimester ultrasound scan (performed in another institution) had revealed a huge ovarian mass. The patient was asymptomatic, denying weight loss and abdominal pain or distention. A more detailed medical record was obtained and there was a positive family history of borderline ovarian tumors (BOTs). The physical examination showed a palpable abdominal mass that reached the umbilicus. The ultrasound performed in our institution showed a 12-week singleton pregnancy and an adnexal mass, measuring approximately 17 × 11.5 cm, with a heterogeneous and highly vascular solid component, arising from the right ovary (). An abdominal magnetic resonance imaging (MRI) was performed afterwards revealing a pelvic mass, measuring 18 cm, arising from the right ovary, with a liquid component but with a major solid area (Figures and ). All laboratory data was within the normal range. CA 125 was 11.5 U/mL. Due to the high suspicion of malignancy, a laparotomy was carried out at 15 weeks of gestation (vertical midline incision). Intraoperative findings revealed a large cystic tumor of the right ovary with a solid component. Peritoneal washing was performed afterwards. The abdomen and the appendix were thoroughly examined and no signs of implants, adhesions, or metastasis were found. Right salpingo-oophorectomy was performed and the frozen section revealed a borderline mucinous ovarian tumor. Definite histology confirmed this diagnosis. The remaining pregnancy was uneventful and a cesarean section was performed at 39 weeks of gestation due to obstetrical reasons. Once again the abdomen and the appendix were systematically examined and no macroscopic changes were observed.\nAfter discussion with the patient secondary staging surgery (peritoneal washing, total abdominal hysterectomy, unilateral salpingo-oophorectomy, omentectomy, appendectomy, and peritoneal biopsies) was performed and no e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old man was admitted to our hospital complaining of exertional dyspnea for 10 days. He had been medicated with oral antihypertensive drugs for 4 years. He discontinued his medications by himself due to the dropping of systolic blood pressure to 90 mm Hg 7 days ago. On the admission, his blood pressure was 130/90 mm Hg and his pulse was regular at 66 beats per minute. The transthoracic echocardiogram (TTE) showed a dilated right ventricle (RV) with marked RV systolic dysfunction (), D-shaped left ventricle (), and showed a large mass, about 50 × 30 mm sized, considered to be a thrombus between the right ventricular outflow tract (RVOT) and the main pulmonary artery (MPA) (). The systolic RV pressure measured by maximal tricuspid regurgitation velocity (TR Vmax of 5.2 m/sec) was about 110 mm Hg. TTE also revealed mass lesion mimicking thrombus in the MPA with severe stenotic component (measured maximal MPA velocity of 4.6 m/sec) (). Spiral computed tomography (CT) of the chest demonstrated an intraluminal filling defect, about 55 × 31 mm sized, occupying the lumen of the MPA () and multiple filling defects of the peripheral pulmonary arteries. Although the patient had normal blood pressure, he was initially treated with intravenous recombinant tissue plasminogen activator (rt-PA, 100 mg for 2 hours) to improve his severely decreased RV systolic function.\nDespite receiving two days of treatment with thrombolytic and anticoagulation therapy, the patients showed little improvement. The follow-up TTE still demonstrated similar features of the previous echocardiographic examination. Dyspnea of the patient aggravated from New York Heart Association functional class II to III. After a thoughtful review of the follow-up TTE, we found several differences that differentiated from the usual echocardiograms of PTE. The mass filled the proximal portion of the MPA with involvement of the pulmonary valves. The mass was also attached to the anterior portion of the RV"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23 year old woman presented at our trauma resuscitation room after a fall from 8 meters. During physical examination (ATLS® protocol) there were no clinical signs of life-threatening injuries. Neurological examination did not reveal any abnormalities either. She did however have a large amount of subcutaneous emphysema of the chest and neck and complained of low back pain. Plain X-rays of the chest confirmed the subcutaneous emphysema of the chest and revealed a pneumomediastinum without signs of pneumothoraces (Figure ). Due to the massive amount of subcutaneous emphysema the normal X-rays were considered inevaluable and subsequent contrast enhanced Computed Tomography (CT) scanning of the neck and chest was performed. This showed an unstable fracture of the first lumbar vertebra, a fracture of the right inferior pubic ramus, a small right-sided pneumothorax and confirmed the pneumomediastinum. CT also raised suspicion of an esophageal injury, in the absence of large pulmonary or tracheal injuries. After administering oral contrast no contrast leakage could be detected on a second CT scan the same day. Bronchoscopy was also performed and showed no abnormalities. Intravenous antibiotics (Amoxicillin and Metronidazol) were administered for 4 days based on clinical and radiological suspicion of esophageal rupture.\nAn emergency operation was indicated for stabilization of the unstable lumbar vertebral fracture and the patient was observed postoperatively at the Intensive Care Unit (ICU). In this phase the Ear/Nose/Throat specialist (ENT) was consulted and during examination the patient only complained of dysphagia and painful coughing. Subsequently, a flexible laryngoscopy was performed which revealed a lesion in the upper esophagus just under the level of the upper esophageal sphincter. A contrast-swallow examination showed contained leaking of contrast from the posterior wall of the cervical esophagus into the retropharyngeal area next to the esophagus (Figure ).\nB"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old female was admitted to the hospital due to severe suicidality. At the time of admission she complained about an irritating feeling in her nose, which made her constantly grimace in the area around the nose. She was excessively worried about having a serious illness of her nose (secondary hypochondriacal delusions) and was suicidal as a consequence. Her belief persisted even after any underlying medical condition of the nose has been ruled out by extensive medical examinations. She also presented with disorganized behavior, stereotypical movements, emotional instability and lability, and a below average level of intelligence during hospitalization. On the PANSS, her symptoms scored 29/23/70 (for the Psychotic, Negative and General Psychopathology Scale, respectively). Brief neurological examination revealed no abnormal neurological signs. As ascertained by the history taken from the patient and her mother, she had a history of school phobia that began at the age of 12 years, emotional disorders, normal cognitive and physical development, and a three-year history of chronic headache. She managed to complete primary and secondary education with the help of school counseling services given to her on account of school phobia. She had not received any psychiatric care before the described admission. A diagnostic evaluation for chronic headache at the University Children’s Hospital was undertaken a year before admission.\nCalcium, phosphate and parathyroid hormone blood levels were normal. Vitamin D levels were decreased with decreased calcium levels in the urine. No signs of calcium depositions in organs other than the described brain regions were determined by ultrasound. Ophthalmological, ear-nose-and-throat examination and electroencephalography were also normal.\nDetailed neurological examination revealed dysfunction of pursuit eye movement, dystonic positioning of both arms when stretched ahead, discrete ataxia of the arms and legs, and a pathological ext"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old woman with hepatitis C was being seen by the gastroenterology service to monitor a liver nodule. Abdominal ultrasonography identified a visceral artery aneurysm as an incidental finding. Angiotomography revealed that it was a saccular aneurysm of the pancreaticoduodenal artery, with a diameter of 40 mm, and showed subocclusive stenosis of the celiac trunk compatible with extrinsic compression ( ).\nThe patient underwent laparoscopic relief of celiac trunk compression ( ), thereby averting the possibility of mesenteric ischemia, as the pancreaticoduodenal artery is an important collateral route between the celiac trunk and the superior mesenteric artery and an undiscovered occlusion of this artery can cause visceral ischemia. The laparoscopic procedure was performed using a 10 mm trocar for the camera, in an umbilical position, and a further four trocars; in the right and left hypochondrium, the left flank, and a subxiphoid position. The gastrohepatic ligament, phrenoesophageal membrane, esophagus, and crura of the diaphragmatic were dissected, with inferior sectioning of the crura to enable the arcuate ligament to be viewed. Relief of celiac trunk compression was achieved by sectioning the arcuate ligament by electrocautery and the crura were drawn back together to prevent gastroesophageal reflux. Doppler ultrasonography conducted before hospital discharge showed that there was no longer compression of the celiac trunk and revealed some residual stenosis and post-stenotic dilation (the pre-stenotic celiac trunk diameter was 10 mm and at the stenosis it was 3.5 mm) ( ).\nThe patient returned 2 months later for pancreaticoduodenal artery aneurysm repair, which was performed under local anesthesia and sedation, via a left brachial access with selective catheterization of the superior mesenteric artery and selective embolization of the aneurysm sac with microcoils, with no intercurrent conditions ( ). Four 20 mm to 25 mm x 50 cm Axium 3D microcoils and two A"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe are presenting a case of a 15-year-old male from a rural area living on a farm and raising livestock. He presented with six months history of easy fatigability, shortness of breath, and dull right upper abdominal pain. Physical examination revealed that the patient had tachycardia at rest and hepatomegaly and no other significant findings. Chest X-ray (CXR) showed clear lung fields and mildly enlarged heart. Ultrasound examination of the abdomen revealed few cysts in the liver without any associated lymphadenopathy in the coeliac group of lymph nodes. As part of the workup, the patient had a CT scan of the abdomen, chest, and brain. The CT showed one cyst in the heart, four cysts in the liver, but no cysts in the lungs or the brain (Figures -).\nThe cystic nature of the lesions and their locations in multiple organs made us think of the HC as the pathology. The serology test for HC using the ELISA test came positive, which helped to confirm the diagnosis. The patient was scheduled for urgent open-heart surgery, fearing the risk of potential rupture of the cyst and the grave consequences which come with that. The patient underwent conventional median sternotomy and aortocaval cannulation with aortic cross-clamp and cardioplegic heart arrest. CT images helped to locate the cardia cyst and its relation to the cardiac chambers. The location of the cyst was confirmed by direct examination of the heart when it was arrested. The cyst was totally located intramurally in the interventricular septum and expanding down mostly to the left side of the diaphragmatic surface of the heart and partly crossing intramurally to the diaphragmatic surface of the right ventricle making a visible and palpable soft cystic bulge. The myocardium overlying the cyst on the left side of the posterior descending coronary artery on the diaphragmatic surface of the heart was fibrosed, making part of the ectocyst wall. This was the most epicardially prominent part of the cyst and was chosen as the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year old male presented with a history of lumbar laminectomy and fusion seven months prior to his initial presentation. He recalls that two days following his prone lumbar operation he began experiencing severe bilateral pain along the respective anterolateral thigh. Lumbar magnetic resonance imaging (MRI) ruled out spinal nerve root-related pathology as causative and a definitive diagnosis of bilateral MP, secondary to LFCN compression during the prone spinal surgery, was rendered. Conservative measures with oral analgesics were initially recommended given the typically self-limited course of this pathology. Despite an increasing regimen, including NSAIDs, narcotics, and anti-neuropathic pain medications, the pain persisted over the course of several months. Additionally, traditional anatomically-guided local anesthetic injections were attempted without improvement in his symptoms. Thus, the patient elected to proceed with operative decompression after eight months of failed conservative therapy and worsening quality of life.\nThe history of failed local anesthesia to even temporarily alleviate symptoms suggested a possible non-classic nerve location and prompted preoperative ultrasound to outline the superficial course of the LFCN. The ultrasound technique utilized has been previously described in the setting of percutaneous injection guidance (Figure ) [].\nSkin markings in the inguinal region and upper thigh indicating the course of the LFCNs were made by the ultrasound technician prior to operative site preparation for surgery. Indeed, anatomically variant LFCNs were identified bilaterally on the preoperative ultrasound with neither nerve passing in a classic location medial to the anterior superior iliac spine (ASIS) (Figure ). On the right, the ultrasound identified the LFCN passing directly over the ASIS, while on the left, the nerve was localized lateral to the ASIS. Oblique incisions were made centered over the marked LFCN locations identified by ultras"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn abnormal shadow with anterior mediastinal calcification and an elevated left hemidiaphragm was incidentally observed in a 57-year-old man who underwent chest radiography during a periodic health examination (Fig ). Chest computed tomography (CT) revealed an anterior mediastinal mass with multiple ring calcifications (Fig ). He denied a relevant medical history and symptoms such as muscle weakness or red blood cell hyperplasia. Physical examination revealed no abnormal findings and no lymphadenopathy. Routine laboratory parameters were within reference ranges. He reported no history of other operations.\nBased on a high index of clinical suspicion for a non-invasive thymoma or teratoma, we decided to perform surgery for accurate diagnosis and treatment. After induction of general anesthesia, an extended total thymectomy and concomitant pericardial resection were performed via a median sternotomy. Using blunt and sharp dissection, the gland was freed from the pericardium and the adjacent mediastinal pleura. Although the tumor was observed to have invaded the pericardium and the left phrenic nerve, the extent of tumor invasion was unclear. A cardiovascular surgeon was consulted, and the invaded pericardium and the left phrenic nerve were carefully resected. The tumor had not invaded the heart, and the remaining thymic tissue was removed.\nThe resected tumor measured 8.0 × 7.0 × 3.0 cm in size (Fig a) and was observed to invade the pericardium directly. In gross sections, the tumor appeared to be a solid mass separated by multiple rings of calcification, and the surgical stage was identified as Masaoka–Koga stage III.\nHistopathological examination revealed that the tumor was encapsulated by a calcified and ossified layer with invasion of the pericardium and pericardial fat tissue (Fig a,b). A high-power view showed epithelioid cells intermingled with lymphocytes and perivascular lymphocytic infiltration (Fig c,d). Based on World Health Organization histopathological cl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old Middle Eastern male with a history of multiple surgical interventions in the gastro-intestinal tract following carcinoma was chosen to be the subject of this preliminary report. The patient initially underwent colonic transposition as a reconstruction followed by a delayed jejunal transposition due to the development of a 12 cm upper oesophageal corrosive stricture.\nHistory and clinical examination revealed no history of further carcinoma; upper endoscopy and radiological examination revealed residual 8 cm upper oesophageal stricture and right recurrent laryngeal palsy.\nThe surgical access was through a previous pharyngectomy scar in the line of the right sternomastoid muscle with the raising of sub-platysmal flaps. Dissection continued to reveal the thyrocervical trunk and inferior thyroid artery with the excision of the previously fibrosed jejunal graft and the preparation of good vascular supply to the proximal jejunum. During which a generous cuff of muscosa was preserved with good exposure of the right piriform fossa and the remaining 8 cm gap from the pirifom fossa to the oesophagus.\nAn upper midline laparotomy was performed with local adhesionolysis. The second loop of the jejunum was identified and harvested on good arcade. The pedicle was ligated and remaining jejunal continiuity established and abdomen closed.\nThe free flap was transposed to the neck with posterior serosal layers to the proximal and distal ends in an iso-peristaltic fashion. A micro-vascular technique was used to create an end to end arterial anastomosis to the transverse cervical artery and an end to side venous anastomosis to the internal jugular vein.\nOnce good flow was confirmed (by microendoscopy) with satisfactory peristalsis and mucosal reaction the flap was further inset with proximal and distal fish mouthing techniques\nAn operating room Storz Hopkins II Forward oblique 30° microendoscope (4 mm diameter and 18 cm long) attached via a stroz fibre optic cable was connec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old man with a swelling in the right palatal region was referred to the department of oral pathology for evaluation and diagnosis. The painless mass was noticed 4 months ago by the patient.\nIntraoral examination exhibited a firm, exophytic, oval mass with an intact overlying mucosa in the region of the right hard palate measuring 3 × 4.5 cm in size []. There were no signs of ulceration, bleeding, discharge, or numbness in the area. The patient did not have the habit of chewing tobacco or betel nut. On general examination, he was found to be afebrile, with no palpable lymph nodes in the head and neck region. He did not mention any sudden weight loss in the recent past and the medical history was noncontributory.\nCT scan revealed a mass on the right side of the hard palate, with no involvement of the maxillary sinus []. A provisional diagnosis of benign tumor of salivary glands was given.\nAn excisional biopsy [] was performed under local anesthesia. and a bony crater-like defect was seen on the palatal bone after soft tissue removal. Histopathological examination of sections of the resected specimen revealed an intact stratified squamous epithelium with underlying vaguely follicular and diffuse proliferation of lymphoid cells [Figure and ]. The follicle-like structures were composed of central large cells (giving a ‘washed-out’ appearance) surrounded by a thin rim of small, round lymphocytes. The central large cells had abundant pinkish cytoplasm and convoluted nuclei with inconspicuous nucleoli []. Epimyoepithelial islands were also observed. On microscopic examination of hematoxylin and eosin (H and E)–stained sections, there was a conflict of opinion over the distinction between benign (reactive) lymphoid hyperplasia (pseudolymphoma) and non-Hodgkin lymphoma. Immunohistochemical investigations were performed to resolve the issue. The large lymphoid cells showed immunoreactivity for CD20 and the rim of small lymphocytes were positive for CD5 ["}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man presented with a 4-day history of swelling and pain behind the left knee with reduced mobility with very short distance intermittent claudication affecting the left calf and reduced range of knee movement. This patient in the preceding week was admitted under the care of medical specialty where a diagnosis of a spontaneous haematoma behind the thigh was made. Haematoma was thought to be a result of the patient being on oral anticoagulation (warfarin) for atrial fibrillation. The patient did not report history of trauma. He looked frail on the current admission on the vascular ward requiring support for some activities at home and had been on treatment for prostate cancer. He had previously also had coccygectomy for metastasis as well as a recent history of permanent pacemaker insertion for syncopal episodes and bradycardia. He also suffered from hypertension and was on a number of medications including warfarin. He was a lifelong nonsmoker and lived in a retirement home. There was no family history of aneurysms.\nExamination revealed extensive bruising at the back of the left thigh and knee with palpable femoral and pedal pulses. The popliteal pulse was difficult to feel due to a large haematoma. The left foot was viable with fully intact sensory and motor function. There was no clinical evidence of calf compartment syndrome on the left leg. The right foot was warm with all palpable pulses in the leg.\nAn initial ultrasound scan revealed PAA with no evidence of popliteal or femoral vein DVT. A CT angiogram performed on the same day showed generalized arteriomegaly and the ruptured 9.4 cm PAA involving only the above-knee popliteal artery () and relatively disease-free 3-vessel runoff to the ankle and foot. Options to treat this patient were either a surgical exclusion bypass with evacuation of haematoma or an endovascular treatment. For a number of reasons including patient frailty, associated comorbidities, and potential feasibility of successfully"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 69-year-old woman whose abnormality was initially identified by chest radiography at a local hospital in 2008. At that time, transthoracic echocardiography revealed a calcified and immobile mass on the posterior mitral valve leaflet. She was referred to our hospital for evaluation of the mass. Her past history was significant with pulmonary tuberculosis at the age of 6 years and systemic hypertension. However, there was no history of infectious endocarditis or chest trauma. Any thrombus formation due to a hypercoagulable state was not recognized. Differential diagnoses included calcified cardiac fibroelastoma and myxoma. We offered her a surgical treatment option because of the potential risk of a thromboembolic event. However, she refused the surgical intervention. She was managed on an outpatient basis and periodically underwent transthoracic echocardiographic evaluations every 6 months.\nThe patient claimed to have chest discomfort in March 2011 and was admitted to our hospital in October 2011. A transthoracic echocardiogram showed that the calcified mass measuring 19 × 8 mm was located between the P2 and P3 areas of the posterior mitral valve leaflet. There was no mitral regurgitation, and her ejection fraction was 67%. There were no findings suggestive of infectious endocarditis (Figure ). On cardiac catheterization, the coronary arteries were intact without an obvious thrombo-occlusive lesion. Computed tomograms (CT) confirmed the severe calcified mass on the posterior mitral valve leaflet (Figure ). Laboratory examinations were unremarkable.\nBecause there was potential risk of thromboembolism, surgical intervention was indicated for the calcified mass or tumor on the mitral valve. Definitive diagnosis was also expected after surgical excision of the mass.\nThe patient underwent surgical removal of the mass with the aid of cardiopulmonary bypass. The mitral valve was inspected through a right-sided left atrial incision. A round mass was origina"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female patient reported with a chief complaint of pain and bleeding gums while brushing in left upper posterior region and for replacement of a poorly constructed bridge in the upper anterior region. She was unable to follow proper oral hygiene because of recurrent bleeding from the swelling in the left upper posterior region.\nPatient's history revealed that the lesion started 3 years back and slowly attained the present stage. She was free of any epileptic symptoms and there was no sign of mental retardation. The patient was communicative but apprehensive. The family history revealed no relevant findings.\nExtraoral examination revealed the presence of portwine stains on the left-hand side of the face, extending along the second division of the trigeminal nerve unilaterally []. Facial asymmetry and macrochelia was noted with enlargement on the left side.\nIntraoral examination revealed prominent reddish purple gingival enlargement posteriorly on the left side [Figures and ]. Blanching on pressure was noted in the enlarged gingiva, suggesting angiomatous enlargement. Upper anterior teeth had a broken fixed partial denture. Teeth on the lower arch were malpositioned. Oral hygiene was poor with extensive amounts of plaque and calculus.\nChest X-ray and PA view of the skull showed no abnormality. Blood picture was normal. Ultrasound Doppler flowmetric study [Figures and ] was done to determine the blood flow in the growth. Treatment plan consisted of oral prophylaxis, surgical excision of the lesion under general anesthesia (GA), and replacement of the worn out bridge in the upper anterior region.\nThe scope of the treatment and the goals were explained and informed consent was obtained from the patient. A thorough plaque control regimen was started from day 1 to minimize the inflammatory component of the gingival enlargement. It included oral prophylaxis, use of chlorhexidine mouth rinse, oral hygiene instructions, and motivating the patient at each visit.\nI"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOn January 4th, 2018, a 57-year-old woman was hospitalized in the department of Psychiatry, Sir Run Run Shaw Hospital because of pain and acid bilge in multiple sites of her upper body for more than 1 year. Over a year ago, the patient started feeling pain and discomfort in the upper left abdomen, and the pain got worse when coughing but with no other discomfort. Two months later, the upper left abdomen pain and acid bilge extended to the front chest, back, abdomen, and upper limbs. The symptoms persisted for months, and aggravated when changing body posture. Test results including cervical MRI, chest CT, abdominal B ultrasound of upper abdomen in a local hospital showed no abnormalities. Treated with Chinese medicine for more than 3 months, there was no significant improvement. About 6 months ago, the patient came to our hospital, expressing the symptoms above and worries about them, with weight loss of about 1–1.5 kg, but denying continuous depression, anxiety, and other symptoms (the score of 24 items of Hamilton Rating Scale for Depression was 12, and Hamilton Anxiety Rating Scale score was 11), and was diagnosed as “somatic symptom disorder.” After 4 months of treatment with 60 mg of duloxetine enteric-coated capsules twice daily and hypnotic drugs, the symptoms were obviously alleviated but not completely relieved and there was a significant weight loss of about 5 kg. Therefore, medication was adjusted to escitalopram tablets 20 mg once daily. Two months later, the patient felt no further improvement.\nWith hypertension history of more than 10 years, the patient claimed that it's not necessary for her to take any antihypertensive drugs to control blood pressure in recent 1 year. She had bronchitis for 12 years but no medicine was needed. She denied any history of diabetes, heart disease and other diseases and claimed there was no history of surgery and trauma. Also, the patient denied long-term chemical substances, drug or poison"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male who is medically free presented to the ED after a motor vehicle collision (MVC) with a speed of 50 m/h, frontal impaction and there was no roll over, or ejection from the car with minimal epistaxis and a small superficial wound over the nose. A nasal X-ray was done to rule out facial bone fractures, which shows no abnormality. Analgesia was given and he was referred to the otolaryngology department for follow-up. However, at that time CT scan was not done. He presented three weeks later to the primary healthcare in which the first impression was migraine and was given analgesia. However, as the headache persisted, he went to the ED and he was given analgesia and discharged. The patient returned to the ED two days later, because the headache was not gone. He described it as a throbbing headache, on and off, which increased with laying down, stress, and at night and relieved by analgesia. He scored the pain severity as nine out of 10 and described it as a pain he cannot tolerate. There was no loss of consciousness, seizures, blurred or double vision, weight loss, fever, weakness, or any neurological deficits. He was vitally stable, and the Glasgow Coma Scale (GCS) score was 15, oriented to time, place and person, intact memory, pupils reactive to light equally, all limbs power were five out of five, no pronator drift, intact sensation, and normal gait. At this time, the CT scan was done and showed bilateral frontoparietal SASDH with midline shift with mass effect upon the adjacent brain parenchyma (Figure ). A cerebral angiogram with embolization was done for him. The patient improved after the intervention and was discharged. He followed up with neurosurgery and another CT which showed that the hematoma regressed in size. After this regression, conversion to chronic SDH was observed in CT (Figure )."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male was referred for surgery from the peripheral center with diagnosis of spine tumor. The patient presented with complaint of sudden onset of asymmetrical weakness on both lower extremities over a period of 3 days. He has associated mild back pain around dorsolumbar region for more than 3 months duration. There was no history of trauma or any injury over the back. Treatment in the previous facility was mainly in the form of diagnostic in the form of MRI and symptomatic in the form of oral gabapentin and nonsteroidal anti-inflammatory medications. He had history of hypertension for 2 years and was on antihypertensive medications in the form of combination of losartan and hydrochlorothiazide. There was no family history with similar weakness. There was no significant history with similar illness. Physical examination revealed heart rate of 102 beats/min, blood pressure of 150/102 mmHg, oxygen saturation (SpO2) of 96%, temperature of 98 degree F, and respiratory rate of 26/min. There were no pallor, icterus, lymphadenopathy, cyanosis, clubbing, edema, and dehydration noted. No jugular venous distension or swelling around neck (goiter) was appreciated. Cardiac examination revealed regular rhythm with normal heart sounds. Respiratory examination revealed tachypnea with decreased breath sounds in bilateral basal areas. Abdominal examination was normal. On neurological examination, cranial nerve functions were grossly intact, however, power in all muscle groups in the right lower extremity was 2/5 and in left lower extremity was 3/5. The sensations of all four limbs were normal; however, the deep tendon reflexes were absent with bilateral flexor plantar response. There was no tenderness or swelling over back noticed. The patient did not have any problem with bowel and bladder movement.\nMRI of dorsolumbar spine showed evidence of intradural extramedullary lesion at L1 level (right-sided prominent) measuring 9.9 × 9.4 × 11 mm in size (). MRI of brain with cer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old man presented to our institution with sudden onset pain in the left trapezius and shoulder.\nAt the time of symptom onset he was engaged at work driving heavy machinery, but denied any recent history of injury or trauma. He had not been recently unwell and denied any constitutional symptoms such as weight loss or fever. Over the following five hours his pain began to also affect his right shoulder and there was associated generalised abdominal pain of increasing severity, most marked in the left and right upper quadrants.\nThe patient had no significant past medical history, specifically never having had an episode of pancreatitis before. He was not taking any regular prescription medications but upon closer questioning admitted to occasional recreational cocaine use, the most recent ingestion of which was within 24 h of hospital admission.\nThe patient had no significant family history of medical illness.\nClinical examination revealed a well-looking man in no obvious distress. Although he was mildly tachypnoeic (20 breaths/min) his other vital signs were normal (heart rate 78 beats/min, blood pressure 129/84 mmHg, temperature 36.9 ºC and oxygen saturations 99% on room air). His abdomen was not distended but there was generalised percussion tenderness most profound in the left and right upper quadrants. Examination of his shoulders revealed no focal tenderness and full active and passive ranges of motion with preserved motor and sensory function.\nInitial biochemical findings included a haemoglobin of 138 g/L, leucocyte count 4.74 × 109/L, platelets 197 × 109/L and international normalised ratio of 1.1. Plain chest X-ray was unremarkable. Repeat blood tests were performed after five hours due to the increasing severity of his symptoms which revealed a haemoglobin of 99 g/L, indicating a significant decrease from the initial value.\nThe combination of worsening abdominal pain and a falling haemoglobin prompted a computed tomography (CT) scan of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old female patient with a past medical history significant for diabetes presented to the emergency department with worsening abdominal pain. The day before she underwent a diagnostic colonoscopy for complaints of chronic diarrhea (2 months) where a transverse colon adenomatous polyp was resected, and several mucosal biopsies were obtained.\nThe patient reported that the abdominal pain started suddenly about 4–5 h after the colonoscopy. She described the pain as being colicky and intermittent, occurring every hour, lasting for about 15 min, and then resolving on its own. She reported that overnight the pain worsened to the point that she sought medical care the next morning when we (the gastrointestinal team) were consulted by the emergency department. Additionally, she noticed that she had some red mucus in her stools on the morning of presentation.\nHer vital signs in the emergency department were stable with a blood pressure of 128/72 mm Hg, a pulse of 83 bpm, and a respiratory rate of 16/min with normal oxygen saturation. Physical examination showed a nondistended abdomen, with mild tenderness over the right upper quadrant without any palpable masses. Her blood work was significant for a white cell count of 13, lactate of 1.2, and a normal metabolic profile.\nIn the emergency department, the patient had an abdominal X-ray, and a CT of the abdomen with intravenous contrast which showed a transverse colo-colonic intussusception (Fig. , , ) with partial obstruction.\nThe patient was seen by the surgical team who deemed her not to be obstructed and opted for conservative management with intravenous fluids and nil per os. On the following day, the patient reported that her symptoms had rapidly improved and subsequently had an abdominal X-ray that showed spontaneous resolution of her intussusception (Fig. ). She was started on a liquid diet which was advanced without any complications. She was discharged on the third day of stay after she had had a normal bowel m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 19-year-old male who had been in a motorcycle accident. The patient was admitted to our department as an open tibial plateau fracture 3 h post-injury. The emergency medical staff at the scene of the injury provided simple dressing and stabilization. The main complaint of the patient was pain and bleeding with limited movement of the knee.\nOn physical examination, after an advanced trauma life support protocol was performed in the emergency department, the patient’s blood pressure and pulse were within normal limits. There was a 5-cm-long wound without active bleeding on the anterior aspect of the knee joint (Fig. ). The femoral condyle was exposed, the suprapatellar pouch was empty, and the injury endpoint was visible at the quadriceps tendon. Internal and external stress tests of the knee joint were negative, and anterior/posterior drawer tests were not able to be performed, as the patient could not tolerate them. The patient had a normal dorsalis pedis pulse without neurovascular injuries or any other accompanying injuries. Plain radiographs showed complete intra-osseous dislocation that locked into a tibial plateau fracture. Computed tomography showed a partial avulsion fracture of the patella and intercondylar eminence (Fig. ).\nThe patient was taken to the operating room for emergency surgery. Intraoperatively, the patella was found to have rotated 360° and was completely locked into the tibial plateau fracture. The dislocated patella was found inside the tibia, approximately 10 cm below the tibia plateau. There were avulsion fractures of the anterior/posterior cruciate ligament insertions on the tibia and a partial patellar avulsion fracture with a “hat-off” type rupture of the quadriceps tendon at the attachment point on the patella; these operative findings confirmed our preoperative diagnosis. After thorough surgical debridement, the patella was pulled out. The tibial plateau fracture was restored and stabilized using an anatomical steel pl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old man with previous posterior MI, persistent atrial fibrillation, hypertension, and moderately depressed left ventricular function (EF = 0,44) was admitted with life-style limiting CCS class III angina. Diagnostic coronary angiography and possible PCI was planned using radial access. He underwent cardiac catheterization from the right radial using a 16 cm 6F hydrophilic introducer sheath (Terumo Interventional Systems, Japan). The radial artery had an anomalous origin from the mid-segment of brachial artery. Coronary stenoses were identified in the right coronary artery (RCA) and PCI was planned as a second stage in 2–3 weeks. At the time of diagnostic examination patient was on warfarin therapy and additional clopidogrel was prescribed for the forthcoming PCI procedure. The International Normalized Ratio (INR) at the time of angiography was 1.09. The sheath was removed and hemostasis was achieved using TR band (Terumo Interventional Systems, Japan). Patient was discharged 6 hr after diagnostic procedure and a small hematoma was noted after removal of hemostatic device without any signs of bleeding.\nThe patient was readmitted 1 month later with painful 6 X 4 cm pulsatile mass over the volar aspect of the right wrist just proximal to the previous radial puncture site (Fig. ). This swelling appeared 48 hr following discharge after lifting a heavy object with the right hand. A systolic bruit was audible over the mass and duplex ultrasonography demonstrated an oval-shape dual chamber pseudoaneurysm measuring 49 X 38 mm, partially filled with thrombus. Pseudoaneurysm sac was connected to the radial artery lumen through a long (6 mm) and narrow (2 mm in diameter) neck (Fig. ). Radial artery was patent and INR at the time of repeat hospitalization was 1.57.\nAt this point we contemplated a combined strategy of PCI of RCA and repair of RAP.\nWe decided to use the affected radial artery as the access site for PCI, because ultrasonography indicated presence of suffi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old man presented to our institution. He previously underwent laparoscopic intersphincteric resection of the rectum with diverting loop ileostomy for lower rectal cancer at the age of 56. The immediate postoperative course was uneventful. A pathological examination revealed that the patient had T1, N1a, M0, Stage IIIA rectal adenocarcinoma. He did not receive adjuvant chemotherapy, and there was no recurrence of cancer during the follow-up period. However, soon after surgery, he developed an anastomotic stenosis requiring repeated endoscopic balloon dilatation.\nHis loop stoma was not reversed because these treatments were unsuccessful. Therefore, the surgeon proposed surgical resection of the anastomosis, but the patient did not agree to undergo permanent colostomy. Consequently, he had lived with loop ileostomy since undergoing surgery.\nTwelve years postoperatively, he felt swelling and pain in the scrotum. He was seen by a local physician and diagnosed with a perineal abscess. He was referred to a urologist at our hospital for treatment. Computed tomography (CT) scans revealed a low-density area and air-fluid level in the perianal region (Fig. ), which was consistent with the signs of a perianal abscess. Drainage was performed, and the abscess was resolved. The urologist was concerned about the cause of the perineal abscess, and anastomotic complications were considered to be associated with the abscess. The patient was then referred to the department of surgery for further evaluation and treatment.\nDuring examinations, we found that the patient did not have a significant medical history, including inflammatory bowel disease. He denied having any allergies. He had undergone surgery for an inguinal hernia and duodenal ulcer. He quit smoking after undergoing rectal cancer surgery. He took oral antibiotics after the perineal abscess was drained; otherwise, he denied taking any routine medications.\nHe was 161 cm in height and 50 kg in weight, and his body ma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old woman presented to our hospital with a mass occurring on the skin of her right chest wall. She had been diagnosed with right breast cancer (T1N0M0, stage I) 9 years previously and had received breast-conserving surgery, sentinel lymph node biopsy, and adjuvant chemotherapy and radiation therapy for the residual whole right breast at a previous hospital. She then developed pigmented skin on her right breast 6 years after surgery, and this lesion was diagnosed as an angiosarcoma. The patient underwent a breast mastectomy to treat for RAAS. Following this, however, the angiosarcoma on her chest wall recurred three times within 2 years. The angiosarcoma was resected each time, and she received radiation therapy to her chest wall after the third operation. Four years after the first occurrence of RAAS, we observed light pigmentation and a dark red tumor (gross diameter of 5 mm) on her right chest wall (Fig. ). Clinically, recurrence of RAAS was suspected, and recurrence of angiosarcoma was diagnosed by biopsy. We considered that it was necessary to remove the irradiated skin as much as possible in order to cure the RAAS. After extensive resection of the irradiated skin and tumor, new skin collected from her right thigh was grafted to the site (Fig. ). Pathologically, the tumor size was 6 mm and the surgical margin was negative. Histologically, there were many spindle cells and dilated vascular channels. Immunostaining showed that the tumor was CD31-positive and mildly positive for CD34 (Fig. ). Ki-67 index was also high. It was revealed that there is no inconsistency as recurrence of RAAS is pathological. After the operation, the patient was hospitalized for 30 days and did not experience any complications. Although some reports suggest chemotherapy can be used to treat RAAS, we considered that this option would offer little benefit in this case, because the patient was elderly and had a history of cerebral infarction. Indeed, the patient has remained angi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female with medical history of hypertension, diabetes mellitus type 2, and chronic kidney disease stage V was transferred to our institution from an outside hospital for further evaluation and definitive management of a migrated intracardiac stent.\nShe initially presented to the outside facility with progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema. She was initially diagnosed with acute heart failure and pneumonia and treated with diuretics and antibiotics. Subsequently, a transthoracic echocardiogram was performed, which revealed a foreign body within the right ventricle. On transfer to our facility, a transesophageal echocardiogram revealed a long stent straddling the tricuspid valve from the right atrium with the other end lodged in the trabeculation of the right ventricle with severe tricuspid regurgitation ().\nOn further investigation, we learned that the patient had undergone peripheral endovascular intervention for May-Thurner syndrome with placement of a self-expanding Nitinol Protege (14 mm × 60 mm) stent to the left iliac vein 6 months prior to presentation.\nA percutaneous endovascular approach with a 35- mm Medtronic-Covidien Amplatzer Gooseneck Snare was initially attempted to retrieve the migrated stent. However, the snared proximal segment fractured, leaving behind 2 stent fragments. After ensuring there was no myocardial perforation or pericardial effusion with intracardiac ultrasound, the patient was referred for surgical extraction via median sternotomy with use of cardiopulmonary bypass.\nDuring the operative procedure, the stent was found to be densely adherent to the tricuspid leaflets and the subvalvular apparatus, with majority of the primary chords to the anterior and posterior leaflets ruptured (). After successful extraction of the stent and native tricuspid valve, she underwent valve replacement with a 29-mm Carpentier-Edwards bioprosthetic valve. Her postoperative course was complicated by hemop"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old obese woman with no medical history presented to our emergency department (ED) complaining of 3 h of right flank pain radiating to her groin. On arrival, the patient was hemodynamically stable but in acute distress, writhing in pain from presumed renal colic. Three hours after arrival to the ED, the patient was noted to be lethargic with systolic blood pressure (SBP) in the 60 s. She was transferred to the trauma bay and administered 2 L of normal saline with SBP up to the 100 s. Emergent computed tomography of her abdomen/pelvis revealed a ruptured 9.2 cm suprarenal AAA with active extravasation. The alpha TTA, the highest level of activation at our institution, was initiated by the emergency medicine attending which mobilized the operating room (OR) supervisor to halt scheduled cases to hold one OR open, the blood bank to activate the massive transfusion protocol (MTP), and the in-house acute care surgeon and anesthesiologist to the trauma bay. The attending surgeon coordinated resuscitation efforts with the MTP as the OR staff set up the room. Within 38 min of the alpha activation, the patient was in the OR with the on-call vascular surgeon for open repair of her ruptured AAA.\nEmergent open AAA repair was performed with the left renal and inferior mesenteric artery sacrificed. Her abdomen was packed and an ABThera™ (KCI, San Antonio, TX, USA) open abdomen negative pressure device was placed with plans for a second look operation as the patient was severely acidotic, coagulopathic, and hypothermic. An hour after transfer to the surgical Intensive Care Unit, the patient was noted with bright red blood per rectum with associated hypotension. Bedside colonoscopy revealed ischemic pancolitis. The patient returned to the OR with the on-call acute care and vascular surgeons for exploration, subtotal colectomy, and ABThera™ replacement. Her remaining hospital course was complicated by acute kidney"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2016, a 67-year-old woman came primarily to our hospital for a consultation about painless mass of the left lower gingiva. Intra-oral examination showed a 46 × 25-mm tumor with induration on the left lower gingiva (Fig. ). A submucosal mass, independent of the gingival tumor, was palpable in the left buccal region. Several cervical lymph nodes on the left side were also palpable. Pathological examination of a biopsy sample taken from the gingival tumor revealed a well-differentiated squamous cell carcinoma.\nA computed tomography (CT) scan with contrast showed a large gingival tumor, with destruction of the adjacent mandibular bone, and four metastatic left-cervical lymph nodes that were markedly enlarged, non-homogeneously enhanced, and partially necrotic. These lymph nodes included two left submandibular and two left upper jugular nodes. CT imaging showed no metastases to the lungs. Magnetic resonance imaging (MRI) showed a large primary tumor on the left side, with its epicenter located in the lower gingiva. The tumor appeared to extend into the sublingual space medially and into the buccinator muscle laterally. A non-homogeneously enhanced mass was identified in the buccinator space along the facial vessels, anterior to the anterior edge of the masseter muscle, and lateral to the buccinator muscle (Fig. ). This mass lay on the cranial side of the primary tumor. The mandibular ramus and pterygoid region that are on the cranial side of BN were not invaded by primary tumor (Fig. ). Moreover, T1-weighted MRI showed a thin layer with high signal, indicative of fatty tissue, between this mass and the primary tumor, indicating that the mass was independent of the primary tumor. Based on its anatomic location, the mass appeared to be metastatic disease to BN. Greyscale sonogram showed some metastatic cervical lymph nodes on the left, and metastatic BN. These cervical lymph nodes were markedly enlarged, round in shape, heterogenous hypoechoic, and without"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 41-year-old Iranian man who has been in good health except mild diarrhea until 36 months ago, when he was suddenly afflicted with severe generalized abdominal pain and rebound in abdominal physical examination. He was attended by surgeon and was operated on. Surgical diagnosis was perforated duodenal ulcer. After discharge, he was prescribed omeprazole for four weeks without any investigation for H. pylori infection. He hasnot had any past medical or drug history before operation but he mentioned mild watery diarrhea and decreased appetite without weight loss since a few months ago. One month after termination of omeprazole course, acute upper GI bleeding as melena occurred and he was again admitted in another hospital. Endoscopy was done. A small bulbar ulcer was the cause. Rapid urease test (RUT) was positive. Triple anti-H. pylori therapy was completed, and omeprazole was continued for another one month. Twenty days after termination of second course of omeprazole therapy urease breath test was done which was negative for active H. pylori infection. No further medication was administered. Approximately ten days later, another bout of upper GI bleeding in the form of melena occurred. He was admitted again in the hospital. Endoscopy revealed duodenal ulcer. RUT was negative. Regarding the history and unusual accumulation of peptic ulcer complications in spite of usual management, hypersecretory states such as gastrinoma were suspected. The result of serologic tests at that time is shown in .\nAbdominal computed tomography (CT) scan revealed a 10 × 8 mm lesion in head of pancreas with peripheral enhancement (in favor of an islet cell tumor) and three superficially located enhancing lesions in both hepatic lobes, in favor of hypervascular metastasis (). CT-guided biopsy of pancreatic lesion was done. Pathologic result was as follows: section reveals fragments of tissue including pancreas with a benign neoplasm composed of monotonous cells looking like"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old man presented after referral by his general dental practitioner with painless swelling in the anterior region of the mandible since 1 year. Swelling was small initially and had increased to the present size.\nOn further elicitation, the patient gave a history of swelling in the lower anterior region after he had hurt himself with a pin while cleaning his teeth 9 years ago. Patient visited a hospital where incisional biopsy was performed and patient was prescribed medications. Swelling subsided after the biopsy and so patient did not get any treatment done for 3.5 years. Patient reported to our department with a painless swelling in the anterior region of the mandible since 1 year.\nClinical examination [Figure and ] showed a painless swelling measuring 4 cm × 3.5 cm in size in the left anterior mandibular region lateral to the symphysis. Generalized mobility in all the mandibular teeth was noted. Splinting was noted in 31 and 41 teeth []. Extraoral palpation of the mandible showed expansion of the bone with no associated lymphadenopathy.\nErythrocyte sedimentation rate, white cell count and flocculation test were within reference ranges and chest radiograph and gamma globulins were within normal limits, which ruled out systemic involvement.\nRadiographs [] Orthopantomograph showed extensive bony destruction with radiolucencies involving the anterior part of mandible where the involved teeth had lost their supporting tissue and appeared to be floating in radiolucent lesion. The lesion had invaded the cortical rim giving a scooped out appearance, typical of single system LCH.[] Differential diagnosis of Ewing sarcoma, lymphoma, leukemia, metastatic disease and osteomyelitis were also considered. We decided to further diagnose the condition by taking an incisional biopsy and examining the tissue histologically.\nHematoxylin and eosin stained sections of the lesion revealed marked chronic inflammation with aggregates of histiocytes that showed features of Lange"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old obese woman presented to an outside hospital in August of 2005 with significant abdominal pain and diarrhea. Computed tomography (CT) revealed a 17 × 13 cm mass in the left upper quadrant that appeared to arise from the body and tail of the pancreas. The patient was taken to the operating room at an outside institution, but the mass was deemed unresectable due to reported involvement of the SMA, stomach, and colon. Wedge biopsy of the mass was consistent with pancreatic VIPoma. Over the next 2 years, the patient was treated with long-acting somatostatin with some improvement in her symptoms. The patient, however, developed repeat episodes of upper and lower gastrointestinal bleeding with associated anemia and ongoing transfusion requirements. Repeat CT scan revealed thrombosis of the splenic vein with numerous large splenic and gastric varices consistent with sinistral portal hypertension. In the summer of 2007, the patient underwent a failed transjugular intrahepatic portosystemic shunt (TIPS) procedure at an outside institution. The patient was therefore referred to the Johns Hopkins Department of Interventional Radiology for variceal embolization.\nThe patient's case was reviewed at the Johns Hopkins multi-disciplinary pancreas tumor board. A repeat three-dimensional (3-D) pancreas protocol CT scan revealed an 18 × 12 cm mass abutting the liver, stomach, spleen, left adrenal, colon and invading the distal duodenum – proximal jejunum at the ligament of Treitz. The splenic vein was occluded. Large collateral vessels surrounded the mass and were associated with extensive gastric collaterals (Figure ). The mass displaced the SMA and SMV, but these vessels were patent and uninvolved (Figure ). As such, there were no obvious contraindications to resection and surgery was recommended.\nGiven the size of the mass and the associated extensive varices, the patient underwent preoperative proximal splenic artery embolization (Figure ). Twenty-four hours following"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA case of a 16 year old female patient who suffered from first grade open multi-fragment fracture of the tibia (AO42-C2) due to a complicated horseback riding accident is presented in this case report.\nOn admission the patient had extensive soft tissue swelling and a first grade open fracture was detected. Initial radiological assessment showed a multi-fragmentary tibia shaft fracture (AO42-C2) with a long intermediate segment (). We decided in favor of temporary external fracture fixation concept due to the extensive soft tissue swelling. Intraoperative we encountered some difficulties achieving a satisfactory alignment of the bone due to a hypermobility of the intermediate segment, however because of the extensive soft tissue swelling internal fixation was not feasible. In the end a satisfactory alignment and reduction could be achieved by an extended position of the lower limp and application of longitudinal traction. Postoperative the patient was treated with strict confinement to bed and additional physical treatments like RICE (rest, ice, compression, elevation) in order to prevent further soft tissue swelling. There was no evidence of a compartment syndrome.\nIt is inherent to the system that external fixation of the hypermobile intermediate fragment is difficult and despite complete immobilization the postoperative radiological assessment showed a secondary dislocation of the hypermobile fragment (). Coherently we encountered insufficient detumescence; therefore we decided to an early change of procedure. In respect of the difficulties encountered during the first surgery we decided in favor of intramedullary nailing of the tibia, to minimize the risk of malunion or deformity in our female patient we utilized the suprapatellar approach.\nThe patient was positioned supine on the radiolucent table. First the external fixator was removed while maintaining axial tension on the injured leg. Hereafter the knee was positioned in an extended position on a sterile pill"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Caucasian male came to our department complaining of the appearance of an asymptomatic left submandibular neoformation progressively increasing in size over 3 months. Medical, family, and psychosocial history were negative for relevant information; also, no previous surgical treatments were reported.\nOn clinical examination the mass measured 8 × 5 cm arising from level Ib (submandibular region) and extended into levels III and IV. Such mass appeared adherent to the underlying structures with soft texture. No pain or other symptoms were present. Right cervical region, oropharynx, thyroid, and upper respiratory airways showed no involvement.\nUltrasound evaluation of the mass revealed a mixed tissue consistency of cystic and solid areas separated by high flow vascular fibrous septa in level Ib.\nContrast-enhanced magnetic resonance imaging (MRI) of the head and neck () showed a 5 × 4 × 3 cm multilobed neoformation originating from the left submandibular gland. A fluid component and solid areas were inside visible. No distant metastases were detected.\nTo integrate MRI data, subsequent head and neck computed tomography (CT) was performed. This examination indicated colliquate areas delimited by a thick pathological peripheral tissue within the mass context.\nFirst, fine-needle aspiration cytology specimen was performed to determine the nature of the disease. It showed malignant cells without distinctive features failing to identify the type of primary lesion. A new US-FNAC was subsequently executed; however, also in this case the primary type of lesion was not identified.\nWe opted for surgical treatment, completely removing the mass by means of ipsilateral neck dissection of Ib, IIa, III, and IV levels.\nHistological examination showed a neoplastic proliferation characterized by two cellular components, substantially distinct from each other. No fusion of the different cell types could be seen. The first cellular component consisted of medium size elements wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male presented with high-grade fever for which he was treated empirically. After the fever subsided, he was discharged. Eleven days later the patient developed headache, vomiting, and giddiness, not associated with convulsion, unconsciousness or any ear discharge. Neurologically and hemodynamically, the patient remained stable and routine blood investigations were within normal limits. There were no visual abnormalities and fundus examination was normal. A contrast magnetic resonance imaging (MRI) [] showed evidence of well-defined altered signal intensity lesion involving foramen of Monro of which appeared hyperintense on T1-weight images, T2-weigth images and short tau inversion recovery images. The lesion did not show restriction of on diffusion weighted imaging. There was mild perilesional edema seen on fluid attenuation inversion recovery images. The lesion caused obstruction of the foramen of Monro bilaterally resulting in hydrocephalus. Postcontrast study revealed peripheral rim enhancement of the lesion. A differential diagnosis of either Colloid cyst or NCC was made.\nAfter preanesthetic evaluation, the patient was planned for endoscopic excision of the lesion. Through a precoronal right frontal burr hole, an endoscope was introduced to assist excision of the lesion. The whole degenerative lesion was excised except small islands of the capsule that was strongly adherent to the ventricular wall []. The lesion was pale, fluffy, avascular and was blocking both foramen of Monro. Considering that ventricular cysticerci may induce a local inflammatory reaction, and fluffy part of the lesion may migrate toward the third ventricle leading to aqueduct blockage, endoscopic third ventriculostomy was done in the same setting. On the 5th postoperative day, patient developed signs of raised intracranial hypertension as well as deterioration in level of consciousness which was treated with emergency ventriculostomy followed by endoscopic visualization of fora"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 62-year-old woman, admitted to a local hospital following a short episode of loss of consciousness related to physical effort, with subsequent generalized tonic-clonic seizures. The patient had features of Hunt and Hess Grade III SAH which was confirmed by CT scan and was referred to the Bagdasar Arseni Emergency Hospital for further management. An angio-CT scan [] and a four-vessel DSA [] were performed, which showed a ruptured ophthalmic artery aneurysm.\nDuring the diagnostic angiography, the interventional radiologist also attempted endovascular treatment, but embolization had to be aborted due to the anatomic particularities of the case. In addition to the multilobulated aspect of the left ophthalmic artery aneurysm, the left ICA was intensely atheromatous, and the right ICA was hypoplastic. These findings related a high thrombo-embolic risk and rendered the endovascular treatment impossible.\nGiven this particular anatomical setting, we decided to perform an early surgical intervention, hoping to offer the patient the best chance of avoiding subsequent vasospasm. The intervention proved challenging, as the aneurysm size and location provided a very narrow working space. The surgical procedure was performed in a classic fashion, beginning with a left pterional flap. The proximal sylvian fissure was dissected after brain relaxation was obtained by having inserted an external ventricular drain into the frontal horn of the lateral ventricle. The ICA was then followed from the bifurcation to the emergence from the cavernous sinus, and additional CSF leakage provided further brain relaxation. We did not need to use a temporal clip, as the proximal ICA was adequately exposed. The base of the left anterior clinoid process was subsequently drilled and the aneurysm was dissected from its adherences. A 10 mm Yasargil titanium clip was applied on the neck of the aneurysm, parallel to the ophthalmic artery. Previously, the artery had been carefully d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis patient was a 57-year-old right-handed traffic policeman with a history of diabetes mellitus and hypertension. He was first admitted to a local hospital due to urgent hematochezia and upper abdominal discomfort. Emergency gastroscopy proved duodenal ulcer bleeding. After blood transfusion, he presented paraphasia, walking instability, and loss of bimanual coordination, characterized by the left hand performing opposite movements to the right hand. He also complained that his left hand did not belong to him but to someone else. More importantly, the patient showed loss of coordination as well as mirror movements between the lower limbs. For instance, he had difficulty going to the toilet by himself, because when his right leg moved forward, his left leg moved back at the same time. This phenomenon disappeared gradually and then mirror movements appeared. Sometime when his right leg moved forward, his left leg did the same action. Two weeks later, he was admitted to our hospital because he suffered from anesthesia of the left side of his body.\nOn examination, the patient was alert and oriented. There was only mildly dysarthric speech. Hypesthesia of his left side of body and face was observed. His motor strength and tone were both normal. But deep-tendon reflexes in all extremities reduced symmetrically and frontal lobe releasing signs such as reflexive grasping were absent. Other general physical examinations were all within normal limits. The brain magnetic resonance imaging (MRI) showed a few regions with low signal intensity in the genu, body, and splenium of the right corpus callosum on the T1-weighted image and high signal intensity in the same area on diffusion-weighted images (DWI), T2-weighted, and fluid attenuated inversion recovery (FLAIR) images (Fig. ). Computed tomographic angiography of the cerebral vessels did not show any obvious stenosis in cerebral arteries. Our patient got 23 and 12 scores in the Mini-mental State Examination and Montreal Cogn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe proband is a 14-year-old previously healthy female born to nonconsanguineous healthy parents who was admitted for having fever, fatigue, lower quadrant abdominal pain, and vomiting. Abdominal computerized tomography (CT) revealed significant hydronephrosis consistent with a right ureteropelvic junction (UPJ) obstruction, for which she underwent ureteral stent placement on hospital day 2. Her postoperative course was complicated by continued abdominal pain and fever, as well as an episode of rectal prolapse. Of note, she also endorsed an episode of rectal prolapse months prior to presentation which was manually reduced at home. On hospital day 6, due to continued fevers, abdominal and pelvic MRI was obtained. This study revealed a pelvic fluid collection concerning abscess; CT guided transgluteal drainage performed by Interventional Radiology resulted in 150ml cloudy yellow fluid. The etiology was believed to be an infected urinoma caused by instrumentation during stent placement and she was treated with ceftriaxone and metronidazole. The patient's fevers and pain continued, prompting an abdominal and pelvic CT on hospital day 10. The imaging was notable for diffuse ascites, bowel wall thickening, and organizing fluid collections within the pelvis. She ultimately went for exploratory laparotomy and washout with intraoperative findings of multiple pockets of turbid fluid. The entire bowel was evaluated and there was no evidence of perforations, fistulas, or other causes of gastrointestinal leakage. Peritoneal fluid cultures grew polymicrobial organisms, however, suggestive of gut flora. She was transitioned to meropenem and fevers eventually resolved prior to discharge.\nTwo months following discharge the patient underwent outpatient elective appendectomy, right pyeloplasty, and ureterotomy with stent placement due to persistent hydronephrosis. Pathology revealed normal appendix tissue. Ureter pathology was significant only for acute and chronic inflammation, with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male presents with complaints of ill-defined right periorbital pain associated with intermittent photosensitivity. His symptoms progressed to involve discomfort in the right upper neck. He had no focal neurological deficits on detailed cranial nerve testing. A formal ophthalmology evaluation was negative for papilledema and visual disturbances. He noted symptomatic relief from applying pressure on the lateral aspect of his right neck at the level of the hyoid bone, and he was noted to “readjust” his neck constantly for symptomatic relief during the clinical visit. The symptoms were refractory to medical therapy. Staring at a computer screen had become increasingly uncomfortable, interfering with his daily occupation. He recalled falling face down while playing soccer several weeks prior to symptom onset. MRI of the brain was normal. MRI of the cervical spine revealed age-appropriate mild degenerative changes and diminutive venous caliber in the neck. A computed tomography venogram (CTV) demonstrated enlarged paravertebral and suboccipital plexus, right worse than left, and dynamic compression of the ipsilateral extracranial IJV by a hypertrophic hyoid bone and thyroid cartilage, worsened with leftward head turn in the presence of contralateral IJV compression in the upper neck (Figure ). The focus of IJV compression, as well as hypertrophy of the paravertebral venous plexus is well illustrated on 3D reconstructions (Figure ).\nAfter extensive counseling and exclusion of alternative possible explanations of his disabling symptoms, it was decided to proceed with decompression of the right IJV via an anterior approach. After induction of anesthesia, a transverse right-sided incision was made following a natural skin crease to expose the posterior half of the greater horn of the hyoid, which was then bisected, and the posterior free portion was disconnected from the thyrohyoid ligament and excised. The superior horn of the thyroid cartilage was also resecte"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 50-year-old man underwent left anatomical hemispherectomy at the age of 5 years because of infantile hemiplegia and intractable seizure disorders. Three months after the operation, the bone flap was removed because of osteitis and substituted by an acrylic cranioplasty in 1971 that is 2 years after the primary operation. The seizures were controlled and the child showed a satisfactory motor and cognitive development, with improvement of the right hemiparesis and good academic results. In 1984, the patient fell off a bicycle with severe head trauma. He developed an epidural hematoma on the right side, bleeding into the left hemispherectomy cavity, and decompensation of a previously documented arrested hydrocephalus []. The patient underwent an emergency right craniotomy to remove the epidural hematoma at the Ancona University Hospital and remained for 3 months in the intensive care in a comatous state, with a new left-sided hemiparesis and reoccurrence of seizure disorders. The patient was then referred to San Camillo Hospital in Rome where he underwent further surgical procedures by one of the authors (SV). A temporary external shunt of the right ventricle was applied to wash and clean the hemorrhagic CSF. A fractured acrylic resin cranioplasty was removed. A naturally “reparative” process closing the left foramen of Monroe was respected. A gel-like chronic subdural hematoma of the cavity was removed. A reduction duraplasty, with a Lyodura patch, was performed to reduce the volume of the subdural hemispherectomy cavity and to substitute a thick hemorrhagic dura. A permanent V-P shunt was applied. Subsequently, an intracranial Silastic breast prosthesis was apposed on the Lyodura patch and maintained in place using an overlying metallic mesh with flattened curvature to further reduce the hemicranium (Fig. ). The rationale for these procedures was previously described in detail in this journal [].\nThe patient’s clinical condition progressively improved with recov"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male presented with a history of trivial fall from a ladder (5 Ft) and landing on the right heel. He complained of pain and swelling. On examination, he had swelling over the medial aspect of right heel (). The skin over the swelling was stretched and it was soft in consistency and tender. No relevant history and family history in view of bone cyst and malignancy. No evidence of any risk factors.\nRadiograph of right ankle revealed an eccentric, expansile, and cystic lesion of the calcaneum with thin septae traversing the cystic cavity giving it a blown out or soap bubble appearance. There was a cortical breach suggesting fracture (). In our case, we avoided computed tomography/magnetic resonance imaging (CT/MRI) due to the expense, and we proceeded with biopsy and histopathological examinations, which is more informative.\nThe patient underwent two staged procedure: First for biopsy followed by second procedure after confirmation by histopathological examination.\nUnder strict aseptic precautions, biopsy was done under anesthesia. The specimen was sent for histopathological examination and it was diagnosed by a pathologist as aneurysmal bone cyst.\nA differential diagnosis of aneurysmal bone cyst or giant cell tumor with pathological fracture was made. Under spinal anesthesia and strict aseptic precautions, the lesion was curetted and the cavity was filled with iliac bone grafts ( and ). The curetted specimen was sent again for histopathological examination, and the diagnosis was confirmed (). The wound was closed, dressed, and below knee posterior plaster slab was applied.\nPostoperatively, a nonweight bearing crutch walking was allowed for 6 weeks followed by partial weight bearing for further 4 weeks. Follow-up was done on 3rd and 6th month of post-operative ( and ). The patient returned to his activities at the end of 6 months, and we are still continuing the follow-up because the recurrence usually happens within 1 year."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old man presented with a 6-month history of pain and swelling in his left knee. His medical history included prior presentation with a similar complaint for 5 years, involving left knee pain and difficulty walking. A mass had been detected in the center of his left distal femur, with a soft tissue component. The mass had increased in size and had become painful. There was no history of trauma.\nPhysical examination revealed a fixed, hard, painless, and palpable mass measuring 7-8 cm in diameter and locating on the patient's left distal femur. The patient had no neurovascular problems and no palpable lymphadenopathy. Standard laboratory test results were within normal limits. A roentgenographic study showed destruction of the distal femur and a corresponding dense soft tissue mass (). An MRI examination revealed a mass with focal cortical bone destruction in the distal metadiaphyseal region of the femur. On MRI, this lesion was mainly located in the subcutaneous tissue but extended through the fascia and into the muscle and bone. Osseous involvement was detected on radiographs as subtle bone erosion of the distal femur anterior cortex. The associated soft tissue was isointense to muscle on the T1-weighted image and was intermediately hyperintense to muscle on the T2-weighted image and showed intense enhancement after contrast medium administration (). No evidence of regional or distant metastasis was found in the patient. Biopsies of the neoplastic lesion contained elevated numbers of inflammatory cells.\nIn February 2011, the patient underwent distal femoral tumor resection and reconstruction with a modular prosthesis. During surgery, the tumor appeared encapsulated and consisted of multiple poorly circumscribed nodules, and the cortex appeared excavated from the outside. The excised lesion was 16 cm × 12 cm × 8.5 cm in size, with a capsule-like structure, and demonstrated a beige cut surface. The tumor had infiltrated the bone tissue as well as the soft tis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old previously healthy Sri Lankan female presented with fever and cough for three days to our Emergency Treatment Unit. Her rapid antigen test and polymerase chain reaction (PCR) for COVID-19 were positive and she was managed as moderately severe covid infection at ICU with noninvasive ventilation and high flow nasal oxygen (HFNO); however, invasive ventilation was not needed. On day 20, her COVID-19 exit PCR was negative and she was transferred to the general medical ward for the continuation of treatment.\nWhile recovering from moderate to severe covid infection, she developed excessive fatigue and shortness of breathing. She had severe pallor and tachycardia on examination. She was oxygen-independent and there were no signs of hypoxia in her arterial blood gas. Her ECG showed normal sinus rhythm and the troponin I was negative. Initial blood investigations revealed an acute drop of hemoglobin to 5.1 g/dl from her baseline of 11 g/dl. White blood cell count and the platelet counts were within normal limits. There was no other evidence of any cardiac or respiratory disease. Transthoracic echocardiogram showed normal left ventricular function with no evidence of pulmonary embolism and the D-dimers were within normal limits. Her high-resolution computer tomography of the chest revealed only resolving consolidation. Her thyroid status was also found to be euthyroid.\nOn further history taking, there was no evidence of any internal or external bleeding. There is no family or past history of hematological malignancy or connective tissue disorders. In summary, she was a relatively healthy female with no risk factors for AIHA until she developed COVID-19.\nHer initial blood tests showed evidence of hemolysis with high reticulocyte count, lactate dehydrogenase (LDH), and indirect hyperbilirubinemia. A blood smear confirmed the presence of severe hemolytic anemia. The direct antiglobulin test was positive. Her Coombs profile confirmed warm-type autoimmune hemolytic a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old Asian male presented to the gastroenterology office for a follow-up of a previously found duodenal lesion. He had an EGD at an outside facility 2 years earlier for evaluation of abdominal pain which showed a 1.2 cm duodenal polypoid lesion in the second portion of the duodenum. Pathology of the polyp revealed heterotopic gastric mucosa with benign lobules of gastric glands. He also was found to have chronically active H. pylori gastritis with numerous Helicobacter organisms and atrophic gastritis with patchy areas of intestinal metaplasia. At that time, he was instructed to follow up for a repeat endoscopy for surveillance in two years. As recommended, two years later he presented to our office for surveillance of his duodenal lesion. Due to his history of atrophic gastritis and a large duodenal lesion, we performed an upper endoscopy that showed atrophic gastritis, duodenitis, and a single 10 mm polyp in the second portion of the duodenum. The duodenal polyp was biopsied. Pathology revealed polypoid gastric metaplastic mucosa with focal epithelial atypia including nuclear enlargement, stratification, nucleoli, and few mitoses. The patient was referred for endoscopic ultrasound to further characterize the lesion and complete resection. Several weeks later he underwent an endoscopic ultrasound that revealed a 13-mm pedunculated and sessile polyp on the lateral wall opposite to the major papilla in the second portion of the duodenum (). The polyp was removed en bloc using a hot snare following a 4-mL saline lift. Two endoclips were placed for hemostasis. Pathology revealed a pyloric gland adenoma (Figures , , and ) with predominantly low grade dysplasia (Figures and ) and some small areas of focal high grade dysplasia. The slides were read by the in-house pathologist and were also reviewed by a GI expert pathologist at the University of Michigan. The patient was recommended to follow up for surveillance upper endoscopy in 6 months due to the areas of hig"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.\nComputed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).\nAfter physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.\nOn the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.\nThe examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of eme"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36 year-old pre-menopausal Asian woman previously in excellent health, presented with a three-month history of a progressively worsening tender right breast lump, with associated ulceration, induration, and erythema, draining serosanguinous fluid. She denied systemic symptoms, as well as any known recent fungal or tuberculosis exposure. The patient is a G2 P2002 who nursed her children without difficulty. She has had no history of breast disease, and her past medical and surgical histories are otherwise unremarkable. She denied tobacco use, any family history of breast diseases, use of any medications including oral contraceptives, or any known drug allergies. Physical examination was otherwise unremarkable with no palpable lymphadenopathy.\nDuring initial presentation to an outside hospital, mammography and breast ultrasound revealed an increased density and ductal dilatation of the right breast with associated edematous changes. All laboratory and other radiological studies were otherwise normal. Although malignancy had not been excluded, the patient received a presumptive diagnosis of mastitis and was treated with a 7-day course of amoxicillin and cefadroxil without improvement. This was followed by a course of cefdinir and gatifloxacin, which was complicated by an antibiotic-induced erythema nodosum. As a result, antibiotics were discontinued and the patient was scheduled for an open breast biopsy. Interestingly, the patient's symptoms spontaneously resolved before tissue sampling was performed.\nTwo months after her initial presentation, a second similar lump appeared in the right breast (Figure ). A repeat ultrasound of this area again demonstrated dilated ducts and debris. Bilateral breast magnetic resonance imaging (MRI) revealed regionally dilated ducts with prominent regional ductal and parenchymal plateau enhancement. Given these findings were not typical for mastitis, and clinical and radiological data could not exclude breast carcinoma, tissue sampling"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male with past medical history of congestive heart failure with ejection fraction of 30%, chronic kidney disease, atrial fibrillation, and alcohol abuse, presented with sudden onset of severe abdominal pain. Admission vitals were stable with the significant except oxygen saturation of 70% on room air. Labs on admission were significant for lactic acid of 5.3 mmol/L (), Acute Kidney Injury (AKI), and subtherapeutic INR of 1.5 on Coumadin. Urine toxicology screen was positive for cocaine use. CT scan of the abdomen was initially unremarkable. The patient was subsequently admitted to the ICU for severe acute hypoxic respiratory failure with potential for decompensation and clinical suspicion of mesenteric ischemia given his subtherapeutic INR in the setting of atrial fibrillation along with sudden onset of abdominal pain and elevated lactic acid without a clear cause. Cocaine abuse may have also been a contributing factor to sudden ischemia. A later repeat CT scan revealed nonspecific bowel wall thickening, and a transesophageal echocardiogram performed revealed an active left atrial thrombus, making mesenteric ischemia a higher differential. Due to the added possibility of sepsis and worsening renal function, there was no clear opportunity for surgical intervention, and conservative management was initiated through heparin drip and BiPAP showing initial clinical improvement. By hospital day 3, however, he suddenly became unresponsive. At that time, his labs revealed blood sugar of less than 10 mg/dl and worsening renal failure. The patient was aggressively managed and given multiple ampules of Dextrose 50% and infusion of Dextrose 5% was started (). Because of further decompensation of renal function, he was started on Continuous Renal Replacement Therapy (CRRT) as well. Despite these measures, his blood sugar continued to have multiple episodes reaching 40 mg/dl. His IV fluids were switched to Dextrose 10% drip and eventually to Dextrose 20% drip becaus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65 year-old male presented to the hospital with a two week history of diarrhoea and vomiting. He had no abdominal pain and no symptoms or signs of gastro-intestinal blood loss. He was initially thought to have gastroenteritis, stool samples were sent and he was treated conservatively. He was noted to be mildly anaemic with a haemoglobin level of 10.7. A flexible sigmoidoscopy (FS) was performed to begin investigation of his diarrhoea. This showed a small polyp which was benign on histology and no other abnormality. He settled and was then discharged home. Barium enema (BE) was booked as an outpatient investigation to assess the rest of the colon, and if negative, oesophageogastroduodenoscopy (OGD) would then be performed to investigate his anaemia. The waiting list for colonoscopy was too lengthy at that time, and the combination of BE and FS routinely replaced colonoscopy.\nThe patient was readmitted three weeks later in hypovolaemic shock with a blood pressure of 88/56, pulse 110. During this admission, he was noted to be cachetic, weighing just over 55 kilograms (Body mass index = 16.2). On further questioning he had lost over 12 kilograms in weight since the onset of his vomiting several weeks before. His admission haemoglobin level on this admission was 7.5.\nIn view of the worsening anaemia on this admission and a past history of duodenal ulcer in 1996, in-patient OGD and BE were requested. Meanwhile, the patient continued to receive intravenous fluid, blood and acid suppressing agents. OGD revealed an opening in the second part of the duodenum, which was biopsied. Histology showed poorly differentiated adenocarcinoma and one piece of normal colonic mucosa. BE clearly demonstrated a fistula between the hepatic flexure and second part of duodenum (figure ), and the patient vomited the barium following his enema.\nSubsequent isotope bone scan and liver ultrasound did not show any signs of metastasis. Computed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male presented with complaints of pain in his left hip following an anterior approach for a THA, which was performed 8 months earlier at an outside institution. Per the operative report, there were no complications encountered with the surgery, including no femoral cortex perforation during reaming. He had undergone appropriate rehabilitation following the index procedure, but his symptoms remained refractory to analgesics and physical therapy. Upon arriving to our practice, a workup was begun for septic loosening of the femoral and/or acetabular component. Initial radiographs at our practice show well-aligned femoral and acetabular component without obvious evidence of loosening and with no periprosthetic fracture (Figures and ). Appropriate laboratory tests, including hip aspiration arthrogram, excluded infection as the etiology of his symptoms. A bone scan demonstrated hyperemia in the left thigh and increased uptake surrounding the femoral prosthesis. A subsequent X-ray arthrogram showed mild extravasation of contrast to the proximal aspect of the femoral component (), suggestive of aseptic loosening of the femoral stem.\nThe patient underwent revision of the femoral stem for THA without immediate complication. A standard, posterior approach was performed and blunt, Hohmann retractors were placed anteriorly and medially around the proximal femur for exposure of the femoral canal for reaming and cement removal. There were no complications encountered intraoperatively. Postoperative radiographs show the femoral and acetabular components in good positioning without periprosthetic fracture or femoral cortex perforation (Figures and ). He was discharged in stable condition on the third postoperative day to a skilled nursing facility.\n10 days postoperatively he presented to the emergency room for tachycardia. Workup in the ER included INR (3.6), basic labs, and a CT of his left lower extremity. CT showed concern for possible underlying hematoma in the ope"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11 years old boy had a sudden onset of swelling in his left lower extremity along with pain which were worsening gradually for past 1 month duration. He had no history of fever, headache, cough, chest tightness, chest pain, abdominal pain and diarrhea. His CD4+ T lymphocyte cell count was 522 cells/μL and plasma VL was 943 copies/mL with a blood pressure around 97/69 mmHg at that time. Initially, topical ointment was applied for 1 month which were ineffective in reducing pain and swelling. Instead, the symptoms were aggravated and suddenly spread to the proximal thigh, accompanied by dyskinesia of left lower leg. The child was a known case of HIV positive since the age of two and was believed to be infected through mother to fetus transmission. He has been taking first-line regimen of ART (AZT + 3TC + NVP) since last 4 years when his CD4+ T lymphocyte cell count had reached 346 cells/μL at that time. The plasma HIV RNA was undetectable after half a year of ART.\nHis mother was HIV seropositive person. The child had no personal and/or family history of thrombotic diseases. There was no history of any prior surgery, trauma, prolonged bed rest, obesity, smoking and any other common risk factors of thromboembolic events.\nOn physical examination during hospital admission, the maximum circumference of his left thigh was 38 cm and the right thigh was 34 cm. The maximum circumference of his left calf was 27 cm and the right calf was 24 cm. His left lower thigh was inflamed and swollen, accompanied by tenderness and presence of varicose veins.\nOn hematological tests, his white blood cell (WBC) count was 3.28 × 109/L with a CD4+ T lymphocyte cell count of 430 cells/μL, hemoglobin (Hb) was 126 g/L and platelets was decreased to 66 × 109/L. On virology test, HIV RNA was found to be 580 copies/"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year old woman with a bioprosthetic aortic valve replacement three months prior and well-controlled diabetes was referred to the ED by her optometrist with one day of right eye pain and decreased visual acuity. She denied having fevers, night sweats, dyspnea or chest discomfort, and did not report a history of chemical exposure or trauma to the eye. On exam, she was afebrile, HR 60 and BP 120/59. Her right eye had diffuse conjunctival injection, corneal opacification and a dense vitreous with loss of red reflex. Visual acuity in the right eye was intact only to hand waving. Extraocular movements were full and there was no periorbital erythema or swelling. Left eye exam was normal with clear conjunctiva and 20/20 visual acuity. Ophthalmology evaluated the patient emergently and vitreous aspiration was performed. Empiric intravitreal vancomycin and ceftazidime were administered for a diagnosis of acute endophthalmitis. The patient was admitted due to concern for a systemic source of infection. Her cardiac exam was benign, without murmurs or pathologic heart sounds. Lungs were clear. There were no stigmata of endocarditis. Initial labs showed no leukocytosis and normal kidney function. An EKG was unchanged from prior. Gram stain from the vitreous aspiration was negative and cultures had no immediate growth. Blood cultures were also negative. A TTE revealed thickening of the posterior aspect of the aortic root but was otherwise unremarkable. Further evaluation with CT angiography (CTA) of the chest was performed and revealed a 3.4x2.25 cm pseudoaneurysm of the ascending aorta with extensive thrombus extending to the mid-descending thoracic aorta ( and 2).\nThe patient was taken for emergent surgery, which revealed disruption of the aortotomy suture line with a large thrombus both outside and within the aorta. The aortic valve was unaffected and there was no evidence of suppurative infection, therefore a Dacron patch was used to close the opening. Three days post"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man had already been diagnosed stage V chronic kidney disease for 2 years but did not receive renal replacement therapy. Otherwise, he had no history of foreign travel and familial problems. This time, he visited our emergency room due to high fever and chills for a day. Abdominal fullness, anorexia, and weight loss had also developed for 3 months before this visit. The physical examinations revealed a tachycardia of 114 beats per minute, fever of 38.4°C, and diffuse abdominal tenderness. The blood sampling showed leukocytosis, azotemia, and increased serum procalcitonin level (Table ). The urine analysis revealed the pyuria, suggesting the complicated urinary tract infection. The abdominal plain film showed mixed osteoblastic and osteolytic changes: cortical thickening, sclerosis with coarsened trabeculae, and flame-shaped lucent lesion in the pelvic bone with right site predominantly (Fig. ).\nConsidering the image results and other clinical symptoms such as anorexia and weight loss, the differential diagnosed of the bone lesion is crucial for the patient. The blood chemistry results on the second day, showed only mild elevation in alkaline phosphatase (ALP) and inorganic phosphorus, while highly elevated parathyroid hormone but decreased corrected calcium was noted, favor secondary hyperparathyroidism due to chronic renal function insufficiency (Table ). On the third day after admission, we check the serum tumor markers of leading causes for bone metastasis in the male patients, such as carcinoembryonic antigen and squamous cell carcinoma antigen for lung cancer and prostate-specific antigen for prostate cancer, and all of 3 markers showed normal or mild elevation (Table ). Monoclonal globulin elevation was not identified in serum screening as well (Table ).\nOtherwise the abdominal plain film, the skull X-ray plain film was performed on the second day after admission and demonstrated no osteolytic lesions (Fig. ). We arranged gallium-67 tumor scan a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old man was diagnosed with bilateral Fuchs’ endothelial dystrophy, endothelial decompensation after cataract surgery with IOL implantation in his right eye, and an initial cataract in his left eye. An uneventful DSAEK was performed on his right eye. After donor graft insertion, an air bubble was injected into the anterior chamber for graft apposition and kept for 5 min at the pressure between 20 and 30 mmHg, followed by exchanging air with a balanced salt solution. At the end of the procedure, a residual air bubble filling 50% of the anterior chamber volume was left. On the second postoperative day, the graft was partially detached, so it was decided to re-bubble the anterior chamber with air. After re-bubbling, the graft remained well centered and completely attached. Postoperative standard medications included fluoroquinolones eye drops four times a day for 2 weeks and prednisolone acetate eye drops 1% four times daily for a month, then to be tapered accordingly. After the initial visual improvement, at five months post-operatively, the patient began complaining about worsening of visual acuity. At that time, the cornea was slightly edematous with no sign of postoperative anterior chamber inflammation. However, ten months following DSAEK, the corneal graft became cloudy and corneal decompensation was diagnosed. Upon slit-lamp examination, in addition to corneal decompensation, central IOL opacification confined to the pupillary zone of the anterior IOL surface was found. The patient subsequently underwent penetrating keratoplasty (PKP) with IOL exchange. During the surgery, the opacified IOL was explanted from the bag and a new IOL was implanted in the ciliary sulcus because of suspected damage to the capsular zonules.\nThe explanted IOL was then imaged by optical microscopy, atomic force microscopy, photoelectron spectroscopy, and mass spectroscopy to investigate the morphology of the surface opacification and its chemical composition. The patient was op"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn a work-up of a 40-year-old female with a history of low back pain, a routine MRI of the lumbar spine identified an incidental lesion. The axial T\n1 weighted image showed a 21-mm round, homogeneous lesion of low signal intensity interforaminally in the left S2 segment of the sacrum. The axial short tau inversion-recovery image showed a well-defined lesion with an inhomogeneous signal intensity throughout the lesion with high peripheral rim intensity. The axial T\n1 image with fat saturation after contrast media injection showed moderate enhancement throughout the lesion and in the peripheral rim (). A radiograph of the pelvis was performed to further characterize the lesion. On clinical examination, the sacral area was not painful to palpation. Owing to the atypical appearance of the lesion and the non-specific nature of the MRI signal pattern, a bone scan was performed that showed a solitary lesion on the left side of the sacrum with increased metabolic activity. For further characterization, and in the search of a potential primary tumour, positron emission tomography (PET)-CT was performed, which showed a well-defined sclerotic lesion with mild fludeoxyglucose (FDG) avidity (average standardized value 2.5) in the S2 segment and no other abnormalities (). Owing to the metabolic activity of the lesion, the patient was referred to the orthopedic oncology department for image-guided biopsy of the lesion. The biopsy specimen consisted of a few small fragments of bone marrow, some skeletal muscle, fibroadipose tissue and blood clots. Infiltration of the otherwise normal bone marrow with scattered small groups of big foamy cells was identified (). The foamy cells had vacuolated cytoplasm and small centrally located nuclei. The cells were negative for cytokeratin AE1/AE3, CD68, barchyury, Melan A, HMB 45, desmin and smooth muscle actin but positive for S100 protein (). The cells contained multiple lipid droplets and numerous large mitochondria; the existence of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe present case report is about a 25-year-old female patient who reported to the Department of Oral and Maxillofacial surgery with swelling in the right lower third of face below the lower border of mandible since 6 months []. Recently, the swelling had suddenly increased in size with severe pain from the past 3 days. On examination, it was associated with infected molar, which was assumed to be the etiology of the swelling, for which extraction was carried out. After extraction, the pain subsided, however, the swelling was persistent and had not completely resolved even after a month. During the follow-up visit, the lesion was soft, non-tender and compressible and it measured 5 × 4 cm in size approximately. The skin over the swelling had normal texture and consistency. No bruits were heard on auscultation. The patient informed us that the swelling intermittently increased and decreased in size and has reached the present size. The growth although painless was cosmetically disfiguring.\nOn investigation, needle aspiration yielded a blood-tinged clear fluid which resembled lymphatic fluid, which was examined in light microscopy. After a routine blood investigations, the patient was advised an orthopantomograph which failed to reveal any bony changes. Later on, the patient was advised to undergo an ultrasonographic scan which revealed a multicystic lesion with internal septations. A computed tomography (CT) scan with contrast was carried out, which revealed a multicystic, homogeneous, non-invasive lesion with low attenuation.\nThe lesion was provisionally diagnosed as a lymphatic malformation and incisional biopsy was planned. A 5-cm extraoral incision was placed in the first cervical crease. Blunt and sharp dissection was carried out to free the lesion from the overlying platysma muscle. Once the lesion was identified, aspiration of some content of the cyst was carried out to reduce the size of the lesion. Blunt dissection was carried out to protect vital structures o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 67-year-old male with a history of hypertension, type 2 diabetes, and hyperlipidemia, who went through the Inova Movement Disorders Program due to a history of fluctuating, progressing uncontrollable movements of the left side of his body. He reports these movements had been present for around 10 years, worsening over time.\nAt baseline, he always felt that his left arm and leg were moving, at times exhibiting large amplitude movements which could knock things down or affect his walking, making him fall. He described it as abnormal, uncontrollable movements that made his arm ‘reach around or fling out’ His leg was also described to ‘dance on its own.’ While at baseline, these were present but minimal stress or anxiety would exacerbate the movements. There were no movement issues on his right side, nor any facial movements noted.\nHis exam showed episodic, mild with some interspersed moderate-amplitude quick movements of the left hand, forearm, proximal arm muscles, as well as movement of the left leg. These were not suppressible, brought out more by distraction or with anxiety, such as discussing an MRI scan as he was claustrophobic. He also demonstrated some lateralizing movements of the head to the left, but no facial or tongue movements. His right side showed no such signs, and his neurological exam was otherwise unremarkable.\nHe was sent for a CT scan of the head initially due to a fear of MRI scanners, and was found to have asymmetric calcification of the right caudate nucleus and anterior putamen (Figure ). The calcification spared the anterior limb of the internal capsule. Laboratory work for parenchymal calcification was then sent and was normal. The MRI of the brain with contrast demonstrated both hypointense gradient echo (GRE) signal in the right caudate nucleus and putamen, as well as an underlying DVA (Figures -).\nGiven the lateralizing of his"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old male with a past medical history of coronary artery disease status post coronary artery bypass grafting, hypertension, chronic obstructive pulmonary disease, diabetes mellitus type 2, and cerebrovascular accident presented to a local hospital with acute abdominal pain and bloating. A computed tomography (CT) scan of the patient's abdomen and pelvis was performed and showed intraabdominal bleed and multifocal liver lesions. Initial complete blood count (CBC) revealed a hemoglobin of 7 g/dL and he was transfused one unit of packed red blood cells prior to transfer to our institution. On arrival, CT angiogram of the abdomen and pelvis showed multiple dense, heterogeneous masses throughout the liver with associated perihepatic and intraperitoneal hemorrhage and areas of tumor blush were noted but no extravasation was seen to suggest active hemorrhage. There was also multiple enlarged periportal and upper mesenteric lymph nodes, likely representing metastatic adenopathy. There were no lesions present on the pancreas. CT chest was obtained and showed no evidence of intrathoracic metastatic disease. Initial blood work revealed normal liver function tests, appropriate response in hemoglobin to transfusion and negative viral hepatitis panel. Tumor markers revealed AFP elevation to 8705 ng/mL, normal Carcinoembryonic Antigen and Cancer Antigen 19-9. Magnetic Resonance Imaging (MRI) of the abdomen and pelvis showed multiple lesions throughout the liver with targetoid appearance. There was no evidence of cirrhosis and these lesions did not have imaging characteristics of typical HCC (Figure ). It was suspected the multifocal liver lesions were HCC given the elevated AFP. However, the MRI was not consistent with HCC and a liver biopsy was obtained. Pathology results were consistent with poorly differentiated, large cell-type neuroendocrine carcinoma with metastatic disease to the liver (Figure ). The patient had an unremarkable colonoscopy and esophagogastroduodeno"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old female was diagnosed with SLE at 12 years of age. At around 27 years of age, she experienced several instances of seizures and began taking antiepileptic drugs. On brain magnetic resonance imaging (MRI), diffuse cortical atrophic changes and an old infarct lesion in the left superior parietal cortex were detected. Three years later, she had fever, clonic seizure and loss of consciousness. On T2-fluid attenuation inversion recovery (FLAIR) imaging, a high-intensity signal change was detected in the left temporal and frontal lobes, both occipital lobes, and the midbrain (). She was also diagnosed with antiphospholipid syndrome. After 15 days of treatment, which included intravenous methylprednisolone, immunoglobulin and anti-epileptic drugs, she regained consciousness and her motor weakness was improved. Follow-up brain MRI showed improvement of the previous lesions, which were suggestive of posterior reversible encephalopathy syndrome (PRES) (). As she had fever and a urinary tract infection (UTI), the infectious condition following immunosuppressant therapy with cyclosporine was thought to be the cause of PRES. At her first admission to the Department of Rehabilitation Medicine, consistently with the dramatic neurological recovery commonly observed in patients with PRES, she showed mild functional and cognitive impairment. One week after the start of rehabilitation, weakness of the left extremities and fever were noted. Brain MRI showed acute infarction in the right basal ganglia (). Acute cerebral infarction was considered related to SLE activation due to UTI. One month after treatment in the Department of Rheumatology, she was returned to the Department of Rehabilitation Medicine. We performed an electrodiagnostic study and whole spinal cord MRI to rule out other superimposed diseases, such as neuropathy, transverse myelitis, and myelopathy. The cross-sectional area of the spinal cord from the cervical through the conus medullaris was markedly thin o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn otherwise healthy 12-year-old boy had left-sided abdominal pain after being beaten in the area. He then experienced temporal symptom improvements, but his symptoms recurred, prompting visit to a nearby hospital. The abdominal roentgenogram could not show abnormal findings []. A mass was detected on contrast-enhanced computed tomography (CT), and he was referred to our hospital forfurther investigation and treatment. Physical examination revealed tenderness on the left abdomen. C-reactive protein was 3.6 mg/dl, and other laboratory tests were normal.\nContrast-enhanced CT showed an oval mass in the upper left abdomen adjacent to the pancreatic tail, clearly separated from the spleen, the left kidney, and the left adrenal gland []. The mass, located below the spleen, was less dense than the spleen. A tubular low density structure connected to the normal spleen was detected above the mass; thus, it was considered as twisting of the vascular pedicle of the accessory spleen.\nUS revealed an inhomogeneous oval mass, measuring 4 cm in diameter below the spleen []. The mass was mainly hyperechoic, similar to the spleen, and the central part showed irregular low echoes. A small amount of ascites was detected in the pelvis. The following day, there was a notable decrease in the internal echo of the mass with linear hyperechoic spots noted in the hypoechoic areas []. Four days later, the expansion of the internal hypoechoic areas was noted, and the linear hyperechoic spots became more prominent []. A tubular structure from the upper edge of the mass to the spleen was detected [Figure and ], and there was no blood flow signal in the mass []. This tubular structure was considered to be a vascular pedicle of the accessory spleen; thus, accessory spleen torsion was diagnosed.\nTwenty-five days after the injury, laparoscopic resection was performed [], and the accessory spleen was found adhered to the omentum and colon, twisted four times around its axis."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old Caucasian man, with a 4-week history of right upper quadrant and right flank pain radiating to his right testicle, presented to his general practitioner. There was no preceding trauma, haematuria or any other systemic symptoms. The past medical history included osteoid osteoma in the left upper femur, which was removed in 2007. He also had L4/5 microdiscectomy. There was no positive family history of medical problems or cancer. He was a non-smoker, had no allergies and was not taking any regular medications. The general practitioner organized an ultrasound, which revealed a large subcapsular haematoma measuring 7 × 5 × 7 cm in the right kidney compressing the renal cortex. Further investigation with computed tomography (CT) scan of the abdomen with intravenous contrast revealed enlarged right kidney with subcapsular haematoma and a mass lesion within the right lower pole measuring up to 7.4 × 7.5 × 9.2 cm with associated paracaval lymphadenopathy producing compression of the right renal vein and inferior vena cava (). The patient was then referred to an urologist for further management.\nPhysical examination revealed that the right kidney area was filled, with minimal tenderness. The haemoglobin concentration was 140 g/L. There was a mild elevation of creatinine (116 µmol/L), and the estimated glomerular filtration rate was 66 ml/min. CT staging showed a large right renal tumour and significant paracaval lymphadenopathy producing compression of the right renal vein and inferior vena cava. The size of the tumour was substantially increased in size to 11.5 × 11.6 × 11.5 cm when compared with that in the previous CT scan.\nA preliminary diagnosis of renal cell carcinoma was made based on the clinical findings and investigations. The patient underwent open radical right nephrectomy, retroperitoneal lymph node dissection and partial excision, and reconstruction of vena cava. The renal samples were sent for histopathology. The right kidney specimen (with fibro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-hour-old female neonate born from a 22-year-old Para 1 mother after term pregnancy. The newborn had protrusion of mass per vagina since birth; she also has a defect at the lower back with no discharge since the time of birth. Additionally the mother has noticed deformity on both legs and feet which barely move. The baby was active since the time of delivery and is sucking well and she passed meconium. The mother had two ANC visits and was vaccinated according to the national schedule and she reported the whole course of the pregnancy as uneventful. She did not have any known medical illness and has never taken any medication during the entire course of the index pregnancy except iron folate which was prescribed during the ANC visit.\nShe had spontaneous onset of labor and the membrane was ruptured spontaneously intrapartum. She gave birth to a 2330-gram female neonate after 5 hours of labor at a local health center. Baby had good APGAR score. Health care providers at the health center noticed defect at the back of the baby and referred her to Hawassa University Comprehensive Specialized Hospital (HUCSH) with the diagnosis of spinal bifida.\nDuring the initial evaluation at HUCSH the baby was active, vital signs were in the normal limits, and all neonatal reflexes were intact. There was 4x4 cm pink mass protruding through the introitus, cervical os is noted at the tip of the mass, the external genitalia appears normal, no discharge or bleeding from the mass, and the mass was reducible digitally and increases in size when the baby cries (see ). There was also 4x4 cm defect at the lumbosacral region the major portion of which is covered with skin while the lower edge is open, no discharge from the mass (see ). Additionally the newborn had bilateral club foot deformity (see ).\nOn investigation, the complete blood count was normal, creatinine level was 0.4mg/dl, and transf"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old caucasian female was diagnosed with thyroid papillary carcinoma after total thyroidectomy in 2001. Diagnosed with postsurgical hypothyroidism under treatment with levothyroxine, 100 micrograms per day. There was no other previous medical history of interest. The patient did not consume tobacco or alcohol.\nIn 2008, a computerized tomography scan (CT) showed locoregional relapse and surgery was performed with resection of locoregional recurrence and left cervical lymphadenectomy. In November 2011, pulmonary relapse was treated with I-131 since November 2011 until March 2012 (total accumulated dose: 850 mCi). In October 2016, a CT scan showed a progression of the disease with cervical and pulmonary progression. The patient started sorafenib, 400 mg twice a day. Stable disease was maintained during 20 months. In June 2018, patient presented an episode of abrupt instability and cervical pain. The magnetic resonance imaging (MRI) (Fig. ) showed a new metastatic lesion in the skull base with destruction of bony structures of the left occipital-petrous region. At this point, a molecular study of the cervical node was performed and a mutation in BRAF was found.\nDue to the lack of alternative therapeutic options, treatment with vemurafenib–trametinib was requested as a compassionate use. In August 2018, patient was started on the combination of dabrafenib 150 mg twice a day and trametinib 2 mg once a day. MRI in October 2018 showed a slight decrease of the metastatic lesion in the skull base (Fig. ). In addition, the patient showed evident clinical improvement with decreased initial headache and cervicalgia.\nA follow-up PET–CT scan was performed in January 2019. Tumor was on radiological partial response. In addition, there was intestinal pneumatosis with mild sign of pneumoperitoneum (Fig. ). Patient had no digestive symptoms and the abdominal medical examination was completely normal. Also normal neurological examination was verified. Routine physical examinat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old gravida 4 para 1 female was presented to our hospital with 7 weeks of amenorrhea and positive for pregnancy test. After menarche at the age of 14 years, her menstrual cycles were regular and occurred approximately every 30 days with menstrual periods lasting 5 days. Her body mass index was 30.7 kg/m2. Transvaginal ultrasonography (TVUS) revealed a gestational sac and fetus in uterus and a solid mass of approximately 5 cm in diameter in the right ovary. The primary clinical course of her pregnancy was good, and magnetic resonance imaging (MRI) was performed at 12 weeks of gestation to assess the solid mass. MRI revealed diffuse enlargement of the right ovary with iso-intensity-to-low intensity on T1-weighted images, heterogeneous relatively high intensity on T2-weighted images, high-intensity signals on diffusion-weighted imaging (DWI), and a low apparent diffusion coefficient (ADC) value [Figure –]. The laboratory values were within normal limits, including those of tumor markers (e.g., carbohydrate antigen 125, carbohydrate antigen 19–9, and carcinoembryonic antigen). Based on these findings, a stromal tumor with a low possibility of malignancy was suspected, and the patient was followed up with TVUS and observation during pregnancy. There was no change in size or characteristics of the tumor with TVUS throughout her pregnancy.\nAt 40 weeks and 1 days of pregnancy, the patient was admitted to our hospital due to premature rupture of membranes and spontaneously delivered a male baby vaginally. The baby's birth weight was 2885 g, and his Apgar score was 8 at 1 min and 9 at 5 min. The postpartum clinical course for the mother and baby were unremarkable.\nA month after delivery, TVUS was performed in the outpatient clinic for follow-up of the ovarian mass and revealed a solid mass in the right ovary measuring approximately 5 cm in diameter. MRI was performed repeatedly at 2 months after delivery MRI revealed that the diameter of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old male patient resident of Nagpur reported at a private E.N.T clinic with a chief complaint of a mass in the right nasal cavity since 3 years. The patient also gave history of right nasal blockage and nasal discharge since 3 years. It was a slow growing growth since onset. The patient gave similar history of right sided nasal mass 5 years back, for which he was operated upon in a private clinic and the mass was removed. The histopathological examination was not performed at that time. He remained alright for 2 years postoperatively. After few months, patient started experiencing intermittent nasal obstruction and nasal discharge in the absence of upper respiratory tract infection. However, as the time passed by these symptoms aggravated and he started experiencing some nasal mass inside right nasal cavity. On anterior rhinoscopy, a solitary, pinkish, pedunculated, irregular, firm mass was located in right nasal cavity. On probing, mass was attached to lateral wall of right nasal cavity and mass did not bleed on touch. Computed tomography (CT) scan was advised and it revealed that the tumor was arising from middle meatus of right nasal cavity and there was widening of osteomeatal complex of right side. On contrast, there was mild to moderate enhancement seen. This mass was quite large and measured approximately 7 cm × 6 cm. Based on the clinical features and radiographic findings, a provisional diagnosis of papilloma was given. The mass was surgically excised by lateral rhinotomy with medial maxillectomy [] and the excised tissue was sent to the Department of Oral Pathology and Microbiology for histopathological examination. Gross examination revealed a single bit of soft tissue specimen of size approximately 3 cm × 2 cm, pinkish-white in color, irregular in shape, firm in consistency with rough surface texture. On histological examination, the hematoxylin and eosin stained section showed polypoid tissue covered with pseudostratified columnar ciliated epi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 35 year-old woman who was diagnosed with GSD Ib at the age of 10 months. Dietary treatment was started with good metabolic control. Since the age of 9 years the patient has received G-CSF treatment for neutropenia and recurrent infections. Since the age of 10 she has suffered from inflammatory bowel disease. The clinical course was further complicated by recurrent abdominal abscesses. At age 25, subtotal colectomy was performed due to long-distance stenosis of the transverse colon with an abscess in the right upper abdomen. Postoperative wound healing was impaired and required surgical wound revision and closure. Pancreatic fibrosis was observed at age 28, exocrine pancreatic insufficiency was diagnosed at age 31, and supplementation with pancreatin was initiated. Hepatosplenomegaly was observed, and the thrombocyte count was significantly reduced to around 40 G/l, possibly due to the massive splenomegaly. At age 33, the patient presented with acute abdominal pain in the lower abdomen. MRI was suggestive of a pelvic abscess, enlarged pelvic retroperitoneal and mesenterial lymph nodes as well as inflammatory alterations of the intestine. The patient had bloody stools, and her overall clinical condition was reduced. Antibiotic therapy with meropenem, ampicillin and metronidazole was started. Explorative laparotomy with extensive resection of the small bowel (side-to-side jejuno-jejunostomy 70 cm distal of the ligament of Treitz and end-to-end jejuno-jejunostomy 150 cm distal of the ligament of Treitz, resection of the stenosing ileodescendostomy) was performed. Abdominal bleeding occurred in the postoperative course, which required 4 further laparotomies within 3 weeks. Secondary surgical closure of the wound could be performed 4 weeks after the initial operation. However, within the consecutive weeks a large wound dehiscence developed with severely impaired wound healing. At its maximum the wound had a diameter of 29 × 18 cm. Surgical revision of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old girl came to the Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India, with a chief complaint of missing or unerupted maxillary anterior teeth. A previous history of trauma to her maxillary anterior region about eight years back was recorded, due to which there was avulsion of few deciduous teeth and few fractured teeth, which were subsequently removed. The patient's medical history was noncontributory. Both parents reported no previous history of tooth or genetic anomalies on either side of the family.\nOn examination, the patient had a deficient maxilla on the right side leading to facial asymmetry. In the maxillary arch on the right side, the central incisor, lateral incisor, and canine were missing or unerupted; the associated alveolar mucosa was enlarged and covered by fibrous tissue []. Also there was a rotated first premolar, erupting second premolar, and unerupted first and second molar on the right side. However, on the left side of the maxillary arch only a central incisor was missing and the rest of the teeth were present. In the mandibular arch, on both sides, all the teeth were present except the third molars. All the teeth showed some degree of hypoplasia. The oral hygiene was poor with an active carious lesion on the mandibular left first molar. There was deficient maxillary growth on the right side, showing signs of arch collapse [].\nPanoramic, occlusal, and periapical radiographs were taken. The mandibular dentition was normal, as was the left maxillary dentition, except the central incisor. In the maxillary anterior region, the right central incisor, lateral incisor, and canine showed malformed and retarded development as compared to the age of the child. There was complete absence of the left central incisor and the right first molar. The second molar was also malformed, but it was not as severe as the other malformed teeth."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe informed consent was obtained from the patient. In March 2012, a 22-year-old female with iron-deficiency anemia, secondary to recurrent episodes of melena, presented as an outpatient to the Department of Gastroenterology at the Second Affiliated Hospital of Nanjing Medical University (Nanjing, China). Since infancy, the patient had exhibited massive characteristic venous malformations of the skin, which were deep blue, soft, rubbery and easily compressible. Between 1991 and 2012, the patient had a history of recurrent GI bleeding and iron-deficiency anemia. The patient did not have any history of non-steroidal anti-inflammatory drug use or peptic ulcers. The patient had received several blood transfusions and, at 12 years of age, an abdominal surgery was performed to resect the hemangiomas in the stomach. A pathological report revealed hemangioma. According to laboratory examinations, the patient exhibited a hemoglobin level of 41.0 g/l, a red blood cell count of 2,410/mm3, a reduced white blood cell count and an increased neutrophil granulocyte count. Skin lesions of various sizes occurred on the abdomen, hip and leg of the patient (). The patient received a blood transfusion and hemostatic therapy. Following hemostatic therapy, a fecal occult blood test yielded negative results. In order to detect the origin of the hemorrhage, a colonoscopy and capsule endoscopy were performed. Endoscopy revealed several strawberry-like mucosal polypoid lesions with abundant vasculature in the colon and lesions ranging between 8 and 20 mm were blue-violet and sessile (). Colon lesions were removed in an attempt to eliminate bleeding under colonoscopy. During surgery, hemangiomas were ligated with a nylon cord and several small blue mucosal polypoid lesions were treated with sclerosing agent during colonoscopy (). The patient was discharged in a good condition. A repeat endoscopy at 3 months revealed completely normal mucosa in the original lesions. A number of small lesions th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old man presented to our outpatient clinic with radiating pain both legs. The pain in both legs was aggravated with walking and relieved with rest, symptoms typical of neurogenic claudication. The patient reported that he had been shot in the left lateral side of the back on 1 year ago. We determined on physical examination that the wound on the left flank had already healed (). At the time that he was shot, the patient had no other complaints, except for pain at the entrance wound. At that time of gun shut, he had to have absolute bed rest and conservative treatment because of a liver injury caused by the gunshot. After several months of treatment, his liver was healed enough to ambulate and walk; however, he needed a cane to walk. After he started walking, he began to experience continuous radiating pain on both lower extremities.\nOn neurologic examination, dorsiflexion of the ankle and big toe on the right leg revealed mild motor weakness (Grade IV). The patient also complained of numbness on the right lower limb; however, patellar and Achilles reflexes were normal. On admission, his ESR and CRP were elevated slightly. Other laboratory findings were normal. A mild degree of voiding difficulty was detected, although that symptom did not bother the patient.\nPlain radiographs revealed a round, radiopaque mass in the spinal canal at the L3-4 level (). Non-contrast reconstructed CT images of the lumbar spine were taken after admission, which revealed that the bullet-shaped mass was within the spinal canal, pointing cephalic at the L3-4 interspace (). The bullet within the spinal canal was located in the intradural space, compressing the nerve root ().\nBecause of his claudication and pain, we decided to surgically remove the bullet from the spinal canal. With the patient prone on a Wilson frame, fluoroscopic guidance was used to plan an incision over the L3-4 spinous process. The L"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Caucasian male presented to the emergency room complaining of a one-day history of abdominal pain. His main symptoms were that of nausea and vomiting, but he also reported periods of diarrhea. In the emergency room, his initial evaluation was significant for lab studies demonstrating a mild metabolic acidosis with a bicarb of 16.6 mEq/L, an elevation of his creatinine to 1.93 mg/dL, and a serum lactate level of 5.4 mmol/L. A computed tomography (CT) scan of the abdomen and pelvis was obtained and reviewed. The appendix was thought to be normal. There was no evidence of free intraperitoneal air, abscess, or volvulus. There did appear to be evidence of enterocolitis involving the ilium, cecum, and the proximal ascending colon. There was no evidence of pneumatosis or obstruction. Over the course of 12 hours the patient underwent conservative medical management, which included intravenous hydration, intravenous steroids, Toradol and Dilaudid for pain management, and the occasional dose of Ativan for agitation. Failure of conservative management along with medical decline lead to an exploratory laparotomy with a right hemicolectomy for an ileocolic intestinal infarction. Postoperative repeat CT scan of the abdomen incidentally showed pulmonary nodules in the lower lobe. A CT scan of the chest was then obtained, which revealed air in the left chest wall and axilla (Figure ). On physical exam there was very subtle mottling of the left shoulder. The patient was emergently taken back to the OR for further exploration of the shoulder with excisional debridement. Seropurulent fluid and extensive subcutaneous emphysema along the fascial planes of the left chest wall were consistent with necrotizing fasciitis. Both wounds were packed with a gauze bandage roll soaked in saline and then the patient was transferred back to the intensive care unit.\nOver the course of 15 days the patient underwent repeat trips to the OR for re-exploration, incision and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient is a 73 year-old right hand dominant female who initially presented to the office complaining of atraumatic right shoulder pain with activity and limited range of motion of longstanding duration. On physical exam, she was found to have significantly limited active range of motion of the right shoulder and clinical signs of impingement. Radiographs at that time demonstrated superior escape of the humeral head with impingement of the greater tuberosity on the acromion and early acetabularization of the acromion (Fig. ). MRI findings were consistent with her x-ray and also demonstrated a lack of contiguous supraspinatus or infraspinatus tendon. At this juncture, the patient was diagnosed with rotator cuff arthropathy and elected to proceed with reverse total shoulder arthroplasty.\nThe patient was brought to the operating room and placed in the beach chair position. An incision was made from just lateral to the coracoid to the medial border of the proximal humeral shaft in line with the axillary fold. Subcutaneous tissue was dissected and the cephalic vein was identified. As the cephalic vein was mobilized and the clavipectoral fascia was incised, a discrete, branching, fascicular nerve was identified lateral and deep to the cephalic vein within the deltopectoral groove (Fig. ). The nerve was further dissected and traced both proximally and distally. Distally, the nerve and all branches were found to be diving into the anterior deltoid muscle. Proximally, it was found to run deep to the conjoined tendon, towards the brachial plexus. The nerve was freed from the deltoid muscle belly, allowing enough excursion to access the glenohumeral joint via a small deltoid window. The remainder of the operation concluded without complication and the wound was closed primarily (Fig. ). The patient was neurovascularly intact post-operatively with intact sensation in the axillary nerve distribution and able to fire her deltoid muscle. She healed without complications. At 4-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35 year-old female, gravida 3 para 2, presented to the emergency department with her first ever episode of angina pain 9 weeks and 3 days following an uneventful caesarian section. The patient noted constant chest tightness with radiation to both arms while getting ready for work. The pain was associated with diaphoresis but she denied dyspnea or nausea. Six years prior she underwent catheter pulmonary embolectomy for a thromboembolism thought to be related to oral contraceptive use. Since then she had been taking warfarin and warfarin was restarted postpartum. Otherwise the past medical history was only significant for hypertension. The family history was notable for a younger sister who was diagnosed with cardiomyopathy six weeks postpartum and a grandmother who died of unknown causes suddenly at age 42 without a relationship to pregnancy.\nUpon physical examination the pulse rate was 83, respiratory rate 16 and blood pressure 130/67. The EKG demonstrated evidence of anterior ischemia. Serial troponin-t peaked at 1.17 ng/mL. The INR measured 1.9 IU. Initial treatment consisted of loading with 300mg clopidogrel. Emergent cardiac catheterization showed left anterior descending (LAD) coronary artery dissection complicated by extensive thrombus (Figure , Additional file ). Otherwise the coronary anatomy was without lesions in the left main coronary artery, the circumflex coronary artery or the right coronary artery (RCA) (Figure Panel A, Additional file ). The dissection affected the mid LAD to the distal LAD with irregular severity. Intravascular ultrasound demonstrated subintimal thrombosis but there was no evidence of a free dissection plane. Three everolimus eluting stents (Xience, Abbott Laboratories, USA) measuring 2.5 × 18 mm, 2.5 × 23 mm and 2.5 × 18 mm were deployed and dilated to 3.5 mm proximally. However, an edge dissection of the most distal stent became apparent after treatment of the target lesion. This was covered with an additional 2.5 × 18 mm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old Caucasian female presented in April 2008 for a consultation. She had a history of osteopenia and had been treated with alendronate (Fosamax) for 3 years. Until recently, her history of dental treatment had been uncomplicated. Her third molars had been extracted and four of her permanent teeth had been restored with amalgams. Throughout her life, she had visited her general dentist for semiannual recall appointments. Her dental hygienist and dentist had recently detected periodontal pockets around her maxillary and mandibular right molars. They referred her to a periodontist, who recommended extraction of teeth 17 and 47 (FDI) and possible surgical treatment of the upper left molars. Since she had a history of bisphosphonate use, she was concerned about the potential for development of osteonecrosis of the jaw (ONJ) after the extractions []. This motivated her to seek a second opinion to explore options for nonsurgical treatment.\nThe patient brought duplicates of periapical radiographs that had been obtained one month earlier by her general dentist. The radiographs revealed the presence of moderate periodontal bone loss around teeth 17 and 16 and early to moderate periodontal bone loss around 27 and on the distal aspect of 37 (not shown). There was severe periodontal bone loss on the distal aspect of 47, which had a pronounced root dilaceration (). In addition, there was a radiopaque mass associated with the distal aspect of 47, near the level of the cementoenamel junction. The size and shape of this mass suggested that it was either calculus or a fragment of a third molar root. The patient's oral hygiene was good and clinical signs of inflammation around the premolars and anterior teeth were minimal. However, there were probing depths of 5 to 6 mm on the mesial aspect of 17 and the distal aspect of 16 and probing depths of 7 mm on the direct palatal and distopalatal aspects of 27. Tooth 47 had 5 mm depths on its distofacial and direct lingual aspects a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54 year old woman with OI type 1 presented in October 2014 with acute back pain without any history of trauma or fall. Computed tomography (CT) scan of the thoracic spine demonstrated a burst compression fracture of the 11th thoracic vertebra (T11), as well as a 2.6x1.3x1.5 cm soft tissue density involving the left transverse process of the 7th thoracic vertebra (T7) (). A CT-guided biopsy of the T7 lesion revealed a heavy infiltration by kappa restricted CD138 expressing plasma cells. Further investigations confirmed the diagnosis of kappa light chain myeloma with lytic lesions involving the right parietal bone and right iliac bone, normal renal function and 30% light chain restricted plasma cells in the bone marrow. A radiographic skeletal survey demonstrated a radiolucent line at the left femur diaphysis with localized periosteal reaction compatible with an incomplete insufficiency fracture, consistent with the diagnosis of AFF (). There was no involvement of the contralateral femur, but both femurs were noted to be significantly bowed. The cortices were not thought to be thickened. Correlation with radionuclide bone scan demonstrated focal increased radiotracer uptake at the left femur fracture site. The patient denied thigh or groin pain. Orthopedic consultation was sought and the consultant recommended against prophylactic femoral nailing in view of the absence of symptoms and of the concurrent diagnosis of MM that might negatively affect the post-operative course.\nThe patient had been diagnosed with OI type 1 in early childhood and never received bisphosphonates until the age of 40 years, when alendronate was initiated for ongoing bone loss at the time of menopause and a patellar fracture. Calcium and Vitamin D supplementation was begun, and low dose transdermal estrogen (estradiol 0.025 mg/day twice a week) was prescribed to alleviate menopausal symptoms. Alendronate was stopped after 10 years of continuous therapy since her bone density had stabilized and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a term male born at 39 1/7 weeks of gestational age by spontaneous vaginal delivery to an 18-years-old mother G2P1A0. The mother had no history of systemic illness. There was no consanguinity in the family. Prenatal screening tests (Human Immunodeficiency Virus, Hepatitis B, and Syphilis) were negative; Group B Streptococcus was positive; the mother did not receive antenatal antibiotics during pregnancy. No prenatal complications were reported, and no fetal anomalies or abdominal findings were detected on antenatal ultrasound. Patient had an Apgar 8 at one minute and 9 at 5 minutes. No complications during labor and delivery were reported.\nAt first day of life, the patient presented with hypoactivity, poor sucking, and cyanosis for which he was admitted to the Neonatal Intensive Care Unit due to suspected early onset of neonatal sepsis. Diagnostic studies were performed and therapeutic management was instituted, including antibiotic coverage. On day #2 of life, the patient presented with marked abdominal distention and marked bright red bloody stools. Oral feedings were discontinued, an orogastric tube was placed for gastrointestinal decompression, and metronidazole therapy was added to antibiotic therapy. The abdominal radiography revealed bowel dilation with no distal air. The clinical findings and presentation raised concern of bowel obstruction. On follow-up X-rays, a persistent radio opaque shadow in the lower abdomen raised the concern of urinary bladder obstruction. A Foley catheter was placed, obtaining 60 ml of urine. On day #4, an abdominal ultrasound was performed and revealed bilateral hydronephrosis, more prominent on the right side due to compression and a prominent parenchymal mass. A barium enema revealed a presacral soft tissue mass. On day #5 of life, an abdominopelvic computed tomography (CT) scan revealed a well-defined mass in the presacral space compressing the rectum and causing severe small and large bowel dilation. The mass"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old Malay girl was admitted to our institution presenting with fever for 4 days that was persistently above 38°C, with a maximum temperature of 39.9°C. This was associated with a papular and pruritic rash over her chest and limbs for 4 days, as well as a tender right neck swelling for 3 days, diarrhea, and bitemporal headaches for 2 days. This was accompanied by early morning vomiting and nausea, but no blurring of vision or other neurological deficits. She also had red eyes and a dry cough that was not accompanied by coryzal symptoms for 1 day. She initially presented to a family physician and was given 3 days of oral azithromycin. However, her right neck swelling grew in size and redness over the last 2 days prior to admission. It was reported that she did not have contact with any sick persons. However, she had travelled to South India a month ago.\nOn physical examination, the child was febrile with a temperature of 38.4°C, and lethargic. Her heart rate was 122 beats per minute, blood pressure was 100/60 mm Hg, and respiratory rate was 27 breaths per minute. There was no pallor or jaundice. An erythematous papular rash was noted over her trunk and limbs, but with no skin peeling. Her conjunctiva was extremely injected bilaterally without any eye discharge. Her lips were red, and she had a strawberry tongue. Her throat was mildly injected with no tonsillar enlargement or exudates. Tympanic membranes were normal bilaterally. There was a palpable right cervical lymph node, measuring 5 by 3 cm, which was tender and warm to touch with overlying erythema, causing limited lateral rotational movement of her neck. On auscultation of her chest, both her heart sounds were heard without any murmurs, and her lung fields were clear bilaterally with no adventitious sounds heard. Her abdomen was soft and nontender, with no hepatos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 24-year-old woman, 1 gravida and 0 para. She was diagnosed with a normal intrauterine pregnancy. There was no abnormality in her medical history and allergy history.\nAt 36 weeks and 2 days of gestation, she was diagnosed with a placental abruption and underwent emergency cesarean section immediately. A female baby weighing 2439 g was delivered with umbilical artery pH of 7.140. The amount of bleeding during surgery was approximately 658 ml including the amniotic fluid. Until the 2nd postoperative day, there were no abnormalities in her vital signs or urinary volume.\nBlood tests were performed on the 3rd postoperative day and revealed severe anemia with a hemoglobin (Hb) level of 3.9 g/dl. Performing an abdominal ultrasound examination and enhanced computed tomography (CT) of the lower abdomen, we found a hematoma with a diameter of 9 cm between the uterus and bladder (). A blood transfusion improved the anemia immediately. She did not complain of abdominal discomfort, and no signs of infection were observed. Thus, a conservative therapy was chosen. She was discharged on the 10th postoperative day and was followed as an outpatient.\nOn the 28th postoperative day, she came to our department with a complaint of abnormal vaginal bleeding. Blood tests did not reveal anemia (Hb 12.0 g/dl). Enhanced CT and magnetic resonance imaging (MRI) were performed, and there were no apparent findings of infection associated with the hematoma; however, we were concerned about a fistula at the site of the uterine incision. To remove the hematoma and check the incision site, we performed laparoscopic surgery.\nWe inserted a 12 mm port in the umbilical region and observed the abdominal cavity. The hematoma was located extraperitoneally inside the chorda umbilicalis (). Then, we performed resection of the hematoma laparoscopically. We cut the peritoneum inside the chorda umbilicalis and successfully reached the interior of the hematoma. The uterine incision site was locate"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male presented with a 6-month history of the appearance of multiple discrete fluid-filled lesions over erythematous skin, of size around 0.1–0.2 cm, which gradually increased to a size of around 1–3 cm. The lesions first appeared over the trunk and gradually over other parts of the body. The lesions used to rupture after 5–6 days leaving behind raw erosions, which were nonspreading in nature. The erosions used to get crusted in the next 4–5 days which fall off leaving behind light-colored skin. There was no history of any drug intake before the appearance of the lesion. On cutaneous examination, few tense bullae of size around 0.5 cm were found to be present in the perineal region []. There were multiple healed hypopigmented lesions with perifollicular hyperpigmentation, with some lesions showing crusting over them. A peculiar finding of the distribution of lesions was that the lesions covered the whole body but spared a band-like area in the hip region both in anterior and posterior aspects []. Oral mucosa was not involved. Remaining systemic examinations were within normal limit. A provisional diagnosis of bullous pemphigoid with the reverse Koebner phenomenon was made with the probable cause of sparing being the tightness of clothing in that particular area. Suspecting the same biopsy was sent for histopathology and direct immunofluorescence from both the lesion and the spared area. The histopathology of the lesion showed subepidermal split with a mixed inflammatory infiltrate, which was composed of predominantly eosinophils, neutrophils, and lymphocytes [], but the histopathology of the spared skin showed no abnormalities []. However, the direct immunofluorescence from the perilesional area showed linear deposits of immunoglobulin G and C3 in the dermoepidermal junction [], but the direct immunofluorescence from the spared area showed no deposits. Indirect immunofluorescence and salt splitting could not be done because of resource constraints. Rest"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old female was admitted to our hospital (Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, China), presenting with recurrent abdominal pain (apparent for >1 year) and paroxysmal abdominal pain accompanied by bloating and loose stools, but no nausea or vomiting. The results of the physical examination revealed abdominal distension and visible intestinal peristaltic waves; however, there was no whole abdominal or rebound tenderness. Orthostatic images of the abdomen showed an incomplete intestinal obstruction, while the results of an oral colonoscopy revealed a narrow lower end of the jejunum, no ulceration and a new neoplasm, which was considered to be narrow small intestine (possibly the lower end of the jejunum). The narrow section was surgically biopsied (2011–6099) and judged to be a chronic mucosal inflammation of the lower end of the jejunum. Laparotomy revealed a hardening and narrowing of the small bowel at the junction of the jejunum and ileum, with significant expansion proximal to the jejunum and a large volume of intestinal contents. Numerous lymph nodes were observed on the mesentery, and the intestinal canal had significant hyperemia and edema. There was a section of diseased small intestine ~1.5 m to the ileocecal valve, and the lumen was hardened and narrow. The two mucous membranes of the small intestine exhibited pathological changes and were smooth and complete. The lesions did not penetrate the mucous layer. Small bowel resection and anastomosis surgery were performed on the narrow section (). The postoperative pathological results revealed a poorly differentiated/undifferentiated carcinoma of the small intestine, with invasion of the cancerous tissue into the intestinal submucosa, muscularis externa and placenta percreta. Extensive invasion of the cancerous tissue was also observed inside the mesenteric layer; however, there was no cancer present in the mucous layer and no metastasis into the intestinal lym"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male patient visited Yeungnam University Hospital with abnormal chest computed tomography (CT) findings on a routine medical examination. The patient was taking medications for hypertension, diabetes mellitus, and hypothyroidism and had a history of traumatic abdominal aortic aneurysm surgery 40 years previously. Chest CT revealed a 3.5-cm oval mass in the posterior mediastinum at the level of the eighth to ninth thoracic vertebrae in addition to multiple pulmonary nodules (). Magnetic resonance imaging (MRI) of the abdomen showed multiple poorly enhanced masses in the liver. The liver masses were smaller than 2 cm and emitted a low T1 signal and a high T2 signal (). We considered the possibility that the lung and liver lesions were metastatic, but blood tumor marker tests were normal. Percutaneous needle biopsy (PCNB) of the pulmonary lesion failed to yield a meaningful sample. With the possibility of neurogenic tumor or pulmonary and hepatic metastases in mind, we decided to perform surgery. We planned to resect the mediastinal tumor and biopsy the pulmonary lesion for diagnosis. We decided to determine the treatment plan for the hepatic lesions based on the surgical pathology results. We performed surgery with the patient in the left lateral decubitus position via video-assisted thoracoscopic surgery. We made 3 ports (5 mm, 10 mm, and 12 mm) using a 10-mm telescope. We identified the mediastinal tumor as observed on chest CT. The mediastinal tumor was located in the posterior mediastinum, close to the sympathetic chain and supplied by feeding vessels from the intercostal vessel. The tumor was well-demarcated without invasion into adjacent structures. After ligation and division of the feeding vessel with a hemoclip, the tumor was removed without difficulty. A pulmonary examination revealed multiple well-circumscribed nodules of different sizes, diffusely distributed on the lung surface. We performed wedge resection to obtain tissue for diagnosis. Af"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old, single, Caucasian woman presented to the emergency department with a 3-month history of experiencing progressive shortness of breath that was associated with bilateral lung infiltrates. She was examined in several clinics and was treated with several courses of different oral antibiotics; however, her condition did not improve, and her shortness of breath progressively worsened over time. She reported a history of low-grade fever, a dry cough, fatigue, and the loss of appetite. Furthermore, she did not have a history of skin lesions, joint pains, or any symptoms that suggested connective tissue diseases. Additionally, her past history revealed that she had been suffering from severe depression for which she was taking oral antidepressants. Upon presentation, she was found to be on daily doses of two SSRI medications. She was prescribed paroxetine 50 mg to be taken once daily, which she was taking for the last 1 year, and owing to a misunderstanding, she was also prescribed escitalopram 10 mg to be taken once daily. As a result, she was taking both medications together for at least the last 6 months.\nA physical examination disclosed that the young lady was suffering from moderate respiratory distress and peripheral cyanosis and that her oxygen saturation, measured by pulse oximetry, was 84% in the room air. During chest auscultation, she exhibited fine bilateral basal crepitations, but she did not exhibit wheezing. Furthermore, she did not present finger clubbing, skin abnormalities, or palpable lymphadenopathy. The examination of her cardiovascular system was unremarkable, and an abdominal examination did not reveal palpable organomegaly. The musculoskeletal and central nervous system examinations also did not reveal any abnormalities.\nFurthermore, her initial investigations revealed a normal complete blood count (CBC), and her renal and liver function tests were normal as well. Her arterial blood gases showed type I respiratory failure with a partial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31 year old female with a history of two cesarean sections, the last one of them three\nyears prior, presented with a painful mass in the left lateral side of the Pfannenstiel\nincision which had been steadily growing. The same patient went a month ago to our\ninstitution's urology clinic with pain in the inguinal region. After a detailed history\nand physical examination an ultrasonography was performed that revealed a 20X12 mm\nhypo-echoic nodular mass, neighboring the rectus abdominis muscle, with minimal\nvascularization. The differential diagnosis included endometriosis and a possible\ndesmoid tumor. The patient was referred to our clinic for further evaluation. The pain\nstarted on the left lower quadrant and radiated towards the inguinal region, and was\nassociated with menstruation. In physical examination a 2 cm wide mass was palpated in\nthe previously described localization. Magnetic resonance imaging was performed which\nrevealed a 20x11 mm mass which is slightly hyper-intense in the T1 sequence, and\ncontrast enhanced after IV gadolinium injection in the T2 sequence, with increased\nsignal intensity and nodular appearance in diffusion weighted sequences. These were\nfound to be consistent with an endometrial implant ( and ). Examination of the\nuterine cavity showed effusion which was at most 15 mm in width when measured. A little\nfree fluid, indicating peritoneal irritation was present in between the intestinal\nloops. No pathological lymph nodes were present in the lower abdomen.\nThe patient was admitted for surgical removal of the mass 2 cm wide fibrotic appearing\nmass was excised () and was sent for\npathological examination. The patient's complaints resolved after the surgery. She was\ndischarged with no complications two days after the operation. Four months after the\nsurgery, the patient came in for a follow-up visit, and had no complaints or\ncomplications. Histopathological examination was consistent with glandular structures of\nthe endometrium with accompanyin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old Emirati male presented to Cleveland Clinic Abu Dhabi (CCAD) emergency department (ED) for the first time in Sept 2015 complaining of severe abdominal pain. The pain has been episodic for the last 4 years and had significantly affected his work and family life. He was seen and admitted to multiple hospitals across Abu Dhabi, including our own, attended different specialists, and underwent a wide range of investigations including blood tests (CBC and differential count, liver and renal profiles and CRP), gastroscopies, colonoscopies, and CT scans and a laparoscopy. The results of all his clinical assessments and investigations did not show any sign.\nOn one of his acute admissions to CCAD, the immunologist was asked to review the patient. Detailed examination of the patient's medical history starting from the onset of symptoms reveled that he used to get 2 swelling episodes every week affecting his face, hands, feet or scrotum and severe abdominal pain twice a week. These swelling episodes and abdominal pain appeared suddenly without any obvious triggering factor, developed over 36 hours and resolved spontaneously in 5-7 days without any medication including analgesics. He reported no laryngeal swellings or respiratory compromise. He denied any fevers, night sweats, weight loss, change in bowel habits or blood in his stools. His swelling episodes were occasionally associated with non-pruritic red skin rash that was mistaken for chronic urticaria for which he was treated with Omalizumab (300mg every 4 weeks) for 9 months without any benefit. Moreover, his response to different types of analgesia, high dose antihistamines, antibiotics and corticosteroids was unsatisfactory. He is a thalassemia carrier; otherwise he is fit and healthy and has no past medical history of note. He has no family history of immunodeficiency, inflammatory bowel disease, autoimmunity or FMF. On examination, he was in pain and his abdomen was soft, tender with guarding and decreased"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn this study, we report a 27-year-old single man with no history of psychiatric disorder or drug abuse. His illness initiated with some pure psychiatric symptoms; for 3 years, the case had a fear with the feeling of being followed by others, without any external stressor. His symptoms were then exacerbated to hesitation and muttering, irritability, anger outbursts, bad tempering, and antisocial behavior. He thought his colleagues at work are likely to harm him due to his good skills at his job. His symptoms gradually tended toward depression, severe fatigue and loss of energy, loss of appetite, and weight loss and were followed by joint stiffness and loss of movement control at upper and lower limbs. After 6 months from the appearance of symptoms, he was brought to a psychiatric office being uncertain of hallucinogenic drug abuse. The psychiatrist prescribed citalopram 20 mg daily, risperidone 2 mg three times a day, and biperiden 2 mg three times a day; however, no improvements in the symptoms were observed.\nAlthough there was no history of psychiatric disorders and drug abuse, due to some motor neuron involvement, the patient was referred to carry out a brain imaging (magnetic resonance imaging [MRI] without contrast) to rule out organic disorders in a month. He was referred to psychiatrist after 6 months from the appearance of symptoms. The psychiatrist also asked the patient to carry out brain MRI following the medical treatment. The T2-weighted MRI demonstrated periventricular and white matter multiple sclerotic plugs with lesions (). Because of the presence of paresthesia, upper and lower limb muscle weakness, ataxia, and urinary incontinency, he was referred to a neurologist. MS diagnosis was made based on the patient’s signs, symptoms, and imaging findings. He took methylprednisolone (5 mg three times a day/until remission) and interferon therapy, which resulted in improvements in sensory and motor neuron involvement and socio-occupational behavior and disa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male patient presented with complaints of a nasal forehead mass which had gradually increased in size over the past 5 years and influenced his appearance.\nThe patient found the nasal-root mass 5 years ago. The mass was the size of a peanut, soft, of normal skin color and with a swollen smooth surface, often exhibiting self-absorption with no other discomfort. In October 2018, nasal mass resection was performed at a local hospital and postoperative pathology was unclear. A relapse occurred in January 2019 and the mass gradually increased in size over the next 10 months, to approximately the size of 5 cm × 2.5 cm. The patient came to our department for a clear diagnosis and treatment.\nThe patient was in good health and had no history of chronic disease. In 2012, he underwent appendectomy in a local hospital due to acute appendicitis.\nPhysical examination of the nose upon admission showed that the shape of the nose was normal. The left part of the nasal-root mass was about the size of 5 cm × 2.5 cm. It was soft, with a smooth surface, no redness or swelling, no ulceration, and no tenderness.\nNo abnormalities in terms of renal function, erythrocyte sedimentation rate (ESR), rheumatism, serum complement (C3/C4), quantitative immunoglobulin determination, immunoglobulin IgG4, antinuclear antibodies or ANCA were found. The possibility of Kimura's disease was not considered before surgery, and IgG4 and IgE levels were not detected before the operation. Positive laboratory results are shown in .\nAfter admission, computerized tomography (CT) and magnetic resonance imaging (MRI) examination of the patient's paranasal sinuses were performed. MRI showed an iso-intense signal in the T1 sequence, iso- and hyper-intense signal in the T2 sequence () and enhancement in the T1 enhanced sequence with an unclear boundary. CT showed a soft tissue signal in the nasal forehead with an unclear boundary ()."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old male patient came to the Urgent Trauma Center after being hit in the chest by a bull. Symptoms were mild pain on the right lower ribs posteriorly without visible contusion marks and without cardiorespiratory compromisation. According to the patient’s medical history he had never had any respiratory symptoms or condition before the incident. A chest X-ray was performed and while there was no sign of broken ribs, pleural effusion or pneumothorax, there was a big, sharply marked, round shadow present on the right lung. Laboratory tests (complete blood count, C-reactive protein, renal function and coagulation parameters), thorax and abdominal ultrasound were performed immediately without any pathological finding. Urgent thorax computed tomography (CT) scan was performed and the radiologist described a dense sharply marked formation filled with fluid sized 10.6 × 11.1 × 11.6 cm in contact with the right main bronchus (Fig. ). The patient was admitted, a bronchoscopy was performed and there was no intraluminal evidence of tumor. A pulmonologist was called in, who then recommended an ultrasound or a CT-guided thoracic puncture considering the formation to be an intrapulmonary hematoma and, less likely, a primary lung tumor or an echinococcal cyst. CT-guided transthoracic puncture was performed and the substance was sent for a cytological analysis which showed that the formation is most likely a pleomorphic adenoma but could also be a hamartoma and required histopatholological verification. From the admittance and during his hospital stay the patient was stable and asymptomatic. The operation procedure was scheduled as soon as the cytological analysis was completed. Right lateral muscle-sparing thoracotomy was performed. Macroscopic examination showed a large reddish capsulated tumor with a smooth surface, clearly demarked from the surrounding lung parenchyma. There were no macroscopic pathological findings on the pulmonary lobes. During the extirpation, surgi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old woman presented with dyspnea on exertion. Chest radiography showed an enlarged mediastinal silhouette. Preoperative computed tomography (CT) and echocardiography revealed a giant cyst (12 × 10 cm in diameter) occupying a large area around the left atrium and ventricle, and it was present behind the pulmonary artery. Based on the preoperative CT findings, a pericardial or an epicardial cyst was suspected. Additionally, attachment of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was suspected (Fig. ). Compression of the left atrium and ventricle was considered to be the cause of her symptoms. Her hemodynamic condition was stable. Percutaneous cystocentesis was performed, and 800 ml of serous liquid was aspirated. However, 1 week after cystocentesis, the cyst recurred, and its size was the same as that before the procedure. Therefore, resection was planned.\nIf the cyst was an epicardial cyst, tight adhesion of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was considered possible. However, we believed that the cyst was more likely a pericardial cyst because a pericardial cyst is more common than an epicardial cyst. Therefore, resection involving video-assisted thoracoscopic surgery (VATS) was planned initially. However, the pericardium was intact and an epicardial cyst was diagnosed intraoperatively. As preoperative CT showed compression of the left atrium, ventricle, pulmonary artery, and pulmonary vein, adhesion was suspected. Additionally, the possibility of cardiopulmonary bypass (CPB) was considered. Therefore, open surgery through median sternotomy was performed. The cyst was found to be attached to the visceral pericardium involving the left atrium and pulmonary artery. Contrary to our expectation, the left ventricle was not involved. Additionally, coronary vessels were not involved. The cyst was most tightly attached to the main pulmonary artery. Thus, it was thought to have or"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old woman Gravid 12 was referred to the Tumor Clinic of Ghaem Hospital, Mashhad University of Medical Sciences in September 2013. Her symptoms were abdominal pain, loss of appetite, nausea, and vomiting from 20 days ago with a history of moderate hematemesis. No severe disease was observed in her medical records. She looked dehydrated and ill in terms of general appearance. Vital signs were blood pressure 70/50 Hgmm, pulse rate 100/minute, temperature 36.1°C and respiratory rate 14/minute. Laboratory studies detected leukocytes 20000 and PMN 87%. Liver and kidney function tests were normal. She was misdiagnosed with the left bundle block view in ECG and the AF rhythm in auscultation which caused her to undergo medical therapy in CCU. At first admission in hospital, abdominal examination revealed tenderness in the right and left lower quadrant of abdomen without rebound tenderness and guarding, and evidence of rigidity and abdominal distention.\nIn sonography evaluation, size of uterus was 133.5 × 80.5 cm with hypoechoic mass 101 × 109 cm in the left lateral of uterine body, which could be probably interpreted as uterine myoma, and some free fluid in peritoneal cavity was also reported. Paracentesis 5 mL suppurative fluid was aspirated under the guidance of sonography. Findings of CT-scan were a round cystic mass with focal calcification at its periphery located in the pelvic cavity with the diameter about 14 × 11.5 cm probably ovarian cyst adenoma ( and ).\nBased on the diagnosis of peritonitis (suppurative fluid aspirated), emergency laparotomy was performed and 700 mL of suppurative fluid in the abdominal cavity with normal appearance bowel and liver was found. The origin of pus draining was a 1 × 1 cm rupture in the anterior wall of uterus. However, there were multiple polypoid tumors in cervical canal yielded stenosis of cervical discharge. After peritoneal irrigation with 5 to 6 L of normal saline, total hysterectomy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80 year old Caucasian male presented to an arthroplasty review clinic 8 and a half years following the insertion of a primary DePuy PFC Sigma Posterior Stabilised (PS) TKA (size 3 tibial tray, size 3 femoral component and 15mm tibial stabilised insert).\nThe initial procedure had been uneventful and the post operative x-rays were deemed satisfactory. He had complained of some anterior knee pain, 1-2 years post operatively. This was attributed to sight overhang of the patella laterally. The patient declined any further surgery at that time as he was extremely mobile, managing long walks and cycling. His range of movement at that time was from 0-120 degrees flexion. As a precaution, his inflammatory markers were checked and found to be within normal limits.\nAt 5 years follow up, he had no complaints and was pain free. He was given a review appointment for a further 5 years. He represented early, however, at 8 and a half years post operatively, complaining about pain in the knee, with episodes of swelling and instability. Interestingly, he was able to sublux his knee posteriorly, using his hamstrings []\nRadiographs showed an inverse shadow of the polyethylene liner protruding anteriorly over the tibial tray. There was no sign of loosening of the tibial tray or femoral component []. This suggested anterior polyethylene subluxation: this subtle sign has been described as indicative of failure of the locking mechanism in posterior-stabilized prostheses [].\nHe was operated on one month later. On making the arthrotomy of the knee, it was apparent that the polyethylene liner had dissociated from the tibial tray and was protruding anteriorly []. On removing the tibial insert it was found that the anterior locking flange on the under surface had fractured from the liner, allowing it to dissociate from the tibial tray. There was a line of wear along the base of the anterior aspect of the stabilising"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old man presented with dry cough of five years duration with no associated breathlessness or wheezing. He did not report a post nasal drip or systemic symptoms. He was diagnosed to have Crohn's disease with gastro duodenal involvement ten years earlier. The diagnosis was established based upon typical features on a duodenal biopsy. He was treated with prednisolone and mesalazine. The Crohn's disease was in remission in less than a year following which prednisolone and mesalazine were discontinued. He was continued on treatment with a proton pump inhibitor. He worked as a university lecturer. He was an ex-smoker of ten pack years and had stopped smoking ten years earlier. On examination he did not have cyanosis, digital clubbing or significant lymphadenopathy. Examination of the respiratory system was unremarkable. A chest radiograph demonstrated bilateral apical infiltrates (Figure ). A full blood count, biochemical profile, angiotensin converting enzyme levels and total as well as specific immunoglobulins were all normal.\nA fibre optic bronchoscopic examination was macroscopically normal. The appearance of the trachea and the bronchial tree was entirely normal. Based on the chest radiograph, a bronchial wash as well as bronchial and trans-bronchial biopsies and were performed from the left upper lobe. The bronchial wash was sterile and negative for acid fast bacilli on stain and culture. The bronchial biopsy showed evidence of a mild inflammatory cell infiltrate, including eosinophils, in the sub epithelial connective tissue. The trans-bronchial lung biopsy was normal. The trans-bronchial biopsy was complicated by a small pneumothorax which did not need any intervention. A high resolution computed tomography (CT) scan showed a normal trachea and normal proximal airways which narrowed and then dilated peripherally. These dilated peripheral bronchi appeared fluid filled. These changes were seen bilaterally, well demonstrated in the left upper lobe (Figure )"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old Asian female patient with a past medical history of hypertension and adenomyosis presented to the outpatient clinic with a chief complaint of painless hematuria for one day, which was associated with generalized weakness for a few weeks prior to presentation. She denied weight loss, nausea, diarrhea, or abdominal pain. The remainder of the review of symptoms was negative. On physical exam, she was afebrile, with a respiratory rate of 15 per minute, heart rate of 80 beats per minute, blood pressure of 130/90 millimeter of mercury, and saturating 99% on room air. Physical examination revealed a mobile mass in the right lower quadrant. She was subsequently referred to the emergency department. The laboratory results on admission are revealed in Table .\nCT scans of abdomen/pelvis with IV contrast showed new right-sided mixed cystic and solid pelvic mass measuring up to 6 cm, which obstructed and invaded the distal right ureter, concerning for malignancy (Figures -).\nCT chest with IV contrast showed multiple pulmonary nodules less than 5 mm. PET/CT revealed increased radiotracer activity in the right pelvic mass consistent with malignancy. Tumor markers including CA-125, CEA, and CA 27-29 were negative. Colonoscopy, mammogram as, well as a recent pap smear, were all negative for malignancy. Based on the diagnostic workup, the patient was thought to have a relapse of sarcoma. She underwent laparotomy with excision of the right-sided pelvic mass along with an abdominal washout. At the same time, she also underwent cystoscopy with right ureteral stent placement.\nTissue pathology was consistent with spindle cell neoplasm and histologic features were consistent with a recurrent stromal cell sarcoma as shown in Figure . The microscopic description of the mass revealed a spindled blue cell lesion with no necrosis, but a moderate mitotic rate. Immunohistochemistry was strongly positive for estrogen receptor (ER), progesterone receptor (PR), WT-1, CD99, and CD 56. T"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old man presented with a 3-month history of cough and shortness of breath during exercise. On physical examination, he had an audible expiratory stridor. The chest X-ray was normal. Computed tomography (CT) of the neck and chest revealed a 1.5 cm polypoid tumor arising from the posterior wall of the upper thoracic trachea (). A flexible bronchoscopy showed a double cone shaped, polypoid tumor arising from the posterior wall of the trachea, 5 cm distal to the vocal cords, and 7 cm proximal to the carina (). Based on the biopsy specimens, the mass was diagnosed as a glomus tumor. To check for an extension of the tumor into the surrounding tissue, an endoscopic ultrasonic exam was performed, and it showed that the tumor was confined to the trachea. Since the tumor was located in the upper trachea, we decided to approach the tumor through a cervical collar incision. After exposure of the trachea, the location of the tumor was identified between the 5th and 6th tracheal rings using flexible bronchoscopy. We divided the trachea one cartilage ring below the tumor and a sterile laryngectomy tube was inserted into the distal trachea. A proximal tracheal division was made one cartilage ring above the tumor. A frozen section analysis confirmed negative margins. Anastomotic sutures were placed using interrupted 4-0 Vicryl sutures (Ethicon, Somerville, NJ).\nThe surgical specimen was 3 cm in length with a luminal diameter of 2.3 cm. There was a 1.3×1.2 cm blue-red protruding nodule on the mucosal surface of the trachea (). The tumor did not show an infiltrative growth into the tracheal cartilage. At the microscopic level, the tumor showed glomus cells, vascular structures, and smooth muscle tissue (). The glomus cells had undergone a transition to elongated, mature smooth muscle cells in some foci (); this feature differentiated this tumor from ordinary glomus tumors. The tumor cells showed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old Hispanic male patient presented to the emergency department with intermittent lower abdominal pain and diarrhea. The patient had a previous history of ulcerative colitis and total abdominal colectomy with J-pouch and ileoanal anastomosis (2012) and a laparoscopic incisional ventral hernia repair with mesh (2015) in another institution.\nThe patient described his pain as intermittent and vague in nature, starting from the suprapubic area and spreading all over his abdomen, rated 6/10. The pain was not associated with fever, nausea, or vomiting. The patient had been having such episodes since his hernia repair but they increased in intensity over the past three weeks. He also had chronic diarrhea with a small amount of blood when he wipes. Physical exam showed a midline incision scar with bulging when coughing and diffuse tenderness all over the abdomen most prominently over the suprapubic/lower abdominal area. The patient looked ill in mild distress and had positive bowel sounds and tachycardia. Initial lab results showed mild normocytic anemia (HGB: 10.5, WBC: 9800, PLT: 579, HCT: 32, and MCV: 70). CT scan () showed thickening and stranding of the J-pouch and rectum, with obliteration of the rectal fat planes, along with mesenteric lymphadenopathy. There was proximal dilatation with partial air-fluid levels within the small bowel, concerning for partial obstruction. A flexible sigmoidoscopy () showed inflamed mucosa with ulceration and adherent mucus. Multiple biopsies were obtained. A large foreign object was visualized in the pouch. It had a rope-like lattice appearance on its outside; the inner contents were not well visualized. The foreign object was not removed then due to the uncertainty of its origin and extent. The patient was then taken to the operating room for pouch exam under anesthesia where the foreign body was removed in its entirety (). The object turned out to be a mesh with tacks and sutures from the original placement one year"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old man received a renal transplantation from cadaver donor on October 1999, after one year spent on dialysis. The early clinical course was characterised by a delayed graft function and two clinical episodes of acute rejection, both treated with steroid pulse therapy. The immunosuppressive treatment consisted of basiliximab, methylprednisolone, cyclosporine, and azathioprine (AZA). At discharge, creatinine plasma concentration was 2.0 mg/dL and remained stable thereafter. On October 2002, AZA was replaced by sirolimus, and some months later cyclosporine was completely withdrawn. No rejection episode, nor infectious problems were observed during the following years.\nIn 2007 the patient, due to work problems, moved to a different hospital for his periodic followup. On October 2010, routine laboratory analysis showed the asymptomatic rise of plasma creatinine to 3.2 mg/dL. An abdominal ultrasonography (US) was performed, showing a hyperechoic solid renal mass that completely enveloped kidney structures. The nephrologist suspected a renal neoplasia and advised the patient to contact us for a deeper clinical evaluation.\nAt admission in our unit, the decline of GFR was confirmed (plasma creatinine: 4.2 mg/dL); palpation of the transplanted kidney evoked no pain, and diuresis was maintained. The US confirmed the alteration of renal structure due to the presence of a conspicuous nonvascularized mass (10.4 × 4.1 cm) that completely wrapped the kidney around, but had the characteristics of fat tissue, with a concomitant hydronephrosis (Figures and ). A RSL was hypothesized, and a computed tomography (CT) scan was performed, since magnetic resonance imaging (MRI) could not be performed due to the presence of abdominal metallic clips. CT (with no contrast medium) confirmed the presence of the extensive fat proliferation that completely covered renal pelvis; the ureter was not visualized, nor calculi could be demonstrated in any scan.\nThree different diagnoses were co"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old female with insignificant past medico surgical history presented with one day of acute onset pain in the periumbilical region that later migrated and confined to the RIF. She had associated intermittent fever, nausea, and loss of appetite. She did not have any urinary symptoms, bowel irregularities, or gynecological complaints. Abdominal examination was performed by two senior surgeons at two different occasions; the same day had findings of guarding and rebound tenderness at RIF. Hematological tests showed polymorphonuclear leukocytosis with left shift. Biochemical tests and urinalysis were normal. Urinary pregnancy test was negative. Abdominal radiographs were unremarkable. USG could not visualize appendix and was inconclusive except for probe tenderness in RIF. CT scan of the abdomen could not be done due to unavailability. A clinical diagnosis of acute appendicitis was made assigning an Alvarado score of 9/10. Laparotomy was performed using the Lanz incision in RIF. Intraoperatively appendix was found to be normal without evidence of inflammation or infection in RIF. In view of symptoms and signs, a possibility of other pathology was thought. Walking the bowel proximally up to 3 feet (1 m) did not show a Meckel's diverticulum or any other small bowel lesions. There were no obvious mesenteric lymph nodal enlargement and pelvic organs looked pristine. Approaching closure, just when the medial edge of the incision was retracted superomedially, a hemorrhagic lesion seemed to appear little deeper in the mid abdomen. Therefore, the incision was extended transversely from the medial edge to explore further. Entire bowel was explored and this revealed an ulcerated lesion measuring 7 × 5 cm arising from the antimesenteric border of the ileum 8 feet (2.5 m) from ICJ with localized interloop hemoperitoneum and inflammatory exudates as shown in . Resection of ileal segment containing the lesion was performed followed by restoration of bowel continuity and peri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.\nAt age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.\nSix months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.\nA clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.\nShe was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.\nMagnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old Greek woman, presented in the General Hospital of Volos with a painless neck mass on the left (Fig. ). No previous operations were recorded in patient's medical history. She reported that the lesion appeared in the last year and had a slow growth. Fine needle aspiration biopsy (FNA) of the lesion revealed a small amount of inflammatory cells mainly lymphocytes and several neoplastic cells with malignant features advocating undifferentiating carcinoma. These cells were either scattered or aggregated with large, hyperdense nuclei, nuclear membrane grooves and several abnormal mitoses. Several neoplastic cells were spindle shaped with solid cytoplasm and multiple nuclei. Computed tomography with contrast of the neck region revealed a bi-lobe lesion of 3.2 × 2 × 4 cm dimensions with peripheral enhancement and hypodense necrotic center in the subcutaneous tissue of the posterior neck triangle with no involvement of the deeper muscle tissue (Fig. ). After a thorough clinical examination, including endoscopy of the nasopharynx, larynx, and hypopharynx, and with no signs of metastatic disease, the lesion was excised under topical anesthesia.\nHistology showed a low grade nodular malignant mesenchymal neoplasm consisting of perpendicularly arranged fascicles of spindle cells with eosinophilic fibrillary cytoplasm, scattered pleomorphic nuclei and irregular mitosis with a rate of 6 to 8 per 10 high-power-fields (Fig. ). The lesion was localized in the subcutaneous tissue, while medially it was in contact with striated muscle without infiltrating it. On immunohistochemical staining, the tumor expressed focal smooth muscle actin (α-SMA) and vimentin, while a small number of tumor cells were also weakly positive to HHF-35, desmin and S-100 stains. According to the histopathology and immunohistochemistry, the final diagnosis was subcutaneous LMS of the neck and the specimen's surgical margins were negative. Brain magnetic resonance as well as computed tomography of l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man presented in 2017 after discovery of a hypervascular, expansile, 7 cm pancreatic body mass involving the splenic vein on routine surveillance CT scan (). He endorsed 1 year of diarrhea and steatorrhea that he had not sought medical care for but denied weight loss, appetite changes, fatigue, pain, or jaundice. He had a history of RCC and underwent a left nephrectomy and adrenalectomy in 2002. Additionally, he developed adenocarcinoma of the ampulla of Vater and was treated with pancreaticoduodenectomy in 2003.\nHe developed pulmonary metastases from the RCC and was treated with right lung segmentectomy in 2006 and three bilateral CyberKnife treatments in 2010, 2011, and 2013. He had surveillance CT scans roughly every 6 months from the discovery of the 2010 lung metastasis until 2015 and then yearly thereafter. He never received any chemotherapy for either the RCC or PDA. He is a former smoker.\nUnfortunately, records of his prior malignancies, treatments, and surgeries were limited. His metastatic workup consisted of a CT scan of the head, chest, abdomen, and pelvis, which revealed no other sites of tumor except the 7 cm mass in the body of the pancreas, and testing his carcinoembryonic antigen (CEA) tumor marker level, which resulted as 0.9 ng/mL. The two main differential diagnoses were metastatic RCC versus recurrent PDA. Imaging characteristics, timeline of the mass development, and normal CEA level were the investigations used to determine that metastatic RCC was most likely and supported the decision to resect the mass.\nThe patient underwent completion pancreatectomy and splenectomy to resect his newly discovered pancreatic lesion. Surgical exploration and dissection revealed that the previous pancreaticoduodenectomy had been completed entirely antecolic. The gastrojejunostomy was able to be left intact throughout the duration of the procedure, whereas the hepaticojejunostomy was reconstructed due to its initial position being too far anterior"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female presented to the emergency room complaining of sharp lower right abdominal pain of 2 days duration; she also admitted to chronic intermittent abdominal pain over the past 2 months. She denied any fever, chills, nausea, vomiting, chest pain or shortness of breath. She did admit to cyclical episodes of diarrhea and constipation. Her past medical history was significant for antiphospholipid antibody with recent stroke and venous sinus thrombosis, lupus and hypothyroidism. Her past surgical history included: caesarian section, total abdominal hysterectomy, laparoscopic cholecystectomy and a total knee replacement. Her family history was negative for any types of inflammatory bowel disorder. Socially, she was married and denied any history of smoking, drug or alcohol use. She took the following medications daily: Coumadin 15 mg, Plaquenil 200 mg and Levothyroxine 25 mcg.\nOn physical exam, she was noted to be afebrile and normotensive. The abdomen was soft with tenderness to palpation in the right lower quadrant. There were normoactive bowel sounds. Laboratory data demonstrated a white blood count of 5300, a hemoglobin of 14.4 and a hematocrit of 43%. Renal function, electrolytes, liver function and urinalysis were all within normal ranges. Her international normalized ratio was 3.5.\nA CT of the abdomen and pelvis without contrast was obtained on admission and revealed a dilated appendix up to 1.5 cm in size with no evidence of obvious appendicolith (). There was evidence of extensive mesenteric edema in the right lower quadrant of the abdomen. It was felt that these findings were consistent with appendicitis with possible early rupture pattern. Due to her history and likely early ruptured appendicitis, she was felt to be a high surgical risk and she was initially treated on the interval appendicitis pathway. This included IV antibiotic therapy and a repeat CT scan of the abdomen/pelvis 48 h after initial presentation. She was also placed on a heparin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old woman with a past medical history of hypertension, hyperlipidemia, cerebrovascular accident (CVA), and left lower lung lobectomy presented to the ER due to intermittent abdominal pain, dysuria, and nausea for one day. Physical exam was significant for diffuse tenderness to palpation, worse in the suprapubic region. Her vitals were blood pressure of 167/78 mm Hg, respiratory rate of 16 per minute, pulse rate 87 beats per minute, and temperature of 95.9 °F. Relevant laboratory workup is mentioned in Table .\nCT scan of the abdomen and pelvis with intravenous (IV) contrast was suggestive of proximal ureteral/ureteropelvic junction rupture and a large amount of fluid in the left retroperitoneum and surrounding the left kidney in the pelvis (Figure ). No clear obstructive etiology was identified on the CT scan. There was no evidence of stone or mass on the CT scan.\nThe patient received broad-spectrum antibiotics in ER. While the patient was in the ER, she was noted to have an atrial flutter with rapid ventricular rate and systolic blood pressure dropped to 89 mm Hg. She was given an amiodarone bolus and she reverted to normal sinus rhythm. Norepinephrine infusion was also planned to be given but once she reverted to sinus rhythm, her blood pressure was noted to improve. She was also noted to drop her oxygen saturation to 70% and was placed on two liters of oxygen through a nasal cannula.\nUrology consultants were consulted and the recommendations were to admit the patient to the intensive care unit (ICU) and placement of percutaneous nephroureteral catheter tube (PNCT). This was done successfully (Figure ). The patient was monitored in ICU and continued on antibiotics.\nOver the course of her stay, the patient clinically improved, and she was transferred out of ICU to medicine service. Due to persistent leukocytosis, a CT scan abdomen and pelvis with IV contrast was repeated, which did not show any clear infectious"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male had a traffic accident while riding his bicycle and hit his left knee on the ground. He presented at our hospital 4 days after the accident. He could walk without crutches but could not extend his knee against gravity. We palpated a subcutaneous depression in the left knee.\nThe patient was 165.5 cm tall, weighed 63.8 kg, and had a BMI of 23.3 kg/m2. He had previously experienced a comminuted left patellar fracture and underwent a total patellectomy when he was 20 years old. After the patellectomy, he had no complaints and had a full range of movement in the left knee. The preinjury Lysholm knee score was 90 []. At 57 years of age, the patient had received mitral valve replacement for regurgitation at another hospital and had been on anticoagulant therapy since then.\nPlain radiographic examination did not show any fracture of the left knee but detected the absence of the patella and a small heterotopic calcification at the distal side of the quadriceps tendon (). Ultrasound examination showed a loose left patellar tendon compared with the contralateral side (), although it could not identify the rupture site. Magnetic resonance imaging (MRI) revealed subcutaneous edema and tendon disruption at the proximal side of the left patellar tendon, which indicated patellar tendon rupture (). We immediately immobilized the left knee with a splint and changed his anticoagulant therapy from warfarin to intravenous heparin.\nSurgery to reconstruct the ruptured left patellar tendon was performed 12 days after the accident. We made a midline incision instead of an oblique incision along the previous scar and found a complete patellar tendon rupture with both medial and lateral patellar retinaculum rupture with about a 2.0 cm gap filled with a hematoma (). These ruptures were at the proximal side of the patellar tendon. We first washed and removed the hematoma and refreshed the ruptured tendon edge with scissors. The length of remained patellar tendon was about 5 c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male with a past medical history of chronic cocaine abuse was found unresponsive in the field. He was given multiple doses of naloxone in the field without any improvement in mental status. On presentation in the emergency department (ED), the patient was found unresponsive to questions and unable to follow commands but withdrawing to painful stimuli, with a Glasgow Coma Score of 8, and tachypneic. Vital signs were significant for a respiratory rate of 38 breaths per minute and oxygen saturation of 90% on 6 liters nasal cannula. Physical exam appreciated no tracheal deviation and no jugular venous distention but exhibited an uneven rise and fall of his chest on the right side compared to the left. On cardiopulmonary auscultation, absent breath sounds of the right lung fields were noted with normal cardiac heart sounds. The patient was emergently intubated for airway protection in the ED, and further evaluation was initiated. Immediate imaging with portable chest X-ray was obtained which showed extensive lucency in the right hemithorax suggestive of large pneumothorax or an air-filled cyst (). A CT scan of the chest was performed which suggested extensive pneumothorax of the right lung without a mediastinal shift ().\nFor this reason, an emergent 24 French chest tube was placed in the right 6th intercostal space but failed to expand the lung. In response, the chest tube was then exchanged for a 32 French tube under the assumption that a larger size may be required, but it too failed to expand the lung. There was no air drainage from either tube placed suggesting lack of a pneumothorax. He was stabilized and admitted to the intensive care unit for further management. A few hours after admission, he underwent bronchoscopy with a right chest VATS which revealed a giant bulla encasing the entire right pleural cavity with its origin in the right upper lobe beginning at the apex. The bulla was extracted, and pleurodesis was performed by mechanical and chemical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 11-year-old boy was the second child of healthy unrelated parents. At the time of birth, his father and mother were 30 and 25 years old, respectively. He was a term newborn and his prenatal as well as perinatal period history were uncomplicated, except for mild hyperbilirubinemia (15 mg/dl of total bilirubin) at day 4 probably due to breast milk which improved with simple phototherapy. His early psychomotor development was normal. He completed the first and second level of elementary school with good scores. He developed one episode of generalized tonic-clonic seizure at age eight. It was repeated several days later; therefore, he was admitted to our hospital and phenytoin was started and the seizures were controlled. At this time precise physical and neurological examination unfolded clinical features of ODDD. Examination of the face revealed a long and thin nose with hypoplasia of nasal alae and anteverted nostrils (). Ophthalmic examination revealed microphthalmos with microcornea (), decreased visual acuity and glaucoma. Hearing assessment was normal. Oral cavity examination revealed yellowish color of the teeth with carries and smaller than normal and atypically-shaped teeth with arrested development appearance (). On skeletal examination, his hand revealed evidence of webbing of the skin (syndactyly) between the fourth and fifth fingers. There was also evidence of camptodactyly and hypoplasia of the mid phalanx of the fifth fingers (). Both parents were carefully examined and showed no stigmata suggestive of ODDD. His school performance was gradually deteriorated after the episode of seizure at age eight. One year later he complained of gait problem that has progressively worsened. There was spasticity of both legs with hyper-reflexia and extensor plantar responses. Gait examination showed spastic paraparesis.\nOn brain magnetic resonance imaging (MRI), symmetrical confluent hypersignal areas of subcortical white matter were evident with decreased signal o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female came to the diagnosis of the oral disease department of Shahed Dental School for dental treatment with a chief complaint of lack of masticatory capability and poor esthetic for the past 20 years. Her medical history was significant for osteoporosis and congenital heart disease (CHD). Her current medication was the daily use of ASA as an antithrombotic, Digoxin for CHD, Enalapril for her hypertension, and vit D. Also, she had been medicating with Famotidine and Omeprazole for the last two years due to her masticatory hypofunction and digestive problems. Her medical practitioner advised that her dental treatment should be limited to noninvasive dental procedures with minimal trauma. The patient revealed that there was an absence of the lower and upper anterior teeth after exfoliation of deciduous teeth and the history of mandibular fractures 25 years ago in a motor vehicle collision. In extraoral examination, the prominent frontal and parietal, hypertelorism, depressed nasal bridge, mandibular prognathism, and maxillary hypoplasia were observed (). Also, the patient was able to move shoulders in front of the chest associated with underdeveloped or absent collarbone ().\nIntraoral examination revealed a long span bridge in maxilla from tooth #15 to #25 and multiple missing permanent teeth in the anterior and posterior regions of the mandible. A panoramic radiograph and CBCT were captured (Figures and ).\nRadiographic findings revealed multiple impacted permanent teeth in the anterior region of maxilla and anterior and posterior regions of the mandible as well as the fracture of the left angle of the mandible which had been fixed with wire. The patient was diagnosed with cleidocranial dysplasia evidenced by clinical and radiographic findings. After consulting with a maxillofacial surgeon, the extraction of all teeth (erupted and unerupted) and replacement by implants was not suggested due to the medical conditions of the patient including osteoporosis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old woman, who had been taking medication of quetiapine as an antipsychotics for depression, experienced mild dysarthria and visited the department of neurology in our hospital. Her symptom was diagnosed as drug-induced lip dyskinesia, which disappeared in a week. Screening head magnetic resonance imaging (MRI) at this time revealed stenosis of the left MCA with no brain parenchymal lesions (), why she was consulted to our department. We performed angiography, confirming moderate M1 portion stenosis (Figures and ). SPECT showed no apparent laterality in CBF, thereby we decided to observe her with no treatment.\nSeven months later, the patient experienced mild weakness and numbness in her right hand and visited our department. Although MRI showed no apparent ischemic change in her brain, arterial spin labelling (ASL) of MRI detected the decrease of CBF in the left cerebrum (), which was thought to well correspond for her symptoms. She was admitted and treated with an antiplatelet agent. Two weeks later, she still complained of numbness in her right hand; thereby, we decided to perform left STA-MCA anastomosis to prevent deterioration of her symptoms. Preoperative SPECT showed no apparent laterality in CBF (). On operation, left temporal craniotomy was performed, and the parietal branch of the STA was anastomosed with the M4 portion on the temporal lobe (Figures and ). The intraoperative course was uneventful, and the patient recovered from anesthesia without any new neurological symptoms\nPostoperatively, her speech was normal until postoperative day 1 (POD1). On POD2, she exhibited mild speech disturbance, which worsened day by day finally resulting in complete motor aphasia on POD6. Her comprehension was kept normal. On POD3, generalized convulsion occurred, which ceased quickly by diazepam, and levetiracetam was initiated. On the same day, she presented with mild weakness of right upper extremity, which improved gradually and disappeared on POD7. MRI and C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur first patient was a 67-year-old male with a medical history of diabetes mellitus type II, hypertension, and benign polyps in the colon (three polypectomies). The patient had a history of tobacco use during the last 50 years; at the time of reference, he smoked 10 cigarettes daily. He had no alcohol overconsumption. When referred, the patient had suffered from dysphagia for 2 months, and he only consumed fluids. Besides a weight loss of 8 kg (weight at referral 83 kg, weight loss corresponding to 9% of initial body weight), the first physical examination was unremarkable, as were the initial blood tests. The primary endoscopy revealed a mucosa covered with white plaques spreading from 30 to 40 cm from the incisors. In the distal part of the affected area, the mucosa protruded and covered almost 2/3 of the lumen and involved the entire circumference (fig. ). The finding was thought to be a candida infection. Biopsies showed severe acute inflammation with reactive changes but without dysplasia or malignancy. A computed tomography (CT) scan showed a thickened wall in the distal part of the esophagus. Since no malignancy was found, the patient was discharged.\nFour months later, the patient was referred again due to a further massive weight loss of 25 kg; at this time he weighed only 58 kg (weight loss corresponding to 36% of initial body weight). Gastroscopy and blood test were performed again, and human immunodeficiency virus, herpes, and HPV infection were ruled out. To rule out achalasia of the esophagus and gastroesophageal junction, a high-resolution impedance manometry examination was performed followed by a positron emission tomography (PET)-CT scan, but neither could explain the condition the patient suffered from. During this period of approximately 4 months, the patient was hospitalized at the Department of Infectious Diseases.\nSix months after the first visit, another gastroscopy was performed showing ulceration and a process protruding into the lumen. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient A.N. is an 83-year-old woman who was living in Iran in January of 2015 when she presented to a local hospital with painless jaundice and dark urine. A CT scan showed a pancreatic head mass compressing the common bile duct. For palliation of hyperbilirubinemia, a palliative stent was placed in the common bile duct. A fine needle aspirate obtained through an endoscopic ultrasound (EUS) revealed a poorly differentiated adenocarcinoma. A follow-up CT scan performed on February 13, 2015 revealed a 3.6 × 2.7 cm pancreatic head mass that abutted the superior mesenteric artery and one of its proximal branches. There were suspicious peripancreatic and retroperitoneal nodes and no evidence of distant disease. At the beginning of March, she began taking 50,000 U vitamin D3 (cholecalciferol) daily, ordered directly from the Internet and not under the direction of a healthcare practitioner. Repeat EUS and biopsy on March 3, 2015 again confirmed adenocarcinoma with papillary features. She was referred to an oncologist and surgeon for evaluation. A triple phase CT was done on March 16, 2015 that showed a stable mass without any evidence of involvement of the celiac axis or superior mesenteric artery. Upfront chemotherapy was recommended, with consideration of surgery in the future.\nShe received gemcitabine/protein nanoparticle-bound paclitaxel in March. On day 10 of cycle 1, she developed neutropenic fever complicated by atrial fibrillation with rapid ventricular response. She was intubated for a brief time who then recovered to her baseline functional status. She was discharged on April 19. Based on her frailty, she was deemed to be a poor candidate for surgery and chemotherapy was not resumed.\nShe was referred to radiation oncology for consideration of stereotactic body radiotherapy, but she decided to first pursue alternative therapies. She visited an alternative care clinic in April and began taking chelodium, curcumin, community mushroom blend, viscosin, and naltrexon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old Caucasian male was attended at Clinicians Associates in Terrassa (Barcelona); the chief complaint was a fistula on buccal area of tooth 37. At that time the patient was diagnosed with multiple myeloma stage III asymptomatic and only 2 doses of zoledronic acid (4 mg), once per month, have been administrated via IV. After a thorough clinicoradiological examination, a chronic suppurated apical periodontitis of tooth 37 was confirmed (Figures and ). Considering that the analytical parameters were rather good and in order to avoid any active infectious lesion before proceeding to a bone marrow autotransplantation the extraction of this second molar was indicated. A couple of days before performing the conventional tooth extraction, antibiotic prophylaxis with Amoxicillin 500 mg/8 h and Metronidazole 500 mg/8 h was prescribed for 7 more days. The healing process had a complete satisfactory evolution and one week later sutures were removed. Two months later, bisphosphonate treatment was reintroduced with calcium supplementation and six months after the tooth extraction the clinicoradiological control of this localization was normal ().\nOne and a half year after that tooth extraction the patient came for a routine control visit and he complained of slight pain in the left posterior alveolar ridge, in the lingual area. The patient mentioned that the discomfort started after a traumatic injury during mastication. Although radiologically there was not any relevant findings, clinically only one incipient point of inflamed mucosa was observed, which seemed like a simple foreign body reaction. Chlorhexidine topical gel was indicated and this lesion was monitored every two or three weeks also by the oral and maxillofacial surgeon in the Mútua Terrassa Hospital. The lesion size increased and an osteonecrosis of the jaw was the presumptive diagnosis. According to the clinical features and the presence of a sinus tract (Figures –), antibiotic treatment was initiated, Am"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old otherwise healthy male patient reported with the chief complaint of watery discharge from a swelling on the right side of the face for the past 1 month. Patient had a history of mandibular condylar fracture from a road traffic accident, for which he was treated elsewhere with direct open reduction and internal fixation of the condyle. The surgical scar was observed on the post-ramus swelling, and there was fistula in one end of the scar that was about 0.5 cm in diameter [Figures and ]. The wound was 2 cm deep and had a healthy granulating margin with no obvious clinical signs of infection, but the wound continued to have a drain of a copious amount of clear, watery, and odorless fluid.\nOn examination of parotid papillae, intraorally, active secretion was present on the left side, but not on the right side. Neurological examination revealed no motor loss due to severance of any branch of facial nerve in the affected side. Location of the fistula and nature of the discharge suggested a laceration of the right parotid gland substance resulting in a sialocele and a right parotid fistula formation. Siaologram confirmed the clinical suspicion [Figures –].\nIn the present case, trauma in the parotid glandular substance lead to formation of sialocele by accumulation of extravasated saliva into glandular parenchyma. It was decided to create a controlled internal fistula with drainage intraorally under local anesthesia. After standard preparation, intraorally, a 1-cm long incision was placed on external oblique ridge behind the third molar. A small artery forceps was forced through the superficial fascia of masseter reaching the sialocele. With the help of this forceps, approximately 5-cm long, slender, sterile, punched plastic tube of diameter 4 mm was positioned with one end in the glandular substance and the other end in the mouth, seated along the vestibule, ensuring complete convenience. The tube was secured by suturing it to the mucosal surface"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old white man, a middle-distance runner (800 m) competing at national level (seasonal best/personal best of 1 minute 52 seconds), developed severe left heel pain in the pre-season in March 2013. His maximum perceived pain intensity was 10 cm on a visual analog scale (VAS) that ranged from 0 to 10 cm, with 10 cm expressing the worst perceivable pain; the athlete had to interrupt all running activity, and severe pain was perceived even when walking or standing. He continued training with aqua jogging and cycling. He got personalized hand-crafted orthopedic gel peads. Two months later he was attended by an orthopedic surgeon, who additionally prescribed oral intake of nonsteroidal anti-inflammatory drugs (NSAIDs) for 8 weeks. The athlete could continue his training but was not free from pain. When discontinuing medication in July 2013, pain returned immediately, and perceived pain intensity during walking was 10 cm on a VAS (range 0–10 cm). Eight sessions of ESWT were thus added to his treatment plan, and were conducted at a German Olympic center. He did not feel better after the treatment and reported a high level of frustration. An MRI was performed in January 2014 showing a calcaneal spur, signs of inflammation at the calcaneal tubercle, and structural changes of the plantar fascia, surrounded by a large edema (see Fig. ). In February 2014 he underwent an open plantar fasciotomy. Four weeks later he was allowed to perform the first units of regenerative running. Pain returned after approximately 1 week of training. An X-ray revealed no pathology and he was recommended to continue with soft training sessions. He received a peppering injection that reduced pain for 12 hours, and NSAIDs were re-prescribed. His running performance remained at a remarkably low level in comparison to his non-injured state, despite regular personalized training sessions. He presented himself at our out-patient clinic in July"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 32-year-old previously healthy female at the 39th week of gestation who accessed the first aim department of a primary healthcare centre of a peripheral hospital for severe dyspnoea and chest pain. Her past medical history did not present other hospitalizations for the same symptoms. Due to the clinical manifestations, the patient was initially treated as a case of pulmonary embolic disease and subjected to a massive anticoagulant therapy. Considering the clinical diagnosis and the child to term, an emergent caesarean delivery was performed in order to avoid foetal complications. The caesarean section was successfully performed under general anaesthesia using Stark's method due to the urgency related to the patient's clinical condition of increasing dyspnoea. Moreover, although the pAVM was still unknown at time of the caesarean section, the execution of spinal anaesthesia seems to be not indicated because of the risk of pAVM association with other AVMs, such as those located in the spinal cord, especially in case of HHT.\nThe foetal outcome showed an Apgar index of 3, 6, and 9, respectively, at minutes 1, 3, and 5; these data are in line with the administration of general anaesthesia and the acute maternal condition of severe dyspnoea.\nTaking into account the foetal weight at birth, it showed a restriction of the expected value. The child weight was in fact 2590 gr at 39 weeks of gestation. However, ultrasounds performed during the pregnancy reported a reduction of the potential foetal growth from the 33 weeks of gestation without any Doppler alteration. This phenomenon should be the result of the chronical adaptation of the pregnancy to the unknown pAVM.\nAs far as the macroscopic exam of the placenta is concerned, a percentage of cotyledons infarcts inferior than 10% was reported.\nConsidering the patient's postoperative course, it showed a subsequently worsening of the clinical conditions, resulting in an acute distress syndrome that required an i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old male presented for consideration of vertebral augmentation due to diagnosis of stage IV, metastatic prostate adenocarcinoma, and worsening back pain. Lupron therapy was initiated at diagnosis four months prior. Docetaxel treatment was planned for six cycles but was subsequently stopped after the first cycle secondary to side effects. No radiation therapy was previously given. PSA level was 120.73 at diagnosis and 0.6 before radiofrequency ablation.\nAt the first appointment, the patient reported mild back pain and required a walker but was able to ambulate without difficulty. He did have pain upon palpation of the thoracolumbar junctional level. He did not have any neurologic deficit at presentation. Computed tomography (CT) scans showed 40% compression deformity of T12. Magnetic resonance imaging (MRI) showed pathologic involvement of T12 and L1 and metastatic involvement of the epidural component, resulting in 40% spinal canal stenosis (Figure ). At this time, vertebral augmentation was recommended although it was believed the epidural component would not be addressed and Radiation Oncology would need to be consulted. In a short period of two months, the patient’s condition deteriorated where he was wheelchair bound due to severe pain, not controlled with NSAIDS or opioids. In addition, repeat studies showed further tumor infiltration involving T11, prompting augmentation of T11, in addition to T12 and L1.\nThe procedure was performed under monitored anesthesia care (MAC) and fluoroscopic guided imaging. Under this image guidance, 10-gauge introducer needles were advanced into the T11, T12, and L1 vertebral levels using a bilateral transpedicular approach (Figure ). A drill and osteotome were used to create cavities at the anterior aspect of the vertebral bodies. Bilateral 17-gauge bipolar radiofrequency probes were advanced into the vertebral cavities and simultaneous application of radiofrequency energy was performed as part of the protocol for volu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man presented to our Neurology Department with pain at the level of the right shoulder and right interscapular–vertebral region, with onset for about 6 months. In the last 30 days, the pain exacerbated and radiated in the anteromedial part of the arm and clavicular area. The patient also reported pain in the joints of the distal part of upper and lower limbs, especially in the small joints, which afterward became swollen.\nThe patient presented with a medical history of arterial hypertension for the last 10 years, treated with beta-blockers and sartans, and he was a heavy smoker (in the last period he used only electronic cigarettes).\nThe neurologic examination was normal, except for slightly diminished deep tendon reflexes of the lower limbs. The patient reported pain that did not correspond to any radicular or nerve territory, which was exacerbated by pressure on the distal third of radius and ulna, but was not related to active or passive movements of the cervical spine. The general examination showed clubbing of the fingers and toes (not mentioned initially by the patient, but present for about 1 year) with an increase of the shoe size of more than 1.5 sizes, enlargement of the large joints, swollen extremities with a tubular appearance (Figs. and ), a right lateral cervical mobile, painless adenopathy of 1 cm diameter, and pachydermia with thickening of the skin of the scalp, forehead, and fingers, with cranial skin folds.\nCervical magnetic resonance imaging performed in another clinic before the admission to our department showed the presence of disc protrusions from C2 to C7, with concomitant C2, C4, and C5 root compressions. The electrophysiological study revealed an active denervation in the territory of the right C5, C6, and C7 roots.\nThe radiographic examinations of the upper and lower limbs depicted symmetric osseous abnormalities, typical for periostosis, and linear halving of the diaphysis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old female reported for replacement of missing teeth. On intraoral examination, there were only two natural teeth present in the oral cavity #13, 23 in the maxilla. Mandibular arch was completely edentulous []. Clinical and radiographic examination revealed that maxillary canines were periodontally sound with no mobility and periapical pathology. Various prosthetic treatment modalities were explained to the patient. The patient was not willing to extract #13 and #23, and due to severe gag reflex and presence of sufficient interarch space for the placement of metal bar, copings, denture base, and teeth arrangement, it was decided to fabricate maxillary palateless bar-supported overdenture. For mandible, treatment option decided was implant-fixed prosthesis as retention and stability are compromised in the mandible to greater extent than maxilla.\nProper case history was recorded for the patient including medical history which was noncontributory, with routine blood investigations and dental and oral examination. Diagnostic impressions and casts were prepared. DentaScan was carried out to evaluate the dimensions of available bone and appropriate-sized implants were selected []. Template in the form of conventional complete denture was prepared for mandible, and the positions of implants were decided before the surgery. Radiographic template was fabricated with the help of gutta-percha cylinders inserted in the expected location of implants and an orthopantomogram (OPG) 2D image was taken []. It helped in determining height of the available bone at the site of implant placement. At the time of surgery, radiographic template was converted to surgical template.\nFlapless surgical protocol was planned as there was adequate amount of bone, 1 mm bone buccolingually, and sufficient attached mucosa was present at the surgical site such that at least 2 mm of attached gingiva would remain around the implant site. Preoperative antibiotics and analgesics were given to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old female was referred from an outside hospital for squamous cell carcinoma of the right ala. The mass measured 2 × 1.5 cm and had an ulcerated portion from a previous punch biopsy site (). A single-stage operation was offered, to which the patient consented. The tumor was excised through all three layers with a 5 mm margin, and the resultant defect measured 2.5 × 2.0 cm. Intraoperative frozen biopsy report was consistent with squamous cell carcinoma. The lining mucosal defect measured 2.0 × 1.5 cm, and the graft for this inner layer was prepared using a septal mucosal hinge flap based on the septal branch of the superior labial artery. The typical incisional boundaries of a mucosal flap are located superiorly, about 1 cm from the nasal dorsum, inferiorly along the maxillary crest, and posteriorly as far as the extent of the defect. The mucosal flap was elevated from the septum in a posterior-to-anterior direction and turned laterally toward the defect, such that the mucoperichondrium was external and the mucosa faced internally () []. A right conchal cartilage graft was harvested, fashioned into a suitable shape, and placed over the mucosal hinge flap to provide structural support. The outermost surface was restored using a nasolabial island flap with a subcutaneous pedicle that was based on a perforator vessel from the angular artery. This flap was designed using a 3 × 2 cm mirror-image template from the contralateral ala, and was elevated in an inferior-to-superior direction. Once rotated over the septal mucosa-conchal graft construct, the flap was sutured into place (). The nasolabial fold was re-established with primary closure of the cheek skin, under which a capillary drain was left for three days and then removed.\nThe postoperative course was uneventful, without any vascular complications. By 6 months, however, scar contraction along the reconstructed rim had resulted in a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old man with known Marfan syndrome was admitted to the emergency department with sudden onset of right arm and leg weakness and slurred speech 50 min before presentation. His past medical history included a metallic aortic valve replacement 12 years ago, which was infected with MRSA and so this was replaced with tissue valve a month later. Other history included mild congestive heart failure (New York Heart Association class II) and a transient ischemic attack 2 years ago. Echocardiography (ECHO) 1 year prior to this admission had shown an ejection fraction of 41% but stable prosthetic valves. He was fit and independent in activities of daily living. His medications on admission were frusemide, bisoprolol, amlodipine, losartan, spironolactone, and fluoxetine. He was no longer taking aspirin and dipyridamole at the time of admission.\nOn examination, he had a partial left anterior circulation syndrome with right hemiparesis (Medical Research Council grade power of 3/5 in the arm and 4/5 in the leg), a right upper motor neuron facial palsy, expressive dysphasia, and right sided visual neglect. His National Institute of Health Stroke Scale (NIHSS) score was 12. His blood pressure was low at 100/80 mm Hg. Apart from the thoracotomy scar, and the tall features of Marfan syndrome his physical examination was normal. Routine blood tests, electrocardiogram and chest X-ray were normal. A computed tomogram (CT) of the head, performed 2 h after symptom onset, did not show evidence of infarction or haemorrhage (Figure ). Intravenous thrombolysis with alteplase at a dose of 0.9 mg/kg bodyweight was started 2 hours and 30 min after the onset of symptoms. There were no immediate complications, and he remained haemodynamically stable. Twenty hours later he became drowsy. His NIHSS score worsened to 18 with more pronounced right hemiparesis. A repeat CT head scan (Figure ) showed an established left middle cerebral artery territory infarct"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year old homeless male, with a past medical history of peripheral vascular disease, type 1 diabetes mellitus, hypertension, and depression, presented to the emergency department with intermittent chest pain and progressive shortness of breath for a few weeks. The patient denied intravenous drug use, although admitted to the use of recreational marijuana. The patient’s vitals on admission were stable except for low saturation on a pulse oximetry of 86% on room air. On physical examination, the patient was tachypnic and had fine crackles in the bilateral lung fields on auscultation. Laboratory results on admission showed a normal complete blood count and basic metabolic panel, but a urine drug screen test was positive for opioids. Because of persistent hypoxia, a D-Dimer was checked and came back highly elevated. The patient underwent a computed tomography angiography (CTA) of the chest to rule out pulmonary embolism. The CTA was negative for pulmonary embolism, however, it displayed extensive miliary densities throughout the bilateral lung fields (). The patient was admitted to the floor with a differential diagnosis of military tuberculosis versus fungal infection. Human immunodeficiency virus (HIV), fungal, and Quantiferron testing were negative. The cardiac work up and autoimmune serology were also unremarkable. The patient was then started on intravenous steroids and inhaled albuterol, although no improvement was seen. The patient remained hypoxemic despite therapy, and, therefore, underwent a bronchoscopy with a lung biopsy to find out the etiology of the disease process. The lung biopsy showed alveolated lung tissue with a miliary pattern of perivascular foreign body histiocytes containing refractory material suggestive of microcrystalline cellulose material (). There was no evidence of malignancy and there were no fungal or acid fast bacilli organisms identified on special stains. The histological features suggested intravenous injection of foreign materi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old woman presented with intense pain in the shoulders that began 2 weeks after injury during a CrossFit competition, especially on the right side, without edema or reduced range of motion. She started the CrossFit practice routine 2 months before the injury. The patient trained CrossFit three times a week without any other sport activity on the remaining week days. Olympic weightlifting (overhead movement) was described as the last activity before the acute pain started. The initial overhead load was 55 pounds and was part of a “novice” training routine with reported adequate technique. One week prior to the CrossFit competition the patient was oriented to increase the Olympic weightlifting load to 75 pounds as a requirement for competition. Repetitions were set to her own limitation. After the injury, she stopped her exercises and applied ice to the shoulders and upper arms. During the following days, she experienced continuous pain and sought medical attention. Physical examination did not show any reduction of passive and active arcs of movements. Also, Jobe and Bear Hug tests were negative. There was only a mild ligamentous laxity and 10 degrees of elbow hyperextension. Her medical history did not include medications, prior fractures, neoplastic disease or prior surgery on the upper extremities. Also, she did not have history of anabolic or glucocorticoid steroid use. The patient’s height was 1.53 m and weighted 54 Kg, with a BMI of 22.9 and was physically active for more than 3 years. She has never had CrossFit lessons or prior training. Before she started CrossFit practice, the patient used to swim three times a week in college, but did not participate in competitions. The patient had an episode of amenorrhea 3 years ago, considered to be due to weight loss, probably due to intense training and reduced caloric intake. Laboratory tests and densitometry were performed in the same period of the imaging"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80 year old female came to the emergency department of our hospital complaining of abdominal pain of recent onset. She related a history of frequent episodes of non-bloody diarrhea of approximately one month's duration, unresponsive to loperamide. Her past medical history included surgical correction of rectal prolapse six months previously, implantation of a pacemaker, anticoagulation, osteoporosis, and hypothyroidism treated with levothyroxine.\nHer temperature was normal. Physical examination revealed lower abdominal tenderness but was otherwise unremarkable. The white blood cell count was 8.1 ×109/L (normal: 4.5-10.8 ×109/L). The patient was admitted to hospital.\nDue to chronic renal failure unenhanced abdominal CT scanning was performed (Fig. ). This showed a 15 cm length of colon at the splenic flexure with significant parietal thickening and fat stranding, as well as pneumatosis and free air in the surrounding mesocolon. Ischemic colitis was diagnosed based on location in a watershed area and signs of necrosis and perforation.\nThe following day the white blood cell count was 20.4 ×109/L. In light of this and the CT scan findings, an exploratory laparotomy was performed which revealed a small amount of ascites. A 16 cm segment of thickened bowel from the splenic flexure was resected.\nThe postoperative course was uneventful. The patient was discharged on the eighth post-operative day. However, the next day she was readmitted to hospital with abdominal pain accompanied by at least ten episodes of non-bloody diarrhea occurring that day. An abdominal CT scan with rectal contrast showed no evidence of anastomotic leak or other abnormality. Stool culture and testing for Clostridium difficile toxin were negative. The patient improved with conservative management. Given the diagnosis of collagenous colitis (see pathologic findings below), treatment with oral budesonide was started and she was discharged on the eleventh day of her hospital stay. One month later she r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old man presented with left renal colic as a complication of nephrolithiasis. The patient was brought in by an ambulance with complaints of acute left flank pain with radiation to the scrotum, nausea, and macroscopic hematuria. This was the first episode of renal colic in his life. At birth, he was diagnosed with a Klinefelter syndrome and was receiving testosterone substitution therapy for the five years before admission.\nHabitus: The patient was tall, slim, narrow shouldered, broad hipped, and with dense and small testes. Slight rebound tenderness to the left lower quadrant suspicious for peritoneal irritation was disclosed on examination; body temperature was 38°C.\nLaboratory investigation showed leukocytosis and pyuria. Admission ultrasound disclosed mild hydronephrosis on the left and raised a suspicion for fluid presence in the perirenal fat.\nAlmost immediately after admission, before the pain was controlled with intravenous analgesics, there was a spontaneous decrease in pain. Computed tomography (CT) with contrast enhancement was performed 2 hours later and showed distribution of the contrast around the left kidney ().\nAlso lower third ureter scanning was performed showing a 4-millimeter obstructive stone at the left ureterovesical junction ().\nA double-J ureteric stent was placed immediately after tomography without technical problems. On the next day, the patient did not have any discomfort and was discharged from the hospital with the prescriptions for peroral tamsulosin and diclofenac.\nThree weeks later, he had no complaints as well. Discharge of stone has not been observed during this period. The red blood cell count, serum creatinine, and urea were normal, and ultrasound of the upper urinary tract was unremarkable.\nControl CT showed a partial distal migration of the ureteric stent (), which was removed with following CT urography showing no extravasation of the contrast out of the upper urinary tract (). On the CT images, there was no evidenc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 42-year-old female who presented with complaints of palpitations accompanied by nausea and vomiting four years back. Her past medical history revealed that she had high blood pressure since four years. At that time she was investigated with radiological studies, serum markers and eventually diagnosed as a case of TA in accordance with the 1990 American College of Rheumatology criteria for TA []. An ophthalmological examination was non-contributory. The cardiovascular assessment showed normal carotid upstrokes with bilateral carotid bruits and soft right and left subclavian bruits with weak peripheral pulses. A computed tomography (CT) aortogram of the chest showed severe stenosis of bilateral subclavian arteries and mild stenosis of the right and left common carotid arteries at the origin (Figure ).\nA CT aortogram of the abdomen showed an occluded left renal artery, a very small left kidney, and mild narrowing of the abdominal aorta below the level of renal arteries (Figure ).\nShe was started on a combination regimen of glucocorticoids with azathioprine. Initially, her symptoms improved for six months, but later there was a clinical decline in her condition. She was switched to cyclophosphamide. During this period, her serum erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) were regularly followed, but as it can be seen in the graphical presentation, except the initial down bulging in 2012 on glucocorticoid and azathioprine regime, it didn’t show remissive response to any regime after 2012 (Figures -).\nAfter six months of follow-up, she was put on etanercept (TNF inhibitor). During her follow-up, her routine radiological imaging and other workup for systemic review was done, but in spite of aggressive biologic therapy, she continued to have active disease. Later in her disease process, she was also put on tocilizumab (humanized monoclonal antibody against the interleukin-6 receptor) and rituximab (chimeric monoclonal antibody a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13 year old female patient is referred to an emergency service with a mostly bilateral retroocular headache after 2 years of evolution. the pain increased in frequency and intensity for two months which caused the patient to woke up in the mornings. Due to this, in the remission site, a cranial computed tomography (CT) scan was performed. It showed an infratentorial lesion, so the initial emergency service physician sends us the clinical record and the patient for integral management. When the patient came, a cranial nuclear magnetic resonance imaging (MRI) was performed [Figures –].\nA large infratentorial mass with robust enhancement, heterogeneous dilation of the lateral ventricles, and other signs of hydrocephalus such as horizontalization of the temporal horns was found. Taking into account the patient's findings and symptoms, it was considered necessary to perform a tumor resection through occipital craniectomy. During the procedure, we did not have any complications []. Furthermore, considering the high risk of hydrocephalus, we performed a system of the fifth ventricle. The patient was sent to the pediatric intensive care unit.\nThe outcome of the 1st day became torpid, with a high rate of production of xanthochromic cerebrospinal fluid (CSF), for which it was considered necessary to perform a ventriculoperitoneal shunt.\nAfter several days of satisfactory evolution, the patient became drowsy again, for that reason it was considered necessary to perform a new cranial CT scan [], in which significant ventricular dilatation was evidenced. With a diagnosis of hydrocephalus due to shunt failure, the patient was taken back to surgery.\nIn the surgery, it was found a high quantity of detritus in the porosities of the proximal catheter shunt, so a review of its functionality and a cleaning was performed. Two hours after the procedure, the patient was awake without neurological deficit. A control CT scan was performed on the 3rd day [].\nFifteen days postoperatively, t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 76-year-old man with severe symptomatic aortic valve stenosis requiring replacement of the valve. He had a preoperative examinations including trans-thoracic echocardiography (TTE), chest X-ray but not computed tomography (CT) of the thorax. His aortic valve area was 0.7 cm2 with mean and peak pressure gradient (PG) 95 and 47 mmHg, respectively. His EuroSCORE was 11; noncandidate for TAVI. After a full median sternotomy and the pericardial opening, we found an unexpected heavily calcified (porcelain) ascending aorta. We did not perform an epiaortic ultrasound to quantify the calcification and to discover an area less calcified for cannulation because we do not dispose. With the palpation, it has been found only a restricted safe area in proximity of the aortic arch. In this, we were able to cannulate the aorta and put a cross-clamp. We discussed the option of TAVI, but we had not a hybrid room for this procedure. The only solution was the surgical AVR. Then we had difficulties in aortic cross clamp; we used two clamps to occlude the aorta due to calcification with the risk of embolism. This was a really very risky action for cracking atherosclerotic plaques and induces a multifocal and severe stroke. We perform the aortotomy very high to avoid the ascending aorta. The aortic annulus was extremely calcified and small (21 mm) with an aneurysmatic dilatation of the ascending aorta (40 mm) extremely calcified. This dilatation was known from the preoperative TTE examination. In the preoperative chest X-ray, we could see also this dilatation, but all these indications of aortic dilatation and the suspicions of porcelain aorta where underestimated. The valve of choice was a sutureless Perceval S valve to manipulate as less as possible the aorta and perform a “rapid” intervention. We were able to implant this valve of the size: Medium. Closure of the aortotomy with the use of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old male presented to our outpatient department with an incidentally detected renal mass on ultrasonography of the abdomen done for a routine health check-up. The patient had no history of loin pain or hematuria. He never had any complaint of bone pain, loss of weight, or hemoptysis. There was no family history of malignancies. He was neither a smoker nor an alcoholic. There was no history of exposure to thorostat or vinyl chloride and he was a farmer by occupation.\nOn evaluation of his hemogram, renal parameters and liver function tests were within normal limits. Contrast-enhanced computed tomography (CT) was done which revealed a 10 cm x 8 cm heterogeneous enhancing mass involving the upper pole and interpolar region of right kidney (Figure ). The inferior vena cava and renal vein were free of thrombus and there was no regional lymphadenopathy. There was no evidence of distant metastases in the liver or bones. CT of the chest was also normal (Figure ). The patient underwent right-sided open radical nephrectomy. On the cut section, the tumor was seen to be composed of focal fleshy and necrotic areas intermingled with vascular spaces (Figure ). Histopathological examination revealed areas of extensive necrosis and anastomosing vascular spaces lined by pleomorphic cells (Figure ). The tumor had a high mitotic index of 25 to 30 per ten high power fields and a ki-67 index of 40%. Immunohistochemistry was done which showed strong positivity for cluster of differentiation (CD) 34; whereas, it was negative for epithelial membrane antigen (EMA), CD 10, and human melanoma black (HMB) 45 consistent with angiosarcoma. The surgical margins were free of tumor and the pathological staging was pT2bN0M0.\nIn view of the histological diagnosis of angiosarcoma, the patient was treated with adjuvant chemotherapy. He received three cycles of paclitaxel-based chemotherapy. The patient is doing well on one year of follow-up. Several reports of primary"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nEleven years ago, a 46-year-old white man presented with painless jaundice. He showed no other symptoms and had no risk factors such as high alcohol consumption or tobacco smoking. With a bodyweight of 73 kg and a height of 175 cm his body mass index (BMI) was 24.49 kg/m2 at the time of presentation. His mother had colorectal cancer otherwise there was no family history.\nAn endosonography showed an intraluminal polypoid tumor with disintegration of all wall layers at the bifurcation of his bile duct system. The finding was confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Biopsies were taken with the pathologic results coming back inconclusive.\nComputed tomography showed an intrahepatic cholestasis and two hypodense lesions in segment VIII of his liver. It showed no signs of metastasis or other unknown pathologies. The analysis of serum tumor marker carcinoembryonic antigen (CEA) was negative and cancer antigen (CA) 19-9 was found to be elevated at 75 kU/l (<37 kU/l).\nHe was treated with right liver lobectomy with resection of the bile duct directly distal of his pancreatic head, resection of the bile duct of his left liver lobe up to the first intersection, and with a regional lymphadenectomy. The reconstruction was performed by biliodigestive anastomosis with Roux-en-Y hepaticojejunostomy. A bile duct drain was inserted in the dorsal bile duct of his left lobe and closed on day 10 after contrast imaging of the anastomosis. Postoperatively, he recovered well. On the planned day of discharge he developed an aphasia leading to further diagnostics, which showed a transitoric ischemic attack of his left-brain hemisphere. He was transferred to neurology and fully recovered.\nA gross examination showed a right hemihepatectomy with a 4×2×2 cm polypoid tumor in his right hepatic bile duct extending into the bile duct junction (mainly intraductal growth type). The liver parenchyma was non-cirrhotic and prominent portal tracts were seen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old female presented 14 months after a two-part left proximal humerus diaphyseal fracture (OTA11 B2). Her past medical history was significant for osteoporosis. Physical examination revealed gross deformity, tenderness and motion at the fracture site. No neurologic deficit was found. Radiographic evaluation revealed an oblique fracture of the left proximal humerus diaphysis with lateral and anterior angulation of the distal fracture fragment []. There was minimal osseus bridging between the proximal and distal fracture fragments with associated callus formation. She was indicated for operative intervention.\nThe patient was administered regional anesthesia and positioned in a sloppy lateral position. An extended anterolateral approach was utilized as described by Gardner et al.[–] The skin incision began at the anterolateral tip of the acromion and was extended to approximately 5 cm proximal to the lateral epicondyle. Proximally, the subcutaneous tissue was divided to expose the raphe between the anterior and the middle heads of the deltoid. The raphe was carefully divided in the “safe zone” above the location of the axillary nerve, 6 cm below the anterolateral border of the acromion.[–] The muscle was separated using blunt dissection proximally. The axillary nerve was then palpated and found to be scarred to the humeral head. Neurolysis was performed and the nerve and surrounding soft tissues were protected with a vessel loop. The deltoid was further divided proximal and distal to the nerve and the insertion site was tunneled under for future plate placement. The lateral border of the biceps was then identified and the muscle retracted medially to expose the brachioradialis and brachialis muscles. The faschia between the muscles was then incised in line with the intermuscular plane and the radial nerve was identified. The radial nerve was found to be scarred down to the inferior aspect of the fracture, and was mobilized. The fracture site was then exposed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78 year-old man was admitted to the outpatient clinic of our department of otolaryngology with complaints of sudden pain of left auricle and ear canal. The patient also showed facial paralysis on left side (House-Brackmann grade III). He didn't have any underlying disease and showed a social history of smoking with 60 packs years and no history of alcohol intake. According to the physical examination, there was found no dermatological lesion such as rash, vesicle or crust near the ear drum, external auditory canal and near the external ear. The patient showed a sensorineural hearing loss of high frequency in both ears on pure tone audiometry. The hearing ability showed no worsening pattern as the symptoms were developed. The pain that was shown in this patient was of great severity compared to that generally shown in Bell's palsy, and he complained of a stronger, deep pain in the external auditory canal rather than in the areas near the auricles. Accordingly, beside to Bell's palsy, we considered an atypical type of Ramsay-Hunt syndrome that doesn't show dermatological lesions, as our possible differential diagnosis. We started with high doses of steroid (prednisolone, 60 mg/day) and antiviral drug (Acylovir 1800 mg/day) after the patient was hospitalized. Even though it's rare to present severe otalgia from primary or metastatic tumors of the skull base, we performed a CT scan of the temporal bone to rule out these possibilities. The findings from the CT scan showed a bony destruction of the temporal bone of the left, anterior attic and sphenoid bone (). Consequently, we could assume that the facial paralysis occurred due to damages of the first geniculate ganglion of facial nerve. We performed a MRI of the temporal bone in order to find out the etiology of the bony destruction of temporal bone and we observed a neoplastic lesion that is invading the base of the skull and left sphenoid bone. It was observed that the neoplastic lesion inv"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old boy presented with asymptomatic swelling of the chin that had been occurring over 18 months. The lesion gradually increased to involve the left side of the lower lip. There was no history of similar lesions elsewhere in the patient or his family members. There was no history of pain, alteration in speech or difficulty in speaking.\nOn examination, there was a skin colored, non-tender, firm and irregular swelling over the left mentolabial groove extending onto the lower lip (). There was bulging of the left part of the lower lip with distortion of the lip architecture even on occlusion of the lips. The mass produced an irregular, smooth protrusion on the mucosal surface of the lower lip without any discoloration. There was no local depigmentation or hypertrichosis. There was no evidence of freckles or café au lait macules and no bruit over the lesion. Clinically a diagnosis of neurofibroma was made and excisional biopsy under local anesthesia and aseptic conditions was performed. The specimen was sent for histopathological examination.\nGross observation showed that the tumor consisted of a skin covered nodule measuring 1×0.5×0.5 cm. The cut surface was solid grey white. Histopathology sections showed an unremarkable superficial skin and a sub-epithelial tumor. The tumor was ill defined and consisted of fascicles of mature nerve tissue arranged in a multinodular pattern separated by fibrocollagenous septa. The cells were seen surrounding the pilosebaceous unit. The nerve fascicles showed an intricate admixture, with mature striated skeletal muscle bundles of varying sizes ranging from 15 to 20 µm with some being up to 50 µm (, ). Few muscle fibers were seen to be contained within the perineural sheath (). Areas of myxoid change were noted as were many capillary sized blood vessels. Mild chronic inflammation was seen. A histopathology diagnosis of BTT involving the mental branch of the trigeminal nerve was made. There"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 48-year-old female who has a history of localized early stage right renal cell carcinoma and had undergone an open right radical nephrectomy in 2002 via a right flank incision. She is in remission currently.\nDuring her surveillance, an MRI done in August 2010 detected an incidental lesion in her spleen measuring 3.9 cm. A follow up MRI done 3 months later showed the lesion to have increased in size to 4.5 cm. Interventional radiology performed a CT guided biopsy and the pathology showed it to be a possible spindle cell tumor or an inflammatory myofibroblastic tumor. A PET CT done showed low level activity in the splenic lesion. She denied any other local or constitutional symptoms.\nShe had previously undergone a left oophorectomy and salphingectomy for an ectopic pregnancy, both via a Pfannenstiel incision. She has 3 children, all vaginal delivery.\nDue to her menorrhagia for the past couple of months, an ultrasound of her pelvis was done which showed large uterine fibroids. She was scheduled for a laparoscopic hysterectomy in 3 weeks.\nPhysical examination was unremarkable except for her previous Pfannenstiel and right flank incisions.\nDue to the indeterminate nature of her splenic lesion with concerns for malignancy, patient was agreeable to undergoing a splenectomy. Discussion with her gynecologist then yielded the possibility doing both surgeries on the same day, possibly doing the laparoscopic splenectomy first, then the laparoscopic hysterectomy. After a careful review of the literature, we also pursued the idea of transvaginally extracting the spleen after the hysterectomy was performed. Pneumococcal and Hib vaccines were given 2 weeks prior to surgery.\nShe underwent surgery in February 2011. Pre-operatively, the left ureter was stented to protect the left ureter in view of her single remaining kidney. The laparoscopic splenectomy was conducted with the patient in the supine position. One 12 mm port and 3 other 5 mm ports were placed in a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n53-year-old woman was admitted to the hospital with a 1-month history of abdominal and flank pain and 10 kilograms of weight loss in three months. She had no remarkable medical history except a 10 pack-year history of smoking. On her physical examination, blood pressure was 120/70 mmHg and her pulse was 72/min. There were no signs and symptoms of adrenal hormonal hypersecretion. Abdominal computed tomography (CT) scan showed 10.5 × 6.5 × 9.5 cm cystic mass with irregular borders located in left adrenal and 6.5 × 3.5 × 4.5 cm lobulated cystic mass with irregular borders and multiple septations in the right adrenal gland. There was also an 8.3 × 6.5 cm cystic mass with irregular borders in liver segment six and the lower margin of this mass could not be clearly differentiated from the borders of the mass described in right adrenal on CT scan ().\nSerum cortisol, serum androgens, urine catecholamines and their metabolites, and the aldosterone to renin ratio were normal. Her liver function tests including ALT and AST were four times higher than normal and renal function tests were normal. Mammography, upper gastrointestinal system endoscopy, and thorax CT were performed to exclude metastasis to adrenals, which gave normal results. Bilateral adrenalectomy, simple nephrectomy, distal pancreatectomy, splenectomy, right hepatectomy, and cholecystectomy were performed. The surgery was completed uneventfully. On gross examination specimen removed from right adrenal was brown and nodular measuring 9 × 6.5 × 4.0 cm and weighed 80 g. Its cut surface showed that the tumor was variegated with whitish-grey firm solid areas and extensive necrosis. The specimen removed from left adrenal measured 8.5 × 6.0 × 3.5 cm and was composed of cystic mass. On microscopic examination the tumor of right and left adrenal showed pleomorphic tumor cells with epithelial and spindle cell morphology with evidence of foci of necrosis. Giant cell formation and high mitotic rates were observed in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 50-year-old Caucasian male who presented to the emergency department with complaints of lower abdominal pain, fever and sweating. On examination, the patient had tenderness to palpation in the right iliac fossa, with significant rebound tenderness and guarding. Body temperature was recorded at 38.5°C.\nThe patient's past medical history was significant for an incident of similar pain six months prior to presentation. He was diagnosed with sigmoid diverticular disease confirmed by computed tomography (CT) scan and managed conservatively. A subsequent colonoscopy confirmed the diagnosis, and did not reveal any other colonic pathology.\nFurther investigations revealed a raised white blood cell count of 16,000 per microliter. CT scan of the abdomen and pelvis disclosed evidence of extensive free gas under the right dome of the diaphragm confirming suspicion of a perforation. Fluid-filled prominent loops of small bowel were noted. However, none of them were dilated to suggest obstruction. Mild bowel thickening was also noted around the cecum. Pneumatosis coli suggestive of ischemic bowel, extending from the cecum to the proximal ascending colon was seen. A blind ending structure with calcifications was also seen (Figure ). Other significant findings on the scan included a liver cyst, consistent with the patient’s previous CT scan, and consolidation at the base of the right lung.\nSubsequently, the patient underwent an emergency laparotomy and a diffuse four-quadrant peritonitis was seen. A giant perforated MD, 80 cm proximal of the ileocecal valve was identified as the cause of the peritonitis. The giant MD measured approximately 10 cm in length and 2.5 cm in width (Figure ). A small perforation at the tip of the MD was observed. No other intraabdominal pathology was identified, in particular, there was no evidence of colonic ishchaemia. Resection of the segment of small bowel bearing the MD was performed with a side-to-side stapled anastomosis.\nPatho"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old male with a past medical history significant only for gout, and hypertension presented as a stroke alert. His last known normal time was 12 hours prior, before going to sleep. His wife noted an episode of right facial droop and speech slurring, which prompted her to call emergency medical services. His wife also described an episode of thrashing in the bed and urination. She mentioned that the day before presentation the patient was “not feeling well” and took aspirin. He did not mention experiencing any specific symptoms.\nUpon presentation to the emergency department, the patient could localize to pain but had a decreased level of consciousness. Vital signs were unremarkable, but frequent premature ventricular complexes were seen on the electrocardiogram. The patient’s wife did not know of any prior history of this. Physical examination was remarkable for 5-mm dilated pupils bilaterally, crackles bilaterally at the lung bases, and decreased level of consciousness. The National Institutes of Health Stroke Score (NIHSS) was 18: 2 for level of consciousness, 3 for visual fields, 2 for the left arm, 2 for the right arm, 2 for the left leg, 2 for the right leg, 3 for best language, and 2 for dysarthria. Laboratory evaluation revealed no leukocytosis, a normal glucose of 115 mg/dL, and lactic acid of 1.4 mmol/L. Urine drug screen was negative, as was the urinalysis. The patient had normal vital signs and thus did not meet the criteria for sepsis. Initial computed tomography (CT) of the brain did not reveal an infarct or hemorrhage (Figure ).\nCT angiography (CTA) of the head and neck did not show any sign of aneurysm but revealed scattered carotid calcifications, a left parotid mass of 2 cm, and a right apical cavitary lesion with peripheral calcifications confirmed by chest radiography (CXR). CXR also revealed several small pulmonary nodules scattered in both lungs as"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female patient attending the dermatology unit of our university hospital was referred to our gastroenterology outpatient clinic in 2002 due to symptoms of epigastric pain, postprandial fullness, and bloating. She reported no other upper or lower gastrointestinal symptoms.\nThe patient had a history of hoarseness since the first months of life. When she was one year old she presented with recurrent blisters, superinfected skin, and mucous membrane lesions that progressed to affect the whole body. Histological analysis of skin biopsies taken at the age of three showed deposition of eosinophilic hyaline PAS-positive material in the dermis and around small blood vessels, confirming the clinical diagnosis of LP. Her parents were nonconsanguineous and no other family members were affected.\nThe hoarseness progressed over the years, and she experienced recurrent superinfected blisters. The skin lesions healed after several treatments with different drugs, including etretinate and chloroquine, but visible scars developed in the areas where the lesions have been present. There was no history of seizures or neuropsychiatric abnormalities.\nPrevious laryngoscopy revealed thickening of the vocal cords and nodules on the base of the tongue and supraglottic portion. Magnetic resonance (MR) imaging showed symmetrical calcifications on the amygdaloid nucleus and uncus.\nOn admission the patient had a hoarse voice, and multiple scars were visible on the face and body. Upper endoscopy showed multiple yellowish nodules throughout the esophagus (), body of the stomach (), and duodenum. There was no evidence of esophagitis or gastritis. Histological examination revealed deposition of eosinophilic hyaline material in the lamina propria and submucosa and around blood vessels (). The material was positive on periodic acid-Schiff (PAS) staining and negative on Congo red staining, confirming the diagnosis of LP. Esophageal manometry was normal.\nColonoscopy also revealed multiple ye"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man presented with severe chest pain and was subsequently diagnosed with extensive anterior wall myocardial infarction. Echocardiography showed akinesia of the anterior septum and anterior wall, and left ventricular ejection fraction was 35%. During admission to the coronary care unit, his blood pressure and urine output were noted to be decreased. Despite inotropic administration, the patient's condition did not improve. Bedside portable echocardiography showed low mitral E velocity and reversed E/A ratio, suggesting volume depletion or dehydration (). Based on Doppler echocardiographic findings, fluid was administered rather than diuretics or volume restriction. After hydration, the patient's condition improved and blood pressure and urine output increased.\nVolume expansion is the first therapeutic measure when a patient presents with hemodynamic instability. However, when the preload of the heart is already high, volume expansion can be hazardous, especially in elderly patients with decreased left ventricular compliance. Because of this concern, despite the need for adequate fluid balance, dehydration in elderly critically ill patients who are admitted to the ICU is not uncommon but usually unrecognized. It is important to avoid hypovolemia in these patients because it can lead to subsequent unexpected complications, such as hypotension and renal failure. Close monitoring is needed in patients being treated with volume expansion because of the delicate balance between excessive pulmonary congestion and reduced preload. Although diuretics are appropriate for the relief of congestion and edema, they are most effective in patients with evidence of fluid retention. In addition, caution should be taken to avoid overdiuresis, which may result in intravascular volume depletion and resultant hypotension or prerenal azotemia. Unlike in patients with grade 2 or 3 diastolic dysfunction (with elevated filling pressures) in whom the addition of diuretics should"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old female patient visited our hospital, complaining chiefly of scalp swelling. Two weeks earlier, the patient had fallen backward. Upon physical examination, we detected a subcutaneous mass in the patient's left posterior parietal area. The 3.5 cm mass was covered by normal skin. She also complained of a little pain on palpation. No tactile pulsation was detected. It was believed to be a posttraumatic subcutaneous hematoma, so we decided to continue observation, and wait for any spontaneous disappearance. The swelling in the patient's scalp decreased in size after one week. She attended no follow-up sessions thereafter.\nTwo months after her first visit, the patient was admitted to the emergency room due to scalp bleeding. The swelling in the patient's scalp had, at that time, increased to 4 cm in diameter with an overlying scalp defect which was oozing blood. Tactile pulsation was detected. The defect was sutured, and the bleeding was controlled via manual compression.\nThe patient was admitted for further evaluation of the pulsatile scalp mass. Brain CT revealed a slight increase in the attenuation of the hematoma in the left parietal scalp, with dense contrast filling (). Upon routine laboratory examination, the level of creatinine in the patient's blood was higher than normal (22 mg/l, normal range 7-14).\nAngiography of the external carotid artery revealed a pseudoaneurysm, which was fed by the left occipital artery (). An aortogram revealed complete occlusion of the right renal artery, as well as severe proximal stenosis in the left renal artery. The radiologist (Y.H.C.) attempted to occlude the pseudoaneurysm via transarterial embolization. However, this attempt failed, due to the complex geometry of the proximal artery. A two-hour attempt was made to occlude the pseudoaneurysm via US-guided manual compression. Thereafter, the pulsation of the scalp swelling became negligible.\nDoppler US, taken five days after the procedure, revealed thrombus formati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old previously asymptomatic male presented to his primary care physician with a complaint of focal penile irritation related to sexual intercourse. The irritation originates from a lesion along the midline on the dorsum of his penile glans. He was referred to a urologist for further evaluation.\nThe patient reported noticing a small dimple along the midline on the dorsum of his glans for as long as he could remember. The lesion had not previously caused him any discomfort, nor did he report a history of discharge, including urine, semen, blood or pus from the orifice. In recent months, the patient has become more sexually active and he has become aware that during and after intercourse the site is painful and inflamed for a short period of time. The patient wants to make sure there is not something wrong with his anatomy and seeks a solution.\nThe patient had no significant past medical history. There is no family medical history of relevance, specifically no one has reported any genital malformation. Physical examination by a urologist demonstrated a well-developed adult male. A small midline opening was present on the dorsum of the penile glans. There was no focal erythema or discharge present at the time of examination. Manipulation of the opening demonstrated a thin lumen that appeared to continue proximally along the dorsum of the penile shaft. The most likely aetiology was determined to be urethral duplication. Imaging was necessary for confirmation and to delineate the particular anatomic presentation in order to plan treatment. Demonstration of communication with the urethra or bladder would require more extensive surgical intervention to eliminate the sequelae of discharge accumulation in the lumen causing infection, cyst formation or recanalisation of the accessory orifice. The patient was referred to radiology for urethrography.\nSince no urine, semen or other discharge had ever been noted to exude from the accessory urethra, a retrograde urethrogr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn May 2014, a 30-year-old Caucasian woman presented to our department (Fig. a). For the past 4 years, the patient had suffered from severe PPR (principally on the forehead, cheeks, and chin) with signs of rosacea fulminans, as well as severe background erythema in the central facial and forehead regions. She had previously been treated with metronidazole 7.5 mg/g cream and permethrin 50 mg/g cream, which had not provided a reduction in the number of inflammatory lesions. She had also been prescribed doxycycline modified-release 40 mg for 18 months, which had also proved unsuccessful in reducing the inflammation.\nAt presentation, the patient reported feelings of hopelessness, indicating a profound impact of the disease on her quality of life. Following diagnosis of PPR with severe background erythema, different treatment options were evaluated. In such a severe case, a specific strategy tailored to the patient was essential, particularly given the lack of success with prior regimens, which seemed to indicate that a more potent treatment regimen was needed in this patient to combat the inflammation upfront. Isotretinoin was initially considered; however, because the patient was not taking hormonal contraception at the time of her visit to our department, this therapy was contraindicated. The patient was offered a gynecology appointment to start hormonal contraception, so that isotretinoin could be an option in the future. The patient was initially prescribed an 8-week regimen of azithromycin 500 mg three times weekly (taken in the morning) in combination with prednisolone 30 mg once daily (reduced to 10 mg once daily after 1 week). The choice of this regimen was based on results from the literature showing that a rapid response can be obtained with a multimodal, tailored approach with a short course of macrolide antibacterials []. Furthermore, the use of corticosteroids over the short term is not strictly contraindicated in the treatment of rosacea and can be conside"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old married housewife presented in the orthopedics outpatient department of tertiary care hospital in Central India with the chief complaints of pain in both thighs, more on the right side and difficulty in walking for the past 2 years. Pain had started spontaneously, was insidious in onset, and localized initially to both thighs. It increased with weight bearing, walking and household chores and partially got relieved on rest and medication. There was pain in elbow, wrist, and both hands for a few months initially. There was no history of fever, loss of appetite, loss of weight, or any change in menstrual cycle. Her joints’ pain and left thigh pain got completely relieved with drugs, but pain in the right thigh and hip area did not improve. She noticed progressively increasing difficulty in walking, squatting, and sitting cross-legged during the past 6 months. She started feeling rest pain in the right thigh and started taking stick support for the past 2 months. She had undergone repeated consultations, investigations, and treatment, but was not relieved of her symptoms.\nExamination revealed painful gait with minimal weight bearing on the right lower limb. The patient was thin built with mild pallor and without any systemic abnormality. Her pulse was 84/minute and blood pressure 130/70 mmHg. Tenderness was present on upper one-third of right thigh and both pubic rami with adductor muscle spasm. Right hip rotations and abduction adduction were grossly restricted with flexion possible up to 70°. Left hip movements were normal except terminal restriction of flexion. There was no neurovascular deficit. Examination of other bones and spine did not reveal any abnormality.\nA clinical diagnosis of Osteomalacia with Looser’s zone in pubic rami and incomplete fracture in right femur was considered. Metastatic lesions, multiple myeloma, or hyperparathyroidism with brown tumors were considered as differential diagnoses. The patient underwent X-rays of relevant areas"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old female with a chief complaint of a progressive headache has been admitted to the Department of Neurosurgery. The headache first has been presented 4 months ago. Before that time, the patient had always been symptom-free, following a normal active life. The pain was pulsating, with a concentration in frontal and periorbital area with no particular radiation. When severe, it has been followed by eye irritation and involuntary tearing. Headache was progressive along the day, and most severe at night. The severity of the pain has also been intensified within the recent weeks comparing to time it started. The patient had no history of seizure or convulsion, aphasia, and diplopia. Otherwise, she gave a history of occasional vomiting, nausea, amnesia, and sphincter dysfunction in form of stress incontinency and equilibrium problems. Cerebellar tests were abnormal, and she could not walk on her own. She had a history of left kidney tumor, for which she had undergone partial nephrectomy for about three years ago. Furthermore, she gave a history of controlled diabetes, hypertension, and hyperlipidemia. No history of ischemic heart disease or cerebrovascular attack was mentioned. She had a drug regimen of insulin, losartan, memantine, atorvastatin, zinc plus, magnesium, propranolol, and venlafaxine. In her physical examination, cranial nerves were intact, with a Glasgow Coma Scale of 15/15. Cerebellar tests were abnormal with obvious equilibrium dysfunction and inability to self-manage walk. Both pupils were normal sized, symmetric and reactive to light. Visual acuity was at level of finger count out of three meters distance. Sensory and motor function of the four extremities were normal; and no sensory level was detected. The patient suffered from sphincter dysfunction in the form of stress incontinency.\nMagnetic resonance imaging (MRI) was performed for better evaluation. In T1 view a well-defined hypo-signal mass was detected in middle gyrus of each frontal lo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old man suffered from immunoglobulin-A nephropathy 2 years before admission and was treated with steroid therapy. He complained of epigastric pain about 9 months before. A mass on the greater curvature of his stomach was found by gastroscopy and gastric cancer (signet cells) was diagnosed by biopsy. The abdominal CT scan showed that there were tumours in the abdominal cavity with enlarged para-aortic lymph nodes. His body surface area was approximately 1.57 m2 as determined from the DuBois formula. He started taking S-1 50 mg, twice daily for 3 consecutive weeks, followed by a 2-week rest period 8 months ago. He also started intravenous cisplatin every 5 weeks and took dipyridamole, lansoprazole, granisetron hydrochloride and naproxen orally every day. He received six cycles of chemotherapy and showed a partial clinical remission.\nHe received 60 mg cisplatin for the last time about 1 month before his admission, and his serum creatinine increased slightly (from 95.47 to 114.92 μmol/l) 1 week after receiving cisplatin. He continued to report appetite loss and went to hospital 1 week before his admission. He also took a blood examination after the consultation and his serum creatinine had increased to 683.33 μmol/l. However, his doctor did not know the result until after his admission. He continued to take S-1 and the other drugs for about 1 week from the start of the renal insufficiency. His appetite loss and general fatigue were aggravated and he consulted the emergency room in our hospital.\nHe was drowsy and on the Glasgow Coma Scale his score was 13 of 15. His blood pressure was 133/82 mmHg and his heart rate 87 beats/min. He complained of a slight stomachache, and slight tenderness was found on physical examination. There was no free air or niveau on the abdominal X-ray. The serum creatinine and blood urea nitrogen were elevated to 1919.16 μmol/l and 32.49"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15 years old girl presented with complaints of pain and swelling over the left wrist for 3 months. She associated the onset of pain to a direct injury to wrist while playing. The pain was mild to begin with and responded to Ibuprofen. The pain later became severe and did not respond to anti-inflammatory drugs. The patient also noted a swelling on the radial aspect of the wrist. The swelling had been gradually increasing in size []. The range of movement at the wrist joint at presentation was dorsiflexion of 45° and palmarflexion of 20°. The grip strength of the left hand was 4 kg as compared to 18 kg at the right dominant hand. Her past medical and family history was unremarkable. Serologic workup performed showed a negative rheumatoid factor, a white blood cell count of 6000 cells/mm, a C-reactive protein of 0.6 mg/L, and a sedimentation rate of 15 mm in the first hour. The radiographs showed a well circumscribed lytic lesion in the distal pole of the scaphoid []. Computed tomography (CT) scan of the wrist showed a lytic lesion with a nidus in the center, with cortical perforations []. Magnetic resonance image (MRI) scan of the wrist showed a well defined eccentric lesion with sclerotic margins and central calcification involving the scaphoid, measuring 5 × 5 mm with inflammatory edema and synovitis of the periscaphoid region and articulations [].\nDorsal approach was selected for the excision of the tumor and synovectomy as there was maximum swelling over the dorsoradial aspect of the wrist. On exploration, there was synovitis of the whole wrist joint, which resembled on naked eye as tubercular synovitis [Figure ,]. There was inflammatory granulation tissue at the scapho-trapezio-trapezoidal joints. Thorough synovectomy was done. The perforation of the osteoid osteoma at the scaphoid was seen as a break in continuity of the surface of the scaph"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA three-year-old male presented to the emergency department (ED) with the chief complaint of one episode of hemoptysis that occurred just prior to arrival. His adopted mother stated that he had cold-like symptoms for the past few days prior to arrival, and on the day of arrival, he began to cough up blood. She brought the blood-tinged rag with her to the ED. He had vomited the night prior, as well as on the morning prior to arrival, and had diarrhea during that same time frame. His adopted mother said that the diarrhea and vomit were not blood-tinged. There had been no change to his urine output. She stated that he had a fever the night prior, as well as on the morning of presentation, with a maximum temperature of 101º F. His adopted mother said that he attends daycare, and that multiple children in his daycare had recently come down with respiratory syncytial virus (RSV).\nHis adopted mother stated that he was born full term with no complications. She also said that he had multiple bronchitis infections since his adoption, which she stated was at a few months of age. According to her, he is up to date on all vaccinations. Due to his adoption status, his family history was unknown.\nHis temperature on arrival to the ED was 98.7º F. He had a pulse rate of 131 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 89/60. Physical exam revealed the presence of clear rhinorrhea as well as diffuse crackles and expiratory wheezing in all lung quadrants.\nA complete blood count and comprehensive metabolic panel were all within normal limits. Chest radiographs in two views were performed, and it was determined that no acute lung abnormalities or pulmonary infiltrates were present (Figures -). A hemoccult test was done on the blood-tinged rag which confirmed that the substance was blood. It was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA British Caucasian female patient aged 10 years and 11 months presented to our institution with a thoracic and lumbar scoliosis. She was noted to have the phenotypic features indicative of Smith-Magenis syndrome at the age of three years and the diagnosis was confirmed with chromosomal studies. There was no family history of syndromic conditions or scoliosis.\nThe development of a scoliosis was first noted at the age of 4 years and the patient was treated with an underarm spinal brace in another spinal centre. The deformity remained stable up to the age of 10 years when the curvature progressed rapidly as the patient started going through her pubertal growth spurt. During that stage, the brace was discontinued as the patient's compliance was very poor and any brace effectiveness was limited due to the fact that the patient was significantly overweight. At presentation to our clinic, she remained premenarchal with a body weight of 63 kg which was above the 95th percentile for sex- and age-matched normal population. Her arm span was 142 cm which was between the 25th and 50th percentiles for stature and her BMI was calculated to be 31.2.\nOn clinical examination, the patient was found to be very hyperactive. Overall, she had a balanced spine with level shoulders and pelvis despite a mild thoracic translocation to the right and no leg length discrepancy. However, she had a severe thoracic and lumbar deformity with a significant rib hump adjacent to the convexity of the thoracic scoliosis, as well as a marked waist line asymmetry with prominence of the pelvis on the concavity of the lumbar curve. There were no skin or soft tissue abnormalities overlying the spine. The patient was a community ambulator and had no neurological abnormality. Neurological examination showed normal tone, muscle power, sensation and tendon reflexes in the upper and lower limbs, as well as symmetrically elicited abdominal reflexes. There were no upper motor neurone signs.\nRadiographs of the spine"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old male with no particular background who, after falling from a 5m height, reported pain and restriction of movement on both shoulders and loss of sensibility and movement in his right arm.\nThe patient showed functional impotence, not being able to perform adduction and internal rotation with both upper limbs, evident ecchymosis in both of his shoulders and absence of humeral, radial, and cubital pulse in his right arm, with signs of acute ischemia (coldness, paleness, diminished sensibility, and motor function of the elbow and the hand), with no capillary filling in the right hand. Oxygen saturation, measured with a pulse oximeter, couldnot be measured in the right index finger in comparison with 99% in the left one ().\nRadiographies and computed tomography showed a fracture-dislocation of the proximal front humerus in both of the shoulders (). A Doppler could not find distal pulse in the right upper limb, so the patient was immediately remitted to surgery.\nIn the surgical room and under general anesthesia, an emergency arteriography was carried out through transfemoral access, and a tear in the intima of the right axillary artery was found, being that the reason why an emergency intervention was indicated.\nThen, through deltopectoral path, we proceeded to perform an open reduction and internal fixation using a pre-molded plaque of the proximal humerus (). After that, an auto-expandable stent was implanted and a bypass graft with interposition of the great saphenous was performed by the service of angiology and vascular surgery (). Finally, a distal embolectomy with a Fogarty catheter was performed to eliminate any thrombus. The control arteriography proved vascular permeability.\nFour days after the emergency surgery, the left shoulder was operated again through deltopectoral path, performing an open reduction and internal fixation with a pre-molded plaque of the proximal humerus.\nThe patient was discharged several days after the humeral,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old Caucasian female presented initially with a spontaneously occurring, non-tender, right anterior chest wall soft tissue cystic-like mass in late 2014 (). Her past medical history included Waardenburg syndrome (a genetic condition associated with hearing loss and changes to hair skin and eye pigmentation), well-controlled non-insulin-dependent diabetes, learning difficulties and she had 15 surgeries performed on her deformed feet. She also suffered from sideroblastic syndrome since 2002 for which she was receiving blood transfusions three times a week with well-controlled iron overload. A month after developing the right anterior chest wall mass, she developed a non-tender swelling in her left elbow which got progressively larger and uncomfortable (). She was seen by both orthopaedic and rheumatology teams, who after reviewing the images suspected that the swelling could be due to an inflammatory reaction rather than infection. She was therefore started on a reducing dose of 30 mg oral prednisolone which she took intermittently for a year. During this time her swelling remained non-tender, however towards the beginning of January 2016 she presented with pain in her elbow joint. Repeat imaging showed worsening of the left elbow joint mass and an enlarging right sternoclavicular mass. She was referred to a specialist centre for biopsy of the right sternoclavicular joint mass for suspected lymphoma. In April 2016, multiple biopsies of her right sternoclaicular joint showed necrotic material and inflammatory cells along with granulation tissue suggestive of osteomyelitis. As no evidence of granulomas was seen, tissue samples were not sent for any mycobacterial cultures. She was started on oral flucloxacillin 1 g QDS to be taken for 4 weeks. At the beginning of May 2016, while on flucloxacillin, she became unwell with signs of sepsis and her left elbow swelling had started to ulcerate. Chest X-ray on admission showed infective changes to the bases of both lun"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old Asian female was presented to our hospital with a recurrence of liver nodular lesions after multiple surgical resections.\nThe patient had received lung lobectomy due to lung cancer in the right upper lobe 11 years ago (). Postoperative pathology showed a 4.0×3.9 × 3.0 cm moderately differentiated adenocarcinoma, with one positive mediastinal lymph node among all the 10 dissected lymph nodes (). She quit adjuvant chemotherapy after one cycle due to intolerance. No elevation of tumor markers had been reported perioperatively.\nSeven years ago, the patient developed jaundice. CT assessment showed a pancreatic head mass with involvement of the distal common bile duct (). Results of tumor markers including CA19-9 were negative. She was then treated with radical pancreaticoduodenectomy, where a 2.5×2.0 × 2.0 cm moderately differentiated adenocarcinoma with negative lymph node metastasis was removed (). Afterward, she received adjuvant S-1 chemotherapy (consisting of tegafur 40 mg, gimeracil 11.6 mg, and oteracil 39.2 mg, administered orally twice a day) for 3 cycles (2 weeks per cycle followed by a one-week rest period), which was also discontinued due to adverse events.\nThe patient was then put on surveillance with an annual imaging assessment. Four years after the Whipple procedure, a follow-up examination showed a solitary liver lesion in segment VII (). She refused interventional treatment or chemotherapy and chose cytoreductive surgery to resect the segment VII lesion. Postoperative pathology demonstrated a 3.0 cm segment VII adenocarcinoma and suggested the diagnosis of liver metastasis ().\nRecently, the patient was admitted for the recurrence of a liver lesion, along with multiple lung nodules (). Recurrence of the previous adenocarcinoma in the liver and lungs was the first impression. The tumor board reviewed her past medical history and proposed the possibility of metastases of the lung adenocarcinoma to the pancreas, liver, and lungs. Liver biopsy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old woman patient visited our outpatient clinic after experiencing headache and blurred vision for 1 month. Her neurological examination was within the normal limits, except that bilateral congested papillae were identified. Her family history was unavailable because she was adopted. MRI revealed a solid tumor with a maximum diameter of 3.5 cm accompanying an internal cyst in the left cerebellar hemisphere. In addition, extensive cerebral edema and ventricular dilation were noted. On presurgical brain MRI, the solid region showed uniform contrast enhancement. On cerebral angiography, feeding arteries were noted to arise from the left anterior inferior cerebellar artery (AICA) and left posterior inferior cerebellar artery (PICA), and both the draining veins to the petrosal vein and the inferior vermian vein were identified [].\nWe performed 200 ml of 10% glycerol (twice a day) with dexamethasone (8 mg/day) for 6 days before the operation. Because the symptoms improved, we did not perform external ventricular drainage prior to the operation. Surgery was performed via the midline suboccipital approach with the patient in the prone position. The dura mater was dissected and ICG fluorescence angiography was performed. We observed the feeding artery coming off the PICA arose from the cerebellar hemisphere and drained via the horizontal fissure, additionally feeding vessels from the AICA were confirmed on the outside. The lesional veins drained into the inferior vermian vein []. Intraoperatively, the feeding artery from the PICA was coagulated first and then cut. Because there was a clear cleavage plane from the surrounding tissue, which was not swollen, detachment was performed, leaving the thick draining veins intact. The most significant draining veins, which converged onto the petrosal vein, were positioned anteriorly on the outside. Finally, these veins were coagulated and cut, and the tumor was removed en bloc. The estimated blood loss was 500 ml. Pathologic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA one-year-old Thai boy was referred to Phramongkutklao Hospital due to subacute fever, abdominal distension, mucous diarrhea, and failure to thrive. He was born at term with uneventful pregnancy, and he is the first child of nonconsanguineous parents. There was no history of autoimmune or primary immunodeficiency disorders in the family. Intradermal BCG vaccination was inoculated at the left buttock without any reaction within 3 months of life, and intramuscular vitamin K was routinely given after birth. He was exclusively breastfed. At 3 months of age, he developed frequent vomiting and irritability. Physical examination revealed enlarged and tense anterior fontanelle. CT brain showed hyperdensity lesion size of 1.5 × 1.8 cm at left temporal lobe with perilesional edema () which was confirmed to be intracerebral hemorrhage. All hematologic, coagulation studies and biochemical laboratory tests () were consistent with deficiency of vitamin K dependent clotting factors. The cause of vitamin K deficiency in this patient was presumed to be caused by malabsorption mechanism. Therefore, intravenous vitamin K was given for 3 days at initial presentation, and the coagulogram data was corrected within 24 hours. One week later, the patient developed steatorrhea. Fat malabsorption was suspected as the levels of fat-soluble vitamins were evaluated (). Cystic fibrosis was excluded by the negative sweat chloride test. At 4 months of age, perianal abscess was detected and treated with amoxicillin/clavulanic acid for 7 days without surgical drainage. However, subsequent pus culture was not performed. At the age of 6 months, lymphadenopathy of 3 cm in size at the left groin was detected. Fine needle aspiration was accordingly performed, and pus culture was found to be positive for BCG and the tuberculin skin test was positive at 15 × 20 mm. Chest X-ray revealed no pulmonary infiltration. The patient was diagnosed with BCG lymphadenitis and was treated with isoniazid and rifampicin."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old man with a history of emphysema, hypertension, and hypothyroidism presented to his primary care physician for routine followup. During the review of systems, he was found to have dyspnea on exertion reported as unchanged from his baseline as well as progressive dysphagia of solid foods over an unspecified period of time. Physical exam was significant only for central obesity and decreased breath sounds with prolonged expiration bilaterally. A modified barium swallow one week afterward showed mild esophageal dysmotility and small caliber of the esophagus throughout. During the exam, the technician made note of hoarseness, which the patient stated had been ongoing for three weeks.\nEsophagogastroduodenoscopy was performed approximately six weeks following initial presentation. Note was made of difficultly passing the endoscope into the esophagus secondary to hypopharyngeal edema. Endoscopy was terminated prematurely due to respiratory distress and decreasing oxygen saturation.\nEmergent intubation was performed and the patient was transferred to the intensive care unit. Approximately three hours postintubation, the patient was awake and communicative, and wished to be extubated. As he had been otherwise stable, the decision was made to extubate. Within minutes, he began having inspiratory stridor. He was able to explain that this “shortness of breath” had been increasingly experienced over the past few weeks, to the point when it was present at rest to varying degrees. The otolaryngology service was called to assist in evaluation of the airway and emergent intubation; examination was normal, including appearance and movement of the vocal cords, and the patient was reintubated successfully.\nPalpation of the neck by the intensivist team as well as the surgical oncology service was significant for mild adiposity and loosened neck folds, but despite easy identification of anatomical landmarks, including the cricoid and apparent movement of the isthmus with swa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78 year-old male patient undergoing endoscopic mucosal resection of colon polyps had been incidentally diagnosed of a 4 cm-sized infrarenal AAA, 1.5 to 2 cm distal from the left renal artery, with extension to the right common iliac artery (CIA), 3.8 cm in maximal diameter on computed tomography (CT) scan. However the patient was asymptomatic and therefore the aneurysm was observed. The patient had a past medical history of hypertension (diagnosed 2 years ago) and gout (diagnosed 5 years ago), and both on medications. Two years later, the patient was diagnosed of prostate cancer and underwent robot-assisted laparoscopic prostatectomy. During the work-up for the operation, the aneurysm was detected on CT scan but the AAA size was unchanged (4 cm) and the patient remained asymptomatic. Postoperatively, the patient suffered from deep vein thrombosis (DVT) needing the insertion of an inferior vena cava filter and anticoagulation.\nDuring the next 8 months, the maximum diameter of the aorta grew to 4.2 cm and that of the right CIA to 4.3 cm, with the aneurysm extending also to the proximal left common iliac artery (). Because of the large sized, rapid growth of right common iliac artery aneurysm, we decided to perform an EVAR procedure. It was planned and performed in two stages. The first stage was the embolization of the right internal iliac artery using a 16 mm vascular plug and the second stage was an EVAR procedure under general anesthesia using a bifurcated modular aortic stent graft (Zenith®, Cook Inc, Bloomington, Indiana, USA). During EVAR, intravenous 5,000 unit heparin injection was done for preventing graft thrombosis. Intraopertive minimal transfusion with red blood cell 1 pint was done, and hemoglobin was slightly dropped from 11.6 g/dL to 10.8 g/dL without definite change of vital sign after EVAR. The overall procedure was done without any other major complications and both lower extremity pulses were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe third patient case presents a 65-year-old female with a lesion in proximity to precentral gyrus (preCG, this patient is labelled as PAT_preCG in what follows). Her KPS decreased during the radiotherapy from 80 (pre-RT) to 70 (post-RT). RPA-class was evaluated to be V. In fact, during the first scan this patient was able to walk by herself, whereas during the last scan she used wheelchair and could walk small distance. This performance corresponds to lower KPS score of 50. PAT_preCG underwent three MRI studies: the first one 5 weeks post-surgery and the second one 5 weeks post-RT. Time between these scan points was 3 months. The third scan was done 4 months post-RT. This patient received chemotherapy between the 1st and 2nd scan points for 6 weeks.\nIn the first postoperative MRI study, the FLAIR scan showed a partial resection of the neoplasm with an area of hyperintense signal located in the right frontal lobe adjacent to the Rolandic fissure. A diffuse and irregular enhancing ring of the lesion was observed in the post-contrast T1-weighted scan with evidence of a fluid filled cavity located in the lateral side and a mural nodule located in the medial edge of the lesion. Maximum two dimension diameters of the lesion in the transverse plane were 30 × 24 mm and in plane area was 486 mm. A mild oedema surrounded the lesion without effect on the right lateral ventricle.\nIn the second post-RT MRI study a reduction in the lesion size was observed. Maximum two dimension diameters of the lesion in the transverse plane were 20 × 18 mm and in plane area of 274 mm. A diffuse, thick and irregular enhancing ring of the lesion was observed in the post-contrast T1-weighted scan. The peripheral oedema was reduced and the right lateral ventricle was slightly dilated.\nIn the third MRI study, the lesion showed a global increase in size"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4 year old male presented to the emergency department with the history of falling off a ladder 3 hours prior. He landed on his face on a wooden spike that embedded itself in the right orbit. His local hospital is not equipped to deal with ocular emergencies so he was transported by car for approximately 40 km to an eye hospital. Unfortunately, no anesthetist was available and the patient was referred to our emergency department. No treatment was instituted prior to referral. To reach our hospital, the patient had to backtrack 22 km and travel an additional 18 km, 40 km in total over rough roads (Figure ).\nOn arrival in our emergency department the child was fully conscious. He was hemodynamically stable with no airway or respiratory compromise. He had no past medical history and was not taking any regular medication. History revealed he was up to date with his immunizations, but history was considered unreliable. He lived with his parents and younger brother in a town in Eastern Nepal. On further examination, no other injuries were found specifically the cervical spine. Gross neurological examination was normal. The foreign body, still in situ, was a sharp wooden peg. It had penetrated the right orbit along the medial side. The cumbersome protruding object constituted a rock and a wire mesh attached to the wooden peg. The weight (approx. 1 kg) and shape of the object made stabilization of the object particularly difficult. It was impossible to evaluate the eye further due to the eye being obscured by the protruding object (Figure ).\nIntravenous access was established. Pain was managed with morphine and prophylactic antibiotics were initiated. CT scan was arranged. Patient was sedated with ketamine and midazolam. The patient was transferred to CT scan with the relative supporting the foreign body all the time. The contrast CT was initially reported by a radiology resident as follows, “foreign body lateralizing globe and penetrating through the medial part of the or"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe obtained the written informed consent to publication from the parent of the patient for this case report because the patient had slight mental retardation.\nA 24-year-old man, with a height of 190 cm and weight of 52 kg, was admitted to our hospital with right neck of femur fracture to undergo closed reduction and internal fixation. He was diagnosed with WHS after birth. Although he had slight mental retardation, he was able to ambulate and perform simple commands. No specific problems were noted on the transthoracic echocardiography, although ventricular premature beats were present on the preoperative electrocardiogram. His blood tests and chest X-ray did not show any abnormal findings.\nOn the physical examination, the patient had facial features identical to patients with typical WHS. The Greek warrior’s helmet appearance, characterized by a prominent glabella, hypertelorism, micrognathia, low-set malformed ears, and a down-turned mouth, was present (). Although mouth opening was more than 3 fingers and neck extension had no limitation, his mandible was small and relatively pushed backward (). His tooth alignment and dental hygiene was under poor condition, and Mallampati score was class II. He had undergone an inguinal herniorrhaphy under general anesthesia two years prior without any complications. The information about the previous general anesthesia was limited because it was dependent on the memory from patient’s mother, but any complication has not occurred during anesthetic management including endotracheal intubation. However, as a long anterior-posterior diameter of chest was noticed on computed tomography (), difficult intubation and airway management were anticipated.\nAfter entering the operating room, the hemodynamic status of the patient was stable with blood pressure of 115/91 mmHg, heart rate of 80 beats/min, and oxygen saturation of 99%. Total intravenous anesthesia was administered with 2% propofol and remifentanil to avoid malignant hypertherm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male first visited our hospital in 1998 with the chief complaints of headache and dizziness of a remote onset. He had experienced the symptoms for about 4 years, but they were aggravated 4 - 5 months before the hospital visit and they were accompanied with pain on both eyeballs and bilateral intermittent tinnitus. Magnetic resonance imaging (MRI) of the brain and cervical spine revealed a 4×4.5×6 cm-sized cystic tumor with a 2×3 cm-sized enhancing mural nodule at the right cerebellar hemisphere (). The cystic tumor had a heterogeneous rim and accompanying hydrocephalus. There were also multiple small enhancing nodules in the left cerebellar hemisphere and cervical spinal cord. The pancreas and kidney showed multiple cysts and bilateral cortical simple cysts, respectively. He was diagnosed as having von Hippel-Lindau disease, based on all these radiographic findings. Under the impression of hemangioblastoma, he underwent a complete excision of the right cerebellar tumor. One month after excision, he received a conventional radiotherapy using 6 megavolume (MV) of photon on both cerebellar hemispheres and cervical spinal cords, with a total dose of 50.4 Gy being divided by 28 times for 47 days. The postoperative radiotherapy was performed to treat both the operated and non-operated multiple hemangioblastomas. The patient made an uncomplicated recovery for the excised hemangioblastoma and underwent an uneventful clinical follow-up for more than 7 years.\nAt the age of 32 years in 2005, however, he experienced headache and dizziness again for about 5 weeks before his latest visit to the hospital. Brain MRI revealed a big right cerebellar cystic mass with a total size of 5.8×3.7×3.1 cm. The mass showed heterogeneous and irregular-shaped enhancement along the thickened walls and the big non-enhancing necrotic center (). It was radiologically suspicious of malignant change, because of the increased size compared to the previous one, the irregular and heterogene"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old female with a past medical history of chronic pancreatitis, type 2 diabetes mellitus, gastroesophageal reflux disease, lower gastrointestinal (GI) bleed, hypertension, paroxysmal atrial fibrillation, cerebrovascular accident, seizure disorder, and pulmonary embolism (PE) presented to an outside hospital after a reported seizure at her nursing home. Emergency medical services were called at the nursing home and the patient was reportedly hypoxic with oxygen saturation in the 70s on room air with subsequent development of agitation and lethargy after the seizure. The patient was transferred to an outside hospital's emergency department (ED), where additional tonic-clonic activity was noted. She subsequently developed hypotension with a blood pressure of 52/36 mmHg that was refractory to crystalloid intravenous fluid resuscitation. Central venous catheter (CVC) was placed and norepinephrine was started for persistent hypotension. Labs were notable for leukocytosis, troponin elevation, and low mixed venous saturation on CVC venous blood gas. The patient was subsequently transferred to a tertiary care facility cardiac intensive care unit for evaluation of cardiogenic shock.\nUpon arrival, the patient was alert and following commands, but disoriented. She was still requiring supplemental oxygen and norepinephrine for hypotension. Given the concern for cardiogenic shock, a stat bedside transthoracic echocardiogram was obtained, which demonstrated a large pericardial effusion with tamponade physiology. The patient was urgently taken to the cardiac catheterization lab for pericardiocentesis with a drain placement. This yielded 580 ml of hemorrhagic fluid with rapid improvement in hemodynamics following drainage. During the pericardiocentesis, fluoroscopy demonstrated two embolized fragments of the IVC filter within the right ventricle (RV). Review of past imaging revealed that the embolized fragment was visualized on computer tomography (CT) of the chest one yea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a 12-year-old girl who was referred from an outside hospital as a case of right mandibular and neck mass, which was rapidly progressive for the last 3 months (). The patient had a computerized tomography (CT) scan done outside, which revealed a destructive mandibular mass. The outside incisional biopsy was inadequate and showed changes suggestive of cemento-ossifying fibroma. The patient was subsequently admitted to the King Faisal Specialist Hospital and Research Center. Her physical examination shows stable vital signs with mild trachea displaced to the left by this large destructive mass. Repeated CT scan of the mandible and neck soft tissue showed a very large expansile lytic mass (7.3 cm craniocaudal × 5.1 cm transverse × 8.2 cm AP) involving the right side of the mandible, causing massive destruction of half of her mandible with extension into her condyle, neck, and medial side of the right mandible (). Areas of septations and bony erosions were seen peripherally. The enhanced study revealed multiple septations that contain wall enhancement within the lesion (Figures and ). The clinical diagnosis was high-grade malignancy, such as Ewing sarcoma. No significant major lymph node enlargement was detected. Visualized brain parenchyma showed no intra-axial or extra-axial masses. Under proper protocol, the patient was admitted to the operating room for biopsy. Intraoperatively, trachea and soft palate were displaced to the left. There was a large soft tissue mass located in the mandible, displacing her teeth all the way to the maxilla. The mass has expanded into the right neck area between sternocleidomastoid and trapezius muscles. Upon reflection of the mucoperiosteum on the lingual and buccal side, a soft tissue tumor was visible (). Careful dissection of the tumor from the lingual mucosa was performed removing a large specimen of approximately 6 × 6 × 3 cm, which was submitted for histopathology examination ( (inset)). Further intraoperative examination r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old lady with hypertension, diabetes, and asthma presented with a one-week history of left groin pain. The pain started insidiously and was localized to the left groin. She was otherwise well and asymptomatic prior to this. There was no history of preceding trauma. Of note, she had a dental extraction procedure two weeks prior to this. She was only on inhaled corticosteroids for her asthma, without any systemic corticosteroids.\nOn examination, she was found to have a tender left upper thigh mass that measured about 4 × 4 cm. Other than this, her lower limb neurovascular examination did not reveal any abnormalities. She did not have any features of distal emboli or splinter hemorrhages.\nInitial blood investigations revealed a total white cell count of 18.6 × 109/L as well as a raised C-reactive protein of 247.7 mg/L. Her diabetic control was also poor with a glycosylated hemoglobin level of 15.4%. Initial blood cultures were also taken which did not reveal any microbes.\nShe underwent an urgent computed tomographic (CT) angiogram of the lower limbs which revealed a thin wall eccentric saccular pseudoaneurysm arising from the proximal third of the left SFA measuring 2.0 × 2.6 × 3.0 cm with a gas containing intramuscular fluid collection seen. Mass effect from the collection and pseudoaneurysm was compressing the adjacent femoral vein causing central intraluminal filling defects, suspicious of deep venous thrombosis ().\nA CT aortogram was done to rule out any other mycotic aneurysms. This revealed moderated intimal calcification of the infrarenal abdominal aorta and bilateral common iliac arteries. In addition to this, a wedge-shaped hypoenhancing area in the right renal inferior pole with adjacent fat stranding was noted, suggestive of possible pyelonephritis. An echocardiogram was also done, which did not reveal any vegetations.\nUrinalysis was performed but no microbes were detected. She was started on intravenous augmentin after the blood cultures were take"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year old male patient reported to clinic with a chief complaint of swollen gums of 5 year duration and wanted to replace his missing teeth. Patient noticed swollen gums prior to his 4 years of edentulous state and the condition persisted to present. He was a known hypertensive and was on medication for the same since 7 years (10 mg Nifedipine/day).On intraoral examination- pink, firm, irregular, nodular, non- tender enlargements were found on labial aspects of maxillary and mandibular residual alveolar ridges. The enlargements were asymptomatic in nature with no history of bleeding. Both arches were completely edentulous (Fig. ). Panoramic radiograph showed no osseous deformities of maxilla and mandibular ridges (Fig. ). Patient’s complete blood count, bleeding time, clotting time and platelet count were with in normal limits. An incisional biopsy was obtained from anterior right side of the maxilla. Histological report revealed hyperplastic and acantholytic stratified squamous epithelium with elongated rete ridges extending into connective tissue which was fibro collagenous and showed focal areas of fibrosis. Infiltration of chronic inflammatory cells and congested blood vessels were seen which suggested of gingival hyperplasia (Fig. ). As patient wanted complete dentures, we planned to surgically excise entire overgrowth. Considering medical status of the patient, drug was not altered because, dose taken by the patient was low (10 mg/day). Local anesthesia devoid of vasoconstrictor was used to remove fibrous tissue from alveolar ridge with help of 15 no. B.P blade (Fig. ). To avoid any discomfort during the early phase of wound healing, a surgical splint was placed on both ridges after thoroughly covering the operated site with periodontal dressing (Coe Pack). The patient was recalled and followed at a period of 1 week, 3 months, 6 months and 1 Year intervals (Figs. , , and ). No recurrence of growth was observed during any of the recall visits. After 3 month"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Chinese female presented with blurred vision in the left eye for 50 days without any obvious inducement. Her medical history included high myopia for more than 50 years, but she had never had diabetes, hypertension, or other systemic illness. On admission, her blood pressure was 100/60 mmHg, her visual acuity was light perception, and her intraocular pressure (IOP) was 5 mmHg in the left eye. An ocular examination performed on the left eye showed a flare and was positive for cells in the anterior chamber. A fundus examination and B-ultrasound revealed retinal detachment with choroidal detachment (A, B).\nAll hematological and biochemical tests were within normal limits. After surgical contraindications were excluded, we performed a combined phacoemulsification without intraocular lens implantation and vitrectomy in combination with silicone oil injection. The choroidal detachment (C, star) was clearly visible before phacoemulsification was performed. After phacoemulsification, 20G and 23G vitrectomy cannulas were placed 3.5 mm from the limbus. The 20G cannula was left open, and the infusion line was placed in the anterior chamber through a clear corneal paracentesis with a bottle height of 40 mmHg. As soon as the infusion line was opened, a copious, thick flux of blood flowed out of the 20G cannulas and was followed a yellowish liquid (D). As the blood flow continued, the choroidal detachment visibly recessed. Though there was tight adhesion between the posterior vitreous and retina, the posterior vitreous cortex was completely separated from the inner surface of the retina. A 1/5PD hole was found in the arch of the vascular arch below the macula (E, black arrow), and a full vitrectomy combined with intravitreal silicone oil tamponade was performed. After surgical treatment, the retinal detachment and choroidal detachment were reduced (F). After treatment with a silicone oil tamponade, visual acuity was hand motion (HM) and counting fingers after 1 day"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).\nThe patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.\nWe performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 44-year-old Asian female, gravida 2, para 2, with no significant previous medical history, presented to urologist and complained that she had experienced dyspareunia over the preceding several months. The nature of the pain was a deep pain, which she experienced every time she attempted intercourse. She did not have vaginal discharge. No psychological factors can be found for her painful intercourse. She denied any episodes of gross hematuria, fever, chills, or irritative urinary symptoms. A pelvic bimanual examination was difficult to perform because of the patient's discomfort. No significant findings were detected on physical examination. Urinary tract infection was excluded as results of urinalysis and urine cytology were normal. The results of other laboratory tests including renal function, liver function, complete blood cell count, and coagulation function were also within the normal range.\nA pelvic ultrasonography revealed a 6.6 × 5.8 cm2 mass lesion located in the trigone of urinary bladder. The mass lesion was confirmed on contrast-enhanced CT to be an enhanced 7.2 × 6.1 cm2 soft tissue mass in the right paravaginal area. CT scan also revealed a lobulated and enlarged uterus consistent with uterine leiomyoma (Fig. ). There was no evidence of thickening of the urinary bladder wall and locoregional invasion. Flexible office cystoscopy was attempted and revealed a rounded, smooth, submucosal mass arising from the trigone of urinary bladder distorting the medial margin of both ureteric orifices. Double J stents could be passed with ease bilaterally. Retrograde pyelogram demonstrated no filling defects or dilation of the both ureters. The biopsies taken with a transurethral resection (TUR) loop showed a benign proliferation of smooth muscle in a connective tissue stroma suggestive of leiomyoma. After a careful discussion about the 2 options of further treatment, open surgical excision, and repeated TUR, the patient opted to receive open surgical excision. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA thirty-three year old gentleman initially presented to Prince of Wales Hospital with a diagnosis of SLE/dermatomyositis overlap syndrome. He was treated with steroid and hydroxychloroquine 200 mg twice daily since 1997. He had a flare up of disease in May 1998 with active vasculitis and myositis, for which he was put on prednisolone and azthioprine 50 mg and 100 mg daily respectively. Upon reassessment one month later, disease activity was under control, and the dosage of prednisolone was reduced to 45 mg daily.\nTwelve day after reducing the immunosuppressive regimen, he was admitted to hospital for treatment of left buttock abscess. The CXR taken on admission was unremarkable. An aspirate of the pus from the lesion grew methicillin-sensitive staphylococcus aureus; he was treated with cloxacillin 1 g intravenously every 6 hourly, together with incision and drainage of the buttock abscess. In view of the underlying active pyogenic infection, the steroid dosage was rapidly tapered from 45 mg to 15 mg daily within the next four days. However, he was noted to have persistent fever associated with mild unproductive cough. A repeat chest radiograph showed new infiltrates over the right upper and left lower zones, and he was empirically treated with intravenous ceftazidime 1 gram every 8 hours, cloxacillin 1 gram every 6 hours and netimicin 100 mg every 8 hours. As there was no clinical response after 5 days of treatment, bronchoscopy and bronchoalveolar lavage (BAL) was performed, which was positive for Pneumocystis jiroveci. Investigation for the presence of co-existing opportunistic pathogens such as cytomegalovirus and aspergillus was negative. On the day after bronchoscopy, he was commenced on intravenous cotrimoxazole 1.3 grams every 6 hours. He remained stable initially with fever on downward trend. However, on the 3rd day of treatment, he developed sudden desaturation with resurgence of high fever, and required supplemental oxygen therapy. Repeat chest radiograph"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old female with no contributing medical history was referred to the Endodontic Department of Qazvin School of Dentistry. She proclaimed that her left maxillary central incisor underwent incomplete root canal therapy five months ago. She stated that she could not continue the treatment due to financial problems. After clinical examination, a longitudinal fracture on the facial surface of the tooth was observed; also a solitary pocketwith a depth of 8 mm was detected in the facial region (). Radiographic examination revealed that the canal has been over-prepared during previous endodontic treatment but it has not been obturated. In addition, periapical radiolucency was observed at the apex of the left maxillary incisor (). The presence of a deep pocket along a longitudinal fracture convinced us to extract the tooth and treat the patient with an implant placement, but as was mentioned above the financial problems were the main patient's limitation for the desired treatment plan.\nIn view of this limitation we decided to extract left maxillary incisor, reconstruct the fracture with adhesive resin cement, perform a root end resection, prepare a retrograde cavity and fill it using filling material, and replant the tooth. A written informed consent was obtained and the patient was scheduled for treatment.\nAt the patient's return, antisepsis was carried out using 0.2% chlorhexidine gluconate; left maxillary incisor was anesthetized using an infiltration and nasopalatine nerve block injection (lidocaine 2% with epinephrine 1 : 80000; Daroupakhsh, Tehran, Iran). The tooth extraction was gently performed using forceps with no intraoperative complications; subsequently tooth structure was carefully examined and it was found that fracture line has been originated from the apex and propagated coronally (). Extracted tooth was kept in moistened gauze using normal saline, and in order to remove inflamed tissue, socket walls adjacent to the fracture region were curetted and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old male patient who had been followed up for 3 years with a diagnosis of Joubert syndrome and chronic renal failure and was receiving peritoneal dialysis treatment was brought into the pediatric emergency service due to vomiting and intolerance to food intake persisting for 1 week. Upon the development of hyponatremia and hypopotassemia, he was hospitalized and the appropriate supplementation treatment was instituted. Blood, urine, and peritoneal fluid cultures were obtained because of febrile episodes. Intravenous (IV) antibiotherapy with tazobactam-ampicillin was initiated. Growth of Candida spp. in his peritoneal culture necessitated the inclusion of liposomal amphotericin B in his treatment, and the peritoneal dialysis catheter was removed. The patient was anuric and had volume overload, so intermittent hemodialysis therapy was initiated and maintained in 3-hour sessions 3 days a week. An abdominal ultrasound was performed, which revealed complicated, lobulated, fluid-filled cystic lesions, the largest with dimensions of nearly 8x5 cm (pseudocyst) in the pancreatic loge, and multiple cortical cysts in both kidneys. An abdominal computed tomography (CT) scan indicated large cystic lesions localized in the anterior abdominal region that were compressing portions of the gastrointestinal system and intraabdominal organs, and which extended from the subhepatic region to the pelvis. Loculated fluid collections that were connected with each other in the peripancreatic area were noteworthy. The patient was evaluated by the department of pediatric surgery, and surgery was planned. During the operation, a cyst on to the anterior abdominal wall and extending from the pelvis to the epigastric region was observed. During attempts to resect the cyst, which was very strongly adhered to the anterior abdominal wall, the cyst ruptured and nearly 2500 cc serohemorrhagic fluid was aspirated. During the intervention, the patient suffered cardiac arrest. Erythrocyte suspen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman with a medical history consisting only of hypertension came to the emergency room (ER) with complaints of chest pain and shortness of breath for 4 days. On admission, she presented with vague discomfort in the right upper abdomen, anterior chest tightness and exertional dyspnea (class III according to the functional classification of the New York Heart Association). Physical examination revealed a blood pressure of 100/80 mmHg, a pulse of 88 beats/min, respiration of 34 breaths/min and a body temperature of 36.2℃. There were crackling sounds in both lower lung fields, but the cardiac sounds were normal. Various laboratory tests were performed on admission, including a blood chemistry profile, coagulation studies and a complete blood count, in which the cardiac enzymes revealed leukocytosis and elevated hepatic enzymes without evidence of myocardial infarction. A chest X-ray taken on admission showed the presence of cardiomegaly without mediastinal widening, patch infiltration in the right lower lobe and blunting of the bilateral costophrenic angles (). The electrocardiogram disclosed sinus tachycardia of 100 beats/min with no S-T or T wave changes. The Doppler echocardiography revealed an ejection fraction (EF) of 56.4%, moderate to severe tricuspid regurgitation, scanty pericardial effusion and bilateral pleural effusions, hepatic congestion, and an increased systolic pulmonary arterial pressure (SPAP) of 75 mmHg (normal range; 15-30 mmHg), suggesting the presence of severe pulmonary hypertension. After a preliminary diagnosis of \"idiopathic right heart failure\", the patient was admitted to the medical intensive care unit for treatment. On the 4th day following admission, atrial fibrillation and a sudden drop in systolic blood pressure to 70 mmHg appeared simultaneously. A follow-up transthoracic echocardiography taken 4 days later again showed a dilated ascending aorta and an intimal flap in the proximal ascending aorta (). The computed tomogra"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 46-year-old right-handed female with a past medical history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type two (DM2), obesity, and hemorrhagic stroke who was transferred from an outside facility to be evaluated for CNS vasculitis. She was admitted to this outside facility for a four-week period prior to being transferred to the primary facility for further evaluation over a subsequent 23-day period. Total duration of hospitalization at both the facilities was close to 7.5 weeks. Approximately one week into the initial four-week admission, her family found that she was very lethargic with diminished responsiveness and pronounced difficulty speaking. In the emergency room (ER), her blood pressure was measured at 243/129 mmHg with a blood glucose value greater than 400 mg/dL. She was started on aggressive antihypertensive therapy and underwent a series of diagnostic tests. Dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel was initiated in combination with high-dose atorvastatin. With respect to her lethargy and fluctuating cognition, there was concern that she may be experiencing complex partial seizures, so lacosamide was also started.\nA baseline computed tomography (CT) scan of the head without contrast showed multiple indeterminate lacunar infarcts involving the head of the right caudate nucleus and left corona radiata. The same day, a magnetic resonance imaging (MRI) was performed and elicited similar findings with the addition of bilateral punctate infarcts of the left thalamus, right periventricular white matter, and right centrum semiovale. Magnetic resonance angiography (MRA) done on the following day showed high-grade stenosis of the left middle cerebral artery (MCA), in addition to markedly diminished caliber of the right MCA and high-grade stenosis involving the left posterior inferior cerebellar artery (PICA). Bilateral carotid ultrasounds showed very mild plaques. An angiogram exhibited an occluded"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old girl with a rapidly increasing valgus angle of the right elbow presented at the out-patient clinic of our hospital. No evident trauma of the affected elbow had occurred. In another hospital, she had been diagnosed with a unilateral congenital radial head dislocation of the right elbow at the age of 3 months, for which a conservative treatment was initiated. Besides the increasing deformity, the patient had no complaints of pain or limitations. On physical examination, the patient was found to have a full and painless ROM and a normal carrying angle of the left elbow. The right elbow showed a cubitus valgus with clinically a carrying angle of 32°. The dislocated radial head was not painful on palpation. The range of motion was nearly full: flexion 130°, extension 10°, pronation 75° and supination 80°, compared with a flexion of 140°, extension of 0°, pronation of 80° and supination of 80° of the contralateral elbow. Plain radiographic evaluation of the right elbow showed an anterior dislocation and deformation of the radial head, with a long narrow neck and a hypoplastic capitellum and an increased valgus angle (Figs. and ). The left elbow showed no abnormalities. Radiographs of both forearms show a mild ulnar bowing on the right side, as compared to the left side (17 and 12°) (Figs. and ). This is probably due to chronic dislocation of the radial head. CT imaging of the elbow showed the anterior dislocation of the radial head with an overgrowth of the radius of 8 mm and a normal ulnohumeral joint. There is a premature ossifying physis of the lateral humeral condyle (Fig. ). Whilst no complaints or limitations were present, treatment was non-operative with clinical observation. No restrictions in daily elbow use were advised. The result of this treatment strategy was satisfactory after a follow-up of 18 months. No increase in valgus angle was seen, and elbow function was not painful. Treatment of the valgus angle can be"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn September 2007, a previously healthy 48-year-old man presented with gross hematuria and right flank pain. He was found to have a 6.6 x 6.1 x 5.9 cm (CC x TR x AP) mass in the right kidney on CT imaging (Figure ).\nOne week later, he underwent a laparoscopic nephrectomy, where a 5.5-cm renal cell carcinoma (RCC) was found on pathology. Histologically, it was a clear cell carcinoma with a Fuhrman grade of 3/4. Resection margins were widely negative.\nIn May 2015, he was admitted to hospital for diverticulitis. A CT scan performed incidentally showed multiple bilateral pulmonary nodules. These were biopsied, confirming recurrence of his RCC. No other sites of metastasis were observed.\nHe was referred to the regional cancer center and a decision was made not to initiate systemic therapy after discussion with the patient, who was completely asymptomatic at the time. Instead he was scheduled for monitoring.\nIn January 2016, surveillance imaging showed progression of the lung metastases and evidence of bone metastases. The patient also reported lower back pain consistent with his imaging findings. A bone scan showed an iliac lesion, as well as disease in his right rib, humeral head, distal femur, olecranon, and left ribs. He was initiated on Sunitinib. A referral was made to radiation oncology for a course of palliative radiotherapy to his symptomatic sites of bone metastasis.\nThe patient continued his follow-up in clinic with medical oncology and palliative care. He did develop a pathologic fracture of the right humerus requiring orthopedic intervention in August 2016. Subsequently, he had a spinal cord compression in November 2017 treated with laminectomy. In June 2018, he underwent excision of a metastasis in his right distal femur followed by total right knee arthroplasty.\nHis systemic therapy was switched from Sunitinib to Nivolumab after four cycles, then to Everolimus after seven cycles, and finally to Axitinib after nine"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old young man status post repair of transposition of the great arteries (TGA) had a coarctation repair using a subclavian flap procedure at 3 months of age. During a recent follow-up exam at 18 years of age, he was noted to have mild upper extremity hypertension, good femoral pulses, and a mild discrepancy in his blood pressures and pulses with right arm greater than the left. He was placed on enalapril for his hypertension. Cardiac catheterization showed findings consistent with previous repair of his TGA, dilated aortic root with aortic incompetence, and no residual coarctation. A year later, he developed gradual onset of dizziness that was exacerbated by the use of his left arm. The patient also developed headaches, blurring of vision, confusion, and an acute syncopal episode while walking to school, which prompted admission and work-up. On examination, a grade 2-3/6 diastolic murmur was noted. His blood pressure in the right arm (127/72) was higher than the left (113/69) and the right arm pulse was stronger than left arm. Neurologic exam at baseline was unremarkable. The patient reported that his dizziness improved when the left brachial artery was compressed.\nBrain MRI with angiography showed no acute changes. Chest CT angiogram [] demonstrated the patient's anatomy status post subclavian flap, with the proximal left subclavian artery dissected away from the aorta and the left vertebral arising distally from the subclavian. shows the patient's carotid artery Doppler ultrasound, which demonstrates retrograde flow in the left vertebral artery consistent with left subclavian steal and continued retrograde flow in the left vertebral artery with left arm exercise. The patient underwent a hyperemia test with no significant change in his systolic blood pressure (SBP) in right arm (119 mmHg to 118 mmHg). However, his SBP dropped from 107 mm Hg to 102 mmHg in the left arm. shows the patient's aortic angiogram demonstrating prograde flow across the right common"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old right hand-dominant woman suffered a fall on her right side in a bicycle accident, and presented at our institution on the same day with severe arm pain. Her medical history included internal fixation for a glenoid fracture 7 years ago, and also hemiarthroplasty (bipolar humeral head type) for a proximal humeral fracture 5 years back. She had also undergone coracoid tip transfer to the glenoid rim for atraumatic postoperative dislocation. All the previous operations had been performed at other hospital. Upon initial presentation, the patient had severe pain in the right arm without vascular or neurological abnormalities, and the right arm was swollen, with deformity. She was not aware of any pain around the shoulder. She stated that although her range of motion in the arm had been limited before the accident, she had been able to live without assistance. Standard radiographs of the humerus revealed a periprosthetic fracture, which was centered at the tip of the prosthesis stem with minimal proximal extension, chronic anterior dislocation, proximal medial side osteolysis, and a thin cortex with osteopenia ( and ) We considered that surgery might have a considerable risk of complication because of the patient’s advanced age, poor bone condition, and history of multiple operations on the shoulder. Therefore, we decided to follow her up conservatively using functional bracing with routine periodic X-ray examinations. Her arm was immobilized using a plaster U-slab in a sling, to rest the arm and allow the swelling to subside for 2 weeks after the injury. After the swelling had improved, we modeled a functional brace. At 2 weeks after injury, the functional brace was applied without a sling, and physiotherapy was started, with very good patient compliance. The arm pain gradually resolved on a daily basis, but after 3 weeks, radiography showed that the fracture gap had widened. Therefore, we treated this fracture using a sling to prevent any traction force on"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a 60-year-old right-handed man with past medical history of relapsing-remitting multiple sclerosis diagnosed 20 years ago with prior beta interferon treatment for 8 years and with chronic left residual hemiparesis who presented to the emergency room after experiencing generalized weakness followed by a fall to the ground with apparent loss of consciousness. While the patient reported no loss of consciousness, he did not have memory of the events surrounding the fall. EMS was called and patient was airlifted to the nearest percutaneous intervention-capable center after the ECG showed a ST segment elevation in the leads V1 to V3, so the ST segment elevation myocardial infarction (STEMI) alert was activated. In the emergency department, the patient was without chest pain. Upon further questioning, he denied any family history of heart disease including no cardiomyopathy, heart failure, arrhythmias, or premature or sudden cardiac death. Vitals demonstrated mild tachycardia to 105 beats per minute and a temperature of 38 degrees Celsius, and labs revealed a negative troponin level. Ultimately, the ST segment elevation myocardial infarction (STEMI) alert was cancelled due to the high clinical suspicion of the type 1 Brugada pattern in a syncopal patient with anteroseptal ST elevations without chest pain. Workup for the febrile episode revealed positive serology for influenza B. Oseltamivir was started and the patient completed 5 days of treatment. The patient was no longer febrile and his tachycardia had resolved, but he continued to show a persistent type 1 Brugada pattern on the ECG during the entire hospitalization course as seen below (). The patient subsequently went for a transthoracic echocardiogram which demonstrated a normal left and right ventricular function and no structural abnormalities. He also underwent coronary angiography, which revealed nonobstructive coronary artery disease.\nUltimately, the primary concern was to elucidate, whether the patient'"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is an obese, but otherwise healthy, 34-year-old male presenting for a robotic laparoscopic inguinal hernia repair. A preoperative electrocardiogram (EKG) revealed a third-degree atrioventricular (AV) block, which was not recorded in the preceding surgical preoperative note. Our patient knew of his condition but did not disclose this information to anyone until it was discovered via history, physical, and chart review on the day of surgery. He was not aware of the risks associated with the anesthetic procedure and did not have an established cardiologist following his condition. The last echocardiogram was nine years ago in 2011, which revealed no systolic, diastolic, or valvular abnormalities. His last visit to a cardiologist was five years ago in 2015, during which he obtained an EKG unchanged from the normal preoperative EKG he received on the day of his elective surgery. While his EKG on the day of surgery was normal, anesthesiology preoperative history and physical revealed that he has a history of congenital complete AV block. He has no current pacemaker in place and his complete AV block was not followed by a cardiologist when he presented for surgery.\nOur patient's past medical history was significant for bradycardia, chest pain, dyspnea on exertion, hypertension, and complete heart block. However, even though our patient's past medical history was significant for the above, his present medical status and vitals were within normal limits, with the exception of his elevated blood pressure at 169/110. History and physical revealed that he was able to do heavy work around the house, such as lifting furniture and running for exercise, which would classify the patient as having greater than 10 METs. However, even though he was presently asymptomatic with greater than 10 METs, the fact that he had no current establishment of cardiac care warranted further investigation, especially with his concurrent hypertension. A cardiologist was called preoperativel"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a 50-year-old right-handed male, with 33-year history of T6 AIS A SCI from a gunshot wound complicated by chronic pain, left hip and knee heterotophic ossification, and a chronic dislocation of his right hip, who initially presented to the emergency room with a right shoulder mass in September 2014. While he initially noticed the mass about 2 months earlier, he presented for evaluation now because of acute onset of pain, weakness and paresthesias in the right arm. He was admitted to the general medicine service for pain management and underwent an initial work up for his right shoulder mass, including advanced imaging and a core biopsy. Physiatry was consulted due to his functional deterioration that precluded him from returning to his previous independent living arrangement. He demonstrated diffuse, mild weakness throughout the right arm that was variable and seemed to be correlated with his reported pain level, but his most consistent and weakest movement patterns were his grade 4/5 weakness in finger abduction and distal interphalangeal joint flexion. He had reduced pin prick sensation over the volar surface of digits 3–5, palm and forearm of the right arm and hand. He was not able to perform transfers to or from his manual wheelchair due to his level of pain. The magnetic resonance imaging (MRI) revealed a heterogeneously enhancing mass with a maximum diameter of 6.9 cm (Fig. ) that involved the right deltoid and pectoralis major muscles. His core biopsy demonstrated a STS that was classified as a high grade (III) spindle cell sarcoma.\nOncology recommended treatment for his STS with a course of outpatient neo-adjuvant radiation therapy followed by gross total resection with wide margins. Physiatry pre-operative consult focused heavily on functional prognostication. The patient expressed multiple times that he placed the highest priority on return to his previous modified independent living arrangement and not only survival after his STS treatment course."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old woman presented to a local physician with an intermittent epistaxis and a facial pain around her nose. Her medical history was unremarkable. Computed tomography (CT) scan demonstrated a heterogeneously enhanced mass lesion centered in the left nasal cavity [].\nShe was referred to our institute for surgical treatment of a nasal cavity tumor. On admission, she suffered from anosmia and diplopia. CT scan, performed 3 months after the first scan, demonstrated that the enlarged mass lesion breaking through the medial wall of the left orbit and pushed the eye laterally []. We considered this might be the reason for her diplopia. For tissue diagnosis, the patient underwent endoscopic exploration from the nasal cavity. Because of heavy nasal bleeding, we combined midfacial degloving approach. Although we could control the bleeding, we could not resect the complete tumor.\nHematoxylin and eosin-stained sections showed neoplastic cells forming small intracellular lumina that included red cells. The endothelium covering blood vessels was hyperplastic. No mitosis and necrosis were observed []. The Ki-67 labeling index was 28%. Immunohistochemical analysis was positive for factor VIII-related antigen, vimentin, CD34, and CD31 []. EHE was diagnosed on the basis of the aforementioned findings.\nMagnetic resonance images indicated that the tumor had invaded the anterior skull base dura matter []. Digital subtraction angiography indicated bilateral ethmoidal arteries as major feeding arteries to the tumor. Because of the aggressive nature of EHE, the cancer board of Tohoku University Hospital agreed radical surgery of the tumor utilizing anterior skull base dissection and endonasal endoscopic exploration.\nBefore the operation, spinal drainage was introduced to reduce brain retraction. Neurosurgeons conducted bilateral frontal craniotomy and excised the anterior skull base dura where the tumor had invaded. The left anterior and posterior ethmoidal arteries were coagulated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old female with no previous history visited a local hospital due to right wrist pain and swelling caused by falling. She was diagnosed with a distal fracture of the right radius, underwent splinting, and returned home. When she visited the local hospital again 2 days after the injury, blister formation on the right forearm was observed, and she was referred to our hospital. The blister was observed along the splint application area () and was considered to be due to the heat and stuffiness of the splint. Plain X-ray examination revealed a distal radius fracture accompanied by dorsal displacement of the distal bone fragment (AO classification: type A2) (Figures and ). Based on the skin condition, we considered conservative treatment by external fixation using a splint or cast to be difficult, and surgery after improvement of the skin state would be more invasive due to bone union and, therefore, planned minimally invasive locking plate osteosynthesis.\nAs we previously reported, surgery was performed using the Henry approach through a 10 mm incision starting from 15 mm proximal to the radial styloid process at 9 days after injury []. In this patient, there was no skin lesion at this incision site, which allowed this surgical technique (). After reduction of the distal bone fragment using a Kirschner wire, osteosynthesis was performed using a volar locking plate (Acu-Loc 2 proximal plate standard, Nihon Medical Next, Osaka Japan) (Figures and ). After the operation, a favorable alignment was obtained (Figures and ). The wrist was immobilized postoperatively in a bulky dressing without an arm splint until the tissue swelling had decreased.\nAll muscles, vessels, and nerves of the anterior compartment—except the radial artery—were retracted ulnarly. The pronator quadratus was incised transversely at its distal portion and dissected off the periosteum using a periosteal elevator preserving its ulnar and radial insertions. Therefore"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old female, nursing home resident, with a past medical history of type II diabetes mellitus, hypertension, cerebrovascular accident, anoxic brain injury with permanent percutaneous endoscopic gastrostomy (PEG) tube and tracheostomy to ventilator was noticed to have a high peak pressure on the ventilator on a routine check by the nursing home respiratory therapist. Suctioning was attempted but was unsuccessful. The tracheostomy tube was changed and during the process, increased resistance was felt. Soon thereafter it was noticed that blood was leaking from around the tracheostomy tube. Emergency medical services were called and the patient was brought to the emergency department. On arrival the patient was found to be hypertensive with a blood pressure of 160/74 mmHg, heart rate of 80 beats per minute, respiratory rate of 18 breaths per minute, O2 saturation was 100% on 100% FiO2 fraction of inspired oxygen (FiO2) on assist control-volume control + ventilator mode and a temperature of 37.8°C. On examination, the patient appeared to be generally edematous and was found to have crepitus on palpation starting at the forehead proceeding all the way down to the chest, abdomen, pelvis and upper thighs. In addition, her upper arms bilaterally also appeared swollen with crepitus present on palpation. Examination of the head and neck revealed a tracheostomy with tracheal tube in place with slightly pink secretions and what appeared to be dried blood on gauze surrounding the tube. On auscultation of the chest Hamman’s crunch, a crunching sound, synchronized with the heartbeat was present, as well as slightly decreased breath sounds at the right apex. Stat chest X-ray was performed which revealed extensive PM associated with subcutaneous emphysema in the neck and right chest wall (Figure ).\nThe patient was emergently assessed by an otolaryngologist and tracheoscopy was performed through the stoma with the tracheal tube in place. It was determined the tracheal tube wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man was admitted at 3 h after the onset of severe back pain and bilateral lower limb swelling. He had a history of stroke and hypertension. On arrival at our hospital, his systolic blood pressure was 80 mm Hg, and he had bilateral leg edema with cyanosis. There was no abdominal bruit, elevation of the jugular venous pressure, or dyspnea. Enhanced CT showed an infrarenal AAA (92 × 75 mm2) and a short fistula (7 mm) running between the right lateral wall of the AAA and the inferior vena cava (IVC) ( and ). The IVC was compressed by the aneurysm (). Angiography was not performed. Just after CT scanning was completed, circulatory collapse occurred, and the patient was rushed to the operating theater. The AAA (90 × 70 mm2) was identified via the transperitoneal approach, but there was no retroperitoneal hematoma. After heparinization, the infrarenal aorta was clamped, the aneurysm was opened, and the bilateral common iliac arteries were occluded with balloon-tipped catheters. Then, we detected a fistula communicating with the IVC via a 7-mm defect in the right lateral wall of the aorta at 3 cm proximal to its bifurcation (), corresponding to the lesion detected preoperatively by CT. There was considerable atheroma around the defect. As soon as the atheroma was removed, massive venous bleeding occurred. Despite digital compression, we could not identify the fistula accurately because of massive bleeding. Accordingly, two balloon-tipped catheters (balloon size: 12 Fr) were inserted through the fistula, and the bleeding was controlled. The fistula was found to measure 22 × 35 mm2 in diameter. It was closed with running sutures of 5-0 polypropylene and a Dacron patch (). Then, the AAA was replaced with a 16 × 8 mm2 bifurcated Hemashield graft (Boston Scientific, Boston, MA, USA). The aortic clamp time was 60 min, and operating time was 161"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA female patient aged 1 year 8 months old presented to the emergency department after falling on an outstretched hand. On radiograph imaging (Figure ), a supracondylar fracture Gartland type III was diagnosed. On her first neurovascular survey, no abnormalities were noticed. The patient was operated on the next day. After closed reduction, two 1.4-mm Kirschner wires in a cross-configuration were placed to stabilize the fracture. On the lateral side, the wire was inserted percutaneously, and the medial pin was placed under direct bone vision. Good and stable fracture reduction was achieved (Figure ). After surgery, the patient was placed in a posterior splint with 60° flexion at the elbow. A neurovascular examination was done, but no neurologic deficit (motor or sensory) was identified, although no documentation of specific sensation testing is found. Active finger movements were observed. The child was released from the hospital on the second day after surgery, with an outpatient clinic follow-up visit programmed 3 weeks after surgery.\nNo motion was allowed at the elbow joint for all this period. The pins were removed after 3 weeks at the outpatient clinic visit (Figure ).\nAbout 6 weeks after surgery, the child began oral antibiotic treatment (Augmentin), which was prescribed by a physician in the community because of a skin infection on the fifth fingertip, on the fractured side. The mother saw the child bite her finger continuously. After a few days of treatment, the child was referred to the hospital because of lack of response to the antibiotic treatment. On her admission to the pediatric orthopaedics unit, amputation of the distal phalanx was noted, and radiograph imaging confirmed the diagnosis (Figures and ). A child abuse workup (total body examination and a social worker inquiry) that was done after admission ruled out this option. We started treatment with systemic intravenous antibiotics (Cefamezin 30 mg/kg) and topical treatment (Syn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old man visited the hospital with oval shape mass in right mandibular angle, which had grown slowly from 3 years before the visit to the hospital as main complaint. There were no particular apparent traumas and no other medical history other than asthma. A soft mass of 5×4 cm in size on physical examination was palpated, there was no presence of facial nerve weakness, and he was complaining that he felt as if the face of the affected side, was turned to ipsilateral direction ().\nA well-defined lobulated mass of 4 cm in size was found in the deep lobe of right parotid gland from Magnetic resonance imaging (MRI) scanning and a pleomorphic adenoma was suspected (). We planned a total parotidectomy and decided to use the ADM to correct for the predicted depression. The mass was located at deep lobe as shown in the MRI images and a total parotidectomy was performed. 5 branches of facial nerve were identified during the surgery and all of them was preserved. The material known as ADM of 4 cm×7 cm in size, 3.4 mm thickness (Flex HD, Ethicon Co. LLC., Somerville, New Jersey and Cincinnati, OH, USA) were adequately trimmed for the depressed part from where the mass was removed. The part between the cheek flap and nerve were augmented centering the depressed site after the mass was removed. After the closed draining tubes were inserted over and under the ADM, the site was sutured (, ).\nDrains were drained by 27 mL/day a day after surgery in bloody character, gradually became serosanguineous, and decreased in volume and drained to less than 10 mL/day 3 days after surgery, but were removed somewhat later. We removed superficial one and cut deep one to allow drainage naturally 5 days after surgery, and removed deep one 7 days after surgery. The surgery site was healed well without any complications such as seroma or"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old male was referred to the Department of Conservative Dentistry and Endodontics with a chief complaint of pain and swelling in his upper right front region. His medical status was noncontributory. After questioning, it was learnt that 5 years back he had got his upper jaw hurt in an accident. After 3 years, he developed swelling in the upper front region and consulted a local dentist. The dentist did root canal treatment of right central and lateral incisors. For next 1 year, the patient was asymptomatic, but there after, he again developed swelling and pain in the upper front region. It was at that point of time he came to our department.\nAn extraoral examination revealed a diffuse swelling on the right side of upper lip. An intraoral examination showed discolored and tender maxillary right central and lateral incisors. Periapical radiographs showed poorly obturated canals and a large radiolucent lesion with a well-defined margin around the apices of teeth 11 and 12 []. The lesion was approximately 13 × 17 mm in maximum diameter. After evaluating all the data, a root canal retreatment of teeth 11 and 12 was planned. A rubber dam was applied, and the access cavities were prepared. The drainage of pus was noted from both teeth. Both teeth were instrumented to ISO size 60 by using the step-back technique. During instrumentation, the canals were irrigated with 3% sodium hypochlorite and then dried and dressed with calcium hydroxide. During the next 3 weeks, the patient was examined weekly, and in each visit the calcium hydroxide dressing was changed. After 3 weeks, the swelling had subsided, but the patient complained of constant dull pain and heaviness in the concerned region. The canals were wet and showed mild discharge. The treatment procedure was changed. The canals were irrigated and dried, a triple antibiotic paste was placed, and the teeth were temporized. The paste was changed every month for a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old male was brought to our department with the complaint of painful, progressive, and nonhealing ulcerated lesion of the tongue for 2 months. He did not give any history of fever, night sweats, cough, decreased appetite, or significant weight loss. There was no history of change in voice or choking. He did not give history of traumatic episode preceding the development of that wound. He denied any history of similar lesions in the past. He was a known case of hypertension taking antihypertensive medications. Besides having hypertension he denied history of other systemic illnesses including pulmonary tuberculosis. He admitted to smoking and drinking alcohol occasionally. The rest of his medical and surgical history was unremarkable. His past dental history was not significant. There was no history of TB in his family members. He was repeatedly treated in a local hospital with topical antiseptics and oral antibiotics (ampicillin plus cloxacillin and metronidazole) and analgesics but the lesion did not subside so he was referred to our hospital for the further management.\nOn general examination he was thin built with general conditions being fair, while, on examination of oral cavity, there was an indurated ulcer measuring 1.0 cm × 0.5 cm on the left lateral border of tongue on the anterior two-third part of tongue (). It was tender with irregular border. It did not bleed on touch. The remaining part of the tongue was normal in texture and color. Mobility of tongue was normal. It was not deviated to either side on protrusion. He had poor orodental hygiene along with sharp tooth adjacent to the ulcerated lesion although the multiple teeth were absent. There were no palpable cervical lymph nodes and no similar ulcers in any other body parts.\nProvisional diagnosis of traumatic ulcer was made as the possibility of ulcer due to repeated trauma by the sharp tooth could not be ruled out based on the physical examination alone. As we thought it could be due to chro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year old woman was presented to the orthopaedic department with a 3-month history of a painless mass in the upper external area of the left gluteus.\nTwo years, previously she underwent an abdominal hysterectomy because of an enlarging mass found in the pelvis, located between the uterus and the recto-sigmoid area. CA 125 was moderately elevated at 61.9 U/ml. The resected mass was bilobular (9 × 7 × 6, 5 cm and 5, 2 × 5 × 5 cm) with hard and partially soft elements. Multiple intramural uterine leiomyomas were also identified. The tumor was diagnosed as \"a leiomyosarcoma\" composed of cellular bundles of spindle cells with medium grade atypia and presence of giant cells. The range of mitosis was very high, up to 50/10 H.P.F (high power field). Immunohistochemical analysis with avidin-biotin-peroxidase complex showed positive reaction for vimentin, smooth muscle actin and desmin (Fig and ). The patient was treated post-operatively with radiotherapy and chemotherapy (Gemcitabine and docetaxel).\nOne year after the hysterectomy, a single metastasis was diagnosed during a routine follow up in the left upper lung lobe treated surgically with lobectomy. The histological diagnosis was compatible with the known primary tumor. One year later, the patient was presented in the orthopaedic department with a painless mass in the left gluteus area. The clinical examination revealed a focal lump in the left gluteal area. The subsequent magnetic resonance imaging study, showed a mass with central necrosis located in the subcutaneous fatty tissue, in close proximity to the gluteal muscles. In addition, a second small lesion with similar findings was detected in the right gluteal muscle (Fig ).\nA diagnosis of soft tissue metastasic disease was suggested and a surgical resection of both masses was undertaken. The post-operative period was uneventful. The histological diagnosis confirmed the presence of a spindle cell sarcoma with central necrosis and morphologic features similar to t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43 year-old female was admitted to our hospital with a chief complaint of right upper pain and palpable mass. On physical examination, there was slight tenderness and semimobile mass in the right upper abdomen. Clinical examination did not demonstrate any persistent weak abdominal pain and mass. Her past medical and surgical history was unremarkable. Moreover, Family history and psychosocial history were also not particular.\nIn abdominal contrast-enhanced computed tomography (CT), 130 × 100 × 90 mm huge cystic mass was demonstrated in right upper peritoneal cavity. The cyst had thickened wall and many enhanced nodules. Many nodules and the thickened wall were slightly enhanced in early phase (A) and gradually enhanced in delayed phase (B). Gadolinium-enhanced magnetic resonance imaging (MRI) showed that intra-cystic fluid was bleeding or mucinous fluid as the intensity was slightly high in T1WI (C), high in T2WI (D), and slightly high in fat suppression T1WI. The thickened wall of the cyst and mural nodules were high intensity in Diffusion-weighted MRI. The findings of connection with pancreatic head suggested a tumor originated from pancreas. The differential diagnoses were MCN, mucinous cystic adenocarcinoma and hemorrhagic cyst. After an extensive discussion in our institute, we planned pancreaticoduodenectomy for this abdominal tumor.\nShe was taken to the operating room by a surgical oncologist who primarily specialized in pancreatic resections and had been in practice for over 10 years. In surgical findings, this tumor did not attach to gastrointestinal tract and originated from pancreatic head (A). The aspirated fluid was bloody and the cyst had re-increased for short time in operation. In these reasons, we diagnosed the tumor as hemorrhagic cyst and selected partial pancreatectomy because this tumor was resected completely (B). The cystic wall was thickened and elastic soft. No tumoral change found in the surface of cystic wall (C). Post-operative course wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man noticed some swelling of his face. A chest x-ray showed a large mass projecting over the right lung field (fig ). A CT scan of the chest showed an enormous anterior mediastinal mass contiguous with the posterior aspect of the sternum and the right ribs, occluding the superior vena cava and compressing the heart (fig ). Blood tests were normal, tumor markers and Acetyl Choline Receptor Antibodies were negative. The patient underwent bronchoscopy and the biopsy showed the features of a carcinoid tumor.\nHe underwent excision of the tumor, which required resection of the superior vena cava and insertion of a graft, resection of the right phrenic nerve and plication of the diaphragm.\nThe finding at surgery was an enormous spherical tumor with an extremely vascular capsule due to the venous collaterals. The tumor was 20 cm from pole to pole and 15 cm in diameter. On the left it bulged into the left pleural space, displacing the phrenic nerve laterally. Superiorly it obliterated the left innominate vein and extend into the strap muscles. There was an enlarged lymph node. On the right it had obliterated the confluence of the innominate veins and the first centimeter or so of the superior vena cava. It enclosed the phrenic nerve over its complete length and was adherent to the medial aspects of the upper and middle lobes of the right lung. There was some thickening of the visceral pleura in this area and there appeared to be some superficial infiltration. Posteriorly it was adherent to the pericardium and there was some thickening of the ascending aorta, consistent with longstanding pressure effects. There was a small bloody pericardial effusion and a rather large right pleural effusion. There was no evidence of any pleural deposits or intrapericardial deposits.\nThe histology of the resection specimen showed a tumor weighing 2.1 kg. The tumor appeared encapsulated with an irregular surface. The tumor invaded the surrounding fat and pleura. There was infiltr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nTwo years ago, an 80-year-old man with intermittent abdominal discomfort in the right lower quadrant of the abdomen was admitted to our department via a local clinic. Although he complained of intermittent abdominal pain and diarrhea, the physical examination and blood test findings were normal. The patient had undergone an intestinal resection at the age of 35 from complications due to tuberculous enteritis. He was currently taking medication for hypertension. A physician in our department performed computed tomography (CT) because of a cystic lesion found within the right lower quadrant of the abdomen through ultrasonography at the referring clinic. The CT scan showed a 5-cm regular hypodense lesion near the cecum without enlarged lymph nodes (). The radiologist indicated that the lesion resembled an AM, but was most likely terminal ileitis due to a postoperative adhesion or the tuberculous enteritis.\nThe patient did not come to hospital for checking the CT results. He then experienced chest pain and visited the Cardiology Department. Coronary angiography revealed angina pectoris, for which he was treated for 3 months. His cardiac problems were resolved, and he revisited the outpatient Gastroenterology Department. At that time, his physician recommended surgery, but he and his guardian refused because of his medical history of cardiac problems. They requested medication instead. For 1 year, the patient was regularly followed up by the outpatient Gastroenterology Department. We repeated the CT scan at 1 year and found that the mucocele had increased to 6 cm (). Again, we recommended surgery, which the patient refused. Three months later, he was admitted to the Emergency Department with abdominal pain and a fever of 38.3℃. His white blood cell (WBC) count was 15.8×103/µL, and his C-reactive protein (CRP) level was elevated (146 mg/L). On physical examination, we found a 7-cm cavity in the right lower quadrant that showed tenderness, heat, and erythema. We performed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female patient complained a mass in her maxilla and mandible. The mass was gradually increasing in size over the last 6 months. The mass caused talking disturbances, swallowing difficulty, dilating gap between upper teeth, and narrowing gap between lower teeth. She also complained hard masses in her fingers and the middle of chest. There was a decrease in height (15 cm in 8 years) and weight (19 kg in 8 years). The patient was on end stage of renal failure and has been treated with hemodialysis 2 times per week for eight years since 2008. The patient was planned to be performed renal transplantation. Comorbidities were reported among this patient, which are chronic heart failure, grade II hypertension, lung tuberculosis on therapy, and hepatitis C. The physical examination showed facial asymmetry with mass in the palatum durum, measured 4 × 3 cm in size (). Palpation revealed hard consistency originated from the bone, smooth surface, and no tenderness.\nX-ray of the maxilla and mandible showed diffused decreasing bone density and multiple lytic lesion, which suggest metabolic bone disease or renal osteodystrophy or hyperparathyroidism (). BNO showed compression fracture in thoracolumbar vertebrae and multiple calcification in soft tissue abdominal and pelvic region compatible with renal osteodystrophy. Bone survey also showed the decreased bone density. Facial CT with contrast showed diffuse hyperostosis, lytic lesion in the mandible bone, maxillary bone, cranium, and multiple calcification in the soft tissue which is compatible with osteorenal dystrophy (). Thyroid ultrasonography showed bilateral multiple cysts in the thyroid, a firm lesion with calcification in the left parathyroid fossa, and oval lesion in the left pericarotid. Parathyroid scan showed an increased activity in the inferior aspect of left thyroid which was suggestive of parathyroid adenoma.\nLaboratory examination showed the elevated ureum (202 mg/dL), creatinine (11.1 mg/dL), and norm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man with Marfan syndrome and no previous cardiac history collapsed on hospital grounds after complaining of bilateral shoulder pain. Within a few minutes, two doctors at the scene started performing chest compressions. The patient was immediately transferred to the emergency room where he was intubated and defibrillated twice due to ventricular fibrillation (), with return of spontaneous circulation (ROSC) in between the two shocks (). During resuscitation, he was treated with adrenaline and amiodarone.\nAfter a second ROSC, cardiac rhythm converted to atrial fibrillation with ST segment elevation in the leads corresponding to the anterior wall. As part of the treatment, he received magnesium 2 g, heparin bolus 5000 IU, and 300 mg aspirin by nasogastric tube.\nThe patient was admitted to the intensive coronary care unit. On admission, the electrocardiogram showed rapid atrial fibrillation with ST segment ele-vation resolution (). Due to hemodynamic compromise, electrical cardioversion was performed, converting to sinus rhythm with diffuse ST segment depression and an ST elevation in lead aVR (). The patient was taken urgently to the cardiac catheterization laboratory due to ST changes and hemodynamic instability. The angiography demon-strated significant two-vessel disease, and a drug-eluting stent was implanted successfully to the proximal to mid-left anterior descending artery (LAD).\nDuring the early post-procedural period the patient became hemodynamically unstable; bedside echocardiography demonstrated accumulation of a new pericardial effusion. The differential diagnosis included coronary artery perforation versus cardiac laceration. After a brief discussion with the heart team, the patient was transferred for a second time to the catheterization laboratory in order to implant a cover stent in case there was indeed a coronary perforation and pericardiocentesis was needed for the accumulated pericardial effusion.\nDuring angiography, instant stent th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male was referred to the emergency unit because of rapidly progressive gait difficulties with subacute onset.\nThe patient had a history of depression and substance use disorders (alcohol and amphetamine). He was treated as an outpatient at the department of psychiatry. Current medications included citalopram 40 mg, hydroxyzine 25 mg and quetiapine 50–100 mg per day, and oxazepam 15 mg as needed. A year before presentation, the patient had a transient episode of mild gait difficulties with unclear aetiology that had resolved spontaneously. At that time, he had gait ataxia with signs of upper motor neuron damage in all extremities. Brain and cervical spinal cord MRI were unremarkable, except for mild atrophy of the cerebellar vermis and frontal cortex, which were interpreted to be related to the long-term alcohol abuse.\nThe patient presented at the university hospital emergency care unit (ECU) with a 2–3-week history of progressive, painless gait difficulty associated with numbness in the hands. The patient had been abstinent from alcohol and amphetamine at least for the past 6 months, which was confirmed by regular laboratory investigations. However, the patient reported having replaced these substances with excessive daily ‘whippet’ abuse. He had discontinued ‘whippet’ use and started oral vitamin B12 substitution based on the information he found on the Internet a couple of weeks before presenting to the ECU. At the time of presentation, the gait difficulty had progressed to a state that he was unable to walk unaided.\nIn the ECU, the patient showed bilateral lower extremity weakness that was the most prominent in distal lower limb muscles. In addition, there were minor distal paraesthesias in all extremities. Vibration sense was absent up to the knee level, but all other sensory modalities were intact on clinical examination. Deep tendon reflexes were 2+ in the upper limbs but absent in the lower limbs. Plantar reflexes were evaluated as extensions in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMr. R, a 21-year-old gentleman from South India, who worked in a cellphone shop, was brought to the hospital with sudden onset breathlessness gradually worsening for the last 2 days. He also complained of generalized weakness and muscle pains. There was no premorbid illness or history of drug intake. On arrival to the hospital, he was found to have tachypnea, tachycardia, and was in hypotension. Chest examination revealed bilateral crepitations. Cardiovascular system did not reveal any murmurs. Abdomen and central nervous system (CNS) examination did not reveal any abnormality. His oxygen saturation was low, and the arterial blood gas analysis (ABG) was done which revealed type 1 respiratory failure with severe metabolic acidosis and lactic acidosis [].\nThe patient was immediately intubated and given fluid resuscitation and shifted to the medical intensive care unit (ICU). His initial hemogram and biochemical investigations revealed leukocytosis, with acute renal failure and deranged liver function tests [].\nChest radiograph revealed bilateral lower zone haziness and electrocardiogram revealed sinus tachycardia. Cardiac enzymes and echocardiogram did not reveal any abnormality.\nIn the ICU, he was investigated for his oliguric renal failure. His creatinine phosphokinase (CPK) was high, which was suggestive of rhabdomyolysis. In view of the worsening renal function and oliguria with severe metabolic acidosis, he was dialysed after consultation with the nephrology team. He continued to require daily dialysis in the ICU. His ventilatory parameters improved gradually, and he was extubated on the 7th day of the admission and shifted to the ward on the 9th day.\nHe was worked up extensively for his renal failure and rhabdomyolysis, including a muscle biopsy which was inconclusive. After ruling out infectious and autoimmune causes, a heavy metal screen was requested. The heavy metals were checked in the patients' blood by inductively coupled plasma mass spectrometer (ICP-MS)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old Asian woman with an underlying anxiety disorder, functional headache, and hypertension was prescribed escitalopram and lorazepam when she presented with progressively worsening headaches to her primary care doctor. Her symptoms did not improve with the medications, and she was unable to eat well and required bed rest. She was transported to our hospital 4 days later after developing chest and back pain with altered consciousness. She was a housekeeper, had no allergies, and had no alcohol or tobacco smoking history. On arrival, her Glasgow Coma Scale score was 3/15 (E1V1M1); both pupils were approximately 4 mm in diameter and reactive. Her blood pressure was too low to be measured, her carotid artery pulse was palpable, her heart rate was 112 beats/minute, and her respiratory rate was 30 breaths/minute. Her conjunctiva was pale. An auscultation of breath sounds did not reveal upper and lower airway obstructions and was within normal limits. Her abdomen was soft and flat without tenderness. She had no skin abnormalities (such as rash). Both legs had no edema. Echocardiography on arrival was performed as point of care ultrasound and revealed a hypercontractile left ventricle with an eliminated left ventricular cavity and a collapsed inferior vena cava without right ventricular dilation. There was no pericardial effusion or obvious large regurgitant jet observed on color Doppler. In response, we immediately inserted a peripheral venous catheter and began introducing fluid resuscitation; however, she developed PEA. Conventional CPR according to the adult advanced cardiovascular life support guidelines (including adrenaline) was initiated and a return of spontaneous circulation (ROSC) occurred. However, her blood pressure was unstable and PEA returned, prompting repeated CPR with immediate administration of fluids and three adrenaline injections. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated for refractory PEA. Whole-body contrast"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-yr-old woman presented with gross hematuria for 2 weeks on November 23, 2009. There was no history of urologic problems. The patient was a non-smoker and had not been exposed to carcinogen. Physical examination and vital sign were normal\nAt the time when the patient was admitted to this hospital, numerous RBC were observed on urinalysis. There were no notable findings on blood test and chest radiography. On cystoscopy, a frond-like mass was observed at the bladder trigone, which measured about 1 cm (). Since hematuria continued, Foley catheterization was performed.\nOn computerized tomography (CT) of the abdomen and pelvis, the findings of enhancement and a small-sized mass were observed on the inner surface between posterior walls in the bladder trigone. The findings of perivesical infiltration and lymph node metastasis were not observed.\nOn the authority of above findings, the authors suspected the case to be carcinoma in situ of the urinary bladder or transitional cell carcinoma, and thus transurethral resection of bladder tumor (TURBT) was performed.\nOn histopathological examination, it was found that 90% of lesions were LELCA and a few lesions were non-invasive transitional cell carcinoma.\nOn microscopy, syncytial growth pattern and indistinct cytoplasmic borders were observed with the severe infiltration of lymphoid cells. The findings of necrosis and mitosis were observed in many regions. It was found that tumor cells invaded the whole lamina propria. Non-invasive transitional cell carcinoma was concomitant fractionally ().\nOn immunohistochemical staining, tumor cells were positive for cytokeratin 7 but were negative for cytokeratin 20 (). The infiltrated lymphocytes were composed of abundant CD3 positive T cells and CD20 positive B cells. For leukocyte common antigen (LCA), lymphoid cells were positive but tumor cells were negative (). In situ hybridization for Epstein-Barr virus was negative.\nThe patient has been without recurrence and metastasis for 3"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old Chinese woman presented to the First Hospital of Jilin University with complaints of abdominal pain, vomiting, and bloody stool for 24 hours. On admission, her general condition was good. Her temperature was 37.1 °C, respiratory rate was 18 times per minute, and heart rate was 80 beats per minute. She did not have cutaneous or scleral icterus. No superficial tumescent lymph nodes were observed. A physical examination showed distended abdomen with no stomach outline, peristalsis, and varicose veins. Abdominal breathing was slightly limited. Abdominal tenderness could be detected in her right abdomen accompanied by rebound tenderness and muscle tension. A palpable mass could be detected in her right lower abdomen. Liver, spleen, and gallbladder could not be touched below the costal arch. Murphy’s sign and shifting dullness were negative. Bowel sound was found to be approximately 7 beats per minute with gurgling. A neurological physical examination had no significant findings. A physical examination of her heart and chest was normal. She was a housewife in a small city with no special family history. She had a history of hypertension for 10 years, and the use of captopril helped maintain a satisfactory level of blood pressure. She denied a history of hepatitis, tuberculosis, and diabetes. Also, no history of drug allergy, surgeries, tobacco smoking, and long-term alcohol consumption was reported. The results of complete blood count, liver function, and blood biochemical indexes are shown in Tables and . The results of coagulation markers of hepatitis B virus, hepatitis C virus, syphilis, and human immunodeficiency virus were found to be negative. Abdominal computed tomography (CT) was performed, which showed some intestinal canals and mesentery entering into the right colon. The CT scan showed a target sign suggesting intussusception in her right abdomen (Fig. , ).\nSurgical exploration revealed that the ICD entered her ascending colon with edema (Figs. ,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old Chinese man who had myocardial infarction on anterior wall was recommended for cardiac surgery after diagnosed with unstable angina. His cardiac function was grade III according to the New York Heart Association classification. Coronary angiography showed triple-vessel lesions. Echocardiography revealed paradoxical cardiac movements in the apex of the left ventricle in the systolic phase without mural thrombosis. The left ventricular ejection fraction was 0.40 and the left ventricular end-diastolic diameter was 55 mm. Preoperative 12-lead electrocardiography (ECG) showed premature ventricular contractions (PVC). 12-lead Holter monitoring confirmed the presence of frequent multifocal VA (26400/24 h) and paroxysmal ventricular tachycardia. The patient had non-sustained ventricular tachycardia, and did not show mural thrombi. The patient took at least three kinds of anti-arrhythmic drugs including beta-blocker, lidocaine, and amiodarone to reduce the occurrence of VA before the operation. However, those anti-arrhythmic drugs did not seem effective for the patient.\nStandard median sternotomy incision was used to expose the heart. Off-pump coronary artery bypass (OPCAB) grafting was performed. A left internal mammary artery was grafted to the left anterior descending artery and a saphenous vein was anastomosed to the diagonal branch, the obtuse marginal artery, and the right coronary post-descending artery sequentially. The border of the aneurysm wall was clear on the beating heart.\nA bipolar intramural electrode placed at the base of right ventricle via right femoral vein was used to record a reference electrogram. Ventricular tachycardia appeared spontaneously during the operation. We used more than 40 predetermined locations on the left ventricle to record bipolar potential to construct ventricular epicardial depolarization map. The time point when the epicardial spike moved the most rapidly, approximately 7 ms, represented the moment at which electrical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old lady without any co-morbid illness presented in May 2006, with history of nonspecific abdominal pain and backache of one year duration. General condition was unremarkable. There was no pedal edema. Examination of abdomen revealed a 6 × 5 cm nodular retroperitoneal swelling in the right hypochondrium. Radiological imaging with ultrasonography, computed tomography and magnetic resonance imaging and magnetic resonance angiography revealed a retroperitoneal mass arising probably from the IVC, encasing the right renal vein and infiltrating the right kidney with ?tumor in the IVC []. Multiple large collateral vessels were also demonstrated []. The infra-renal IVC was completely blocked by the tumor [Figures and ].\nShe underwent exploratory laparotomy under general anesthesia on 5 July 2006. The tumor was found to be arising from the suprarenal IVC (around 2 cm below the hepatic veins) with dense adherence to right kidney and extension of tumor down to right renal vein and both common iliac veins (whitish discoloration and thickening) []. Left renal vein was free and IVC was patent at its entry. The collaterals were large and well-developed. But the IVC below the renal veins was blocked completely by the tumor which became circumferential. The tumor which extended downwards was intra-luminal in the lowermost part of the IVC. She underwent resection of the infra hepatic IVC distally up to just beyond the bifurcation of both common iliac veins with right nephrectomy and legation of left renal vein. The IVC was resected beyond the bifurcation of common iliac veins because of the suspicious thickening and whitish color of the IVC. In the immediate postoperative period, she developed anuria and azotemia (5 mg/dl of creatinine and 80 mg/dl of urea.) The USG and Doppler study done then showed congested left kidney with sluggish flow in the left renal vein. She was re-explored within 18 h. Intraoperatively the left kidney appeared congested and there was a small"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old Asian woman (G3P1) who had undergone emergency cesarean delivery owing to a compound presentation at full term was referred to our institution with a suspicion of abnormally located gestational sac. She had undergone laparoscopic cholecystectomy and open appendectomy previously. She did not have any medical, family, or psychosocial history. She had missed her menstrual period without any other symptom and visited a private obstetrical clinic to confirm the pregnancy. However, she was diagnosed as having an abnormal pregnancy such as cervical or CSP by USG.\nAt our institution, she reported that her last menstrual period was just 5 to 6 weeks prior. However, USG revealed a gestational sac in the anterior lower uterine segment with a fetus measuring 4.83 cm crown-rump length (CRL) with positive cardiac activity, corresponding to 11 weeks and 6 days of gestation. Color/power Doppler images depicted a hyperechoic rim of a choriodecidual reaction with excessive vascularity (Fig. ). Although we could observe a definitive abnormally located gestational sac, our patient did not have any pain during the physical examination. She admitted that her last menstrual period was different from her usual menstrual periods. Because CSP or cervical pregnancy was suspected, we performed computed tomography (CT) for a definitive diagnosis. The CT scan showed an intrauterine gestational sac in the lower uterine segment bulging through the anterior uterine wall at the site of the cesarean scar. No invasion of the urinary bladder was observed (Fig. ). On presentation, her β-human chorionic gonadotropin (β-hCG) level was 66,536.8 IU/L (Day 1). Initially, we injected 50 mg of methotrexate (MTX) mixed with 9 mL of normal saline in the amniotic sac through a 22-G needle transabdominally under USG guidance. Simultaneously, 2 ml of amniotic fluid was aspirated for termination of the pregnancy. However, fetal cardiac activity was still observed 2 days later (Day 3), without significa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman with no remarkable medical and family history was admitted to our hospital. When the patient was admitted to our hospital, the patient was of moderate build, was well nourished, had no yellowing of the bulbar conjunctiva, had no conjunctival pallor, and displayed no unusual finding in the heart or lungs. The abdomen was flat; the liver and spleen were not palpable. No remarkable finding was observed. An elastic, hard tumor approximately 30 mm in diameter with relatively distinct boundaries was felt in the left C/D region. The tumor was observed to be not fixed to the pectoral muscle and had not infiltrated the skin. No abnormal nipple discharge was observed, and axillary lymph nodes were not palpable. Peripheral blood and blood biochemistry test results were normal.\nBy mammographic examination, a local asymmetric shadow was observed in the left M area, and the tumor was classified in Category 3 (Fig. ). Ultrasonographic analysis revealed that a hypoechoic area measuring 18 × 31 × 24 mm with partially calcified areas and a hyperechoic margin was observed in the C/D region of the left breast. The lesion had a Tsukuba elasticity score of 2 and internal blood flow, strongly suggesting malignancy (Fig. ). By CT examination, a thoracoabdominal CT scan did not reveal anything unusual, such as enlarged axillary lymph nodes or distant metastases in other organs.\nBased on the above findings, the patient was given a preoperative diagnosis of T2N0M0 Stage IIA cancer of the left breast, and left modified radical mastectomy and axillary lymph node dissection were performed.\nThe tumor was a solid, light gray nodular lesion with distinct borders and measured 32×22 mm. Histologically, the tumor was a squamous cell carcinoma with prominent keratinization exhibiting an infiltrative growth pattern. The tumor had no connection to the epidermis and partially transitioned into the atypical ductal epithelium (atypical metaplasia) in the area surrounding the focus. These"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 69-year-old woman who presented to her primary care physician with worsening cough and pain wrapping around her chest to her back. The chest pain was initially thought to be pleuritic in nature and related to an exacerbation of her chronic obstructive pulmonary disease (COPD). When there was no improvement in her symptoms with treatment of her COPD, and considering the confounding radicular distribution of her pain, a plan was made to have an MRI of the spine performed to explore other possible etiologies of her pain.\nPrior to the scheduled MRI, the patient was seen in the emergency department and diagnosed with a myocardial infarction due to hypertensive emergency. During her admission to the hospital, the patient was noted to be experiencing neck pain, bilateral upper extremity pain in a C8-T1 dermatomal distribution and a loss of urinary and fecal urges. On examination, the patient’s force of flexion and abduction in her upper extremities were mildly reduced. The strength in her lower extremities was decreased. Her deep tendon reflexes were 3+ in her bilateral upper extremities and 3+ in her bilateral lower extremities with clonus at the ankles.\nShe had bilateral extensor plantar responses. In light of these progressive myelopathic symptoms a spinal MRI was done.\nThe initial pre and post -contrast MRI of the entire spine showed extensive, mostly brightly enhancing intradural extramedullary nodules extending from C5–6 to T11 (Fig. ). Some nodules at the T6 level were only minimally enhancing, with pre-contrast T1 hyperintensity apparent. The lesions were causing multilevel severe central canal stenosis with multilevel cervical and thoracic spinal cord compressions. The largest mass conglomeration extended from C6 to T4, measuring up to 1.2 cm AP × 1.9 cm transverse × 10.0 cm CC. Despite the extensive mass effect with flattening of the spinal cord, the spinal cord demonstrated no intramedullary T2 hyperintensity except for a small focus of enhancin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old Iraqi male presented in February 2011 to the American University of Beirut Medical Center (AUB-MC) with fever, chills, chest pain, anorexia, and weight loss after being operated on for a presumed malignant thymoma in India. His initial history goes back to May 2010 when he was diagnosed with myasthenia gravis in Iraq and was started on prednisone 60 mg orally and mestinon 60 mg orally three times per day. A computed tomography (CT) of the chest done in Iraq showed a cystic mediastinal mass abutting the right ventricle described as thymoma (images not available) but very similar to the CT done at our institution later. No interventions were undertaken in Iraq. He was then referred for right lateral thoracotomy in India in November 2010. Pathology revealed malignant thymoma. The patient remained hospitalized in India for 3 weeks where he reported chills, weight loss, and sweating without any documented fever. He was started on chemotherapy (unknown regimen) and was discharged home on levofloxacin 500 mg orally daily for ten days. No microbiological work-up was initiated in India to try to detect an underlying infectious process. The period from December 2010 until February 2011 in Iraq was characterized by recurrent chest pain, fever, chills, sweating, cough, and greenish sputum production. Blood tests at that time showed a WBC of 26,000/μL. Repeated CT of the chest showed multiple cystic masses impinging on the right ventricle and left atrium described as metastasis in concordance with his history of malignant thymoma (). At a local hospital, he received blood transfusion, fluconazole, and cefotaxime both at unknown frequency and dosage without improvement. He then had a PET scan in Lebanon showing cystic masses in the chest with necrosis and invasion of the pericardium described as metastasis. He presented to our institution where echocardiography showed two large anterior fluid collections one of which was compressing the right ventricle with a third"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female Caucasian patient was referred to the periodontology department for evaluation of a gingival recession on the maxillary left second molar. The patient's medical history revealed no systemic diseases or allergies. The clinical () and radiographic () evaluation revealed 5 mm Miller Class II recession [] on the second molar buccal aspect. There was discomfort during tooth brushing, described by the patient, and permanent inflammation in this area. The probing depths were ≤2 mm, and apically to the recession, there was absence of keratinized gingiva. The proposed treatment was a connective tissue graft combined with a laterally displaced flap.\nPrior to the surgery, the patient underwent one session of scaling and polishing and received oral hygiene instructions in order to reduce the local inflammation. After explaining the objectives of the surgery, a written informed consent was obtained. The surgery started with the administration of local anesthesia and careful scaling of the exposed root surface, and a partial-thickness flap dissection was extended down into the vestibule, permitting passive coronal positioning of the flap. While preparing the flap, an oroantral communication was found apically to the first molar mesial buccal root with 3 mm diameter ().\nOroantral communication closure started by suturing the Schneider membrane with a 6 0' absorbable suture (monofilament polyglecaprone suture, Surgiclryl-Monofast ®SMI-Belgium) to close the perforation (). A connective tissue graft was harvested from the palate according to the technique described by []. The recipient bed was measured as well as the palate thickness. Using a #15 blade, oriented perpendicular to the palatal surface, a single incision was made 3 mm apical to the gingival margin of the maxillary teeth. The partial-thickness dissection was made as apically as needed to obtain a graft measuring 12 mm length and 7 mm width. The connective tissue was elevated from the palate, and the d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male patient reported with a chief complaint of swelling on the right side of the face for the past 2 months []. The swelling was initially noticed as a small lump which gradually increased to the present size. Medical and family histories were noncontributory. Examination revealed swelling in the right side of the face about 1.5 × 2 cm in size in the region of angle of mandible. There was no draining sinus and the skin over the swelling was clinically normal.\nIntraorally the swelling was present in the buccal aspect of right mandibular second molar measuring about 1.5 cm × 1 cm in dimension. Mucosa over the swelling was clinically normal. Buccal cortical bone expansion was seen along with obliteration of buccal sulcus. On palpation the swelling was firm, nontender and extended superiorly to involve the anterior border of ramus of the mandible.\nCT scan revealed an osteolytic lesion about 2.5 cm × 2 cm in dimension, extending from the distal aspect of 47 to the ramus of the mandible. Destruction of buccal cortical plate was evident. The clinical and radiologic findings were suggestive of odontogenic tumor [Figures –].\nSubsequently, an incisional biopsy was performed under local anesthesia and the specimen was sent for histopathologic examination. Microscopic evaluation of the sections revealed interlacing fascicles of spindle-shaped cells arranged in a biphasic pattern set in a collagenous stroma. Spindle cells were seen with oval, round and tapering nuclei with pale eosinophilic cytoplasm. These cells were seen alternating with closely packed cells with small rounded nuclei and eosinophilic cytoplasm []. Vascular spaces mimicking the hemangiopericytoma pattern were also observed []. Cellular atypia was not noted. Based on these findings we arrived at a diagnosis of myofibroma.\nImmunohistochemical staining was carried out for vimentin, S100, αSMA, CD68, and desmin. Positive immunoreactivity was observed for vimentin and αSMA [Figures and ]"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 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 ).\nAs a result of this decreased angle, an abrupt collapse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second patient was a 70 year-old male admitted to our hospital for progressive cognitive decline. He had a history of ISS stage I IgG kappa MM (in the absence of chromosome 17 deletion or a 4;14 translocation) with onset six years previously. He had initially been treated with two VAD induction cycles and a subsequent hematopoietic stem cell autograft and had shown a partial response. After three treatment-free years, the patient presented with a progression of MM. Combination therapy with bortezomib and an anti-insulin-like growth factor-1 antibody was introduced. These agents were withdrawn after 4 months because of the occurrence of severe neuropathy and were not replaced. Eighteen months later, combination therapy with lenalidomide, dexamethasone and an anti-CS1 antibody was initiated following an increase in the M component, with no signs of hyperviscosity syndrome. After one month of treatment, the patient complained of memory loss, apathy and word-finding difficulties, with repercussions on ADL. An initial cognitive assessment revealed a severe impairment in episodic memory (with poor free and cued recall in the FCSRT, see Table \n), whereas other cognitive functions (such as executive function and construction) were within the normal range. The patient’s global cognitive efficiency was scored as 128 out of 144 on the Mattis Dementia Rating Scale (DRS)\n[] and 26 out of 30 in the MMSE. The neurological examination was normal. Brain MRI revealed widespread white matter lesions and overall atrophy. The patient was offered regular clinical monitoring. Seven months later, the patient developed erythroderma and so lenalidomide was withdrawn. The patient and his wife both reported an overall improvement in cognitive function, with a decrease in apathy and improved memory. The patient had recovered his independence in ADL. A cognitive assessment was performed six months after the withdrawal of lenalidomide treatment. Although the patient’s global cognitive efficie"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old man with no background medical history or past ophthalmic history was referred by his general practitioner for a left nasal pterygium. The lesion had been causing ocular irritation and had initially been reviewed by an ophthalmologist 10 years earlier. Since that time, the patient reported that the lesion had slowly grown and his irritation had worsened. On examination, best-corrected visual acuity was 20/20 bilaterally and anterior and posterior segment examinations were unremarkable apart from a left conjunctival lesion. This pearly white lesion was situated on the nasal limbus of the left eye and was circular in shape with a 4 mm diameter. It was easily mobilized and appeared to be free of any deeper scleral invasion. Overall, the lesion had an appearance in keeping with an ocular surface squamous neoplasm and wide local excision of the lesion, and reconstruction with a superior autoconjunctival graft was recommended with adjunctive mitomycin C. This uncomplicated procedure was undertaken 3 weeks later.\nHistopathology of the operative specimen reported a possible low-grade mucoepidermoid carcinoma, and the specimen was referred to an ophthalmic pathologist who confirmed the diagnosis of low-grade conjunctival mucoepidermoid carcinoma 2 weeks later. Initial hematoxylin and eosin stains were followed by periodic acid-Schiff diastase stains, which confirmed the mucinous components of the lesion ( and ). The specimen showed conjunctival and limbal tissue that was infiltrated with carcinoma at the limbus. It was composed of islands of well differentiated epithelial cells showing both squamous and glandular differentiation with the glandular lumina containing inspissated mucoid material (). No immunohistochemical testing could be conducted on the specimen. A course of 0.04% mitomycin C was prescribed four times a day for 1 week, followed by only ocular lubricants for 1 week, followed then by another week of mitomycin C four times a day.\nOn review 2 months"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old man with left groin pain and swelling was referred to our hospital. He had a history of hypertension, dyslipidemia, interstitial pneumonia, chronic kidney disease, and myocardial infarction requiring percutaneous coronary interventions. He underwent aortic valve replacement and the Maze procedure for aortic valve regurgitation and atrial fibrillation at 68-year-old, followed 3 months later by endovascular aortic repair (EVAR) for abdominal aortic aneurysm. At one month after EVAR, he underwent femoro-femoral arterial bypass (FFB) for limb graft occlusion following EVAR. He also had a history of repeated ventricular tachycardia and underwent implantation of an implantable cardioverter defibrillator (ICD). In addition, he had prostate carcinoma treated with radiation therapy. On physical examination, the subcutaneous FFB graft was palpable in the suprapubic region, and left inguinal hernia was identified. Computed tomography (CT) revealed a left inguinal hernia and a FFB graft anastomosed between bilateral common femoral artery in the subcutaneous space anterior to the pubis (). Because the patient was considered at high risk for general anesthesia and had previous radiation therapy to the pelvis which can develop adhesions in the preperitoneal and peritoneal cavity, we scheduled an anterior tension-free hernioplasty under local infiltration anesthesia. Aspirin was continued in the perioperative period to reduce the risk of cardiovascular ischemic events. The location of the subcutaneous FFB graft was marked on the skin with a pen (). The surgical field was prepared and draped with an iodine-impregnated occlusive dressing, then step-by step local infiltration anesthesia was administered, starting prior to making the incision with the combination of 1% lidocaine with epinephrine 1:100,000 and 0.25% bupivacaine. A 6-cm skin incision was made from 1-cm above the center of the left inguinal ligament toward the midline, and the subcutaneous tissue was dissect"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old Moroccan woman with no significant past medical history presented to gynecological consultation in June 2009 with a one-month history of dysuria, burning urination, and progressive lower abdominal distention. She had previously given birth to one child. The patient was menopausal since ten years ago.\nClinical examination revealed a painful distended abdomen with bulky uterus. The adnexa were normal on palpation.\nTransabdominal ultrasonography demonstrated a solid uterine mass. The ovaries were not visualized and there was no ascite. Magnetic resonance imaging (MRI) of the pelvis showed a voluminous and heterogeneous uterine mass measuring 12 × 10 cm. The lesion was located at the uterine corpus and was displacing bladder and rectum. The ovaries appeared normal and there was no lymphadenopathy. The tumor appearance suggests a calcified fibroma.\nThe patient underwent a total simple hysterectomy. During surgery, a 12 cm mass was attached to the uterine corpus. The en bloc resection of this voluminous mass was impossible and the tumor was fragmented. Up to 20 pieces were removed. On sectioning, the fragments were macerated and showed various tissue consistencies.\nMicroscopically, the tumor was an immature teratoma, composed of a mixture of embryonic mature and immature elements. The tissue types found included nerve ovoid cells involved in a fibrillar background, active cartilaginous foci, and glandular formations. The immature component was dedifferentiated cells around epithelial tubes with the presence of mitoses ().\nOur patient recovered well from surgery and a surveillance approach was taken.\nThree months later, the patient presented with vaginal bleeding. On digital examination of the vagina, she was found to have friable mass filling the upper half of the vagina with severe bleeding.\nPelvic and abdominal computer tomography (CT) scan revealed a bulky mass of 14 × 8 cm filling the pelvic cavity. The tumor was involving the bladder and the rectosigmoi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old lady presented to shoulder clinic with a one-year history of pain over her left dominant acromioclavicular joint. Her pain originated following a fall onto her shoulder having been knocked off of a pushbike during a collision with a motor vehicle. The primary complaint was of pain, making the patient's work as a machinist difficult. She also complained of a visible but subtle deformity of her acromioclavicular joint resulting in problems keeping the strap of her bra in place.\nClinical examination in the outpatient clinic revealed an obvious acromioclavicular joint dislocation with palpable crepitus on reduction, dynamic instability on clinical testing, and painful movements above 90 degrees of forward flexion and abduction. Radiographs confirmed a diagnosis of grade II ACJ dislocation []. As she presented with a symptomatic shoulder, she was counseled for an elective ACJ reconstruction. This was a chronic ACJ dislocation and the indication for operation was pain with dynamic instability on clinical examination. At operation, she underwent an uncomplicated ACJ reconstruction using the synthetic ligament technique. Bone quality appeared normal intraoperatively and a chronic grade III injury was noted at time of operation in contrast to the preoperative imaging. Immediate postoperative radiographs were entirely satisfactory.\nFirst follow-up appointment at 2 weeks postoperatively demonstrated no obvious clinical concerns, good wound healing, and no signs of infection or of failure of reconstruction. For the first six weeks postoperative, she undertook passive shoulder exercises under the supervision of the physiotherapists with movement restricted to less than 90 degrees of forward elevation and abduction. At six weeks, this was increased to active range of movement exercises. Follow-up appointment at six weeks revealed no clinical problems and her preoperative symptoms had completely settled.\nAt 3-month follow-up, the patient reported a firm, painful lump"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy of average built presented to the orthopaedics department with a draining non-healing sinus at the lateral aspect of his right lower thigh for the last 9 months (Figure\n). Pain was minimal. The margins of the sinus were hyperpigmented and thickened with excoriation of the surrounding skin; pus was expressed out on pressure. Palpation was painful but did not reveal any mass around the sinus. Regional lymph nodes were enlarged compared to the contralateral side. Distal neurovascular status was normal. The knee joint was not swollen, and the range of motion was normal except for a mild terminal restriction of flexion due to pain. Detailed history revealed that about 9 months ago, he fell down from a tree which is approximately 15 feet in height and sustained injury from wooden branches at the right thigh. He also had transient loss of consciousness from the impact. After consciousness was regained, he noticed a small wound over the outer aspect of his right thigh. There was not much bleeding, and he considered it a minor injury. The wound, however, nearly healed. After about 3 weeks, he noticed swelling and frank pus started coming out of the wound. He sought traditional treatment and got some temporary relief. The amount of pus decreased in-between and the size also diminished, but complete healing never occurred. During the whole course, he did not develop any fever, loss of weight, cough, or chest pain. After 9 months from the day of injury, he visited our hospital.\nAfter admitting him for detailed evaluation, the differential diagnosis considered chronic osteomyelitis, fungal infection, tuberculosis, and implanted foreign body. Blood parameters and X-ray examination of the area came out to be normal and osteomyelitis was ruled out (Figure\n). Pus culture revealed growth of Staphylococcus aureus. FNAC obtained from the enlarged regional lymph node showed nonspecific findings. Implanted radiolucent foreign body was thought as a possibility for persis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old male patient reported to the department of conservative dentistry and endodontics following trauma to the maxillary anterior region due to a road accident around 20 days back. He complained of fractured maxillary incisors and presented a desire to get them restored in order to have an aesthetic smile. Clinical examination of the patient revealed complicated crown fracture of the upper incisors. An intraoral swelling with a sinus tract was present on the labial gingiva between upper right central and lateral incisor (Figures and ). A radiograph of the maxillary anterior region illustrated horizontal root fracture at the middle third of the upper right central and lateral incisors () but clinically no mobility of the coronal fragment was evident. On the other hand the roots of the upper left central and lateral incisors were intact and endodontic treatment had been done for the upper left central and lateral incisors ().\nAfter explaining the treatment plan to the patient and obtaining his consent, endodontic treatment with the upper right central and lateral incisors was initiated. The working length was correctly determined and canals were cleaned, shaped using K files in a step-back manner to an apical file size #60. The remainder of the canals were shaped to obtain a uniform taper from apex towards coronal. An interappointment calcium hydroxide dressing was given and the patient was recalled after 7 days.\nOn the second visit, when the swelling had resolved, root canals were sectionally obturated with gutta percha cone and AH plus sealer. A gutta percha cone of the same size of the prepared root canal (size #60, with a taper of 2%) was selected and tried into the canal to obtain a snug fit. It was then cut to obtain a section which would be 2-3 mm short of the apical fragment of the root. A suitable plugger which loosely fits 2-3 mm short of the apical root fragment was selected and a stopper was set at this length. The sectioned gutta percha was then"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Brazilian male patient was admitted to the hospital with a palpable lump in his right breast, located at the junction of the upper quadrants of the right breast (Fig. ). On physical examination, the lesion appeared firm with irregular margins. Axillary lymphadenopathy was negative and there were no palpable supraclavicular nodes. On breast imaging, ultrasonography showed a hypoechoic mass with partially defined contours measuring 4.0 × 3.0 cm, located at the upper region of the right pectoralis major muscle at the 12 o’clock position with muscle infiltration (Fig. ). Histological examination of core biopsy samples revealed a malignant tumor. Preoperative exams, such as X-rays and chest CT scan, abdominal US did not show any signs of disease. Radical mastectomy was then performed, due to pectoralis major muscle infiltration, consisting in removal of the breast along with the major and minor pectoralis muscles. Biopsy of the sentinel lymph node was performed. Gross examination revealed a solid tumor measuring 3.7 × 3.5 cm with a yellowish-tan cut surface and local foci of hemorrhage. Histopathology showed intravascular papillary proliferation of endothelial cells, spindle cell areas and necrosis, atypia and prominent mitotic figures, consistent with the diagnosis of high-grade angiosarcoma with areas of infiltration of the pectoralis major muscle (HE staining, magnification of 400×) (Fig. ). Histopathology also demonstrated a surgical specimen with clear margins, absence of angiolymphatic and perineural invasion, in addition to sentinel lymph node free of metastasis. Immunohistochemical study revealed a tumor positive for CD31 marker (Fig. ), confirming the vascular nature of the tumor. At the two-week follow-up of the surgical procedure, adequate wound healing was observed, without any evidence of the disease. The patient was transferred to the clinical oncology department, where he presented with severe headache and seizures after the second cycle of a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old Japanese girl, gravida 0 para 0, who was the monozygotic twin sister of the patient in Case 1, visited our gynecologic department for ovarian screening 3 months after the first operation of Case 1. Transrectal echography revealed bilateral ovarian cystic tumors with calcified structures. Tumor marker levels (CA125, SCC, CEA, and CA19-9) were normal. The bilateral ovarian cystic walls were extracted, and normal ovarian tissues were preserved by laparotomy. Pathological analysis of the cyst wall disclosed that there were benign teratomas in both ovaries.\nSixteen months after the first surgery, bilateral ovarian tumors were detected with echogram and pelvic MRI (right side: 4.4 cm, left side: 8.0 cm in diameter) during her regular check-up (). The ovarian tumors were accompanied by a solid part and high echoic part inside. Blood examination of tumor markers revealed a mild, elevated CA125 (37.5 U/mL). Bilateral cystectomy was performed 20 months after the first surgery. Examination of the other pelvic and abdominal organs found no disseminated and metastatic lesions in the surgery. There were no swollen pelvic lymph nodes. The histological diagnosis was an immature teratoma of grade 1 with International Federation of Gynecology and Obstetrics stage I in the right ovary and a benign mature teratoma in the left ovary. The girl's postoperative condition was good, and she was discharged without any complications. An additional surgery and chemotherapy were not planned according to a deliberated discussion with her family.\nAfter being discharged, she continued to be followed every other month. Four months after the last surgery, a right ovarian cystic mass (4 cm in size) was detected, and it enlarged to 6 cm two months later (). The blood CA125 level (32.3 U/mL) was in the normal range. Therefore, a third laparotomy was performed 7 months after the second surgery. The right adnexa, appendix, and greater omentum were resected. Examination of the other"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 50 year old male who received a LURT 8 years prior to presentation. He had previously undergone bilateral native nephrectomies 2 months prior to transplant for PKD. His early course was complicated by biopsy-proven acute cellular rejection, vascular type, 5 days after transplant, which was effectively treated with anti-thymocyte globulin and intravenous immunoglobulin. He subsequently went on to enjoy excellent graft function. Initially, he was maintained on standard triple immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and prednisone.\nTwo years prior to presentation, he developed numerous squamous cell carcinomas of the skin treated with resection and radiation. One of these lesions was an invasive poorly differentiated SCC (Bowen’s type) of the left auricle, requiring auriculectomy and reconstruction. Tumor margins were negative. His immunosuppression was reduced by stopping his MMF.\nOne year prior to presentation he developed a parotid mass found to be SCC by fine needle aspiration. It was felt that this was a metastatic lesion from the auricular tumor. At this time, he was switched from a dual immunosuppressive regimen of tacrolimus and prednisone to sirolimus (SRL) and prednisone. He underwent a left parotidectomy and neck dissection with pathology showing invasive keratinizing squamous cell carcinoma, poorly differentiated. The tumor was 4.6 cm with lymphovascular and perineural invasion. Surgical margins were negative, but 5 out of 23 periparotid and cervical LNs were positive for metastasis with focal extranodal extension. He underwent radiation therapy and cetuximab. A surveillance PET CT performed 6 months after treatment revealed 5 bilateral pulmonary nodules, which grew over 2 months from 6 mm to 10 mm. He initiated systemic treatment with carboplatin, paclitaxel and cetuximab with minor improvement initially, followed by disease progression in the lungs and mediastinum after 7 months of treatment. He was then treated wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-month-old female with no significant prior medical history, prior significant infections, or developmental concerns presented with worsening fatigue and intermittent fevers. The initial evaluation demonstrated leukocytosis, anemia, and elevated inflammatory markers. Infectious evaluation, including chest X-ray, monospot test, rapid streptococcal screen, HSV testing, and UA, was unremarkable. A viral etiology was considered most likely and the patient was discharged home with return precautions. Over the following week, the patient had no significant improvement, and she was admitted to the hospital for further evaluation after repeated laboratory investigations yielded similar results.\nOn admission, her symptoms included intermittent fevers with concurrent irritability, fatigue, and decreased solid food intake; she appeared at her baseline when not febrile. No signs or symptoms of localized infection were present at that time, and her family denied sick contacts. On the morning following admission, the patient experienced a right upper extremity focal seizure requiring prompting immediate brain MRI. MRI demonstrated an extensive left subdural fluid collection consistent with a subdural hematoma and associated left to right midline shift []. Several posterior components of the fluid collection demonstrated diffusion restriction and raised suspicion for the superinfection of the hematoma. Blood cultures were sent, and the patient was taken for immediate surgical evacuation with ultrasound-assisted burr hole drainage and subdural drain placement. Intraoperatively, the drained fluid was consistent with chronic blood products with foul-smelling superimposed infection. The fluid was collected for microbial analysis, and the patient was started on empiric antimicrobial coverage. The fluid cultures demonstrated M. morganii, and the antibiotic regimen was subsequently converted to meropenem monotherapy. Blood cultures and subdural fungal cultures remained negative at 5"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMr. BH, 39 years old, right-handed, presented with a Bennett fracture of the first right metacarpal following a work accident. The fracture was initially treated in another institution by reduction and percutaneous pinning using Iselin’s technique. Three weeks later, the patient developed an inflammatory reaction around the entry point of the distal pin, at the second metacarpal. A purulent discharge led to early removal of the distal pin. The isolated organism was a methicillin-sensitive Staphylococcus aureus. Regular topical treatment was given, and antibiotic therapy was initiated for five weeks based on laboratory results. Bone healing of the Bennett fracture was obtained in the sixth week after the accident, and the proximal pin was removed.\nThree months later, the patient was referred to us by his doctor because of persistent pain at the second right metacarpal, accompanied by attacks of inflammation and intermittent purulent discharge. Standard hand X-ray demonstrated the presence of an area of osteolysis surrounded by osteocondensation at the second metacarpal, indicating a focus of osteomyelitis along the path of the distal pin (). An MRI was performed on the hand. It confirmed the diagnosis, revealing the extent of the focus of osteomyelitis, the path of the fistula, and the inflammatory extension into neighboring soft tissues ().\nSurgical treatment called for the induced membrane technique.\nThe first stage included a segmental resection of the area of osteomyelitis through a dorsal approach with excision of the reformed tissue while preserving the index finger extensor tendon.\nThe second metacarpal was stabilized with a mini external fixator, and a cement spacer was interposed ().\nAntibiotic therapy was initiated for six weeks based on sensitivity testing. The external fixator was then removed, and the hand temporarily immobilized with a splint until there was healing along the path of the inserts.\nThe second stage was performed in the eighth week. The ce"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old woman presented for cesarean delivery for fetal breech presentation at 39 weeks' gestation under spinal anesthesia. Her previous obstetrical history included two previous first trimester abortions and a full-term pregnancy delivered by cesarean section due to breech presentation. Her present antenatal course was smooth, except for a progressive painless swelling in the right flank noticed at 20 weeks' gestation. Multiple ultrasound examinations were done at different intervals during the course of pregnancy. They demonstrated a rapidly growing sharply defined abdominal mass, heterogeneous in echogenicity and smooth in contour, highly suggestive of a subserosal uterine leiomyoma. No other signs and/or symptoms were reported. The patient denied smoking, drinking alcohol, or taking any medications besides her prenatal vitamins.\nIntraoperatively, the tumor was found to be extra-peritoneal originating from the right abdominal wall. It was whitish in color, hard in consistency, and fixed to its surroundings. It was arising from the lateral wall (rectus and external oblique muscles) reaching the vicinity of the anterior superior iliac spine. Following the delivery of a live male newborn (Birthweight: 3560 g; Apgar score 9 at 5 min) through a lower segment transverse uterine incision, a general surgeon was called in for an intraoperative consultation. Frozen sections revealed benign spindle cells suggestive of a desmoid tumor (), although a sarcoma could not be ruled out in view of the tumor rapid growth. The patient consented to a wide surgical excision of the mass within the same surgery. Radical resection of the tumor was performed including affected abdominal wall muscle and a peripheral margin of healthy tissues surrounding it. The patient tolerated the procedure well. She developed right femoral lateral cutaneous neuralgia that resolved spontaneously a few weeks later.\nGrossly, the tumor was a 12 × 9.5 × 7 cm mass weighing 457 g, ovoid in shape, firm in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old gentleman with past medical history of diabetes, hypertension, and peripheral vascular disease presented to the emergency department with acute onset right-sided vision loss. The patient had been in his usual state of health 4 weeks prior when he experienced transient visual loss in his right eye and later started having left-sided headache along with difficulty in chewing food. He underwent a color-duplex ultrasound as outpatient for the evaluation of his symptoms which showed undetectable blood flow indicative of complete occlusion in right internal carotid artery and critical stenosis of more than 70% in left internal carotid artery (ICA). Bilateral common (CCA) and external carotid arteries (ECA) were patent though diffusely atherosclerotic with an estimated plaque burden more than 50% (,)).\nBased on the carotid duplex findings, he was diagnosed to have symptomatic carotid stenosis secondary to wide-spread atherosclerosis. His right ICA was not considered amenable to surgery and after a discussion with vascular surgery, he underwent a left carotid endarterectomy with no immediate complications. However, he continued to have persistent symptoms with progressive deterioration. He also noticed weight loss, anorexia and morning stiffness in his shoulders. On the morning of presentation, he lost complete vision in his right eye while experiencing blurry vision in his left eye. He was examined by his ophthalmologist who detected ischemic optic changes highly suggestive of GCA and thus referred him to the emergency department with recommendations to be immediately started on high dose IV corticosteroids.\nHis vitals, on presentation, were as follows: BP 126/72 mm Hg, Pulse 92/min and afebrile. Detailed examination revealed cachexia along with left temporal and shoulder girdle tenderness. Pulses were diminished in all extremities except left dorsalis pedis which was absent. Bilateral carotid bruits were also appreciated. Visual acuity was noted to be 0/20"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 26-year-old man who suffered a severe cranio-facial trauma in 2004, caused by a car accident. Consequently, the patient presented subarachnoid hemorrhage and panfacial fracture. After an initial assessment in the emergency services, the patient was admitted to the intensive care unit of our Hospital. Here, the profesionals involved in the case decided that the subarachnoid hemorrhage did not require surgical treatment. Notwithstanding the above, the patient needed close monitoring in the intensive care unit for several week. Therefore, in the light of these developments, we also adopted a conservative attitude with regard to the facial trauma. In fact, during ICU stay the patient presented an unstable neurological status. Due to all this, we decided to reassess the patient in a year with the aim to estimate the fallout of trauma. Finally, when the patient came to the outpatient department of Maxilofacial unit we could observe the typical signs of CCF. Indeed, the physical examination of the patient showed zygomatic-orbital dystopia with pulsating exophthalmos and chemosis of the right eye. Moreover, the patient referred decreased vision in this eye. In addition to all this, we note the presence of an orbital murmur. This finding made us suspect the existence of CCF secondary to trauma. Bearing this in mind, a craniofacial CT scan was performed in order to confirm the diagnosis. As expected, this test showed the presence of CCF draining into the right superior ophthalmic vein. Thus, we decided to present the case to the interventional neuroradiology service of our Hospital.\nAfter evaluating the case, Neuroradiologists decided to carry out a bilateral arteriography of the head. This test also proved the existence of a direct posttraumatic CCF. In addition, this test also showed that the fistula presented high blood flow, with significant impact on intracranial hemodynamics (Fig. ). Against this backdrop, neuroradiologists decided to treat the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52 year-old woman presented to our hospital (University Hospital, Newrak, New Jersey) in February 2011 with complaints of irritable, anxious mood and inability to focus for one month. She also gave history of decreased need for sleep and excessive spending in the same time period. On exam, she was well groomed, had fast speech but not pressured, irritable and labile affect but no grandiose ideas.\nPatient denied ever having similar symptoms in her life before. Treatment history revealed that patient had taken nefazodone, bupropion, duloxetine and clonazepam but has never taken any antipsychotic medication in her life. Her routine laboratory examinations (complete blood count, liver function test, and urine analysis) were within normal limits. CT scan of head and brain (without contrast) was negative for any acute changes or other pathology.\nPatient was diagnosed with bipolar disorder with current episode of mixed type. Patient did not want to take lithium or valproate medications fearing about their side effects. She was started on aripiprazole 15 mg at bedtime which was increased to 15 mg twice a day after 4 days. Patient started feeling better and was discharged on day 10 with aripiprazole 30 mg/day at bedtime and clonazepam 0.5 mg twice a day.\nOn patient's first follow up visit no medication side effects were reported or observed. On her second follow up visit, she complained of disturbing motor symptoms which included intermittent involuntary painful jaw clinching and abnormal tongue movements. Physical exam showed involuntary chewing movements of jaw, lip smacking, infrequent tongue protrusion and twisting and side to side movement of the tongue. Patient scored 14 on abnormal involuntary movement scale (AIMS). She had never experienced these symptoms before in her life and was not taking any other medications which could explain these extrapyramidal symptoms. Serum copper, serum ceruloplasmin and serum thyroid stimulating hormone levels were found to be in nor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old African American woman presented with a roughly 40 × 20 cm left flank tumor () to the Surgical Oncology Group of Rutgers Cancer Institute of New Jersey. The patient reported having a left-sided hemangioma removed at the age of 3 years but persisted with a port wine stain on her left flank since that time. Approximately 3 years prior to presentation, the patient had her first pregnancy and reported that during her third trimester, she noticed a mass developing on her left flank. During this time, the mass slowly grew to approximately its size at the patient's presentation at our institution. Following delivery of her first child, the patient reported medical evaluation had demonstrated the mass to appear to be a recurrence of her hemangioendothelioma. Following her second pregnancy, the size of her tumor did not significantly change, nor did it affect her pregnancy. It was at this time when she presented to us for evaluation for possible surgical resection after undergoing biopsy showing a Dabska tumor. The patient then presented to the Plastic Surgery Division at Rutgers-Robert Wood Johnson Medical School for evaluation of reconstruction in conjunction with her planned tumor resection.\nDuring radical resection, the tumor was dissected down to the abdominal wall fascia, as the tumor did not appear to violate the fascial space. Specimens were submitted intraoperatively to pathology for frozen section, with final diagnosis ultimately showing a 30 × 22 × 4 cm3 Dabska tumor. After tumor extirpation, the patient had a defect extending from the umbilicus to the mid-posterior back from the tenth rib to below the hip (). Abdominal wall reconstruction was performed with 2 fasciocutaneous-type flaps raised to the level of the costal margin, medially to the umbilicus and posteriorly to the area of the trapezius. Inferiorly, the flaps were extended onto the lateral tensor fascia lata area, posterior to the superior buttock region, and medially into the groin crease"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old Caucasian male patient was brought to the resuscitation bay of our Emergency Department after a syncopal episode and was noted to be in shock. His initial observations include Heart Rate 126/min, Blood Pressure 102/79 mmHg, Respiratory rate 32/min, temperature 36.8C and oxygen saturation of 98% on 2 L of nasal prongs. The patient had a Glasgow Coma Scale of 14 and was clinically dehydrated. Abdominal examination revealed a distended abdomen that was tender in the left upper quadrant with no evidence of peritonism. Laboratory tests showed polycythaemia with Haemoglobin of 189 g/L and white cell count of 20.3 × 109/L with preserved renal and hepatic functions. Arterial blood gas analysis was consistent with normal anion gap metabolic acidosis with a pH of 7.28 and lactate of 4.5. The patient responded to initial fluid resuscitation.\nFurther history was obtained: he had a 2-day history of progressively worsening upper abdominal pain associated with multiple episodes of dark coloured emesis and loose bowel motions. The pain was exacerbated by oral intake. He had a background of ulcerative colitis diagnosed at the age of 40 which required one course of oral steroid with no further follow up or treatment.\nAs the patient remained in a stable state, a CT abdomen was performed which demonstrated a long segment of superior mesenteric vein (SMV) thrombus extending into the portal vein. This resulted in venous engorgement with associated thickening of jejunal wall and extensive mesenteric stranding suggestive of intestinal ischemia. There is also a moderate amount of free fluid with no evidence of intramural gas or perforation (, ).\nAcute mesenteric venous thrombosis was diagnosed and management options were explored. Although the CT appearances were sinister and suggestive of intestinal ischemia, the patient had no signs of peritonism. Thus, decision was made for conservative management. Heparin infusion was commenced, nasogastric tube was inserted and the patien"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year old Thai woman presented to our facility with a two-month history of urinary incontinence induced by coughing.\nShe had a history of cervical squamous cell carcinoma, stage IIb, which was treated 15 years previously with radiation therapy. Her six-month interval follow-up pelvic examination and cervicovaginal PAP smears had revealed negative findings and the disease had been considered as in complete remission by the attending radiologist. She was first referred to our gynecology department to find out the cause of her incontinence. On pelvic examination by a gynecologist, her uterine cervix was found to be atrophic with an extraluminal compression at the anterior vaginal wall, covered by an intact vaginal mucosa. Laboratory investigation results revealed mild hematuria (3 to 5 red blood cells per high-power field) and mild anemia (hemoglobin 10 g/dL, hematocrit 31.1%). Eventually, our patient was referred to our urology department for further management.\nDuring the process of the Q-tip test, the applicator was passed with difficulty and deviation to the right. Cystoscopy was performed. Her urethra showed no meatal stenosis and unremarkable mucosa, but the device was passed with difficultly due to external compression from the left side of the proximal urethra. Her bladder had a large sessile mass on the left lateral wall with extension to the bladder neck. Both ureteral orifices could be identified clearly with unremarkable appearance and efflux. Clinically, the differential diagnosis included recurrent cervical cancer, bladder cancer and retroperitonal sarcoma. Urine cytology and transurethral resection of the bladder tumor were performed, with a negative cytology report and a pathological diagnosis of high-grade urothelial carcinoma. A computed tomography scan demonstrated a heterogenous enhancing mass, 5.3 × 6.5 × 6.0 cm, at the left inferior-lateral wall of the bladder with invasion of the uterus and attachment to the left pelvic side wall, as shown in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old boy was hospitalized because of acute abdominal pain, melena, and vomiting. Mild abdominal pain was present for the preceding 6 months in the right lower quadrant. No weight loss or other specific symptoms were present. Before the onset of the symptoms, no signs of malignancy were present and he had not undergone a thorough abdominal examination till then. Additionally, he did not have any chronic diseases and had no family history of malignancy. Distended abdomen and decreased bowel sounds were observed during the physical examination. Diffuse direct and indirect tenderness was present throughout the abdomen. At presentation, melena was present; however, blood pressure and other vital signs were normal.\nPlain radiography indicated a suspicious state of ileus; however, we could not see the exact mechanical obstruction. Physical examination and radiographic findings warranted further examination; hence, in view of the patient's age, we ordered abdominal computed tomography (CT) scan immediately. Abdominal CT scan confirmed the presence of ileocolic intussusception with distal segmental ischemic changes (Fig. ). Because the patient had visited our hospital after 24 hours of the onset of his symptoms with suspected ileocolic obstruction, we decided to intervene with emergency surgical resection. The initial laboratory results revealed anemia (hemoglobin = 7.1 g/dL) and he had ongoing melena; therefore, red blood cell transfusion was performed. Inflammatory markers such as white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate were normal. Platelet count and disseminated intravascular coagulation (DIC) score were also within the normal range. These normal laboratory results and a lack of familial history made bleeding diathesis highly unlikely. Since levels of tumor markers like carcinoembryonic antigen (CEA) and cancer antigen (CA) 19–9 were within the normal range, we could not find any indication of malignancy before histol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old woman complained of a slightly swollen left leg and low lumbosacral pain (visual analog scale score: 4), and was admitted to our department. She had a history of diabetes mellitus and hyperlipidemia for more than 20 years, and these were treated by medications prescribed by her endocrinologist and cardiologist. She had an L3 OVCF, with a visual analog scale score of 8 2 months previously, and was successfully treated with PVP. She was discharged on postoperative day 2, with no cement-associated complications and a visual analog scale score of 2 (. Accordingly, a newly fractured vertebra was suspected at admission to our department. A physical examination showed a slightly swollen left leg with no other major complaints. The intensity of the low lumbosacral pain did not increase when she slightly twisted her spine. No major abnormalities of a regular laboratory test were observed.\nThe patient suddenly fainted when she was taking a shower on admission night 2. After general resuscitation of moving her back to the bed and resting with electrolyte fluid supplementation, she gradually became conscious and returned to a normal status. The next day, magnetic resonance imaging of the spine, computed tomography angiography, and ultrasonography were performed. No newly fractured spinal vertebra was detected. No major abnormality in the arteries or deep veins in both lower extremities was detected on ultrasound. A cement leakage that started from the L3 level and migrated to the L1 level, and was suspended in the inferior vena cava was detected (. Another cement leakage was detected in the right pulmonary artery (. After 4 days of general conservative therapy, the patient became agitated and her left leg started swelling (. Her condition became severe. General anti-coagulation therapy with 3000 units of low molecular weight heparin daily was empirically implemented. Relevant blood tests were performed again and showed the following: D-dimer concentration, 9.45 mg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old man presented to the radiation oncology clinic for surgeon’s consultation, requiring an adjuvant radiation to his scalp after extensive resection of a primary scalp lesion.\nSix years earlier, the patient had developed a scalp lesion on the right parietal side and underwent a resection. The initial pathology report indicated squamous cell carcinoma. After nearly 6 years of being disease-free, he noted a new lesion on the same spot, which had disseminated and involved almost all scalp tissue within one month. On magnetic resonance imaging, a vegetative and enhancing mass over the right parietal bone measuring 74 mm × 74 mm × 38 mm was noted, with suspicious invasion to the external table of bone and adjacent bone marrow. Multiple suspicious lymphadenopathies on the left cervical levels 2 and 5 as well as the left occipital and parotid regions were reported with short axis diameter (SAD) of about 10 mm. A core needle biopsy of suspicious lymph nodes indicated squamous cell carcinoma and later, the patient underwent an extensive scalp surgery for resection of the lesions. The skin defect was covered with a rotational flap and skin grafting.\nThe surgical pathology report indicated a 9-centimeter large tumor with 2.5 cm thickness, and the tumor was classified as poorly differentiated SCC. The tumor showed lymphovascular invasive features, but perineural invasion was not detected. Deep margin of the excised tissue was affected by the tumor; however, bone trabeculae and intervening marrow were not involved. The surgeon additionally resected two other suspicious lesions on the right frontal and left parietal regions of the scalp. The former was reported to be actinic keratosis grade 3 (Bowen’s disease), while the latter showed features of early invasive SCC in a background of actinic keratosis with a thickness of 2.2 mm and close medial margin (3 mm).\nWe intended to treat the patient with adjuvant radiotherapy to a total dose of 66 Gy with 6 MV photons. However"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old man visited the clinic due to a limited MIO of 28 mm and pain in the left TMJ when chewing and opening his mouth. The patient had undergone orthodontic treatment for several years before visiting the clinic and had a history of stabilizing splint therapy in an oriental medical clinic.\nMagnetic resonance images were obtained with the expectation that anterior disc displacement without reduction and a masticatory muscle disorder were responsible for the patient's condition, based on physical examinations.() The images revealed anterior disc displacement with reduction on the left TMJ and adhesion of the right articular disc. Anterior positioning splint therapy and botulinum toxin injection were used to relieve the stiffness of the bilateral masseter muscles, but no improvement in TMJ pain or MIO was observed. Arthroplasty of the right TMJ was performed to resolve the adhesion of the articular disc, but the movement of the mandible was not satisfactory in the operating room. A few months after surgery, the patient continued to complain of TMJ pain, a grinding sound in the bilateral TMJs, and mouth opening limitation. CT images were taken to determine the possibility of TMJ osteoarthritis or neoplasm, and an elongated right coronoid process and heterotopic bone formation were detected on the medial and inferior surfaces of the right zygomatic arch.()\nThe patient underwent a right coronoidectomy under general anesthesia, and the heterotopic bone was removed. Immediately after surgery, the MIO was increased to 43 mm in the operating room. Physical therapy was initiated three weeks postoperatively; at the 15-month follow-up visit, the patient's MIO was found to have increased to 63 mm with protrusive and lateral movements to the right and left of 7 mm, 10 mm, and 7 mm, respectively. No specific abnormality was noted except for a slight right deviation when opening the mouth, multiple grinding sounds from the left TMJ, and mild pain in the right masseter muscl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old boy with morbid obesity and no known prior psychiatric history underwent sleeve gastrectomy. Prior to the surgery, he weighed 167 kilograms with a body mass index (BMI) of 54.5. Within a few months postoperatively, he weighed 70 kilograms with a BMI of 22.8. The patient’s substance use disorder started at the age of 15, one year after the bariatric surgery. Of note, the patient's parents were separated and he lived with his mother and siblings. None of his family members or relatives had a history of substance use disorder. He initially started using fenethylline (marketed under the brand name Captagon), as it was a common substance used by his peers at school. He started with two tablets daily and increased his use gradually up to 15 tablets daily. He started smoking cannabis a year later, at the age of 16, starting with one cigarette per day and increasing his use gradually until reaching a peak of 20 cigarettes per day. The patient started drinking alcohol occasionally at the age of 16 as well, and it soon became an issue of excessive use on a daily basis. The patient drank different types of alcoholic beverages. He reported incidents of fainting in relation to alcohol use but had never experienced withdrawal. He mentioned that he started using alcohol as a way to reduce his use of other substances. Two years later, at the age of 18, the patient started using methamphetamine, which caused him to develop paranoid ideation, auditory hallucinations, severe insomnia, and aggressive behavior. The patient was admitted to an inpatient psychiatric unit for a few days and was started on haloperidol 3 mg orally twice daily, benztropine 2 mg orally twice daily, and quetiapine 50 mg orally as needed for insomnia. His psychotic disorder improved with the cessation of substance use and the treatments initiated on the inpatient side. After his discharge, he unfortunately relapsed and continued to use the aforementioned substances.\nAfter arranging for close follow-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old healthy man presented to the surgery clinic of Ghaem Hospital, complaining of abdominal pain, which was generalized, dull, and acute and started two days before he came to the clinic. The pain was constant, and he declared its intensity 4 out of 10, with no radiation. Moreover, he did not reveal any correlation between pain intensity and eating or activity. He did not mention any recent fever, nausea, or vomiting. He did not report any past medical history of surgery or hospitalization.\nOn his medical examination, vital signs were as follows: heart rate = 98/min, respiratory rate = 14/min, blood pressure = 115/70 mmHg, and axial temperature = 37.3°C. His abdomen was soft, and there was just a mild generalized tenderness without rebound or guarding. There was no sign of organomegaly, scar, or herniation. The rest of his examination was normal.\nComplete blood count was normal, and blood chemistry did not show any abnormal findings other than high ESR (53 mm/hr) and high CRP (187 mg/l) with the normal range of ESR (0-22 mm/hr for men) and CRP < 10 mg/l.\nCoronal sections of the abdomen-pelvic CT scan with IV contrast showed a hepatic hydatid cyst with water lily sign in the right lobe of the liver with a compressive effect on the adjacent diaphragm and the left lobe of the liver and hydatid cyst of the bladder dome (). In axial sections of the CT scan, hepatic hydatid cysts were seen with water lily sign and pressure effect on the diaphragm and an intact capsule in the right and the left lobes of the liver. Free abdominal fluid was present (). In other axial sections of the pelvis, a hydatid cyst was seen with an intact capsule on the bladder dome ().\nOpen abdominal surgery was performed with the final diagnosis of hydatidosis. There was an intact cyst without any invasion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43 year old male patient was referred to our hospital for an elective laparoscopic sigmoidectomy due to complicated sigmoid diverticular disease. The patient complained of a 4 month history of mild lower abdominal pain that was predominately localized to the left lower quadrant. The pain was associated with alternating bowel habits and several episodes of bleeding per rectum mixed with stool. The patient also recently noticed onset of dysuria, pneumaturia, and fecaluria. His past surgical history is significant for bilateral laparoscopic hernia repair (TAPP) with mesh placement, which was fixed with tacks 7 years previously and varicocelectomy 5 years ago. He has no relevant medical history of note.\nExamination of the patient revealed mild left lower quadrant tenderness to palpation. All laboratory markers were within normal limits. A CT abdomen and pelvis revealed multiple sigmoid colon diverticula, diffuse mural thickening of mid sigmoid colon with severe adjacent fat stranding, abscess formation adjacent to the sigmoid colon with air pockets sized 3 × 7 × 8 cm (), and a colo-vesical fistula formation causing severe mural thickening in the roof of the urinary bladder with air pockets in the urinary bladder. Colonoscopy revealed multiple sigmoid diverticulitis and inflammatory sigmoid lesion that was biopsied; the lesion however could not be bypassed due to fear of perforation. Biopsy revealed mild chronic colitis and was negative for granuloma or dysplasia.\nThe patient was admitted and prepped for laparoscopic sigmoid colectomy and excision of colo-vesical fistula. Intraoperative findings revealed a sigmoid colon abscess, a colo-vesical fistula, left inguinal region mesh eroded into the colon from his previous laparoscopic hernia repair (). Abscess drainage, excision of the colo-vesical fistula and sigmoidectomy with removal of the mesh was performed. The right mesh was in place.\nPost operatively the patient was started on antibiotics (tazocin), had an abdominal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old man, weighing 56.2 kg and 170 cm tall, was diagnosed with advanced rectal cancer, and after concurrent chemoradiation therapy, underwent laparoscopic low anterior resection. After 2 weeks from discharge, he was readmitted to the hospital for nausea and vomiting and was diagnosed with postoperative small bowel obstruction around the ileostomy. He underwent a small bowel resection because he did not improve from conservative treatment. After reoperation due to the small bowel obstruction, he reported abdominal discomfort and postprandial stabbing epigastric pain with nausea and vomiting. He showed a weight loss of 9 kg over 18 days since the readmission (). An abdominal CT scan was performed under suspicion of postoperative intestinal obstruction, which demonstrated moderate gastroduodenal dilation with compression of the SMA, and 7 mm of aortomesenteric distance, consistent with SMA syndrome (). Gastroduodenoscopy showed reflux oesophagitis grade III and a fluid-filled first and second portion of the duodenum, and stenosis of the third portion. Conservative medical treatment with high-calorie total parenteral nutrition (TPN) and anti-emetics was initially administered for 2 weeks. The administration of nutrients was set at 1500 kcal/day, and the total volume of TPN was 1440 mL. The ingredients of TPN administered during this period were glucose 187 g/day, protein 72 g/day and lipid 58 g/day. Even after TPN treatment, his weight continued to decline. Although we tried to increase the total calorie of TPN, we could not afford it due to the fluid overload. So then surgery was considered first, but the perioperative risk was expected to be high in preoperative risk evaluation due to his poor nutritional status and severe bronchiectasis. Consequently, jejunal feeding tube placement past the obstruction via endoscopy was offered for the treatment of SMA syndrome.\nAn endoscopy-guided jejunal feeding tube (Abbott’s 12 Fr) was passed through the third portion of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old Japanese woman was referred to our hospital because of hepatic tumors detected by abdominal ultrasonography during a screening examination. Her medical and family history was unremarkable; her occupational and residential history showed no apparent exposure to asbestos. She received no medical drugs, and neither smoked tobacco nor drank alcohol. On admission, her general status was unremarkable; her temperature was 36.2 °C and her blood pressure was 110/70 mmHg with a regular heart rate of 80/minute. A physical examination revealed no abnormal findings; neurological examinations were unremarkable. All laboratory data, including levels of the serum tumor markers carcinoembryonic antigen, cancer antigen 19-9, alpha fetoprotein, protein induced by vitamin K absence or antagonist-II, and cancer antigen 125 were within normal ranges (Table ). An abdominal enhanced CT scan revealed four hypervascular, round hepatic tumors. One tumor, which was 32 mm in diameter, was in contact with the lateral liver segment and the hepatic hilus; the other three tumors were in contact with the diaphragm and measured 7 mm in segment 4, 17 mm in segment 7, and 15 mm in segment 8 (Fig. a–d). There was no pleural effusion or ascites, and no other nodular lesions in her chest or abdomen were observed. Similar to the CT findings, magnetic resonance imaging (MRI) revealed a tumor of lower intensity than the liver on T1-weighted images, and with higher intensity than the liver on T2-weighted and diffusion-weighted images (Fig. a–c). Upper and lower gastrointestinal endoscopic examination findings were normal. We hypothesized that the tumor arose from her liver, and diagnosed our patient as having multiple hepatic hemangiomas, at first. However, imaging findings were not typical of hepatic tumor: all tumors were on the edge of the liver and the tumor margins were clear. Moreover, the tumor in segment 7 appeared continuous with the diaphragm with similar high-density contrast medium ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 11-year-old girl presented to her local hospital with an acute onset of severe abdominal pain, showing signs of hypovolemic shock and requiring emergency resuscitation prior to transfer to a tertiary pediatric center. She had fainted at school earlier in the day and been sent home. That afternoon, she had vomited once and rested in bed. She woke during the night, screaming in pain. An ultrasound scan at the local hospital demonstrated a ruptured spleen with an associated perisplenic hematoma and a large volume of free fluid in the peritoneal cavity. These findings were confirmed on a contrast-enhanced computed tomography scan (\n), which also demonstrated active extravasation of contrast from a branch of the splenic artery. After further resuscitation at the tertiary center, including multiple blood product transfusions, she was transferred to the interventional radiology suite where angiography via a femoral arterial approach showed gross disorganization of the splenic vasculature at the site of parenchymal rupture, with several truncated vessels and active bleed points noted (\n). Distal embolization of individual bleeding vessels proved impossible due to anatomical distortion by the surrounding hematoma and vessel spasm. In view of the emergency nature of the situation, coil embolization of the proximal splenic artery was performed, with complete occlusion of splenic arterial flow. This inevitably involved partial devascularization of the pancreatic tail.\nThe patient's vital signs and transfusion requirements improved immediately after coil deployment. She made a slow but steady recovery on the intensive care unit and was extubated 3 days after admission. Her recovery was complicated by transient pancreatitis that was conservatively managed. She was discharged from the hospital 4 weeks later. Follow-up showed reconstitution of most of the splenic parenchyma, though she was vaccinated and commenced on prophylactic antibiotics in view of presumed hyposplenism.\nThe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-years old female patient was diagnosed with a mucosal melanoma of the urethra (patient characteristics: see ).\nAt the time of primary diagnosis, inguinal lymph node metastases were detected. A complete resection of the urethra and a radical dissection of the left inguinal lymph nodes was performed concomitantly in our surgical department. Only 1 month after the intervention intravaginal mucosal metastases were diagnosed and histologically confirmed (). Computed tomography (CT) scans showed nodal metastases in proximity of the left iliac vessels with no option to obtain a complete resection of the tumor masses. Molecular analyses of the tumor showed wild types in the BRAF- and NRAS gene and a p.K558dup mutation of c-KIT on exon 11. In view of the locally advanced, inoperable melanoma a systemic therapy with the PD-1 inhibitor pembrolizumab was induced and temporary obtained stable disease. After administration of 10 cycles of pembrolizumab the patient started to suffer from recurrent vaginal bleeding, which significantly restricted the patient's quality of life. Clinical examinations revealed ulcerated pigmented intravaginal metastases. Imaging confirmed loco-regional progress without distant metastases (). Hence, 4 weeks after the last dose anti-PD1 antibody and in agreement with our patient, we initiated treatment with the oncolytic virus T-VEC (first administration 106 PFU/ml, followed by 108 PFU/ml at week 3 and followed Q2W, 1–3 mL). In cooperation with our department of gynecology T-VEC was injected directly into the intravaginal mucosal metastases. The injections provoked moderate local bleeding of the mucosa, and the patient suffered from flu-like symptoms a few hours after injections. The patient did not show any signs of a herpes infection at any time. Our patient reported that the T-VEC applications were tolerable and that the side effects did not restrict her daily life. Laboratory investigations did not reveal any significant pathologic findings. Af"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old Japanese man presented with swelling of the gingival in the molar region of the left mandible. Approximately 2 weeks prior to the first visit, the patient noticed swelling of the gingiva, and panoramic X-rays were taken at a dental clinic. The images revealed radiolucent findings at the site, and the patient was referred to our facility for examination. The patient had a moderate physique and was well nourished, but he was taking medication for hypertension.\nIntraoral findings showed that the upper and lower jaws were edentulous, with a relatively irregular border from the centre of the mandible to the gingiva of the molar region on the left side. Diffuse swelling and surface ulceration were observed. There was neither tenderness nor numbness of the lips ().\nPanoramic radiographs revealed a barely perceptible, polycystic radiolucent area with slightly irregular margins in the left molar region of the mandible ().\nComputed tomography showed a radiolucent area with little radiopacity. Internal uniformity was observed at the site, with thinning of cortical bone which lacked continuity in some areas (). After 1 month, a biopsy and a needle aspiration were performed. Five millilitres of yellow-white content was aspirated. The results of bacteriological analysis were negative. Histopathological findings revealed that the squamous epithelium was accompanied by chronic inflammatory cell infiltration. Based on these findings, a diagnosis of benign tumor of the mandible was made, and after 2 months, excision and curettage were performed under general anaesthesia. The lesion partially adhered to the bone, and the surface of the peripheral bone was slightly rough. An inferior alveolar neurovascular bundle was also observed below the tumour, and this was preserved. After excision of the tumor in one piece, curettage was performed and the wound was left open. Seven months after surgery, there has been no recurrence of the tumour, and the patient is currently being"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old Caucasian male, with a past medical history of atrial fibrillation on warfarin and metoprolol, and coronary artery disease on atorvastatin with previous coronary artery bypass grafting and placement of a dual-function pacemaker/ implantable cardioverter defibrillator (ICD), was on a motor boat in a remote location. The patient’s boat went over a wake of a larger boat passing by. He bounced off his seat in a vertical direction and subsequently landed on his tailbone. After the high impact fall, he complained of both immediate lower back and diffuse abdominal pain but did not seek out urgent medical help.\nTwo days after the initial incident, he started to become pale and diaphoretic; additionally, his ICD delivered three shocks over a 30-min period. He presented via ambulance service to a local community hospital in hemorrhagic shock with a blood pressure of 63/22 and heart rate of 118 beats/min. A primary survey was pertinently positive for hemodynamic instability and diffuse abdominal and lower thoracic spine tenderness.\nHe was resuscitated with 1 L of normal saline leading to an improvement of his pressure to 106/88. Initial laboratory investigations included a hemoglobin of 95 g/L, lactate of 6.1 mmol/L, creatinine of 129, and a supratherapeutic INR of 8.8. An initial non-contrast CT abdomen and pelvis showed moderate hemoperitoneum with sentinel clot in the left upper quadrant and pericolic gutter, as well as the area adjacent to the posterior wall of the stomach. An additional finding of a severely comminuted, minimally displaced burst fracture of the T10 vertebral body was noted (). Further interventions included INR reversal with 3 mg of Vitamin K and 3000 units of prothrombin complex concentrate, and administration of 2 units of packed red blood cells and 2 L of normal saline. Based on clinical severity, the patient was transferred to the trauma service at a tertiary-care Level 1 trauma center"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 6-year-old boy visited Samsung Medical Center with complaints of dyspnea and a barking cough lasting for 3 days. Chest radiography revealed a mass-like lesion in the right upper mediastinum. Chest computed tomography demonstrated a well-defined posterior mediastinal mass measuring 4 cm, which was suspected to be a neural foraminal extension to the thoracic spine (T3–T4). Magnetic resonance imaging was conducted for further evaluation; it showed a right upper paravertebral enhancing mass with an adjacent neural foraminal extension to the T2–T5 spine (). A preoperative neurologic examination revealed that the patient had no abnormalities. He underwent mediastinal mass excision by video-assisted thoracic surgery. The mass was in the right posterior mediastinum, was located at the T2–T5 level of the spine, and did not extend to the neural foramen. It was resected by electrocautery. The sympathetic chain at the T2 level was inevitably resected as part of the complete resection of the mediastinal tumor during the operation, because the tumor originated from this sympathetic chain. The intraoperative course was uneventful, with a stable hemodynamic status throughout the surgery. After the patient was sent to the post-anesthesia recovery unit, a sharp midline facial demarcation was observed, and the left face, neck, and chest (contralateral to the operation site) became flushed and warm (). These findings were noted to increase in intensity when the patient cried. In contrast, the right face, neck, and chest (ipsilateral to the operation site) were pale and cool and did not change in color when the patient cried. A neurologic examination including that of the cranial nerves was normal, and miosis and ptosis were absent. The patient’s vital signs and laboratory tests were normal. The symptoms, including the color and the warmness of the face, started to show minimal improvement within an hour and completely resolved without any treatment 3 hours after su"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old man underwent a living donor kidney transplant at our transplantation unit in 2003. His postoperative course was uneventful. The procedure resulted in normalization of his renal function and no signs of rejection were reported in his follow-up records.\nThe patient was compliant with his immune-suppressive therapy and maintained frequent follow-up visits to his nephrologist during which he had normal renal transplant function.\nIn 2013, the patient travelled outside the country for work purposes. During his overseas stay, he had gradual deterioration in his kidney function for which he was treated conservatively until his creatinine level ranged between 2.0–3.0 mg/dL. A kidney biopsy of the transplant was performed in March 2014 and he was informed that no obvious pathology could be determined. Conservative management was continued.\nIn June 2015, the patient returned home and he was admitted for further investigations at our transplant unit. Upon admission, a right iliac fossa pulsatile mildly tender mass was felt and a bruit was clearly audible. His creatinine ranged between 4.0–4.5 mg/dL. Duplex ultrasound revealed a 110 × 90 mm partially thrombosed aneurysm adjacent to the upper half of the transplanted kidney. The exact origin of the aneurysm could not be determined by the ultrasound. A multisliced computed tomography (CT) angiogram showed a 115 × 91 mm false aneurysm extending superiorly to a level above the aortic bifurcation.\nA three-dimensional reconstruction of the CT scan demonstrated that the transplanted kidney was supplied by two arteries. The aneurysm was originating from the distal part of the upper renal artery (URA), which was anastomosed to the common iliac artery during the original surgery. Few branches were identified originating from the proximal part of URA and supplying parts of the upper and middle segments of the kidney.\nThe lower pole of the kidney was supplied by the lower renal artery (LRA) that was anastomosed to the externa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12 year old boy presented to the emergency for the onset of acute anisocoria. Two hours before the boy had started to complain of a blurred vision; his mother, a paediatric nurse, noticed a pupil asymmetry with a clearly dilated right pupil (Figure ). Eyes were normal at wake up and during the early morning; the boy had spent the all morning playing in grandmother's garden. There was no history of trauma, eye drops' instillation, nebulised drugs or local ointments. His past medical history was negative.\nOn physical examination the boy was well, orientated and collaborative. In room light the right pupil was round, but the reaction to light was sluggish. Left eye's reaction was normal. Anisocoria was more evident in bright light. Ocular motility was normal. On slit lamp the pupil was round and no signs of trauma were detected. Consensual pupillary light reflex of the left eye was elicited. In the anterior chambers no inflammatory changes were detected and both irises and fundi examination were normal.\nA third nerve palsy was considered but the performed cerebral MRI was normal.\nOn further investigation the boy explained that he had spent the morning doing gardening and especially working on a \"trumpet plant\". A quick internet search helped to find a picture of \" Datura suaveolens \", commonly known as trumpet plant, immediately recognized by the child and his mother (Figure ). The boy did not refer a direct contact of leaves or flowers with eyes, however he referred to have handled both leaves and flowers and to have removed new small plants arising at the bottom of the plant. It is very likely that an accidental hands-eye contact after touching the plant had occurred.\nThe day after anisocoria was much less evident and completely resolved in three days. The patient was diagnosed with pharmacologic mydriasis secondary to unintentional contact with Datura"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old trans man who had been on testosterone therapy for 10 years presented to the emergency department with central chest pain. His high-sensitivity cardiac troponin was 24 ng/L (female reference range <16 ng/L, male reference range <26 ng/L). How should he be managed?\nCardiac troponin is released from damaged cardiomyocytes and is one of the most common biomarkers used in the prediction of myocardial infarction. There is considerable debate regarding the use of sex-specific reference ranges for high-sensitivity cardiac troponin (hs-cTn), as there is uncertainty whether the use of sex-specific reference limits impact upon clinical management or outcome prediction (). However, as upper reference limits based on sex-specific 99th percentiles for hs-cTn are subtly higher for people recorded as males than those recorded females in population studies (), use of sex-specific cutoffs for hs-cTn assays have been endorsed by the International Federation of Clinical Chemistry and Laboratory Medicine (). The difference has been attributed to people presumed male at birth having a larger cardiac mass as well as subclinical coronary artery disease (). No studies have been performed to examine cardiac mass changes that may occur with masculinizing hormone therapy in people presumed female at birth. There are however data in polycystic ovary syndrome in which high testosterone concentrations are a clinical feature (albeit far lower than testosterone concentrations seen in transgender men). Polycystic ovary syndrome has been associated with higher left ventricular mass index and larger left atrial diameter over 5 years of follow-up, even after adjustment for blood pressure, body mass index, glucose, and lipids (). Large population-based studies have also shown that left ventricular mass correlates with body weight, lean body mass, and fat mass (). There is currently insufficient data to draw an inference regarding the appropriate reference range in people using gender-affi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report on a 63-year-old female patient who presented in January 2016 with the following symptoms: complaint of cold sensation affecting the upper arms on both sides (left > right), weakness and arm claudication, with an increasing inability to perform work on the computer, and symptoms of a fatigue syndrome. The patient was unable to perform her employment as a hospital secretary. Clinically, pulselessness of the brachial and radial artery on both sides was noted. Bruits were discovered in the left and right subclavian artery. A blood test revealed increased levels of the inflammatory markers C-reactive protein (CRP 47.9 mg/dL) and an increased Erythrocyte Sedimentation Rate (ESR 74 mm/h). The patient had a history of hypertension, hyperlipoproteinemia, and osteoporosis; she was a former smoker and reported moderate daily alcohol consumption.\nA neurological examination, an MRI of the cervical spine, and myocardial scintigraphy were without pathological findings. Duplex ultrasound of the carotid artery and upper extremities revealed noticeable intima-media thickening. For suspected large-vessel vasculitis, a diagnostic angiography was carried out, which revealed bilateral stenosis of the axillary artery at the transition to the brachial artery and, on the left side only, an additional stenosis in the proximal segment of the brachial artery. TA was diagnosed based on the American College of Rheumatology criteria, with four out of six criteria met.\nThe patient was admitted to a rheumatological specialist clinic in March 2016. Treatment with prednisolone 20 mg daily was started, but there was no improvement of the arm claudication. Therefore, the patient received cyclophosphamide 15 mg/kg body weight × 0.75 (=600 mg) plus prednisolone (75 mg/d initially, reduced in stages to 30 mg/d at the time of hospital discharge). Six cycles of cyclophosphamide at 3-week interval were planned, at the end of which treatment with methotrexate 15 mg subcutaneously once a week accomp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old Caucasian female presented to the surgical office with a chief complaint of chronic epigastric abdominal pain for seven months duration. The patient was referred to the office after an emergency department visit for her chronic abdominal pain. The workup showed normal laboratory values with a nonspecific, lobulated soft tissue lesion located within the mesentery of the upper abdomen measuring up to 3.2 cm on computed tomography with intravenous and oral contrast. The patient noted her pain had developed and had been persistent since she underwent laparoscopic appendectomy for acute appendicitis roughly one year prior. She described her pain as sharp in nature with intermittent flares. The patient reported that eating exacerbated her symptoms. She endorsed anorexia as well as weight loss. Physical examination at that time was considered unremarkable. The patient’s medical history included gastroesophageal reflux disease, gastritis, depression, and a seizure disorder. The patient’s surgical history included a cholecystectomy for cholelithiasis, hemorrhoidectomy, tonsillectomy, and an appendectomy. Family and social history were non-contributory.\nBased on the initial radiographic results and the location of the mesenteric lesion, the patient was referred for endoscopic evaluation and possible biopsy. They were then started on a trial of proton pump inhibitors. The patient had multiple visits to her primary care provider and was eventually transitioned to sucralfate as her symptoms were unresolved. The patient underwent esophagogastroduodenoscopy that revealed LA Grade B gastroesophageal reflux disease, a 2 cm hiatal hernia, and diffuse gastritis. Repeat computed tomography of the abdomen and pelvis with intravenous and oral contrast was performed revealing a lobulated lesion at the level of the kidneys within the anterior mesenteric fat, concerning for an enlarged lymph node or a neoplastic mass as demonstrated by the arrow in Figure . The mass was deemed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old man was referred to our department with the chief complaint of discomfort on the right side of his neck. He had no medical history. He had initially become aware of pain on the right side of his neck three years before visiting our department. He first consulted with the oral and maxillofacial department of a local hospital. Computed tomography (CT) at that hospital showed styloid process prolongation; however, the patient reported mild discomfort upon follow-up. The discomfort on the right side of his neck worsened, and he was referred to our hospital for the treatment of his neck symptoms.\nThe patient had no systemic disease at the initial visit. He was aware of the discomfort of the right side of his neck when he turned his head (). A rigid bone-like structure was palpable in the right submandibular region. In addition, panoramic radiography revealed an elongated right styloid process beyond the mandibular plane (). CT showed styloid process prolongation on both sides (). The length of the styloid process was 60 mm on the right side. Calcification of the minor horn of the hyoid bone and the styloid process' tip was also observed. Moreover, prolongation of the right superior cornu of the thyroid cartilage was observed, with a length of 23.2 mm. The cervical symptoms might have been due to the extension of the superior thyroid cartilage angle. Still, the discomfort that occurred during the neck rotation coincided with the tip of the styloid process. The patient was diagnosed with symptoms of styloid prolongation .\nSurgical trimming of the elongated styloid process with an extraoral approach was performed under general anesthesia. A skin incision was made in the submandibular region, and detachment was performed to reveal the intermediate tendon of the digastric muscle. A styloid process was observed near the hyoid bone. After the detached surrounding area, the styloid process was resected using an ultrasonic bone scalpel (). The stylohyoid ligament wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old female of Sri Lankan origin living in New Zealand for past 21 years presented after an incidental finding of a 23 mm left lingular lesion. The lesion was first identified on a routine plain chest radiograph (following a hospital attendance with headache) and further delineated by computed tomography (CT) scanning. It was described as peripheral lesion with nodular appearance, with contact of the visceral pleura. The lesion appeared to have increased in size in comparative plain radiographs taken eight weeks apart. There was no interval cross-sectional imaging to confirm the subjective enlargement.\nThere were no respiratory symptoms of note, and no history was obtained of prior significant respiratory illness. Past medical history was notable for type 2 diabetes and treated hypertension. The patient had been a lifelong non-smoker, although her husband had been a heavy smoker and had died of lung cancer 10 year prior. There was no significant occupational exposure.\nIn view of radiological suspicion of pulmonary malignancy, a CT-guided fine needle aspiration was done. This showed mildly atypical cells and no definite diagnosis was possible on the degree of atypia. A positron emission tomography (PET) CT demonstrated a 17-mm lingular sub-pleural nodule abutting and distorting the major fissure without clear evidence of transgression. The nodule demonstrated minimal PET avidity (maximum standardized uptake value of 2.4) but no signs of nodal involvement or distant disease (Fig. ).\nRoutine laboratory testing was unremarkable, including a normal full blood count with normal white cell differential (eosinophil count of 0.1 × 109), and a normal C-reactive protein. No serum immunoglobulin E level was done.\nThe case was discussed at multidisciplinary meeting and it was agreed that possibility of pulmonary malignancy could not be excluded, with a concern of the lesion being very close to the visceral pleura. She was hence put forward for surgical excision of the l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old female, with chronic kidney disease, hypertension, diabetes mellitus, obesity, and prior right femoral neck fracture treated with dynamic hip screw, presented with a chronic right leg infection. Approximately one year prior to presentation, she sustained a right distal femur fracture treated with retrograde intramedullary nail fixation, which was complicated by early hardware failure requiring revision. She then developed a MSSA infection, requiring removal of hardware and placement of an antibiotic spacer. She completed a course of antibiotics and subsequently underwent total knee arthroplasty, which was complicated by MRSA infection with development of a sinus tract communicating with the distal femur. She underwent three more irrigation and debridement procedures, long-term IV Vancomycin, and replacement of an antibiotic spacer at the most recent debridement. Her sinus tract persisted and she presented for second opinion to discuss alternatives to amputation. On examination, she had a draining sinus tract near the knee, which probed to a depth of 5 cm. Her right lower extremity was 4 cm shorter than the left. ESR was 16 mm/hr and CRP 0.58 mg/l.\nRadiographs at presentation are shown (), and she was taken to the operating room where cultures were obtained and all hardware and antibiotic cement were removed. The femur and tibia were then reamed and an 11.5 mm × 700 mm Smith and Nephew intramedullary nail was placed with gentamicin cement packed around the nail. Intraoperative cultures had no growth and she was placed on IV Vancomycin for six weeks given her history of MRSA and MSSA. Postoperative images are shown ().\nHer postoperative course was complicated by Vancomycin-resistant Enterococcus (VRE) PICC line infection and E. coli UTI, which were treated at an outside hospital. At follow-up, she was noted to have a draining sinus at the distal femur, which was treated with wet-to-dry dressings. Inflammatory markers were then trended and decreased over"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63 years old lady carried out a complex re-laparotomy for a postoperative small bowel occlusion after a radical cystectomy because of urothelial carcinoma. The procedure lasted 3 h because of thick adhesions that needed to be cleared. At the end of the procedure, total blood loss was 2 litres, and two Units of Packed Red Blood Cells (PRBC) were infused. During the surgical procedure, a central venous catheter was placed in the internal jugular vein by ultrasound-guided puncture of the vessel, but an inadvertent puncture and cannulation of the right subclavian artery occurred before catheter placement. Because of the ultrasound-guided procedure, the anesthesiologist thought to have cannulated the carotid artery and applied local pressure for a few minutes. Two hours later, when the patient was in the Intensive Care Unit (ICU) around midnight, a chest X-ray to check the correct position of the central venous catheter revealed a massive hemothorax (), while the patient was hypotensive and responder to crystalloids and blood infusions. A chest drain was inserted without any substantial output but a small amount of clotted blood. The patient rapidly worsened, despite appropriate resuscitation with 10 U of PRBC, 8 U of Fresh Frozen Plasma (FFP), 3 U of cryoprecipitate and 1 U of platelets from apheresis. A second chest X-Ray to check tube position revealed a tension hemothorax (). The team in charge of the patient, comprising the anesthesiologist that did the general anaesthesia for the surgical procedure, made the diagnosis of suspected subclavian artery perforation and tension hemothorax with both hypovolemic and obstructive shock. The team decided to bring the patient in the hybrid room to control the likely bleeding for the right subclavian artery. While the patient has been positioning on the angiographic table, the ECG monitor showed severe bradycardia, with a heart rate of 30 and an impending cardiac arrest with a systolic blood pressure of 30 mmHg. An emergency"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man with blurred vision in both eyes of one-month duration was referred to the Nara Medical University Hospital on January 19, 2016. His medical history showed that he had undergone cataract surgery on both eyes 7 years earlier, and he had also been diagnosed with chronic hepatitis C and interstitial pneumonia.\nAt his initial examination, his BCVA was 20/20 in both eyes, and his intraocular pressure (IOP) was 19 mmHg OD and 17 mmHg OS. He had + 2 inflammation according to SUN Workshop scale in the anterior chamber of the both eyes but not in the vitreous. Funduscopy showed no remarkable inflammatory findings in the retina and choroid. The inflammation of the anterior chamber in both eyes was resolved by 1% topical prednisolone acetate four times/day.\nTen months after his initial visit, + 2 inflammations in the anterior chamber recurred with small white keratic precipitates, and + 1 inflammations vitreous opacities according to SUN Workshop scale were detected in both eyes. Topical prednisolone and sub-Tenon’s injection of triamcinolone acetonide were administrated for both eyes. These treatments were effective for the left eye but not for the right eye and 2 months after, the inflammation in the anterior chamber increased to + 3 and the opacities in the vitreous got worse to + 4 inflammation in the right eye (Fig. ). His visual acuity in the right eye had decreased to 6/20 at this time. The results of laboratory examinations were essentially normal including blood cell counts, hepatic and renal function, serum levels of ACE, calcium, IL-2, and anti-HIV antibody, thus potential cause of immunosuppression was not detected.\nA masquerade syndrome was suspected because the steroid therapy was not effective for the ocular inflammation. To confirm the diagnosis, 25-gauge microincision vitrectomy was performed and aqueous humor and undiluted vitreous samples were collected. During the operation, fine vitreous opacities were observed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old gravida 6, para 5 mother who is 38-week pregnant from last normal menstrual period has presented to Tercha General Hospital (a rural hospital in Southern Ethiopia). The patient is referred from a health center 60 kms far from this hospital for suspected “big baby” in labor. The patient was an illiterate housewife. In terms of past obstetrics history, all previous deliveries occurred at home vaginally with live birth with no major complication. During the index pregnancy, she had antenatal care visits at a nearby health center without ultrasound examination. She reports that the current pregnancy is heavier than previous ones and associated with significant discomfort than her previous pregnancy experiences. Otherwise, she has no self or family history of twinning in the past.\nExamination shows a stable gravida with normal vital signs. Abdominal examination shows big for date uterus with two cephalic poles in the lower abdomen and positive fetal heartbeat. Standard ultrasound examination confirmed twin pregnancy with both in cephalic presentation and adequate amniotic fluid; single placenta with no visible dividing membrane; fetal heartbeat is visible at two sites and is in a normal range. Upon pelvic examination, the cervix is 8cm dilated with left occiput-anterior position at a station 0. Fetal membrane is ruptured with clear liquor passing. With diagnosis of twin pregnancy (both cephalic presenting), in active phase of first stage of labor patient is admitted to labor ward and management of labor started in the standard way.\nIn the next few hours labor progressed well and the first baby is crowning. Duty midwives are attending the delivery. Subsequently, with maternal effort the head and upper extremities of the first baby are delivered and the remaining part of the fetus is delivered by ‘gentle' traction by the midwives. But after delivery of the whole body, baby 1 remained ‘attached' to the mothers' perineum, though the baby is crying vigorously ()"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-week-old premature boy, with a birthweight of 1280 grams, was intubated with a 2.5 mm endotracheal tube via the nose and ventilated for severe hyaline membrane disease (HMD). After receiving two doses of surfactant, the premature neonate was successfully weaned off ventilation and extubated to nasal continuous positive airway pressure (CPAP). On day 9, his clinical course was complicated by a pulmonary hemorrhage, requiring re-intubation. He was given another dose of surfactant and stabilized on high-frequency oscillation ventilation (HFOV). The chest radiograph showed extensive bilateral pulmonary interstitial emphysema, with the left side more extensively involved in comparison to the right. A hemodynamically significant patent ductus arteriosus was treated by intravenous paracetamol. The baby's condition did not improve, and he was selectively intubated into his right main bronchus. The position of the endotracheal tube was radiologically confirmed, allowing the right lung to be oscillated while the left lung was rested. The baby was nursed on his left side for a period of 36 hours, after which the endotracheal tube was retracted into the trachea and secured in that position. The baby's ventilatory status subsequently improved, allowing for extubation on day 7 after the relapse. On day 28 of life, he presented with severe stridor, requiring re-intubation. Difficulty during intubation suggested that subglottic stenosis might be present. One week after this re-intubation a flexible bronchoscopy was performed, which revealed two major findings. The first was a Cotton grade 2 subglottic stenosis, and the other abnormality was near-complete obstruction of the bronchus intermedius. The subglottic stenosis was dilated to 5 mm with the aid of a balloon dilator (Boston scientific Mustang™ balloon dilatation catheter). The bronchus intermedius was extremely narrow, and a 2.2 mm flexible bronchoscope was not able to pass through the area of stenosis.\nAfter 2 weeks, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45 year old Caucasian woman had a long history of falls due to progressive ataxia since the age of 10. Her birth history and early developmental milestones were unremarkable. She completed secondary school and achieved basic qualification in education but was never good in sport. At age 17, she developed poor night vision and bilateral hearing deficit. She had bilateral cataract surgeries and used hearing aids at age 31. She experienced fatigue but did not complain of overt muscle weakness. She developed moderately heavy proteinuria (Albumin to creatinine ratio 152) but with normal serum albumin level since age 43.\nHer mother has glucose intolerance and her father has sensorineural deafness. There was no family history of neurological disorder, eye problem, or cardiomyopathy. All her siblings are fit and well, and as such did not request molecular genetic testing.\nHer resting blood lactate level was normal and creatine kinase (CK) level was 276 U/L. There was no glucose intolerance. Her renal function declined gradually and the current urea and creatinine levels were 11 mmol/L and 97 µmol/L, respectively (compared to 5 mmol/L and 88 µmol/L 8 years ago). Renal ultrasound demonstrated loss of cortico-medullary differentiation, increased echogenicity and asymmetrical kidney size (left kidney measured 7.9 cm, right kidney 10.2 cm). Nerve conduction studies were normal at age 28. Her initial CT head and cranial MRI showed bilateral basal ganglia calcification, periventricular white matter changes and cerebral and cerebellar atrophy ().\nClinical examination (at age 43) revealed pigmentary retinopathy, deafness, bilateral pes cavus, areflexia in the lower limbs, mild myopathy with MRC grade 4+/5, cerebellar signs, loss of proprioception sense and vibration sense in the lower limbs and broad-based gait.\nShe was admitted to hospital with left sided weakness and loss of mobility at age 44. The neurological deficit evolved over 12 hours. There was no associated speech distur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn August 2015, following a maxilla-facial trauma, a 10-year-old boy patient was admitted at the maxilla-facial department. The patient had no general health problems, was not taking any treatment, had no allergies and was not subjected to passive smoking. The young patient had a significant dental Class II malocclusion (Angle classification) due to skeletal Class II mandibular etiology (Ballard classification). Clinical and radiological examination revealed a complete extrusive luxation of 11 and 21 and intrusive luxation of 12 and 22. Practitioners decided to place a Dautrey arch. Two weeks later, the patient came to the dental emergency due to injuries caused by the Dautrey arch (). Three months later, after removing Dautrey arch, a multi-attach treatment combined with Powerscop was put in place (). Following the beginning of his orthodontic treatment, in December 2015, the patient’s attending dentist performed the endodontic treatment of 11 and 21, after the occurrence of root resorption consecutive to the absence of endodontic treatment immediately after the trauma. The patient was then referred to the endodontic department 3 years after trauma. The first treatment phase is described in and , , , , and .\nIn February 2020, following the avulsion of the tooth 12, clinical and radiographic examination revealed a bone deficiency in the buccal area. The cephalometric analysis from October 2019 showed that the patient was in his pubertal growth spurt []. Combined with the patient’s young age and his incomplete growth, this contraindicated the placement of conventional diameter implants. Another option for managing this clinical case was to maintain the gap between 13 and 23 by placing a removable prosthesis. However, there is some risk of blocking the jaw’s growth, as well as a lack of acceptance of the device. The patient chose not to have a removable prosthesis. The patient wanted a fixed, comfortable and esthetic solution. Bone capital had to be preserved for impl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().\nAfter resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.\nThe patient ha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 60-year-old Sinhalese man from a rural area of central Sri Lanka who presented to a teaching hospital with on-and-off fever of 4 months’ duration and pain in the lateral aspect of the right upper thigh of 2 months’ duration. He had been admitted to a local hospital 3 weeks prior to admission to our hospital with a history of nearly 3 months of on-and-off fever and a painful lump at the lateral aspect of the thigh. He had been treated for multilobar pneumonia at the local health facility with intravenous meropenem and teicoplanin for 14 days, and he required intensive care unit management during the course of his illness. Although his pain and the size of the lump at the lateral aspect of the thigh decreased with treatment, the lump and pain over the area persisted even after he was discharged from the local hospital. Further, he experienced on-and-off fever again, though he was afebrile upon discharge from the local hospital. With time, he experienced difficulty in walking with increasing severity of pain in the lateral aspect of the right upper thigh, for which he sought medical advice. On admission to our hospital, he had high-grade fever, and he denied any respiratory or urinary symptoms. His bowel motions were normal with normal color and contour. He was a farmer and had a history of exposure to surface water. He was a nonsmoker and never used alcohol. He was diagnosed for the past 8 years with type 2 diabetes mellitus, which was treated with oral hypoglycemic drugs. He was not receiving any medication other than oral hypoglycemic drugs, and he denied recent use of steroids. He did not have any high-risk behaviors.\nOn examination, he was febrile (102 °F) and mildly pale but not icteric. He did not have enlarged peripheral lymph nodes or skin rashes. He had a small induration over the lateral aspect of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old man was admitted to our institution with a five-month history of a painful enlarging mass at the right popliteal fossa and calf. There was no history of trauma. His past medical history was unremarkable. He had undergone a primary total knee arthroplasty of his right knee seven years previously for degenerative knee osteoarthritis.\nClinical examination showed painful restriction of the range of motion of the right knee, and a palpable mass at the posterior-medial aspect of the knee (Figure ). The calf was slightly painful during palpation and passive stretching.\nPlain radiographs of the right knee showed narrowing of the medial compartment, varus deformity of the arthroplasty, and features of loosening including radiolucent lines next to the femoral and tibial components. Some degree of polyethylene wear, especially in the medial compartment, was suspected (Figure ). Magnetic resonance imaging of the right knee showed a cystic lesion located at the postero-medial aspect of the knee joint mimicking a popliteal cyst or soft tissue sarcoma (Figure ). Plain radiographs of the chest were normal. A routine laboratory examination including complete blood cell count, serum chemistries, erythrocyte sedimentation rate and C-reactive protein reported values within normal ranges. Triplex ultrasonography showed no evidence of deep venous thrombosis.\nFine needle aspiration biopsy was carried out, but it was non-diagnostic. A core-needle biopsy revealed a black fluid containing thick, amorphous metallic debris and fragments of broken polyethylene. Histological sections showed necrobiotic tissue, wear debris and metallic particles, fibroblasts, osteoblasts, histiocytes and multinucleated giant cells. Nucleous atypia and mitotic features were not observed. Gram stain and cultures were negative for infection.\nRevision knee surgery showed massive metallosis, osteolysis of the distal femur and the proximal tibia and extensive polyethylene wear and deformation distributed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old Caucasian female was diagnosed with acetylcholine receptor antibody positive oculo-bulbar myasthenia gravis nine months ago. Her initial presenting symptoms were drooping eyelids, double vision and difficulty swallowing with diurnal variation and characteristic fluctuation of symptoms. She initially failed her bedside swallow evaluation with notable aspiration to thin liquids on modified barium swallow (MBS). She underwent plasmapheresis with complete resolution of symptoms following IVIG as her swallowing functions didn’t improve with the latter. Eventually patient’s repetitive nerve stimulation study and antibody titers confirmed the diagnosis of postsynaptic neuromuscular junction disorder. Prior to discharge patient was started on pyridostigmine 60 mg 4 times daily, gradually up-titrated dose of prednisone 30 mg daily and mycophenolate 1000 milligrams twice daily. Her past medical history included generalized anxiety disorder and allergic rhinitis for which she continued to follow with her primary physician at discharge.\nDuring her routine neurology clinic follow-up patient was noted to have recurrence of drooping eyelids and change in voice with concerns of impending myasthenia exacerbation. As she responded very well to plasmapheresis compared to IVIG, she was started on regular plasma exchange, 3 exchanges every 4 weeks. She continued to take rest of her medications including prednisone 30 mg daily and mycophenolate 1000 milligrams twice daily. Patient’s CT chest showed 6.7 cm lobulated soft tissue mass in anterior mediastinum with no local invasion, consistent with thymoma or thymic carcinoma. She was referred to cardiothoracic surgery for possible thymectomy (which had been put on hold due to patient request).\nFour weeks ago, patient presented to emergency department (ED) with fever, chills, cough with minimal clear sputum production, exertional shortness of breath, decreased sense of taste and smell, decreased appetite going on for the past 5"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 14-year-old female presented to the office with sharp, generalized abdominal pain and dark brown urine since the previous night. Additionally, the patient noticed that her whole body ached after running for two hours that same day. She was afebrile and had a cough and runny nose for the past three days. All of these symptoms were not preceded by trauma or Streptococcus infection within the past month. Her last menstrual period was 20 days earlier.\nOn observation, the patient looked well. All vital signs were normal. Physical examination findings were unremarkable (non-tender abdomen, no edema noted on extremities). Urine sampling demonstrated light yellow clear urine. A urine dipstick was not performed because it was unavailable in the office. Consequently, the patient was advised to call the office or go to the emergency room should she have the reemergence of abdominal pain or brown urine. Shockingly, the office was notified that the patient had been admitted to a hospital with acute renal failure the following day. She was in the hospital for three days before finally being discharged home to be followed up by the renal clinic.\nFour months later, the patient presented to the office with diffuse back pain of one day's duration. The pain did not radiate anywhere. She also presented with chest pain that had been going on for five months. The pain occurred mainly in the left lower breast area, and it typically increased with inspiration. It occurred roughly one to three times per week and, along with a cough, was associated with recreational sports. The patient stated that the last time she had any chest pain was the previous week. An electrocardiogram (EKG) taken four months earlier was unremarkable. She denied any palpitations, nausea, vomiting, and any dizziness during exercise or rest. Upon further questioning, it was discovered that her throat had felt ‘tight’ for the past year when running, and she often tried"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 60-year-old man who was the husband of the patient described above. He experienced lumbago on the same morning his wife was hospitalized. Fever and disturbance of consciousness occurred in the evening, and he visited the emergency room at another hospital. He had completed the course of neoadjuvant and adjuvant chemotherapy and radiation for glioblastoma 6 years ago, and was able to carry out his daily activities independently. He had no medical history of pneumonia or a history of pneumococcal vaccination. Although right lumbar pain was observed, the origin of fever was unknown; antimicrobial treatment was initiated with 4.5 g piperazine/tazobactam every 8 h. The results of the blood test taken at hospitalization are shown in Table . Pneumococcus was detected in his blood culture as well, and the regimen was changed to 2 g ABPC every 6 h. There were abnormal findings in the lumbar MRI scan taken on hospital day 2. Nonetheless, the results of the spinal fluid test, head MRI, thoracoabdominal contrast CT, transesophageal echocardiography, did not reveal presence of infection at other sites. Because lumbago persisted, MRI was performed again on hospital day 9; the consequent MRI results revealed purulent spondylitis (Fig. ). The patient was transferred to our hospital on hospital day 9. To normalize white blood cell count, CRP level, and blood sedimentation rate and to improve CT findings, antimicrobial drug treatment was carried out for a total of 9 weeks.\nBoth patients tolerated the antimicrobial treatment well, and recovered completely. A 13-valent pneumococcal conjugate vaccine was administered initially, and a 23-valent pneumococcal polysaccharide vaccine was administered 1 year later in both patients. More than 1 year has elapsed since the completion of treatment, and there has been no recurrence.\nIn the bacterial strain analysis (Table ) performed on the samples from both patients, the capsule serotype was 12F identified by the capsule quellin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female patient who had no specific medical history visited the hospital with facial asymmetry (chin deviation to the right side), limitation of mouth opening, and jaw pain that had persisted for two years. The clinical examination showed limitation of mouth opening (approximately 20 mm) along with TMJ pain on the left side and deviation of chin top to the right side. The radiography and computed tomography showed signs of considerable osseous proliferation extended to the cranial base and multiple radiopaque lesions suspected as phlebolith.() The initial diagnosis was osteochondroma on the left condyle. She underwent condylectomy, and her chin top--which deviated to the right side--was also reduced to the midsagittal plane. Active physical therapy was conducted, and clinical favorable mouth opening (approximately 32 mm) was finally achieved in four months.() Two years after surgery, however, she complained of limitation of mouth opening and discomfort of mastication. The X-ray revealed trauma from occlusion (TFO) in the maxillary molar area on the ipsilateral side as well as progressive osteoarthritis on the previous resection area. Total TMJ replacement using stock prosthesis on the ipsilateral joint was finally planned.\nStock TMJ prosthesis consists of fossa and condylar components, each of which requiring preauricular and retromandibular approaches. After condylectomy was performed to secure spaces for prosthesis via the preauricular approach, retromandibular incision was conducted. Bone trimming of uneven surface on articular eminence was followed by the installation of fossa component, and subsequent positioning of the condylar component was accomplished. After the optimal occlusion of the patient was maintained, fixation of the mandibular component was done with titanium screw.() Since the TMJ replacement, the patient had not suffered from remarkable postoperative complications including ipsilateral facial nerve weakness, paresthesia, pain, and d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Caucasian, 27-year-old female was being followed up during her second pregnancy. Her past medical and obstetric history was unremarkable. This was her second pregnancy; her older child from the first pregnancy was well. There was no family history of renal diseases or congenital abnormalities. She was not on treatment with any medications. A dating ultrasound scan was performed at 15 weeks of gestation showing a single live foetus.\nThe pregnancy advanced uneventfully. The anomaly ultrasound scan at 20+2 weeks of gestation showed evidence of duplex right kidney with dilatation of the upper moiety. The ultrasound scan was repeated at 23+6 weeks of gestation with the same findings. The dilatation of the upper moiety was measured at 10.8 mm. The right kidney was in normal position and there was satisfactory parenchymal differentiation. The left kidney, the ureters, and the bladder appeared normal. The amniotic fluid index was normal throughout the pregnancy. A follow-up scan at 32+1 weeks of gestation showed the right duplex kidney with resolution of the dilatation previously seen. The foetal growth was optimal. No other abnormalities were detected in the antenatal scans.\nShe delivered a male infant via normal vaginal delivery at 39+2 weeks of gestation. The infant was born in good condition without any perinatal complications. An ultrasound scan () was performed at 12 days of age. This scan showed features consistent with an uncomplicated right duplex kidney measuring 6.1 cm. The left kidney had a single collecting system and was measuring 5.2 cm. Both kidneys were visualised within the renal fossae and had normal parenchymal differentiation. There was no pelvic dilatation and the ureters were not visible in either of the kidneys. The bladder looked normal. Clinically, the infant was asymptomatic with normal blood pressure and renal function. There were no other evident congenital abnormalities.\nThe infant had a follow-up ultrasound scan at 3.5 months of age. During"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female with a past history of endocarditis status post mitral prosthetic valve repair an year ago and continued intravenous drug use presented to the emergency department with altered mental status. On initial arrival, the patient was found to be hypotensive with systolic blood pressures of 50 mmHg and 60 mmHg, a heart rate of 110 beats per minute, a temperature of 38.1 degree Celsius with mild respiratory distress, and an oxygen saturation of 95% on room air. There was difficulty in establishing vascular access due to severe vasoconstriction (increased peripheral vascular resistance from shock); however, ultrasound-guided vascular access was ultimately established. The 12-lead electrocardiogram showed ST-segment elevations in high lateral leads, and cardiac catheterization lab was activated immediately after loading aspirin, clopidogrel, and statin therapeutic heparin drip. On left heart catheterization (LHC), she was found to have an embolus lodged in her left main coronary artery which was removed. When flow was restored, an intra-aortic balloon pump (IABP) was placed due to severe refractory hypotension despite inotrope and vasopressor support with dobutamine and norepinephrine, respectively. However, the patient continued to experience ventricular arrhythmias on the monitor and on electrocardiogram (Figure ).\nA tentative diagnosis of severe mixed shock (cardiogenic and septic) was made with the source suspected to be a probable prosthetic valve endocarditis (PVE) due to continued drug use. The patient was started on broad-spectrum antibiotics in addition to hemodynamic support. Due to worsening hypoxia and respiratory distress, she was intubated and mechanically ventilated. Her chest x-ray showed worsening bilateral pulmonary infiltrates (Figure ).\nA transthoracic echocardiogram revealed severely depressed right and left ventricular function with mitral and aortic stenosis but with no obvious vegetations on the valves including the prosthetic mitr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old man was admitted to our department with the diagnosis of an adenocarcinoma of the gastroesophageal junction. Preoperative staging was negative for distant metastases. Endoscopic ultrasound findings confirmed the presence of a locally advanced tumor (type I – Siewert classification). It was an adenocarcinoma of the distal esophagus arising from an area with intestinal metaplasia and infiltrating the esophagogastric junction from above. As a consequence preoperative synchronous chemoradiotherapy was proposed. The scheme was consisted of fluorouracil (15 mg/kg of body weight) daily for five days and cisplatin (75 mg/m2 of body surface area) on day 7 and a course of radiotherapy (40 Gy administered in 15 fractions, anterior-posterior mediastinal fields) over a a three week period, beginning concurrently with the first course of chemotherapy. After the completion of chemoradiotherapy, the stage of the disease was reevaluated (CT scans of the abdomen, chest, pelvis, upper gastrointestinal endoscopy and ultrasound). Restaging was completed with no evidence of distant disease and surgical removal of the primary tumor and lymphadenectomy was proposed. The patient was eligible for an Ivor Lewis esophagogastrectomy.\nHe was intubated with a left-sided 37-F double-lumen endotracheal tube by a specialist anesthesiologist experienced in cardiothoracic surgery anesthesia. The technique includes the following points. The tube was held with the bronchial curve concave anteriorly. As the tip was passed through the larynx, the tube was rotated 90 degrees to direct the endobronchial part to the intended side. The tube was then connected to the breathing circuit via a double catheter mount.\nThe abdominal part of the operation was uneventful. During the second phase and while the intrathoracic esophagus was being mobilized a hissing noise was heard and a careful inspection revealed part of the double-lumen tube and the inflated tracheal cuff protruding through the ruptured m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year old female with a history of coronary artery disease, hypertension, and thrombocytosis suffered a witnessed trip and fall onto a nightstand. The patient took 75 mg of clopidogrel daily in addition to an 81 mg aspirin tablet. She reported a mild headache however had no change from her baseline mentation per family members with no evidence of obvious injury aside from a small area of ecchymosis near a small forehead laceration. She remained up and ambulatory with no further complaints. Ten hours after her injury the patient presented to the Emergency Department with stridorous and agonal respirations with a profoundly decreased level of consciousness. She was noted to have developed extensive ecchymosis on the anterior portion of her neck and chest. Her symptoms had begun rapidly shortly prior to arrival while lying in bed. Family reported that she had been in the constant company of her husband with no further falls or injuries that had occurred since her fall. The patient was intubated upon hospital arrival due to respiratory extremis with obvious swelling and crepitus noted on neck examination. A noncontrast CT scan of head was unremarkable while there was demonstration of a large retropharyngeal hematoma measuring 3.6 cm by 5.3 cm by 20 cm on a CT of the cervical spine with no evidence of fracture. Her hemoglobin was 9.5 gm/dL and platelets were 1234 per deciliter, with an INR of 3 and a slightly below normal and activated partial thromboplastin time of 23.9 seconds (reference range 25-35 seconds). A CT angiogram of the neck was subsequently obtained demonstrating active bleeding from the anterior ligaments of the vertebral column that was not felt to be amenable to embolization (). Given the extent of the hematoma intraoral surgical evacuation was performed with bleeding from the anterior vertebral spine controlled with Bovie cauterization, placement of topical thrombin, and drain placement. No reaccumulation of hematoma was noted during her hospital c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old male presented to a Level 1 Emergency Department as a transfer after a traumatic injury to the right eye. The patient reported that he was repairing farming equipment when a pair of pliers slipped and hit him in the right eye. He reported experiencing complete vision loss in the right eye for several minutes. At time of ophthalmic examination, 8 h from time of injury, patient reported that although his vision had slowly returned and was back to normal in the upper portion of his visual field, the lower portion remained “darker and hazy.”\nExternal examination was significant for pronounced periorbital ecchymosis and edema on the right. Ocular examination revealed a VA of 20/40 on the right and 20/25 on the left on Snellen chart. 10/11 plates were identified in the right eye and 11/11 in the left via Ishihara subjective color testing. Confrontational visual field revealed depression in the inferior quadrants in the right eye. Intraocular pressure was 16 mm Hg in the right eye and 11 mm Hg in the left. Pupil examination was significant for a 2+ rAPD in the right eye. Motility examination in the right eye revealed 30% restriction of ocular movements in all fields of gaze. Slit lamp and dilated fundus examination of both eyes revealed scattered subconjunctival hemorrhage of the right eye but otherwise was unremarkable with no retinal or disc edema on fundoscopic exam. The patient did not have macular or retinal nerve fiber OCT or fundus photography at presentation.\nAn initial noncontrast CT scan at an outside hospital showed retrobulbar hemorrhage with mild proptosis (shown in Fig. ). A repeat CT scan performed 7 h later revealed a stable hematoma surrounding the optic nerve within the optic nerve sheath with surrounding fat stranding and a superior orbital rim fracture with a fragment displaced into the orbit. Based on clinical and imaging findings, a diagnosis of ONSH secondary"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 53-year-old female with no significant past medical history who presented back to the hospital with similar complaints of chest pain. The family and social history were noncontributory. Electrocardiography (EKG) showed normal sinus rhythm with no ischemic changes (). On previous admission, the patient had presented with new-onset chest pain that was sudden, constant, and severe, with fever and leukocytosis. The patient was deemed at that time to have a viral illness in addition to costochondritis and was discharged on cyclobenzaprine as well as a nonsteroidal anti-inflammatory (ibuprofen).\nThe patient’s chest pain did not improve, and she returned after the initial admission to the hospital. The blood cultures from the previous admission came back positive for Staphylococcus aureus. The patient had, at the previous admission, originally presented with leukocytosis at 19,000 white blood cells per mL and with fever as high as 102°F (39°C) that had both immediately trended down. Low-grade fever was also present on this admission without leukocytosis. The patient did have some days on which her heart rate was above 90 beats per minute and respirations were occasionally over 20, thus septic by criteria.\nThe Infectious Disease service was contacted for management of infection and recommended to repeat blood cultures to confirm no further growth of the organism after administration of antibiotics for 48 hours. The patient was also switched to intravenous (IV) ceftriaxone 2 g daily from IV vancomycin 1,250 mg twice daily, as the Staphylococcus bacteria were sensitive to ceftriaxone and resistant to penicillins. With the presentation of chest pain in addition to mild murmur, fever, and bacteremia, it was thought the patient may have some suggestion of endocarditis, and a transthoracic echocardiogram was performed. The patient had normal ejection fraction and only trivial regurgitation of valves, except for the mitral valve, which showed mild regurgitation."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old male with chronic pulmonary and cardiac conditions developed blood per rectum and a change in stool caliber which lead to workup with colonoscopy. This demonstrated a 4 cm proximal anal canal lesion with biopsy identifying invasive poorly differentiated squamous cell carcinoma. Staging CT of the brain, chest, abdomen, and pelvis demonstrated an isolated hepatic metastasis as the only distant site of disease (). The patient was treated with chemoradiotherapy including 5-FU, Cisplatin, and 50.4 Gy radiation followed by further Cisplatin-based systemic therapy. Twelve weeks after completion of chemoradiotherapy, anoscopy demonstrated complete resolution of the anal canal lesion with a remaining scar that was biopsied and was negative for carcinoma. Additionally, imaging of the liver revealed reduction in the size of the hepatic metastasis. However, 6 months later, surveillance anoscopy and imaging revealed recurrence of the anal canal primary and enlargement of the hepatic metastasis with biopsies of both demonstrating SCC. The anal lesion was increasingly symptomatic causing pain, tenesmus, and bleeding. Repeated imaging of the brain, chest, abdomen, and pelvis confirmed that the disease was still isolated to the liver and anal canal; therefore, synchronous abdominoperineal and liver resection were undertaken. Pathologic analysis revealed that the primary was 5.7 cm and was associated with negative lymph nodes, proximal, distal, and radial margins, and the hepatic metastasis was 6.1 cm and also had negative resection margins ().\nDespite having an uneventful postoperative course, three months after surgery, the patient presented with blurry vision and right eyelid ptosis. CT of the head and MRI of the brain demonstrated a 4 cm intracranial mass eroding the sphenoid and temporal bones, and an involvement of the left orbit, optic nerve, and rectus muscle (). Biopsy demonstrated metastatic SCC identical to the anal and hepatic lesions (). At this point stere"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old man was referred to our hospital in 2019 with a complaint of a painless mass in the left palate. The patient was aware of the swelling in his right palate for approximately 2 years. However, he noticed a recent and rapid increase in the swelling. Hence, the patient initially consulted a general dental practitioner, where a diagnosis of a tumor of the palate was established. The patient was subsequently referred to our department. His medical history revealed febrile seizures at the age of 1 year, and his family history was unremarkable. On initial assessment, no systemic symptoms were observed. An extra-oral examination revealed facial symmetry. No swollen cervical lymph nodes were palpable bilaterally. Intraoral examination revealed a dome-shaped mass measuring 4.0 × 3.0 cm on the left side of the hard palate, extending anteriorly to the distal first premolar area and posteriorly to the soft palate. The mucosal surface of the mass was smooth, but partially ulcerated (Figure ). On palpation, the mass was elastic hard in consistency. Panoramic radiography revealed opacity of the left maxillary sinus with an impacted tooth and the level of the left maxillary sinus floor was lower than that on the right side (Figure ). Computed tomography (CT) revealed a well-demarcated multilocular-appearing expansile radiolucent lesion in the left maxillary sinus with an impacted tooth in the posterior wall (Figure ). Magnetic resonance imaging revealed a nonhomogeneous, mildly enhancing lesion in the left hard palate and alveolar process, along with a highly enhancing homogeneous lesion in the left maxillary sinus (Figure ). CT of the neck revealed no enlarged bilateral lymph nodes, and CT of the abdominal and thoracic regions revealed no other specific findings.\nIncisional biopsy of the palate revealed the epithelium comprising primarily squamous epithelial cells and the focal presence of clear cells and ghost cells along with the presence of calcifications, which su"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. In 2005, he had been admitted to the Department of Endocrinology because of cold sweating, facial flushing, and uncontrolled blood pressure. A ~7 cm right adrenal mass had been observed on computed tomography (CT) and there had been no distant metastasis on an MIBG scan. The patient had undergone laparoscopic right adrenalectomy due to PCC. After surgery, he had been followed up in the outpatient clinic until 2007. During that period, there was no evidence of metastasis in abdominal CT. The patient had also been treated for hypertension and type 2 diabetes mellitus for 3 years and had a history of coronary stent insertion for non-ST-elevation myocardial infarction in March 2012. At admission to the Department of Gastroenterology, he experienced dizziness, diaphoresis, general weakness, and poor oral intake; his blood pressure was 130/80 mm Hg and his heart rate was 78 bpm. Contrast-enhanced abdominal CT and magnetic resonance imaging (MRI) were performed. They revealed a ~10 cm hepatic mass in the right lobe of the liver that had a high signal intensity on T2-weighted images and early arterial enhancement and delayed washout on dynamic contrast-enhanced images. Also, it had a low signal intensity on the hepatobiliary phase and high cellularity on the diffusion phase (). The hepatic mass was considered to be hepatocellular carcinoma rather than malignant PCC. For these reasons, liver biopsy was performed to evaluate the incidental hepatic mass. The patient was given the α-adrenergic antagonist phenoxybenzamine to prevent a hypertensive crisis before biopsy because we could not completely rule out the possibility of metastatic PCC. However, during and after the liver biopsy, his vital signs were stable. PCC was finally confirmed on the basis of morphological and immunohistochemical findings, with the specimens staining positive for chromogr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 60 year-old male smoker with a history of chronic obstructive pulmonary disease (COPD) who presented with a two-week history of increasing shortness of breath and occasional wheezing. Review of systems was otherwise negative. Past medical history was remarkable for mild COPD, but the patient had otherwise been free of health problems. Physical examination of the chest revealed clear lung sounds bilaterally, and no other abnormal physical findings were evident. Chest x-ray demonstrated a right pneumothorax, and a subsequent CT scan confirmed a right pneumothorax (less than 10% of lung volume), a small right pleural effusion, and two large blebs in the right lung. No mass lesions were apparent. A nuclear medicine lung perfusion and ventilation scan showed retention of radiotracer consistent with COPD and heterogeneous patchy areas of perfusion, most likely related to air-trapping. It was decided to procede with surgical exploration and possible excision of the patient's emphysematous blebs. A right mini-thoracotomy was performed, and a large bleb was readily identified within the anterior chest, which was resected. A separate aarea of possible abscess was noted in the right apex, which on dissection by the surgeon contained yellow viscous fluid. Otherwise, no mass lesions or findings suspicious for carcinoma were encountered.\nHistologic examination of the patient's bullous resection revealed emphysematous changes and mild subpleural fibrosis. Additionally, multiple glandular structures were noted within the pleural tissue (Figure ). These structures were composed of plump epithelioid cells with mild nuclear enlargement, fine chromatin, and inconspicuous nucleoli. No mitotic activity was evident. The glands were surrounded by fibrovascular tissue and showed no evidence of vascular or lymphatic invasion. The majority consisted of irregular small acinar structures, and there was no evidence of cribriforming or formation of solid structures. Immun"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old nonverbal female presented to the emergency department (ED) from home with her daughter who had noted that the patient has been acutely grimacing in pain from even the lightest palpation over her right flank. She had decreased urine output for the prior two days and her family had noticed an enlargement on the right side of her back one day prior to her ED visit. Of note, the patient presented with poor functional status, was totally bedridden, and was on no antibiotics. She also had a renal flow scan several months prior to her presentation, which revealed the absence of blood flow to the left kidney. A nephrectomy was ultimately rejected based on her medical history and current health status. The patient's medical history was significant for CVA with left hemiparesis, sacral stage 4 pressure ulcers, DM, HLD, failure to thrive, and asthma. Her past surgical history included a left double J-stent placement, an appendectomy, and a tracheostomy that was reversed.\nOn physical examination, the patient appeared to be in mild distress with a blood pressure of 93/50, heart rate of 116, and otherwise normal vital signs. Abdominal examination was remarkable for tenderness to palpation over the right flank with visible erythematous skin seen in the same area. Results of the initial laboratory tests were significant for a lactate of 2.9, white blood cell count of 18.4, hemoglobin of 7.1, platelet count of 933, albumin of 2.3, and potassium of 5.8, yet with a creatinine of 0.62. She underwent an IV contrast computed tomography (CT) scan of the abdomen and pelvis, which revealed a right hydronephrotic kidney that contained numerous large calcifications (Figures and ). The right previously placed ureteral stent was in satisfactory position. There was an extremely large fluid collection in the right retroperitoneum extending into the right flank consistent with leakage of urine from the obstructed right kidney ().\nWhile, in the ED, urolog"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman (G4,P2), at the 15th gestational week of twin-pregnancy following IVF-embryo transfer, was found to have a solid adrenal mass on a regular checkup. MRI revealed a 11×7.5 cm right suprarenal hypervascular mass with mixed signal intensity in T2-weighted images (). The diagnosis of PC was confirmed by laboratory analysis (). The patient had no genetic testing and her family history was not indicative of any hereditary disease. She had two previous vaginal deliveries (14 and 11 years ago) and a history of one abortus at 10-week gestation two years earlier. The patient confirmed that she had no symptoms relating to PC in her previous deliveries. She had no genetic testing and her family history was not indicative of hereditary disease. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. Perinatological ultrasonography revealed normal morphology of dichorionic and diamniotic male and female fetuses.\nA multidisciplinary team consisting of urologists, anesthesiologists, endocrinologist, and obstetricians focused on the therapeutic approach. The patient did not receive any medical treatment for alpha or beta blockade preoperatively. She underwent laparotomy with a subcostal incision and transperitoneal tumor resection at 17 weeks of gestation (). During surgery blood pressure (BP) was stabilized with phentolamine and esmolol, with occasional bouts of brief hypertensive periods up to 240 mm Hg systolic pressure. A hypervascular mass with fragile large veins was dissected free of the upper pole of the right kidney, between the vena cava and the lower border of the liver. The estimated blood loss was 1100 ml. The patient was transfused with 3 units of erythrocyte suspensions. The postoperative period was uneventful and she remained hemodynamically stable. Histopathological examinations were in accordance with a PC.\nShe had a norma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the clinical case of a 29-year-old male patient treated at the Instituto Nacional de Cancerología of Colombia with a diagnosis of chronic myelogenous leukemia (CML) in high-risk chronic phase since February 2010. He started treatment with imatinib at a dose of 400 mg, obtaining a hematological response in the second month but not achieving a cytogenetic response in the 18th month. At that time, the patient continued treatment in another institution. It was possible to elucidate that the patient had a change of his treatment to dasatinib in March 2013 with the previous verification of the lack of cytogenetic response documenting a level of BCR-ABL transcription of 6.3%, period after which the patient, unfortunately, lasted eight months without treatment due to assurance problems. In September 2016, a BCR-ABL transcription level of 58% was documented, without a real knowledge about how much time he had taken dasatinib continuously at the moment of BCR/ABL evaluation; then, nilotinib treatment was begun.\nThe patient was readmitted to our institution in March 2017 and we diagnosed a progression to blast crisis of myeloid origin with a bone marrow study that documented 72% of blasts with karyotype without the growth of metaphases, being also very striking, the concomitant infiltrative cutaneous involvement, bone lesions of lytic type and hypercalcemia that required the use of zoledronic acid as an oncological emergency (Figure ).\nAt the end of the induction with 7 + 3 (seven days of cytarabine and three days of idarubicin) chemotherapy associated with bosutinib for 14 days and after several infectious complications, including invasive fungal infection and bacteremia due to Enterococcus faecium, as well as symptomatic hypocalcemia because of bisphosphonates, it was documented a percentage of blasts by flow cytometry of 29% in bone marrow and the existence of 46% of cells with basophilic versus mast cell characteristics on day 28 at the end of induction (Figures"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old boy sprained his left ankle by forced inversion while playing soccer. He and his mother were referred to our clinic 2 days after the injury. No issues were noted in his family history, developmental history, or psychological conditions. He was a right-handed active Japanese boy with normal physical development, 140 cm tall, weighing 31 kg. He suffered from the same left ankle sprain 3 months before the present injury, although he recovered completely within a few days at that time.\nAt the first visit, he could walk using his left foot, reporting pain in the lateral aspect of the ankle during motion at an intensity of 85 mm on a 100 mm VAS. X-ray images showed no abnormal changes in the ankle joint or surrounding bones. An analgesic poultice was prescribed and he was allowed to walk with the diagnosis of a grade-1 ankle sprain. Running, sports, and physical activity were prohibited and the patient was requested to revisit 1 week later. Two days after the first examination the patient visited again, reporting increasing pain with a 94 mm VAS score. The painful area had expanded to the entire foot. He could not bear weight on his left foot with allodynia and hyperpathia in the sole. These were obviously unusual signs for a grade-1 ankle sprain. A supporting band was worn and non-weight-bearing ambulation using a pair of crutches was instructed by a physical therapist. Oral acetaminophen (400 mg/day) was prescribed, but was ineffective. On the fifth day, VAS score increased to 100 mm both in motion and at rest. Intense allodynia and mild edema were observed in the entire foot. The patient reported difficulty standing on his left foot because of fear of evoking pain induced by touching his foot on the floor. Subcutaneous bleeding suggestive of underlying ligamentous ruptures was not seen anywhere in the foot. CT performed to detect deep injuries, such as bone contusions, revealed normal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old Caucasian man suffered from a distortion of his right ankle seven months prior to presentation. The incident happened when he was at work. Due to persisting pain in his joint he first saw a general practitioner. An X-ray image of the patient's right ankle showed no pathological findings. The joint was immobilized for six weeks in a plaster cast, which was then followed by physical therapy. Six months after the therapy, however, the patient still suffered pain in his ankle with no sign of any improvement. A magnetic resonance imaging (MRI) scan revealed an unknown but well-circumscribed localized tumor at the ventral part of the ankle, coupled with focal bulging and erosion of the tibia and talus (Figure ). The MRI detected no damage to the fibular collateral ligaments. On examination, about thirteen months after trauma of the ankle, tenderness to pressure was found at the ventral aspect of the right ankle next to the medial malleolus. A dorsal extension of the ankle was very painful. The collateral ligaments showed no insufficiency and a new X-ray still did not show any conspicuous findings. An ultrasound investigation showed a solid, homogeneous hypoechoic mass measuring 3.5 × 2.5 × 2 cm. It was not clear whether the tumor was directly connected to the joint. An impingement syndrome of the right ankle caused by a synovial hypertrophy was diagnosed preoperatively.\nThe tumor was resected through a ventral access. A brownish yellow tumor that was mainly solid was found during surgery. The tumor showed adhesions to the capsular of the patient's ankle and the complete tumor was treated with marginal resection (Figure ). A small hypertrophy of the cartilage below the tumor was also removed. However, the complete cartilage of the joint was not damaged.\nMicroscopically, the tumor was partially encapsulated and composed of round to polygonal cells. Some were spindle cells and some were multinucleated giant cells (Figure ). The diagnosis of localized tenosynovi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old male presented with a complaint of swelling on both sides of the groin for the past 40 years and left groin pain for 1 month. The pain reduced when the patient was in the supine position. The patient had undergone bilateral inguinal hernia suture repair 50 years ago. He had no sexual dysfunction and was fertile; he was married with three sons. On physical examination, a swelling of approximately 10 cm in diameter was found in the left groin extending into the left scrotum and a swelling of approximately 3 cm in diameter was found in the right groin. The swelling was reducible on both sides. Laboratory data were normal. Computed tomography showed a herniation in the left groin, but not in the right. The hernia contents seemed to be the intestinal tract and solid tissue considered the omentum (Fig. ).\nAfter confirming the patient's fitness to undergo anesthesia, surgery was planned. TAPP was performed. There was a fibrous structure linking the left and right hernia orifice and a muscular structure in the hernia sac on the left (Fig. A). It was difficult to separate the peritoneal cavity and the structure of the fiber and muscle. The muscular structure was continuous in the pelvic cavity and adherent (Fig. B). We consulted a pediatric urologist and noticed that the muscular structure was a vagina and fibrous structure was a salpinx, and we diagnosed the patient with PMDS (Fig. C). We explained it to patient family and it was decided to resect a vagina and a salpinx for hernia repair. After dissection of the uterus, right salpinx, and the upper part of the vagina, supravaginal hysterectomy and right salpingectomy were performed. We divided the vagina with a linear stapler after dissecting the vagina as much as possible. Following which a preperitoneal mesh repair was performed for bilateral inguinal hernia. The mass comprised of Müllerian duct derivatives with a rudimentary uterus and right salpinx (Fig. D)."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old man was referred to our department with persistent serous fluid discharge via a Penrose drain that had been intraoperatively placed into the operation site and had remained until postoperative day 10 after orthopedic internal fixation with metal screws for multiple pelvic bone fractures. The creatinine and blood urea nitrogen values of the discharged fluid were 25.56 mg/mL and 86 mg/mL, respectively. Subsequently, intravenous urography was performed, which showed urinary extravasation arising from the right distal ureter suspicious of a right distal ureteric injury (). Renal ultrasonography was also performed, which confirmed grade I hydronephrosis of the right kidney. Following this, a percutaneous nephrostomy (PCN) tube was successfully inserted to divert the urine output into an external drainage bag. To further specify the location and severity of the right distal ureteric injury, an antegrade nephrostogram was performed via the PCN tube, which clearly demonstrated extravasation of contrast material around the right distal ureter (). However, an antegrade attempt to internalize the right ureter by placement of a double J ureteric stent failed. After detailed discussion with the patient, it was decided to proceed with an emergent reconstructive operation to repair the right distal ureteric injury. A midline laparotomy was performed to obtain adequate surgical exposure of the injured right ureter. After careful dissection, the right ureter was found to be displaced medially by a well-formed urinoma secondary to urinary leakage along the right pelvic side wall. In addition, reactive inflammatory changes adjacent to the injured ureter had resulted in adhesions that made ureteric dissection difficult. Two penetrating holes leaking urine at the same level of the right distal ureter were intraoperatively identified. After complete evacuation of the urinoma, approximately 2 cm of the injured ureteral segment was excised and an additional ureteral dissectio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-yr-old Asian man who presented with intermittent melena and significant weight loss was diagnosed with small bowel GIST with multiple liver metastases and peritoneal seeding on May 25, 2010. He underwent jejunal resection and anastomosis with palliative intent. The excised jejunal GIST measured 7 × 5 × 5 cm and had a c-KIT exon 9 mutation (1,510-1,515 duplication). After surgery, the patient was treated with 400 mg/day imatinib. He had no concomitant medications or co-morbid diseases.\nTwo months later, the patient developed grade 3 edema, grade 3 ascites, and grade 2 vomiting, with chest radiography revealing layering of a moderate amount of pleural fluid. Because the patient had peritoneal seeding, it was hard to determine whether his ascites and pleural effusion were due to imatinib toxicity or the progression of GIST. Although the follow-up abdomino-pelvic computed tomography (CT) scan showed that the patient's liver metastases had not changed significantly, disease progression was suspected, which prompted a cessation in imatinib treatment and a commencement of sunitinib treatment. The patient was transferred to our hospital for a second opinion after he had been taking sunitinib for approximately 2 months. A thorough review of his previous serial CT scans showed no definitive evidence of disease progression whilst he was on imatinib treatment. We therefore decided to resume 400 mg/day imatinib and use 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT for accurate assessment of response to imatinib treatment.\nOne month after the patient restarted imatinib, a PET/CT scan revealed a significant decrease in maximum standardized uptake value from 4.2 to 2.9 in one of his liver metastases (), suggesting the tumor was responding to imatinib. However, the patient required paracentesis once weekly to control his ascites, and he complained of peripheral edema and dyspnea. Because imatinib blood level testing revealed that the patient had very high i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old man who was a current smoker was admitted to our hospital for hemoptysis in July 2011 (day 0). Before admission, pulmonary emphysema and multiple pulmonary bullae were detected on a chest computed tomography (CT) scan, and we also discovered that the patient had hypertension. He had a history of lobectomy of the left lower lobe for lung cancer in 1993, with no recurrence; two episodes of bacterial pneumonia; gastrectomy for gastric cancer in August 2010; right spontaneous pneumothorax that required tube drainage in November 2010; and hospitalization for dyspnea in February 2011, at which time chest radiographs showed left lung opacity and a chest CT scan showed consolidation with pleural effusion in the left lung. Several bacterial antibiotics failed to improve the opacity on chest radiographs. A sputum culture was negative for Aspergillus. The lack of efficacy of bacterial antibiotics and the presence of multiple bullae and precipitating antibody to Aspergillus in the serum (day -163) led to a presumptive diagnosis of chronic necrotizing pulmonary aspergillosis. Voriconazole with a loading dose of 800 mg a day followed by a maintenance dose of 400 mg a day was started on day -155. A switch from intravenous to oral administration of voriconazole at a dose of 400 mg a day was made on day -106. With administration of voriconazole, the opacity on chest radiographs had significantly improved by June 2011. The patient underwent transurethral resection of bladder cancer in March 2011. Oral voriconazole was continued at our outpatient clinic until his admission for hemoptysis. He had no hematologic neoplasm.\nOn admission, a chest radiograph (a) showed consolidation in the upper field of the left lung and an infiltration shadow in the middle and lower fields of the left lung. A chest CT scan (b) showed consolidation in the pulmonary bullae adjacent to the aortic arch. These shadows were considered to be due to hemorrhage. Bronchoscopy revealed slight bleeding"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old female patient was first administrated to our hospital because her right leg was 18 cm shorter than contralateral side (Fig. ). When she was 4-year-old, she contracted right tibia pyogenic osteomyelitis, leading to a 6-cm tibial absorption involving the distal epiphysis. The patient had no other past medical history. When she was 5, the tibia defect was reconstructed by her ipsilateral vascularized fibular graft. However, progressive leg length discrepancy developed with limited range of joint motion (ROM) (Table ). When she was 16, lengthening of FVFG with a unilateral external fixator was performed to correct the LLD (Fig. ). We executed an open osteotomy at the level of the middle metaphysis of the matured fibular graft. The patient received preventive intravenous antibiotic (Cefuroxime) for 72 h. The latency period was 7 days after the operation and distraction was performed at a rate of 1.0 mm per 36 h in four increments of 0.25 mm, and when the length of bone regeneration had reached approximately 6.0 cm, the distraction rate was reduced to 1.0 mm every 48 h []. Clinical and radiological examination was carried out every 15 days to assess new bone formation and the pin sites []. The rate was adjusted according to the discomfort and swelling of the limb and the quality of the regenerate bone like our previous study []. Partial weight-bearing was allowed as soon as union of the vascularized fibula graft on either junction was observed on radiographs. We achieved equalization with a unilateral external fixator in 26.5 months. The mean external fixation index was 44.2 day/cm. She had a pin-track infection and local inflammation, which were managed with pin care and oral antibiotics. The unilateral external fixator was removed when at least three of the four cortices were observed to be united on anteroposterior and lateral radiographs. She was able to walk without walking aids or braces,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 68-year-old man with a 30-year history of hypertension and regular hemodialysis for 11 years who had undergone forearm arteriovenous fistula surgery to treat end-stage renal disease 9 years prior. A long-term hemodialysis catheter (14.5F/23 cm, BARD) had been placed in the right internal jugular vein for hemodialysis 2 years prior. 2 days before the current visit, the hemodialysis cuff catheter ports caused blood oozing during hemodialysis, and the right cuff catheter was pulled out to stop the blood oozing. 1 day before the current visit, a cuff catheter was placed in the patient's left internal jugular vein for hemodialysis. Using the Seldinger puncture technique, the operation was performed under DSA in an interventional radiology room. The cuff catheter was introduced via smooth introduction and positioning of the guidewires. After dilator and guidewire removal, the catheter was inserted into the left internal jugular vein with the removal of the peel-away sheaths (). The patient reported mild pain in the left side of his chest during catheterization. The surgeon immediately checked the location of the catheter placement and found that there was no venous blood being drawn from the cuff catheter. DSA analysis revealed that the tip of the catheter could not reach the upper 1/3 of the right atrium (the tip of the catheter was in this position, which can meet the requirements of hemodialysis, as shown in ). The surgeon decided to adjust the catheter the next day because the patient could not continue to tolerate the operation.\nThe next day attempts were made to adjust the catheter via a rotating method, but during that process, the catheter pierced the brachiocephalic vein and entered the mediastinum (). Opening the breast area and suturing the brachiocephalic vein were initially considered, but it was surmised that this could be lethal given the patient's history of long-term anemia and uremia. Immediate multidisciplinary consultation with interv"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female presented to the emergency room at our institution with intractable abdominal pain and fever. She has a history of dysuria and hematuria for 10 months, which at the time prompted an MRI demonstrating an abdominal wall mass with extension into the bladder. Outside biopsy was reported as “inflammation”. She was initially treated with antibiotics. A cystoscopy was performed and a transurethral bladder biopsy showed acute and chronic cystitis and Von Brunn nests. Cytology report indicated presence of atypical urothelial cells and she was then referred to the urology service due to suspicion for malignant neoplasm. Follow up CT scan imaging demonstrated a heterogeneous ill-defined enhancing soft tissue density in the space of Retzius inseparable and compressing the anterior aspect of the urinary bladder measuring 11.3 × 4.5 × 12.8 cm with a peripherally enhancing loculated collection measuring 4.7 × 6.0 × 3.0 cm along with marked thickening of urinary bladder . As strong suspicion for malignant lesion persisted, a repeat percutaneous biopsy was done that again demonstrated infiltrative granulation tissue and chronic inflammation.\nAs the patient’s symptoms continued to progress, including persistent hematuria diagnosis was uncertain despite multiple percutaneous and transurethral biopsies, she was referred to Surgical Oncology team for multidisciplinary management. As there were still concerns for neoplastic malignant process vs desmoid vs pseudoinflammatory neoplasm, the multidisciplinary team recommendations were to offer operative management in coordination with the surgical oncology and urology teams with an intention to provide larger tissue for definitive diagnosis to guide extend of surgery, which would include complete bladder removal with construction in the form of ileal conduit, abdominal wall resection with abdominal wall reconstruction if malignancy were to be confirmed intraoperatively.\nIntraoperative cystoscopy demonstrated an ulcerated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old female with no known medical condition, underwent a caesarian section in 2014 and started to complain of abdominal mass 2 years later. She underwent resection in another institution and the pathology showed insufficient resection reaching the superior margin, <1 mm from the lateral margin, and 1 mm from inferior and deep margins. The patient was offered radiotherapy, however she refused.\nShe was followed up with biannual MRI’s with no recurrence. Two years later, the patient noticed a growing mass. The follow-up MRI revealed development of a well-defined oval-shaped soft tissue lesion at the site of the previously resected anterior abdominal wall desmoid tumor measuring 4.3 × 2 cm, heterogeneously hypertense on T2, hypointense on T1 and significant enhancement on the delayed post contrast images, in keeping with a recurrent desmoid tumor (Fig. ). Following the MRI, the patient was referred to our institution.\nThe mass presented with a gradual increase in size and moderate pain. On physical examination there was a 5 × 3 cm hard, well-defined mass in the right lower quadrant. There were no skin changes. An MRI revealed a well-defined soft tissue mass confined to the right rectus abdominus muscle. A Tru-cut biopsy from the mass revealed a spindle cell neoplasm consistent with recurrent desmoid tumor. The patient’s family history was insignificant for malignancy. All her laboratory investigations and tumor markers were normal. After counseling the patient, resection was performed, using the advantage of intra-operative ultrasound (US) to localize the margin providing the patient maximal surgical benefit with minimal risk of a positive margin.\nRather than simply using palpation, intraoperative ultrasound guidance was used to determine the margins of the desmoid tumor. The ultrasound was used to define a 2 cm margin at each qudrant, which was then marked using electrocautery. The marks were then connected in a ring giving a 2 cm margin around the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36 year-old female complained of persisted dull pain over epigastric area for 2 months. No associated symptoms such as heartburn, nausea, and vomiting can be elicited. She visited local clinic and a mass was palpated in the left upper quadrant area. At the same time, abdominal sonography showed a huge hepatic mass at left lobe of liver. So, she received examination of abdominal computed tomography (CT) thereafter. Abdominal CT () revealed a huge left hepatic mass with a size of 20 x 15 cm. She was then transferred to our institution for further management. Initial laboratory data were only notable for a decreased hemoglobin level of 9.7 g/dL and a mildly elevated level of alkaline phosphatase (139 U/L). The serum marker of hepatitis B or hepatitis C was also negative. Tumor markers, including serum carcinoembryonic antigen (CEA), CA19-9, and α-fetoprotein level (AFP) were within normal value. Angiography revealed this huge hepatic mass was supplied by left hepatic arterial (). After studies, she received operation for excision of the tumor. The excised liver measured 20 x 15 x 10 cm and weighed 793 gram. The cutting surface showed a huge soft mass of size 14 x 12 x 6 cm with whitish to pinkish surface (). There was no central necrosis in the tumor. The tumor margin was greater than 5 cm away from the nearest section margin. There was no cirrhotic change at the remaining part of liver parenchyma. Microscopically, the lesion was mainly composed of hyperchromatic and mild pleomorphic spindle cells admixed with many reactive plasma cells and lymphocytes. These neoplastic cells formed fascicles, storiform and whorls pattern. They had plump cytoplasm and indistinct cell borders with vesicular or granular chromatin and small nucleoli. Some giant cells and fibrous bands were seen but rare mitotic figures were found within the tumor (). These tumor cells were positive for expression of CD21 and CD35 by immunohistochemical staining and positive for expression of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old female patient was initially referred to our vascular department for investigation of bilateral lymphedema. Her echocardiogram showed mildly impaired LV with evidence of segmental wall motion abnormality and hypertrabeculation in the apex suggestive of noncompaction. Further questioning revealed a history of sudden death in two of her brothers. One of the deaths was related to an unknown cardiomyopathy. The history of the patient started at birth when she had difficulty swallowing and several delayed milestones such as walking and talking at the age of 5. Due to socioeconomic issues, the parents did not seek medical assistance. As the patient matured, there was an additional history of palpitations, which were occasionally associated with syncopal attacks. The patient had generalized, but progressive weakness throughout the years. Her weakness increased with activity and decreased with a rest. The weakness was mainly proximal, worse in the upper limbs. Due to constant fatigability, she dropped out of school.\nHer vital signs were normal on physical examination, she demonstrated normal heart sounds. Lower limbs bilateral nonpitting edema up to the knees, proximal bilateral upper and lower limbs weakness with intact sensation, waddling gait, and easy fatigability with few steps were noted.\nComputed tomography coronary angiogram was performed to exclude coronary artery disease. Results showed segmental wall motion abnormality and revealed normal coronaries, LV dilatation, and lateral wall and apical noncompaction with the noncompacted myocardium to compacted myocardium ratio in the range of 2.5–3.5 []. CMRI was done for further evaluation of LV function and volume. Her CMRI showed mildly dilated LV with mild global hypokinesis and a marked decrease in longitudinal shortening. End-diastolic volume was 120 mL, end-systolic volume was 61 mL and the ejection fraction was 50%. In addition, multiple areas of noncompacted myocardium, particularly in the apex and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old mentally subnormal boy from rural background was brought by his family with a lump in the left subareolar region which was first noticed 6 years back as a small pea sized nodule and grew painlessly to the size of presentation. The patient had no other complaints and his relatives denied any history of similar complaints in the family. The family members reported delayed milestones for the patient who performed poorly for his age and had poor speech and mental development. On examination the patient showed hypertelorism, low set ears, and left sided undescended testis. The breast examination showed a 6 × 6 cm size lump underlying the areola which was firm to hard in consistency and fixed to the overlying thinned skin. The lump was mobile over the underlying muscle. The patient had no axillary lymphadenopathy. On evaluation, otorhinolaryngoscopic evaluation of the patient was within normal limits. Core needle biopsy of the patient showed fibrocollagenous tissue with mild epithelial hyperplasia and was suggestive of gynaecomastia. Ultrasonography of the axillae and the abdomen was normal. Ultrasonography of the scrotum localised the left testis to the left inguinal region.\nIn view of clinical suspicion the patient was advised a wide local excision of the lump and axillary sampling which on histopathological examination revealed a 5 × 4 cm firm grey lesion harbouring secretory carcinoma with foci of stromal fibrosis and apocrine change with pathologically negative 8 lymph nodes. The margins were negative for presence of the tumor. The tumor was negative for estrogen and progesterone receptors and Her2neu. On immunohistochemistry the tumor stained positive for S-100 stain ().\nIn view of the subnormal mentation of the patient and the lack of definitive supportive data in the disease subset, his relatives refused adjuvant therapy. The patient subsequently is on periodic surveillance and is healthy after 6 months of follow-up."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old male presented to the emergency department for evaluation of neck and chest pain. He was running at a brisk pace when he felt a sudden sharp pain in his neck followed by sustained pain in the center of his chest and neck. He reported the sensation of shortness of breath and nausea, but no dysphagia or dysphonia. There was no history of trauma to the head, neck, or chest. He was previously healthy with no prior medical problems or prior surgeries and had no history of familial or congenital medical conditions. Most notably, the patient had no family history of sudden cardiac death, aortic disease, or connective tissue disease. The patient endorsed having no known allergies and did not take any medications on a daily basis.\nOn arrival, he displayed mild tachypnea with a respiratory rate of 22 breaths per minute, but otherwise had normal vital signs with a blood pressure of 128/80 millimeters of mercury, heart rate 66 beats per minute, temperature 37 degrees Celsius, with 98% oxygen saturation on room air. His airway showed no evidence of impending compromise. He appeared to be in moderate distress secondary to pain. He demonstrated respiratory splinting and held his neck and shoulders still to prevent worsening of pain. He had mild nasal flaring, but his lungs were clear to auscultation bilaterally. He had no evidence of stridor. Palpation of the chest revealed tenderness near the right sternoclavicular region of his chest. Pulses were palpable and equal in all extremities.\nA chest radiograph showed lung markings to the periphery bilaterally, no consolidations, and no opacities (). The mediastinum appeared widened, which prompted a computed tomography (CT) angiogram of the chest and neck to better evaluate vascular anatomy. This revealed a pseudoaneurysm of the proximal innominate artery (). There was also high attenuation blood tracking from the superior mediastinum to the descending aorta suggesting rupture of the pseudoaneurysm and formation of a medi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second case refers to a 48-year-old woman, a busy manager with a history of depression and sleep disturbance. She has had three terminations of pregnancy and one delivery by cesarean section. She smokes approximately ten cigarettes per day and has high cholesterol serum levels. She takes several medications: a selective serotonin reuptake inhibitor (escitalopram), two benzodiazepines (delorazepam and clonazepam), and a statin. She reports a four-year history of urinary symptoms: daily UUI episodes, mild stress urinary incontinence (SUI), and two episodes of nocturia per night. She wears pads every day. The urology consultation revealed some degree of pelvic pain, especially during vaginal examination. The urine dipstick was negative and there was no PVR. No specific causes of the symptoms such as urine tract infection were identified. The patient also complained of mild dyspareunia and occasional constipation. The urine culture turned out to be sterile, with no blood in urine, and the pelvic ultrasound scan and urine cytology were also negative. The cystoscopy, which was performed as a result of the presence of storage symptoms and to rule out a bladder tumor in this current smoker, was normal.\nIn OAB patients, it is of utmost importance to consider all comorbidities. Anxiety and depression may play a role, feeding a vicious circle. Moreover, medications to treat neurological or psychiatric disorders can influence OAB and be responsible for side effects [, ]. Gastrointestinal disorders are frequently associated with OAB, such as constipation in this case, but patients rarely raise the topic. An overlap exists between irritable bowel syndrome and OAB [].\nThe patient was prescribed a β3 agonist, pelvic floor muscle training (PFMT) and bladder retraining. Four months later, she noticed some degree of improvement, but had stopped the treatment as she felt that she had no time for PFMT. She was not compliant with the bladder drill either, and soon stopped"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old male was referred to our clinic with an 8-year history of multiple painless scrotal nodules that had progressively increased in size and number. The few 0.5–1 cm subcutaneous papules on both hemi-scrotal tissues were sometimes itchy. The patient denied a history of scrotal trauma or ingestion of any medication before the onset of a papule. There was no urethral discharge, penile ulceration, or inguinal swelling. The patient noticed some of the papules disappeared after discharge of a whitish or chalk-like substance from them. He had no previous history of sexually transmitted infection. As the number and size of the nodules were increasing, he became uncomfortable, embarrassed, and did not want others to see the lesion. He reported that he was not sexually active and had avoided intimate relationships because of his scrotal lesions. There was no history of any chronic illness or medication use. Physical examination showed multiple palpable but painless dark brown intradermal nodules on the scrotum. The calcified nodules involved both hemi-scrotum, but were preponderantly on the left. No other skin lesion was noticed. The phallus was circumcised and the testes were palpable and grossly normal. Laboratory evaluation revealed normal serum phosphorus and a slightly lower calcium level. The patient underwent excision of the lesions near the median raphe under local anesthesia using a single elliptical incision. Other individual nodules on both hemi-scrotums were excised individually and closed separately to preserve some uninvolved skin and to allow for adequate scrotal skin closure. The defects were closed using 3-0 prolene suture interrupted technique (). There were no postoperative complications to date, and the patient had an excellent scrotal cosmetic outcome.\nHistology sections revealed calcium deposition, and basophilic globules of varying sizes and shapes within the reticular dermis. There was an occasional scalloped appearance, with some of the sma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old man visited our hospital complaining of anterior chest pain. He had no significant medical or family history, and the vital signs were stable. Ischemic events were not observed in electrocardiography, but chest X-ray and computed tomography (CT) showed a cystic lesion (6.0 × 7.0 × 10.0 cm) in the anterior mediastinum (Fig. a). Although the cystic capsule demonstrated contrast enhancement, its fluid component had low radiation absorbance. Based on these findings, we suspected the mass to be a thymic cyst. Blood tests indicated the presence of inflammation (white blood cell count 11,200/μL and C-reactive protein 3.38 mg/dL).\nTwo days after hospitalization, the patient developed dyspnea and his chest pain worsened. Subsequent chest CT showed that the cystic lesion had become inhomogeneous and the radiation absorbance of the cyst’s fluid component had increased (Fig. b). The cyst wall became thickened, and bilateral effusion was observed. Blood tests indicated that hemoglobin levels had decreased from 15.8 to 12.8 g/dL, and levels of inflammatory markers had increased, with the fever exceeding 38.5 °C. Needle aspiration biopsy and tumor wall biopsy with a small skin incision were performed; however, we could not obtain a diagnosis. One week after admission, general condition and laboratory data of the patient gradually improved. A chest CT on day 13 showed that the tumor had become small in size with a thickened wall (Fig. c). The effusion on the right side had decreased and that on the left side had disappeared.\nThe patient had recovered enough to undergo surgery; the tumor was resected by sternotomy on day 18. The tumor was found to be encased in a smooth, yellow, and elastic coat. The tumor was densely adhered to the junction of the left brachiocephalic vein and superior vena cava, and it was required to detach the tumor from the dense adhesion site carefully. The right phrenic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n63-year-old woman who had suffered from the right medial knee pain for 5 years and was not responsive to conservative treatment was admitted to our clinics. 30° varus-valgus stress X-ray indicated that the patient had an intact MCL and LCL. After the detailed physical examination and reviewing of X-ray images, it was decided that UKR would be the most suitable option for the patient with anteromedial knee osteoarthritis. After spinal anesthesia application and sedation, the UKR surgery was performed with a standard minimal invasive midline vertical incision and a medial parapatellar approach; the patella was removed laterally but not dislocated or everted. The patient received a medial partial knee implant with a mobile-bearing insert (medium size with 4 mm thickness; Oxford®, Zimmer Biomet Inc., Warsaw, IN, USA). Following the UKR surgery (), weight bearing was allowed as tolerated by the patient and a standard postoperative physiotherapy was started on the first postoperative day. The patient was discharged at postop 2nd day when she met the following criteria: independent ability to get dressed, to get in and out of the bed, and to sit and rise from a chair/toilet; independence in personal care; and mobilization with crutches. After discharge, a home-based exercise program was given to the patient. At postoperative follow-up, our patient acquired a full knee RoM in the postop 1st month and returned to independent daily activities without any external support in the postop 3rd month.\nAt postoperative 1st year after first UKR application, the patient fell down while getting on a public bus; this caused that the right knee of the patient was exposed to the valgus force vector. After that moment, the patient heard a pop sound and felt an incredible pain that prohibited the flexion and/or extension of the medial side of the right knee. And then she was admitted to our emergency department. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old previously healthy woman underwent a curative resection of the medical compartment of the right thigh for a malignant spindle cell tumour. Due to clear resection margins and absence of any metastatic deposits in imaging, she was not given any adjuvant therapy. She was followed up for 5 years, and she was otherwise well and asymptomatic without any evidence of local recurrence.\nAfter a period of 5 years, she developed an acute onset generalized severe abdominal pain and collapsed. She did not have any external bleeding manifestations such as haematemesis or melaena. There was no history of abdominal trauma. She was immediately admitted to the emergency department, and she was found to be in class III haemorrhagic shock with a pulse rate of 125 beats per minute and a blood pressure of 90/60 mmHg. Her abdomen was distended and diffusely tender. She was immediately resuscitated with intravenous crystalloid boluses and blood transfusion. Her serum beta-Human Chorionic Gonadotropin (beta-HCG) was negative, excluding a ruptured ectopic pregnancy. Her full blood count revealed a haemoglobin level of 5 g/dl, and a massive transfusion protocol was initiated. Her other basic investigations and clotting profile were within normal limits. Despite resuscitation, her vital parameters did not improve and her abdominal girth was gradually increasing. The abdominal ultrasound scan revealed moderate amount of free fluid with a mass around the proximal part of the pancreas. There was no evidence of abdominal aortic aneurysm, and other solid organs were normal. Hence, a decision was taken to proceed with an emergency exploratory laparotomy. A computed tomography was not done as the patient was haemodynamically unstable.\nA midline laparotomy was performed. There was 4.5 litres of haemoperitoneum, and a linear tear in the gastrocolic omentum with a haematoma in the lesser sac. Active bleeding was noted from a nidus which was situated posterior to the body of the pancreas, an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAfter a multidisciplinary evaluation, at the end of November 2019, a 13-year-old girl attended the Pain Therapy Clinic of the Ospedale Pediatrico Bambino Gesù in Rome, where acupuncture is also practiced as an analgesic technique. She reported pain in the left wrist and hand, with intensity 10 on the Numeric Pain Rating Scale (NRS), pulsating, and always present, thus preventing any movement. Marked hypersensitivity and allodynia were present at the level of the left fingers, wrist and hand. Pain was present in both flexion and extension of the wrist and caused a marked reduction in strength in the left wrist and hand, making a handshake impossible for the girl. There was no redness but swelling and sweating at the level of the fingers of the left hand. The pain was so intense that it interfered with her regular attendance at school, generating social withdrawal phenomena, which are unfortunately very frequent in patients with chronic pain.\nPain began three months before the consultation, after an accidental fall with trauma to the left wrist. It gradually increased and did not respond to either NSAIDs or limb immobilization. The diagnostic tests performed at the time (X-ray, Doppler ultrasound and magnetic resonance imaging) were negative, as were the blood chemistry tests ( and ).\nFrom the age of 8, the girl was followed by a pediatrician in our hospital for a history of cramps and pain in the lower limbs, especially in the ankle and left knee, both in the absence of trauma or caused by frequent falls. In the following years, clinicians found bilateral flatfoot (with subsequent surgery), mild ligamentous hyperlaxity and vitamin D deficiency. In addition, borderline cognitive level with motor coordination disorder and executive function deficit, as well as stuttering, were then diagnosed. Elements of anxiety emerged from the administration of Self Administered Psychiatric Scales for Children and Adolescents (SAFA-A, D and S)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old Kashmiri female presented to our department after having sustained a fracture of femur in the supracondylar region. After initial management, the fracture was fixed with a dynamic condylar screw assembly. After an uneventful postoperative period, the patient was discharged with advice to undergo supervised physiotherapy. 3 months into the postoperative period, the patient reported to our emergency department with pain in the thigh. X rays revealed a fracture above the dynamic condylar screw at the plate bone interface. The patient was admitted and revision surgery with a longer barrel plate performed. The patient followed up for a period of 4 months and was bearing weight when she again had pain in the peri implant area. Radiographs revealed a fracture of the femur at the new peri implant region. The patient's femoral neck radiograph revealed an osteoporosis grading of 3 according to Singh's classification []. Keeping in view the potential morbidity associated with the repeat plating we planned a method that would be less invasive and less destructive to the local fracture environment. The proposed surgery was explained to the patient and her attendants. The ethical board permission was sought and obtained. The patient was taken to the operating room and placed on a fracture table. The screws in the plate were removed percutaneously under image intensifier control to ensure the patency of intramedullary canal leaving the plate insitu to avoid reexposure of the bone surface. The fracture was reduced and fixed with a reamed antegrade intramedullary nail. Anticipating the difficulties in distal locking with an insitu plate an external locking device comprising of a distal full ring and a proximal Italian arch connected by two threaded rods were used. No blood transfusion, bone grafting were used and the mean operating time was 40 minutes. The patient was ambulated on the first post operative day and discharged from the hospital on the same day after advis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 89-year-old gentleman was admitted to a district general hospital with right groin and thigh pain. He was known to suffer from Alzheimer's dementia, osteoarthritis, previous proximal femoral fracture with dynamic hip screw (DHS), and severe aortic stenosis. He was living in the local area in a nursing home, requiring care with all activities of daily living, spending the vast majority of the day in bed. He was able to transfer with assistance of two into the chair but unable to walk prior to admission.\nOn admission, he was found to have an externally rotated right hip and pain on movement of the hip. His abbreviated mental test score (AMTS) on admission was zero, and that was felt to be his baseline. On auscultation of the precordium, a very quiet second heart sound was heard with an additional ejection systolic murmur present.\nBasic blood tests showed a haemoglobin of 115, white cell count of 11.9, C-reactive protein of 130, sodium of 137, potassium of 3.8, urea of 8.3, and creatinine of 113.\nPelvic X-ray was reported to identify generalised osteopenia, left DHS, and displaced surgical neck fracture of the right femur. An urgent echocardiogram identified an ejection fracture of 60% and a severely stenosed aortic valve with an area of 0.8 cm2 and a gradient of 71 mmHg.\nBased on his cardiac, cognitive, and functional status, the decision was made that his outcome was extremely poor and he was deemed not to be a surgical candidate.\nAs a result of him not undergoing a conventional operation and him being managed conservatively, we felt that consideration for a phenol nerve block would aid pain relief and assist in being able to discharge him into the community for end-of-life care. As the patient lacked capacity to consent for a proposed intrathecal phenol injection for intractable hip pain, secondary to the fracture, it was deemed in his"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 50 year old male who received a LURT 8 years prior to presentation. He had previously undergone bilateral native nephrectomies 2 months prior to transplant for PKD. His early course was complicated by biopsy-proven acute cellular rejection, vascular type, 5 days after transplant, which was effectively treated with anti-thymocyte globulin and intravenous immunoglobulin. He subsequently went on to enjoy excellent graft function. Initially, he was maintained on standard triple immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and prednisone.\nTwo years prior to presentation, he developed numerous squamous cell carcinomas of the skin treated with resection and radiation. One of these lesions was an invasive poorly differentiated SCC (Bowen’s type) of the left auricle, requiring auriculectomy and reconstruction. Tumor margins were negative. His immunosuppression was reduced by stopping his MMF.\nOne year prior to presentation he developed a parotid mass found to be SCC by fine needle aspiration. It was felt that this was a metastatic lesion from the auricular tumor. At this time, he was switched from a dual immunosuppressive regimen of tacrolimus and prednisone to sirolimus (SRL) and prednisone. He underwent a left parotidectomy and neck dissection with pathology showing invasive keratinizing squamous cell carcinoma, poorly differentiated. The tumor was 4.6 cm with lymphovascular and perineural invasion. Surgical margins were negative, but 5 out of 23 periparotid and cervical LNs were positive for metastasis with focal extranodal extension. He underwent radiation therapy and cetuximab. A surveillance PET CT performed 6 months after treatment revealed 5 bilateral pulmonary nodules, which grew over 2 months from 6 mm to 10 mm. He initiated systemic treatment with carboplatin, paclitaxel and cetuximab with minor improvement initially, followed by disease progression in the lungs and mediastinum after 7 months of treatment. He was then treated wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old man with hypertension and a family history that included two brothers who died of an aortic aneurysm was brought to the Emergency Department after falling from his bicycle. He reported abdominal pain since one day. On examination, he was pale and had a pulse rate of 64/min, a blood pressure of 70/50 mmHg, a body temperature of 36°C, and a respiratory rate of 16 breaths/min. He had abdominal tenderness with muscular rigidity, especially in the upper abdominal region. A full blood count showed a haemoglobin level of 6,4 mmol/L, while all other laboratory tests were within the normal range. A chest X-ray showed normal lung fields and no pneumoperitoneum. As a vascular incident was feared, an abdominal ultrasound revealed free abdominal fluid around the liver and spleen without an aortic aneurysm. An abdominal computed tomographic (CT) demonstrated fluids in the omental bursa with a normal aspect of the pancreas but was unable to point to the origin of the free fluid. After resuscitation using standard techniques, the patient was transferred to the operating room under the diagnosis of intra-abdominal haemorrhage of unknown origin. During laparotomy, three litres of blood were obtained from the abdominal cavity but no active bleeding was found. Inspection of the omental bursa revealed a hematoma surrounding the pancreas. The patient was packed using several large volume gauzes and admitted to the intensive care unit. The next day, these gauzes were removed and again no active bleeding was seen. The next four days were uneventful. However, on the fifth day, the patient developed acute severe abdominal pain. An abdominal computed tomographic angiography (CTA) revealed a 14 mm splenic artery aneurysm () as well as a 12 mm aneurysm of the coeliac trunk. In retrospect, on the first CT, a 9 mm focal contrast-filled dilatation of the splenic artery could already have been identified in a large hematoma (). This was initially missed.\nA ruptured splenic aneurysm wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old man was admitted to the Department of Surgery at our hospital for complaints of fever and anorexia. There was no abdominal pain, nausea, or abdominal distension. He had a high fever, anorexia, tachycardia, and tachypnea. He had no comorbidities or surgical history. The white blood cell count, liver enzymes, and C-reactive protein level were elevated. Abdominal ultrasonography showed a hypoechoic lesion with a maximum diameter of 40 mm in the left lobe of the liver (Fig. ). Abdominal contrast-enhanced computed tomography (CT) revealed a lesion with coexisting low- and high-density areas in segment III of the liver. The lesion was adjacent to the stomach antrum and had a maximum diameter of 55 mm, with enhancement at the edge. The lesion contained air and a high-density linear object measuring about 24 mm (Fig. a, b). We suspected a liver abscess secondary to gastric perforation caused by a foreign body. The patient underwent abscess drainage and removal of the foreign body using five-port laparoscopic surgery. Adhesions had formed between the liver and reticulum due to inflammation (Fig. a). We confirmed pus leakage, performed lysis of adhesions, and found a fish bone inside the reticulum (Fig. b–d). The fish bone was removed laparoscopically. We lavaged the abscess cavity with saline. The operation was completed with the insertion of a drain inferior to the left lobe of the liver. There was no bile leakage from the abscess cavity. The total operative time was 62 min, and the total intraoperative blood loss was 20 ml. The pus culture showed the presence of Streptococcus anginosus, which matched the result of the blood culture. We used meropenem until postoperative day 10. The clinical course was uneventful, and the patient was discharged on postoperative day 11. When the patient was discharged, we changed the antibiotic treatment from meropenem to a combination of potassium clavulanate and amoxicillin hydrate according to the indications"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old Hispanic male with a past medical history of diabetes, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and remote smoking history (quit 29 years ago) was admitted to the hospital by his pulmonologist for recurrent bilateral pneumonia over the past 10 months. The patient's initial symptom was a cough associated with lying supine, eating, or drinking. He also reported that his oxygen saturation would decrease to the 80s while sleeping and unintentional weight loss of 40 pounds over the past 10 months. On further questioning, the patient reported having progressive dysphagia from solids to liquid over the past 10 months.\nHe reported being admitted to a different hospital approximately three-weeks prior, where he was diagnosed with persistent pneumonia and treated with antibiotics and steroids. The patient's hospital course was complicated secondary to pleural effusion, which required a thoracentesis. Pleural fluid analysis was negative for malignancy. CT scan of the chest during his previous hospital stay revealed extensive bilateral infiltrates and a 3 cm density in the left upper lobe. He was discharged and to follow up as outpatient with his pulmonologist.\nOn this admission, his initial vital signs were temperature 98.2 F, pulse 84 beats per minute, respiratory rate 15 breaths per minute, blood pressure 111/69 mmHg, and oxygen saturation 93% on room air. Physical examination was significant for rhonchi and lymphadenopathy. Chest X-ray and CT of the chest showed pneumonic infiltrates and pleural effusion (Figure and Figure , respectively), which required drainage by thoracentesis.\nAs the patient had dysphagia and weight loss, a barium swallow was done, which was remarkable for slow emptying and severe backflow in the esophagus followed by coughing associated with dysphagia. The patient had undergone an esophagogastroduodenoscopy (EGD) due to findings on barium study. EGD revealed a gastric fundi mass approaching the gastroesophageal juncti"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old multiparous woman (G3P2) presented with abdominal swelling 10 weeks after her second vaginal birth. She had a normal pregnancy follow-up and birth process, until now, and her medical and family history did not show any feature. In the gynecological examination, external and internal genital organs were normal in size and structure. Postpartum uterine involution was regular. In the abdominal examination, a mass starting from the pelvic level, but with indistinct relation to genital organs and extending to the right upper quadrant, was palpated. In the abdominal ultrasound screening, a multiloculated mass divided with septal structures, including cystic and solid areas starting from the suprauterine level reaching to the subxiphoid region, was detected. In the further evaluation using computerized tomography () and magnetic resonance imaging () a mass starting from the pelvis and extending to the transverse colon, 26 × 22 × 16 cm in size, solid, loculated, hypervascular, and in certain regions associated with some colon segments was observed. CT angiography was performed in order to evaluate the resectability of the mass showed invasion into the superior mesenteric artery and distal branches. Biochemical tests and tumor markers were not diagnostic. According to these findings, a general surgery consultation was requested with the prediagnosis of extragenital tumoral mass.\nIntraoperative observation showed an association between the mass and an approximately 15 cm of jejunal segment; furthermore many millimetric implants were diagnosed on the peritoneum. En bloc mass with a 20 cm jejunal segment resection and a left pelvic side wall peritonectomy with omentectomy was performed (). Additionally, peritoneal implants were sampled. Frozen section examination was reported as malign stromal tumor. The postoperative period was uneventful and the patient was discharged on the postoperative 7th day.\nPathologic Examination. Three peritoneal biopsies (measuring 1 cm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman was diagnosed with endometrial cancer by curettage because of vaginal bleeding. In a preoperative examination, chest computed tomography (CT) showed a tumor that was located at the right anterior mediastinum. Total hysterectomy with double appendages was performed on 13 March 2019. A pathological examination showed that the tumor was 3.5 × 2.5 cm, it was highly differentiated endometrial adenocarcinoma, and it invaded the superficial myometrium (<1/2 of the myometrium). There was no metastasis in bilateral pelvic lymph nodes. Because the endometrial lesion only invaded the muscle layer, there was little possibility that the anterior mediastinal tumor was related to the endometrial cancer. The staging of endometrial cancer was pIA. The patient did not receive any adjuvant therapy and was told to seek further treatment for her mediastinal tumor.\nSix months after the radical operation, the patient was admitted to the Department of Thoracic Surgery without any discomfort. Preoperative thoracoabdominal CT showed a solitary 5.2- × 8.0- × 7.1-cm (W × L × H) tumor in the right mediastinum near to the pericardium (). A bone scan did not show bone metastasis. We explained the treatment plan for the patient and obtained consent for the treatment.\nOn 7 September 2019, the patient had an operation under video-assisted thoracoscopy. The tumor was in the right cardiophrenic angle, approximately 8 cm in maximum diameter, with a hard texture and clear boundary. The tumor adhered to the pericardium and lower lobe of the right lung. After separating the adhesions, we found that the tumor had grown in the diaphragm rather than in the mediastinum (). To completely remove the tumor, we performed thoracotomy through the right fifth intercostal space. The diaphragm was resected along with 1 cm from the margin of the tumor (). We then found that the tumor had grown into the abdominal cavity (). We stripped the tumor from the liver’s surface and removed the tumor with the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old female presented to the Accident and Emergency Department at Alder Hey Children's Hospital in Liverpool with a 2-day history of spontaneous pain, reduced oral intake and a left-sided cervicofacial swelling. On observation, she was pyrexic at 38.4°C. All other observations were within normal limits. The patient was otherwise fit and well with no relevant medical history and no known allergies. She was born at full term with a normal delivery. Both parents reported no previous history of tooth or genetic anomalies on either side of the family.\nClinical examination revealed a diffuse swelling extending from the left buccal space to the infraorbital margin. The left eye was open and visual acuity was 6/6 on the Snellen chart. There was no evidence of cervical lymphadenopathy.\nIntraoral examination demonstrated a marked fluctuant buccal swelling adjacent to the upper left deciduous canine and upper left deciduous first molar and a discharging sinus with pus exudate above the upper left deciduous central incisor []. The left maxillary dentition was partially erupted with hypoplastic and hypocalcified teeth and associated gingival enlargement. The primary teeth had abnormal morphology and were yellowish with a mottled, irregular surface. The upper left deciduous canine had a vertical crown fracture down to the amelodentinal junction []. The pulp horns were exposed on the upper left deciduous first molar [], and the upper left deciduous second molar was unerupted. The remaining dentition was caries free and had developed normally.\nAn orthopantomogram [] showed an abnormal morphological dentition to the upper left quadrant affecting the primary teeth from the upper left central incisor to the upper left deciduous second molar which was unerupted. It also showed that the upper left first permanent molar dental germ was affected. These teeth were radiolucent with a characteristic ghost appearance and appeared less developed in comparison to the primary teeth on th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male was admitted to hospital with a history of dyspnea at rest for 2 d, a cough producing mucus, loss of appetite and diarrhoea. Pneumonia was suspected, and the patient received intravenous antibiotic treatment. During the patient's second night in hospital, he was found groggy and walking near his room by the nurses. They took him back to his room and connected a new antibiotic dose to his venous catheter. A few hours later, he was found unconscious, lying on the floor next to his bed. His peripheral venous catheter was connected to a nasal cannula delivering O2 from the wall, with a flow rate of approximately 2 L/min, and the antibiotic dose was found in the garbage can. As post-mortem lividity was present, no resuscitation attempts were performed by the clinicians and the death was pronounced. The body was immediately brought to the University Center of Legal Medicine (Lausanne, Switzerland).\nBefore any manipulation of the corpse, a native CT scan was carried out at around 10 h post-mortem using an eight-row CT unit (CT LightSpeed 8, GE Healthcare, Milwaukee, WI). All scanning parameters are detailed in . A forensic pathologist immediately viewed the native CT images. To evaluate the distribution of gas because of physiological changes in the body after death, the radiological alteration index (RAI) was used as proposed by Egger et al. []. The RAI was based on the analysis of samples from seven sites (heart cavities, liver parenchyma and vessels, left innominate vein, abdominal aorta, kidney parenchyma, L3 vertebra and the subcutaneous pectoral tissues).\nAll images were interpreted in a consensus reading by one board-certified radiologist and one forensic pathologist who were trained in forensic imaging. A post-mortem radiological report was prepared and described all findings from the native CT scan. The native CT scan revealed the presence of subcutaneous, intramuscular and intravascular gas,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old female patient presented suffering from pain in the left upper arm over two months. The patient had been diagnosed with CCD at another hospital based on clinical features, radiographic findings, and genetic testing. The clinical characteristics included hypoplasia of the clavicles, narrow pelvis, short stature, and craniofacial malformations (). Physical examination of the left upper arm revealed no findings of redness, swelling, or tenderness. Radiographic examination revealed radiolucent lesions without any periosteal reaction in the humerus (). Magnetic resonance imaging (MRI) showed a low-signal-intensity lesion on T1-weighted images and a high-signal-intensity lesion on short-tau inversion recovery (Figures and ). In addition, a remarkable signal enhancement in the segment was found on contrast-enhanced T1-weighted MRI. A plain computed tomography (CT) showed calcification in the whole diaphysis of the left humerus (). Bone scintigraphy demonstrated increased focal uptake in the lesion (). For definitive diagnosis, we performed an open biopsy of the lesion. Based on histopathologic examination of the biopsy specimen, we diagnosed the patient with conventional chondrosarcoma in the left humerus (). On the other hand, we could not find any positive immunostaining cell for Runx2 in the lesion () and excluded metastasis of pulmonary or other lesion based on the findings of radiographs, CT, and bone scintigraphy. Thereafter, we performed wide resection of the lesion in the proximal humerus and sling procedure using free VFG for reconstruction of the large bone defect (). The distal end of the grafted bone was fixed to the proximal stump of the humerus with a locking plate. The tendons of the biceps femoris and palmaris longus, which were looped around the acromion with rotator cuff resection, were used to suspend the head of the fibula for reconstruction of the shoulder joint (Figures and ). The resected tumor was finally diagnosed as chondrosarcoma gr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case presents a 68-year-old female patient with a chief complaint of swollen gums and pain on mastication which has been recurring for the past 5 years. According to the patient, she started taking amlodipine 5 mg/day 7 years ago and started experiencing enlargements of the gingiva 5 years ago. She stopped taking amlodipine for 6 months and claims the enlargements improved. However, her physician recommended that she continue taking amlodipine 10 mg/day due to her uncontrolled hypertension. Medical history was taken in which the patient reported having diabetes mellitus type II and hypercholesterolemia for the past 8 years. She takes a series of drugs for her medical conditions (). She has been hypertensive for the past 7 years and has been taking amlodipine since then. She stopped amlodipine 2 years ago for 6 months due to gingival overgrowths; however, amlodipine had to be continued due to her uncontrolled hypertension.\nOn taking dental history, it was found that she underwent multiple gingivectomies in the past with recurrence every few months. During previous episodes, the patient had described the condition as similar to the one presented currently with excruciating pain and pus discharge. Furthermore, the patient described the treatment advised as “gum shaping by the doctor”. From patient's explanations, it was assumed that the clinical picture matched the current situation, and a history of NUG could have been prevalent at that time period.\nThe patient presented with a dental history that includes thick deposits of calculus and plaque on all remaining teeth with fibrous, nodular, hard gingival overgrowths extending to most of the clinical crown in the anterior and posterior parts of the maxillary and mandibular arches (). The overgrowths can be classified as grade III according to Bokenkamp's 1994 classification for gingival overgrowth [] (). Additionally, a yellowish-white pseudomembranous slough was found covering the interdental papilla in the mandibu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old woman with sudden chest pain and dyspnea was admitted to the emergency room and intubated on arrival owing to disturbed consciousness. She had hypertension but no history of asthma or chronic obstructive pulmonary disease. Chest radiography showed mediastinal widening (Fig. a). Computed tomography (CT) of the chest revealed rupture of the descending thoracic aortic aneurysm, which compressed the lower trachea and both main bronchi. The maximal diameter of the aneurysm at the level of the carina was 9 cm (Fig. b, c).\nEven with aneurysmal rupture, after intubation and during the diagnosis, her vital signs were maintained stable enough to be transferred to our hospital. We performed an emergency thoracic endovascular aortic repair (TEVAR, seal stent graft S&G Biotech Inc., Yongin-si, Korea, proximal 34 × 30 × 110 and distal 28 × 110). TEVAR was performed uneventfully and following admission to the intensive care unit, her vital signs were stable.\nHowever, even with the mechanical ventilator support, carbon dioxide (CO2) retention was not easily resolved, and sudden oxygen desaturation with unusually high airway pressure and low tidal volume was repeated. Moreover, the suction tube was difficult or unable to pass the endotracheal tube. We were aware that the patient had airway compression in the initial CT, but anticipated that the extrinsic compression pressure of the ruptured aneurysm would be relieved after the TEVAR. Due to the failure to wean the patient from the mechanical ventilator, the follow-up chest CT was performed. Despite the stent graft in the aorta (Fig. a), the hematoma of the ruptured aneurysm continued compressing the lower trachea and both main bronchi (Fig. b, c).\nWe planned to insert a silicone bronchial stent under rigid bronchoscopy. However, after removal of the endotracheal tube, the rigid bronchoscopy was unable to enter the trachea. Further, re-intubation was not possible even with the anesthesiologist owing to the extrinsic pre"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 5-month old female Swiss Mountain dog presented to the local veterinary practice for clinical evaluation of gait abnormalities of the hind limbs. The orthopedic examination revealed lameness in the lower right hind limb and a bony thickening at the level of the metatarsophalangeal joint between the II and III digit phalanges, covered with normal skin. The complete blood count, serum chemical and electrolyte analyses were within normal limits, apart from elevated levels of calcium and phosphorus, which were attributed to the young age (5 month) of the animal (Table ). The dog underwent a radiographic examination. Two well-defined lesions within the right II and IV phalanges of the right pelvic limb were found (Fig. a), in the shape of well circumscribed, mineralized new bone formation with a trabecular pattern. The dog underwent surgery to remove the lesion on the II phalange, and the excised tissue was sent for a histopathological examination. This revealed well-differentiated bone tissue, hyaline cartilage, and fibrous tissue in addition to hematopoietic tissue and connective tissue. Based on the histopathological findings, multiple cartilaginous exostoses (ostechondromatosis) were diagnosed. In the 1 month follow-up examination, the dog showed progressive ataxia of hind limb, a stiff gait and hyperesthesia in the thoracolumbar vertebral column. Radiographs of the hips and vertebral column exposed similar lesions to those in the pelvic limb. They were located in the distal part of the femur, on the tail and on the thoracic spinous processes of the lumbar vertebral bodies (Fig. b, c) and on the ribs (Fig. b).\nAt the age of 8 months, the dog was presented to the Wrocław University of Environmental and Life Sciences at the Department of Internal Medicine with Clinic of Horses, Dogs and Cats for neurological assessment. The neurological examination revealed a wide-based stance and proprioceptive ataxia in the hind limbs, moderate proprioceptive deficits in the hind l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old man presented with a 2-month history of facial pain and limited mouth opening associated with a 3-week history of swelling of the right cheek. Radiographic analysis revealed a loculated, fluid-filled, well-demarcated lesion destroying and expanding the ascending ramus, extending out into the soft tissues, from the condyle down to the angle (Fig. ).\nIncisional biopsy and histological examination revealed KCOT.\nA decision was made to decompress the lesion to try and shrink the cystic space, encouraging bony infill. Over the following 3 months the patient underwent a further three re-packing procedures with irrigation of the cavity. The site of the cyst and difficulty of access necessitated general anaesthesia. The patient was admitted on one occasion for intra-venous antibiotics following an acute infective episode affecting the area. During the third operative procedure a split nasopharyngeal tube was inserted into the cyst cavity and sutured in position (Fig. ). The patient was encouraged to flush the cavity clean through the tube drain.\nRadiographic examination over the following few months showed new bone formation and within 9 months of the initial biopsy the drain was expelled by formation of new bone (Fig. ). One year after the commencement of treatment the patient was admitted for enucleation of the cystic remnant. At the time of this procedure a small cyst was removed from the right upper ramus and condylar neck, together, with a separate cyst associated with the lower right wisdom tooth. The patient made an uneventful post-operative recovery and histology revealed two KCOTs with a thick parakeratinized type of epithelium typical of radicular cysts.\nPlain films along with CT scan, with 3 mm slices, were performed a further year later and showed good bone regeneration in the right ramus and condylar neck (Figs and ). No evidence of cystic recurrence was seen and no abnormalities within the adjacent soft tissues. High-resolution magnetic resonance"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old Caucasian male presented to dermatology for initial evaluation of multiple recurring cysts, nodules, and papules. For several years, his family medicine physician treated him for sebaceous cysts (by local excision) located mostly on his upper back, but recurrence and complexity warranted further evaluation. At this visit, he described the presence of cysts that would come and go, occasionally becoming inflamed and tender. He also inquired about numerous white facial papules that were otherwise asymptomatic.\nThis patient had struggled with inflammatory cysts and other skin lesions for many years before being tested for BHD. In 2011, he had a large 11 cm x 7 cm painful fluctuant cystic structure located over the upper thoracic spine, along with about 20 small scattered furuncles distributed across his back. The examination also revealed a chronic non-inflamed sebaceous cyst, 2 cm x 4 cm, located anterior to the left knee. In 2015, the patient developed another sebaceous cyst, 1 cm in size, located near his right jaw. The smaller nodules scattered across his back were still present and would come and go.\nPhysical exam findings from the dermatology visit showed a 1 cm firm mobile nodule on the right cheek, a 2.5 cm firm mobile nodule on the right upper back (epidermoid cyst), and several 1 cm firm mobile nodules on the right superior back. Additionally, the patient had numerous white 0.2-0.4 cm papules distributed across his nose, cheeks, and forehead.\nThe numerous white facial papules raised concern for genodermatosis, specifically BHD syndrome or Cowden syndrome. Interestingly, the patient reported they had been present for many years, but they were not mentioned in previous records. A shave biopsy of one of the papules was sent for histopathological analysis and identified as a perifollicular fibroma. This piece of information was instrumental in leading toward an eventual diagnosis. The further genetic evaluation confirmed the presence of an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old Afghan woman from Afghanistan presented with abdominal pain and swelling in her right hypochondrium. The clinical differential diagnosis included simple liver cyst and hydatid cyst. A CT scan of her abdomen and pelvis showed a large cystic lesion in her right upper abdomen measuring 17.0 × 17.0 × 15.0 cm in dimensions. It was pushing the hepatic flexure inferiorly and right kidney posteriorly and abutting the head of her pancreas and the anterior abdominal wall anteriorly. It was abutting the right lateral abdominal wall on the right side and lesser curvature of her stomach on the left side. It demonstrated few enhancing septa. No solid areas or calcification were seen. It was difficult to determine the exact site of origin. However, it seemed to be arising from her liver with exophytic growth in a downward direction. Her intrahepatic ducts were not dilated. The cystic mass was pushing her portal vein upward. Her portal vein was however normal in diameter. The mass was pushing her gallbladder and her right kidney downward (Fig. ). Differential diagnoses of hydatid cyst of the liver and large necrotic abscess were given. She underwent excision of “liver cyst” in November 2012. The specimen was received as a single, flattened, irregular, firm tissue piece, which appeared to be part of a cyst wall. It measured 4.5 × 3.5 cm in diameter and was 0.4 cm in thickness. The outer surface was gray white and shiny. The inner surface was tan brown with hemorrhagic areas. Solid or nodular areas were not seen. The microscopic sections showed a cyst wall lined by a single layer of mucinous columnar epithelium with subepithelial spindly ovarian-type stroma. There was no dysplasia. The acid mucin in the epithelial cells was highlighted on mucin stain (PAS+/−AB); epithelial cells and stroma were positive for IHC stains CK AE1/AE3 and ASMA respectively. A diagnosis of intrahepatic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old male was admitted to hospital emergency due to 4 h of chest pain in 13 January 2016. In fact, he had suffered from fatigue after activity for more than 10 days and felt chest tightness and chest pain for 4 days before admission. The patient, a taekwondo trainee, had a healthy body, and his family history was unremarkable. Emergency aortic computed tomographic (CT) scan showed a thickened aortic wall, bilateral pleural effusion and pericardial effusion (Figs. a and b). Cardiac colour ultrasound suggested aortic hematoma or dissection (Fig. ). On the basis of the condition and the results of auxiliary examination, the formation of aortic dissection should be considered. The next day, after excluding surgical contraindications, the patient was performed an emergency operation. Cardiac surgeons underwent ascending aortic replacement and aortic arch replacement. They developed postoperative comprehensive treatment measures, including anti-infection, adjustment of cardiac function, nutritional nerve and symptomatic supportive treatment, and the patient recovered well and was discharged after 15 days. The cause of aortic dissection was unclear, although the surgeons extracted arterial tissues and pericardial tissues and sent them for pathological examination. In fact, postoperative pathology of the aortic wall tissue showed aortitis, such as visible necrosis, granulation tissue hyperplasia and a large number of acute and chronic inflammatory cell infiltration (Figs. b, c and d). However, the surgeons and the pathologist at the time did not consider the cause of aortitis or aortic dissection due to GPA because of a lack of understanding of GPA-induced aortitis or aortic dissection. This event is one of the starting points of our study. We want to attract the attention of clinicians. GPA is also a common cause of aortitis and even aortic dissection.\nOn the first day of 2017, the patient was re-examined for aortic CT because of a 6-day fever and right chest pain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman at the time of the first operation was referred after identification of a tumor embolus inside the hepatic vein on abdominal ultrasonography during a medical examination. The tumor was suspected to be leiomyosarcoma of the IVC localized to the middle segment on dynamic CT, and surgery was performed (). The segment of the IVC from the renal vein junction to the diaphragm was approached using an epigastric region L-shape incision and de-rolling of the liver. First, the IVC and bilateral renal veins were clamped on the distal side, but no decrease in blood pressure was observed. Then, the IVC on the proximal side of the hepatic vein junction was clamped after performing hilar clamping with the Pringle technique. The tumor had originated in the venous wall of the middle segment of the IVC, reaching the porta hepatis and growing into the lumen. The tumor with the IVC was widely excised with adequate margins. The proximal clamp was then transferred to the IVC in the lower liver to release the hilar clamp, and the resected vessel was replaced by an artificial graft (expanded polytetrafluoroethylene (ePTFE); 16 mm with ring) by simple clamping (). She was discharged 20 days postoperatively without any major complications.\nMicroscopically, the lesion comprised fascicles of spindle-shaped cells with blunt-ended nuclei and was diagnosed pathologically as leiomyosarcoma originating from the IVC (). Excisional margins were negative for tumor cells.\nNo adjuvant therapy such as chemotherapy or radiation was performed. After discharge, the patient underwent annual follow-up PET-CT and magnetic resonance imaging (MRI). Two years after the first operation, PET-CT showed an intense accumulation of fluorodeoxyglucose (FDG) at the anastomosis on the distal side of the graft, and tumor recurrence was suspected ().\nContrast-enhanced CT revealed an extramural mass approximately 2 cm in diameter growing on the lower side of the pancreas head at the distal anastomosis of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old man presented to the emergency department with a 1-month history of intermittent nausea, chills, and jaundice. Preoperative laboratories revealed an elevated total bilirubin and alkaline phosphatase. Serum tumor marker analysis revealed a normal carcinoembryonic antigen (CEA) but an elevated CA 19-9. The patient underwent a magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography that revealed thickening of the proximal common bile duct with proximal biliary dilatation and an absence of distant disease. Incidentally noted on the MRI was that the third portion of the duodenum did not cross to the left of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), and the majority of the small intestine lies in the patient's right abdomen, whereas the large intestine lies in the left. Also, the SMA lies to the right of the SMV consistent with gastrointestinal malrotation (). The patient underwent endoscopic retrograde cholangiography with biliary endoprosthesis placement for decompression. Upon surgical exploration, a mass was identified in the proximal common bile duct (with no evidence of disseminated disease) and gastrointestinal malrotation was confirmed. Oncological resection of the extrahepatic biliary tree was performed from the level of the bifurcation of the right and left hepatic ducts to the intrapancreatic portion of the bile duct, along with a portal lymphadenectomy. A biliary enteric reconstruction was created with a Roux-en-Y hepaticojejunostomy. To compensate for the malrotation, the proximal jejunum was divided 50 cm distal to where the duodenum exited the retroperitoneum and the 50 cm Roux limb was brought up in a right paracolic position rather easily, as the hepatic flexure of the colon was absent, such that it simply rested over the top of the duodenum. An end-to-side hepaticojejunostomy was formed in a single layer, and the Roux limb was tacked down to the retroperitoneum to prevent intestinal hernia"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old man was lost consciousness and was transferred to our hospital. The patient had a history of testicular cancer treated with chemotherapy 2 years earlier and was in remission. He was barely able to communicate, and the complaint was unknown. Furthermore, he was in shock with cold extremities. His blood pressure was unmeasurably low, and neither the radial nor the common carotid artery was palpable. However, his limbs were still moving. His Glasgow Coma Scale result was E1V2M4 and his mental status was agitated state. Peripheral intravenous infusion was initiated and transthoracic echocardiography revealed pericardial effusion and almost no systole. Pericardial fluid was hyperechoic, which could signify hematoma formation. Pericardiocentesis was duly considered, but if a hematoma was present, it could have led to insufficient drainage. We decided to initiate ECMO in the emergency ward based on a judgment of obstructive shock or cardiogenic shock. Seven minutes after arrival, cardiopulmonary resuscitation (CPR) was started because of CPA (his breathing and limbs stopped moving), before beginning ECMO. We also considered emergency left thoracotomy, but ECMO was prioritized. We inserted an ECMO catheter under ultrasound guidance. ECMO circulation was started 17 minutes after arrival and 10 minutes after CPA. Twelve-lead electrocardiography (ECG) revealed a QS pattern and ST elevation in leads V1-V5 (Figure ). We did not drain the pericardial fluid, but ECMO flow was stabilized using rapid infusion. The patient was immediately cooled with ECMO and reached a body temperature of 34°C 23 minutes after CPA. He was then transferred for computed tomography (CT) for diagnosis. Contrast-enhanced CT showed no acute aortic dissection (AAD), but the anterior wall myocardium showed poor contrast; hence, we diagnosed LVFWR. According to his family, he had never complained of chest pain. We assumed that the myocardial infarction had occurred 12 to 24 hours before his arri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman presented to us after an accident in which her back was impacted by an 80-kg-heavy-giant rubber tire with metal wheel hub. When the tire fell down from about 10 m high, the patient was standing right under it and the middle thoracic back was hit by the tire from above. She felt pain in her back and remained in place until emergency personnel arrived. After conservative management in the local hospital for 3 days, the patient was transferred to our hospital safely. During the 3 days in the local hospital, the patient received neurotrophic factors and antithrombotic reagent given by venous transfusion without any reduction treatment and she hesitated to accept a surgery. Upon examination, her blood pressure was 142/94 mmHg, pulse rate 60 per minute, respiratory rate 15 per minute, and body temperature 37 °C. She denied numbness and weakness in her extremities. Physical examination revealed that she was neurologically intact without focal sensory or motor deficits and had normal reflexes. Neurological examinations revealed a Frankel grade E. According to ASIA scoring system, the patient got 112 points for light touch sensation, 112 points for pain sensation, 50 points for the upper limb main muscles, and 50 points for the lower limb main muscles. No perianal sensory was lost. Normal anal contractility and sphincter reflex were observed. A severe tenderness point was found in the middle back. She had Medical Research Council (MRC) grade 5 power in both lower limbs. Associated injuries were pulmonary contusion resulting in right pleural effusion, which was treated by chest tube insertion in the local hospital. No neurogenic bladder or fecal incontinence was observed.\nSpine radiography revealed a burst fracture of T7 with complete fracture-dislocation and sagittal displacement of the T6-7 vertebrae (Fig. ). Spinal computed tomography revealed fractures involving the left pedicle of T4; spinous process, vertebral laminae, and bilateral pedicles of the T"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old left-handed man who works as a mechanic and firefighter presented to our institution with hand pain and cold intolerance for 3 months. He was referred by a local vascular surgeon who had made the diagnosis of hypothenar hammer syndrome (HHS) following an angiogram of the right upper extremity showing complete occlusion of the ulnar artery (). On initial examination, Doppler signals of the ulnar artery, superficial palmar arch, and ring/small digital arteries were absent in the right hand. Subsequently, the patient developed an ulcer on his right long fingertip after minor trauma that had not healed over a 4-week period. He suffered ischemic hand pain and severe cold intolerance. After conservative management failed, the decision was made for operative intervention. We proposed using an arterial graft versus a venous graft in order to improve long-term patency. Our plan was to utilize the descending branch of the lateral circumflex femoral artery (DLCFA) as an arterial graft.\nIntraoperatively, Doppler ultrasound revealed a segmental thrombotic defect extending from the superficial palmar arch, across the Guyon canal, extending 10 cm proximally in the forearm. The ulnar artery was resected back to healthy bleeding pulsatile flow, resulting in a segmental defect of 12 cm. Final pathology of the submitted ulnar artery segment revealed organizing thromboembolus in the lumen, which at the time of resection was adherent to the lumen.\nThe DLCFA was harvested, with care taken to prevent injury to the lateral femoral cutaneous nerve. A 12-cm segment of the artery was circumferentially dissected, as well as approximately 2 cm of 2 branching vessels at the distal end of the segment that would be used to reconstruct the superficial palmar arch and common digital arteries with one graft. With the arterial graft completely dissected, it was ligated both distally and proximally.\nThe arterial graft and recipient vessels were examined under the operative microscope. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old lady presented with left supraorbital firm swelling for 3 months which started as a nodule of the size of a grain of rice. Swelling increases in size rapidly involving eyelid, entire orbit, and subsequently to the forehead. It also becomes intermittently painful. She started to loss her left eye vision gradually until it completely loss one month later. The patient presented to the ophthalmology clinic where further investigations were done. On examination, there was a huge soft to firm lesion involving entire left orbit extending to nasal bridge and forehead as shown in . Right eye vision is 6/12 with no visual field loss but left eye completely blind. There is no nodal involvement or organomegaly. Further detailed investigations ruled out systemic involvement. Computed tomography (CT) orbit and CT brain done as shown in . Due to the intracranial extension of the tumor, magnetic resonance imaging brain was done as shown in and the patient was referred to neurosurgical. The patient was planned for surgery electively 2 weeks later. On the day of admission 1 day before surgery, the tumor size has doubled compared to its size in clinic review 2 weeks prior. The patient subjected to craniotomy with total tumor excision and reconstructive cranioplasty approached through a bifrontal incision.\nIntraoperatively, the tumor is fleshy, friable, well defined, and highly vascular. The tumor noted to originate from orbital adnexa but sparing the globe. There is an invasion of bone and dura over the frontal lobe with 2 cm by 2 cm intracranial extra-axial tumor in the left frontal convexity. The frozen section was sent intraoperatively and reported as malignant tumor unable to rule out lymphoma. Thus, complete excision of the tumor was done including the bone, dura, and the intracranial tumor. Nasal bridge, frontal bone, and left eye orbital wall completely eroded by tumor, thus, needing reconstructive cranioplasty with titanium mesh, nasal bridge repair with sugar me"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male patient visited our clinic in May 2005 due to detachment of a porcelain-fused-to-metal crown on the left maxillary central incisor, which had been connected at another clinic in 2000.\nThere were no special findings in his physical and extraoral conditions. On intraoral examination, mesiodistal fracture lines were found on the remaining tooth structure. A swelling and slight redness were observed on the peripheral soft tissue, but there were no acute symptoms such as purulence or pain [Figure and ].\nRadiographic examination showed no inflammatory symptoms, such as an increased periapical space, bone resorption, or periapical radiolucency, thus, the inflammation was judged confined almost exclusively in the gingival tissue. A nasopalatine foramen was found adjacent to the apex of the maxillary left central incisor [].\nThe maxillary left central incisor had a root fracture and required extraction. After a careful consultation about various treatment options, the patient desired implant treatment. Because there existed no obvious signs of acute inflammation or any other symptoms of the soft and hard tissue, postextraction immediate implant placement was planned. Prior to the implant treatment, the patient was subjected to meticulous scaling of all the remaining teeth and oral hygiene instruction session.\nIn May 2005, the maxillary left central incisor was extracted. After careful curettage of the extraction site, the mucoperiosteal flap was reflected. There was no resorption of the labial bone and an implant (TiOblast, Astra Tech, Mölndal, Sweden, ø 4.5 mm, length 13 mm) was placed into the fresh extraction socket with good primary stability. The osteotomy was made so that the implants would be located centrally in relation to the socket; however, careful drilling was conducted in order to preserve the buccal wall. The gap between the fixture and the socket wall was filled with autogenous bone particles collected during the surgery. The wound was clos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-years old unmarried female from Bajura district of Nepal came to the dermatology out-patient department with a complaint of a single plaque over the right upper lip for the last 6 months. Lesion started as a small red papule which gradually increased in size with central crusting. No history of fever or weight loss was given. There was no significant family or medical history. Multiple over the counter treatment was used as trial without relief. There was no history of travel outside of her village until the time for consultation.\nOn examination, a single round to oval crusted plaque approximately 1.5 × 1.5 cm was noted over the right upper lip. Neither an induration nor easy bleeding was noted. No regional lymphadenopathy was present ().\nA slit skin examination was done for acid-fast and Giemsa stain which was negative for any organism. An incisional biopsy was done which showed multiple epitheloid type multinucleated giant cells suggesting Lupus vulgaris. However, a mantoux test revealed an induration of only 2 mm in 48 hours.\nThe morphology of lesion prompted us to investigate furthermore for cutaneous leishmaniasis before starting on anti-tubercular medications. We decided to do PCR for Leishmania species from the lesion. The sample was sent to the Laboratory of the Central Department of Biotechnology, Tribhuvan University, Kathmandu, Nepal due to unavailability of PCR in the National Academy of Medical Sciences, Bir hospital. PCR was done using the nested protocol previously described by Noyes, et al. in 1998. The DNA template for PCR was extracted manually from the lesional tissue. After second-round PCR, a band size corresponding to the size of approximately 700 bp was obtained that confirmed the presence of Leishmania parasite (). The band size corresponded to that typical of Leishmania donovani.\nA serological test conducted with an rk39 rapid diagnostic test kit also tested positive for this case.\nAn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 56-year-old woman presenting with decompensated cirrhosis caused by hepatitis C virus (Genotype 4). As a part of our routine pre-transplant workup, we performed dynamic abdominal computed tomography (CT), which showed 2 focal hepatic lesions, measuring 1.5 and 3 cm, in the liver segments 8 and 5, respectively. On dynamic imaging, the lesion in segment 8 showed the typical vascular pattern of an HCC (), but that in segment 5 showed an atypical vascular pattern and was closely related to the inferior vena cava (). Serum alpha-fetoprotein (AFP) level was normal, but serum carbohydrate antigen 19-9 (CA19-9) level was slightly elevated (63 U/mL); extrahepatic spread was ruled out. The patient was assumed to have HCC on the basis of the presence of 2 focal hepatic lesions within a cirrhotic liver having viral hepatitis, particularly the smaller lesion in segment 8 that showed the typical vascular pattern of HCC on dynamic imaging. The model for end-stage liver disease (MELD) score was below 14; however, because the patient met the Milan’s criteria for selecting patients with an HCC for LT (), she was listed for LT and underwent uneventful deceased-donor LT after a 3-month waiting period. Histopathological examination of the explant confirmed that the lesion on segment 8 was an HCC (), but that on segment 5 was a cholangiocarcinoma (). Further histological evaluation of the lesion on segment 5 revealed that the tumor cells expressed cytokeratin (CK) 7, CK19, and carcinoembryonic antigen (CEA) and lacked AFP expression, liver-specific antigens, CK20, and CD34. The cell morphology and phenotype of the tumor cells were consistent with those of cholangiocarcinoma. Our standard immunosuppression protocol includes tacrolimus, mycophenolate mofetil (CellCept), and a tapering course of steroids; however, on the basis of the findings of the 6-week follow-up examination of the explant after LT, tacrolimus was replaced with sirolimus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old woman was transferred from another hospital after being diagnosed with COVID-19. She had been admitted to the other hospital after 8 days of fever, when she developed respiratory distress occurred during isolation. At the time of her transfer to our hospital she was being treated with empirical antibiotics and oseltamivir and was receiving 4 L/min of supplemental oxygen via nasal prongs. Her CXR and CT findings at the previous hospital are shown in . The LUS was performed with the patient in the supine position. Multiple B-lines were observed in the anterior right upper lung field, and both anterior lower lung fields, but not the anterior left upper lung field. Her lung aeration score was 3 points (), based on the LUS findings in both anterior areas. Although lopinavir/ritonavir was started immediately after transfer to our hospital, she was intubated on Day 3 after her respiratory symptoms became more severe. LUS performed on Day 4 showed a worsening of her pneumonia, with the lung aeration score of 5 points (). After mechanical ventilation, the patient’s CXR and LUS aeration score improved from 5 to 4, but her hypoxia remained severe (ratio of arterial oxygen partial pressure to fractional inspired oxygen [P/F ratio] 133 on Day 8). As a rescue therapy for ARDS, methylprednisolone (1 mg/kg intravenously) and inhaled nitric oxide were administered.\nDespite these interventions, the patient continued to deteriorate, and veno-venous extracorporeal membrane oxygenation (ECMO) support was started on Day 16. Her CXR showed worsening of her pneumonia, and a LUS performed on Day 18 (2 days after ECMO application) showed a lung aeration score of 13 points (), which was worse than it had been on Day 3 (the day of intubation). () The patient was subsequently diagnosed with hospital-acquired pneumonia caused by carbapenem-resistant Acinetobacter baumannii cultured from a respiratory sample.\nUnder the ECMO support, LUS was performed before"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old black female presented with painful lower lip swelling of 2 weeks duration. She was initially seen by a physician whom she claimed had given her anti-allergic medication and painkillers in the form of tablets for 1 week, but the situation worsened and the swelling and pain increased. She was then prescribed intravenous penicillin for another week with no improvement, after which she presented to our hospital for assessment and further management. There was lower lip swelling with discharge from the exfoliated crusted lower lip surface. The condition had started as a small pimple on her chin just below the lower lip on the left side which was painful and increasing in size. She attempted to open it and did not use any antibiotic. After 48 h she became febrile and her lower lip became swollen. She went first to a physician, then presented to our dental hospital. The patient’s medical and family history was non-contributory, and there was no history of trauma, hospitalization or current medication except those prescribed by the physician. She was lactating and had a 6 month old boy.\nThe patient’s oral cavity was examined carefully and good oral hygiene was noted. There were no obvious odontogenic causes or lip paraesthesia. Panoramic radiograph was done to exclude odontogenic causes and was insignificant. A thorough facial examination followed and a small crusted pimple was noticed on the left side of the chin. There was extensive swelling involving the whole lower lip and extending to involve the chin and submental area (Fig. ) with pus discharging from the left side of the chin just beneath the site of the pimple (Fig. ). The patient’s blood investigations were negative for HIV and hepatitis, with a TWBC of (25.8×), random blood glucose of 190 mg/dl and a creatinine of 0.7 mg/dl. She was anemic (10 g/dl), mildly hyponatremic (134 mmol/l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40 year old woman presented at our clinic with severe mitral valve rheumatic stenosis. Intraoperative findings showed a typical rheumatic disease with commissural fusion and thickened valve leaflets, but a relatively preserved mitral valve apparatus.\nWe performed a mitral valve repair consisting of bilateral commissurotomy papillary muscle splitting and placement of a rigid anuloplasty ring (SEGUIN, St. Jude Medical) N. 30. Intraoperative echocardiography showed a good performance of the valve. No stenosis and regurgitation were detected. The postoperative period was uneventful and the patient was discharged on the 7th postoperative day in good conditions. No signs of pericardial effusion were noted on echocardiography.\nThe patient was readmitted at our institution a week after on an emergency basis with clinical signs of cardiac tamponade. After confirmation by echocardiography of the presence of massive pericardial effusion, a central venous 18 F catheter was placed in the pericardial space. An amount of 1300 milky fluid was drained gradually and the patient get better. The pericardial fluid laboratory analysis showed chylomicrons and elevated triglycerides. Lymphocytes were seen on microscopy. The diagnosis of chy lopericardium was obvious. Microbiology studies were negative. Parenteral nutrition was initiated and oral nutrition was stopped. Somatostatin 0,6 mg three times a day and antibiotic prophylaxis was constituted. The patient was treated conservatively for 30 days.\nThe average daily drainage was 75 ml but it did not decrease and stop during this period. Under these circumstances and taking in consideration the prevention of other complications we decided to reexplore the patient in sternotomy in an attempt to find the place of the leakage and close it. The patient was given to eat fat 12 hours before surgery and on the operating room by gastric tube. No place leakage was observed. We ligated and sutured thymus gland remnants and the pericardial edges wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old female had a car accident and sustained fracture of both tibial bones. She underwent internal fixation of the fractured tibial bones under general anaesthesia. One week later she developed generalized muscle weakness and acute respiratory distress. She was transferred to the ICU where mechanical ventilatory support was given after intubation. Clinically she had bilateral lower motor neuron facial palsy and quadriparesis. The upper limb power was 3/5 bilaterally and lower limbs were 0/5 proximally and 2/5 distally. She had total areflexia of all four limbs and the plantar responses were mute. She was assessed by a neurologist and a diagnosis of acute GBS was suspected. Nerve conduction study (NCS) showed prolonged distal latencies, absent H reflex and reduced conduction velocities suggestive of acute demyelinating polyradiculoneuropathy. The blink reflex was abnormal with prolonged motor latency of both facial nerves. The patient refused lumbar puncture, hence cerebrospinal fluid examination was not done; as she complained of back pain. Other investigations including full blood count, blood biochemistry, autoimmune screen, protein electrophoresis, and porphyria screening were negative. Serological tests for Mycoplasma pneumonia, Epstein-Barr virus and hepatitis virus were negative. The clinical picture and electrophysiological findings were consistent with GBS. She was treated with intravenous immunoglobulin (IVIG; 0.4 g/kg for 5 days). While in the ICU she developed severe bulbar weakness. After the first course of IVIG, she started to improve slowly. The facial weakness and motor power in her limbs improved slowly. However, weaning from the ventilator was delayed due to bulbar weakness and inter-current respiratory tract infection. A second course of IVIG was given after 2 weeks. Chest infection was treated with piperacillin and tazobactam along with chest physiotherapy. Subsequently she recovered and after 3 weeks of ICU care, she was extubated. This"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old Korean male patient presented with an ill-defined erythematous indurated patch on the umbilicus (). The patient had not received any treatment for 1 year as the lesion was asymptomatic. Recently, the patient was referred to our center after an incisional biopsy. The tumor was cleared after three stages of MMS. We received the patient's consent form about publishing all photographic materials.\nHistopathologic examination revealed basaloid tumor cells forming nests and cords in the dermis and subcutaneous tissue (). The tumor showed cribriform or tubular structure without connection to the epidermis. Abundant mucin was observed inside the tubular structure (). Tumor cells had hyperchromatic nuclei but did not demonstrate distinct cellular atypia (). Immunohistochemical study against receptor tyrosine kinase (cKIT) and epithelial membrane antigen (EMA) showed strong positive for tumor cells. The tumor was diagnosed as ACC upon histopathologic examination and immunohistochemical study. Physical examination and whole-body positron emission tomography fused with computed tomography (PET/CT) performed to exclude the possibility of metastasis from other original lesion showed no evidence of additional lesion. Finally, the patient was diagnosed as PCACC.\nIn the process of removing the tumor, the umbilicus was completely eliminated with an asymmetrical defect that extended into the left upper quadrant, which required elaborate reconstruction. The size of the postoperative defect was 2.0×1.8 cm (). An elliptical repair was done at the left side of the defect to close the paramedian defect as well as to remove the dogear. To close the remaining central defect and to recreate the concavity of the umbilicus, about 0.5 cm of the soft tissue was removed from the surgical margin, deeper layered purse string sutures were placed to adjust the size of the umbilicus, and the superficial purse string suture involving the dermal layer was tacked at 3 areas at 12, 4, and 8 o'"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the history of an 82-year-old man with chronic lymphatic leukemia (B-CLL), diagnosed in 2004 who received rituximab, fludarabine and cyclophosphamide for four cycles between May 2010 and October 2010 as first-line therapy. The past medical history showed arterial hypertension and prostate cancer treated with radical prostatectomy in 2005.\nIn July 2014, an SCC of the skin located in the scalp was diagnosed and completely resected without any signs of metastases. At that time, there was no sign of progressive B-CLL. In January 2015, the patient presented with progressive lymphadenopathy, night sweats, fever and weight loss and a worsening of peripheral blood count with a decrease in hemoglobin (from 11 to 9 g/dl) and a reduction of thrombocytes (from 60 to 20 × 109/l). Further examinations revealed a progression of the B-CLL with generalized lymphadenopathy and an increase in monoclonal B-CLL population (up to 65%) in peripheral blood detected by FACS. Therefore, salvage therapy with ibrutinib was started in January 2015.\nAfter an initially very good response to ibrutinib with fast significant lymph node regression and improvement of the peripheral blood count, in February 2015, he presented with progressive painful cervical swelling and numbness of the right side of his face. At that time, the B-CLL was in stable remission, and therapy with ibrutinib was stopped immediately. An MRI scan revealed a progressive cervical tumor. A lymph node biopsy showed an infiltration of a keratinizing, moderately differentiated squamous cell cancer of the skin due to a metastatic manifestation of the squamous cell cancer of the scalp diagnosed in July 2014. In February, first-line treatment with primary radiochemotherapy (cisplatin 20 mg/m2 days 1–5 and radiation with 60 Gy) was initiated. He received a total of three cycles until April 2015. There were no signs of metastases at the end of therapy. However, the primary tumor, located retroauricular, was not resectable"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old man, who had experienced sudden weakness and numbness in the left lower extremity for 4 weeks, visited our emergency department for evaluation and treatment. Over several days, his gait disturbance gradually worsened and the numbness had extended to the left upper chest region. There was no evident traumatic episode before admission. A physical examination conducted at presentation revealed gait disturbance with spasticity. He was able to stand by himself, but needed a crutch for walking. A neurological examination showed motor weakness of left lower extremity (Grade IV). In addition, sensory disturbances of vibration and positional sensation were present on the left side below the T4 dermatome. Impaired perception of pain and temperature stimuli were also noted on the right side below the T4 dermatome. Brown-Séquard syndrome of the cervicothoracic or thoracic spine was then suspected. Plain radiographs of the cervical spine showed multiple degenerative changes. Accordingly, magnetic resonance imaging (MRI) of the whole spine was performed. Sagittal T2-weighted MR images revealed a left-sided cystic extradural lesion at the C7-T1 junction (), and axial images showed that the extradural cystic lesion markedly compressed the spinal cord (). The lesion appeared homogenously isointense on T1 weighted images and exhibited heterogeneous high signal intensity on T2 weighted images. Under a presumptive diagnosis of a cystic lesion in the lower cervical spine, emergent surgery was performed. Because there were additional osteophytes causing cord compression at C4-5 and C5-6, modified expansive laminoplasty of C5-6 and a laminectomy of C7 followed by complete removal of the extradural cyst were performed. The lesion was homogeneous, bright yellow in color, firm in consistency, and slightly adherent to dura mater, and contained a small amount of serous fluid. Pathological examination showed the cyst to be composed of fibrous connective tissue and to have a distin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old male, a seasoned cyclist with no past medical history, presents to the emergency department with complaints of lightheadedness and diaphoresis after a bicycle fall. Patient was participating in a bicycle race when another rider ahead of him fell causing the patient to swerve to avoid him. Patient states that he fell on his left side and hit a tree with his right leg. Patient was wearing a helmet and did not suffer any chest or head trauma. After the fall, he felt lightheaded and diaphoretic and complained of mid back pain. Patient denied any chest pains or shortness of breath. Patient was subsequently brought to the hospital directly following the accident by ambulance.\nIn the emergency department, patient was noted to be in no acute distress; initial blood pressure was 128/69 mmHg with pulse of 65 beats per minute. He was afebrile, not tachypneic, and well appearing with marked right thigh swelling and tenderness to his medial thigh. Given the dizziness and diaphoresis initially, patient had an ECG performed which showed lateral ST segment elevation () and had a subsequent troponin I that was positive, 0.49ng/mL, with a Creatine Phosphokinase (CPK) of 617 U/L.\nThere was initial concern for a possible cardiac contusion, although the patient had no chest wall trauma and thus was admitted for further evaluation. As an inpatient, an echocardiogram was performed demonstrating normal right and left ventricular function and trace pericardial effusion while the patients troponin continued to trend upwards towards a maximum of 21ng/mL. He was loaded with Aspirin and Clopidogrel as well as initiation of a heparin infusion, Lisinopril, and a Beta Blocker. Coronary angiography was subsequently performed demonstrating a spontaneous coronary artery dissection of left anterior descending coronary artery. No further diagnostic study was performed at that time. Further history revealed that he took multiple caffeine Jello shots and drank a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 2. The patient was a 40-year-old female without history of smoking and with a history of exposure to birds. She had a history of childhood asthma and a family history of breast cancer. She was diagnosed at 37 years with bilateral invasive ductal carcinoma with axillary lymph node metastasis during pregnancy. She received neoadjuvant chemotherapy before surgery with Adriamycin and cyclophosphamide followed by docetaxel. She underwent bilateral mastectomy with dissection of axillary lymph nodes and received adjuvant chemotherapy with 4 cycles of cyclophosphamide, methotrexate, and fluorouracil with concomitant radiotherapy afterwards. The initial chest radiography after the diagnosis of breast cancer was normal. However, in the follow-up chest radiographs, a progressive loss of lung volume at the expense of the upper lobes was noticed, which manifested by superior shrinkage and distortion of the pulmonary hila, and the appearance of coarse irregular linear opacities at higher fields and biapical pleural thickening with linear opacities of scar appearance in the neighboring lung parenchyma (see ). 15 months after radiotherapy, the patient presented with acute dyspnea and chest pain. She was diagnosed with right spontaneous pneumothorax that required thorax drainage.\nSubsequently, she presented exertional dyspnea with ordinary physical activity (New York Heart Association Functional Class II) and dry cough, for which she was referred to our consult for further study.\nOn physical examination, she had a low BMI of 19, no acropachy, and diminished global vesicular breath sound. The chest X-ray showed worsening compared to the previous one, with apical pleural thickening, hilar retraction, and flattened thorax on the lateral projection ().\nThe first HRCT performed to this patient 16 months after diagnosis of breast cancer showed only discrete linear opacities of fibrotic appearance in both lung apices.\nHowever, the second HRCT, performed during the period in which the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-day-old-male baby, born at 35 weeks gestational age with 2 kg birth weight was referred for ROP screening. During the early neonatal period, there was a history of multiple systemic problems like shock, seizures, anemia, and respiratory distress syndrome requiring ventilator support for four days. The child was diagnosed to have stage 3 zone 2 posterior ROP with flat neovascularization, multiple vascular loops with intraretinal shunts in zone 2 posterior avascular retina, and plus disease in both eyes. In view of anticipated rapid progression, laser photocoagulation by Indirect ophthalmoscope laser delivery (LIO) was planned. Detailed history regarding COVID symptoms and travel from containment zone, elicited from parents, was negative. COVID-19 status of the parents and child was unknown. After obtaining informed consent from parents, the baby was taken up for LIO under topical anesthesia.\nLaser treatment in a crying baby can be a significant aerosol-generating procedure.[] To avoid this, an ACB was used. ACB has six sides, named A-F, described in detail later. The baby was dressed up in OR (operating room) dress and covered with a small blanket, adequate to prevent hypothermia. Trained OR assistants handled the baby under the supervision of the anesthetist and the surgeon. The baby was placed inside the ACB and removed via the open side B after lifting the plastic sheet. For easy access by the surgeon, the baby was placed over two pillows covered with blankets inside the ACB. ECG chest leads, and pulse oximeter probe were connected and, heart rate and oxygen saturation were monitored by an anesthetist throughout the laser procedure. The suction machine attached to a suction tube passed through Side A aperture was switched on. The baby was held by an assistant through side B, while the surgeon did laser by passing the hands through the holes in sides C, D, and E []. The laser was performed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 29-year-old pregnant female, who originally presented with a small nodule on the tip of her right nipple, at approximately 28 weeks of gestation. The lesion increased in size over the next few weeks and showed no improvement with a 2-week course of antibiotic treatment (Keflex). Due to the progressive increase in the size of the lesion, the patient was referred to a general surgeon and underwent an incisional biopsy. As seen in Figures and , the biopsy showed fragments of squamous epithelium with hyperkeratosis, keratotic plugging, and filiform acanthosis. These features were interpreted as consistent with a squamous papilloma. On review at our institution, we agreed with the originating pathologist's description of the lesion. However, due to the patient's clinical history and the degree of hyperkeratosis and keratotic plugging, in our opinion, findings were more consistent with hyperkeratosis of the nipple.\nThe patient delivered a healthy infant but was unable to nurse on the right side due to sloughing of the nipple skin and pain. In addition, the lesion continued to increase in size. On physical examination at our institution, a soft, exophytic mass of the right nipple was noted. The areola was uninvolved. No other abnormalities in either breast and no axillary lymphadenopathy were detected. A mammogram was performed and revealed no masses, calcifications, or sites of architectural distortion within the breast parenchyma. The radiologist noted that, due to the heterogeneously dense breast composition, small masses could be obscured and a targeted ultrasound was performed. The ultrasound revealed an enlarged right nipple, approximately 1.7 cm in diameter with a hypervascular nipple mass. The subareolar ducts were normal in size, without evidence of an intraductal mass. Although the previous sample had been interpreted as benign, the biopsy was superficial, and, given the progressive increase in size, excision of the lesion was recommended. The pa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old gentleman with hypertension, cholelithiasis, and previous left ureteric calculus had an episode of syncope and lower abdominal pain. On examination, he was tachycardic at 137 beats per minute and hypotensive at 68/53 mmHg. The patient was given intravenous 0.5 mg of adrenaline and started on a noradrenaline infusion during resuscitation. Ultrasound scan done in the Accident and Emergency Department showed a large amount of intra-abdominal free fluid.\nA CT mesenteric angiogram showed a large volume hemoperitoneum and active contrast extravasation in the region of the greater omentum (Figures and ). The source of the haemorrhage was initially not discernible. However, after careful comparison with a previous CT scan done 3 years earlier, a long aberrant omental artery demonstrating a cockscrew pattern arising from the left gastro-epiploic artery was noted terminating in a large fat containing structure within the lower right abdomen.\nA catheter angiogram was performed with a view to identify and embolize the bleeding vessel. Angiogram performed from the splenic artery confirmed the presence of an active haemorrhage from an aberrant artery which extended from the splenic hilum down to the right iliac fossa (). The artery terminated in a small cluster of abnormal cockscrew shaped vessels. Successful embolization of the artery was performed using coils and N-Butyl cyanoacrylate (glue). The patient remained haemodynamically stable and recovered well.\nThe CT scans were reviewed again in view of the abnormal vasculature in the right iliac fossa. It was noted that there actually was a large lipomatous lesion in the right iliac fossa. It had grown slightly in between the CT scans and was causing displacement of the small bowel loops. A MRI confirmed the presence of a fatty lesion with several abnormal internal vessels.\nImage guided biopsy of the lesion was performed. Pathological specimen of the fat-containing mass demonstrated lipomatous tissue with focal fibro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old female patient visited the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital, with a complaint of severe difficulty in eating due to limitation of jaw function and trismus. The patient had a history of multiple TMJ surgeries for reduction of condyle fracture of both sides and arthroplasty/coronoidectomy due to trismus. Clinically, the patient exhibited the maximum mouth opening of 8 mm and relapse of severe trismus (Fig. ). After CT scan was taken, type IV TMJ ankylosis on both sides was confirmed (Fig. ). Since the glenoid fossa and condyle of both sides were completely fused, the anatomic structures were indistinguishable. Gap arthroplasty or interpositional arthroplasty could not be applied to this patient because bony TMJ ankylosis in both sides was complete and recurrent. Therefore, we decided to use the 3D virtual surgical planning, CAD/CAM-fabricated surgical guide, and stock TMJ prosthesis system (Biomet, Jacksonville, FL, USA) for total joint reconstruction.\nThe 3D virtual surgery was performed with a specific navigation surgery software (FACEGIDE, MegaGen implant, Daegu, South Korea). As the first step, both condyles and their surrounding hyperplastic bone were removed, while making it sure to avoid the mandibular foramen. The second step was virtual placement of the condyle and fossa components of the stock TMJ prosthesis. After placement of the fossa and condylar components, any areas of interference were investigated by virtually opening the jaw.\nAfter confirmation of the position of the fossa and condyle components, the surgical guides were fabricated by using the CAD/CAM technology. The surgical guides consist of the upper and lower parts. The upper part is designed to be adapted onto the root of the zygoma, which guides the location of upper margin for resection of the root of the zygoma and the position of the fossa component of the stock TMJ prosthesis. The lower part is designed to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old man was admitted to our hospital with a two month history of general weakness, intermittent left lower quadrant abdominal pain, weight loss, constipation and signs of partial bowel obstruction. Physical examination revealed a palpable tender mass in the left abdomen. There was no history of melena or mucus. The overlying skin and subcutaneous tissue were unremarkable. A barium enema showed narrowing of the distal sigmoid colon. Colonoscopy revealed inflammatory changes of the sigmoid colon – the mucosa was erythematous and edematous, but there were no colonoscopic features of Crohn's colitis or ulcerative colitis. Computed tomography was negative except for a small amount of free fluid present in the abdomen. Laboratory findings were normal. The pre-operative impression was of a possible cancer of the sigmoid colon although the pre-operative investigations were not conclusive, particularly because no mucosal mass was identified. Laparotomy was performed through a midline incision. The mesentery of the sigmoid colon was markedly thickened, constricted and puckered. The color varied from yellow to red-brown suggestive of fat necrosis. The normal architecture of the adipose tissue was lost and was replaced with an irregular nodular mass involving appendices epiploicae of the colon. There was a moderate amount of serous effusion in the peritoneal cavity. No enlarged lymph nodes were identified. On macroscopic pathological evaluation the mesenteric mass was composed of areas of pale yellow and reddish-brown color with focal hemorrhage. The blood vessel walls were thickened and congested. The bowel wall adjacent to the mesenteric mass was thickened, edematous and markedly congested (figure ).\nMicroscopic pathologic sections from the involved mesentery demonstrated a chronic reactive inflammatory process with exuberant proliferation of fibroblasts, fibrocytes and fibrosis (figure ). Scattered areas of steatonecrosis and lipid-laden macrophages, lymphocytes an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female presented to our department with a seven-year-history of involuntary movements of the abdominal wall. The movements were initially intermittent. However, they gradually evolved over time to occur more frequently. There was no pain but some discomfort was accompanying the movements. The movements were not voluntarily suppressible and disappeared during sleep. The rate and the amplitude of the involuntary movements were increased by stress. Five years prior to presentation, she underwent cholecystectomy, hysterectomy, and oophorectomy. One year later she was diagnosed with depression and irritable bowel syndrome. She was treated with lorazepam, fluoxetine, chlorodiazepoxide, and clidinium bromide. The patient is a chronic smoker with chronic obstructive pulmonary disease. She had no family history of movement disorders.\nHer neurological examination was unremarkable. Semirhythmic writhing wavy movements involving abdominal wall and paravertebral muscles producing displacement of umbilicus were observed. These movements occurred exclusively in the sitting and standing positions, and abolished on lying on her sides and significantly decreased when lying supine (Additional file 1: video, segment 2). The movements did not show any variation in intensity or frequency during respiration.\nLaboratory, radiological, and fluoroscopic investigations were normal similarly to case I. Abdominal ultrasound depicted fatty liver. A diagnosis of belly dancer’s dyskinesia was made and she was started on trihexylphenydil and clonazepam, but without noticeable benefit.\nUtilizing the same aseptic technique and under ultrasound guidance, a total of 240 units of BTX was injected into the rectus abdominus muscles bilaterally, in which 40 units/site in a total of 6 sites were administered. The patient reported marked improvement and she was able to sit on the chair and walk independently 3 weeks after the injections with no side effects. She has been on regular follow ups e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old Chinese man presented to our hospital for further management of a laterally spreading tumor (LST)-like lesion in the proximal rectum accidently discovered on colonoscopy over 1 mo prior.\nThe biopsy results indicated an inflammatory hyperplastic polyp. The patient had no obvious symptoms and received screening endoscopy as part of a routine health examination. Gastroscopy showed chronic atrophic gastritis and inflammation of the cardia.\nThe patient had a history of diabetes mellitus for more than 6 mo and was administered metformin and other drugs to control his blood sugar. He also had a history of hypertension for more than 1 mo without medication.\nHe had a long smoking history of over 30 years, with an average of 20 cigarettes per day. He also had a drinking history for more than 30 years, with half a catty of liquor per day.\nPhysical examination upon admission showed that the patient was 1.82 m in height and 94 kg in weight. He had a blood pressure of 139/84 mmHg with a heart rate of 68 beat/min. He had clear lungs and normal heart sounds with no murmurs or gallops on auscultation. There were no obvious pathognomonic signs during physical examination of the abdomen.\nNo significant abnormal laboratory results were recorded in this patient.\nColonoscopy in our hospital also revealed a 25 mm × 20 mm, LST-like slightly elevated lesion in the proximal rectum with a red color (Figure ). To observe the microstructure and capillaries of the lesion, magnifying endoscopy with narrow-band imaging (NBI) was carried out. It showed enlarged and dilated branch-like vessels on the surface of the tumor similar to those of gastric MALT lymphoma (Figure ). The margin of the lesion became clearer, and a type II pit pattern was observed on magnifying endoscopy after indigo carmine staining (Figure and ). Gastroscopy revealed atrophic gastritis and cardia mucosa erosion with irregular microstructure and capillaries on"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 18-year-old male patient was referred to our outpatient clinic because of masslike lesion in his left calf. He had a history of car accident and left isolated and closed tibia fracture 30 months ago that was treated by open reduction and internal fixation with 4.5mm broad DCP plate (, ). The surgical approach was through 1 cm lateral to tibial crest and plate was in lateral aspect of tibia. In this period, the patient was fully asymptomatic and had no complaint in routine follow-up. The patient had no significant past medical history. After 2 years, union was obvious in AP and lateral radiographs, and removal of tibial plate was decided. The plate had been removed 7 months ago on patient’s request. At the time of surgery, we used the previous incision and found that the bone was completely united. Plate and screw removal was done without any complication (eg, plate or screw break down).\nAfter the operation, the bone in radiograph was completely united and the patient was discharged when we find near 50-100 cc collection in the drain at the second day post operation.(). Examination at this time showed he was intact in neurovascular examination.\nAt the first post operation visit, he was asymptomatic and progressive partial weight bearing had been described. About 4 weeks after plate removal, he came back with mild paresthesia in the left foot at the plantar surface. Also, he had firm, pulse less and non-tender swelling with unclear border on the posterior aspect of the leg which gradually increased over time. Position of ankle was plantigrade.\nIn vascular examination, we found the dorsalis pedis and the posterior tibialis pulses were equal to the opposite leg. We followed this patient without further investigation.\nAt about 3 months after plate removal, paresthesia became persistant. We prescribe EMG/NCV for the patient. This assessment showed tibial nerve axonal injury pattern. Thus, we thought that paresthesia was due to iatrogenic tibial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn eight-year-old girl presented to us with complaints of diffuse swelling of the right thigh and skin rash. Her parents denied history of fever, swelling anywhere else, any systemic complaints, bleeding from any site, or trauma. On local examination, her right thigh was diffusely swollen and tender to touch. There were no signs of inflammation. No abnormal mobility was found in the underlying femur. General physical examination revealed scaly, erythematous, brown to red papular lesions over the scalp, abdomen, inguinal region, and palms (). There was no pallor, icterus, lymphadenopathy, clubbing, edema, or swelling anywhere else. Rest of the general as well as systemic examination was unremarkable. X-ray of the limb showed a well-defined lytic expansile lesion in the diaphysis of femur with surrounding periosteal reaction (). Rest of her investigations including complete hemogram, liver function tests, coagulation profile, skeletal survey, and chest radiograph were unyielding. Patient was treated conservatively by us with a functional brace while being investigated for the cause. The skin lesion biopsy revealed inflammatory lesion with numerous uni-, bi-, and multinucleated histiocytes in the background of numerous eosinophils and lymphocytes. The patient was subjected to bone biopsy which showed similar findings consistent with Langerhans' cell histiocytosis. The follow-up radiograph of femur at two weeks showed signs of healing of the lesion. However, two weeks after presentation, the child developed alteration of sensorium and started having recurrent seizures associated with symptoms of raised intracranial pressure. There was no associated fever, signs of meningeal irritation, or focal neurological deficit. She succumbed to her illness within 72 hours. MRI head could not be done due to very sick general condition of child and CSF study was not done because of raised intracranial pressure and suspected space occupying lesion. Postmortem lumbar puncture as well a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman was referred to the Department of Gastrointestinal Surgery of The University of Tokyo Hospital for evaluation of a gastric lesion in August 2005. During esophagogastroduodenoscopy, a 30-mm flat and depressed lesion was identified at the anterior wall of the upper gastric body and was diagnosed as Type 0-IIc gastric cancer (Fig. ). A pathological analysis of the biopsy specimen determined a moderately differentiated tubular adenocarcinoma (tub2). The patient underwent laparoscopic-assisted total gastrectomy (LATG) with Roux en-Y reconstruction and lymph node dissection (D1 + No. 7) in accordance with the Japanese Gastric Cancer Treatment Guidelines []. A pathological analysis of the specimen revealed the depth of the lesion remaining in mucosal layer, without any lymph node metastasis. The patient showed good progress after the operation and did not receive any further treatment including chemotherapy. She was only instructed to continue oral iron supplementation for postoperative chronic anemia after discharge. She became pregnant 1 year and 8 months after the operation. After her pregnancy, radiographic examinations were excluded during the follow-up period while oral iron supplements were continued. In addition, 500 μg of methylcobalamin (MeCbl), an active form of vitamin B12, was intramuscularly injected once a month for a potential vitamin B12 deficiency, although her serum vitamin B12 level was within normal range. No pregnancy-associated discomfort or illness was observed including hyperemesis gravidarum during her pregnancy while the fetus was developing normally. In May 2008, the baby was born by vaginal delivery at 41 weeks of gestation. Delivery time was 4 h and 20 min, and the baby was delivered as a healthy normal child weighing 3076 g. The mother’s weight change and the uterus height change of the fetus are shown in Fig. a–c.\nAfter delivery, she continued to take oral iron supplements and vitamin B12 intramuscular injection and had k"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old South Indian female presented with a swelling on the left zygomatic region of the face since a year with a history of the swelling initially appearing small in size which subsided. It later recurred a month before visiting the clinic. The swelling was associated with fever with no other associated history of epistaxis or headache.\nOn clinical examination, extraoral inspection revealed slight fullness in the left maxillary region. There was a firm, nontender mass palpable in the floor of left orbit just below the inferior orbital margin. The swelling measured about 4 cm in diameter with the surface appearing normal []. Visual acuity, visual field, and eyeball movements were normal. There was no regional lymphadenopathy. A small nasal polyp was noted on the left nasal cavity. Palpation revealed it to be tender and soft.\nThe intraoral inspection revealed her oral hygiene to be poor. Malaligned dentition with calculus debris and mobility was seen. There was an intraoral swelling seen at the palatal region measuring about 5 cm in diameter extending from 24 to maxillary tuberosity region. On palpation, it revealed to be tender and hard to firm [].\nOcclusal radiograph and orthopantomogram revealed the presence of minute radiopaque structures resembling calcifications in an ill-defined hazy radiopacity in the left maxillary sinus suggestive of the residues of the eroded bone [Figures , and ]. Cone-beam computed tomography (CBCT) revealed soft tissue opacity in the left maxillary sinus with the extension of the mass into the left nasal cavity almost invading the nasal septum along with prominence in the calcification seen in the center of the sinus cavity as well []. Bony erosions were seen involving the left floor of the orbit, nasal wall, and nasal septum. The sinus cavity appeared expanding as an expression of the pressure due to the growing mass [].\nThe patient was further sent to the Department of Oral Pathology for a biopsy which conferred to be schwannom"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old Japanese man with a history of distal partial gastrectomy for gastric cancer 10 years earlier was admitted for surgical treatment of intrathoracic esophageal cancer (T3, N2, M0, stage III). He underwent subtotal esophagectomy with three-field lymph node dissection and removal of the remnant stomach with the abdominal lymph nodes. The alimentary continuity was reconstructed with a pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. Anastomosis of the esophagus and jejunum was carried out instrumentally with a circular stapler. A postoperative enteral contrast examination showed smooth passage and no deformity of the reconstructed jejunum. The patient was discharged about 4 weeks postoperatively. About 6 months after the esophagectomy, the patient was readmitted to our hospital because of abdominal discomfort and vomiting. His vital signs were stable and unremarkable. He was thin, with a body mass index of 18.6 kg/m2. Physical examination revealed that the pedicled jejunum through the antethoracic space was markedly dilated and the abdomen was soft and flat (Fig. ). Laboratory data showed only leukocytosis with no other remarkable findings. A chest roentgenogram revealed an increased cardiothoracic ratio of 70%, and an enteral contrast study showed a bird’s beak deformity. The swallowed barium remained static in the reconstructed jejunum. Computed tomography of the thoracoabdominal region showed the reconstructed jejunum within the pericardium anterior to the heart (Fig. ). We diagnosed the patient with IPDH after esophagectomy and performed an emergency laparotomy. Upon opening the abdominal cavity, we found that the reconstructed jejunum had herniated into the pericardium through an approximately 4-cm-diameter diaphragmatic defect without a hernia sac (Fig. ). The herniation was easily reduced, and t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male patient reported with the complaint of a scar and hollowing on the right side of forehead, following road traffic accident 3 months back. He had received conservative treatment only. On examination, there was a “S-” shaped concavity present at the junction of lateral one-third and medial two-third of right eyebrow extending upward, approximately of about 6 cm × 4 cm in size, in the right lateral forehead [Figure ��]. Computed tomography scan revealed comminuted frontal bone fracture in the right side without any dural tear [Figure –]. Thus, a cosmetic correction of the defect was planned.\nA stereolithographic model of the defect area of the skull was reconstructed. The undercuts were blocked with modeling clay. An impression of addition silicone impression material in light body consistency was made and poured in Type III dental stone. A wax pattern was fabricated with base plate wax so as to provide proper bony contour of the depressed defective area alongside covering the gaping bony defect [Figure and ]. Care was taken to match the external bony contour of the affected region with that of the unaffected contralateral side. The wax pattern was then acrylized with double heat-cured medical grade PMMA of the colorless variety. Due to its less residual monomer, it is supposed to cause least tissue irritation [Figure and ].\nCare was taken to gradually blend the margins of the acrylic fabrication with the edges of the defect. Holes were drilled around the edges of the acrylic fabrication and on the surface with a number 8 round bur which would be helpful to secure the prosthesis with screws to the underlying bone. Once satisfactory fit was achieved, the prosthesis was finished and polished and made ready for surgical placement.\nOroendotracheal intubation was done. Coronal flap was elevated. Dissection was done to the pericranium. Disposable Raney clips aid in hemostasis."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old woman with hepatorenal polycystic disease and end-stage renal failure who was on chronic hemodialysis was admitted to our center because of a recent history of dyspnea and palpitations.\nPhysical examination revealed wide splitting of the first heart sound and an enlarged liver and left kidney. Bilateral mild edema of the calves was observed. A 12-lead electrocardiogram (ECG) showed paroxysmal atrial fibrillation. Blood tests revealed high creatinine and blood urea nitrogen levels due to severe chronic kidney failure (serum creatinine=10.4 mg/dL).\nTransthoracic echocardiography showed a large, polylobulated, echogenic, highly mobile mass that occupied most of the right atrium and extended from the inferior vena cava (IVC) and prolapsed into the right ventricle through the tricuspid valve during diastole ( and angiographic run in , ).\nCardiac magnetic resonance imaging (MRI) failed to reveal if the observed mass represented thrombus or the terminal part of an intravascular tumor ().\nCT angiography (angio CT) showed an extensive, serpiginous, highly vascularized mass originating in the right internal iliac vein, which extended to IVC up to the right cardiac chambers. Massive linear calcifications were seen along IVC and above the renal veins (confirmed by angiography run in Video. 2). Cystic transformation of the liver and kidneys was extensive. The right kidney was ectopic and occupied most of the pelvis (). No pulmonary artery embolus was noticed.\nCoronary angiography showed calcified coronary atherosclerosis, but no significant obstructive coronary artery disease.\nThe terminal mobile segment of the tumor was considered to carry an increased pulmonary embolic risk, although at the time of diagnosis no signs of pulmonary embolism were noted. Therefore, surgical excision of the tumor was considered. The high calcific burden and the out of shape aspect of IVC led to the decision of a two-stage procedure.\nTo ensure an appropriate access and to facilitate th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year old male was involved in a motor vehicle accident and suffered from multitrauma including fractures of the processus spinosi of the cervical vertebra 7 and thoracic vertebrae 1 and 2, fracture of the processus transversi of the thoracic vertebrae 8 to 11, fractures of the right olecranon, the left clavicle and a third-degree open right tibial fracture with severe soft tissue defect exposing the tibial fracture zone (Schatzker C). At first entry to the combined center of traumatology and reconstructive surgery an external fixation was performed combined with a plate osteosynthesis (LCP proximal tibial plate 3,5/6, Johnson&Johnson Synthes) to ensure limb salvage. In a second procedure the osteosynthesis was planed to be replaced by a coated tibial nail (e.g. PROtect expert tibial nail, Johnson&Johnson) after the coverage of the vacuum sealed soft tissue defect and a 6-week antibiotic therapy to avoid chronic infection with subsequent osteomyelitis. Prior to the subsequently discussed operation, an attempt to cover the defect was made by performing a free ALT flap with end-to-end anastomosis to the posterior tibial artery, but ended with flap necrosis due to arterial embolism triggered by the massive intima damage in spite of temporary therapeutic anticoagulation. The decision to make an end-to-end anastomosis within the primary injury zone is debatable, even though a preoperative CT angiography showed sufficient flow of the posterior tibial artery. The clotted posterior artery was ligated after removal of the ALT flap.\nNegative wound pressure therapy (NPWT) was used for coverage and preconditioning of the 8 x 18 cm soft tissue defect (Figure 1 ). Preceding the free LD flap an AV loop system (AV loop marked * in Figure 2 ) was constructed by the vascular surgery department on the popliteal P3 segment. The patient was thus ready to have the defect covered by means of a free LD flap with microvascular connection to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man suffering from the bilateral knee and ankle arthralgia for several months was transported emergently to our hospital owing to acute respiratory distress and hemoptysis. Upon arrival, he was in a shock state. Chest roentgenography revealed severe pulmonary congestion; cardiac echogram revealed a large mass in the LA that incarcerated into the mitral valve. Additionally, chest computed tomography (CT) revealed a tumor in the LA; thus, he was diagnosed with acute left heart failure caused by the mass that obstructed cardiac blood flow (Fig. ).\nAn emergency surgery was performed under cardiac arrest with extracorporeal circulation, which was established in the usual manner with bicaval direct cannulation. Because of the dimensions of the tumor and its pedicle attachment, we could approach through both the wall incisions on the right-side LA from the right upper pulmonary vein and atrioseptostomy from the right atrium. The tumor pedicle widely and irregularly originated from the right upper and posterior LA wall and extended to the lateral LA wall, which included the right upper pulmonary vein. The tumor was visibly extirpated and invaded the LA wall (Fig. ). The shape and function of the mitral valve were intact, and the large defect in the LA wall was reconstructed using a bovine pericardial patch. It was 159 min under extracorporeal circulation, and the aortic cross-clamping time was 123 min.\nExtracorporeal circulation weaning and post-operative course were uneventful, and arthralgia in both lower limbs disappeared immediately after surgery. The pathological diagnosis was UPS with clear resection margins (R0 resection), which invaded the atrial muscular layer (Fig. ). Subsequently, as imaging studies soon and 3 months after surgery did not reveal tumor presence, we decided to adopt a more suitable treatment strategy without involving adjuvant therapy after surgery if UPS relapse or metastasis occurred. Specifically, we planned to perform re-surgical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA one-day-old male Nigerian neonate of Igbo ethnicity was referred from a private hospital with complaints of bleeding from the mouth and vomiting of blood shortly after delivery. Frank bleeding started about an hour after delivery. There was no bleeding from any other site. He had vomited nine times on the first day of life and three times on the day of presentation.\nHe had received some antibiotic injections from the referring clinic but bleeding had persisted. A diagnosis of neonatal sepsis with disseminated intravascular coagulopathy was made and he was referred to our hospital.\nThe pregnancy had been supervised in a maternity home and had been uneventful. Delivery was at term by a traditional birth attendant (TBA). Further history revealed that the lingual frenulum had been clipped by the TBA about an hour after birth, after which bleeding had commenced. The indication for frenotomy could not be ascertained.\nThe baby was the last of five children, four girls and a boy. All the other children had undergone the same procedure, performed by the same TBA, within the first few hours of birth, with minimal complications. The family was of a low socioeconomic background.\nOn examination, our patient was in respiratory distress, severely pale and had cool extremities. He was noted to have a bleeding severed frenulum. His peripheral pulses were weak and thready and his systolic blood pressure was unrecordable. His heart rate was 180 beats per minute with normal heart sounds. His respiratory rate was 94 cycles per minute and breath sounds were vesicular. His abdomen was flat and soft with no palpable organs. He was conscious but lethargic, with a depressed anterior fontanelle. His primitive reflexes were depressed but he had normal tone in the limbs. A review of his systems showed that he was very weak, had poor suck and had not passed urine in the last eight hours.\nA diagnosis was made of severe anemia and hypovolemic shock secondary to acute blood loss, occurring after"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThirty-two and 5/7 week twin males were born to a 23-year-old woman who initiated prenatal care at 28 weeks. The mother had a history of illicit substance use, including marijuana and cocaine, and had been incarcerated early in her pregnancy. Additionally, she had a history of appropriately treated gonococcal infection. Prenatal serologies demonstrated that she was not infected with HIV, Treponema pallidum, or hepatitis B virus, and she was immune to Rubella. An uneventful Cesarean delivery was performed because of premature and prolonged rupture of membranes, and the infants required only blow by oxygen during resuscitation. APGAR scores were 7 and 8 for twin A and 8 and 9 for twin B at 1 and 5 minutes, respectively. Both infants were small for gestational age and were tachypneic with mild retractions. The physical exams were otherwise unremarkable, and the infants were transferred to the neonatal intensive care unit for further evaluation and management where they were started on continuous positive pressure ventilation. On the day following delivery, the patients’ mother was noted to have an ulcerated vaginal lesion suspicious for HSV. The mother denied a history of herpetic outbreaks, and primary genital herpes was subsequently confirmed by a positive viral culture for HSV-1 but negative IgM and IgG serologies.\nThe infants were started empirically on intravenous acyclovir at 60 mg/kg/day administered every 8 hours. Initial workup of the infants for neonatal herpesvirus infection included surface viral cultures; lumbar puncture with cell counts, glucose, protein, and polymerase chain reaction (PCR) analysis for HSV DNA; complete metabolic panel; and a complete blood count. All laboratory values for both infants were within normal limits for gestational age, and the HSV PCR and surface viral cultures were subsequently reported as negative. Because of the high-risk clinical scenario, however, routine EEG was conducted on day of life 7 to evaluate for signs of encep"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-years-old boy was admitted in our tertiary care hospital with painful swollen and stiff left knee joint for last 15 days. He sustained trivial injury and did not inform about the incident to his parents and carried his daily activities for 7 days after which he developed fever with painful swelling of the left knee. His anxious parents took the kid to local general practitioner who prescribed oral drugs for 3 days. The kid does not show a response to the oral drugs and the fever and swelling increases gradually.\nLater the kid was brought to our center, on examination in the emergency room; the kid was febrile and anxious. His left knee examination shows swollen erythematous, warmth, and tender joint with fullness in suprapatellar region. Range of movements was painful and restricted. There was effusion in the joint which was clinically confirmed by positive patellar tap test. There was no evidence of any external injury to knee. Retrospective questioning following surgery he narrated an incident of thorn prick to his left knee while playing with his friends 15 days ago and he removed the broken twig of the thorn on the spot itself.\nRoutine blood examination was done, and the result was elevated total count (16.1×103), differential count (polymorphs - 73%, lymphocytes - 20%, and basophile - 07%). Erythrocyte sedimentation rate was - 28 mm/h and C-reactive protein positive. Hemoglobin was - 10.3 g/dl. Plain radiography of the left knee joint shows no obvious bony injury except for soft tissue swelling (). Magnetic resonance imaging (MRI) of the left knee joint was advised which was reported as extensive synovitis with effusion and thickened suprapatellar plica and multiple enlarged inguinal and popliteal lymph nodes with larges measuring 1.5 cm × 1.0 cm.\nThe suspicion of septic arthritis was raised. Knee arthrocentesis was done under sterile precautions, seropurulent fluid was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old Caucasian male had previously seen a urologist for recurrent low-grade bladder cancer, which required multiple resections. Unfortunately, he was lost to follow-up and presented to his family physician several years later with abdominal discomfort and weight loss. An abdominal CT scan was ordered, which found a 10 cm cystic mass in the superior pole of the left kidney, concerning for malignancy with suspected splenic hilar invasion. A full metastatic workup was undertaken. No evidence of metastatic disease was identified ().\nThe patient underwent a radical left nephrectomy, splenectomy, distal pancreatectomy, completion nephroureterectomy, and RPLND. In anticipation of a difficult resection, the thoracoabdominal approach was selected to maximize surgical exposure. Intraoperatively, the tumour was found to involve the distal pancreas, which was resected with assistance from the general surgery team. During the kidney dissection, an incidental left upper ureteric mass was identified. Given the patient's history of recurrent bladder cancer, urothelial malignancy was suspected, and a completion nephroureterectomy was performed. A 28 Fr chest tube was placed prior to the closure of the thoracic cavity and connected to low suction. No complications were encountered during the procedure and EBL was 4000cc. Three units of packed red blood cells and 1 L of fresh frozen plasma were administered intraoperatively.\nThe patient's postoperative course was slow, but uneventful. The epidural and chest tube were discontinued on postoperative day 5, and he was discharged on postoperative day 9, once deemed physically fit for independent living by physiotherapy and occupational therapy.\nFinal pathological analysis confirmed high-grade transitional cell carcinoma (TCC) with extensive tumour necrosis. Tumour was found to be invading peripelvic fat, renal parenchyma, perinephric fat, and the tail of the pancreas. The resection margins, including the pancreatic margin and the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old Caucasian British woman presented to our emergency department with a three-day history of shortness of breath, pyrexia and non-productive cough. Her only significant past medical history was well controlled hypertension. She was independent in her daily activities, did not smoke cigarettes and reported a good cardiorespiratory reserve prior to the onset of symptoms. The diagnosis of community-acquired multilobar pneumonia was made with a CURB-65 score of three. She was admitted to the high dependency unit with type 1 respiratory failure and a high alveolar-arterial oxygen gradient. She received intravenous antibiotics (piperacillin/tazobactam and erythromycin) and non-invasive high-flow continuous positive airway pressure (CPAP). By the fourth day, our patient had deteriorated, with a chest radiograph showing bilateral alveolar and interstitial infiltrates and a ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) of < 26.6 kPa, which required invasive ventilation. The criteria for ARDS were met and the cause was thought to be a combination of the direct pneumonic pulmonary injury and extrapulmonary severe sepsis. With protective lung ventilation, low dose methylprednisolone, antibiotic therapy and a negative fluid balance, gradual improvement was made; over the following five days respiratory parameters weaned sufficiently to allow an uncomplicated percutaneous tracheostomy to be performed. On day 10, a period of desaturation required recruitment maneuvers with a Mapleson C circuit that resulted in notable surgical emphysema. The cause was thought to be a tracheal injury sustained at the time of tracheostomy insertion. An adjustable flange tube was positioned under bronchscopic guidance just proximal to the carina in an attempt to limit any further tracking of air through the potential tracheal defect. Despite these measures, a high alveolar-arterial oxygen gradient and peak airway pressures persisted. A chest r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old female presented to neurology department with a history of severe pain in the right side posterior aspect of the head for 2 months’ duration. The pain was gradually increasing is intensity. She also complained of slurring of speech. She was a known case of diabetes mellitus on treatment for the past 10 years. On examination, there was slight deviation of the tongue to the left side with fasciculations. There was also a neck swelling which moved with deglutition. Fine-needle aspiration cytology of the neck swelling showed colloid goiter.\nShe was advised magnetic resonance imaging (MRI) of the brain for evaluation of headache. MRI showed altered signal intensity with a lytic lesion in the right condyle of the occipital bone. Neoplastic etiology was suspected, and the patient was subjected to a whole body fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT).\nFDG PET-CT [] showed a metabolically active lytic lesion with minimal soft tissue (21 mm × 16 mm) in the right condyle of the occipital bone. In addition, there was a metabolically active hypoenhancing soft-tissue lesion in the left lobe of thyroid gland measuring (21 mm × 27 mm). No other metabolically active lesion was noted in rest of the organs.\nThe patient underwent total thyroidectomy subsequently which confirmed the presence of 3.5 cm × 3.3 cm sized follicular variant of papillary thyroid cancer. The patient was referred for radioiodine ablation of the metastases. In view of significant pain in the head, radiotherapy to the metastatic site was planned before radioiodine therapy, and she received 30 Gy in ten fractions.\nWhole body iodine scan [] performed as per routine protocol, after 15 days of external beam radiotherapy, showed thyroid remnant with an iodine-avid osseous lesion in the occipital bone. No other distant metastases were made out. Her preablative stimulated thyroglobulin level was 203.33 ng/ml. She received 193 mCi of iodine-131. She, presently"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 42 years old male presented to our institute with history of gradually progressive and painless swelling over left calf since two months. He was a non-smoker, laborer by occupation. The patient noticed a firm swelling in calf region of left leg 5 years ago. No history of trauma or infection prior to the appearance of the mass was reported. No family history of any such swelling in the past. Patient was operated for swelling over calf region 20 years back but no records were available. There was a history of gradual increase in deformity of left foot since 3 years and the patient had started walking on toes on left side with no dorsiflexion at ankle joint.\nOn examination, there was a single, non-tender, hyperpigmented scar of size 8×3 cm over mid-calf region fixed to underlying structures. A large, well defined non-tender, firm, swelling was palpable in posterior aspect of left leg measuring about 28×8 cm extending from tendoachilles region up to 5 cm distal to popliteal fossa and medially and laterally up to border of tibia and fibula respectively. The overlying skin was normal with no discoloration and local raise of temperature. Movement of knee joint was normal. There was fixed equinus deformity of left foot (). No inflammatory signs, skin changes or adenopathies were present. No bruits were heard on auscultation. Neurovascular examination of left leg and foot was normal. Laboratory findings were within normal limits. Radiological examination revealed large soft tissue mass with linear and streak-like ossification around the left tibia. MR Angiography () showed arteriovenous malformation in left calf with multiple feeding arteries arising from popliteal, peroneal and anterior tibial artery and large draining veins draining deep into venous system of leg. The tibia and fibula marrow showed normal signal intensity.\nBecause of patient symptoms and with clinical diagnosis of a vascular malformation, a wide surgical excision of the lesion was done"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old man with a history of infiltrative vesical carcinoma treated with intravesical immunotherapy 13 years previously was referred for recent-onset pain in the pelvic girdle. Pain was assessed by a visual analog scale (VAS) at 8/10 and was much increased with walking, which was limited to a short distance and required the use of a crutch. CT revealed extensive osteolytic metastasis involving almost all the right iliac wing and acetabulum together with the right sacral wing (\n). Bone scintigraphy and 18F-FDG PET/CT revealed multiple other skeletal lesions. Biopsy of the pelvic bone revealed an epidermoid carcinoma. A vesical biopsy gave negative results, but because the prostate was clinically enlarged and the prostate-specific antigen level was increased (5 ng/mL), a prostate biopsy was performed and revealed epidermoid urothelial tumoral infiltration. The patient received a first course of systemic chemotherapy with carboplatine (AUC 5) and paclitaxel (80 mg/m2), a first infusion of bisphosphonates (4 mg acid zoledronic), and analgesics.\nGiven the pending risk of fracture and severe pain, the decision was taken in a multidisciplinary consultation to stabilize the pelvis before continuing systemic treatment and to attempt percutaneous osteosynthesis rather than open surgery because of the comorbidities and risk of complications with extensive surgery. Extension of the bone destruction to the sacral wing and anterior acetabulum precluded the use of the locked and perforated nail recently described to reinforce the arcuateiliac line []. Therefore, a combination of double screwing and cementoplasty was planned to restore weight-bearing force transmission from the spine to the hip.\nThe first step of the procedure consisted of percutaneous double osteosynthesis with two perpendicular screws. The optimal position and dimensions of the screws were determined from 3D CT-scan reformations of the pelvis. The percutaneous osteosynthesis procedure was performed under C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male presented with a history of left-sided chest pain for a few years that had been progressively worsening over the last 3 months. The pain was characterized as vague and intermittent, although there were some fluctuations in intensity. He had a gunshot wound to the left upper abdomen resulting in diaphragmatic and splenic rupture 30 years ago. He stated that his spleen had been removed at that time. Other medical history included chronic hepatitis C and a 30 pack-year history of smoking. His physical examination revealed several abdominal scars, but was otherwise unremarkable. Routine blood work demonstrated no significant laboratory abnormalities. A peripheral smear was not obtained. On presentation, his chest X-ray showed a large, ill-defined, clearly marginated mass along the left heart border on the posteroanterior view. In comparison, the chest radiograph obtained 1 year previously was reviewed, and the lesion was noted, in retrospect, to have been present at that time; it had obviously grown over the 12-month period between the two examinations (Figures A and B). Computed tomography (CT) of the chest with intravenous contrast showed a large, homogeneously enhanced mass of 13 × 3 × 8 cm extending from the level of the aortic arch inferiorly along the mediastinal contour into the left upper quadrant, corresponding to the lesion seen on the chest radiograph (Figure C). Technecium-99 m (99mTc) sulfur colloid scintigraphy was performed based on a high index of suspicion for splenosis given the patient’s trauma history and subsequent splenectomy. Thick linear uptake was present in the medial left hemithorax, corresponding to the mass on the chest CT, and was consistent with splenic tissue (Figure ). Although the diagnosis of intrathoracic splenosis was established, the patient was referred to the thoracic surgery service because of symptoms refractory to pain control with analgesia as well as the interval growth of the mass. Video-assisted thoracosc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33 yrs old female presented to us with knee pain after history of fall with minimal swelling. Anterior and lateral knee radiograph showed features suggestive of Giant cell tumor and intercondylar fracture. A CT scan further strengthed the suspicion of GCT ( & ). Surgical decision of arthroscope assisted fixation of the fracture and intralesional curettage of the GCT was contemplated considering the age and proximity to the joint. With knee in 90deg flexion standard antero-lateral portal was taken at the soft spot above the joint line 2cm lateral to the patellar tendon. Hematoma was drained, antero-medial portal was established with outside in technique. The joint was copiously irrigated. The reduction of the fracture was confirmed under vision with the help of the arthroscope. A guide wire was passed from the lateral femoral condyle, 6.5 mm drill bit was used and with a 70mm 6.5mm CC screw with washer fracture was fixed. The portals were closed with 3.0 ethilone. A lateral longitudinal incision was taken on the distal femur extending upto the screw. The fascia was incised to expose the lateral femoral condyle. A cortical window of 2x2cm was made with an intact perisosteal hinge 2cms above the screw head (). the cortical window. After introduction of the scope the light source cable was rotated to have a 360 deg visualization of the tumor cavity. The surrounding structures of the cortical window were covered with sterile mop to avoid spillage of the tumor cells coming out along with the irrigation fluid in the surrounding tissue. The irrigation fluid was started. A small curette, 4.5 mm shaver tip and a high speed burr were used to curette the GCT cavity. The end point of curettage was visualization of the normal cortical bone through the arthroscope. During the curettage copious normal saline was used for irrigation of the cavity. After curettage dry visualization of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old male basic military trainee reported chronic, intermittent bilateral hip and groin pain since childhood, which acutely worsened over the past two weeks related to increased physical training. He reported mild discomfort associated with long periods of walking which increased with running, left greater than right. Pain decreased but persisted at rest. The patient’s pain resulted in walking with a limp. Physical examination was notable for joint pain in both hips with active and passive motion, which worsened with weightbearing. The patient appeared younger than his stated age. Bilateral hip radiographs were obtained with frog leg views (Figure ). Findings were concerning for left SCFE, possible right SCFE, and abnormal delayed skeletal maturation without significant closure of the femoral physes or apophyses.\nThe radiologist recommended orthopedic referral and obtaining a bone age assessment to estimate the amount of delay in skeletal maturation. He was subsequently admitted by the orthopedic department for treatment with bilateral surgical pinning. Magnetic resonance imaging (MRI) of the bilateral hips was ordered prior to surgery, which further supported findings consistent with left SCFE (Figure ).\nSubsequent clinical follow-up initiated by his primary provider and the referred endocrinologist were notable for an elevated thyroid-stimulating hormone above 160 mcIU/mL, a low level of free thyroxine, and an elevated serum thyroperoxidase antibody level of 765 IU/mL, findings consistent with hypothyroidism likely secondary to Hashimoto thyroiditis. Further history obtained from the endocrinologist revealed symptoms consistent with hypothyroidism: fatigue, constipation, increased sleep, and problems with losing weight but without cold intolerance. A bone age study demonstrated a markedly delayed bone age, consistent with Greulich and Pyle male standard for 13 years and 6 months, incongruent with the patient’s chronologic age of 19 years and 2 months (Fig"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old African-American woman presented to her primary care physician for evaluation of a palpable right breast mass in the upper outer quadrant that she had identified several days prior to presentation. Bilateral mammography demonstrated a spiculated mass with pleomorphic calcifications in the axillary tail of the right breast at the 10:00 position, which corresponded with a palpable 4 cm mass on physical examination (Figure ). A second, less distinct mass in the upper inner left breast was also visualized. An ultrasound of the right breast demonstrated an irregular hypoechoic and vascular mass measuring 3.3 × 2.1 × 1.9 cm in diameter that abutted the underlying pectoralis major muscle at the 10:00 position in zone 3, 13 cm from the nipple. No abnormalities were identified in the upper inner left breast on subsequent imaging. Taken together, these findings were assigned a BI-RADS 5 classification. The patient was referred to the breast surgery team at the Stefanie Spielman Comprehensive Breast Center at The Ohio State University Wexner Medical Center for further management.\nOn establishment of care, the patient revealed a family history of breast cancer involving her maternal cousin, who was diagnosed with left breast cancer at age 27 and right breast cancer at 33 years of age. Of note, her cousin was positive for the T37K variant of uncertain significance in BRCA1, an allele suspicious for deleterious effects. The family history was also significant for a maternal aunt diagnosed with ovarian cancer at 58 years, and a maternal grandmother who developed breast and ovarian cancer during the 7th and 8th decades of life, respectively. On physical examination, the patient had a palpable, firm 3-4 cm mass within the upper outer quadrant of the right breast. No other masses or nodules were identified in the left or right breast. The nipples appeared normal bilaterally. There was no evidence of cervical, supraclavicular, or axillary lymphadenopathy. These findings"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA59-year-old male reported with a chief complaint of a growth on the left side of upper lip. The lesion had been present for the last 6 months with gradual increase in size. Previously, the patient had undergone surgical excision of the lesion twice in the same area from an outside clinic only to notice it regrow again. He had the habit of smoking cigarettes for the past 25 years, around 20 cigarettes per day. The patient also gave a history of anemia for the past 1 month and was taking folic acid medication regularly. No other signs and symptoms were present.\nOn close clinical examination, an exophytic growth was seen on the left corner of upper lip. The growth was about 1.5 cm in length and was brown. On palpation, the growth was firm to hard in consistency and was slightly tender. Intraoral examination revealed a grayish-white patch on the left commissural mucosa and the dorsum of tongue measuring about 3 cm × 1 cm in dimension. Both the white patches were nontender and nonscrapable in nature. Hard tissue examination revealed several missing teeth (15, 16, 17, 25, 26, 27 and 46) and Grade II mobility with respect to teeth (11, 21, 22, 23, 31, 41, 42 and 47). Generalized gingival recession and attrition were also seen in .\nExcision of the lesion on the lip along with its adjacent grayish-white patch was done using CO2 laser. Satisfactory healing was observed after a week. The gross specimen received measured about 28 mm × 7 mm × 4 mm. One end of the specimen was soft in consistency, and the other end was firm which represents the horn [].\nThe histological sections revealed hyperkeratotic stratified squamous epithelium with underlying connective tissue. The epithelium exhibited acanthosis, spongiosis, hyperkeratosis and broad rete pegs with pushing margins along with parakeratinized keratin plugging. The underlying connective tissue exhibited mild"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old Hispanic woman presented to the emergency department with a 1-week history of intermittent fever. She was seen by an emergency room doctor at that time and was sent home after being diagnosed with pneumonia after a chest radiograph was performed showing a questionable left lung base infiltrate and discharged with levofloxacin and ibuprofen. The patient returned to the emergency department 3 days later because of worsening symptoms described as weakness and inability to walk coupled with fever of 101 degrees Fahrenheit. As per the family, the patient was unusually confused, had difficulty with comprehension, and articulating her needs. In addition to these symptoms, the patient denied any other constitutional symptoms, sick contact, recent travel, or interaction with pets or animals. A thorough physical examination revealed crackles in the right middle and lower lungs; therefore, another chest radiograph was performed showing increased patchy density at the left lung base as compared with prior exam. She was started on 1 gram of ceftriaxone daily and 500 mg of azithromycin daily for treatment of the pneumonia at this time. A series of neurological examinations initially revealed a mildly confused elderly woman who was, nonetheless, oriented to person, time, and place. The patient stated she felt weak but was able to move her legs. She could move her arms but could not raise them more than approximately 10 inches. Consequently, the neurologist ordered the first CT scan which had unremarkable findings. On day 2 of admission, the patient was awake, alert, but oriented only to person. She denied headache but had a rigid neck with her speech becoming increasingly incomprehensible although she was able to follow few simple commands. Neurological exam was significant for asymmetric facial droop and left arm dropping fast than right and drop arm test. Stroke notification was called, and another noncontrast CT of the head was performed which was unremarkable.\nLa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old male presented with the left cervical and submaxillary lymph node enlargement with size of 30 mm × 30 mm. The following lymph node biopsy was completed and the pathological evaluation showed reactive lymphoid hyperplasia characterized by vascular, atrophic germinal lesions with surrounding concentric “onion skin” layers of lymphocytes (Fig. ), defined as the hyaline vascular variant of CD. He denied weight loss, lymphadenopathy, tuberculosis, diabetes mellitus and hypertension. He gave no history of bone pain and drug abuse. The bone marrow (BM) cytology indicated no clonal plasma cell infiltration. Thereafter the patient was treated with irradiation dose of 30 Gy in 10 fractions with clinical response. The clinical evaluation remained stable in annual follow-up visits. In the 4th visit, the patient was diagnosed in an outside hospital with 2-diabetic mellitus on basis of increased blood glucose, C peptide release test and oral glucose tolerance test (OGTT). The blood glucose was well-controlled by the hypoglycemic and diet therapy for three years when he presented to the previous hospital with progressive hand-foot numbness spreading from the proximal extremes to distal ends. The electromyography test confirmed the hampered nerve conduction velocity of bilateral ulnar, median and peroneal nerves. The cerebrospinal fluid (CSF) biochemistry from lumbar puncture indicated the slightly elevated protein (1.1 g/L, normal, 0.1~ 0.4 g/L) with normal cell count. The blood monoclonal protein level and bone marrow cytology was normal. Based on the resultant diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP), the patient was treated with daily intravenous pulse methylprednisolone therapy of 1.0 g for three consecutive days. Due to the minor clinical response, the diabetic peripheral neuropathy was suspected with following insulin injection and oral mecobalamin therapy. However, the manifestation of hand-foot numbness remained constant. One and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old man presented to our hospital due to sustained headache and uncontrolled hypertension. The patient had a history of hypertension diagnosed approximately 10 years previously. His hypertension was poorly controlled despite a combination of three different antihypertensive agents (candesartan 16 mg DP, amlodipine 5 mg DP and hydrochlorothiazide 12.5 mg DP).\nPhysical examination showed a blood pressure of 140/80 mm Hg in both arms, a heart rate of 69 beats/minute and no audible murmur. There was no significant pathologic finding in the chest radiography. His echocardiogram showed enlarged sinus portion of ascending aorta with moderate aortic regurgitation (grade 3), suspicious of aortic aneurysm, but left ventricular systolic function was well preserved. Due to the significantly enlarged sinus portion of ascending aorta, the patient underwent multislice spiral computed tomography (CT) angiography for evaluation of aorta anatomy. CT angiography showed focal significant stenosis of the descending aorta, just below the left main pulmonary artery level with vigorous collateral blood flow (). Invasive aortography was then performed, which showed severe aortic coarctation distal to the origin of subclavian artery (). According to the quantitative aortography measurements, the coarctation segment was a minimum of 8 mm in diameter and 40 mm in length. The diameters of the thoracic aorta above and below the coarctation segment were 19 and 22 mm, respectively. The patient was then planned for elective percutaneous balloon dilatation with subsequent stent implantation.\nUnder the local anesthesia, bilateral retrograde femoral artery approach was carried out. A 7 Fr arterial sheath was inserted into the right femoral artery and then in sequence a 5 Fr arterial sheath was also inserted into the left femoral artery. After this, a 5 Fr pigtail catheter was placed at the coarctation segment following successful wiring with a 0.035 inch Terumo guidewire (Terumo, Tokyo, Japa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-yr-old male presented to the emergency department with acute mental changes after a traffic accident on September 16, 2006. He was hit by a car while riding a motorcycle. On physical examination, he exhibited a stuporous mental state. There were positive light reflexes on both sides, but no spontaneous nystagmus. He had bilateral ear bleeding and multiple contusions on his body. An otologic examination revealed a bilateral hemotympanum. The function of the other cranial nerves was impossible to check due to his stuporous mental state.\nAn emergency brain CT scan revealed a hemorrhage in the left temporal subarachnoid space with a pneumocephalus. A high resolution CT scan of the temporal bone revealed bilateral transverse temporal bone fractures involving the otic capsules with evidence of a bilateral pneumolabyrinth (). The fracture line extended to the internal auditory canal on the left side and was associated with a pneumocephalus in the internal auditory canal.\nHe was admitted to the neurosurgical department for conservative treatment. Two days after the trauma, he exhibited an alert mental state with a complete bilateral hearing loss. No facial asymmetry or weakness was observed.\nAudiometry was performed 25 days after the trauma. There was no reliable response to the application of a pure tone or speech stimuli at the maximum limits of the audiometer. Immitance audiometry revealed a type A tympanometry on both sides. Vestibular function testing revealed the absence of any caloric responses bilaterally with ice water.\nThe patient was offered a cochlear implant soon after the trauma. However, he accepted the fact that his deafness was permanent near three months after the trauma and decided to get an operation of cochlear implantation. Follow-up audiometry revealed similar to the previous one, except residual hearing response at 500, 1,000, and 2,000 Hz on the right side. A repeated high-resolution CT scan of the temporal bones was obtained which showed no ev"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10 year-old Hispanic male presented with a fluctuant mass in the right maxilla. Computed tomography (CT) scan revealed a 3.3 cm soft tissue lesion with destruction of the adjacent maxillary bone and sinus, and displacement of several teeth. Biopsy demonstrated OGCC. Preoperative staging five weeks later revealed size progression and metastatic disease. The mass now measured 5.3 cm. A right submandibular node and several enlarged right cervical lymph nodes were noted corresponding to FDG avidity on PET. Right-sided modified radical maxillectomy and palatectomy, and right-sided modified radical neck dissection was performed one week later. Significant involvement of the buccal mucosa and submandibular gland were noted. After multiple attempts, final surgical margins were negative. Pathology confirmed OGCC (). Seven of thirty-eight Level I and II lymph nodes were positive for metastases. The tumor was positive for EGF receptor indicating cellular expression of EGFR protein. One week after surgery, maxillary packing was removed in the operating room. No tumor recurrence was appreciated. Adjuvant therapy was recommended given the rapid pre-surgery growth, positive lymph nodes, and concern for microscopic residual disease. A lesion in the right buccal space was noted at the time of radiation simulation (19 days after surgery). Given these findings and prior history of rapid growth, this was presumed recurrent tumor. An intensity modulated radiation therapy (IMRT) plan was designed for the entire rightsided postoperative bed and bilateral neck. The patient received 44 Gray in 22 fractions (6 mega-Volt photons) prior to receiving a break for treatment-related toxicities. Imaging obtained then showed a 4.9 cm soft tissue mass in the right cheek and a 1.7 cm left gingivolabial soft tissue mass (). Biopsy confirmed OGCC. Radiation volumes were expanded to include the new disease.\nIn summary, the postoperative bed received 60 Gray in 30 fractions over two plans (44 Gray in 22"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAfter falling off a mountain bike down an incline into some brush, a 49-year-old male mountain biker presented to an outside ED with normal vitals, severe vertigo, nausea, intractable vomiting, profound hearing loss, and tinnitus. A CT was performed, which showed opacification of the ear canal, but did not comment on any abnormalities of the inner ear. The patient was transferred to our facility for further management. On examination, there was a spontaneous right-beating nystagmus and the facial nerve was intact. A tree twig was embedded in the left external auditory canal, obscuring visualization of the tympanic membrane.\nTemporal bone CT demonstrated a linear foreign body projecting from the external auditory canal to the oval window, and an additional, separate small foreign body projecting into the vestibule. Presence of extensive intralabyrinthine air was detected radiographically (). On axial view, air bubbles were seen in the vestibule, posterior semicircular canal, and the scala vestibuli compartment of the cochlear basal turn, as well as in the lateral and superior semicircular canals (). Preoperative audiogram conducted at bedside revealed normal hearing on the right side and moderate-to-severe mixed hearing loss on the left.\nThe patient was diagnosed with a traumatic PLF with extensive pneumolabyrinth due to penetrating temporal bone injury and was taken urgently to the operating room less than one day after his inciting injury. A three- centimeter tree twig was lodged in the ear canal and found to be penetrating the tympanic membrane. Postauricular approach included mastoidectomy and intraoperative assessment of the middle ear ossicles and extent of injury. The long process of the incus was dislocated but still attached to the malleus, the stapes was deeply embedded into the vestibule, and the oval window was completely open but covered by blood clot. All penetrating foreign bodies were extracted. Temporalis fascia was used to seal the oval window and a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn apparently healthy 32-year-old male patient complained of reduced strength in his left hand. Over the past few months this phenomenon occurred especially and repeatedly when holding a frying pan, but there was no pain or weakness in any of the other muscles. He had two operations on his left middle finger at the ages of 10 and 18 due to a macrodactyly. Neurological examination gave evidence for a reduced sensitivity for touch in his left middle finger. In neutral position, there was no deficit of strength. Electroneurography showed mild CTS, without sign of axonal lesion of the radial nerve. In abduction of the left arm, there was a slight weakness in pronation, radial deviation and elevation of his left hand. Occasional fasciculations were observed in his left brachioradial muscle. Overall, we hypothesized a possible brachial plexus pathology. MRI of the left brachial plexus (Fig. ) showed an accessory muscle, attached to the medial aspect of the first rib and superior border of the scapula near the base of the coracoid process. The muscle caused a significant narrowing of the costoclavicular space (Fig. b). No regular subclavius muscle could been identified on either side. Arm abduction or weight bearing would most likely accentuate the narrowing of the costoclavicular space, with subsequent compression of the brachial plexus.\nOverall, NTOS with compression of the brachial plexus which increases with arm elevation and abduction was likely []. The muscle having this negative effect was identified as SPM which was first described by Rosenmuller [] and was recently described in a post-mortem study of a patient suffering from Edward’s syndrome []. In this Japanese study [], 124 corps were examined and SPM was found to be present in 11 patients (8.9 %) and identified as a possible cause of NTOS []. The first case report on the presence of SPM in a live patient with NTOS was published in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old lady with a long-standing history of dyspnea on exertion and cerebellar abscess 8 years back that was managed conservatively underwent right total knee replacement under spinal anesthesia for severe osteoarthrosis from a nearby center. She had no prior history of vascular risk factors or ischemic heart disease. The patient was well in the immediate postoperative period. On the second postoperative day, she was noted to have acute onset weakness of the left leg followed by right upper limb and was shifted to our center for further management.\nOn arrival, the patient was restless, drowsy with tachypnea and was having grade 0 power in the right upper limb and left lower limb with bipyramidal signs, without features of intracranial hypertension, cranial nerve dysfunction, fever or meningeal signs. She was evaluated with magnetic resonance imaging, which showed fluid attenuation inversion recovery (FLAIR) hyperintensities in the anterior and posterior circulation territories, some showing restricted diffusion suggestive of infarcts of varying ages [Figure –]. Vessel imaging was normal. Her chest radiograph showed multiple shadows, which was initially interpreted as secondary to aspiration []. Arterial blood gas analysis showed type 1 respiratory failure (on O2by mask 6l/mt-p O242.7, p CO231 hco3 26, p H 7.54). She was intubated and ventilated in view of altered sensorium, respiratory distress and hypoxemia.\nPresentation in the early postoperative period following orthopedic surgery with focal neurological deficits, multiple cerebral infarcts and respiratory failure made us consider pulmonary embolism and postoperative stroke as the first possibility. There were no features to suggest fat embolism. Lower limb venous Doppler did not show any deep venous system thrombosis; however, the pelvic veins could not be studied. Her cardiac evaluation, including transthoracic echo and 24-h ECG, were normal.\nThe patient showed improvement in sensorium and weakness by th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old female came to our clinic complaining of gradual loss of visual in the left eye for 5 months. She had been diagnosed with acute retinal necrosis in the right eye, and wide-field photograph of the right eye showed patchy and diffusive retinal necrotic lesions (Fig. ). Pars plana vitrectomy was performed due to retinal detachment of the right eye 5 months earlier. The visual acuity in the left eye at the time of initial presentation was 20/20. In the meantime, she noticed floaters in her left eye. Superior retinal necrosis had been detected and it was recorded in her previous medical chart. The aqueous fluid from the left eye was positive for herpes zoster virus (VZV). She received repeated (nine rounds) intravitreal ganciclovir injection (3 mg/0.1 ml) into her left eye, one injection every 2 weeks, and systemic antiviral therapy for 5 months. The patient noticed a decrease in the visual acuity of the left eye and was referred to our clinic.\nWhen the patient came to our clinic, her best corrected visual acuity was 20/400 OS, 20/33 OS. The intraocular pressure was within the normal range in both eyes. There was no inflammation in the anterior chamber, and the lens was normal in the left eye. There was no posterior necrotizing involvement and no macular edema or exudation in the left eye. Indirect ophthalmoscope examination revealed pigmentary change in the superior peripheral retina of the left eye. Slight abnormality of the interdigitation zone in the fovea area of the left eye was detected on OCT. Angio-OCT revealed normal capillary density of superficial retinal capillary, deep retinal capillary, outer retina, and choriocapillaris layers in the left eye (Fig. ). The Humphrey visual field (central 24–2 threshold test) showed massive visual field damage in the left eye. The amplitude and implicit times of pattern visually evoked potential (VEP) and flash V"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 56-year-old female with history of syncope due to third degree atrioventricular heart block presenting initially with onset of stroke symptoms six days after pacemaker placement and two days after hospital discharge. At 5 PM she developed abrupt onset of left facial droop along with left upper and lower extremity weakness. The patient was initially treated at an outlying hospital and received alteplase at 6:35 PM for treatment of acute ischemic stroke.\nA chest radiograph performed at the outlying hospital prior to alteplase administration demonstrated an enlarged cardiac silhouette when compared to prior radiographs showing only borderline cardiomegaly. Upon administration, the patient reported mild chest pain and was given nitroglycerine and morphine. Her chest pain resolved and she was transferred to our comprehensive stroke center for admission. The patient presented to our emergency department at 10:10 PM with a heart rate of 122 beats per minute (bpm) and a blood pressure of 109/41 millimeters of mercury (mmHg).\nAt 11:20 PM the patient went for a computed tomography angiogram (CTA) after an initial assessment by the emergency physician in consultation with the stroke-team attending physician. After CTA at 10:28 PM, she was documented to have a blood pressure of 49/25 mmHg and heart rate of 109 bpm. She was returned to the resuscitation bay for re-evaluation. Cardiac tamponade was suspected due to the extreme hypotension in the setting of thrombolytic administration after recent pacemaker placement.\nOn reassessment, the patient had become confused with a Glasgow Coma Scale of 14. The emergency physician performed a POCUS, which demonstrated a pericardial effusion with features of cardiac tamponade including diastolic collapse of the right ventricle (). At that point the diagnosis of cardiac tamponade was made. The patient was alert and responsive, so an intravenous bolus of normal saline was given while a stat surgical consult was obtain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 76-year-old Caucasian male with extensive past cardiac disease history who presented to the hospital with a complete heart block. The patient felt weak and lethargic over the last 2 weeks and it worsened before the admission so he took his blood pressure at home and found his pulse to be very low on the blood pressure machine so he called the ambulance to go to the hospital. There were no symptoms of volume overload like dyspnea on exertion, leg edema, or other symptoms of congestive heart failure (CHF) exacerbation. The patient had a history of a sinus of Valsalva aneurysm (SVA) as well as coronary artery aneurysms; so in the past he had a Bentall procedure, which included placement of a mechanical aortic valve (#23 St. Jude prosthesis) and a conduit replacing the ascending aorta (aortic reconstruction). At that time, there was also a single-vessel bypass using a vein graft to the right coronary artery due to right coronary aneurysm. This was in 1997. He was following up with his cardiologist who did periodic CT/MRI of the chest with contrast to follow the previously diagnosed aneurysms. The repeated chest imaging was showing an ascending thoracic aortic aneurysm as well as the sinus of Valsalva and coronary artery aneurysms and was controlled with medical therapy and follow-up. Warfarin was given for anticoagulation for the metallic aortic valve. The size of thrombosed SVA was gradually increasing over time with 6 cm in diameter in 1999 and then progressed to 7.5 in 2000 and then to 7.3 × 6.5 cm by 2003. By 2004, size went up to 8.5 × 6.4 cm. The size remained stable on the subsequent CT scans that were done regularly. In 2009, the size went up to 8.1 × 7.2 cm. There were multiple cysts throughout the liver, the largest of which were seen in the right hepatic lobe measuring up to 14.7 × 11.3 cm and in the left hepatic lobe measuring"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old (gravida 2, para 2) woman presented the nearby hospital complaining of persistent defecation disorder and vomiting. Although her family history was notable for pancreatic cancer in her father, there was no other familial history of cancer, including breast and ovarian cancer. Her past medical history is unremarkable. Her past surgical history includes right ovarian cystectomy for a dermoid cyst at the age of 30. A computed tomography (CT) scan showed a large pelvic tumor adjacent to the rectum. Laboratory findings showed that her serum level of cancer antigen (CA) 125 increased to 315.2 IU/ml. Magnetic resonance imaging (MRI) demonstrated that a 93 × 65 × 62 mm-solid tumor with cystic parts was located immediately dorsal to the rectum (Fig. ). CT and MRI showed no evidence of dissemination, lymph node metastasis, nor distant metastasis. Colonoscopy showed strong extrinsic compression at the rectum with intact mucosa; however, biopsy of the rectum and the tumor site was not performed during colonoscopy. Based on the MRI finding that a perirectal cystic tumor was present without peritoneal dissemination, stage IA ovarian cancer was suspected, and she was referred to our hospital for treatment. At laparotomy, the tumor was located dorsal to the rectum and existed entirely in the retroperitoneal space (Fig. a). There were no apparent lesions in the peritoneal cavity including bilateral adnexa, uterus, and peritoneum. Peritoneal washing cytology was negative. After bilateral salpingo-oophorectomy and total abdominal hysterectomy, en bloc resection of the retroperitoneal tumor together with lower anterior resection of the rectum was performed (Fig. b). Whereas the tumor was adhered to the rectal wall, the tumor itself was relatively well-capsulated and easily separated from surrounding fat tissues. Based on pathological diagnosis of the retroperitoneal tumor: high-grade serous carcinoma, she received 6 cycles of adjuvant chemotherapy with carboplatin, paclit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn 2004, an 80-year-old Caucasian male underwent bilateral cordectomy for Tis carcinoma in the left cord and microinvasive T1 carcinoma at the right one. In the same year, he was diagnosed with prostatic carcinoma (Gleason score 3 + 3) which was treated with radiation therapy for a final total dose of 64 Gy. Since then, he has been controlled regularly on a 6-month basis. His family history was negative for cancer, but he suffered from mild hypertension that has been treated with a sartan drug for 17 years, and he also suffered from mild dyslipidemia without any medication besides dietary control.\nIn January 2014, he was admitted at the dermatologic unit of our institution for a pigmented cutaneous lesion at the occipital region of the scalp and an ulcerated lesion in the left temporal region, which were both radically excised. The pathologist reported a BRAF, c-KIT, and N-RAS wild-type lentigo maligna melanoma in the occipital scalp, while the ulcerated lesion at the temporal region was classified as an actinic keratosis. Full skin and ocular examinations, chest X-rays, and abdominal sonogram excluded the presence of clinical detectable neoplastic deposits. Due to his medical history, the patient was admitted to a three-month follow-up program. In January 2015, for the appearance of a swelling in the left parotid gland, he received an MRI and a subsequent biopsy, which led to a diagnosis of pleomorphic adenoma.\nIn May 2014, he was diagnosed with hypochromic, iron-deficiency anemia in the absence of overt clinical signs of bleeding and normal urine analysis. Fecal occult blood test was strongly positive. The patient was put on oral iron therapy without positive results for three months and therefore was referred to the endoscopy unit for upper and distal gastrointestinal tracts examination. Esophagogastroduodenoscopy showed the presence of several nonbleeding, bluish to black, gastric lesions of a few millimeters in diameter (Figures and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of an 11-year-old right-hand-dominant White Portuguese girl who presented with pain in her right elbow following a fall onto the outstretched hand that occurred while she was riding a bicycle. She was unable to move her elbow actively due to pain. A physical examination revealed mild swelling and tenderness over the lateral aspect of the distal part of her humerus. The child had a restricted range of motion of her elbow, especially with flexion. Joint stability was considered normal and no neurovascular signs were observed. The diagnosis was made on a lateral and an oblique radiograph (Figures and ), which revealed a displaced fracture of the capitellum of her right elbow, a typical Hahn-Steinthal or Type I fracture. An anteroposterior radiograph of the distal part of her right humerus did not reveal a definite fracture. No other injuries were detected.\nOur patient was treated by open reduction and internal fixation. Under general anesthesia, an attempt was made at closed reduction but complete reduction could not be achieved that way. With a pneumatic tourniquet in place, a posterolateral incision was made (Figure ). Further manipulation of the fragment allowed reduction that was held in the correct position with two temporary Kirschner wires. The final fixation was performed with two 3.0 mm cannulated screws. The screws were inserted in a posteroanterior direction through the posterior surface of the lateral condyle. An intraoperative dynamic examination showed satisfactory stability of the osteosynthesis and anatomic articular congruity. A protrusion of the tip of the screw on the articular surface was carefully avoided (Figure ). Postoperatively, her elbow was immobilized in a long arm cast at a right angle, with the forearm in a neutral position for three weeks. The postoperative outcome was uneventful, allowing our patient to leave the hospital 48 hours after surgery.\nThe follow-up period was of one year with regular clinical examination a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 5-month old female Swiss Mountain dog presented to the local veterinary practice for clinical evaluation of gait abnormalities of the hind limbs. The orthopedic examination revealed lameness in the lower right hind limb and a bony thickening at the level of the metatarsophalangeal joint between the II and III digit phalanges, covered with normal skin. The complete blood count, serum chemical and electrolyte analyses were within normal limits, apart from elevated levels of calcium and phosphorus, which were attributed to the young age (5 month) of the animal (Table ). The dog underwent a radiographic examination. Two well-defined lesions within the right II and IV phalanges of the right pelvic limb were found (Fig. a), in the shape of well circumscribed, mineralized new bone formation with a trabecular pattern. The dog underwent surgery to remove the lesion on the II phalange, and the excised tissue was sent for a histopathological examination. This revealed well-differentiated bone tissue, hyaline cartilage, and fibrous tissue in addition to hematopoietic tissue and connective tissue. Based on the histopathological findings, multiple cartilaginous exostoses (ostechondromatosis) were diagnosed. In the 1 month follow-up examination, the dog showed progressive ataxia of hind limb, a stiff gait and hyperesthesia in the thoracolumbar vertebral column. Radiographs of the hips and vertebral column exposed similar lesions to those in the pelvic limb. They were located in the distal part of the femur, on the tail and on the thoracic spinous processes of the lumbar vertebral bodies (Fig. b, c) and on the ribs (Fig. b).\nAt the age of 8 months, the dog was presented to the Wrocław University of Environmental and Life Sciences at the Department of Internal Medicine with Clinic of Horses, Dogs and Cats for neurological assessment. The neurological examination revealed a wide-based stance and proprioceptive ataxia in the hind limbs, moderate proprioceptive deficits in the hind l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female presented to the emergency department in our hospital with acute bilateral eye vision loss. Her past medical history included an undocumented splenectomy, diabetes mellitus, and hypothyroidism. Two weeks prior to the onset of visual symptoms, she reported flu symptoms, including fever, myalgia, and dry cough. The patient neglected these symptoms and did not benefit from any treatment. Fifteen days later, the patient presented with a sudden drop in visual acuity in the left eye without pain, eye redness, or headache which became blinding after 24 hours with involvement of the contralateral eye after four days, associated with right hemibody weakness. Her admission parameters were as follows: pulse 94 beats per minute (bpm), blood pressure 135/88 mmHg, temperature 38.2°C, and oxygen saturations were 85% on room air.\nHer neurological examination on admission revealed complete bilateral blindness with no perception of light. Pupil responses to light were abolished with horizontal nystagmus and unremarkable fundoscopic findings. No other obvious abnormal findings in cognitive function, cranial nerves, or neck rigidity were demonstrated. Motor system examination revealed normal bulk in all four limbs. There was hypotonia, most marked on the right side. Power was grade 4/5 in the right hemibody and 5/5 in the left side. There was no involuntary movement or seizures. Plantar reflexes showed bilaterally Babinski signs. All modalities of sensation were conserved. Clinical examination of other systems revealed no abnormalities She presented with breathlessness a few hours after her admission to the neurology department. She was then transferred to the intensive care unit following clinical deterioration and continued increasing oxygen requirements where she was started on non-invasive ventilation.\nThe patient had magnetic resonance imaging (MRI) (1.5 Tesla) of the brain and orbits with and without contrast, which revealed right parietal nodular signal abno"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old woman visited Nara Medical University Hospital with complaints of hoarseness and a left-sided neck mass (45x30 mm) in October 2018. Left vocal cord paralysis was confirmed endoscopically. The larynx was displaced to the right by a slow-growing left thyroid lobe tumour. We were unable to identify the border between the larynx and the tumour. Computed tomography showed a calcified thyroid tumour extending from the left side of the thyroid cartilage to the upper part of the cricoid cartilage (). Positron emission tomography/computed tomography showed no evidence of distant metastasis. The tumour was histologically diagnosed as papillary thyroid carcinoma (PTC) with no evidence of poorly differentiated carcinoma or ATC. Subsequently, the patient was diagnosed with PTC (cT4aN1bM0, stage III).\nTotal thyroidectomy with hemi-laryngectomy and neck dissection was performed. The laryngeal defect was reconstructed using a prefabricated anterolateral thigh (ALT) flap and free rib cartilage grafts in order to maintain laryngeal function.\nAfter tumour excision, bilateral paratracheal and left lateral neck dissection was performed. The dissected tissues were gathered toward the thyroid, and the thyroid was dissected from the trachea with relative ease. We resected from the thyroid cartilage to the superior edge of the cricoid cartilage in order to complete en bloc extirpation of the lesion because the tumour involved these structures. We resected approximately 40% of the laryngeal defect, which would have resulted in loss of airway and phonatory function. To compensate the laryngeal defect, grafting using an ALT flap and free rib cartilage was performed as follows: First, the left ALT flap (15x7 cm) was harvested and laid over the surgical defect, and microscopic vascular anastomoses were established. The flap had two perforators based on the left lateral circumflex femoral artery descending branch. The left superior thyroid artery was used as the recipient artery and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male patient with large anterior mediastinal mass was referred to our hospital for treatment. The patient was pathologically diagnosed as cervical schwannoma and underwent surgical resection twelve years ago. He had re-operation because of the recurrent neck tumor four years ago. No specific neural, cardiovascular and respiratory disfunction and neoplasms his history contained as well as his family history. The patient suffered from chest oppression and shortness of breath for four months, and these symptoms gradually became worse. The Preoperative CT confirmed that the patient was diagnosed as TM and large anterior mediastinal mass (Fig. ) Due to occasion of severe airway overreaction during the process of his endoscopy, fiber bronchoscopy was not finished.\nConsideration of potential risk from serious TM, the patient was intubated with guidance of fibreoptic bronchoscopy in the supine position, then underwent median sternotomy and tumor resection followed by tracheal suspension. The prime procedures of this surgery were briefly depicted by hand drawings (Fig. a: tumor site exposure; Fig. b: further sculpture of removed autogenous rib cartilage; Fig. c: anchoring malacial tracheal rings and membrane by fresh graft) and details of surgical procedure were as follows:\nStep 1: Tumorectomy. After medisection of sternum followed by opening pretracheal fascia, upper principal bronchus and frontage of cervical schwannoma were revealed. Along the line between the tumor and its adjacent tissue,the tumor was underwent entire resected.\nStep 2: Fabrication of scaffold. Partial autogenous rib cartilage was removed from 5th rib, and its top and bottom parts were penetrated with flexible steel needle to form two channels available for thread, which could manufactured a scaffold to anchor the extensive malacial tracheal rings and membrane (Fig. ).\nStep 3: Tracheal suspension. Free rib cartilage graft, fixed with bilateral tracheal rings, were deposited in front of mala"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n62-year-old male patient working as a farmer and suffering from type 2 diabetes was admitted to the Neurology Department due to paraplegia of lower extremities, sphincters disturbances and sensation disturbances from the level of Th6. During the last 14 days preceding hospitalisation he moved with significant difficulty and reported weakness of the lower extremities. 4 days prior to admission he spent most of his time mainly in bed and suffered from paraplegia of lower extremities. After admission to the Neurology Department, initial diagnostics showed the presence of destructive changes within vertebral bodies, arches and spinous processes in the thoracic segment (Th5–Th6).\nCT scans revealed destruction of the thoracic vertebras, infiltration changes in paravertebral soft tissues and pathological mass in the spinal canal. Initial diagnosis included infiltrative malignant tumour of the vertebral column. Consulting neurosurgeon recommended MRI examination. Examination revealed the presence of changes suggesting inflammatory process of the thoracic spine Th5–Th6, inflammatory changes within intervertebral discs and vertebral bodies and changes inside the spinal canal suggesting fluid mass empyema compressing the spinal cord (Figs. , ).\nAdditional information collected from the patient and his family revealed that the patient suffered from the zoonosis, erysipeloid, 2 months priori to admission and was treated. Infection occurred after skin cut on the right leg with the fragment of the pig bone. Patient observed the presence of skin inflammatory process; subsequently, the process spread in the form of phlegmon of the right leg integuments. Patient was initially treated in the Department of Surgery and referred to the Orthopaedic Clinic due to skin phlegmon. Bacteriological tests revealed E. rhusiopathiae. Patient underwent drainage of the subcutaneous tissues. Targeted antibiotic therapy was implemented and continued for about 3 weeks after operation. As the family rep"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 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.\nThe 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 ().\nPercutaneous 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.\nThe 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 ().\nMicroscopic 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"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 30-year-old male patient who was treated initially in another facility for SS of the left thigh. He underwent wide excision with free margins. The tumor measured 3 cm in its greatest diameter. Anatomopathological examination showed: a monophasic spindle cell synovial sarcoma in a fascicular arrangement. Immunohistochemistry showed positivity for bcl2, cytokeratin, epithelial membrane antigen (EMA), CK, and negativity for chromogranin A, synaptophysin, and vimentin. About 6 months later, he was admitted to our institute for a local recurrence confirmed by biopsy. A thoracic-abdominopelvic computed tomography (CT) scan was performed and didn’t reveal any secondary locations. The patient underwent a wide excision, with a vascular replacement of the femoral artery and coverage with a flap of the left rectus abdominis muscle. The following operations were straightforward. The Surgical limits were free. The search for the SYT-SXX fusion transcript was not completed. The patient underwent six cycles of ifosfamide-based chemotherapy followed by adjuvant external radiotherapy at a dose of 54 Gy. After 15 months of regular clinical and radiological follow-up, the patient presented a pancreatic mass diagnosed on a CT scan. The mass was located on the tail of the pancreas. It was heterogeneous, solid, enhanced after the injection of the contrast agent. Tumor markers: ACE, CA19-9, and NSE were negative. A biopsy under CT scan was performed and the histologic exam confirmed the metastatic nature of the pancreatic mass. The patient was reluctant to surgical treatment, and he was lost of view for 4 months. Due to the onset of transfixing abdominal pain and the increase in abdominal volume, the patient consulted after 4 months. An abdominal ultrasound showed an increase in the size of the lesion to 15 cm. The thoracic-abdominopelvic CT scan was performed and it showed a pancreatic mass invading the transverse colon without any other metastatic localizations ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old Caucasian woman with no significant past medical or family history presented to her primary care provider with a one-year history of sore throat and dysphagia to solid foods. She reported a remote smoking history in her teens and rare alcohol consumption. Workup included a barium swallow study with a persistent filling defect in the upper esophagus measuring 5 cm × 1.8 cm originating from the posterior right wall of the esophagus. Differential diagnosis included both benign and malignant lesions of the upper esophagus. Upper endoscopy with endoscopic ultrasound revealed an ulcerated, friable mass extending from 15 to 19 cm from the incisors with evidence of invasion into the muscularis propria and suspicion for regional node involvement (Figures and ). Biopsies from the upper endoscopy were positive for moderately differentiated invasive adenocarcinoma (Figures and ).\nThe patient was staged as T3N1M0 after a PET/CT of the neck demonstrated a hypermetabolic esophageal mass with adjacent right paratracheal and superior mediastinal lymphadenopathy. CT scan of the chest, abdomen, and pelvis were negative for distant metastases. Six weeks of definitive/neoadjuvant chemoradiotherapy were delivered according to the Ilsen regimen (cisplatin 30 mg/m2 and irinotecan 65 mg/m2 on weeks 1, 2, 4, and 5 of radiation). Radiotherapy consisted of a total of 64.8 Gy to the primary esophageal tumor and adjacent nodes plus 39.6 Gy to superior mediastinal nodes. Follow-up PET/CT 14 weeks after completion of definitive chemoradiation therapy revealed continued hypermetabolic activity in the proximal esophagus and repeat upper endoscopy revealed residual tumor. Otolaryngology performed a cervical esophagectomy, lymph node dissection, and left radial forearm microvascular free tissue transfer reconstruction of the cervical esophagus. The pathologic specimen contained moderately differentiated adenocarcinoma of the esophagus undermining the squamous epithelium, with metastasis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy six-year-old female was transferred to the pediatric intensive care unit at the Ann and Robert Lurie Children's Hospital of Chicago at Northwestern University (a quaternary care institution) for a persistent barking cough and increased respiratory distress. Earlier that day, she had presented to a local immediate care facility due to a cough that had worsened over the prior two days. She was admitted to the hospital at the immediate care facility due to wheezing and shortness of breath that continued to worsen despite nebulized albuterol, nebulized racemic epinephrine, and subcutaneous epinephrine. Intravenous (IV) ampicillin/sulbactam was also given. The decision was made to transfer the child to a quaternary care facility for further workup and treatment. While in route, an anterior-posterior (AP) radiograph and a lateral chest radiograph (CXR), which had been taken prior to transportation, was reviewed and it revealed a circular foreign body extending from C3 to C6 (Figures and ). This was the patient's first documented radiograph. Upon arrival, the patient had her first evaluation by a pediatric otolaryngologist.\nThe patient's parents reported that the patient had a barking cough and hoarseness that had varied in severity over the last 9 months. She had been diagnosed with recurrent croup. Upon further questioning, the family revealed that the child had a choking event while playing with a rubber band 9 months earlier. She was evaluated in a local emergency department shortly after the choking event and had had 4 to 5 emergency room and/or primary care physician visits over the last 9 months due to the barking cough and hoarse voice. She had received dexamethasone and oral steroids three times over the course of 9 months. This did often provide temporary relief of her symptoms. She did not have a direct or an indirect laryngeal exam, and no radiographs were taken.\nUpon arrival at the quaternary institution, the patient was in mild distress. Her oxygen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old lady with a known history of controlled hypertension, avascular necrosis of the right hip, lupus nephritis status post cadaveric renal transplant in 2014, with chronic graft rejection, and a history of abdominal pain that was attributed to an abdominal wall hematoma diagnosed previously by ultrasound (US) abdomen, presented to an outside facility with severe 10/10 stabbing chest pain radiating to the back that started suddenly while the patient was sitting down; she also complained of some abdominal pain that was mild as compared to her chest pain. At the outside facility, the patient was noted to be hypertensive. Serial electrocardiograms (EKGs) and troponins were done, and they were unremarkable. The patient was later found to have acute kidney injury with a creatinine of 7.4 and her last known creatinine was around 4.2. Given the patient’s acute kidney injury, computed tomography (CT) abdomen without contrast was done to evaluate the renal graft, which eventually came back unremarkable. The patient was then transferred to our facility due to the availability of transplant services in our hospital with a working diagnosis of acute on top of chronic kidney disease secondary to worsening chronic graft rejection.\nUpon initial presentation to our hospital, the patient had a blood pressure reading of 214/89 as well as an episode of chest pain. The patient's pain and blood pressure slowly improved after receiving 1 mg of hydromorphone hydrochloride, with blood pressure returning to 130/70 mmHg. The patient's home blood pressure medications were then resumed.\nFrom that point onward, the patient was no longer complaining of any chest or abdominal pain. Her blood pressure ranged around 113/70 throughout her stay. Upon questioning the patient about her blood pressure control, she said that it was always controlled and that it was only high on presentation because of the severe pain she was in. A complete physical exam was done on admission, including bilateral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn eleven year old male patient reported with a complaint of the presence of a small sized tooth in the upper front region of the jaw since 4 years. Extra orally the patient presented with a symmetrical face and with a convex profile. Intra oral examination revealed that he was in the late mixed dentition period with retained maxillary primary left central incisor (61) and non eruption of the left permanent central incisor (21) [] and Angle's Class I molar relation. The radiographic examination consisting of intraoral periapical [], occlusal and panoramic views with an orthopantomogram revealed an irregular radiopaque mass suggesting of an odontome like structure between 21, 61 and 22 along with impacted 21 close to the nasal floor. A preliminary diagnosis of impacted permanent left central incisor due to the odontome like structure was made. The treatment plan included surgical removal of the calcified mass and guided eruption of 21 using Closed-Eruption technique.[] The following treatment objectives were established for this patient:\nSurgical removal of the calcified mass Guiding the eruption of 21 and to align it orthodontically To achieve good gingival attachment and symmetrical gingival margins for both the maxillary central incisors; and To create a stable functional occlusion.\nUnder local anesthesia, a full thickness mucoperiosteal flap was reflected from 11 till 22. The bone covering the odontome like structure was carefully removed and the calcified mass was retrieved along with the extraction of primary central incisor. Six supernumerary teeth were retrieved from the calcified mass, four teeth were conical in shape and two were in tuberculate form []. A final clinical diagnosis of an impacted maxillary central incisor due to multiple supernumerary teeth was made. The lingual surface of the exposed central incisor was etched, washed and a flat Begg bracket was attached to it. Elastomeric chain was engaged to the bracket on one side and the other end was le"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male who complained of pain in the right inguinal region underwent abdominal ultrasonography, which revealed a 6-cm sacciform tumor in the right lower abdomen. The patient had no medical history including surgery, trauma, or inflammatory disease, and he was referred to our hospital for further evaluation. Enhanced computed tomography (CT) showed continuity between the cystic tumor, which measured 66 mm×72 mm, and the right external iliac vein (EIV) (). Further, vascular ultrasonography indicated that the mass was a section of the ectatic vein. The mass was diagnosed as a right EIV aneurysm without stenosis or obstruction of the proximal flow. Although the patient did not present with any symptoms, 99mTc-macroaggregated albumin scintigraphy revealed a pulmonary thromboembolism in the inferior lobe of the right lung. Venography revealed a large saccular aneurysm of the EIV with flow stagnation (), whereas arteriography of the common iliac artery did not indicate any sign of an arteriovenous fistula. Preoperative anticoagulant treatment with warfarin was initiated, and aneurysmectomy was recommended to prevent disastrous complications, such as massive pulmonary embolism and rupture.\nOne month after the aneurysm was diagnosed the patient underwent resection to treat the right EIV aneurysm. With the patient under general anesthesia, the aneurysm was exposed via a retroperitoneal incision in the right lower quadrant (). The aneurysm did not adhere to the surrounding tissue and did not have feeding vessels. The border between the normal venous wall and the aneurysm was easily detectable. An abnormal venous wall occupied more than one-third of the circumference of the vein; therefore, compared to venorrhaphy, patch plasty was considered suitable to preserve the lumen. Following the intravenous administration of heparin (7,000 U), the proximal and distal portions of the aneurysmal sac were clamped, and longitudinal venotomy was performed. The excess vein wall w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old- male patient, is a known case of advanced keratoconus in the left eye, for which he underwent deep anterior lamellar keratoplasty (LK) 2 years ago. The patient had quiet post-operative course and all sutures were removed 8 months after the surgery with BCVA of 2030 but eventually his vision started to decrease to a BCVA of 20400 at presentation. Upon examination, he was found to have quiet conjunctiva. Examination of the cornea showed suture-less corneal graft with sub-epithelial non-vascularized elevated corneal opacity that was more prominent in the temporal aspect of the graft measuring about 2.5 × 3 mm with faint smooth borders. The nasal aspect of the opacity was less dense compared to the temporal one with sparing of the visual axis. Otherwise, the graft was relatively clear with no evidence of underlying edema (a).\nTopographically, there was an irregular corneal surface on the sagittal curvature map due to massive flattening effect caused by the corneal opacity temporally with total anterior astigmatism of 16 diopters, also there is evident anterior elevation corresponding to the area of opacity. on pachymetry map there was marked thickening at the area of the opacity temporally (b).\nThe patient was counseled regarding the surgical option for visual rehabilitation of his condition and he was offered simple peeling in the minor operating room under topical anesthesia, which was done in a similar fashion as in case 1 with no complications. The excised tissue was identical to the other 2 cases with thick irregular corneal epithelium, absent Bowman’s layer and sub-epithelial fibrosis but there was a small focal area of degenerative non-inflammatory pannus (c and d). Three weeks after the procedure the BCVA improved to 20100 with more clear graft (e). On topography, there was pronounced regularization of the anterior curvature map with reduction of astigmatism of about 4 cylinders due to mechanical removal of this sub-epitheliual opacity. Also"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old African American male with a past medical history notable for chronic pancreatitis, insulin-dependent diabetes, hypertension, peripheral arterial disease, and gout presented to the emergency room complaining of acute left upper quadrant abdominal pain. At baseline, he was fully functional, has held office jobs, smoked a few cigarettes per day over the course of a few years but quit over 5 years prior to initial presentation, and reported drinking around four alcoholic beverages daily. Home medications include insulin, metformin 500 mg daily, lisinopril 40 mg daily, amlodipine 10 mg daily, metoprolol 25 mg twice per day, rosuvastatin 40 mg per day, aspirin 81 mg, clopidogrel 75 mg per day, and allopurinol 100 mg. Family history was notable for insulin-dependent diabetes and hypertension in his mother and hypertension in his father. Eighteen months prior to the current presentation, he presented to the emergency room with postprandial abdominal pain. Physical examination revealed an uncomfortable but alert patient who was tachycardic to 110 beats per minute and had decreased breath sounds at the bilateral lung bases. Abdomen was nontender but mildly distended. Neurologic examination was unremarkable. Computed tomography (CT) imaging of the abdomen was notable for necrotizing acute pancreatitis and a fluid collection between the pancreas and stomach measuring 7.1 × 2.8 × 8.8 cm (Fig. ). He was managed supportively and discharged. A few months later, he was admitted for diabetic ketoacidosis secondary to pancreatic necrosis; no abdominal imaging was obtained at that visit. Repeat CT abdomen 5 months after the initial episode, or 2 months after his diabetic ketoacidosis admission, revealed no change in size of the pancreatic pseudocyst (not shown).\nOn the current presentation, the patient presented with 4 days of postprandial, sharp abdominal pain with radiation to his back. The patient stated the pain was of different character than the original episode of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAfter due patient consent and approval from the institutional ethical committee, we present the following report:\nA 63-year-old old woman, menopausal since 20 years presented at the Gynecology OPD at All India Institute of Medical Sciences, Raipur, with a chief complaint of discharge per vaginum since 6 months. Per speculum examination revealed a cervix flushed with vagina and friable tissue at the external os. There was a 2.5 cm × 2 cm firm mass in the posterior fornix confirmed on per rectal examination. Bilateral parametria and rectal mucosa were free from tumor. Pap smear and biopsy revealed a squamous cell carcinoma. Ultrasound reported a uterus of size 6.8 × 3.2 cm. The endometrial cavity was distended with echogenic content and minimal fluid. Both ovaries were normal suggesting a diagnosis of “asymmetrical hetero echoic thickening of the endometrium with collection in the endometrial cavity, suspected carcinoma endometrium.” Magnetic resonance imaging (MRI) abdomen and pelvis [] revealed a fluid-filled endometrial cavity, an irregular, circumferentially thick, intermediate to high signal intensity endometrium surrounded by thin hypointense rim seen in the fundus, body, and lower uterine segment. The endo-myometrial junction was mildly obscured, and the visualized myometrium was normal in signal intensity. The lesion was seen extending into the cervical canal reaching just proximal to the external os, and the internal os was seen mildly widened by the lesion. A small nodule was noted in the stroma of the anterior cervical wall with signal characteristics similar to the endometrial lesion, and it was suggested to represent local spread. The uterine serosa, parametrium, mesorectal fascia, urinary bladder, and lymph nodes were not involved. Bilateral adnexa was reported normal.\nThere was a “diagnostic dilemma” given findings of cervical malignancy on biopsy but predominant endometrial lesion on imaging studies.\nA Type III Radical Hysterectomy with bilateral pelvi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old man was involved in an automobile accident and was brought to our hospital by ambulance. He had been in the front passenger seat and had been wearing a three-point seatbelt. He reported severe back pain, but showed no neurological deficit.\nAnteroposterior and lateral radiographs of the spine showed an increased gap between the 1st and 2nd lumbar spinous processes and 2nd lumbar vertebral fracture (figures not shown). Magnetic resonance imaging (MRI) of the spine also demonstrated an L2 vertebral fracture and disruptions of the posterior ligamentous complex between L1 and L2, in combination with extensive subcutaneous hematoma ().\nComputed tomography (CT) of the spine in the sagittal orientation and 3-dimensional (3D) CT further revealed the involvement of the superior end plate of the L2 vertebra, comprising horizontal splitting from the left pedicle, through the left transverse process, and reaching the center of the neural arch (). The right-sided L2 pedicle was intact.\nAfter checking the general condition of the patient and excluding intra-abdominal injury by enhanced CT and ultrasonography, the patient underwent L1-L2 single-level instrumented fusion using a posterior approach. Initially, monoaxial pedicle screws with conventional trajectory were placed at L1 and L2 pedicles on the right side (intact pedicle side). A rod slightly bent in lordosis was then introduced and connected with these pedicle screws with a compression force applied between screws. This procedure achieved reduction and the fracture gap at the left L2 pedicle and lamina was completely closed. Polyaxial pedicle screws were used on the left side. A pedicle screw with a conventional trajectory was placed at the left L1 pedicle. A CBT pedicle screw was then inserted through the fractured L2 pedicle under fluoroscopy. This CBT screw was used as an alternative to an osteosynthesis screw. A rod was introduced on the left side, bilateral facet fusion with local bones obtained from the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old female patient without serious intercurrences underwent surgery for grade 2 invasive endometrial uterine carcinoma. After adjuvant brachytherapy, the patient was regularly followed up. Twenty-three months after the primary surgery, she developed vertigo and temporary left-sided hemiparesis. Brain MRI showed a solitary lesion in the right temporal lobe (Fig. ). Considering its favorable location, the patient's good general condition, and the absence of extracranial illness, the patient was indicated for neurosurgery and underwent radical resection without any sign of residual tumor on the postoperative CT scan. Histology confirmed metastasis of the adenocarcinoma. Adjuvant RT was not indicated, and observation by control MRI 3 months after surgery was recommended. This MRI, performed 2.5 months after the surgery, unfortunately showed early local recurrence with an enhancing lesion localized ventral from the resection cavity and widely touching the dura with perifocal edema (Fig. ).\nConsidering the patient's continuing good general condition, confirmed absence of extracranial disease, and operability of the newly discovered recurrence, the patient was indicated for a second resection, which resulted in a subtotal resection limited mostly in areas infiltrating the dura mater. Histology verified metastasis of a partly necrotic tumor of a similar appearance to that in the previous resection.\nThe patient was indicated for postoperative RT, and planning of RT started exactly 1 month after the operation, when the patient underwent planning MRI. Unfortunately, there was further progression of the tumor on this MRI, with distinct propagation along the adjacent meninges, especially more rostrally. No third operation was planned anymore, and the patient, with rapidly progressing metastasis, was indicated for palliative RT. Considering the character of the primary disease, the absence of extracranial metastases, and the locally aggressive behavior of the known macr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old Japanese man was referred from another hospital presenting with altered mental status, loss of appetite, and urinary retention. He had been in a long-term care facility for 10 years due to mild sequelae after measles, which he had contracted when he was young. He was able to ambulate with the aid of a walker and independently perform all activities of daily living. Two and a half months prior to his visit to our hospital, surgical treatment was performed for a left femoral neck fracture resulting from a ground-level fall. Since then, the patient had needed a wheelchair due to his inability to cooperate and difficulty with rehabilitation. One week before his visit, he had fallen when he got out of his wheelchair independently. Three days after the fall, he was taken to a local clinic because of fever and urinary retention and was diagnosed with a urinary tract infection. On the day of his visit to our hospital, he presented with progressive altered mental status and loss of appetite over 3 days, which brought him to the psychiatric hospital, where no abnormal findings were revealed by head computed tomography (CT). Thereafter, he was referred to our hospital for further evaluation.\nOn arrival, he appeared lethargic, poorly responsive to questions, and unable to follow commands, which did not allow us to acquire an informative history and perform a thorough physical examination. The patient’s vital signs were as follows: Glasgow Coma Scale score of 13 (E4V4M5), 24 breaths per minute, heart rate of 70 beats per minute, blood pressure of 107/70 mmHg, oxygen saturation of 98%, and temperature of 36.7°C. Lower abdominal distention was evident without any remarkable findings on chest exam. Apparent weakness in his bilateral lower extremities was noted. The patient denied back pain. Blood test results showed elevated blood urea nitrogen of 63 mg/dL and creatinine level of 2.93 mg/dL. CT scan of the torso identified transverse fracture"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report on a 63-year-old female patient who presented in January 2016 with the following symptoms: complaint of cold sensation affecting the upper arms on both sides (left > right), weakness and arm claudication, with an increasing inability to perform work on the computer, and symptoms of a fatigue syndrome. The patient was unable to perform her employment as a hospital secretary. Clinically, pulselessness of the brachial and radial artery on both sides was noted. Bruits were discovered in the left and right subclavian artery. A blood test revealed increased levels of the inflammatory markers C-reactive protein (CRP 47.9 mg/dL) and an increased Erythrocyte Sedimentation Rate (ESR 74 mm/h). The patient had a history of hypertension, hyperlipoproteinemia, and osteoporosis; she was a former smoker and reported moderate daily alcohol consumption.\nA neurological examination, an MRI of the cervical spine, and myocardial scintigraphy were without pathological findings. Duplex ultrasound of the carotid artery and upper extremities revealed noticeable intima-media thickening. For suspected large-vessel vasculitis, a diagnostic angiography was carried out, which revealed bilateral stenosis of the axillary artery at the transition to the brachial artery and, on the left side only, an additional stenosis in the proximal segment of the brachial artery. TA was diagnosed based on the American College of Rheumatology criteria, with four out of six criteria met.\nThe patient was admitted to a rheumatological specialist clinic in March 2016. Treatment with prednisolone 20 mg daily was started, but there was no improvement of the arm claudication. Therefore, the patient received cyclophosphamide 15 mg/kg body weight × 0.75 (=600 mg) plus prednisolone (75 mg/d initially, reduced in stages to 30 mg/d at the time of hospital discharge). Six cycles of cyclophosphamide at 3-week interval were planned, at the end of which treatment with methotrexate 15 mg subcutaneously once a week accomp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old female was admitted to the Emergency Department of Sekghoma Memorial Hospital, Serowe village, Botswana, past midnight with progressive swelling of her face, tongue and breathing difficulty for about 8 h. The family gave a history of change of antihypertensive medication recently. She has been started on tablet enalapril, 20 mg, once daily, orally, 2 days back. On examination, she was conscious, coherent but very anxious. Her heart rate was 123/min, regular. Blood pressures were high and reading was 180/96 mmHg. Her room air oxygen saturation was 91% (SpO2). There was no stridor. On auscultation of chest, air entry was good bilaterally and there were some conducted sounds from pharynx due to excessive secretions. The tongue was grossly swollen, hard in consistency, it was wedged between the teeth and she was not able to close her mouth []. Lot of secretions were pooling in and dribbling from the mouth. There was no space in oral cavity for oral intubation. Only possible airway managements were a blind nasal intubation or surgical airway. It was not possible to transfer this case to a tertiary care hospital by helicopter as there were landing issues in darkness. Transfer by road was risky for patient as it would have taken 5 hours. It was decided to go ahead with management locally. The patient was started on oxygen support at the rate of 5 l/min by facemask for building up her oxygen reserves in case of airway emergency. Lateral view X-ray of neck was done which showed airway patency as fine []. Elective blind nasal intubation as a proactive airway management was risky due to less chances of success and more risk of further airway compromise. There were no ear, nose, and throat (ENT) specialists available for either evaluation or surgical airway management. She was injected with 100 mg of hydrocortisone, intravenously and 0.5"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old white male was found down in the field after he reportedly grabbed a “live” electrical wire. On the way to the local hospital, he regained consciousness but remained confused thereafter. He had sustained second-degree burns at the entry wound in the right palm and had a small exit wound in the right foot. Ecchymosis was also noted on right side of the body over the knee, thigh, and shoulder. A pan CT scan of the body did not reveal any major abnormality, including fractures. He remained hemodynamically stable but was pleasantly confused with a nonfocal neurological examination. A CT scan of the brain showed multiple hypodensities in the left parietal region and frontal region bilaterally. All serology labs were normal except total creatinine kinase levels, which peaked at 1100 U/L. Hence, he was transferred to the burn unit in our hospital for further management of burns with rhabdomyolysis. On examination, he was a pleasant gentleman with complete amnesia of the inciting event. He was alert but disoriented to all spheres. Most of the responses were limited to either head nodding or a few words associated with tangentiality and paraphasia. Repetition was impaired, but comprehension was preserved for simple commands. The cranial nerves and motor and sensory systems were clinically normal except limitation of the right arm's movement due to pain. MRI of the brain using 1.5 Tesla MRI machine showed multiple areas of diffusion restriction in the bilateral medial frontal lobe and bilateral basal ganglia along with watershed areas in the left frontal and temporal regions (). Susceptibility-weighted images showed hemorrhage in the left basal ganglia and insula (). T2-weighted images showed hyperintensity in the corresponding regions. MR angiogram did not reveal any filling defect or obvious vasospasm but showed aplastic A1 segment of the right anterior cerebral artery (). Based on these findings, acute stroke was diagnosed, likely due to vasospasm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old female with achondroplasia presented with an 8-month history of progressive weakness in the upper extremities with numbness and a gait disturbance. A neurological examination revealed weakness (grade 3/5) in the bilateral intrinsic muscles and hyperreflexia in the bilateral upper extremities with a positive Hoffmann sign; the knee and ankle reflexes were also increased bilaterally. She had decreased sensation in the bilateral upper extremities and a spastic gait with clumsiness of her hands, although she had no bowel or bladder difficulties. Lateral radiographs showed hypoplasia of C1. Computed tomography (CT) disclosed bony canal stenosis caused by the C1 posterior arch and edge of the occipital bone [], and magnetic resonance (MR) imaging demonstrated atrophy of the spinal cord and a high-intensity intramedullary lesion at the C1 level [].\nThe patient underwent posterior decompression of the CVJ. We resected the C1 posterior arch and the rim of the occipital bone (approximately, 7 mm from the edge of the foramen magnum). Intraoperative ultrasonography confirmed sufficient resection of the bony structure. At this stage of operation, the dura matter did not expand significantly. The thickened reactive fibrous tissue band was noted between C1 and the occipital bone []. Because sparing this fibrous tissue band carefully from dural matter did not improve compression at CVJ, the band and the dura mater underneath were carefully dissected longitudinally to achieve decompression, and the dura mater was left open without a patch graft. The arachnoid membrane was preserved []. The patient's motor weakness and gait disturbance improved immediately after surgery. Although the arachnoid membrane appeared intact during the surgery, the output of suction drainage indicated CSF leakage. One week after the surgery, she complained of a severe headache and nausea. Postoperative MR imaging revealed a moderate collection of CSF at the surgical site. Brain CT demonstrated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old female patient was presented with an approximately 3 cm peri-areolar mass in the 12 o’clock position in her right breast on physical examination, with no nipple retraction, skin dimpling or palpable axillary lumps. Bilateral mammograms showed very dense breast tissue with a suggestion of an asymmetric density in the right retro-areolar area. It was however difficult to characterize the lesion due to increased breast density (Figures , ). Subsequent ultrasound examination of the whole right breast revealed a 26-mm ill-defined, somewhat heterogeneous, lobulated mass in the area of the palpable abnormality, mostly isoechoic to surrounding normal breast parenchyma. Ultrasound-guided core biopsy of the palpable mass was performed using a 14-gauge needle with three passes from the medio-lateral approach (Figures , ). Histopathology showed invasive mucinous carcinoma of the breast and the diagnosis was given to the patient 12 days after the biopsy. At the second visit, two separate masses were felt on physical examination, one mass in the 12 o’clock and a further adjacent hard nodule at 2 o’clock in the sub-areolar location. A second ultrasound scan was performed, which showed a new 12-mm heterogeneous, cone-shaped nodule contiguous with the main mass pointing medially and towards the skin (Figure ). Since the new palpable abnormality developed following the biopsy and aligned to the expected location of the biopsy needle tract, post biopsy organizing hematoma was suspected with a differential diagnosis of tumor displacement and growth in the biopsy tract. Dynamic contrast-enhanced MRI was performed to determine disease extent and to exclude additional lesions and tumor growth in the biopsy needle tract. The main tumor mass measured 25 mm which exhibited predominantly type 2 (plateau) time-signal intensity curves. Linear enhancement was demonstrated medial to the mass in keeping with the biopsy tract. Although this vague linear enhancement showed type 1 (stea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old male was referred to the authors after undergoing chest X-ray (CXR) with evidence of left-sided rib fracture and pleural effusion on 27 January 2015. The patient had developed an intractable cough in December and was started on prednisone and antibiotics by a pulmonologist. The patient was admitted with COPD exacerbations twice in January for intravenous steroid and antibiotic therapy. Following the second time of hospitalization, the patient had some improvement and was discharged on a steroid taper.\nThree days following discharge, CXR and dedicated left-sided rib films showed a displaced left 8th rib fracture and left-sided effusion. Physical examination was notable for a 10 × 15 cm mass of the left chest flank associated with ecchymosis. The patient was also seen to have paradoxical motion of this mass with respiration. When lying in the right lateral decubitus position, there was note of concavity at the left 8th rib space. The patient denied respiratory distress but did exhibit decreased breath sounds on the left side. A CT was obtained with evidence of rupture of the left hemidiaphragm measuring 11.4 cm with herniation of omentum, splenic flexure, stomach, and anterior spleen into the chest cavity. There was displacement of bilateral 7th and 8th ribs with a left-sided 8th rib fracture and herniation of the abdominal contents through the intercostal space (Figures and ). This herniation transcended the diaphragmatic injury and involved a subdiaphragmatic abdominal intercostal hernia on the left side. An abdominal intercostal herniation was also evident on the right side in the space created by the 7th and 8th rib displacement.\nGiven the complex nature of the injury, surgical repair of the diaphragm and hernia was required. The patient underwent a left posterolateral thoracotomy; the incision was made over the defect in the chest wall. Omentum, transverse colon, and stomach were encountered in the extrathoracic hernia sac. These structures were mob"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously well, 16-year-old man presented after sustaining with a major traumatic injury to pubic and the scrotal region; this occurred as a consequence of an autonomous motorcycle accident during a motocross race occurred about 12 hours before hospital admission. Physical examination revealed extensive scalp injury of the pubic and scrotum skin involving bilateral testis and penis (); the patient underwent emergency surgery for evacuation of a haematoma and debridement of necrotic tissue. Preoperatively brain, lung and abdominal computed tomography (CT) scan did not showed bleeding internal lesions. The emergency colordoppler ultrasound (CDU) of the testis demonstrated the bilateral integrity of the tunica albuginea; in addition, an apparent normal flow of intratesticular vessel was recordered. Surgical esploration showed the testes anchored to the gubernaculum testis and the bilateral section of spermatic cord () in correspondence of the abdominal-pelvic tract, therefore abdominal incision was performed to search the proximal spermatic cord tracts those presented a full section without active bleeding. A vascular anastomosis between the dissected spermatic cord was not recommended by vascular surgeon therefore a suture to prevent bleeding was performed. Although the bilateral spermatic cord section both testes did not showed the typical necrotic color () therefore hoping that cremasteric and deferencial vessels could spray the testicles a conservative management was adopted. The next morning the patient underwent bilateral intratesticular sperm biopsy for cryopreservation and a total of 14 spermatozoa were picked up and deposited at the assisted reproduction center. After 1 week the testosterone level was equal to 1 ng/ml therefore hormonal substitution therapy was given; in addition, CDU of the testis did not showed intraparenchimal blood flow that was confirmed by microbubble contrast agent Sonovue administration. The patient was discarged 20 days from trauma"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male with a medical history of right inguinal hernia repair during childhood, presented with a history of left groin swelling for three months. There was a progressive increase in its size. Initially, he had been able to reduce the mass, but now it had become irreducible. His history revealed no symptoms of bowel obstruction.\nOn examination, he looked comfortable with normal vital signs and no signs of distress. On palpation, a large mass was found in the left inguinal region extending to the left scrotum, about 10 cm in diameter. Cough impulse was present; the transillumination test was negative; and the mass could not be reduced.\nAs the presentation was not typical for an incarcerated hernia, further investigations were done. An ultrasound examination of the area revealed normal testes with no hydrocele; it also showed that the mass had increased vascularity most likely representing omentum.\nThe patient was prepared for surgery and taken to the operating room where the left inguinal canal was explored. The content of the hernia could not be reduced, so the hernia sac was opened and a piece of omentum was seen extending from the internal ring to the scrotum. The incision was then extended into the scrotum and a large encapsulated mass was encountered attached to the omentum []. The mass was easily delivered out of the scrotum as it was not attached to the scrotum or the testes and it was completely excised along with a small piece of omentum to get a clear margin. The hernia was then repaired using a prolene mesh. The patient's postoperative course was uneventful and he was discharged from hospital after one day with no complications.\nGrossly, the mass measured 19 × 9 × 7 cm and was well encapsulated. The cut surface had a yellowish myxoid appearance [].\nThe histopathological examination revealed that the tumor consisted of bland spindle-shaped and satellite cells evenly distributed in a collagenized and myxoid stroma []."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old male patient was referred to the Stomatology Department complaining of an increased gingival volume in the region of the mandibular anterior teeth. According to the patient, the lesion grew within one month. The patient also reported being alcoholic and a former smoker. His medical history included hypertension and diabetes mellitus type 2 and the patient reported a basal cell carcinoma detected five years ago. No additional information about infectious disease as C hepatitis or AIDS was reported. The extraoral examination revealed no lymphadenopathy. The intraoral examination revealed poor oral hygiene, general periodontal disease, and a sessile nodular lesion located on the buccal and lingual gingiva of the mandibular incisors extending to the floor of the mouth. The patient had lost all maxillary teeth in the past because of periodontal disease. The lesion presented a lobulated surface, flabby consistency, and dark red color, measuring 2 cm in diameter (). The teeth involved had biofilm accumulation, calculus, and mobility, hampering masticatory functions. A panoramic radiograph showed significant horizontal bone loss adjacent to the anterior teeth, extending to the mandibular left first premolar (#34).\nAccumulation of calculus was also observed, suggesting a condition of chronic periodontal disease (). The hypothesis of a reactive hyperplastic lesion related to the severe gingival inflammation was considered. In this context, the potential diagnoses included pyogenic granuloma, focal fibrous hyperplasia, peripheral giant cell granuloma, and peripheral ossifying fibroma. Additionally, squamous cell carcinoma and lymphoma were also suspected in face of the rapid progression of the lesion.\nConsidering these hypotheses, an incisional biopsy was performed under local anesthesia. The histopathological exam showed a diffuse proliferation of atypical large lymphoid cells, displaying numerous mitotic figures ().\nPredominantly, the neoplastic cells presented"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old multigravid female was visiting our private clinic for a routine antenatal transabdominal ultrasound check at 16 weeks gestation. Two foetuses joined at the chest and abdomen were identified by two-dimensional ultrasound, and further confirmation was made by three- and four-dimensional ultrasound. There was blood incompatibility between the parents (the husband was A+ whereas the mother was A–). Anti-D was previously administered after delivery of her first child, a single viable healthy male baby. She had no history of abortion or miscarriage. Her height was 165 cm, weight 63 kg, looked normal, was neither anaemic nor hypertensive and had no history of chronic diseases.\nThe last menstrual date of this twin pregnancy was unknown. The mother did experience normal foetal movements. She had no vaginal discharge or hyperemesis gravidarum. Her abdomen was slightly large for the date of pregnancy. There was no family history of twins.\nA Voluson 730 ultrasound machine from GE Healthcare (Waukesha, WI) was used. The transabdominal ultrasound was performed and two conjoined female foetuses were detected; each foetus was with a single head and a pair of arms and legs. The twins were joined at the lower chest and the upper abdomen. Only one functional foetal heart was observed centrally between both the foetuses with slight tendency towards one of the foetuses ( and ). Single anterior placenta was seen with the umbilical cord and a normal amount of liquor. The colour Doppler study showed two aortic arches emerging from the single functional heart (). On the basis of these findings, a diagnosis of dicephalic thoraco-omphalopagus conjoined twins was made ().\nThe parents were informed of the malformation and the likely outcome if the twins survived after delivery. They decided to terminate the pregnancy and refused further evaluation and investigation. A CS was performed at the request of the parents in the hospital and the delivery of viable conj"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old male patient visited the endocrinology department with increased blood sugar for 5 years. During a routine abdominal computed tomography (CT) examination, an abnormal shadow was incidentally found in the right liver. Further magnetic resonance imaging (MRI) of the mass revealed signs of a malignant liver tumor. Therefore, he was transferred to our hepatobiliary surgery department for further treatment. Since the onset of disease, the patient had no obvious discomfort, except for weight loss of approximately 8 kg within 4 months. He had a history of chronic viral hepatitis B for 5 years and is regularly treated with tenofovir at 300 mg/day. Blood test results are summarized in . The levels of alpha-fetoprotein, serum carbohydrate antigen (CA) 19-9, total bilirubin, and direct bilirubin were abnormally elevated. Abdominal CT scanning of the tumors was then performed. Plain scanning revealed a giant hypointense mass (10 × 7 × 6 cm) involving the right liver that was oval-like, irregular, and with septations inside (). On dynamic CT scanning, the tumor edge showed irregular ring-like enhancement with strengthened septations, moderate enhancement in arterial phase (), continued enhancement in portal vein phase (), but attenuation in the equilibrium phase (). On MRI, the lesion appeared as an inhomogeneous high and low intensity on T1-weighted images () and T2-weighted images () with septations inside. On enhanced MRI scanning, the arterial phase of the enhancement scan was slightly inhomogeneously intensified, there was no signal enhancement in the inner part, and slight edge and separation enhancement (), with the enhancement range gradually increasing in the portal vein phase and attenuating in the equilibrium phase (). A sub-focus with a diameter of approximately 8 mm was found in the lateral segment of the left liver, which presented as slightly enhanced (). The tumor was accompanied by an embolus in the right posterior portal vein ().\nThe patient was d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old G4P3003 at 34 weeks and 4 days of gestation was transferred from an outside hospital to our tertiary care center with left upper quadrant pain and newly diagnosed splenic artery aneurisms. Initial evaluation was with an abdominal ultrasound followed by CT () and CT angiogram which showed two SAA of 2.3 cm and 1.9 cm in the hilum (Figures and ).\nThe nature of the pain has been intermittent and present since her last pregnancy four years ago. However, the pain worsened acutely and persisted requiring her to seek emergent care a day prior to her admission. Her past medical history was significant for abnormal pap smears, history of herpes, recent urinary tract infection that was treated, bilateral renal stones, and iron deficiency anemia. The total timeframe between worsening of the pain prompting the diagnosis of the aneurysm and thereafter labor onset followed by delivery was less than 24 hours.\nFamily history was significant for maternal autoimmune hepatitis and primary biliary cirrhosis.\nOn examination, vital signs and physical exam were normal except for tenderness in the left upper quadrant on abdominal exam, but without rebound or guarding. Fetal monitoring showed reactive and reassuring tracings, and tocometry revealed irritability without regular contractions. On admission, preterm labor workup was negative (cervical length 3.5 cm by transvaginal ultrasound, cervix 1 cm dilated, 60% effaced, fetal station -3, and negative fetal fibronectin). Also, laboratory studies were performed including liver enzymes, amylase, and lipase that were within normal.\nRegarding management, the care of this patient was approached in a multidisciplinary fashion involving the general obstetrics team, maternal-fetal medicine, vascular surgery, general surgery, trauma surgery, interventional radiology, and the neonatal intensive care team. A contingency plan for exploratory laparotomy, neonatal delivery, and control of the maternal hemorrhage was made with the team in c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female was referred to our medicine dental department in UHC Sahloul, Sousse, for treatment of tooth #46. She suffered from major coronal destruction and needed to have her first molar restored. The medical history was noncontributory. Radiographic and clinical examinations were performed initially, and an extensive glass ionomer cement restoration of a nonvital tooth (46) was identified (Figures and ). The tooth was treated endodontically. The patient had an acceptable oral hygiene and a favorable occlusion. After removing the restoration, an endocrown restoration was recommended because of the amount of remaining tooth structure and the thickness of the walls (). The prosthetic decision was to restore tooth (46) with an endocrown fabricated from lithium disilicate ceramic (IPS e.Max CAD). The preparation for the endocrown is different from the conventional complete crown. This monolithic, ceramic adhesive restoration requires specific preparation techniques to be suitable for especial biomechanical needs.\nThis is aimed at achieving achieve an overall reduction in the height of the occlusal surface of at least 2 mm in the axial direction and to get a cervical margin or “cervical sidewalk” in the form of a butt joint. The cervical margin has to be supragingival and enamel walls less than 2 mm have to be eliminated.\nDifferences in levels between the various parts of the cervical margin should be linked by a slope of no more than 60° to escape a staircase effect. We used a cylindrical-conical diamond bur held parallel to the occlusal plane, to reduce the occlusal surface. Then we used a diamond wheel bur to control the orientation of the reduction and to guarantee a flat surface thanks to its shape.\nWe used a cylindrical-conical diamond bur with a total occlusal convergence of 7° to create continuity between the coronal pulp chamber and endodontic access cavity. The bur was orientated along the long axis of the tooth; the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male presented with a chief complaint of painful swelling of the left upper jaw; he had had the swelling for 2 months. The swelling was associated with decreased vision and watering from the left eye for this period. The patient's past medical history and family history were non-contributory. He had had the habit of smoking and alcohol consumption for 30 years.\nExtraorally, a solitary swelling was observed involving the left middle third of the face, which was non-tender and hard in consistency with no changes in surface temperature (). Intraorally, a well-defined swelling was located on the alveolus of the left maxilla in the region of the first, second, and third molars with obliteration of the buccal vestibule. On palpation, the swelling was non-tender, and firm to hard in consistency ().\nPeriapical radiographs () showed a characteristic \"ground glass\" appearance and symmetric widening of the periodontal ligament space in relation to the left maxillary canine and the first and second premolars. A panoramic radiograph () revealed complete destruction of the left maxillary antral walls and zygomatic process of the maxilla, and the center of the lesion exhibited numerous calcifications.\nThe coronal section of the CT scan (bone algorithm; ) revealed a hypodense mass involving the left maxillary antrum with complete destruction of the superior, inferior, medial, and lateral walls, with invasion of the mass into the nasal fossa, orbit, and the hard palate. There was also destruction of the conchae of the left nasal fossa. The inferior aspect of the lesion showed a micro-multilocular pattern, whereas the rest of the areas exhibited calcifications distributed haphazardly.\nAxial sections of CT (soft tissue algorithm) showed calcifications at the left maxillary alveolar process as well as in the left maxillary antrum. Complete destruction of all walls of the left maxillary antrum was observed with diffuse calcifications ().\nBased on the radiological"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old white Caucasian man, without prior history of heart disease was admitted with symptoms of weakness, dizziness and chest discomfort for several hours. Physical examination revealed low blood pressure (85/50 mmHg) and a weak, regular and rapid pulse. The electrocardiogram (ECG) showed a wide-complex tachycardia with LBBB morphology and left axis deviation. Because of continuing hemodynamic instability, the patient was cardioverted to sinus rhythm with a single 300 J shock.\nThe ECG during the episode of the tachycardia was consistent with sustained VT of right ventricular origin. Post-cardioversion ECG showed negative T-waves at the inferior and precordial leads with a QRS duration of 110 ms and the presence of an epsilon wave in V1 (Figure ).\nChemistries were normal with the exception of troponin I which was positive. The patient was subsequently started on metoprolol. Continuous ECG monitoring revealed multiple episodes of non-sustained VT. Cardiac ultrasound examination showed a normal left ventricle and a slightly enlarged right ventricle with local dyskinesia and diastolic bulging of the free wall (Figure ).\nAs a diagnosis of ARVC was most likely, the patient underwent simultaneous cardiac catheterization and electrophysiological study. His coronary arteries and left ventricle were normal. Right ventriculography in the right anterior oblique view confirmed the local hypokinesia of the free wall with diastolic bulging. During the electrophysiological study, a sustained VT was provoked with identical morphology to the one on admission. The VT responded to antitachycardia pacing and the defibrillation threshold was 17 J.\nA magnetic resonance imaging (MRI) scan that followed revealed diffuse areas of fat tissue at the right ventricular wall especially localized at the free and lateral segments, while multiple small aneurysms were also present (Figure ). Right ventricular ejection fraction was 30%. Left ventricular free wall and intraventricular septum we"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old woman patient who is a homemaker was accepted to our hospital with the complaint of a 10-day pain in her right upper limb. She mentioned that the pain first involved the elbow and then the forearm, particularly the medial part of it. Nearly 10 days before, while she was cleaning and shaking the rug, she developed a discomforting pain in her right elbow. She explained that the pain in her elbow had become worse and in 24 hours spread through her whole forearm. She added that, previously, the pain had been partially responding to NSAI drugs, but subsequently, it continued to progressively increase.\nThere was a pain in her medial forearm and elbow. She felt abnormal when she was palpated on her medial forearm. During her examination, she was able to describe the point where her pain started in the proximal part of her elbow. On detailed neurological examination, a region of dysesthesia which extends from the elbow to the medial forearm was detected (Figure ). The patient had no history of polyneuropathy, chronic systemic disease, injection or surgical intervention at the elbow. Range of motion, motor, and reflex examinations of both upper extremities were normal. Cervical spine examination was normal. Varus-valgus stress test for the elbow was normal. Medial epicondylitis test and tinel test for the ulnar nerve were negative.\nX-ray views of the elbow, including oblique views, appeared normal. Electromyography showed normal findings in the right biceps, triceps, flexor digitorum sublimis, pronator quadratus, interosseous and abductor pollicis brevis muscles, and nerve conduction studies in both upper limbs except for the right MACN were found normal. The MACN is stimulated antidromically at the lateral border of the biceps brachii tendon in the cubital fossa. An active surface recording electrode is placed on the anteromedial surface of the forearm 14 cm from the active stimulating electrode."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old man presented to his general practitioner with symptoms of cough and progressive shortness of breath. He was previously well other than longstanding treated hypertension and he had no significant family history. On further questioning he also described night sweats and unexplained weight loss.\nHe was referred to the local chest clinic where salient findings on examination included oedema of the extremities, dilated chest wall veins and palpable cervical lymphadenopathy. Examination of the cardiovascular, respiratory and abdominal systems was otherwise unremarkable. Blood tests performed recently had shown elevated ferritin and C reactive protein with otherwise normal haematology and biochemistry results.\nA chest x-ray performed one month previously at the onset of symptoms was normal. A repeat chest x-ray now showed bilateral pleural effusions and extensive reticulonodular shadowing [Figure ]. Urgent ultrasound guided biopsy of the neck masses was performed along with CT of the chest, abdomen and pelvis.\nUltrasound examination of the neck confirmed bilateral enlarged lymph nodes in the supraclavicular, and lower and midjugular regions with thrombosis of the right internal jugular vein. Needle biopsy of the lymph nodes was performed.\nCT demonstrated lymphadenopathy affecting the cervical, mediastinal and hilar regions and thrombosis of both jugular veins with extensive collateral circulation. Throughout both lungs there was extensive septal thickening typical of lymphangitis carcinomatosa as well as nodular areas suggestive of pulmonary metastases and moderate bilateral pleural effusions [Figure ]. Within the abdomen, a 9 × 13 cm mass containing central necrosis was present arising from the lower pole of the right kidney and associated with extensive retroperitoneal lymphadenopathy [Figure ].\nAppearances were those of a renal cell carcinoma (Clinical TNM Stage T3N2M1) with lymphangitis carcinomatosa as part of extensive lymphatic spread. The initial nee"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.\nAt age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.\nSix months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.\nA clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.\nShe was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.\nMagnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA six years old female child weighing 12 kg, admitted with history of gradual abdominal distension that was noticed by the mother for the last 2 years but did not seek any medical advice as there were no other associated complaints. With an increase of abdominal girth and vague abdominal pain, parents took the child to a nearby general practitioner who advised ultrasound and referred the child to our facility. On examination child appeared comfortable with abdominal fullness. Abdominal examination did not reveal a distinct mass though vague fullness was present oriented more in vertical direction. There was a definite feel of fluid thrill on palpation.\nUltrasound done previously showed cystic mass in abdomen. With female gender a differential diagnosis included ovarian cyst in addition to mesenteric and omental cyst. CT scan abdomen was advised. This showed a large cystic mass occupying almost whole of the abdomen and located under anterior abdominal wall with viscera pushed posteriorly (Fig. 1,2). A diagnosis of omental cyst was made at this stage.\nLaparotomy was performed. On opening peritoneum a huge lymphatic cyst was found (Fig. 3). It was delivered out with difficulty and that too after partially evacuating it. More than 1500 ml of milky fluid was drained out. The anatomy was then identified more clearly. It was found between leaves of transverse colon mesentery and extending into its root (Fig. 4). The redundant leaves of mesentery were excised without jeopardizing blood supply of colon and left open so as to prevent re-accumulation of fluid. Drain was kept and wound closed.\nPost-operative course was uneventful and patient discharged on 4th day. Biopsy was reported as consistent with mesenteric cyst. Parents were counseled again as to possible recurrence of the lesion and a regular follow up was planned. At three months follow up child is well. On ultrasound a small hypoechoic area of 4cm x 4cm was noted in mid abdomen. A repeat ultrasound after a month is ad"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn a 19-year-old, mentally disabled male, chest radiography was done because of a sudden episode of cough. Metallic, hook-shaped foreign bodies were identified in both the main bronchi.\nThe right-sided FB was removed by fiber-optic bronchoscopy in the regional hospital, whilst the left-sided extraction failed with the left-sided FB persisting in the left main bronchus ().\nUpon urgent admission in a tertiary institution, extraction was attempted by rigid bronchoscope under general anesthesia. Bronchoscopic extraction failed, associated with some bleeding and subcutaneous emphysema immediately after the intervention. The increasing mediastinal and subcutaneous emphysema raised suspicion about an iatrogenic airway lesion, so surgery was indicated. Esophageal injury was previously ruled out by esophagoscopy, revealing many metallic FBs in the stomach. At thoracotomy, a significant mediastinal emphysema (), together with diffuse adhesions, was noticed. After the lung liberation, a proximal 0.5 cm of the noncurved part of the metallic hook was found to protrude through the perforated membranous wall of the left main bronchus, 1 cm away from the descending aorta (, arrow). The part of the FB protruding outside the bronchus was grasped by the clamp and, by following the curved shape of the FB, gentle maneuvers were applied by pulling the sharp end (hook) of the FB in the direction outside the bronchus. The FB was removed from the bronchus (insert on ) without the need for additional bronchotomy. The remaining 10 × 1 mm defect in the bronchial wall, caused both by manipulations during a bronchoscopic extraction attempt and subsequent surgical extraction, was sutured by interrupted PDS 3-0 stitches, and the lung fully inflated. No air leaks appeared during the water test. Having in mind the dimensions of the defect and tensionless suture, no suture-line protection was performed.\nAfter the thoracotomy closure, laparotomy was done and several sharp metallic pieces of different"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 33-year-old Caucasian man without any specific personal or familial history. He was an active smoker without alcoholic intoxication. In 2009, he presented a lesion of the lower lip. He underwent resection of this lesion, and the first pathological analysis revealed a salivary ductal ecstasy.\nOne year later, he developed a peripheral facial paralysis associated with left trigeminal neuralgia. MRI showed perineural invasion of the trigeminal nerve within the temporal fossa (fig. ). Surgical biopsies performed in July 2010 identified secondary lesions from a well-differentiated SCC localized around the V and VII nerve sheaths. According to this diagnosis, a new pathological analysis of the previous resection of the lip was performed in a cancer reference center and diagnosis of SCC of the lip was made. The patient started radio-chemotherapy in September 2010. He received 70 Gy in 35 fractions, and five courses of an association of 5-fluorouracil and cisplatinum. First radiological assessments, 4 months after the end of radio-chemotherapy showed no residual disease.\nHowever, in November 2011, the patient presented with new neurological symptoms: paraparesis and back pain. MRI showed medullary myelitis without meningeal enhancement. Lumbar puncture revealed inflammatory cells without atypical cells within the cerebrospinal fluid (CSF). Cerebral MRI and positron emission tomography scan were normal with no evidence of visceral metastasis. Multiple sclerosis was suspected and the patient received several corticosteroid flashes who led to partial improvement of symptoms. Nevertheless, other explorations were negative, and it was not possible to certify the diagnosis of multiple sclerosis. In early 2012, the patient relapsed and developed paraparesis once again. Sequential lumbar punctures found no abnormal cells. He was given a symptomatic treatment combining corticosteroid and plasma depletion. In March 2012, CSF analysis showed intrathecal immunoglobulin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old female reported to the department of oral pathology with the chief complaint of pain in the left side of the face for the past 1 month. History of presenting illness revealed a swelling which was initially small and gradually progressed 1 week before to the current state. Pain was sudden in onset, intermittent in nature, which aggravated on mastication and did not subside over medication (the patient was advised Combiflam tablet for 5 days, twice daily and intramuscular injection of cefixime for 3 days by physician whom she visited earlier). The patient revealed a past medical history of regular treatment for progressive SSc/lupus overlap syndrome, secondary Sjogren's with interstitial lung disease and PAH for the past 10 years. The patient was hospitalized for left lower limb cellulitis 8 years back and was discharged after complete observation and medication. Vitamin D insufficiency was suspected and corrected by calcirol granules.\nThe patient also had a complaint of difficulty in swallowing and spasm-type pain which was diagnosed as esophageal dysmotility and reflux disorder and was advised on prokinetic agents, low-fat diet and to avoid cold exposure to extremities. The patient also revealed a history of whitish skin lesion on both her legs and foot 20 years before these lesions have not progressed. The patient revealed no history of autoimmune disease in the family. The patient had undergone multiple uneventful extractions and complete prosthetic denture treatment. The patient also revealed a history of impaired taste sensation. On general examination, patient's vital signs were normal, and left submandibular lymph node was palpable, roughly oval, firm in consistency, tender and mobile.\nOn extraoral examination, facial asymmetry was seen in the left side of the face as a solitary diffuse swelling. The swelling extends from the middle third of the body of the mandible anteriorly to 1 cm behind the auricle posteriorly and superiorly at the level of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms (Fig. a) showed hemorrhage in the left temporal lobe, and the patient was admitted in our department with a clinically confirmed diagnosis of ��hemorrhage in the left temporal lobe”. The patient had a previous history of hypertension for more than 10 years, and was under medication to control and maintain the blood pressure to be around 130/80 mmHg. The patient denied the history of diabetes and had no bad habits, such as smoking and drinking alcohol. Physical examination at admission revealed that his body temperature was 36.2 °C and blood pressure was 196/119 mmHg. The patient was conscious and suffered from incomplete aphemia. Bilateral pupils were of the size and round, the diameter of pupils was 3 mm, and pupils were sensitive to light reflexes. Muscular strength of the limbs was about grade 4. Bilateral pathological signs were negative, and there was no significant abnormality noticed during nervous system examination. Head MRI conducted the next day after admission indicated no significant vascular malformations (Fig. b). General consultation evaluated that bleeding sites of the patient were slightly different from hypertensive intracerebral hemorrhage. The hematoma sites were close to the middle cerebral artery and the walking areas of its branches, mainly in the temporal lobes. Therefore, cerebral vascular hemorrhage and other causes could not be excluded, and head CTA was further suggested. Head CTA performed on 17th May 2017 showed that the patient suffered from intracerebral hematoma caused by aneurysm rupture at the M1 bifurcation of the left middle cerebral artery, without any significant subarachnoid hemo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old woman and her 30-year-old husband presented with history of primary infertility over a period of 4 years. Although she did not report a history of pelvic inflammatory disease or sexually transmitted infection in the past, she had ultrasound confirmed bilateral hydrosalpinges, and both of her fallopian tubes had been removed laparoscopically. Thereafter, she required fertility assistance by in vitro fertilization (IVF).\nAfter confirmation of a pregnancy in the 1st attempt of IVF in February 2005 she was admitted to the local hospital with abdominal pain during the first trimester. Following an ultrasound suspicion of an interstitial pregnancy, she underwent a laparoscopy, which confirmed a right cornual ectopic pregnancy. The operation was then graduated to a laparotomy, and the cornual ectopic was removed by a longitudinal incision on the right cornu. After evacuating the products, the bleeding was minimised by diathermy coagulation. Postoperatively, she received supplementary treatment with intramuscular methotrexate to resolve any remnant trophoblastic tissue. Trophoblastic tissue, however, remained viable for up to 3 months after the first dose of methotrexate, and serum hCG was detectable albeit at low concentrations (27–45 iu/L). She opted for a conservative management as opposed to a repeat dose of methotrexate, and it was finally 8 months before all evidence of trophoblastic activity disappeared completely.\nShe conceived again after the 2nd attempt of IVF performed in February 2006. This time she presented with an acute abdomen at 6-week gestation at her local hospital and underwent an emergency laparoscopy. She was then found to have 1200 mL of haemoperitoneum. Active bleeding at the right cornu was seen, but trophoblastic tissue attached to the uterine cornu was not seen. Subsequently tissue found amongst the blood clots was histologically confirmed to be the “product of conception.” Due to this very early rupture, the exact location of this p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old man, who had been injured during a wrestling competition, was referred to our hospital with an abdominal pain. He had no significant past medical history. On physical examination, he was a thin young patient with stable vital signs. He had pain and mild tenderness in left upper quadrant region. Laboratory tests including complete blood counts, liver function test (LFT) and blood chemistry were normal. Anti-hydatic cyst antibody test was negative. Erythrocyte sedimentation rate (ESR) was high (62 mm/h) and culture for enterococcus was positive. Abdominal computed tomography scan revealed a complicated cystic lesion with dimensions of 118 x 130 mm between spleen and the left kidney and a compression effect into the kidney. The mass had septa and calcification in its inferior part. Using contrast enhancement, no abnormal vessel or enhancement was noted (). Thus the patient underwent a semi-elective operation. During the operation, a huge cystic structure was discovered filled with thick, brownish secretions in retroperitoneal area. The cyst was about 20 x 20 x 20 cm in diameter and adjacent to spleen, adrenal gland and kidney. Postoperative course was uneventful; the patient was discharged on day 3, and had remained asymptomatic during the follow-up period of 4 years.\nOn gross examination, the specimen consisted of an opened creamy brown ovoid cystic lesion, measuring 10 x 8 x 7 cm with irregular surface. On opening internal surface was brownish and irregular, wall thickness from 0.2 cm to 1.5 cm. The cyst was submitted for microscopic examination.\nHistological sections showed fragments of cystic wall, lined by bronchial type pseudostratified cylindrical epithelium resting on fibrovascular connective tissue containing extensive foci of mononuclear inflammatory cells aggregates and presence of smooth muscle fascicles. There were foci of non-neoplastic adrenal tissue attached to external surface of the cystic lesion. A subsequent cytological examination wer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old Japanese woman was admitted to our hospital because of visual field loss and unsteady gait. The patient spent time gardening as a hobby and was on infliximab and methotrexate therapy for rheumatoid arthritis. Two months before admission, her left visual field loss had steadily progressed, and she felt low-grade fever and general malaise. A high signal in the right occipital lobe and the left parietal lobe was detected in the MRI fluid-attenuated inversion recovery (FLAIR), and the lesions were enhanced by gadolinium (Fig. A–D). Brain biopsy of the right occipital lobe lesion demonstrated granulomatous inflammation, but no pathogenic micro-organisms were detected using either microscopic examination or culture. A diagnosis of neurosarcoidosis was made by the neurologists based on the brain biopsy findings.\nThe symptom of unsteady gait was temporarily relieved by intravenous methylprednisolone (IVMP); although, it worsened soon after discharge, followed by readmission to our department. At the time of readmission, there were no notable findings in the chest and abdomen and no uveitis was noted. A brown spot with a scab, about 10 millimeters in diameter, was observed inside the left upper arm. Neurologically, left lower visual field and mild weakness in the distal muscles of the upper limbs were observed. Deep tendon reflexes and muscle tonus in the upper and lower limbs were normal, and there was no ataxia or sensory impairment. Analysis of blood samples showed no abnormal findings in the blood cell count or the coagulation system. Serum angiotensin-converting enzyme II activity was 12.9 U/L and lysozyme level was 6.2 μg/mL. Antinuclear and antineutrophil cytoplasmic antibodies were negative. Specific antibodies for aquaporin 4 and myelin oligodendroglia were also negative. Tumor markers were not elevated. Antiparasitic antibodies and blood cultures were also negative. The CSF collected 1 week after brain biopsy was colorless and transparent, and the ini"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman presents to the Emergency Room with palpebral edema as well as various erythematous plaques in supraciliary and malar areas that appeared and have gradually worsened a couple of days prior to presentation (). Initially the patient did not share having changed her daily facial hygiene, making any diet changes, getting any animal bites, or taking any new medication.\nOn exanimation, the patient had facial swelling, pain on palpation, and flushing.\nA full blood count was performed with no alterations of the blood formula, neither leucocytes nor the eosinophils, and no inflammatory markers or IgE elevated.\nStill suspecting an allergic reaction, she was given treatment with corticosteroids and antihistaminic medication, both intramuscularly and with a unique dose.\nFour days later, the patient returned to the Primary Care consultation due to recurrence of her symptoms and was referred once again to the Emergency Room where she was clinically diagnosed with cellulitis and received antibiotic treatment (amoxicillin with clavulanic acid) along with corticosteroids and antihistaminic medication once again.\nAlthough she referred a short period of improvement of the symptoms, the swelling and rash reappeared when the treatment was suspended along with another two nodules of hard consistency localized on the cheekbone of the right facial side ().\nDuring the fourth Primary Care consultation, the patient was interrogated more thoroughly and only then she mentioned that she was visiting, for about four months, an Esthetic Private Clinic, where she was injected in various sessions with Metacrill, as a facial lift, for beauty purpose. Apparently no other patient suffered the same symptoms.\nDue to suspecting an allergic reaction to the Metacrill and the failure of the initial treatments, she was referred to the dermatologist.\nDuring the dermatology consultation, a biopsy of one of the granulomas was performed, being diagnosed as Chronic Edematous Panniculitis to a f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old female patient with gravida 2, para 0, living 0 and abortion 1 with a history of 24 weeks of amenorrhea, presented to casualty with bleeding per vagina and loss of fetal movements since 2 days. She was from a low socioeconomic background. She had not undergone any antenatal checkups. She had a previous history of abortion. The patient had a history of second-degree consanguineous marriage. Past and personal histories were not significant.\nOn general physical examination, it was observed that the patient was a middle-aged female, moderately built, and nourished. Pallor was present. Per abdomen examination revealed that the uterus was relaxed and uterine height was of 24 weeks. Fetal heart rate was absent. Per vaginal examination revealed partially closed os, admitting only tip of finger, and effacement was absent. Routine biochemical investigations were within normal limits. Hemoglobin level was 7.2g/dL, hematocrit was 22%, and peripheral smear showed microcytic hypochromic and normocytic hypochromic red blood cells with normal white blood cells and platelets, giving a picture of dimorphic anemia. Coagulation profile was within normal limits.\nEmergency antenatal ultrasound examination was carried out and it showed conjoint twins with loss of fetal cardiac activity. After obtaining informed consent from the patient and attenders, induction of labor was initiated with prostaglandins and the pregnancy was terminated by vaginal delivery. Dead male baby weighing 1800g was delivered. After obtaining consent, the fetus was sent to pathology department for histopathological examination.\nExternal examination revealed male fetus with head circumference of 30cm (both the heads), chest circumference of 15cm, abdominal circumference of 20cm, and foot length of 7cm. The fetus had complete duplication of cranial structure with three eyes. One eye of both the duplicated head was fused in the center. Two nose, two ears, two mouths, of which one lip showed cleft lip and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old boy with no urological or medical history presented to his general practitioner with a six-month history of strangury, poor flow, suprapubic discomfort, urinary frequency and urgency. He had also noticed one recent episode of visible haematuria. There was no family history or congenital abnormality noted. Blood tests revealed a normal renal function. An ultrasound of his urinary tract had been ordered in the community, which had shown two large polypoidal masses arising from the right and left lateral walls of the bladder, measuring up to 2.1 cm and 2.5 cm, respectively. The remainder of the urinary tract was unremarkable, and there was no significant post-void residual volume ().\nThe patient was referred urgently to be seen by the urology team. Following further discussion in clinic with the patient and his parents, a decision was made to proceed directly to cystoscopy under general anaesthetic for further evaluation and possible resection of these lesions. A urine cytology was sent which showed a few inflammatory cells but no overtly malignant cells to be present. Serial urine cultures had revealed no growth and he had no history of previous urinary tract infections. On cystoscopic examination, following dilatation of a tight urethral meatus from 14Ch, the two large polypoid lesions were identified on either side of the bladder neck that they were partially obstructing, resembling malignancy in some areas and inflammatory masses in others (). The remainder of the urethra was normal. Neither ureteric orifice was visualised. Both lesions were resected using a 17Ch resectoscope, and a small red area on the posterior wall was biopsied. A decision was made to remove the majority of the lesions from around the bladder neck, leaving as much normal or non-polypoid tissue as possible to reduce the risk of bladder neck stenosis. The patient was kept overnight for bladder irrigation, and the catheter was removed the following day with no postoperative complicat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 11-year-old girl presented with headache for 3 weeks, weakness of all the four limbs for 2 weeks, and rapidly progressive vision loss for 10 days. At 16 months of age (10 years back), she underwent fenestration of posterior fossa arachnoid cyst with ventriculoperitoneal (VP) shunt insertion when she had become lethargic and lost motor milestones. She improved and returned to baseline and was doing fine.\nThree weeks before presentation to our center, she developed persistent frontal headache and vomiting which progressively increasing. On the 7th day of illness, she was evaluated elsewhere by an ophthalmologist. Visual acuity was reportedly normal. There was no papilledema. Magnetic resonance imaging (MRI) was done, which showed a posterior fossa arachnoid cyst with VP shunt in situ and normal-sized ventricles []. Cerebrospinal fluid (CSF) examination revealed acellular CSF with normal biochemistry, but opening pressure was not measured. She also had aching over the limbs. Headache decreased after the CSF drainage (25 mL).\nDuring hospitalization, she developed symmetrical proximal as well as distal weakness of all the four limbs without sensory loss. She also developed difficulty in chewing and jaw drop without facial sensory loss. There was left-sided facial, palatal, tongue, and neck weakness. Eleven days after the onset of headache, she developed horizontal binocular diplopia. Then, she started having diminution of vision in both the eyes, which progressed over 5 days to complete blindness with worsening of headache. There were no seizures, ataxia, fever, and loss of weight or appetite. There were no other systemic complaints. She received pulse methylprednisolone with no improvement. At presentation at our center (3 weeks after onset of illness), she was conscious, drowsy, and had a normal general physical examination and hemodynamically stable without any features of Cushing's triad but had neck stiffness.\nExamination revealed absent perception of light bil"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-year-old female patient reported with a painless swelling over the right lateral border of the tongue for the past 4 months. There was no history of trauma in that region. There was complaint of slight dysphagia and globus sensation. Medical history and general physical examination were unremarkable. There was no regional lymphadenopathy.\nOn physical examination, there was a single 2 cm × 2 cm soft, well-delineated, nontender mass occupying the right lateral aspect of the tongue.\nThe swelling was sessile, submucosal, and firm in consistency with a smooth surface. Overlying mucosa was normal in appearance and not fixed. Tongue movements and speech were normal. The magnetic resonance imaging (MRI) showed a medium-sized hyperintense lesion arising from the anterior two-third of the right half of the tongue along the lateral border on T2-weighted images measuring 1.9 cm × 1.3 cm × 1.9 cm []. Heterogenous enhancement of the lesion on intravenous administration of Gd-DTPA was observed. The MRI was suggestive of involvement of the intrinsic muscles of the tongue on the right side with no involvement of the lingual neurovascular bundle or the base of the tongue. Level IB and II lymph nodes were enlarged bilaterally.\nAn incisional biopsy was done for the patient under local anesthesia and was submitted for histopathological examination. The lesion was suggestive of AR. The mass was explored under general anesthesia with an intraoral approach. The tumor mass was marked with methylene blue. An elliptical incision was marked around the tumor mass and it was excised from the surrounding musculature of the tongue []. Care was taken to preserve all the adjacent vital structures; a two-layer primary closure was done with 3-0 vicryl. No postoperative complications were noted. There was no recurrence noted up to 2 years of follow-up.\nHistopathological examination of the excised specimen revealed large polygonal vacuolated cells with a granular cytoplasm and abundant glycogen th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male patient was referred to the Department of Otolaryngology-Head and Neck Surgery, Kobe University Hospital, for the evaluation of a 6-month-old, large neck mass that had gradually increased in size. Written informed consent was obtained for surgery including neck dissection. Upon examination, the mass presented as a swelling of approximately 4×5 cm in size, located in the left posterolateral side of the lower neck. It was non-tender, hard, and attached to deep neck structures. A contrast enhanced computed tomography scan revealed a large soft tissue mass in the left posterior neck that involved both the anterior and medius scalene muscles (, ). Magnetic resonance imaging (MRI) revealed an iso-intense mass on the T1 weighted image and a low-intensity mass on the T2 weighted image (). On the anterior side, the mass extended up to the sternocleidomastoid muscle (SCM), with splaying of the left internal jugular vein. No pathological finding was detected in the upper aerodigestive tract by endoscopic examination. After an inconclusive fine needle aspiration, surgical extirpation of the tumor was performed. We did not perform preoperative incisional biopsy because incisional biopsy of neck masses before radical treatment is associated with poor prognosis. The negative influence of preoperative incisional biopsy on prognosis is possibly because of tumor cell dissemination or changes in lymph flow. We were ready to perform a neck dissection procedure if the tumor was malignant. A preoperative incisional biopsy was performed at the beginning of the surgery. The pathological diagnosis of the biopsy was fibromatosis. In response to the clinical findings, a wide excision of the tumor was performed. We encountered difficulty because of local infiltration of the surrounding tissues. Parts of the scalenus medius and SCM were also resected because of tumor invasion. The carotid artery, internal jugular vein, the remainder of the SCM, lower cranial nerves, phrenic n"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 60-year-old woman of West African descent, with no history of asbestos exposure, who originally presented 24 years ago to another institution with acute abdominal pain. At that time, she underwent an exploratory laparotomy and was found to have nodules diffusely covering the peritoneum. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed for suspected ovarian carcinoma, and biopsies were taken of the peritoneal nodules. The pathology from this original surgery was interpreted as low-grade papillary mesothelioma. She then received six adjuvant cycles of intravenous cyclophosphamide, doxorubicin and cisplatin. She underwent a second-look laparotomy six months later, and still had gross disease visible in the peritoneum. Post-operatively she received three additional cycles of intraperitoneal cisplatin and intravenous sodium thiosulfate. She subsequently received maintenance therapy with alternating courses of tamoxifen and megace alternating every two weeks.\nShe presented four years later with obstructive gastrointestinal symptoms and was again found on laparotomy to have diffuse peritoneal studding. Pathology from this surgery was interpreted again to be papillary mesothelioma. As a result, she began six cycles of carboplatin and cyclophosphamide chemotherapy for suspected progressive disease. Several months later, she presented with complaints of shortness of breath, orthopnea, and worsening lower extremity edema. A multi-gated acquisition scan (MUGA) revealed an ejection fraction of 14% and enlarged cardiac silhouette on chest X-ray, and she was clinically diagnosed as having anthracycline-induced cardiomyopathy. Medical therapy was initiated at that time for congestive heart failure.\nTwo years later, she was found on a computed topography (CT) scan to have an interval increase in loculated subhepatic fluid collection and a lobular soft tissue mass in the right subphrenic region. She then received three cycles o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.\nShe reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.\nDuring her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.\nThe oncology team became involved at this time. Her CLL was the suspected etiology of the neck mass and lymphadenopathy, and intravenous fluids and allopurinol were started to prevent tumor lysis syndrome. Further laboratory workup showed the predominantly lymphocytic, elevated WBC count as before and a normocytic anemia, hemoglobin 10.6 g/dL. Smudge cells were present on the peripheral blood smear. Iron studies, B12, and folate were normal. Flow cytometry"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old female with cancer in the right breast underwent a modified radical mastectomy in December 2001. At that time, the patient was diagnosed with breast cancer in stage T2N1M0. The tumor was positive for estrogen and progesterone receptors on immunohistochemical staining, and negative for HER2 overexpression by fluorescence in situ hybridization. Postoperatively, the patient was treated with adjuvant chemotherapy of cyclophosphamide, doxorubicin, and 5-FU every 3 weeks, for 6 cycles duration from December 2001 until May 2002, and hormonal therapy (toremifene citrate) from May 2002 until April 2006.\nIn April 2006, a follow-up bone scan revealed metastasis to the left scapula (), for which the patient was treated with doxorubicin and docetaxel every 3 weeks for 3 cycles. A follow-up bone scan revealed exacerbation of the metastasis, and in March 2007 (). At that time, the patient received intravenous (IV) zoledronic acid (4 mg) to prevent skeletal complications.\nIn October 2010, the patient accidentally tripped while walking and subsequently, felt pain in her right hip. Because she had no problems walking, she did not receive any specific treatment. A follow-up bone scan 1 month later demonstrated a focus of increased tracer uptake; however, the patient had no complaints of hip pain (). The finding was thought to be a bone metastasis, and zoledronic acid was administered on an ongoing basis.\nIn March 2011, the patient underwent X-ray evaluation at a local clinic because of intermittent right hip pain that was negative for fracture (). The following April, she developed pain in her right hip while jogging and had problems walking. Subsequent X-rays showed a right subtrochanteric fracture () and she underwent an open reduction with internal fixation (using compression hip screw & autogenous iliac bone graft) (). A bone biopsy of the fracture site demonstrated acute and chronic inflammation.\nIn addition, the left femur was observed to have cortical thickening a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man with history of grade 1 follicular lymphoma since 2013 with no indication for therapy being followed by oncology for clinical surveillance presented with worsening shortness of breath and hemoptysis. Physical exam was unremarkable, and lab workup showed chronic anemia. Computerized tomography (CT) imaging of the chest showed an enlarging 2.0 cm density in the posterior right upper lobe of lung (RUL) as well as scattered pulmonary nodules in the RUL. With his extensive history of smoking, he underwent bronchoscopy with endobronchial ultrasound-guided biopsy (EBUS) of mediastinal lymphadenopathy. Bronchoscopy revealed lung mass with endobronchial lesions and mediastinal lymphadenopathy. Although clinically on bronchoscopy it appeared to be cancer, biopsy was negative. He subsequently was sent to interventional radiology for biopsy of an RUL spiculated mass, which again was negative for cancer. Needle biopsy sections of lungs were suggestive of organizing pneumonia.\nWith clinically suspected cancer and two separate negative biopsies, we decided to proceed with positron emission tomography (PET) scan to reassess approaches for tissue biopsy. Meanwhile patient was started on antibiotics with which he had significant improvement clinically and his shortness of breath and mucus production got better. Patient had PET scan that showed extensive mediastinal lymphadenopathy throughout the right mediastinum and LA which could probably correspond to patient’s known lymphoma ( and ) as his biopsied right spiculated lung mass did not appear to be growing and had less impressive uptake. Patient was recommended to have repeat EBUS; however, he refused to undergo any further procedures or biopsies.\nThree months later, patient underwent repeat chest CT with contrast that showed right hilar and mediastinal mass measuring 7 cm in size with involvement of right and left brachiocephalic veins, SVC and a large tumor thrombus in the LA (). He had transthoracic echocardiog"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old Hindu female, married for 5 years, living with her husband, a 4-year-old son, and a 20-weeks-old daughter, and in-laws in a joint family, belonging to the middle socioeconomic strata, came to psychiatry OPD with complaints of having thoughts which were extremely distressing to her. The thoughts were of her performing sexual acts with Lord Hanuman and also of her children sharing incestuous relations. The thoughts first began 2–3 days after delivery of her daughter, 5 months ago. They would initially occur only when she would happen to view her newborn daughter's genitals, whereas bathing her or cleaning her, when she would happen to see Lord Hanuman's image on her daughter's genitals. This persisted for around a month. After that, she began having thoughts of her son having sexual relations with her daughter. This would earlier occur only when her two children were sitting or playing together but eventually began occupying her thoughts throughout the day. Alongside, the thoughts of her performing sexual acts with gods also began increasing. The thoughts were also associated with vivid visualization of the act as if occurring in front of her eyes and continuing to be seen by her even when she would shut her eyes in an attempt to stop the images. She would try her best to suppress such thoughts by diverting her mind to other thoughts or by keeping herself occupied with work, which, albeit effective in the beginning, was not helping her. These thoughts grossly violated her moral and religious ethics and were causing her immense distress. She took cognizance that the thoughts were her own, and that they were unreal and impossible. She would feel apprehensive with palpitations, tightness in chest, and restlessness. She also began reporting no interest in the world around her and her daily activities. She completely stopped breastfeeding her daughter, and vehemently refused"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old female patient from a less-developed region was first seen at our institution almost seven years ago for evaluation of mBC. This patient had been diagnosed a few months earlier at another institution with infiltrating ductal carcinoma (mucinous type). Both ER and progesterone (PR) receptors were positive in 90% and 60% of the cells, respectively, while Human Epidermal Growth Factor Receptor (HER/neu) was negative on immunohistochemical staining. Her pathology results were reviewed and confirmed at our institution.\nStaging at the time of diagnosis and at presentation to our institution showed a tumor in the left breast and left axillary lymph node involvement, in addition to right hilar lymph node involvement and a right lung mass (Figure ).\nShe was treated with four cycles of adriamycin and cyclophosphamide; however, there was no significant response. She was then switched to docetaxel and four cycles were administered, again with no response. Given the lack of response, both hilar lymph nodes and the lung mass were biopsied and pathology test results confirmed the original diagnosis of invasive mucinous carcinoma (Figure ). Again, both ER and PR were strongly positive while HER2/new was negative.\nGiven the stable nature of her disease, the absence of a visceral crisis, and because of the patient’s social issues and the limited availability of appropriate medication in her home region, she was started on tamoxifen along with ovarian ablation using gonadotropin-releasing hormone (GnRH) agonists (goserelin, 3.6 mg subcutaneously, every four weeks). Follow-up imaging studies showed a significant disease response three and six months later. Our patient continued on the same treatment, with no major side effects. Follow-up CT scans at nine months showed a continued response in the breast mass and complete resolution of the right lung mass and the right hilar lymph nodes. Moreover, tumors in the left axillary lymph nodes had completely disappeared (Figure )."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old male presented to an outside facility with the complaint of increasing low back pain over the past month that radiated bilaterally to the level of his ankles. The pain was accompanied by progressive lower extremity weakness to the point where ambulation became impossible 3 days prior. He also complained of bilateral calf and anterior thigh numbness with paresthesias. He denied changes in normal bowel and bladder function. He had been evaluated 3 weeks prior at the same facility with similar but less severe complaints and diagnosed with bilateral sciatica. Workup during the more recent visit revealed an L2 mass invading the spinal canal for which the patient was transferred to our facility for neurosurgical evaluation [].\nThe patient had noted a left testicular mass 3 years ago and stated that it had been enlarging in size and was painful to touch. He denied having ever brought this complaint to the attention of a physician. He also admitted to poor appetite and significant weight loss over the prior month amounting to 25 pounds and attributed this to his major depression. He denied fevers, vision changes, night sweats, or any other palpable lesions or rashes.\nThe patient was a pale, anxious-appearing male who was alert and cooperative, tachycardic, and hypertensive. He exhibited tenderness to palpation in the midline lumbar spine. Upper extremity strength was normal. Right hip flexion, knee extension, dorsiflexion, and plantar flexion were grade 4/5. The same motor groups were only at anti-gravity strength (3/5) on the left side. Rectal sphincter function was normal. On sensory exam, saddle anesthesia was noted as was decreased sensation to light touch in a distribution that approximated the bilateral L2 and L3 dermatomes. His reflexes were grade 2+ throughout and no long-track signs were observed. His left testicle was enlarged and a mass was palpable that was non-tender at the time.\nA magnetic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old Chinese female patient presented to our clinic complaining about a 1-year history of a growing lump at the medial third of her right clavicle, associated with recurrent and aggravated pain. Limited range of motion of the right shoulder was reported as well. The patient experienced no compression and difficulty in breathing. Physical examination indicated the right shoulder had limitations in adduction, abduction, back extension, and elevation. A hard lump with a diameter of 7cm × 5 cm lump at the medial third of right clavicle was palpated with pain and slightly swelling. No redness and skin lesion around the lump; no muscular atrophy and weakness; no dislocation or deformity of the shoulder joint and no thoracic varicosity were observed.\nThe X-ray film and computed tomography (CT) scan showed the sclerotic bone remodeling of the medial third of the right clavicle (Fig. ). After admitted to the ward, a percutaneous bone biopsy was performed, revealing a suppurative inflammation with bone destruction, without the signs of malignancy (Fig. ). A diagnosis of clavicle osteomyelitis was suggested. Thus, conservative treatments with antibiotic (based on drug sensitivity, clindamycin was given 1.2 g/d for 2 weeks) and non-steroidal anti-inflammatory drugs were given. The patient was discharged after the pain was relieved.\nIn the next 7 months, the symptom of pain gradually worsened and radiated to her right arm. Despite the intake of non-steroidal anti-inflammatory drugs and treatment with antibiotic, the pain was still obvious. Meanwhile, she started complaining of muscle weakness and limited mobility of the right shoulder. The lump of right clavicle was bigger than before and developing to her right neck. After admitted to the ward, X-ray film and 3D reconstruction of CT scan were carried out. Despite the conservative treatments were given, the pain and swelling of the right clavicle were still not relieved, seriously affecting the patient�"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old woman was referred to our neurosurgery department from gynecology and general surgery due to paresthesia and pain in perianal area. By then, her symptoms had persisted for 2 months. Previously, she had been examined in general surgery and in gynecology. After the gynecologist confirmed an abnormal mass in the retrorectal space by pelvic MRI and CT, she was admitted to our department for surgery. There were no abnormal findings by digital rectal examination or on perianal skin. Pelvic CT showed a bony defect on the lower sacral bone near the cyst (). Pelvic MRI with gadolinium enhancement showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image. The size of the mass was about 6 cm, of which was a multilobulated mass on the sacrococcygeal area. The uterus was enlarged and heterogeneously enhanced (). Surgery was performed with the patient in prone position under general anesthesia. After making a 10-cm long midline skin incision, 3 cm distant from the anus, we exposed the lamina by dissecting the soft tissue. The bony defect was palpable above the cyst wall. The additional laminectomy was performed to take the large mass out. While performing a careful cyst dissection, we realized that the demarcation of the cyst was good, and there was no evidence of cyst rupture. The cyst contained soft suctionable yellowish material of creamy consistency. A small incision was made on the cyst wall, and the cystic contents were aspirated with a syringe. After the cyst wall was sutured, marginal cyst dissection was performed although part of the cyst wall was stuck to other tissue. The contents were removed with no significant spillage into the retropelvic cavity. Complete excision of the retro-rectal tumor (which was fixed to the apex of the coccyx) using posterior midline approach was performed (). Histopathology exam of the retropelvic cyst revealed a multiloculated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA female patient, 39 years old, is complaining of diffuse abdominal pain, more prominent in the flank and left hypochondrium, initially bearable and with response to simple analgesics, but with progressive and significant worsening in the last 24 h. The patient reported bilious vomiting and denied fever or other similar episodes in the past. She was admitted in good general condition, moderately dehydrated and discolored. On abdominal palpation, there was evidence of diffuse pain without peritonitis. The patient was given IV hydration with crystalloids and underwent an abdominal/pelvic CT scan, which identified a voluminous expansive formation in the pancreatic tail, with compression, but without direct invasion of the splenic vein (Figure ). Laboratory tests showed CA 19–9 serum concentration greater than 1,000,000 U/mL, with no other changes.\nUpper gastrointestinal (UGI) endoscopy did not show any extrinsic compression or gastric/duodenal wall invasion.\nAn MRI of the upper abdomen was performed in order to better characterize the lesion, with evidence from projection imaging of a mass in the pancreatic tail, predominantly with cystic aspect, multiloculated, with thick septations and regular margins, showing heterogeneous contrast enhancement and areas of T1 signal hyperintensity, possibly corresponding to hematic content. Its size was 63 × 60 × 61 mm (Figure ).\nNo endoscopic ultrasound was indicated, since the main diagnostic hypothesis was a mucinous lesion with malignant transformation, and its treatment included surgery, provided that no metastatic disease was found.\nClinical stabilization and preoperative evaluation was performed, with no additional significant findings. The patient was the taken to the operating room. At first, she underwent a diagnostic laparoscopy, with no signs of peritoneal and liver metastasis. Laparotomy was then performed, and a distal pancreatectomy with splenectomy was conducted. The patient had an uneventful postoperative outcome an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old woman with a past medical history of hypertension, preeclampsia, anxiety, and bipolar disorder on buspirone, presented to the emergency department with triage complaint of “multiple complaints”. Her history of present illness revealed a persistent headache that initially started one week prior to arrival. The patient recalled onset in the evening associated with nausea and vomiting. She went to an urgent care the next day and received medications, after which she felt better for about two days. When her symptoms recurred, she went to an outside hospital where she had a computed tomography scan of the head and lumbar puncture, both of which were negative. The patient was admitted for an elevated troponin level and received a cardiac catheterization without intervention, findings significant for 60% blockage of a single vessel. The patient presented to us one day post discharge due to persistent headache. She described the headache as similar to her prior preeclampsia headache, feeling \"like a grip around\" her entire head.\nHer initial vital signs were as follows: blood pressure 172/92 mmHg, pulse 81, respiratory rate 18, and oxygen saturation 99% on room air. A physical exam revealed a woman in pain but nontoxic appearing. Her heart and lung sounds were normal. Her neurological exam was unremarkable with no focal numbness, weakness, or abnormalities with coordination, gait, or cranial nerves. The chest plain film, initial lab, and electrocardiogram results were normal.\nThe patient received one liter intravenous fluids, metoclopramide intravenous, and ketorolac intravenous with minimal improvement and still appeared uncomfortable on multiple reassessments. The patient was placed in the observation unit and a magnetic resonance imaging (MRI) of the brain was ordered.\nThe magnetic resonance imaging (MRI) of the brain showed three punctate regions of focal restricted diffusion in the left middle frontal gyrus, right parietal lobe, and left temporal lobe that"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man was diagnosed with a massive tumor having a central ulceration in the transverse colon after undergoing screening colonoscopy (Fig. ). Computed tomography (CT) revealed that the patient was suffering from multiple metastases in the right hepatic lobe. Biopsy specimens obtained by colonoscopy showed only necrotic debris. Although confirmative diagnosis was not made, our clinical diagnosis was colonic carcinoma associated with multiple liver metastases. After obtaining the patient’s informed consent, we planned surgical resection of both primary colonic tumor and metastatic liver tumors.\nLaparotomy revealed many whitish deposits that were widely distributed in the peritoneal cavity. One of the disseminated deposits was sent for pathological examination. A diagnosis of metastasis of sarcomatoid tumors was made on the basis of histological examination using intraoperative frozen section analysis. The patient underwent only partial resection of the transverse colon to confirm the histological diagnosis of the tumor. The small bowel was not involved in the colonic tumor. In addition, no other tumors were found in the gastrointestinal tract. The postoperative course was uneventful. The patient was discharged on postoperative day (POD) 12.\nThe colonic tumor measured 8.0 × 6.0 × 4.0 cm and appeared as an exophytic growth with a deep central ulceration that opened the colonic lumen (Fig. ). Microscopically, the tumor consisted of solid sheets of spindle tumor cells with moderate atypia (Fig. a). Immunohistochemical analysis revealed that the tumor cells were positive for KIT (Fig. b) as well as CD34, and negative for alpha-smooth muscle actin and S-100 protein expression. Based on these histological and immunohistochemical findings, the tumor was diagnosed as a GIST of the transverse colon. The tumor showed markedly high mitotic index, counting 11 in 10 high-power fields. The Ki-67 labeling index was 40 % (Fig. c). Lymph node metastasis was also seen in a p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 67-year-old female who was recently treated with a decompression and 10th thoracic to second lumbar fusion secondary to formation of an epidural hematoma from a 12th thoracic vertebra fracture (type unknown). While in a physical therapy session the patient suffered a fall forward, trying to break her fall with her arms outstretched above her head. After the fall the patient’s arms were stuck in full abduction and pronation and she was in significant pain. The patient’s presenting position is displayed in . She arrived in the emergency department where X-rays were taken and demonstrated bilateral inferior shoulder dislocations, LEH ().\nOrthopedics was consulted to evaluate and treat. Upon evaluation, the patient was distally neurovascularly intact with 2/4 radial pulses bilaterally, sensation intact to light touch about the fifth cervical to first thoracic dermatomes, and motor function was intact in all peripheral motor groups of the upper extremities. The emergency physician provided sedation with closed reduction performed by the orthopedic service. The right shoulder was reduced using traction through the humerus through a flexed elbow to control the limb, and the opposite hand was used to place superior pressure on the humeral head through the axilla to guide the head into the glenoid. Slight external rotation and adduction was added as the head cleared the glenoid. Attention was then turned to the left shoulder, which was reduced, in a similar fashion; however, this shoulder was converted from an inferior to anterior dislocation using pressure in the axilla and slight external rotation.\nFollowing this, traction through the humerus external rotation, and lateral pressure on the humeral head yielded a successful relocation of the glenohumeral joint. After reduction the patient remained neurovascularly intact bilaterally. The patient was placed into bilateral shoulder slings, advised to avoid active shoulder range of motion, and admitted to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 5-year-old female who was referred for evaluation and management of recurrent episodes of cellulitis in the left scapular region. A small cystic lesion had first been noted at the age of 2 years. While this had initially been an asymptomatic, small lump that grew in size over time, it first became symptomatic when the patient was 4 years old. The lesion developed surrounding induration and erythema, as well as purulent drainage and tenderness. Over the next 1-year period, she went on to develop 3 such episodes of cellulitis. This was treated with a 10-day course of cephalexin by the patient's family physician, and it was due to these recurrent episodes of infection that we saw the patient in consultation.\nPhysical examination revealed a playful and well-appearing 5-year-old female, weighing 24.8 kg and measuring 114.5 cm in height. Review of systems and cardiorespiratory examinations were unremarkable. On inspection of the left scapular region, approximately 7 × 5 cm area of cellulitis was noted, with a small opening and associated purulent drainage. The surrounding skin was tender to palpation, but there was no appreciable fluctuance. Thus, the initial working diagnosis was infected epidermoid cyst. An ultrasound of the affected area showed a complex cystic mass measuring 3.9 × 2.9 × 3.7 cm within the subcutaneous fat (). Deeper margins of the mass were poorly demarcated due to the degree of inflammation, and the lesion appeared to abut the underlying musculature. Since these findings were nonspecific, an MRI was obtained to further characterize the lesion. The MRI revealed the presence of a subcutaneous cystic lesion just superior to the scapula measuring 1.6 × 3.5 × 2.8 cm. While the mass abutted underlying muscular fascia, there was no extension into the underlying trapezius muscle itself (Figures and ). Thus, the decision was made to pursue surgical excision of the lesion. This was performed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man was admitted for mobility of tooth. The dentist suggested the presence of a mass located at the tooth root by physical examination. Computed tomography revealed a well-demarcated radicular cyst of 4 cm in diameter at the tooth base. Carcinomatous infiltration of squamous cell carcinoma was observed in the excisional biopsy of the lesion. In microscopic evaluation, tumoral infiltration revealed features of moderately differentiated squamous cell carcinoma. Malignant cells infiltrated the underlying connective tissue stroma in solid groups and sheets. Numerous neutrophils were present within the cytoplasm of the malignant cells as well as in the surrounding stroma. The internalized neutrophils were intact (). Desmosomal connections were observed between the tumor cells in some areas. The tumor cells showed moderate cellular pleomorphism. The diffuse immunoreactivities of P63 and CK5/6 were determined in the malignant cells by immunohistochemical staining. Additionally, perineural invasion was found, whereas vascular invasion was not observed. Because surgical margin was positive for tumor cells, partial maxillectomy and bilateral neck dissection was performed. Bone infiltration was present. Furthermore, diffuse neutrophilic emperipolesis was observed in cancer cells by microscopic evaluation. Some of the neutrophils in the tumor cells revealed degenerative changes by high-power field (×1000) microscopic evaluation (Figures –), while some neutrophils included apoptotic bodies. Nearly one year later, local relapse developed and additional therapeutic manipulations including surgery, radiotherapy, and chemotherapy (cisplatin) were done. Tumor recurrence occurred in the periparotid and right neck lymph nodes after six months (). Chemotherapy (cisplatin) and radiotherapy were performed for the recurrence. Two more relapses developed in the right neck, left submandibular lymph nodes and in the superficial and deep soft tissues of the neck three months apar"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 29-year-old female with a history of diabetes mellitus type 1 who presented to the clinic for evaluation of recurrent symptoms of sinusitis and a persistent nasopharyngeal mass. Her symptoms first started at the age of 12 with chronic nasal congestion, repetitive sinus infections and chronic cough. Her tonsils and adenoids were removed at the time, but her symptoms persisted. Between the ages of 13 to 15 she was found to have a recurrent adenoid mass and tonsillar regrowth. She underwent another adenoidectomy and tonsillectomy. Microscopic description of the specimen showed overall preservation of the architecture with follicular hyperplasia and mildly expanded paracortex with scattered immunoblasts. The follicles show polarized germinal centers and contain numerous tangible body macrophages. Immunohistochemistry showed that the interfollicular paracortical cells are positive for CD3, CD5, CD10, CD43, BCL-2, CD1a, CD7, CD4, CD8, and TdT. The tumor was also negative for clonally rearranged immunoglobulin heavy chain gene and negative for clonal T-cell receptor gamma chain gene rearrangement. Additionally, the patient was noted to have an enlarged right cervical lymph node. Due to concerns about malignancy she was hospitalized for a bone marrow biopsy that was deemed negative.\nOver the following years the patient developed progressively worsening severe thick nasal drainage, rhinorrhea, frontal pressure and headaches, for which she presented to the clinic again at the age of 25. Her neck and sinus CT scan revealed maxillary sinus disease and significant lymphoid hyperplasia in the adenoid and tongue base region as well as a right cervical lymph node. She underwent a revision endoscopic sinus surgery and an adenoidectomy. Biopsy of the right-sided inflammatory process demonstrated an atypical T-cell lymphoid infiltrate, with a Ki-67 of 50–60%. She was then given a month of methylprednisolone (2 mg) taper and her cervical adenopathy diminished in size f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female presented with swelling in the frontal region of the skull since 2 years and another swelling in parieto-occipital region since 4 months. Both the swellings over skull have been painless and gradually progressive in size, thus the delay in presentation. No significant past medical history. On examination, swelling in frontal region measured 18 cm in sagital and 13 cm in coronal directions and 7 cm in vertical dimension. The veins over swelling were distended and it was pulsatile in nature, firm in consistency and fixed to skull. The skin over the swelling was stretched but otherwise normal. Left orbit appeared distorted by the swelling but vision was normal []. The second swelling was located in parieto-occipital region right side and measured 3×4 cm pulsatile in nature and firm in consistency []. Incidentally a thyroid swelling was noted involving mainly right lobe around 3×2 cm, firm and not associated with any pressure symptoms []. Patient did not have any neurological deficit or psychological illness. The patient was clinically euthyroid with normal general physical, systemic, and neurological examination. Routine blood tests and thyroid function tests were normal. Ultrasound study of neck revealed 2 × 1.5 cm neoplastic solid nodule in right lobe of thyroid. Rest of the thyroid gland and neck was normal. X-ray of skull showed lytic lesion in frontal and occipital region of skull. Contrast enhanced computed tomography (CT) demonstrated a 13 × 18 cm size expansile osteolytic lesion in the fronto-parietal region on both right and left side of anterior half of skull. The lesion was extending intracranialy and causing compression of the underlying fronto-parietal lobes on both sides. Similar expansile osteolytic lesion of smaller size are seen in the occipital region on both sides largest measuring 4×3 cm on right side. On postcontrast study, these lesions showed significant enhancement suggesting increased vascularity and also areas of necrosis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-yr-old woman with a nasal radix mass visited our clinic. Thirty years earlier at a local clinic, she had undergone augmentation rhinoplasty with a material presumed to be silicone. She had had no complication afterwards. However, 5 yr previously, a nasal mass developed that had increased gradually. Physical examination showed a 3.5×2.5 cm round, soft, painless mass on the midline of nasal radix (). The nasal dorsum and the tip were firm on palpation and a small cruciate incision scar was found at the infratip lobule, which was supposed to be the entry of the augmentation material. On computed tomography (CT) scan, a heterogeneous cystic mass was observed at the radix and the cyst was continuous with a homogenous density at the nasal dorsum, which was first thought to be a silicone implant ().\nA presurgical diagnosis of nasal radix cyst associated with previous augmentation rhinoplasty was made, and a direct, open approach was chosen to remove the cyst. After a skin incision on the center of the cyst, it was dissected down to the nasal bone. The cyst was connected to the dorsal mass, which were removed together in en-bloc fashion (). For safe removal of the graft material over the tip area and effective tip-plasty, the tip was exposed with an open approach.\nGrossly, the removed cystic mass had a thick, fibrous wall with dirty cheesy material inside. The cystic wall was composed of dense fibrous tissue containing dispersed, microsized amorphous foreign materials (). Foreign materials were surrounded by foreign body type multinucleated giant cells and induced granulomatous reactions. Infiltration of chronic inflammatory cells was also observed.\nA scanning electron microscopy (SEM) showed a fragment of foreign body () and energy dispersive radiography spectroscopy (EDX) showed presence of silicone (Si) in the removed specimen (). The lesion was diagnosed as a foreign-body type cyst associated with silicone material used for the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man presented with a 1-month history of lower back pain. Three days before admission he had developed cyanotic changes in his left lower extremity, which gradually worsened. Eighteen months previously the patient had been diagnosed with superficial bladder cancer and had undergone transurethral resection of the bladder tumor (TUR-B), followed by intravesical BCG therapy (Onco Tice strain BCG; 12.5 mg BCG injected through a catheter into the bladder every week for 6 weeks). Three months later, another TUR-B was performed because atypical cells were observed in his urine. Histological examination revealed transitional cell carcinoma in situ and he underwent another 3 cycles of intravesicular BCG therapy (13 months, 10 months, and 1 month prior to presentation).\nThe patient's temperature was 37.5℃ and his other vital signs were stable. Computed tomography of the abdomen revealed an aortic aneurysm involving the abdominal aortic bifurcation and left proximal common iliac artery, with inflammatory soft tissue infiltration in the pre-vertebral space and focal pseudoaneurysm; these had not been seen on a scan performed 17 months earlier (). Magnetic resonance imaging of the lumbar spine revealed minor cortical erosion of the L4 vertebral body and paravertebral phlegmonous and abscess-like soft tissue lesions around the L4 vertebral body ().\nExcision of the aneurysm, wide debridement of the psoas abscess, and an in situ aorto-biiliac interposition graft with a rifampicin-soaked Dacron graft were performed. The graft was fully covered with omentum. Surgical exploration confirmed a 3×3 cm cystic lesion in the anterior of the psoas muscle, with a hole leading to the site of suspected spondylitis. Pathologic examination revealed chronic granulomatous inflammation of the vascular wall, but microscopy did not reveal any microorganism. A polymerase chain reaction (PCR) was positive for M. tuberculosis complex, and 10 colonies of this complex were isolated after 31 da"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72 years old woman proceeded to the Emergency Department complaining of acute lower right abdominal pain, mild fever, mild weight loss and constipation. The past medical history of the patient was free.\nThe patient was presented with severe lower right abdominal pain, with signs of local peritonitis and a palpable mass in the same region. The body temperature was 37.2–37.4°C, while arterial blood pressure and cardiac rate 150/90 mmHg and 90/min respectively. The signs of local peritonitis combined with the palpable mass of the lower right abdominal area suggested perforation of the appendix and abscess formation. The laboratory examinations of the patient showed leucocytosis with white blood cell count (WBC) 19000 (with macrophage prevalence: 89%). Colonoscopy revealed obstruction of the right colon. Biopsies were not acquired because the colon lumen was obstructed and the endoscope could not approach the lesion. Computerized tomography (CT) scans of the abdomen (Figure ) revealed a soft lobular mass, measuring 5 × 5 cm, attached to the ascending colon and cecum, compatible with a tumor. The most possible diagnosis was that of a perforated colonic tumor. The patient underwent explorative laparotomy and right hemicolectomy with an end-to-end ileocolonic anastomosis. Thorough exploration of the abdominal cavity revealed no other pathologic findings.\nThe surgical specimen consisted of a 10 cm length of the terminal ileum and the whole of the right colon. The serosa was very heavily covered by suppurative exudates and fibrotic tissue.\nMicroscopic examination of the surgical specimen revealed thickening of the ascending colon wall with neutrophilic infiltration. Numerous polymorphonuclear leukocytes within the muscularis and a fibro-purulent reaction over the serosa with actinomycotic \"sulfur granules\" in it, were found in high power magnification (Figure ).\nUpon receiving the pathology report, systemic intravenous penicillin treatment was initiated. Therapy continued"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old man was transported via emergency medical services to the emergency department (ED) following a motor vehicle collision. The patient was the restrained driver and was rear-ended while slowing down to make a turn. There was moderate damage to the rear of the patient's vehicle. The car was an old model vehicle and was not equipped with airbags. The patient was ambulatory at the scene but as a precaution he was transported via emergency medical services to the ED on a backboard and wearing a cervical collar.\nOn presentation, the patient was in no apparent distress and his vital signs were blood pressure of 157/78, pulse of 82 with a respiratory rate of 18 (unlabored), and pulse oximetry of 97% in room air. The patient initially complained of neck pain, bilateral upper extremity and shoulder pain, and numbness in both hands. A friend who accompanied the patient to the ED noted the patient's voice was raspy sounding. The patient's past medical history was significant for atrial fibrillation for which he took coumadin. He also had an automated implantable cardioverter defibrillator. The patient noted that his implanted defibrillator had not discharged today and he was in his normal state of health prior to the accident.\nHis physical exam was significant for midline cervical spine tenderness and his anterior neck exam was normal without tracheal deviation, jugular venous distention, or appreciable masses. The patient exhibited no neurological deficits except a complaint of bilateral hand numbness but his motor function was preserved and had full range of motion in all extremities. The patient had multiple abrasions over the anterior portion of both legs and over his right elbow. Laboratory studies revealed the patient had an INR of 3.5.\nA chest X-ray and plain film images of the patients shoulders were both normal without evidence of osseous injuries. An extended focused assessment with sonography for trauma was negative for pneumothorax and abdominal, pelvi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case report describes a 25-year-old female patient presenting to the Department of Orthodontics at the Centre of Dentistry, Oral and Maxillofacial Surgery at the University Hospital Tübingen due to acute pain in the right TMJ and mouth opening disorders in 2019. There were no general diseases or allergies in her medical history. The patient stated that she did not consume alcohol or nicotine; she was taking contraceptives. Over a period of 5 years the patient’s distal bite was treated with removable and fixed orthodontic appliances. The initial examination showed fixed retainers in both the upper and lower jaws (Fig. a + b). Despite orthodontic treatment, there was still a slight asymmetric distal occlusion on both sides (Fig. c + d). This was slightly more pronounced on the left due to slight mandibular tilt to the left (Fig. e). The mouth opening disorder severely restricted the patient in her everyday life. Previously, craniomandibular dysfunction was assumed due to multiple grinding facets on the teeth and bruxism. Therefore, a bruxism splint was already worn at night. The initial panoramic radiograph is shown in Fig. .\nThree months later, the patient reported that she woke up with severe pain in her right TMJ after sleeping and was not able to close her mouth. When repositioning the lower jaw by herself a very loud cracking sound at the right TMJ occurred. After that, she had a mouth opening disorder and constant pain. The patient gave this constant pain a score of 7 on the verbal numeric rating scale (VNRS) (0–10). She was prescribed muscle relaxant therapy with methocarbamol twice a day. Although the pharmaceutical treatment with methocarbamol resulted in some slight pain relief, it also had some general medical side effects such as circulatory weakness and dizziness. The patient was also referred to the Department of Orthodontics. Due to severe pain a functional analysis of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old female patient reported with a chief complaint of swelling and pain on the right lower 3rd region of the face []. The patient was moderately built. No significant medical and family history. On extraoral examination, a diffuse swelling was present on right lower 3rd of the face, measuring approximately 3 * 4 cm, extending anteroposteriorly from right commissure to right angle of mandible and superioinferiorly from 1 cm below the right alatragal line to right inferior border of mandible which on palpation was firm in consistency and tender with slight rise in temperature. Intraoral soft tissue inspection revealed a diffuse swelling measuring approximately 2 * 3 cm on right buccal mucosa obliterating the buccal vestibule extending from the distal aspect of 45 to the mesial aspect of 48. On palpation, there was buccal and lingual cortex expansion; the swelling was firm to hard in consistency and tender without pus or blood discharge when palpated apico-coronally. Intraoral hard tissue examination revealed root stumps in relation to 46. The provisional diagnosis of the radicular cyst was made and differential diagnosis as dentigerous cyst and ameloblastoma. OPG [] revealed a welldefined large unilocular radiolucency, measuring approximately 4 × 5 cm in size on the right body region of the mandible surrounded by a well defined sclerotic border, sparing 2 mm of the inferior border of the mandible. The lesion was extending mediolaterally from the distal aspect of 45 up to the mesial aspect of 48 and there was root resorption of 46 and 47. CBCT [] revealed the measurement of the lesion in all three dimensions, that is, anteroposteriorly (AP), mediolaterally (ML) and superioinferiorly (SI) as about 32.1 mm, 18.2 mm and 19.1 mm respectively. It revealed bicortical expansion with a displacement of inferior alveolar nerve. Radiographic diagnosis of the radicular cyst and differential diagnosis as unicystic ameloblastoma was given."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old woman with dyspnea, and recent aggravation of the condition 10 days prior, was referred to our institution for further evaluation of the tracheal mass. The woman had no outstanding medical history; however, upon a physical examination, a stridor and wheezing sound was examined by auscultation.\nA digital chest radiograph showed a well demarcated mass with round opacity located in the mid level of the trachea (). A non-contrast enhanced chest CT scan was performed at a local clinic and revealed a well defined, intraluminal mass with homogeneous soft tissue attenuation in the trachea (). The mass was round in shape with a diameter of 1.5 cm. Next, a contrast-enhanced chest CT (Somatom Sensation 64, Siemens Medical Solutions, Erlangen, Germany) scan revealed a heterogeneous enhancement pattern representing a strong nodular enhancement in the peripheral portion of the mass, accompanied with a central area of low attenuation on the axial images (). Further, a photomicrograph helped determine that the round submucosal mass was primarily composed of hypercellular areas with some collagen-rich areas. In addition, various sized blood vessels were noted along the periphery of the mass, along with dilated and branched vessels in the central portion of the mass ().\nThe oblique sagittal reconstruction images clearly demonstrated the orientation of the mass and length of the tumor (). In addition, no evidence of tracheal wall invasion was observed. The volume-rendered and virtual bronchoscopic images clearly depict a round intraluminal mass arising from the anterior tracheal wall (). Furthermore, a conventional bronchoscopy revealed the round mass with prominent of small blood vessels on its smooth surface. Although the bronchial mucosa was intact, a bronchoscopic biopsy was not performed with the possibility of massive bleeding. Consequently, the surgical excision of the mass was performed via a segmental resection of the trachea and an end-to-end anastomosis.\nA his"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old boy presented to the Cornea Clinic of our hospital with a conjunctival mass lesion on his left eye, which had developed over the course of a few weeks. During a slit lamp examination, the lesion was found to be lobulated with corkscrew vessels that infiltrated the temporal, nasal, inferior and superior bulbar, and forniceal conjunctiva (Figures and ). He had a positive history of recurrent herpetic keratitis on the same eye and had undergone penetrating keratoplasty six years earlier. However, his corneal graft had failed with total opacity and vascularization due to recurrent herpes simplex keratitis (HSK) in the corneal graft. The right eye was normal.\nHis history revealed that he had suffered from eczematous skin lesions, recurrent skin bursts, and sinopulmonary infections since early childhood and recurrent generalized HSV infection. He had been diagnosed with HIES at the age of three based on elevated serum IgE levels and other clinical features. He did not have a positive family history of HIES or any other immunodeficiency.\nAt the onset of the lesion discussed here, a differential diagnosis of a conjunctival lymphoid tumor, conjunctival papilloma, and ocular surface squamous neoplasia was given. Because the patient was prone to recurrent HSK, recurrent herpetic lesions were not considered in the differential diagnosis because the patient presented a papillomatous mass lesion of the conjunctiva. Thus, the pathogenesis was suspected to be HPV because the dendritic lesion and stromal infiltration had not be seen in the failed graft. For a specific diagnosis, an incisional biopsy was obtained from the conjunctival lesion, and sections were prepared and stained with hematoxylin and eosin using the periodic acid-Schiff technique to observe the sections under light microscopy (Olympus BX43, Tokyo, Japan). Microscopic examination revealed conjunctival tissue with dense, diffuse, acute, and chronic inflammatory cells that infiltrated the lamina propria a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman, gravida 5 para 4 presented at 32 weeks pregnancy. She first presented to her primary general practitioner with a small vulvar lesion that she had first noticed one year prior. The lesion was suspected to be benign Bartholin’s cyst and treated with broad-spectrum antibiotics. The patient noticed no improvement and had many other consultations with different clinics when she was advised to the same diagnosis and treatment. Initially, the swelling was constant in size, however, it started to enlarge rapidly. A significant increase in size was noticed during pregnancy and causing a restless feeling. The patient was thus referred to our hospital. She had no significant gynecological past history, prior gynecological malignancies, or condyloma acuminatum. Her pregnancy course was uneventful. The medical, surgical, and family histories were noncontributory. No medications had been taken before or during the pregnancy.\nPhysical examination revealed a healthy woman with normal vital signs. Abdominal examination reveals a gravid abdomen with a fetus of appropriate size for the gestational age in cephalic presentation. Pelvic examination revealed a vulvar mass at the left side involving left labia majora and minora. The mass was painless, rounded, firm in consistency, freely mobile with an intact overlying skin measuring 15.0 x 10.0 cm diameter (Figure ).\nNo palpable lymph node was detected. Pelvic Magnetic Resonance Imaging (MRI) with heterogeneous signal intensity on T2-weighted images showed a solid mass with no cystic signal intensity measuring 4.8 x 7.2 x 10 cm. The radiological impression was labial leiomyoma.\nAt 34 weeks of pregnancy, the patient was admitted for tumor resection. A baseline fetal cardiotocography and obstetrics ultrasound were normal. Under spinal analgesia, the tumor was completely resected with minimal blood loss (Figures , ). No frozen section samples were taken. The patient and her fetus tolerated the procedure well. The histopa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.\nThe patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male not known to have any chronic medical illness, presented complaining of epigastric and left upper quadrant pain for 1 month, associated with intermittent nausea and vomiting, and aggravated by fatty meals, with no other associated symptoms. He had frequent visits to the emergency department where he was managed with analgesia and antacids with mild symptomatic improvement. Clinical examination was unremarkable with no evidence of jaundice or abdominal tenderness. His blood test results showed a normal complete blood count, kidney function, and liver function. Chest X Ray revealed dextrocardia with stomach fundic gas shadow on Right side (). Abdominal ultrasonography revealed transpositioning of the solid organs with a left sided liver and gallbladder with a solitary stone and mild wall thickening. We elected to perform a Magnetic Resonance Cholangiopancreatography to delineate the anatomy and to rule out any anomalies within the biliary tree. It confirmed the previously noted findings, showed no evident anomaly within the biliary tree, and confirmed the diagnosis of situs inversus totalis (, ). The patient was Scheduled for an elective laparoscopic cholecystectomy.\nThe Operating room equipment arrangement was adjusted as Mirror Image of Routine Laparoscopic cholecystectomy (). The Monitor was placed on left side of the patient. The surgeon with the camera assistant were on right side of the patient and the first assistant was on left side of the patient. The abdomen was scrubbed and draped in the standard aseptic technique. The first infraumbilical 11 mm trocar introduced and pneumoperitoneum induced using the open technique. Three 5 mm trocars were placed, at the xiphisternum which was used for the surgeon’s left hand, at the left midclavicular line 2 cm below the costal margin which was used as working port for the surgeon’s right hand and at left anterior axillary line 5 cm from the costal margin which was used for retraction of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 4-year-old boy, weighing 17.5 kg, with no relevant medical or surgical history and no documented allergy or medication intake, scheduled for circumcision. His preoperative vital signs were a heart rate 98 beats/min, blood pressure 100/56 mmHg, temperature 36.6°C, and a respiratory rate of 20/min. Chest was clear to auscultation and no cardiac murmur was identified. The anesthetic plan was explained to the parents and included general anesthesia and a penile block for postoperative pain management.\nAnesthesia was induced in the presence of the parents with oxygen/nitrous oxide and sevoflurane administered through a face mask, with the patient breathing spontaneously. Propofol 40 mg and fentanyl 25 μg were administered after intravenous access. Anesthesia was maintained with sevoflurane at an end tidal concentration of 3.5% in a 1 L equal mixture of oxygen and air after securing the airway. The heart rate was noticed to be in the range of 80 beats/min, dropping to 60 beats/min. Ringer's lactate solution was administered at 10 mL/kg/h. A close observation of the electrocardiogram (ECG) tracing revealed a complete dissociation of P wave and QRS complex []. Blood pressure was normal and the patient was normothermic. The surgeon was notified, and resuscitation equipment was brought to the room. A trial of switching from sevoflurane to desflurane did not produce any change in the heart rate and was equally tolerated by the patient. Inhalation agents were discontinued and propofol infusion started at 300 μg/kg/min for the remaining 25 min of the procedure. There was no change in hemodynamics or in the ECG tracing. Atropine 250 μg was administered intravenously for a heart rate below 60 beats/min with a transient effect of increasing the heart rate to 80 beats/min. A penile block, with 10 mL of 0.25% bupivacaine was performed at the end of surgery. The patient was transferred awake to the recovery room"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 1 was a 69 year old Caucasian male with a BMI of 17.7 and a history of GERD, asthma, hypertension, emphysema, recurrent SBO and bilateral inguinal hernias. His surgical history included SBO surgery at birth, childhood appendectomy, 3 laparoscopically repaired hernias from 2008–2010 with a surgical mesh inserted, Nissen fundoplication and partial thyroidectomy in 2010, laparotomy for SBO secondary to extensive adhesions in July 2010 and January 2011. Immediately after surgery in 2011, Patient 1 underwent a small bowel radiographic series that showed an incomplete SBO at the junction of the proximal mid ileum, and dilation throughout the small bowel, likely due to adhesions per the radiologist (A). He was still experiencing symptoms of SBO (bloating, nausea, inability to eat normally) three months following the 2011 laparotomy, and reported a significant impact on his quality of life, focused on the changes to his diet that occurred after the SBO. He also reported abdominal tightness and significant intermittent pain (10/10 on a pain scale).\nPatient 1 received no further medical interventions after his 2011 radiography prior to receiving this manual physical therapy treatment. Upon initial physical therapy evaluation, he presented with pain; visible scarring superficial to tissues that felt like deep palpable adhesions (consistent with his physician’s 2011 diagnosis of abdominal scarring), decreased visceral mobility (decreased ability for organs to glide normally), and tightness throughout the abdomen; myofascial, osseous and visceral hypomobility; and decreased quality of life due to SBO. He also presented with decreased strength and range of motion in both hips and trunk, and in his cervical, thoracic, and lumbar spine at the initiation of his physical therapy regimen.\nIn 2011, Patient 1 underwent 20 h of intensive manual physical therapy over the course of five days with a focus on improving range of motion, and decreasing scar tissue, adhesions, and soft"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 21-year-old man was admitted to our hospital after being referred from another medical institution because of worsening left eye (LE) uveitis. He was treated 3 weeks earlier with oral acyclovir and topical steroids because of suspected LE herpetic anterior uveitis as serological tests revealed positive immunoglobulin M to herpes simplex virus-1. Initially he responded to treatment but 2 weeks later, his vision declined from 6/9 to counting fingers (CF), resulting in his referral to our center.\nThe patient denied any relevant past medical history. However, he mentioned that a month earlier he was examined for LE discomfort and diagnosed with allergic conjunctivitis following minor blunt trauma from a tree branch.\nOn examination, visual acuity (VA) was 6/6 in the right eye (RE) and CF at 1 meter in the LE. Intraocular pressure was 14 mmHg in both eyes. RE anterior and posterior segments were normal. There was a remarkable LE anterior chamber reaction with dust-like keratic precipitates, cells (4+), flare (2+), and some iris nodules. Fundus assessment was not possible because of dense vitritis. B-scan and high-frequency ultrasound did not reveal any intraocular foreign body. Aqueous tap was performed and the sample was sent for culture and polymerase chain reaction analysis. It was negative for all herpes viruses and for 16S rDNA. Meanwhile, with oral steroids and valacyclovir, the patient showed signs of improvement and LE VA improved to 6/15. Despite the remarkable improvement, it was insufficient as the patient continued to have marked anterior uveitis and vitritis. A white shadow was noted in the peripheral temporal retina of the LE which again could not be assessed properly due to vitreous opacities (). The patient eventually underwent pars plana vitrectomy and laser retinopexy was performed around the white peripheral temporal lesion, which was later believed to be the site of penetrating injury by a thorn on the tree branch from the previous trauma des"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old Saudi man presented with a six-month duration of right cheek swelling and left upper eyelid swelling. Physical examination revealed right cheek erythematous mass of size 3 × 3 cm and a similar erythematous mass over left upper eyelid of size 1 × 2 cm (); however, clinical examination revealed no lymphadenopathy or any visceromegaly. Hematology, electrolytes, serology for Lyme disease, systemic lupus erythematous, thyroid function tests, blood cultures for mycobacteria, and angiotensin-converting enzyme were all within normal limits.\nIncisional biopsy from left eyelid mass and excisional biopsy from right cheek mass were taken, which showed a nodular inflammatory infiltrate within the dermis consisting of histiocytes with plasma cells and lymphocytes aggregates. Large histiocytes were found with vesicular nuclei and emperipolesis. Immunohistochemistry demonstrated the positivity for S-100, CD68, and CD45 and negativity for CD1a, which confirmed the diagnosis of extra-nodal RDD (). Patient was started on oral prednisone 30 mg per day for 3 weeks and then tapered over the subsequent 2 weeks, which showed a minimal response of left eyelid mass.\nAfter discussing the case in multidisciplinary meeting, patient was given 30 Gy in 15 fractions radiation therapy with 6 MV photons to left eyelid mass (). Magnetic resonance imaging (MRI) of head and neck showed more than 90% of reduction in size of eyelid lesion. After 3 months of radiation therapy, MRI of head and neck revealed the reappearance of masses in left eyelid and right cheek (). Patient was started on Rituximab, cyclophosphamide, vincristine, and prednisolone (RCVP) based chemotherapy 8 cycles with partial response, and he was reirradiated to left eyelid mass with 6 MeV electron 10 Gy in 10 fractions with complete response. Patient remained disease-free for one year and without any late radiation induced sequelae. After one year again, there was reappearance of right cheek mass, and at the time of repor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male presented to us with complaints of painful swelling of his right knee joint with inability to bear weight. He had undergone surgery (done elsewhere) for GCT of lateral condyle of femur 22 months ago in the form of curettage and bone grafting from iliac crest (: Pre-operative and : 3-month post-operative radiograph). The patient did not relieve his pain in knee joint (which he had before surgery) throughout the course of the treatment. He consulted the primary surgeon for the same and advised active range of motion exercises. The pain kept on increasing, especially in last 6 months, and on examination, he had tenderness over lateral and posterior aspect of knee joint with diffuse swelling and limited range of motion (10—°) when presented to us. Investigation in the form of radiograph () depicted diffuse osteolysis and cortical destruction in lateral femoral condyle. Magnetic resonance imagingMRI of the lesion illustrated the heterogeneous decreased signals on T1 sequences and areas of hyperintensities on T2 sequences with overall picture suggestive of recurrence ( and ). Complete surgical excision of the tumor and articular surface reconstruction was planned as described by D’ Aubigne []. A 15-cm long vertical incision was made over anterolateral aspect of distal thigh and right knee and quadriceps tendon, patella and patellar tendon exposed. A 3-cm wide, musculovascular pedicle separated at inferior border of vastus lateralis muscle, approximately 10-cm proximal from lateral border of patella. Patella was then enucleated from rest of its attachments, releasing quadriceps tendon all around except the pedicle, leaving a rim of 4-mm soft tissue to spare vascular supply. Lateral condyle of femur was exposed and excised en bloc with whole tumor mass with the help of saw and osteotome. The deep articular surface and medial aspect of patella were freshened. The anterior surface which was to be used as articular surface was rotated inferiorly, brought at"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old asymptomatic man presented to our hospital for follow-up of an abnormal cardiac shadow found on chest X-ray during a medical check-up. He was found to have a benign tumor in the parapharyngeal space 6 years ago. The tumor had gradually grown in size and he felt pain around the back of his teeth and had difficulty in swallowing associated with mass pressing symptom; he had the tumor resected 4 months ago. On histopathology exam, the tumor was identified as a schwannoma. The patient had no medical or family history of cancer, including intradermal carcinomas. There were no abnormal findings in his eyegrounds, such as juvenile cataract, and his audiometry results were normal. Computed tomography (CT) showed three masses measuring 16 × 14 mm in the posterior mediastinum, 15 × 13 mm in the left pulmonary hilar area, and 12 × 10 mm in the right pulmonary apex area (Fig. ). The patient had undergone CT exam at another institute 6 years ago prior to the CT scan performed at our institute. Retrospective evaluation of the previous CT scan revealed that the posterior mediastinum tumor was 13 mm in size at that time. Chest magnetic resonance imaging (MRI) revealed that these masses had low intensity on T1-weighted sequences and high intensity on T2-weighted sequences. Cranial high-quality MRI showed no evidence of bilateral vestibular schwannoma. The thoracic surgeons at our institute initially diagnosed multiple mediastinal tumors.\nResection of the right apex area lesion had the associated risk of causing recurrent nerve deficit symptom; hence, removal of the two other tumors was planned initially; the posterior mediastinum tumor by right thoracotomy and the left pulmonary hilar area tumor by left thoracotomy in a single operation. During right thoracotomy, a small pericardial incision was made and they noticed the posterior mediastinal tumor to be at the cardiac chamber; surgery was suspended immediately. Following surgery, the patient underwent transesophageal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old Caucasian woman presented for evaluation after a 2-year history of left hip and knee pain. On physical examination, the left knee presented with a mild effusion, tenderness and with stiffness and decreased mobility. The hip showed a true capsular pattern of limitation and pain with internal rotation of the hip. Radiographically, the left knee showed degenerative osteophytic changes and osteophytes in all compartments of knees and mild to moderate narrowing of the joint space. In case of the left hip, radiographic evaluation showed also advanced osteoarthritic changes.\nSince the physical examination and radiographic findings were compatible with the diagnosis of an end-stage hip osteoarthritis and knee osteoarthritis, the patient was first listed for a cementless total hip arthroplasty (THA) (Fig. ), followed by a cemented total knee arthroplasty (TKA) (Fig. ).\nDuring surgical dissection it was noticed that the articular capsule and the cartilage of the femoral head were black (Figs and ). Histological sections of bone and soft tissue demonstrated classic findings of ochronosis, including multiple pigmented areas by deposition of ochre-coloured granules, reactive giant cells, hyaline cartilage degeneration and a thickened and inflamed synovium. The case was discussed intraoperatively with the Senior Surgeon: the macroscopic evaluation of bone quality seemed reasonable and the OA diagnostic was the most consensual between the team. We maintained our initial plan and finished the cementless THA.\nAfter surgery she confirmed that was never diagnosed with alkaptonuria in her past. She was re-examined and we found black ochronotic pigmentation in sclera and ear cartilage (Fig. ), as well as dark urine. A high level of HA was also found in the urine. She was evaluated by a senior rheumatologist and progressed favourably without any complications.\nEight months later she was treated for her left end-stage knee osteoarthritis and we noticed again the presence of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman with a past medical history of Grave’s disease presented to the hospital complaining of sudden onset of facial and bilateral arm swelling, as well as \"bruising\" in her neck, abdomen, and arms, all of which she developed over a few days. Further, the patient reported fatigue, neck tightness, and dyspnea on exertion. She denied any other symptoms and the remainder of the full review of systems, including weight loss, was negative. Social history was significant for 40 years of smoking. The patient was hemodynamically stable with good oxygenation on 2 L of oxygen by nasal cannula. Physical exam revealed swelling of the face, neck, and both arms, superficial varicosities on the neck, chest, back, and arms, as well as mild inspiratory stridor. Computed tomography angiography (CTA) of the thorax and neck showed a large central mediastinal mass occluding the pulmonary artery and extending into the right atrium, encasing the superior vena cava (SVC), abutting the trachea but not causing tracheal narrowing (A), as well as pulmonary emboli at the right lower lobe (B). Given the tobacco abuse history, lung cancer leading to SVC syndrome was suspected, although other malignancies such as lymphoma were in the differential. The patient was started on a heparin drip and the Pulmonary and Hematology-Oncology services were consulted, both of which agreed for the need for tissue diagnosis of the likely malignancy and rapid initiation of treatment.\nA complicating factor in this patient’s care was her adamant belief that the swelling was an allergic reaction to one of the many over-the-counter herbal and homeopathic medications that she was taking to try to rid her body of the “flukes” which she claimed to have seen in her nasal secretions and stool. The patient soon moved on to express the belief that her mediastinal mass was caused by her parasites and demanded treatment for them rather than for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-month-old girl was referred to our institution in December 2009 with a right femoral lesion, with concerns of neoplasm or osteomyelitis. Her parents noticed that she had shown a decrease in the use of her right lower extremity especially at about 3 months of life when the patient would not bear weight on her right lower extremity when held up in an upright position. The patient’s ability to sit upright was also somewhat limited because she preferred to have her right hip and knee extended. At age 7 months, her pediatrician obtained a roentgenogram that showed a lytic lesion in the right proximal femur. The past medical history was unremarkable. Clinical examination showed an afebrile infant who moved her right lower extremity much less than the left and preferred keeping her right hip and right knee extended with external rotation. There was no erythema, warmth or mass in the right lower extremity. The results of routine laboratory studies were normal.\nRoentgenograms of the right femur showed an osteolytic area in the intertrochanteric region, surrounded by a sclerotic rim and lamellar periosteal reaction (Fig. ). A magnetic resonance imaging (MRI) study showed a focal, 1.1 × 0.9 × 1.2 cm, high T2 signal lesion centered in the intertrochanteric region of the proximal right femur. There was marked lamellar periosteal reaction involving the proximal right femoral metaphysis extending to the mid diaphysis, with extensive, ill-defined intra- and extraosseous edema (Fig. ). The differential diagnosis included chronic osteomyelitis with a Brodie’s abscess, eosinophilic granuloma, osteoid osteoma, and small round blue cell tumor such as Ewing sarcoma or metastatic neuroblastoma.\nA CT-guided core needle biopsy of the lesion was performed. The axial CT scan at the time of biopsy showed a 1-cm lucent lesion eccentrically located within the medial aspect of the proximal femur with marked periosteal new bone formation (Fig. ). Cultures of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old right hand dominant male presented with a chief complaint of a soft tissue mass on the volar surface of his left forearm. He first noted the mass around age 11. The mass grew slowly between the ages of 11 and 13 before stabilizing in size two years prior to presentation. Initially the mass expressed a thick whitish fluid when squeezed, but at the time of presentation the fluid was thin and the drainage minimal. The mass was not painful and he reported no paresthesias in the hand. He denied any similar masses elsewhere on the body and had no history of malignancy. There was no family history of similar masses. He did not have a history of urinary tract malformation.\nOn physical examination, the patient was a well-appearing 15-year-old male in no acute distress. On the volar surface of the left mid forearm, there was a 2.0 × 1.5 cm pedunculated mass with a pinpoint central sinus (Figures and ). The mass was well-circumscribed, soft, and mobile. There was no surrounding erythema or warmth. A scant amount of thin, white fluid could be expressed from the central sinus. He had normal strength and sensation in the left elbow, wrist, and hand and had a palpable radial pulse. The remainder of his physical exam was remarkable for an accessory nipple on the left chest wall along the vertical “milk line” ().\nGiven the prior growth and bothersome appearance, surgical excision of the mass was planned. Prior to surgery, consent for photography was obtained from both the patient and his father. An elliptical longitudinal incision was used to excise the mass and the underlying tissue. The mass was firm and well-circumscribed and had the appearance and texture of breast tissue (). The skin was closed using absorbable sutures. A soft dressing was applied and the patient recovered uneventfully.\nThe soft tissue specimen with an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old unmarried woman was admitted to the Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China because of severe unresponsiveness and twitching in October 2019. Subsequent computed tomography of the skull showed low-density shadows of the left temporal lobe and bilateral frontal lobe. Magnetic resonance imaging (MRI) of the skull and intracranial blood vessels showed direct enhancement of the cranial veins and brain. Diffusion imaging of the brain showed multiple filling defects, abnormal enhancement and diffuse signals at the distal end and branch of the superior sagittal sinus, the left transverse sinus-sigmoid sinus-internal jugular vein and the right transverse sinus. The patient’s prothrombin time was 13.4 s, prothrombin activity was 77% and D-dimer was 0.88 μg/ml. The patient was considered to have CVST with brain parenchymal damage (cerebral oedema and venous infarction). Therefore, the patient underwent whole cerebral angiography via femoral artery catheterization and catheterization thrombolysis. After the operation, the patient was given comprehensive treatments, such as thrombolysis, sedation and lowering of intracranial pressure.\nThe patient’s bone marrow aspiration result was verified to be normal. To identify the cause of CVST in such a young woman, a thorough medical history was taken and the patient reported a history of increased menstrual flow for 6 months, increased vaginal discharge and a peculiar smell for 1 month. Prior routine examination of leucorrhoea in the local hospital showed inflammatory changes. After taking oral anti-inflammatory drugs for 1 month, the condition did not improve. Then, the patient was given an urgent examination with uterine accessory ultrasound to prompt the following question: is this condition uterine disease? MRI of the pelvic cavity demonstrated an enlarged cervix with an irregular shape. The neurologist asked the gynaecologist for two consultations"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old female patient came to the department with a blackish discoloration in the right upper front tooth region for 1 month (). Her previous dental history showed that she had undergone trauma when she was 8 years old. She suffered tooth avulsion wrt to right and left upper central incisors. Her previous records depict she was treated with rigid arch fixation and was following up for apexification procedure. However, currently patient started noticing reddish turned black discoloration in the right front tooth for the past 1 month. There was no history of pain or tenderness. On clinical examination, there was grade II mobility with discoloration at the cervical margin of 11. However, 21, appeared to be clinically stable and lacking any signs of inflammation. On radiographic examination, there appeared to be marked oval-shaped radiolucency involving radicular pulp space and coronal third as well (). Following which a diagnosis of inflammatory perforating internal resorption wrt 11 and replacement resorption wrt 21 was made. Consecutively, a treatment plan for surgical intervention wrt 11 was made.\nThe treatment objective was:\nTo halt the process of root resorption wrt 11.\nTo provide stability for 11 and preserve alveolar bone wrt 11 to later receive implant prosthesis.\nThe procedure was started by administering an infraorbital and nasopalatine nerve block along with local infiltration to provide for profound anesthesia. Now using a 15 no. BP Blade vertical incision was given on the labial aspect of the 11 and 12 region and an envelope flap was raised. The site was thoroughly irrigated with normal saline. Upon inspection, the labial cortex of the maxilla and the labial root surface of the right maxillary central incisor had undergone serve root resorption (). A 90% aqueous solution of trichloroacetic acid was applied over the resorptive lesion for 1 to 2 minutes using a cotton pellet. Following this, curettage of the resorbed cavity was done to remove any devi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old man referred to our facility for the management of abnormal computed tomography of the chest identified during investigation for atypical chest pain. His past medical history was significant for chronic hepatitis C complicated by liver cirrhosis and hepatocellular carcinoma (HCC). He underwent chemoembolization and radiofrequency ablation of the liver as bridging therapies prior to uneventful orthotopic liver transplantation (OLT), a curative treatment for HCC. The explanted liver was cirrhotic and contained two 4.5 cm extensively necrotic lesions consistent with poorly differentiated HCC on pathological examination. There was an extensive intravascular invasion, and tumor was presented within an intracaval thrombus, which was removed during surgery. After the OLT, he was maintained on immunosuppressive therapy with tacrolimus and prednisone. Unfortunately, he was diagnosed with prostate cancer a few months later and underwent prostatectomy as curative treatment. At this time, his immunosuppressant was changed from tacrolimus to sirolimus, which had shown to delay HCC recurrence when compared to regimens that use tacrolimus in retrospective study.\nPhysical examination of his chest revealed normal breath sounds. Cardiovascular examination was unremarkable for abnormal heart sounds or murmurs. The rest of his physical examination was normal. Cardiac workup was negative for myocardial injury. Computed tomography of his chest images is shown in . The patient subsequently underwent endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) of right paratracheal lymph node station 4R ().\nPathological examination revealed highly cellular and clusters of large, loosely cohesive sheets of tumor with thin-walled traversing blood vessels. The tumor cells had a moderate amount of granular cytoplasm containing occasional hyaline globules. Nuclei were round to oval in shape and moderately pleomorphic, with prominent nucleoli and scattered intranuclea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old North African man, with no past medical history, consulted our out-patient clinic for a painless left scrotal mass. There was no history of previous orchitis or scrotal contusion. He noted the mass a month ago. A physical examination found a 2 cm palpable mass in the upper pole of his left testis. There were no signs of scrotal inflammation. The mass had a firm consistency and regular margins. Palpation of his right testis and the lower pole of his left testis were normal. Routine blood tests were normal. As a testicular tumor was strongly suspected, a bioassay of testicular tumor markers was ordered. Alpha-fetoprotein, human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) were in the normal ranges. There was no bacterial growth in urine analysis, including Mycobacterium tuberculosis screening. A scrotal ultrasound showed a homogeneous testicular parenchyma, with a conserved vascularization on Doppler. An extratesticular mass was observed, attached to the upper pole of his testis. The mass was isoechoic to the testis parenchyma, and poorly vascularized Doppler (Fig. ).\nHe underwent a radical inguinal orchiectomy. We first performed a high ligation of the spermatic cord. The operative specimen included the testis and the tunica vaginalis in one piece (Fig. ). The macroscopic aspect of the supratesticular mass looks similar to splenic tissue (Fig. ). There were no macroscopic lesions of the testis and the spermatic cord. His postoperative course was uneventful. He was discharged on the second postoperative day.\nHistological examination of the operative specimen confirmed the presence of regular splenic tissue in the suspect mass, without any signs of malignancy. The splenic proliferation had its proper and regular capsule, demarcating it from the testis. Testicular pulp, the albuginea and the tunica vaginalis had a preserved microscopic architecture (Fig. ). He was examined 3 weeks after orchiectomy and he was examined again 2 months after"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male with edentulous maxilla was referred to the University Department of Oral and Maxillofacial Surgery of the “Evaggelismοs” general hospital due to a migrated implant into the right maxillary sinus. The patient suffered from chronic obstructive pulmonary disease and therefore he had quitted smoking. Five years ago he underwent dental rehabilitation with the placement of six implants in the maxilla and four in the mandible. In less than 2 months after initial placement, all implants had failed to osseointegrate. A year and a half later the patient underwent guided bone regeneration with bovine-derived xenograft and 7 months after this point, another 10 implants were inserted into both the maxilla and mandible. Two months later, all implants had once again failed to osseointegrate. During the attempt of removal by the dentist, one of the implants was displaced into the maxillary sinus, without the dentist being able to retrieve it. The patient then visited another dentist, who could not either remove the migrated implant.\nUpon arrival to our clinic, a full medical and dental record was retrieved from the patient, and he was scheduled for surgical removal of the implant. Prior to operation, the patient underwent a radiographic examination with water’s X-ray (Fig. ), as well as CBCT examination (Fig. ) which confirmed implant migration and revealed its exact position inside the maxillary sinus.\nSurgical procedure initiated with local anesthesia by injecting xylocaine 1% andepinephrine 1:100,000 solution in the soft tissues involving the right half of the maxilla. After a crestal incision, a full-thickness mucoperiosteal flap was raised, exposing the anterior-lateral wall of the maxilla in an area extending from canine to molar region. Using a high-speed rotary instrument under sterile saline solution irrigation, a rectangular window was created in the anterior-lateral maxillary wall. The implant was detected through the bony window and captured by a mos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-month-old full-term female with a history of respiratory syncytial virus bronchiolitis at two weeks of age presented to our hospital via emergency medical services with the chief complaint of ALTE. As per the mother, the patient was noted to have an episode of perioral cyanosis, coughing, and increased work of breathing after being placed on her back immediately following a bottle-feed. When the mother noted these symptoms, she picked up the patient who was described as “pale” and “limp.” A bystander was able to forcefully pat the patient's back and formula was expressed from the mouth. By the time medical personnel arrived, the patient was back to her baseline behavior.\nUpon further questioning, it became clear that the patient had a several month history of chronic cough, congestion, and feeding intolerance for which she had already undergone an extensive outpatient workup. This workup included testing for various immunodeficiencies, as well as a laryngoscopy by otolaryngology. Per report, these tests and the above procedure did not reveal any pathology. The mother reported that the primary care physician had seen the patient earlier in the week of presentation for increased coughing and prescribed nebulized albuterol treatments and a short course of steroids for presumed reactive airway disease. Neither intervention alleviated her symptoms. While this was the patient's first episode of cyanosis associated with cough, the mother reported a worsening of the patient's cough and shortness of breath upon lying flat and after feeding.\nAfter admission to the floor, the team observed the patient feed which resulted in a choking-like episode and overt respiratory distress, only alleviated by positional maneuvers. Other pertinent positives on her physical exam were baseline audible breathing with occasional inspiratory stridor. Given the patient's increased symptomatology with feeding and her concerning baseline respiratory exam, she was deemed unsafe for oral feeds un"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old girl presented with a 6-month history of slowly growing mass on the volar aspect of the right middle finger []. An incisional biopsy was done at a local hospital, but it was not conclusive and the specimen was not available for reexamination. Clinically, the mass was fixed to the dermis and the flexor sheath. However, there was no numbness and there was full range of motion of the finger joints. A magnetic resonance imaging showed an enhancing lesion that is adherent to the flexor sheath []. Excisional biopsy was done through a zigzag volar incision. Intraoperatively the tumor was found to have ill defined borders. It was adherent to the dermis, flexor sheath and both digital nerves. Part of the flexor sheath was resected and the tumor was shaved off from the dermis by sharp dissection. No skin excision was done and both digital nerves were preserved. The tumor size was 2 × 1.5 cm []. Postoperatively, a small area of the skin flap became necrotic and this was treated conservatively []. Histological examination showed all the classic features of EHE. The tumor consisted of numerous epithelioid cells which are arranged in clusters, trabeculae and cords in a myxoid background []. Another characteristic histological feature of this tumor is the presence of intracytoplasmic vacuoles []. The mitotic rate was 3/10 high power fields (HPF) with evidence of focal pleomorphism. The tumor cells were extended to all resection margins. A panel of immune histochemical stains was done and showed positive staining of tumor cells with CD34, CD31, and factor VIII []. Tumor cells were negative for other markers confirming the endothelial origin of the tumor. We considered the malignant potential of the tumor and the positive resection margins and we offered the patient further management in the form of wide resection of volar soft tissues and flap reconstruction. The family refused and elected for followup. The followup protocol was local examination and radiological work"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old male reported to the Department of Periodontics and Implantology, DJ College of Dental Sciences and Research (Uttar Pradesh) with a chief complaint of painful, bleeding swollen mass in his lower front teeth region []. Patient noticed these swelling 9 months ago in his lower jaw in front and right region, which was slowly increasing in size. Gingiva had a reddish pink appearance and bled on probing was present. Probing depth ranged from 7 mm to 9 mm with an attachment loss of 5-7 mm in the mandibular anterior teeth region. Grade 2 mobility was present around the mandibular central incisors and Grade 1 around the mandibular lateral incisors and canines and mandibular right first premolar. Patient had a poor oral hygiene and had left oral hygiene measures since 3 months due to pain while brushing. Patient had visited a physician 2 months ago and was under antibiotics, but that did not improve his condition. Patient was systemically healthy and did not report a positive drug history. After taking a detailed history, it was found that the patient used an herbal tooth powder since past 7 years. Radiographs showed a moderate amount of bone loss in the mandibular anterior region []. A blood specimen was obtained in order to rule out leukemia or other blood dyscrasias. Provisional diagnosis of the chronic generalized gingivitis with localized gingival enlargement was made.\nTreatment and follow-up-initial periodontal therapy comprising of scaling and root planning and oral hygiene instructions were given. Patient was also instructed to rinse with 0.2% chlorhexidine twice daily. The patient was advised to discontinue the use of herbal toothpowder. The appearance of the gingiva improved after 10 days []. However, complete resolution of enlargement was not accomplished. Gingivectomy was performed [] and the excised mass [] was sent for biopsy. Postoperative follow-up after 3 months showed firm and resilient gingiva with no enlargement []. No"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old woman was admitted to the internal medicine ward with painful lesions on her lower left leg of recent onset. Her medical history included prosthetic aortic and mitral valves, chronic ischaemic stage 4 kidney disease, multifactorial anaemia (due to valvar leak, gastrointestinal loss and chronic kidney disease) and a recent diagnosis of oligoarthritis of unknown aetiology. She was under the care of cardiology, internal medicine and rheumatology clinicians.\nThe patient had been on warfarin for over a decade. She was also taking calcium carbonate supplements, receiving weekly intravenous iron supplements, and had been recently started on prednisolone 20 mg daily for the oligoarthritis.\nThe lesions were described as initially small violaceous nodules with diameter of 3 cm or less on the posterior side of the patient’s left leg. By the time of admission, they had progressed to typical stellate ulcers (). The initial differential diagnosis by a dermatologist was warfarin-related ulcers, vascular ulcers or calciphylaxis. Warfarin was suspended and replaced with low molecular weight heparin adjusted for renal function. A first skin biopsy was inconclusive.\nWithin 5 days the small nodules had developed into necrotic ulcers with eschars that covered the entire left calf. General surgery, palliative care and nutrition specialists were consulted. Pain control and wound management were essential as the necrotic bed was spreading and there was a risk of superimposed infection ( and ). Pain management was also challenging as the patient reacted with confusion and agitation to an opioid combination. Administration of a morphine bolus, transdermal fentanyl and oral gabapentin was effective.\nLaboratory findings were non-specific and did not suggest calciphylaxis. The patient’s anaemia worsened and gradual acute-on-chronic renal failure was observed. Parathyroid hormone (PTH) levels were normal, as were calcium and phosphorous levels throughout the patient’s admission. Ho"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 40-year-old Asian man with complaints of bleeding and discomfort in his anus of 2 months’ duration. He was an employee with average income who did not smoke tobacco or drink alcohol. He had no weight loss or urinary symptoms, and no substantial family history. He denied any significant medical or surgical history. His abdomen was soft, non-tender, and non-distended, with normoactive bowel sounds. In examination, a mass could be touched by finger tips. The mass was large and bleeding. In subsequent examinations, blood was detected in a stool sample. His vital signs were: blood pressure, 130.77 mm Hg; respiratory rate, 18 breaths/minute; heart rate, 83 beats/minute; and temperature within normal limits. Oxygen saturation was 98% on room air on admission. In colonoscopy, a large lobular tumor was diagnosed at 4 cm above the dentate line, which was suspicious for malignancy. Various samples were taken from the tumor. The rest of his large intestine did not show a clear pathologic lesion in the colonoscopy.\nHigh-grade adenocarcinoma was reported in pathological examinations. In subsequent diagnostic procedures, his carcinoembryonic antigen (CEA) level was normal. Computed tomography (CT) scans revealed that metastatic lesions were not detected in his liver, abdominal viscera, and chest. In CT scans with or without contrast, and magnetic resonance imaging (MRI) scanning, an ectopic kidney was detected incidentally on his right pelvis without any prior urinary symptoms. The left kidney was in its original location, and both kidneys were functional. Renal function tests provided normal results.\nIn subsequent investigations done by MRI scanning for staging the tumor, a pelvic rectum tumor was reported to be interfering with the T3 N1 mesorectal lymph nodes (Figs. , ). The case was discussed in a multidisciplinary cancer team; afterward, our patient was regarded as a candidate for neoadjuvant radiotherapy. He underwent 45 GY radiation in 25 fractions to the p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Japanese 26-year-old man without any relevant medical history had progressive refractory massive ascites of unknown origin. He shortly developed hematemesis. An endoscopy revealed spurting bleeding from esophageal varices, and he was referred to and then admitted into our hospital. He underwent emergency endoscopic injection sclerotherapy (EIS). The laboratory data on admission showed severe liver dysfunction without any suggestion of chronic liver diseases, such as cirrhosis. The hepatitis viral markers, including hepatitis B and C, were all negative. Color Doppler ultrasonography (US) revealed a heterogeneous enlarged liver, shunt vessels between his middle and right hepatic veins (MHV and RHV, respectively), and retrograde flow in MHV. Computed tomography (CT) is a more sensitive modality for showing parenchymal abnormalities. In our case, enhanced CT revealed much clearer heterogeneity of the liver with decreased attenuation in the periphery. It also showed shunt vessels between MHV and RHV. The latter was markedly dilated, and it seemed to have some flow into the IVC, whereas his left hepatic vein was obstructed. Furthermore, sagittal CT images suggested severe stricture of his IVC at the level of the liver. Angiograms confirmed marked narrowing of his IVC at the level of the liver (Figure ). Magnetic resonance imaging (MRI) revealed findings similar to those of the CT. From these findings, and the rapid onset of the clinical manifestations, we diagnosed this patient as having acute BCS. Within one week, our patient developed massive hematemesis again. Subsequently, he showed manifestations of acute liver failure, possibly due to \"shock liver\". Since we could not find a donor for deceased liver donor transplantation (DLDT), we decided to perform PTA first. A balloon catheter was inserted into his right femoral vein, and the stricture of the IVC at the level of his liver was dilated using a 12 × 40 mm balloon catheter. After PTA, the pressure difference betwee"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old man presented with a 2-week story of dry cough and progressive dyspnoea. He had been submitted to an allogeneic hematopoietic cell transplant procedure for a refractory acute myeloid leukemia 4 months before hospital admission. The patient developed grade III graft-versus-host disease (GVHD). He was taking cyclosporine and prednisone 10 mg daily. He received prophylaxis with posaconazole oral solution (200 mg daily) in the first 15 days following transplantation (during the neutropenia phase, as per local protocol). A chest computed tomography revealed a bilateral interstitial infiltrate and multiple nodules with a maximum size of 1.3 cm, without halos (Fig. ). He was non-neutropenic at this time. Bronchoscopy was performed and BAL fluid analysis was negative for fungi (microscopy and culture). The BAL GM index was 0.9. An open lung biopsy revealed invasion by branched hyphae, suggestive of Aspergillus sp. Voriconazole was initiated at standard doses but the patient died 6 days later of respiratory failure and dysfunction of multiple organs and systems. Cultures of the lung specimen were negative.\nThis was a transplant recipient who had undergone posaconazole prophylaxis and who developed an IFD 3 months after the end of the 30-day prophylactic regimen. Posaconazole prophylaxis represents a safe and effective strategy against fungal infections in transplant patients [, ]. Although there is an ongoing debate regarding the optimal approach to the prevention of IFD in allogeneic stem cell transplant recipients, recent guidelines support the use of prophylactic antifungal agents in these patients, particularly in the context of GVHD [, ].\nThere are important differences between aspergillosis in neutropenic hosts and in non-neutropenic hosts []. In neutropenic hosts, angioinvasion is a hallmark of the disease and this is associated with a high frequency of dissemination to other organs. In this scenario, classic radiologic findings such as pulmonary nodules"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old male, warehouse worker, presented with a noticeable mass in the left side of his abdomen and weight loss of three and half stones over a four-month period. His past medical history and family history were unremarkable. Physical examination revealed a large, nontender, and fixed left-sided abdominal mass and a normal neurovascular examination except an isolated reduction in light touch sensation in the L2-L3 dermatomes of his left leg only.\nAn abdominal and pelvic magnetic resonance imaging (MRI) and computed tomography (CT) demonstrated a large, 19 × 16 × 11 cm mass arising from the anterolateral aspect of the L3 pedicle with peripheral calcification, completely obliterating the distal psoas muscle and causing a considerable mass effect to surrounding structures, with displacement of the left kidney. Distally, the tumour extended to the level of the pelvic inlet but not into the spinal canal (Figures and ).\nCT guided biopsy of the left abdominal mass confirmed the diagnosis of a low-grade chondrosarcoma arising from an osteochondroma from the lateral body of the L3 vertebrae. The difficult anatomical location and the large size of the lesion greatly increased the complexity and risks of any surgical approach. In order to improve the chances of surgical success and reduce and prepare for possible risks and complication such as catastrophic haemorrhage, spinal instability, and paralysis/neurological deficit, a two-stage surgical procedure and a multidisciplinary team approach to a curative en bloc tumour resection were utilized.\nIn the first stage, a posterior midline incision to expose the lumbar spine was performed. Bilateral pedicle screws were placed at the levels of L2 and L4, with rods fixated at the end of the procedure for spinal stabilisation. Bilateral laminectomies and facetectomies were performed leading to exposure of the nerve roots, of which the left L3 nerve root was identified and ligated. A partial osteotomy was carried out at the level"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn otherwise healthy 33-year-old woman, gravida 3, para 2, from a Sephardic Jewish origin, was initially referred to our institution at 30.6 weeks of gestation due to a large neck mass found on prenatal ultrasonography (US). Her previous two pregnancies were uncomplicated. The fetal sonogram showed a 10 by 8 cm mass on the right side of the neck, which was not present in detailed scans taken at 14 and 22 weeks. The mass was composed of a cystic portion and a solid portion containing blood vessels and was growing rapidly in subsequent ultrasound studies. A significant polyhydramnios with amniotic fluid index (AFI) of 50 suggested an upper gastrointestinal obstruction and a highly possible airway obstruction as well. Findings were confirmed by fetal magnetic resonance imaging (MRI). In anticipation of the difficulty in establishing a secured airway at birth and the potential complicated resection of the giant tumor after birth, the mother was referred to our hospital for consultation.\nThe parents were in consultation with the maternal fetal team, neonatologist, anesthesiologist, pediatric surgeon, and otolaryngologist. The parents were presented with a guarded prognosis but insisted that the pregnancy continue with maximal efforts during delivery and during the neonatal period.\nTherefore, a planned EXIT procedure, which provides the best chance to establish a patent airway, was offered to our patient, presenting the risks []. Specifically, we informed the parents about the risks for the mother, including significant hemorrhage from the uterus due to the uterine relaxation necessary to avoid placental separation, with a possible uterine resection in the case of a life-threatening hemorrhage.\nKnowing the risk of an unplanned preterm delivery due to polyhydramnios and uterine contractions, we scheduled our patient for a planned cesarean delivery at 34 weeks organizing and preparing a multidisciplinary team ready to perform the EXIT procedure.\nA multidisciplinary team inc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57 year old woman presented to her ophthalmologist complaining of protrusion of her right eye in August 2005. She had exophthalmos of left eye 20 years ago and she was diagnosed as Graves’ disease which resolved without any treatment or intervention. She was without complaint for 20 years until presenting to her ophthalmologist who felt that her exophthalmos was due to Graves’ disease but she was found to be borderline hypothyroid. Six months later, she developed redness, dryness, and pain in the right eye with worsening exophthalmos. She also complained of double vision and headaches. She was started on thyroid replacement for borderline hypothyroidism but had no relief in proptosis. Antibiotics were prescribed for suspected bacterial infection of the right eye without resolution of her symptoms. She was then started on prednisone 80 mg daily for possible autoimmune/inflammatory etiology and her symptoms improved significantly. At this time, her visual acuity was noted to be 20/25 in the affected eye. Fundoscopic exam was normal. Hertel exophthalmometry, ocular tension, and biomicroscopy were not documented. An MRI of brain and orbit revealed an enhancing soft tissue mass behind the right globe (). The biopsy of the soft tissue mass revealed transmural inflammation with fibrinoid necrosis consistent with necrotizing vasculitis as well as also evidence of lymphocytic infiltration in the fatty tissue consistent with Graves’ disease (). ANA, ANCA, ACE, anti-SSA and anti-SSB antibodies were negative though the patient was found to have an equivocal MPO-ANCA of 6. A diagnosis of limited WG was made. Patient was started on oral cyclophosphamide at 2 mg/kg/day in August 2006 and prednisone was continued. A repeat MRI of the orbit in November 2006 showed decreased enhancement and infiltration of fat adjacent to right optic nerve. In April 2007, cyclophosphamide was discontinued because of leucopenia and methotrexate was started. The prednisone has been discontinued. She"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 48 year old woman with a screen-detected left breast cancer. She was found to have an abnormal bilateral screening mammogram which demonstrated a suspicious area of architectural distortion in the right breast and an obscured nodule in the left breast. This prompted further imaging with diagnostic mammogram and ultrasound. This was especially concerning for a solid microlobulated nodule in the left breast measuring 7 mm in size at 3:00 and a persistent suspicious area of architectural distortion in the right breast with two adjacent simple cysts. Bilateral breast biopsy was performed. Ultrasound guided core biopsy of the suspicious right breast lesion was consistent with sclerosing adenosis with usual ductal hyperplasia. No atypia or malignancy was noted. Ultrasound guided core biopsy of the left breast lesion was consistent with grade 2 invasive ductal carcinoma, ER 10%, PR 0%, Her2/neu negative (1+), Ki 67 1%. Bilateral breast MRI was performed which showed no suspicious lesions in the right breast and a 2–3 mm ovoid rapidly enhancing nodule with plateau kinetics reflecting a portion of the originally biopsied cancer. No other suspicious lesions were noted within the left breast, left axilla, or internal mammary chain. Her case was reviewed, and the multi-disciplinary decision was to proceed with breast conservative surgery first. She was taken for right partial mastectomy and left partial mastectomy with sentinel node biopsy. Final pathology of the right breast did not show any evidence of malignancy. Initial pathology of the left breast was initially concerning for a biologically unfavorable invasive ductal carcinoma, NOS type. However, further pathologic review revealed that the patient had a grade 2, 8 mm secretory carcinoma. The diagnosis of secretory carcinoma was suspected based on histologic findings which included a microcystic and tubular growth pattern with luminal secretions. The tumor cells were polygonal with eosinophilic to foamy cy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Hispanic man presented to the emergency department complaining of right groin pain for one week. He described the pain as aching (6–8/10) in severity, localized to the right groin, precipitated by walking, and relieved by resting for approximately 10 minutes. The pain had progressively worsened over the previous week, and causing a painful limp at the time of presentation, he denied any morning joint stiffness, muscle aches, other joint pain, rash, fever, or back pain. He had taken a few tablets of nonsteroidal anti-inflammatory drugs every day for the last week, with minimal pain relief.\nUpon review of other organ systems the patient described that he had been feeling subtle weakness in the left upper and lower extremities which started three years earlier and became slowly progressive. He stated that the weakness was not causing any limitation of activity or falls and denied any history of urinary or bowel incontinence, numbness, or pain in the extremities other than the presenting complaint.\nWhen evaluated for the weakness two years earlier an MRI of the brain was ordered and reviewed by his primary care physician with reportedly normal results.\nOn physical examination, no erythema or swelling around the right hip or groin area, and no inguinal lymphadenopathy were noted. The passive range of motion of the right hip was limited and painful, especially forced internal rotation. Passive internal and external rotation of the extended leg “log roll test” and straight-leg raise test elicited pain. Bilateral hyperpigmentation from the knees to the toes was noted, with mild bilateral lower extremity pitting edema, and normal peripheral pulses.\nCranial nerves examination revealed a left spinal accessory nerve lesion as the patient was unable to shrug his left shoulder. Tongue fasciculation was noted with a slight deviation of the tongue to the left on protrusion, suggesting a left hypoglossal nerve lesion. The remainder of cranial nerves examination was nor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old male with a history of left testicular cancer treated with chemotherapy (Bleomycin, Etoposide, Cisplatin; BEP), radiotherapy, retroperitoneal lymph node dissection, and partial left nephrectomy in 1992 presented to hospital with complaints of left lower abdominal mass for 3–5 years, associated with ulceration and active drainage. He was asymptomatic with β-hCG and alpha-fetoprotein (AFP) levels within reference ranges (<2.39 and 1.4, respectively). On examination, inspection of abdomen revealed well-healed midline scar with bilateral incisional hernias and a 10 × 8 cm mass in the left lower quadrant () firm and fixed to the abdominal wall. An open lesion characterized by yellow, non-purulent drainage was noted in the left lower quadrant. CT imaging of abdomen and pelvis with contrast revealed a multiloculated large cystic mass in the left inguinal canal measuring 11 × 7 × 7.7 cm () along with a similar soft tissue nodule in the right inguinal area. A right retroperitoneal soft tissue mass in the mid abdomen was also identified, measuring 3.3 × 4.2 × 5.7 cm (). Changes of prior left nephrectomy and orchiectomy consistent with treatment of previous left-sided testicular cancer were also noted.\nBiopsy of right retroperitoneal mass revealed squamous cell-lined cystic lesion followed by left lower quadrantabdominal mass excision and complex wound closure. An elliptical incision was made in the left groin incorporating the lesion, and subcutaneous flaps were created. Dissection was carried down to fascia where the mass extended into inguinal ring and the lower edge of the external oblique aponeurosis, extending into the abdomen. The mass was excised and noted to be multi-loculated and heterogeneous in consistency. The fascia and peritoneum that was adhered to the mass were then resected. A superficial inguinal lymph node was excised and sent to pathology as a separate specimen, and no other inguinal or femoral enlarged lymph nodes were found. Final pathology"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old male was an unrestrained passenger in an automobile travelling between 60 and 70 mph. This car was the involved in a road traffic collision at an oblique angle with another vehicle. The patient in question was a rear seat, nearside passenger.\nAt the scene of the collision, the passenger-side front seat trapped the patient for approximately 1½ h. Once released the patient was then transferred by helicopter to a local trauma center.\nUpon arrival, the patient was stable despite tachydcardia with Glascow coma scale of 15/15. Primary and secondary surveys were performed, and trauma team noted open wounds in both right forearm and left thigh. There were bruises and patient was complaining of pain and difficulty in using his jaw. The abdomen was soft and normal oxygen saturations were maintained. The extremities were neurovascularly intact distally, and the patient was complaining of pain in the right leg.\nHe had been administered opiate analgesia, oxygen and tranexamic acid. Once stabilized the patient was transferred for an urgent computer aided tomography (CT) scan, which revealed the following injuries: Subcondylar fracture of the mandible, open fracture of the right ulna and radius, open fracture of the left femur, inferior dislocation of the right hip joint, small splenic laceration, and contusion of left pulmonary base.\nThe same day as admission the patient was taken to the operating theater for reduction under general anesthesia of the inferior dislocation of the right hip joint. With hip abduction traction, external rotation and flexion of the hip joint multiple attempts were made to reduce the hip joint, but unsuccessfully. It was therefore considered necessary to attempt an open reduction of the inferior dislocation. An anterior approach was used and the hip capsule opened anteriorly. The acetabulum was empty and the ligamentum teres ruptured. The femoral head was stuck within the obturator region; inferior to the transverse acetabular"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old female with a recent diagnosis of acute lymphocytic leukemia was admitted to our hospital due to persistent fever and left-sided perioral dysesthesia following initiation of chemotherapy. Clinical examination revealed ulcerous lesions in the patient’s palate. Further laboratory tests were notable for pancytopenia and elevated CRP and ESR. Cultures of tissue samples taken from the oral lesions revealed multidrug-resistant Pseudomonas aeruginosa and Pseudomonas fluorescens and intermediate antibiotic sensitivity Acinetobacter baumannii. Chemotherapy was discontinued and the already instituted empiric antibiotic coverage was adjusted according to antibiograms. Head and facial computed tomography (CT) revealed extensive bone erosion of the maxilla around the dental alveoli without signs of inflammation of the paranasal sinuses. Anatomic variation was the bony dehiscence of the superolateral wall of the left sphenoid sinus [], with concomitant carotid artery protrusion into the sinus and separated by the sinus cavity by only dura and mucosa.[,] One and a half month later, there was sudden-onset epistaxis that was managed successfully by tamponade by ENT surgeons. Postcontrast head and facial CT imaging revealed inflammation of the left nasal cavity and paranasal sinuses –especially the left sphenoid sinus – without any gross vascular abnormalities. Further episodes of intermittent epistaxis were noted although clinical and laboratory signs of infection remitted during the following fortnight. A repeat head-facial contrast CT scan was performed at that time. It showed containment of the infection but revealed a large enhancing lesion protruding into the left sphenoid sinus, which on further CT angiography (CTA) and digital subtraction angiography (DSA) were determined to be a 0.9 × 2 cm infectious irregular multilobulated pseudoaneurysm of the cavernous ICA [ and ]. The patient underwent emergent complete selective endovascular occlusion of the pseudoaneurys"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old male was transported to the emergency department after a traumatic near total amputation of the right distal tibia due to a motorcycle accident; the patient's leg was run over by a truck. The distal portion of the leg was severely crushed and the only remaining portions were the anterior and posterior tibial nerves, the tibialis anterior tendon, and some soft tissue connections, with no viable blood flow to the distal stump (). The amputation site was critically contaminated, with circumferential degloving tissue loss of approximately 15 cm in length at the distal portion of the lower leg ().\nA comminuted fracture of the tibia and fibula was observed at the distal portions with damage to the ankle joint. Despite the severity of the damage to the amputated region, the general condition of the patient remained fairly stable. The total ischemia time was more than 10 hours of warm ischemia.\nAfter an external fixator was applied to the open tibial fracture and internal fixation was performed for the fibula, wound exploration was performed (). Thrombosis of the anterior tibial artery and a 20-cm-long segment of the artery's crushed intimal structure were observed, along with a similarly damaged vein. The posterior tibial vessels showed an arterial gap of 10 cm, with one accompanying vein ruptured and the other vein crushed with a venous gap of 7 cm (). The posterior tibial vessels appeared more promising for a successful repair. A lesser saphenous vein graft was harvested from the contralateral leg in a 12 cm segment for the arterial reconstruction (). After blood flow resumed, 400 mL of blood was drained before the vein was repaired.\nThe ruptured vein was repaired primarily, and the vein with a 7 cm gap was repaired with an 8 cm strip of arterial graft from a non-thrombosed segment at the middle portion of the thrombosed anterior tibial artery ().\nThe healthy vein graft was considered more reliable for the arterial reconstruction than the arterial graft fro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male patient presented to emergency department after an assault with an incise wound in the external canthus of the left eye and severe alcohol intoxication, which prevented history taking. The physical exam of the ocular globe was not possible due to the large hematoma that hindered opening the eyelid. The exploration of right eye was normal. Therefore, the skin wound was initially sutured with a polypropylene 5/0 interrupted suture and an orbital computed tomography (CT scan) and skull X-ray were performed. An intraorbital foreign body with triangular shape of 4.6 cm x 2 cm was seen in the left orbit, passing through the orbit and the ocular globe, fracturing the superomedial wall of the orbit, with a probable associated fracture of the ethmoidal cells, and reaching the anterior cranial fossa, causing pneumocephalus (Figures and ). The patient did not present any neurological symptoms beyond his alcohol intoxication nor did he develop rhinorrhea at any time, and the Glasgow Coma Scale/Score was normal (15/15). He remained under observation and was treated with intravenous antibiotic (ciprofloxacin 200 mg twice daily, for five days, selected due to its broad spectrum for gram negative and positive) and corticosteroids (methylprednisolone 80 mg per day for 3 days). Surgical extraction was performed. The foreign body turned out to be a fragment of a dagger. The extraction was done locating the end of the foreign body after removing the suture of the wound and disinserting the lower eyelid to have a wider surgical field. The foreign boy was carefully extracted without exerting force. It was then possible to see a corneoscleral wound 2 cm long affecting the upper cornea 7 mm and the sclera 8 mm located from 9 to 2 o'clock positions. It was closed with nylon 10/0 suture and polyglactin 910 7/0 suture. The entrance area in the orbit was revised, with special attention to the upper nasal quadrant,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report on a 63-year-old female patient who presented in January 2016 with the following symptoms: complaint of cold sensation affecting the upper arms on both sides (left > right), weakness and arm claudication, with an increasing inability to perform work on the computer, and symptoms of a fatigue syndrome. The patient was unable to perform her employment as a hospital secretary. Clinically, pulselessness of the brachial and radial artery on both sides was noted. Bruits were discovered in the left and right subclavian artery. A blood test revealed increased levels of the inflammatory markers C-reactive protein (CRP 47.9 mg/dL) and an increased Erythrocyte Sedimentation Rate (ESR 74 mm/h). The patient had a history of hypertension, hyperlipoproteinemia, and osteoporosis; she was a former smoker and reported moderate daily alcohol consumption.\nA neurological examination, an MRI of the cervical spine, and myocardial scintigraphy were without pathological findings. Duplex ultrasound of the carotid artery and upper extremities revealed noticeable intima-media thickening. For suspected large-vessel vasculitis, a diagnostic angiography was carried out, which revealed bilateral stenosis of the axillary artery at the transition to the brachial artery and, on the left side only, an additional stenosis in the proximal segment of the brachial artery. TA was diagnosed based on the American College of Rheumatology criteria, with four out of six criteria met.\nThe patient was admitted to a rheumatological specialist clinic in March 2016. Treatment with prednisolone 20 mg daily was started, but there was no improvement of the arm claudication. Therefore, the patient received cyclophosphamide 15 mg/kg body weight × 0.75 (=600 mg) plus prednisolone (75 mg/d initially, reduced in stages to 30 mg/d at the time of hospital discharge). Six cycles of cyclophosphamide at 3-week interval were planned, at the end of which treatment with methotrexate 15 mg subcutaneously once a week accomp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old male patient visited our hospital with complaints of limitation of ROM in the left knee and inability to walk for 9-months. Nine months prior, he visited a local hospital after a motorcycle traffic accident and was diagnosed with an open fracture of the left femur shaft and an intra-articular fracture of the proximal tibia. He underwent an operation using the Ilizarov external fixator at the femur and tibia. Two months after the first surgery, the Ilizarov fixator was removed and changed into a monoaxial external fixator for the left femur and converted to internal fixation with a screw for the left tibia. One month later, he underwent an operation for conversion to internal fixation with intramedullary nailing of the left femur. At that time, he underwent manipulation of the knee joint for ankylosis. On physical examination at the initial visit to our hospital, he had tenderness and dimpling in the superior aspect of the patella and markedly decreased mobility of the patella (including mediolateral and superoinferior translation). He had quadriceps atrophy (a 3-cm decrease in mid-thigh circumference as compared to the contralateral limb). His left knee ROM was between flexion contracture of 30° and further flexion of 90°. On plain radiographs, nonunion of the left proximal tibial fracture and femur shaft fracture were shown. The lateral radiograph revealed a fracture in the superior pole of the patella and patella infera (). The ultrasound showed discontinuity of the quadriceps muscle fiber and hypoechoic hematoma ().\nUnder the presumptive diagnosis of a chronic quadriceps rupture with a patellar superior pole avulsion fracture of the left knee and nonunion of the left proximal tibia fracture, we performed quadriceps reconstruction using tibialis anterior allograft tendon and additional screw fixation. Initially, after removal of the fibrotic nonunion site, 2 cannulated screws were used to fix the nonunion fragment of the proximal tibia at full flexio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old woman visited our outpatient clinic with an erosive nodule on the scalp. She had been treated for juvenile dermatomyositis and had been administered immunosuppressive agents such as cyclosporine and prednisolone since she was 1 year old. On her initial visit, physical examination revealed a dome-shaped, easy-to-bleed nodule on her parietal scalp (Fig. ). In addition, a wide-spreading scarring alopecia-like lesion was observed on the whole scalp. The size of the nodule was approximately 32 mm in diameter. Skin biopsy from the nodule revealed a dermal infiltration composed of atypical keratinocytes with dyskeratotic cytoplasm (Fig. ). Around the tumor mass, a dense infiltration of lymphocytes was observed. We diagnosed this patient as having a moderately differentiated SCC on the parietal scalp and excised the tumor with a 10-mm margin. Four years after the initial excision, another red nodule developed in the left temporal region (Fig. ). Since the histological findings of the second tumor were similar to those of the first cutaneous SCC (Fig. ), we excised the tumor with a 10-mm margin. Eleven months after the second surgical treatment, a keratotic lesion was apparent around the grafted area (Fig. ), and again we excised it with a 10-mm margin. The histological findings of the third tumor were similar to those of the first cutaneous SCC, which was a widely spread SCC in situ (Fig. ). Additionally, we performed a random biopsy on the patient's scalp, and there were no atypical cells – only homogenization of the collagen bundle with carcinosis.\nSince recurrent multi-focal lesions were detected in this case, and since a previous report suggested that IL-17 plays a key role in cutaneous SCC carcinogenesis, we employed immunohistochemical staining for IL-17 as well as IL-17R in the lesional skin of each of the cutaneous SCC in our case. Immunohistochemical staining revealed that these atypical keratinocytes strongly expressed IL-17R (F"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old male was admitted to our hospital with a 5-day history of severe dizziness, mild chest pain and dyspnea. On admission, he had a pulse rate of 115 bpm, a blood pressure of 80/60 mmHg, and a respiratory rate of 24. He had a history of hypertension and no diabetes mellitus. On physical examination, there were no pathological signs for heart sounds, but some wet rales were detected in the lower lung region. There was minimal bilateral leg edema. Cardiac troponin T levels were clearly normal. The electrocardiogram (ECG) did not show any new myocardial infarction (MI) sign. When checking patient history, we discovered that he had suffered STEMI four weeks prior. In the coronary angiography performed, an occlusive lesion was detected in the distal circumflex artery and he was discharged with medical treatment (). There was a right type of coronary dominance. Transthoracic echocardiography showed a 3-cm wide wall defect on the posterior side of the left ventricle, a 57-mm pericardial effusion and the left ventricular ejection fraction (LVEF) was 40% (). The operation was performed immediately via standard median sternotomy. Adherence of the pericardium was at an advanced level. The anterior part of the pericardium was dissected carefully for cannulation. We used cold potassium-based cardioplegia (Plegisol®, Baxter, Chicago, USA) for cardiac arrest and continued with cold blood cardioplegia. After a standard cardiopulmonary bypass (CPB) procedure, we separated the entire pericardium from the heart. On the posterior region we detected a formation like pseudo-aneurysm which was a 2-mm thick membrane formed by adhesion. It was almost completely covered the posterior face of the left ventricle. After opening this membrane, the myocardial defect was seen (). We considered that it was a subacute situation because of the non-existence of fragile necrotic tissue. The defect was sutured with eight separated and teflon felt supported 3-0 prolene sutures ( and )."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old male with no significant past medical history presented to our facility with a history of worsening pain and swelling in the medial aspect of his proximal left lower extremity over the past several years. Anteroposterior (AP) and “frog leg” lateral radiographs of the left lower extremity revealed a dense lesion consistent with dense matrix, adjacent to the medial aspect of the femur (). An MRI of the left lower extremity revealed that the lesion was of extraskeletal origin, arising from the adductor magnus, without any involvement of the femur (, ). The solid heterogeneous mass was located in the posterior compartment of the proximal-to-mid thigh and measured 9.6 × 7.3 × 13 cm in the transverse, AP and vertical dimensions, respectively. Multiple tiny hypointense foci, which corresponded to the calcific density noted on the prior plain radiographical studies, were noted centrally. The mass was otherwise of intermediate soft-tissue intensity on T\n1 weighted images and moderately hyperintense to muscle on T\n2 weighted images. Following intravenous administration of gadolinium, moderate enhancement of the mass, excluding the central portion, was observed. Superiorly and inferiorly, the margins of the mass were indefinite, and the mass demonstrated peripheral vasculature, which was most prominent at the cephalad and caudad margins. The mass was centred within the adductor magnus muscle fibres that were displaced around the mass. Anterolaterally, the mass was very closely approximated to the posterior cortex of the femur and the fascial margins that separated the quadriceps and the posterior compartments (Supplementary videos). No obvious signal abnormality was noted within the femur to indicate invasion or primary osseous origin. Post-excision pathology confirmed the presence of mesenchymal chondrosarcoma.\nIn the interval, surveillance imaging for metastatic disease with CT scan of the chest, abdomen and pelvis was performed. At 18 months, multiple bilatera"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.\nTo obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.\nThe right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ult"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old Native American female presented to the ER with a bladder infection, and a urine culture grew E. coli. She was treated with trimethoprim/sulfamethoxazole and developed a diffuse rash including the palms and soles. There was no lymphadenopathy present upon physical exam. One month later, she presented to the clinic with a month of severe pounding headaches, blurry vision in the right eye, and pain over the temporal area on the right side. Her ESR was elevated with a normal CRP. The suspected diagnosis was giant cell arteritis, and she was started on 60 mg of oral prednisone daily that helped the headaches. A temporal artery biopsy was done and showed no evidence of vasculitis. The patient was tapered from the steroid and started having progressive blurry vision and floaters. Three months later, the patient presented to the emergency department and was admitted to the hospital due to the blurry vision and floaters at which time she had a positive fluorescent treponemal antibody absorption test. She was HIV negative. The patient had a Venereal Disease Research Laboratory test of the cerebral spinal fluid done which came back negative. Her cerebral spinal fluid cell count was 178 nucleated cells with 164 lymphocytes, and protein was 53 mg/dl. She had a serum rapid plasma reagin titer of 1 : 1024. She was diagnosed with secondary and early neurosyphilis for which she was started on 24 million units per day of IV penicillin G, and severe uveitits for which she was started on 60 mg of oral prednisone and 1% prednisolone acetate eye drops. The uveitis was likely secondary to the syphilis infection. A CT scan of the head showed four osseous lesions (Figures –). An immunohistochemical stain of a skull biopsy was done which came back positive for Treponema pallidum, thus confirming syphilis as the cause of the bone lesions. An echocardiogram was performed which did not show any significant cardiac defect. The patient completed 14 days of 24 million units"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man was admitted to our hospital for the treatment of a rectal tumor found incidentally by rectal examination. The tumor, about 3 cm in diameter, was located on the right side of the lower rectum 3 cm above the anal verge. The pathological analysis of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) indicated that the rectal cancer invaded into the muscularis propria without distant metastases and that lateral pelvic lymph node (LPLN) was not enlarged with a maximum long-axis diameter <3 mm. The most important problem was that the patient had a huge benign prostatic hypertrophy, the size of which was 85 × 80 × 70 mm (Fig. a–c). To achieve complete TME with negative CRM, a hybrid transabdominal-transanal approach for ISR was conducted.\nFirst, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old African-American male with past medical history of hypertension and diabetes was briefly lost follow up for 9 months. He presented to our primary care clinic for his routine follow-up examination with complaints of a progressively worsening infected right foot ulcer for over six months. Patient also admitted to having pain and foul smelling drainage from the ulcer. Patient denied any tobacco or alcohol use. Physical exam was unremarkable except for an ulcer on the plantar aspect on his right forefoot measuring 6 × 5 cm with an ulcerated area at the base of fourth and fifth metatarsal involving the interdigital cleft and extending to the forefoot (). The ulcer was necrotic, black with bleeding and minimal purulent drainage. The patient was started on oral antibiotics with local wound care and surgical consultation requested. Outpatient surgical evaluations revealed a black eschar with punctuate areas of bleeding after the removal of the eschar. The patient was admitted to the hospital for surgical debridement of the presumptive diabetic necrotic ulcer. Laboratory studies including C-reactive protein (CRP) were within normal limits. His hemoglobin A1C was 5.6% indicating excellent control of his diabetes. Radiographic studies of the foot did not show air in the soft tissue, bony involvement, or signs of osteomyelitis. In the operating room under careful examination, the edges of the lesion were irregular with hyperpigmentation highly suggestive of a malignancy. An excision biopsy with 2 mm margin was sent for frozen section and pathology evaluation. Pathologic diagnosis was acral lentiginous melanoma. The tumor had an ulcerated surface that permeated the papillary and reticular dermis without permeation of subcutaneous tissue, suggestive of a Clarke level 4 (Figures , , , and ). Maximum tumor thickness was 3.5 mm, and mitotic index was <1/mm2. A positron emission tomography/computed tomography (PET/CT) was negative for metastatic disease. A definitive p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA non-smoker female, aged 45 years, reported with a moderately large growth in the mandibular anterior region. Medical history was insignificant. The patient was from low socioeconomic class. History revealed that a small nodule appeared 5 months ago, which was painless and caused spacing in the lower anterior teeth.\nOn examination, the patient’s lips were incompetent. Lower lip approximation was difficult due to large swelling protruding from the lower gingival region. Oral hygiene was considerably poor, which may be due to poor oral hygiene awareness, since oral hygiene is inversely related to socioeconomic class.\nThere was a pale pink swelling in the mandibular right central and lateral incisor region. The surface was nodular and irregular, with no ulceration. The growth measured 2.2 × 3.0 cm in size and was extending out from labial gingiva, displacing the central, lateral incisors and canine teeth, and extended lingually. The nodular growth extension in lingual was slightly smaller than that in the labial []. The growth was considerably hard in consistency, sessile and not easily movable.\nIntraoral periapical radiograph was taken, which revealed erosion of the crest of bone. The possible reason of crestal bone erosion in the area may be long-standing plaque-induced inflammation and constant pressure of the growth. Clinical appearance and consistency was of a hard fibrous growth, which therefore led to a provisional diagnosis of peripheral calcifying fibroma or peripheral odontogenic fibroma (POdF).\nPhase 1 periodontal treatment was carried out. Consent for the surgical procedure was obtained from the patient after proper counseling.\nUnder local anesthesia, the whole growth was excised and the underlying surface was thoroughly curetted up to deepest possible tissue and crestal osteoplasty was done. After controlling bleeding, periodontal dressing was applied and the patient was discharged with prescription of pain killer and chlorhexidine mouth wash. Follow-up v"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old teenage boy initially presented in a district hospital, with a swelling at the right side of his neck, without any significant clinical symptoms. Although full details of the work-up performed at the time are not available, he was diagnosed with a branchial cleft cyst and was offered surveillance with follow-up imaging. Eight years later, he visited our unit. Physical examination revealed a painless palpable well-defined mass () within the right carotid triangle with positive Fontaine and Kocher I signs []. There was no palpable lymphadenopathy. An ultrasound scan was performed depicting a solid mass of mixed echogenicity in the right carotid triangle echogenicity in the left carotid triangle. This was suspected to be neurogenic in origin because of its location. A digital subtraction angiography (DSA) () followed, which revealed a 60x35mm protruding mass in the right carotid bifurcation, causing local compressive effects and posterior displacement of the vessels. The patient was admitted in our unit in order to be treated surgically. During the operation a large CBP was identified as seen in . The tumor was classified as Shamblin II and was completely excised. Histopathology study showed a 3 cm carotid body paraganglioma with characteristic “zellballen” growth pattern and cell nests surrounded by prominent fibrovascular stroma, with no evidence of malignancy (). The patient had an unremarkable recovery and was discharged home on the second POD.\nThe surgical technique adopted in both patients consisted of an oblique incision along the sternal head of the left sternocleidomastoid muscle under general anesthesia. Our strategy was to expose, dissect, and isolate the proximal common carotid artery using a vascular tape. The ansa cervicalis was also exposed early in the operation. The carotid bifurcation was exposed in a caudocranial approach. The proximal external and the proximal internal carotid arteries were isolated and controlled with vessel loops. Di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old Caucasian woman was admitted to the Emergency Department of our Institution because of bloody diarrhoea – up to 10 bowel movements per day – during the last month, 3 weeks after quitting smoking. Physical examination showed no abnormalities but confirmed haematochezia on digital rectal examination. Colonoscopy showed continuous severe colonic inflammation with small ulcers from the anus to the descendent colon, classified as grade 3 in Mayo endoscopic sub-score and 3 points in Ulcerative Colitis Endoscopic Index of Severity (UCEIS); complete examination was not performed because of the risk of perforation. Empirical antibiotic treatment with ciprofloxacin and metronidazole, as well as oral and rectal mesalamine were started and partial symptomatic improvement was achieved. Venous thrombosis prophylaxis with subcutaneous enoxaparin, 40 mg per day, was started. At admittance, haemoglobin, white cell count, platelets, fibrinogen and C reactive protein (CRP) were within the reference range. Stool cultures were negative. Cytomegalovirus (CMV) infection was also ruled out in colonic biopsies (polymerase chain reaction – PCR – and, later, immunohistochemistry). As bloody diarrhoea persisted 48 h later, and histopathological examination of colonic biopsies showed crypt distortion, a mixed inflammatory infiltrate of the lamina propria and crypt abscesses suggesting the diagnosis of UC, intravenous methylprednisolone (1 mg per kg of weight, daily) was started. After 3 days of corticosteroids the patient achieved partial clinical response (6 bowel movements per day, Edinburgh index 2 points, CRP within the normal range); nevertheless, 2 weeks later infliximab therapy (5 mg/kg of weight) was started due to sustained clinical activity, with 10 bloody bowel movements per day and a progressive increase of CRP levels, up to 10 mg/dL. Three days after the first dose of infliximab, the patient presented a massive lower bleeding with haemodynamic instability and severe a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old female, nursing home resident, with a past medical history of type II diabetes mellitus, hypertension, cerebrovascular accident, anoxic brain injury with permanent percutaneous endoscopic gastrostomy (PEG) tube and tracheostomy to ventilator was noticed to have a high peak pressure on the ventilator on a routine check by the nursing home respiratory therapist. Suctioning was attempted but was unsuccessful. The tracheostomy tube was changed and during the process, increased resistance was felt. Soon thereafter it was noticed that blood was leaking from around the tracheostomy tube. Emergency medical services were called and the patient was brought to the emergency department. On arrival the patient was found to be hypertensive with a blood pressure of 160/74 mmHg, heart rate of 80 beats per minute, respiratory rate of 18 breaths per minute, O2 saturation was 100% on 100% FiO2 fraction of inspired oxygen (FiO2) on assist control-volume control + ventilator mode and a temperature of 37.8°C. On examination, the patient appeared to be generally edematous and was found to have crepitus on palpation starting at the forehead proceeding all the way down to the chest, abdomen, pelvis and upper thighs. In addition, her upper arms bilaterally also appeared swollen with crepitus present on palpation. Examination of the head and neck revealed a tracheostomy with tracheal tube in place with slightly pink secretions and what appeared to be dried blood on gauze surrounding the tube. On auscultation of the chest Hamman’s crunch, a crunching sound, synchronized with the heartbeat was present, as well as slightly decreased breath sounds at the right apex. Stat chest X-ray was performed which revealed extensive PM associated with subcutaneous emphysema in the neck and right chest wall (Figure ).\nThe patient was emergently assessed by an otolaryngologist and tracheoscopy was performed through the stoma with the tracheal tube in place. It was determined the tracheal tube wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman experienced a blunt neck trauma due to a bicycle accident. After a car collision car the impact with the windscreen wipers caused the injury. At the time, the patient was suffering from Graves’ disease, positive for anti-thyroid-stimulating hormone receptor antibodies, with a multinodular goiter and was receiving long-term medical therapy with carbimazole 5 mg per day. Two hours after the accident, the patient presented to the emergency department with painful swelling of the neck, inspiratory stridor and increasing hoarseness. The clinical examination revealed a palpable mass on the right anterior part of the neck. Emergency tracheal intubation was performed due to progressive breathlessness and dyspnea. Subsequently, a contrast-enhanced computed tomography revealed a laceration of the right thyroid lobe with surrounding hematoma and tracheal deviation to the contralateral side (Fig. ). Therefore, the patient underwent emergency neck exploration with a 4-cm Kocher incision followed by a right hemithyroidectomy. Intraoperatively, the dorsal aspect of the right lobe of the thyroid gland was found to be ruptured with active arterial bleeding from branches of the inferior thyroid artery. The recurrent laryngeal nerve was macroscopically identified and preserved. Because of the bleeding into the surrounding tissue, it was particularly difficult to definitely identify the parathyroid glands due to anatomical complexity in this case. Even the location of the upper parathyroid gland, normally identified on the posterior surface of the upper pole of the thyroid gland, was not obvious, due to disturbed surrounding tissue caused by the bleeding. Postoperatively, the patient was monitored in the intensive care unit for 32 h. The patient was extubated after a further six hours, and the subsequent postoperative course was uneventful. Hoarseness disappeared spontaneously after two days. The histopathological analysis confirmed a multinodular goiter. Laryngosco"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman without known comorbidities was transferred to our hospital due to fever and abnormal laboratory test findings. She had not taken any medications prior to the emergence of symptoms. She had climbed a mountain about two weeks prior to our hospital admission and had no memory of insect or tick bite. The patient was admitted to another hospital due to fever after 7 days of climbing. She had a fever with a maximum temperature of 39 °C, aggravating nausea, and vomiting. Abdominal CT revealed hepatosplenomegaly. Therefore, she was referred to our hospital seven days after the onset of symptoms. The patient was alert with a blood pressure of 90/60 mmHg, pulse of 84 beats/min, and body temperature of 37.6 °C on admission. Physical examination revealed no palpable lymph nodes, and there were mild macular rashes on the trunk and both thighs but no eschar. The patient stated that the skin lesions tended to improve 1–2 days before admission. Mild tenderness of the right upper quadrant of the abdomen was noted. She complained of febrile sensation, vomiting, and nausea. The initial complete blood count revealed leukopenia and thrombocytopenia. She had increased aspartate aminotransferase (AST), alanine transaminase, and lactate dehydrogenase (LDH) levels. The blood test findings are shown in .\nBased on the patient’s outdoor activity history and laboratory findings, an SFTSV infection or other tick-borne diseases were suspected. Since SFTSV infection and other tick-borne diseases cannot be differentiated based on clinical characteristics alone, and the relevant serological test results take time, ciprofloxacin (400 mg intravenously twice a day) and doxycycline (100 mg twice a day) were administered empirically while waiting for the test results (). The patient’s fever and vomiting gradually improved, and the white blood cell and platelet counts approached normal levels. Since the patient’s LDH remained elevated, she underwent 18F-FDG PET/CT on the eighth hospit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn April 2007, a 46-year-old woman was referred to the Department of Otorhinolaryngology, Seoul National University Hospital for evaluation and further treatment of bilateral huge cheek masses. The masses had grown intra-orally and filled the whole oral cavity, disturbing normal mastication so that the patient had lived on soft or fluid diet (). Although her dentist had recommended surgery 5 years earlier, she was reluctant of undergoing operation and had repeatedly delayed the surgery. Over the 5 years, the disease was aggravated and the size of the mass increased progressively with intra-oral bleeding occurring intermittently.\nImaging work-up including neck computed tomography (CT) scan and magnetic resonance imaging (MRI) was performed. Large bilateral masses showed strongly enhanced solid tumors originating from the mandible which resulted in expansile destruction and erosion of both sides of the mandilble (). These lesions extended from the body to the condyle of the mandible. Intra-oral mucosal deep tissue biopsy from the left side mass was conducted and it was reported as an inflamed granulation tissue with necrosis. Therefore, the initial diagnosis was presumed to be central giant cell granuloma. Incidentally detected thyroid nodules on the CT scan were studied with ultra-sonography guided fine needle aspiration (FNA) cytology and the results were simple benign nodules (). Though the cheek masses had locally destructive features, there was no evidence of malignancy. Due to the patient's hesitancy about having an operation, we initially tried intra-lesional triamcinolone injection rather than surgical resection. Intra-lesional steroid injection is the alternative treatment of central giant cell granuloma, especially in large lesions, which may compromise vital structures []. The patient was treated once a week with an injection of 40 mg of triamcinolone into both mandibular tumors. The triamcinolone injections were not effective except transient size reductio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-month-old female infant weighing 3050 g with Apgar score of 9 and 8 at 1 min and 5 min was referred to our centre to enter Home Parenteral Nutrition Program (HPN). The girl was born to a non-consanguineous Polish couple and delivered by spontaneous labour at 35 weeks of pregnancy. There were no records of genetic diseases in the family tree. During the ultrasound scan at 22 weeks, megacystis has been noticed in the fetal pelvis with bilateral pelvicalyceal dilatation. At 24 weeks gestation, fetal magnetic resonance imaging (MRI) was performed which revealed a large cystic mass with a maximum diameter of 8 cm and moderate bilateral hydronephrosis. Because of lower urinary tract obstruction, fetal vesico-amniotic shunt (VAS) was implanted at 31 weeks. At birth, there was abdomen distension and absence of intestinal sounds. A few hours after birth, the patient presented food intolerance and gradually developed respiratory distress. The infant has not passed stool for the first 24 hours. Because of these symptoms, intestinal obstruction was suspected. The nasogastric tube for decompression of gastrointestinal tract was inserted, and the central line was implanted to apply total parental nutrition (TPN). Abdominal radiography showed gastric distention and multiple dilated loops of small bowel (). Contrast study of upper gastrointestinal tract excluded the mechanical bowel obstruction. Microcolon was detected in the barium enema (). The infant underwent exploratory laparotomy on 2nd day of life, in which markedly enlarged intestinal loops extending to 20 cm from Bauhin's valve were discovered. A full-thickness biopsy was taken and ileostomy was performed.\nThe histological findings were nonspecific (smooth muscle cell vacuolization and insignificant disorders of cytoskeletal architecture). Alpha-smooth muscle actin (alpha-SMA) immunoreactivity was maintained. After surgery, the patient still presented oral feeding intolerance. Stoma has not passed intestinal content, a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old, male, from the urban environment, heavy smoker – 1 pack of cigarettes per day for 25 years, alcohol consumer, referred to Coltea Clinical Hospital, E.N.T. Department for dysphagia, odynophagia, left ear pain and the presence of a tumor mass of the neck, which he stated that appeared about 6 months prior to the examination, with a slow and progressive evolution. The patient is known to have high blood pressure, maximum value of 210 mmHg, under treatment, and without any other significant pathology.\nWhen performing the clinical exam we found an ulcerated tumor mass in the hypopharynx, referring to the left lateral wall of the pharynx and to the root of the tongue. The tumor process extended to the lateral region of the neck involving the submandibular gland, the levels II-V lymph nodes, large vessels of the neck and skin. Imaging studies confirmed the extension of the tumor process. The Doppler ultrasound examination showed a near to 0 blood flow through the external carotid artery and its branches. After performing a biopsy from the tumor under local anesthesia – invasive squamous cell carcinoma, we informed the patient about the choices of therapy and obtained his informed consent to perform the surgical intervention.\nWe performed a tracheostomy in order to ensure a maximum access to the oro and hypopharynx, radical neck dissection with the resection of the internal jugular vein, accessory spinal nerve, sternocleidomastoid muscle, entire fatty tissue from the clavicle to the base of the skull. In order to get the access to the entire tumor mass we needed to perform a lateral mandibulotomy (). The resection piece included the root of the tongue, lateral wall of the pharynx, the submandibular gland, lymph nodes levels II to Va and skin.\nThe pharynx was primarily closed with silk sutures and the continuity of the mandible was made by plates and screws osteosynthesis. The remaining defect was then closed with a pectoral musculocutaneous pedicle flap"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female presented complaining of recurrent right forearm pain for the preceding three months. The pain was felt predominantly in the volar aspect of the forearm running from the wrist to the elbow and was associated with parasthesia of the entire hand. Onset of the pain was always after exertion—she was a competitive rower and typically would experience the pain after intense rowing. She also noted slight swelling and a flexion contracture with ulnar deviation of the wrist. Following cessation of activity, the pain would subside over approximately 15 minutes and sensation return to normal. She had no medical history of note and no prior trauma to the upper limb.\nOn examination, the upper limb appeared of normal bulk compared to the contralateral side. Assessment of tone, power, and sensation of the right upper limb was normal. Radial and ulnar pulses were palpable at the wrist. There was no objective evidence of Thoracic Outlet Syndrome and cervical spine movements were normal. After using an indoor rowing machine, the symptoms were reproduced, the volar aspect of the right forearm tense and the wrist held in a flexed and ulnar deviated disposition ()—attempts to manually extend the wrist and digits was painful. Symptoms subsided gradually on cessation of rowing disappeared completely by 15 minutes.\nPlain radiographs of the elbow to the wrist were normal. Nerve conduction studies showed a borderline carpal tunnel lesion but ulnar nerve function was normal both before and after provocation with exercise. Electromyography of the forearm musculature did not show any underlying myotonic or myopathic disorder. Compartment pressure testing of the volar compartments confirmed a raised resting pressure of 20 mmHg. A diagnosis of chronic exertional compartment syndrome of the flexor aspect of the forearm was made and surgical decompression offered.\nA flexor compartment release was performed of the volar compartments via an incision ulnar to the midline on the vo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old young woman presented to the outpatient medicine department with the complaints of dry cough which was relentless for 1 month provisionally diagnosed as upper respiratory tract infection. On enquiry, the patient revealed that she had shortness of breath during cold seasons suggestive of bronchial asthma. She had no childhood illness indicating rheumatic heart disease. There was no significant past medical or surgical illness. She was married for two years but did not conceive yet. Her immunization history cannot be elicited as she could not remember them all. Her family members were in good health, and there was no worth mentioning illness that runs in the family. The patients' menstrual cycle was regular with an average menstrual flow. She was of a lower middle class socioeconomic status family. No family member had been suffering from any significant illness.\nGeneral examination revealed she was ill looking with mild tachypnea. Her heart rate was 90 beats per minute which was regular in rhythm; blood pressure was 80/60 mmHg; JVP was not raised. There was no anemia or edema. Her nasal mucosa was congested indicating upper airway infection.\nPrecordial examination showed normal apex beat in the left 5th intercostal space with little bit lateral displacement. There was palpable p2 with left parasternal heave but no palpable thrill. Intensity of the 1st heart sound was normal. The second heart sound was loud over the pulmonary area but not definitely splitted. There was an ejection systolic murmur over the pulmonary area with no radiation or respiratory variation.\nRespiratory system examination revealed a respiratory rate of 22 breaths per minute. There was no crepitation or rhonchi.\nAs our patient was being investigated for her illness, her chest X-ray revealed cardiomegaly with RV type apex, pulmonary conus was full and bulged, and right pulmonary artery was dilated (). ECG showed right bundle branch block with right axis deviation.\nSubsequently, her ec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old female walked into our clinic with intractable dizziness and nausea for 3 days. She was undergoing dialysis for her chronic renal failure caused by familial polycystic kidney disease. She had a history of neck clipping of unruptured left middle cerebral artery aneurysm some 13 years ago at another institution. Her GCS was E4V5M6 so WFNS grade was I. Head CT scan demonstrated small amount of SAH in the interhemispheric fissure []. CT angiography revealed 6 mm ACoA aneurysm, as well as complete clipping of left middle cerebral artery aneurysm []. Endovascular surgeons were reluctant from coiling because of wide neck of the aneurysm.\nOperation was performed via anterior interhemispheric approach. Dissection of interhemispheric fissure between rectus gyrus and genu of corpus callosum provided sufficient exposure of the ACoA aneurysm. During dissection, left olfactory nerve was missing and A1 segment of left ACA adhered to surrounding brain tissue, suggesting ACoA had been explored in the previous operation. The adhesion was more prominent around the aneurysm, and hypothalamic artery was encased in the aneurysmal wall with glue material []. Gentle and meticulous dissection was performed, but minor leak of blood occurred from the neck of the aneurysm adjacent to right A2. Any attempts for neck clipping only enlarged laceration of aneurysmal neck. Trapping of the aneurysm including the neck laceration was unavoidable to secure the aneurysm, with simultaneous revascularization of right A2 because right A1 was aplastic on initial CT angiography []. Temporary hemostasis of lacerated neck was obtained by compression with cottonoid under flow control for a few minutes. Back to A3 segment of ACA, A3-A3 side-to-side anastomosis was performed with bilateral A3 cross-clamping time 37 min []. The aneurysm, together with hypothalamic artery, was trapped with two aneurysmal clips []. Complete elimination of the aneurysm and reconstruction of right A2 segment of ACA was c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.\nIn the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().\nThe patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.\nA non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().\nAn ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n44-year-old man had a history of trauma and splenectomy dating back to 2008 due to a high fall accident injury. The patient came to our hospital for routine follow-up health check for trauma. During the interview with the doctor, the patient had complaints of fatigue, flu-like symptoms and occasionally had the sense of thoracalgia for about a week. During the physical examination, a well healed laparotomy scar measuring about 10 cm in the upper left abdomen was identified. No spleen was palpable when palpation of left costal region was conducted by the doctor. No other significant findings were identified. All laboratory findings were within normal range. Hematology and biochemistry tests were within normal range. All other laboratory findings were within normal range too. Pulmonary function tests and cardiovascular examination showed the normal state. Plain chest computed tomography (CT) with an attenuation value 52HU was performed. There were multiple nodules under the left upper lobe tongue segment, lower lobe basal segment subpleural and right diaphragmatic, partial fusion showed wavy changes with uniform density. There were clear boundary and enhanced scanning lesions, measuring up to 18 mm, suggesting suspicious for primary lung cancer. There were old fractures of the left side 9th and 10th ribs, and no right sided pulmonary lesions or mediastinal lymphadenopathy were seen on CT. Contrast-enhanced CT scans showed obvious enhancement in soft tissue masses (Fig. ).\nBased on CT imaging, the surgery of left thoracic exploration and lumpectomy of the chest wall was planned to relief symptom, remove masses. After discussed with patient. Via video-assisted thoracic surgery (VATS) was performed to remove the masses. During the operation, we found mass on the surface of the upper lobe of the left lung, and a large number of nodules that scattered on the surface of left lung surface, diaphragm and mediastinal pleura. The largest nodule was tough in texture, regular in s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old woman with a medical history of coronary artery disease, ischemic cardiomyopathy, carotid artery stenosis, renal artery stenosis, chronic kidney disease, hypertension, and hyperlipidemia presented to the ED with two months of right lower extremity pain and swelling. She stated that both symptoms had worsened to the point where she was having difficulty ambulating. The patient also related new symptoms of tingling in her right foot that had started today. She revealed that she had a lower extremity ultrasound done 11 days ago with the onset of these symptoms.\nHer initial vital signs were within normal limits. Her physical exam was remarkable for an enlarged, cold, discolored right lower extremity with calf tenderness and non-palpable or Dopplerable pulses in the foot. The vascular surgeon was consulted and recommended the patient be given a heparin bolus and placed on a heparin drip with a lower extremity venogram ordered for the morning. Meanwhile, a bilateral lower extremity ultrasound was done showing right-sided DVTs (Figure -). CT of the abdomen and pelvis was done without contrast due to the patient's chronic kidney disease. A ventilation perfusion scan (V/Q) was ordered and care was transferred to the inpatient team.\nAfter the patient was admitted to the medical ward with a heparin drip in place, she underwent a ventilation-perfusion (V/Q) scan which showed a high probability of a PE (Figure ). CT abdomen without contrast on admission showed only bilateral hydronephrosis secondary to enlarged para-aortic lymph nodes.\nDuring her hospitalization, she was maintained on the heparin drip for the management of her right-sided DVT. However, despite the heparin drip and maintenance of an appropriate partial thromboplastin time, her right leg pain and swelling did not improve. Vascular surgery took her to undergo a catheter-directed thrombolysis and angioplasty of right leg, after which her symptoms improved.\nShe underwent a left para-aortic lymph node bi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female was seen in the emergency department regarding bilateral knee pain after a motor vehicle collision. As she was restrained, she likely experienced a sudden flexion force across the knees. Plain film radiography demonstrated no abnormalities and she was discharged home. On follow-up, she complained of mild swelling with clicking of her knees which caused her pain. She denied any locking sensation of her knees. Prior to the accident, she had no complaints of knee pain.\nPlain film radiography was repeated in office and demonstrated no pathology.\nThe patient's physical exam revealed no visual deformity. She ambulated with a slightly antalgic gait. There were mild effusions present bilaterally. Passive range of motion was limited secondary to pain. There was a five-degree extension lag present on the right knee while the left knee achieved full extension. Flexion was symmetric to 135 degrees with pain at the extreme. She complained of pain with medial joint line compression and McMurray's testing was positive medially (both audible clicking and pain) bilaterally. Lachman test was stable and symmetric bilaterally. There was no posterior lag. Valgus and varus stressing was normal. Further clinical knee testing was negative. She admitted that her right knee was more symptomatic than the left one.\nMRI revealed findings consistent with bilateral medial meniscus bucket handle type tears. There was no evidence of abnormal meniscal shape. All ligaments, including her ACLs, were intact bilaterally. No further pathology was noted.\nAttention was paid to the right knee first, as the patient had limited passive range of motion and was where she reported the most pain. Traditional anteromedial and anterolateral portals were utilized. On initial visualization, no tear was noted of the medial meniscus. When the probe was introduced, however, there was a clear medial meniscus bucket handle type tear. The tear appeared in the red-white zone of the meniscus as the poste"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male presented after a motor vehicle rollover accident. He was taken to the emergency where standard X-ray revealed odontoid fracture. He was transferred to the tertiary care center for further management in a rigid cervical collar. Physical examination revealed significant tenderness in the upper cervical spine. He had restricted neck flexion up to 30 degrees and extended to neutral. He had minimal lateral bending motion and refused to turn head from side to side because of pain. His neurological examination was normal. Anteroposterior (AP), lateral and open mouth odontoid films were obtained followed by computed tomography (CT) scan. CT scan confirmed the diagnosis of Type II odontoid fracture with a gap of 2.5 mm and anterior displacement of the dens by 4 mm. The fracture angulation was 27 degrees with an associated anterior and posterior arch of atlas fracture leading to unstable left lateral mass of C1 (). Magnetic resonance imaging (MRI) showed intact transverse ligament. Possible treatment options were nonsurgical management in a halo vest as well as surgical management. Both were discussed with the patient. The patient denied a conservative treatment with halo vest because of the long duration of treatment and high incidence of associated complications.\nSince the fracture had angulation of 27 degrees, the surgeon felt that it would be difficult to get appropriate trajectory for screw fixation and in turn adequate reduction. Hence, anterior odontoid screw fixation was not considered. Considering the patient's young age and the limitations of C1-C2 fusion including significant loss of cervical rotation, temporary internal fixation with a lateral mass fixation of C1 and pedicle fixation of C2 without fusion was planned. The intention was to remove the internal fixation after radiological healing of odontoid fracture to maintain the rotational motion of the cervical spine. As a part of the preoperative work-up, CT angiogram was done which showed t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 59-year-old man with an unremarkable medical history who worked as a civil engineer. During an accident at work, he got buried deeply under a large amount of sand, collapsed, and then transported to the emergency department of our medical center (day 1). Computed tomography (CT) revealed bilateral pubic and sciatic fractures, anterior partial separation of the right sacroiliac joint, and left sacral fracture (Denis zone II, a) accompanied by a 15-mm vertical dislocation (b). Additionally, a giant bone fragment (25 × 5 mm2) was present in the spinal canal at the S1 level (c, d). He had numbness at the left S2 region but no complaints related to motor impairments or bladder and rectal dysfunctions. He was, therefore, diagnosed with S2 nerve root compression caused by the bone fragment in the spinal canal and thus patient required immediate removal of the bone fragment and decompression to improve the numbness of S2 root maximally. He underwent surgery on day 2.\nFirst, a robust minimally invasive anterior fixation was performed by INFIX in the supine position in a time-effective approach to prevent further deterioration of the S2 nerve root compression when changing position. After INFIX, he was moved to a prone position. Then, decompression was performed by laminectomy to release the S2 nerve root, and the large bone fragment was removed (a). Finally, sacral vertical reduction and strong posterior fixation were performed by the CSF method (b).\nThe operative time was 90 min on INFIX and 237 min on laminectomy and CSF. The estimated blood loss was 400 mL. Postoperative CT proved that vertical dislocation of the sacral fracture had reduced to 7.5 mm (c). Sensory numbness was alleviated; however, the patient experienced discomfort and pain due to protrusion of the anterior screw and rod, so the anterior implant was removed 3 months post-surgery. The posterior implant was removed within"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man was assigned in our department with a 2 months history of stereotypic vertigo attacks. The symptoms appeared immediately after a head concussion. The initial CT scan of the head at the emergency department was without pathological findings. Due to persistent symptoms, a cranial MRI scan of the head was performed, also with normal findings. The attacks were triggered by a specific change in head position, namely when lying down into a supine position, or when looking upwards by reclining his head in sitting or standing position. He reported having a spinning sensation and a severely blurred vision during the attacks and an increasing feeling of nausea with repeated attacks. The patient was otherwise in full health and worked in a bakery. Due to vertigo, his general practitioner put him on permanent sick leave after the accident.\nApart from positioning maneuvers, the clinical neurotological, extended neurological, and ENT examination showed normal findings throughout. The video head impulse tests for all 6 semicircular canals showed normal gain values (>0.8 for horizontal and >0.7 for LARP and RALP planes) and no suspicious catch-up saccade patterns. The dynamic visual acuity test was also normal to both sides. Cervical vestibular evoked myogenic potentials showed a normal, symmetric reflex threshold of 90 dB SPL bilaterally. Ocular cervical vestibular evoked myogenic potential showed normal reflexes bilaterally with a 27% asymmetry ratio to the left side, which was interpreted as normal (cutoff 35%). Normal cyclorotation of the eyes was found in fundus photography. Video nystagmography showed normal ocular motion in smooth pursuit and saccade testing, absent head-shaking nystagmus, and a strong reaction to caloric ear irrigation on both sides without pathological asymmetry. The testing of the subjective visual vertical showed a slight tilt (2.2°) toward the left side (normal range <1.9°). Pure tone audiometry was normal and did not suggest any damag"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man, referred to the orthopaedic outpatients department in July 1997, presented with a painful right hip of several months' duration. Examination revealed a grossly reduced range of movement in the right hip. His previous medical history included gout, controlled by 300 mg allopurinol. Radiographs of the pelvis revealed severe osteoarthritic changes of the right hip and a normal left hip.\nHe was kept under review for one year, during which his pain increased and in August 1998 he underwent a right Exeter cemented total hip replacement via a posterior approach. Immediate postoperative recovery until hospital discharge was uneventful, with radiographs of the hip showing no problems. At a routine 6-week follow-up it was noted that although pain free he was making slow progress. There was no leg length discrepancy and the range of movement of the right hip was good, with 100° of flexion, 30° of abduction, 15° of internal rotation and 20° of external rotation. However, the muscular strength was reduced in comparison with his left hip and he had an unsteady gait. He was referred to a physiotherapist and made good progress with improvement in hip strength. Follow-up at one year revealed him to be making excellent progress, and at two years post-operatively he was discharged, entirely symptom free and very happy with his surgical result.\nThe patient did not see his general practitioner about hip pain until he next presented in November 2006 complaining of pain in the left groin. An anterioposterior radiograph of the pelvis revealed degenerative changes in the left hip and a dislocated right total hip replacement (Figure ). The dislocated femoral component had formed a neoacetabulum within the ilium, in which it was freely articulating (Figures and ). He remained pain free on this side, had 5 cm of true leg length shortening, with a good range of movement, and was very pleased with his hip replacement. He was later placed on the waiting list for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis was a case report of a 20-year-old male patient, with weighing 56 kg, was admitted to our hospital with a painless huge, tense swelling of around 12 cm × 10 cm size in the floor of the mouth. The mass was gradually increasing in size and extending to the submental and submandibular region occupying the upper anterior part of the neck []. He had a history of discomfort while eating and difficulty in deglutition, speech and sleep for 6 months. The intraoral part of the mass was extending more toward the left, deviating the tongue toward right and making the uvula and soft palate invisible thus graded as Mallampati IV [].\nThe general and systemic examinations revealed no abnormality. On evaluation of airway, the mouth opening was three fingers, thyromental distance could not be assessed due to the position of the swelling, Mallampati was graded IV[] and there was slight restriction of neck movement. Nasal patency was checked using cotton wisp.[]\nRoutine investigations were within normal limit including bleeding time and coagulation time. Indirect laryngoscopy, done by ear, nose and throat surgeon, was found to be normal. Lateral X-ray neck showed soft-tissue shadow at upper part of the neck and computed tomography scan of the neck showed a cystic lesion with septae not involving any part of trachea or larynx []. Excision of ranula was planned under general anesthesia after awake nasal intubation as the first line of airway management and retrograde intubation was thought as the second line of management, keeping tracheostomy as back up.\nPatient was explained and reassured about the technique of anesthesia. He was kept fasting for overnight. Premedication was given with glycopyrrolate, ranitidine and ondansetron after intravenous cannulation in the operating room.\nPatient was supine in sniffing position and standard American Society of Anesthesiologists monitors were attached. Transmucosal topical anesthesia of nasal passages was performed by gentle insertion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male presented with sudden visual disturbance that started one month prior to presentation. The patient had been having problems with blurred vision, loss of peripheral vision, and floaters in his left eye only. He was specific in that his symptoms were only occurring out of his left eye. He stated that his symptoms started with his central vision loss and then he could not see out of the peripheral part of his vision. He did have a history of ocular migraines, but these symptoms were different than his usual migraines. These new symptoms were persistent and not intermittent. In addition, he had just had a full eye examination by a neuro-ophthalmologist the week before and no eye abnormalities were found. The patient denied any events that provoked or alleviated the complaint. There was no significant medical and social history related to his chief complaint. He worked as a construction worker and reported a significant amount of stress in his life. Magnetic resonance imaging (MRI) of the brain and carotid ultrasound were recently done and were reported as normal.\nPast medical history included a history of lumbar back pain, gastroesophageal reflux, allergic rhinitis, and depression. He had a minor surgery as a child for his knees and a broken ankle. He was married, non-smoker, and worked full time as a construction worker. Family history was otherwise unremarkable. He had no recent foreign travel history. Review of systems was otherwise normal.\nOn physical examination, his vitals were normal. He was awake, alert, and oriented, and his mental status was normal. He had a normal eye examination except that he had a monocular left-sided inferior visual field defect (confirmed by formal visual field testing). Right eye examination was normal including visual eye fields. The remainder of the neurological and physical examination was normal.\nInitially, as the eye examination was normal and the symptoms were monocular, an assumption was made that the symptoms"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male was admitted to the clinic with numb upper limbs, feelings of weakness and an unstable gait that had been apparent for more than one month. The patient complained of a sense of strapping in his chest and an inability to grip with his hands or hold objects without dropping them. Furthermore, the patient had weak fine finger movements, such as writing, and felt his walking was like walking on cotton. Physical examination revealed normal neck and bilateral shrug activities, Grade IV flexion and extension strength of the elbow muscle, numbness in the bilateral forearms and hands and weak fist-clenching abilities. The bilateral Hoffmann sign was (+), the lower extremity muscle strength was of Grade IV, the muscle tension was high and the tendon hyperreflexia was (++++). The cervical MRI revealed high signal changes at the C3–4 level in the spinal cord and slipped discs were observed at C3–4 and C4–5 ().\nThe MRI examination indicated that the compression at the C3–4 level of the patient’s spinal cord was of Level 2, according to the Nagata grading, and T2W MRI revealed high signal changes within the same level of the spinal cord. In addition, the patient exhibited symptoms typical of motor neuron injury in CSM. Laboratory tests measured that the level of serum VB12 was 182 pg/l, which was below the normal range (211–946 pg/l). Although the spinal cord compression was not serious, there were high signal changes in the intramedullary spinal cord that were apparent with T2W MRI, and the clinical manifestations were typical of spinal cord injury. The VB12 deficiency of the patient may have been the factor leading to the spinal cord damage.\nSimilar to the patient in case one, the patient in the present case underwent anterior decompression-fusion and internal fixation and, following three months of VB12 replacement therapy, the balance of the patient when walking"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man with 1-year history of a retractable mass in the right groin arrived at our emergency department with a 5-day history of progressively aggravated right inguinal pain associated with the appearance of an incarcerated right femoral hernia. He denied abdominal pain and distension, nausea and vomiting, fever, and any other signs of bowel obstruction. He had no other relevant medical history. His vital signs were normal, and his body mass index was 18.0 kg/m2. Physical examination revealed a non-reducible tender lump in the right groin below the level of the right inguinal ligament. The lump was approximately 6 × 4 cm in size, warm, and erythematous. Routine blood examination revealed a white cell count of 8.62 × 109/L and neutrophilic granulocyte percentage of 75.7%. A computed tomography scan revealed a quasi-circular hypodense lesion of approximately 6.0 × 4.0 × 4.0 cm located medial to the right femoral vessels and connected to the abdominal intestines (–). There were no signs of intestinal obstruction.\nThe patient was preoperatively diagnosed with a right incarcerated inguinal hernia and taken to the operating room for surgery under general anesthesia after providing written consent for treatment. Preoperative prophylactic antibiotics were administered. An oblique incision was made above the inguinal ligament in the right groin, and an anterior approach was performed. Dissection in layers revealed an incarcerated right femoral hernia under the inguinal ligament, and the hernia could not be reduced from below. The peritoneum was dissected through Hesselbach’s triangle, revealing a non-reducible appendix in the femoral canal without signs of peritonitis. The tip of the appendix was purulent and swollen. After yellow-white purulent fluid was extracted by fine needle puncture from the hernia sac, the tip of the appendix was still unable to be reduced because the femoral ring was narrow and the tip of the appendix was purulent and swollen. We cut off th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 32-year old woman with a one-year history episodes of cholecystitis treated conservatively. She did not have any other disease history. After an abdominal magnetic resonance imaging that confirmed multiple gallbladder stones (Fig. a), an elective LC was performed without intra-operative complications. The recovery was uneventful and the patient was discharged two days after operation. On the second day after discharge, the patient developed severe right upper abdominal pain and she was sent to our emergency department at 8:30 pm. At arrival, her heart rate was 110 bpm and the blood pressure was 80/55 mmHg. The hemoglobin dropped to 86 g/l from 127 g/l. The CT scan showed a 10.9 × 12.5 × 6.6 cm ISH in the right liver without obvious free fluid in abdominal cavity (Fig. b). Two hours after fluid resuscitation including 2 U red blood cell, the hemoglobin further declined to 78 g/l and the hemodynamics remained unstable. The abdominal pain was not relieved, after intravenous analgesics. A Doppler ultrasound was performed, two hours later and it found the hematoma had increased in size. Active intrahepatic bleeding was suspected. We called radiologist for consultation, however, the interventional angiography and embolization was not available at mid night. We explained the potential risk of sudden rupture of hematoma during conservative methods which may cause sudden death, to the patient and her relatives. After careful consideration of the continuous decline of hemoglobin, unstable hemodynamics after fluid resuscitation, we explained our surgical plan to the patient and her relative. We planned to perform laparoscopic exploration at first, if the hematoma continued to expand, we would evacuate or drain it, if not, we would put a drainage tube under liver which could serve as an early warning of rupture. The patient requested surgical method to reduce the risk of sudden death. Therefore, an emergency laparoscopic exploration was performed under general"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-year-old girl weighing 9.5 kg was referred to department of palliative care in the month of September ‘08 with the diagnosis of neuroblastoma stage IV and disseminated systemic disease. The child presented with proptosis of right eye with periorbital ecchymosis and secondary deposits over scalp. She had developed paraparesis [secondary to lumbar mass]. There was no role for oncological intervention at the time of reference to palliative care. On presentation to palliative care department, child was crying incessantly, had no relief with ibuprofen syrup and was started on oral morphine solution 1 mg 8 hourly with nimesulide syrup 5 ml BD. After 24 hrs she had taken 4 prn doses besides three regular doses. The parents had to carry the child on the shoulders and walk around the ward round the clock. She could not be made to sleep on the bed. By 36 hrs she was titrated to receive 2 mg 4th hrly along with nimesulide syrup. Constipation was managed with lactulose syrup 5 ml on alternate days. She had no other side effects. She was comfortable, sedated but arousable. Parents were counseled and had accepted the prognosis well. They wanted pain relief and comfort for the child. They were taught eye care and dressing for the scalp metastases. She was discharged after 72 hrs and was on regular follow up every fortnight till death in the second week of December.\nThe morphine requirement escalated as follows. On discharge 2 mg 4th hrly with prn doses. On first visit it was increased to 5 mg 4th hrly. At second follow up it was increased to 7.5 mg 4th hrly. At the subsequent visit, it was increased to 10 mg 4th hrly with prn doses till death. Parents returned the remaining oral morphine solution to the department after the death of the child and reported that child was comfortable, feeding, and sleeping well until death"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old male patient came to the hospital with multiple traumatic brain injuries caused by a motorcycle accident. He had a history of diabetes and asthma, for which he had been pharmacologically treated for several years. He also had a history of open surgery to treat peritonitis 3 years before. Upon arrival at the hospital, he was in a lethargic state (Glasgow coma scale; E3V5M5), with a loss of direct and indirect light reflexes due to damage to the right optic nerve. Skull X-ray and cranial computed tomography (CT) showed comminuted fractures of the skull and multiple areas around the skull base, a Le Fort type II fracture of the facial bones, multiple comminuted fractures of the nose and around the orbit, and a small amount of pneumocephalus in the anterior recess (). Plastic surgeons decided to delay operating on the facial fractures because of severe edema of the face and orbit, and the patient was treated conservatively at the bedside. On day 8 following the trauma, the patient complained of severe headache and nausea, and CT performed on day 8 revealed a large tension pneumocephalus with a tented configuration and noticeably enlarged shadows of air compressing both sides of the frontal lobe (). As an emergency treatment, a rupture of the dura mater in the area of the right anterior cranial fossa was sutured using a subfrontal approach, and fixation surgery was performed on fragments of the comminuted fractures. Four days later, open reduction and fixation surgery were performed on the multiple facial fractures in the department of plastic surgery. On cranial CT performed 2 weeks postsurgery, pneumocephalus was no longer observed (). Subsequently, the patient did not have any specific abnormal symptoms and was discharged in a favorable condition. Two months after surgery for tension pneumocephalus, however, the patient returned to the hospital with primary complaints of memory loss, problems in walking, and urinary tract dysfunction. On cranial CT taken"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old male with a history of Tetralogy of Fallot (TOF) repair (with Dacron Patch over a large ventricular septal defect (VSD)) was admitted with complaints of fever and weight loss for 2 months and left sided abdominal pain since 1 week. He was recently admitted with similar complaints to another hospital where he was found to have a right sided pneumonia and was being treated with intravenous ceftriaxone. Later, suspecting infective endocarditis, gentamicin was added but as the patient was still having persistent fevers of 40°C, he was referred to our hospital. On examination, the patient was of lean built with grade IV clubbing without cyanosis, and there were no peripheral stigmata of infective endocarditis. He had a loud pansystolic murmur on the left sternal edge and had tenderness on palpation of the left upper abdomen. His initial investigations showed a high white blood cell count and C-reactive protein (CRP) (). A chest X-ray showed left mid and right lower lung zone infiltrates, and an ultrasound of the upper abdomen showed an ill-defined splenic lesion without internal vascularity suggesting either an abscess or infarct. Three sets of blood cultures were subsequently negative. Echocardiogram showed vegetation on the VSD patch along with dehiscence, a large VSD, and moderate right ventricular outflow obstruction. A CT abdomen with contrast was done which showed multiple liver, splenic, and lung abscesses with infarcted left kidney and thrombus at the bifurcation of the aorta secondary to the septic embolic phenomenon. Cardiothoracic surgery consultation was sought, and the patient underwent a redo-sternotomy and removal of vegetations from right ventricular outflow tract site, removal of Dacron Patch, and complete repair of TOF. Postoperative echocardiogram did not show any residual VSD or vegetation, only mild left ventricular dysfunction and moderately reduced right ventricle function was seen. The vegetation removed from right outflow tract and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 15-year-old male had experienced symptoms for 3 weeks prior to admission, which were initially limited to persistent bilateral frontal headaches. Two weeks before presentation, he began to complain of peripheral vision loss in his left eye, which at one point became bilateral then returned again to just left-sided visual field deficits. His symptoms again worsened in the 4 days leading up to admission, when he began to complain of increased headache severity, along with new ataxia, left-sided hemiparesthesias, and worsening vision loss. His speech became rambling and incoherent, and he was generally sleepy. On the day he was admitted, all of his symptoms were at their peak severity.\nUpon admission, the patient was sleepy but alert and oriented. His eye examination revealed decreased peripheral vision bilaterally and a lack of convergence. He reported left-sided facial numbness, and he demonstrated difficulty with finger-nose pointing and heel-to-shin on his left side. Strength was decreased in the left upper and lower extremities. Magnetic resonance imaging (MRI) revealed multiple areas of ischemic infarction throughout the posterior circulation of the brain. The lesions were seen in the left lobe of the cerebellum, the right and left occipital lobes, and thalamus bilaterally. They appeared to be of various ages, which suggested a stepwise and stuttering course of infarction. Selected MRI images are presented in . The MRI also revealed an abnormal bony process off the left occipital condyle that appeared to be in contact with a small left vertebral artery. It was felt that the bony spicule was likely traumatizing the left vertebral artery resulting in emboli showering to areas of the brain in the posterior circulation and leading to infarctions. The MRI findings prompted magnetic resonance vascular studies with 3-dimensional reconstruction. These images showing the left vertebral artery and the occipital bony spicule are presented as . Echocardiogram and coagul"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn eighteen-year-old male patient was brought to our emergency department five hours after an alleged history of suicidal attempt with gunshot under the chin. He was presented with a burst open face and no recognizable structures on the face, except for the eyes. He was uncooperative and drowsy. His arterial blood pressure was 80/60 mm Hg and pulse rate was 124/min. His respiratory rate was 26/min and was slightly distressed. He was unable to lie supine as the shredded structures tended to fall back; causing airway obstruction and blood trickled into the oropharynx causing him considerable distress.\nAfter initial resuscitation in emergency department with intravenous fluids (colloid and crystalloids) and blood transfusion patient was stabilized and suctioning of the blood from the upper airway, a closer examination of the face was done. There was comminuted fracture of mandible, maxilla, and nasal bones. Tongue, hard palate, and nasal structures were not recognizable []. Three loose teeth were seen embedded in the lower half of the face. The eyes were spared and his vision was unimpaired. Cerebrospinal fluid leak could not be made out because of the presence of blood. The expired gases had an exit near the root of nasal structure, which could be made out by the movement of cotton strands and no foreign body was present. The neck was not injured. Nervous system examination, as far as could be elicited, was normal with no cranial nerve damage or sensory and motor weakness. On auscultation, the breath sounds were normal with no added sounds, suggesting no aspiration of blood into trachea. Rest of the systemic examination was also normal. Chest radiograph was normal and no foreign body was present. He was scheduled to undergo emergency tracheostomy for airway management, debridement, and closure of facial laceration under general anaesthesia.[]\nThe patient was shifted to the operating room in the sitting position. We planned for tracheal intubation under sedation using"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old African American man with a past medical history of herpes simplex virus (HSV) infection presented to the emergency department with a chief complaint of right knee pain and swelling of a couple of weeks. The symptoms began shortly after the patient returned from his trip to Minnesota where he was diagnosed with gonococcal urethritis by urine polymerase chain reaction (PCR) at a local emergency department. He had initially presented with a thick white urethral discharge and had been treated with one dose of cefixime 400 mg and doxycycline 100 mg twice a day for seven days. The patient returned to Connecticut and presumably finished his antibiotics treatment.\nOver the next two weeks, the patient developed right knee pain and swelling and sought care in an outside emergency room. He was noted to have bilateral conjunctival injection in addition to right knee synovitis. He was given ibuprofen as well as erythromycin ophthalmic ointment. The patient returned the following day to the same emergency room due to minimal relief of his knee pain and this time was given prednisone taper for five days starting with 50 mg daily. Six days later, he presented to our emergency department with ongoing right knee pain.\nUpon presentation, the patient also endorsed complaints of right ankle pain and swelling as well as left lateral hip pain. He had also complained of open sores on his penis, which per patient felt very similar to his prior HSV outbreaks. On further questioning, he noted feeling febrile but denied fatigue, weight loss, eye pain or redness, vision changes, rhinitis, ear discharge, chest pain, shortness of breath, abdominal discomfort, nausea, vomiting, diarrhea, dysuria or urethral discharge. Patient admitted to smoking about two to three cigarettes a day and drinking alcohol occasionally but denied use of illicit drugs. He has had multiple sexual partners over the past six months and did not use protection.\nOn physical examination, he was febrile (102.9°F)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 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.\nThe 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 ().\nPercutaneous 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.\nThe 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 ().\nMicroscopic 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"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old woman with no medical history was admitted to our intensive care unit (ICU) a few hours after a longboard fall without initial loss of consciousness or head trauma. The patient was not able to walk and she had to be transported to find help. When the medical team arrived, she was conscious, Glasgow coma scale (GCS) of 15, without hemodynamic or respiratory instability and with a left femur fracture. During the medical transport, she received analgesics medications and immobilization after the reduction of the fracture. The initial body CT scanner, performed 3 hours after the trauma, found a left femur fracture and an anterior left pneumothorax, without cerebral lesions.\nShe presented secondarily a neurologic status impairment with a GCS of 11, initially attributed to an excess of analgesic therapy. Anyway, she was operated with a left femoral nailing during which a prolongated hypotension without hypovolemia or other obvious causes occurred. At the end of the surgery, 7 hours after the initial injury a new brain scan was performed. It showed the appearance of a cerebral swelling ().\nPostoperatively, she was admitted to the ICU because of consciousness disorders requiring a drug induced coma to permit a mechanical ventilation. A cerebral fat embolism was rapidly suspected. Despite a hemodynamic stability and a normality of the PaCO2, the transcranial Doppler ultrasound found a bilateral high pulsatility index at 2.2 and low end-diastolic flow velocity below 20 cm/s. These Doppler profiles led us to suspect an intracranial hypertension. A new brain CT scan, performed 16 hours after the trauma, confirmed a diffuse major cerebral edema. No other organ dysfunctions, rash, or petechiae were noticed.\nThe patient was managed as a severe brain injury. An intracranial pressure catheter was inserted and found a very high intracranial pressure (ICP) of 75 mmHg. Despite a maximal medical treatment including osmotherapy, hypothermia, barbiturate sedation, and use of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old female patient presented with a painful right breast in a previously implant based right breast reconstruction for correction of Poland syndrome [].\nClinical examination revealed hypoplasia of the right breast, absence of the right pectoralis major muscle, ipsilateral upper limb anomalies and pectus excavatum chest wall deformity without cardiac or respiratory impairment []. A Baker III capsular contracture was observed in the right reconstructed breast and a volume deficit over the inner and lower poles, compared with the left side, was also noted.\nThe patient was seeking treatment of the painful breast and aesthetic improvement of both the breast symmetry and the sternal depression. CT angiography imaging of the chest and abdomen showed a 2A1 pectus excavatum chest wall deformity according to Park's classification [], as well as a hypoplastic appearance and a substernal displacement of the internal mammary vessels. A free DIEP flap was considered for reconstruction.\nAfter the implant and capsule removal, a new subglandular pocket was prepared, extending from the mid-axillary line to the left border of the sternum and from the manubrium to the xiphoid process. Thoracodorsal artery and vein were prepared to accommodate the flap. At the same time a pre-shaped DIEP flap based on the size of the contralateral breast was raised and anastomosed to the thoracodorsal vessels []. Almost the whole flap was de-epithelialised, sutures were placed to maintain the pre-shaped breast mound and buried into the prepared skin pocket to reconstruct the breast, providing both breast projection and pendulous appearance, and also forming the anterior axillary line in the area of the pectoralis major tendon and filling the depressed chest and sternum area. A small 2 cm × 1 cm skin island was left intact and placed at the inframammary fold for flap monitoring. Nylon bolster sutures were placed through the skin to the adipose tissue of the flap and remained for 2 weeks to secu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man visited the emergency department of our hospital due to sudden paraplegia of both lower extremities caused immediately after slip down. On presentation to the department, both his lower limbs were observed to be almost paralyzed, with a motor grade of 2 or lower in both limbs. This paralysis showed a gradual aggravation. The patient had a history of renal cell carcinoma diagnosed 7 years prior, and achieved remission without any recurrence after total nephrectomy and adjuvant chemotherapy. He was also diagnosed with papillary thyroid carcinoma 5 years ago, and yet again achieved remission after surgical treatment. The patient signed an informed consent statement, and the study was approved by the Institutional Review Board of the Yeungnam University Medical Center.\nThe plain radiograph revealed the collapse of the T12 vertebral body. CT showed an acute burst fracture at the T12 vertebral body with an osteolytic mass-like lesion within the vertebral body and pedicle, causing severe encroachment of the spinal canal (Fig. ). Magnetic resonance imaging (MRI) revealed a bulging posterior cortex, with an acute fracture of the vertebral body and severe compression of the spinal cord (Fig. ). Considering his medical history and the MRI findings, a pathologic fracture with a tumorous condition was suspected. Therefore, the evaluation of the malignant potential and metastasis in the remote area was necessary. Hence, 18FDG PET/CT was performed, and 18FDG uptake at the T12 level was measured. A maximum standardized uptake value (maxSUV) of 1.7 was noted, with a central FDG defect on the vertebral body (Fig. ); this was interpreted as a benign fracture by a senior radiologist. Additionally, there was no positive uptake in the other body parts on PET/CT. Although there was a discrepancy between the interpretation of the spine fracture lesion on MRI and PET/CT, the patient required emergent surgical treatment owing to acute paraplegia caused by spinal cord compre"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.\nIn the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().\nThe patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.\nA non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().\nAn ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old caucasian male with an unknown past medical history presented to the Bayfront Hospital ED in St. Petersburg, Florida, in early November. The average outside temperature that night was in the mid to upper 60s. The patient was initially found by local police officers lying unconscious in a ditch next to his bicycle. When EMS arrived on scene the patient was cold, unresponsive, GCS 3, covered in ants and without any other obvious signs of skeletal or traumatic injury. The patient was fully immobilized in a cervical collar and on a backboard prior to transport to the ED and was intubated secondary to his low GCS. The patient's vitals at the time showed sinus bradycardia at a rate of 30-40s, palpable pulse but an unobtainable blood pressure on multiple attempts.\nAt 08:22 the patient arrived at the ED and upon transfer to the trauma bed was noted to be in ventricular fibrillation. At that time AED pads were attached and advanced cardiac life support (ACLS) protocol was initiated. Trauma protocol labs were sent which consisted of CBC, CMP, serum cortisol, serum ETOH, amylase, TSH, cardiac enzymes, and a coagulation profile.\nDuring the resuscitation the emergency room physician and trauma surgeon noted that the patient was very cold to the touch. A rectal temperature was performed but the temperature did not register. Per trauma protocol, the patient was being given warm IV fluids as well as warm humidified air via mechanical ventilation. It was not until 09:06 that the patient's temperature was accurately recorded to be 24.9°C (76.9°F). At approximately 09:22 the patient had been undergoing ACLS protocol for one hour and had been defibrillated 13 times and given five rounds of epinephrine, two rounds of atropine, and two rounds of amiodarone. With the patient still in ventricular fibrillation, it was decided to continue cardiopulmonary resuscitation with chest compressions"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old female, G1P1, was hospitalized in The First Affiliated Hospital of Guangxi Chinese Medicine University with a perianal mass found more than 4 years ago. The patient denied contraceptive use, injury, obvious pain, chills, or fever, and change in urine or stool. At the local hospital in 2013, a perianal incision and drainage procedure was performed on the diagnosed perianal abscess (the specific process was unknown). The postoperative incision had healed and the mass had decreased in size. The mass increased during a 2015 pregnancy. Postpartum the patient used no contraceptives, had no injury, pain or other symptoms; the untreated mass was smaller after childbirth. With the mass now larger than that in 2015, the patient presented to our hospital in 2017 for treatment. The patient had a history of broad bean disease and a past caesarean section. The patient had no family history of genetic atypical leiomyoma. The diagnosis was a perianal subcutaneous mass (nature to be investigated). The patient was signed share her perspective or experience consent for treatment and surgery, and since this article belongs to the clinical retrospective study, an ethical approval was not required.\nThe 5 cm × 4 cm × 4 cm sized mass was located on the left side of the anus and vagina; it was firm upon palpation, had distinct boundaries, was approximately 1.5 cm from the edge of the anus and vagina, was fixed and nontender. On rectal examination, the rectal mucosa was smooth and, similar to the mass in the intestinal wall, was extremely difficult to palpate the pole.\nThe magnetic resonance imaging (MRI) scan revealed: (1) an occupying lesion in the left perineum; the specific process was unknown. A 4.1 cm × 5.2 cm × 4.9 cm sized round mass was observed on the left side of the circumference (unclear if this was a fibrous tumor, tendon sheath giant cell tumor,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old female with a known history of GT presented to the Emergency Department (ED) with a chief complaint of HMB. She was diagnosed with GT in infancy in setting of extensive bruising, recurrent mucosal bleeding, and persistent gastrointestinal bleeding. Prior to menarche, she had recurrent episodes of epistaxis and an episode of deep tissue hematoma that was managed outpatient with aminocaproic acid. She had two hospital admissions secondary to gingival and dental bleeding requiring treatment with intravenous recombinant rFVIIa and a tooth extraction. She had no need for major surgical procedures to date. She was followed by a Pediatric Hematologist for her condition but had not yet been evaluated by a Pediatric Gynecologist prior to menarche due to limited access.\nPrior to presentation to the ED, she had experienced menarche followed by 24 days of HMB refractory to high-dose oral contraceptive taper (norgestimate-ethinyl estradiol 0.25 mg-25 mcg three times daily for three days, twice daily for two days, and daily thereafter). As bleeding continued, she was brought to the ED for further evaluation and admitted for management of acute blood loss anemia with a team of Pediatric Hematologists and Gynecologists.\nEvaluation included a transabdominal pelvic ultrasound that revealed a thin endometrial stripe of 5 millimeters. She was started on intravenous estrogen therapy (intravenous conjugated estrogen 25 mg every four hours) and transitioned to oral estrogen (conjugated estrogen 2.5 mg every 4 hours) for a total of 48 hours. During this initial phase, the patient required 5 units of packed red blood cells due to acute blood loss anemia. Upon improvement of her vaginal bleeding similar to a light menses, she was transitioned to daily oral progesterone (norethindrone acetate 10 mg twice daily). Unfortunately, her HMB soon returned. Due to persistent bleeding refractory to the aforementioned hormonal therapy, she received leuprolide acetate (intramuscular 11.25"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old woman presented with acute onset of abdominal pain with recent hematochezia and constipation. The pain was initially described as being most severe in the suprapubic area, followed by diffuse involvement of the entire abdomen, and ultimately localizing to the right lower quadrant. The clinical differential diagnosis at this point included acute appendicitis, ovarian cyst with possible rupture, urinary tract infection, internal hemorrhoids, inflammatory bowel disease, and pancreatitis. An abdominal computed tomography (CT) scan demonstrated an irregular, right adnexal mass measuring 8.8 × 7.8 cm (). A pelvic ultrasound also demonstrated a large right adnexal mass measuring 9.1 × 8.4 × 7.7 cm with internal vascularity. The mass was radiographically concerning for an adnexal tumor with possible ovarian torsion. The decision was made to perform a diagnostic laparoscopy and remove the adnexal mass. During the operation, the mass was noted to be an extrinsic sigmoid colon mass with active bleeding and hemoperitoneum (approximately 400 milliliters of blood) without involvement of the adnexa. The uterus, bilateral fallopian tubes, ovaries, and liver were grossly normal intraoperatively. The procedure was changed to an open laparotomy and the mass was resected along with the sigmoid colon and a low pelvic anastomosis was performed. The patient recuperated well after surgery. A CT scan was performed after six months to assess for residual or metastatic disease. The scan demonstrated multiple new ill-defined, low attenuating lesions in the liver, the largest measuring 6 cm in greatest dimension. A follow-up magnetic resonance imaging (MRI) scan showed several subtle, ill-defined areas of restricted diffusion that were not consistent with metastatic disease. Four years after surgery, the patient remains free of disease.\nGrossly, the mass was fragmented and 16 × 11 × 9 cm in size (aggregate measurement). The mass was well-circumscribed but unencapsulated and appear"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21 year old male presented to the emergency department with severe acute abdominal pain. He had been playing football earlier and was struck in the abdomen by an opponents shoulder. At the time, the impact was considered to be trivial. Subsequently, he developed abdominal pain and was brought to hospital. He had a history of Crohn's disease and was being managed by the gastroenterologists as an out patient. A Barium enema several months previously had shown evidence of Crohn's disease in the terminal ileum and ascending colon. He had no previous surgery and was not on steroids at the time.\nOn examination he was hypotensive and tachycardic. His abdomen displayed signs of generalised peritonitis.\nBlood test showed mildly raised inflammatory markers and an erect chest x-ray showed no convincing evidence of pneumoperitoneum. The patient was fluid resuscitated and given he was haemodynamically stable; a CT was performed to diagnose further prior to surgery. Clinically, a splenic injury was the working diagnosis. Computed tomography scan revealed free gas and a perforation of the ascending colon (fig ). There was no evidence of splenic laceration or subcapsular haematoma of the liver. He proceeded to laparotomy.\nThere was evidence of Crohn's disease involving the distal 10 cm of small bowel and right colon up to one third the way of the transverse colon. 2 perforations were evident in the ascending colon, which was thickened. There were no apparent strictures distal to the perforation that could have resulted in a distended area of bowel that ruptured. A right hemicolectomy and primary anastamosis was performed. The resection involved 10 cm of terminal ileum, which corresponded to the diseased segment of small bowel as shown on the barium study done previously. Histology of the specimen confirmed macroscopic and microscopic features of Crohn's disease. Unfortunately, the patient developed a post-operative wound infection that resulted in a return visit to theatre for a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old girl was referred to our department following the discovery of cardiomegaly on the chest X-ray during recent exploration for recurrent lower respiratory infections.\nHer personal history was uneventful until the age of 5 weeks when she was hospitalized for viral bronchiolitis. At that time, a first echocardiography was performed because of a cardiac murmur and was considered normal. Since then, she showed recurrent wheezing and - lower respiratory tract infections. Allergic asthma and a gastro- esophageal reflux were excluded. Additionally, at the age of 7 months, transient hypo-gammaglobulinemia was diagnosed that was treated for 12 weeks by immunoglobulin substitution until normalization of the immune status. Symptomatic treatment did not lead to significant improvement of the clinical condition. Instead, chronic cough and wheezing persisted as well as frequent lower respiratory tract infections requiring frequent antibiotic administrations. In the course of her chronic disease, the patient underwent at least 10 chest X-Rays in different institutions that always showed a cardiomegaly. The last one led to cardiological assessment.\nAt clinical examination, weight and height were on the 25th and 50-75th percentile, respectively. Blood pressure and transcutaneous oxygen saturation were normal. The precordium was hyperactive over the right ventricle and the apex beat was deviated left- and backwards. The rest of the examination was normal.\nECG showed a right axial deviation, a first-degree A-V block and an incomplete right bundle branch block.\nAt echocardiography there was an axial deviation of the heart to the left, an enlarged right ventricle and dilated trunk of the pulmonary artery. The right pulmonary veins appeared enlarged while the left ones could not be depicted with sufficient precision. The atrial septum was intact in all its portions. No cardinal vein could be identified.\nAn additional imaging with angio-computed tomography (CT) was performed t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.\nShe reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.\nDuring her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.\nThe oncology team became involved at this time. Her CLL was the suspected etiology of the neck mass and lymphadenopathy, and intravenous fluids and allopurinol were started to prevent tumor lysis syndrome. Further laboratory workup showed the predominantly lymphocytic, elevated WBC count as before and a normocytic anemia, hemoglobin 10.6 g/dL. Smudge cells were present on the peripheral blood smear. Iron studies, B12, and folate were normal. Flow cytometry"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old, 7-months pregnant primigravida visited the Department of Obstetrics and Gynecology of our hospital for routine antenatal checkup. Physical examination revealed distended abdomen with fundal height corresponding to 30–32 weeks of gestation. Multiple fetal parts were felt and a single fetal heart sound was auscultated below the umbilicus toward the left of midline. On per vaginal examination, the os was found to be closed with uneffaced cervix. Three months earlier, her first ultrasound scan taken at a peripheral hospital was misdiagnosed as a single live intrauterine fetus of 18 weeks gestational age. Later she was referred to the Department of Radiology, and the ultrasound images showed twin monochorionic, diamniotic intra-uterine pregnancy with a viable, normal-appearing first twin and amorphous structured second twin []. The placenta was located in the left lateral region of the upper uterine segment []. On further examination, the first twin showed normal morphology and growth with gestational age of 31 weeks in cephalic presentation. Fetal Doppler and echocardiography revealed normal parameters without any signs of cardiac failure in the first twin. The second twin showed disrupted growth and incomplete formation with absent head, upper limbs, heart, and thoracic structures. It had well-developed lower limbs and poorly developed lower abdomen with an abrupt ending at the top to form a blunt end. There was gross, diffuse soft tissue edema in the second twin []. Umbilical cord was seen entering the second twin with intact blood flow and pulsed Doppler study revealed reversal of the flow on the spectral pattern []. Ultrasound findings were consistent with TRAP sequence twin with an acardius acephalus which was confirmed on Magnetic Resonance Imaging. Magnetic resonance imaging showed twin monochorionic, diamniotic intrauterine pregnancy with the normally developed first twin in cephalic presentation on the left and malformed, small, grossly edematous"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-month-old male was seen in our pediatric oncology department because of a growing parotid gland mass. The mass was congenital and was followed by the pediatric oncology team with a prediagnosis of hemangioma. The patient’s magnetic resonance imaging (MRI) scan showed an infantile hemangioma in the proliferative phase filling the parapharyngeal space ().\nThe child then received propranolol therapy, but despite this treatment the mass continued to grow, and the child was referred to our department at the age of 10 months. The otorhinolaryngological examination revealed an 8×7-cm mass filling the left parotid region, with normal facial nerve motor functions (). Histopathological diagnosis of the mass was provided by an incisional biopsy as sialolipoma.\nWe planned to perform total excision of the mass with a transparotid approach. The facial nerve was monitored intra-operatively, and surgery was performed under magnification using surgical loops. A standard modified Blair incision was used, flaps were raised (), then the facial nerve was identified in a standard fashion using a tragal pointer and posterior belly of the digastric muscle as landmarks.\nThe main trunk of the facial nerve was found to be unusually elongated before pes anserinus. A soft lobular mass was encountered. A tumor involving the superficial parotid lobe was first dissected, then the deep lobe of the parotid gland and portion of the tumor filling the parapharyngeal space were gently dissected under the facial nerve (). A Jackson-Pratt drain was inserted into the wound after the excision of the tumor.\nOn macroscopic examination, the mass was found to be a lipomatous specimen, 9×8×4 cm in size. The cut surface was consistent with the appearance of a lipoma. Histopathologic examination confirmed the diagnosis of a sialolipoma. The lesion was composed of mature adipose tissue mixed with acinar, ductal structures of a normal salivary gland ().\nThe postoperative period was uneventful. The patient’s faci"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old woman (married, having 3 children) presented with a painless mass in the right breast discovered by self-examination one year before reporting it. She had no other symptoms or previous breast problems and no family history of breast cancer.\nOn clinical examination, palpation of the right breast revealed a painless, mobile, hard mass at the 1-o'clock position (upper inner quadrant) that measured 5.0 cm in width and 4.0 cm in height. There was no tethering of the skin or peau d' orange, and there were no enlarged lymph nodes in the axillary region. The opposite breast and the axilla were normal. Hematological investigation results were within normal limits, and chest X-ray, electrocardiogram showed the heart and lung functions were normal. A large mass was also noted in the mid-lower right part of the abdomen. Clinical diagnosis of the right breast mass and abdominal mass was ambiguous.\nUltrasound scan of the breast showed a hypoechoic area measuring approximately 28 cm in anteroposterior diameter in the upper half of right breast. Meanwhile, it was demonstrated that a relatively circumscribed complex echoic mass with posterior enhancement and uneven density and abundant vessels existed in this area. Calcifications were found focusing in the breast lesion, and several axillary lymph nodes were highly suspicious of metastasis. There were no other focal lesions noted on the scan. Mammography demonstrated an increased density with smooth contour corresponding to the palpable mass. The patient had also undergone an initial computed tomography scan, which revealed a spherical multicystic mass in the right abdomen that measured 259 mm in length, 170 mm in width, and 106 mm in height.\nFine-needle aspiration cytology and intraoperative frozen sections demonstrated and confirmed the malignancy of the mass in the right breast as infiltrating ductal carcinoma (IDC). Upon review of the biopsy specimen from the breast tissue at a multidisciplinary meeting, the diagno"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-month-old Hispanic girl presented to the emergency room with 10 days history of progressing left periorbital swelling. She was initially treated with antibiotics without improvement. The patient did not have any fever, vomiting, cough, eye discharge or sick contact.\nOn examination, she had swelling with proptosis at the left eye without erythema. There was a localized mass that was palpable, restricting the movement of the left eye. Incidentally, the patient found to have pubic hair Tanner stage III but no breast buds or clitoral hypertrophy. The remaining physical exam was unremarkable. There was a significant past medical history of a third-line family member with a diagnosis of uterine cancer at the age of 40 years and a second-line family member with a history of recurrent thyroid nodules.\nInitial laboratory work up including complete blood count, basic metabolic panel, and liver function test were all normal. Computed tomography (CT) scan of the head revealed a single left orbital mass that has retro-orbital and postseptal extension. This mass measured 2.5 × 3.5 × 1 cm and was not associated with focal bone erosion or invasion to the optic nerve [].\nBecause the patient had evidence of precocious puberty, the differential diagnosis at this point was broadened to include rhabdomyosarcoma, neuroblastoma, germ cell tumor or concurrent episode of childhood neoplasms. The patient subsequently underwent further evaluation with whole body positron emission tomography (PET) scan that showed another mass (6 × 6 cm) in the left suprarenal area []. Bone scan, bone marrow biopsy, and urine catecholamine were all negative.\nDue to concern of adrenarche, the patient had endocrine work up that showed advanced bone age with significantly elevated dehydroepiandrosterone sulfate (DHEAS).\nThe previous finding raised the possibility that those two masses might be two different tumor entities. She underwent a subtotal surgical resection of the left retro-orbital lesion (about 75"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old African American female was following up for her chronically elevated alkaline phosphatase levels. She had a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, allergic rhinitis, and chronic lower back pain. Patient has a family history of arthritis, cardiovascular disease, and diabetes mellitus; she denies ever using alcohol or tobacco.\nWith the onset of elevated alkaline phosphatase level and vague abdominal pain in 2013, an abdominal ultrasound performed in December showed hepatic steatosis. Viral serologies for hepatitis during 2013 were negative, as a gastrointestinal consult was required to determine the need for a liver biopsy. A liver biopsy was subsequently performed, which showed focal mixed micro and macrovesicular steatosis. Portal tracts showed minimal focal chronic inflammation, no significant fibrosis, and no iron deposition.\nThe vague abdominal pain that she was experiencing waxed and waned for two years. Additionally, the patient experienced some vague chest pain and dyspnea that prompted an echocardiogram in February of 2015, which demonstrated a left ventricle ejection fraction of 44%. Consequently, a left heart catheterization in the following month showed no significant coronary disease with a dilated left ventricle with an ejection fraction of 50%. A 2-year follow-up in July of 2015 showed suspicious cirrhosis by Computed Tomography (CT) scan (), possibly due to granulomatous changes and chronic inflammation. A CT scan was determined to be necessary for our patient because of rising alkaline phosphatase without other explainable etiologies, in addition to the patient's appetite suppression and vague abdominal pains. Patient's weight during this time was 207 lbs (93.89 kg) and was advised to diet and exercise. After 4 months of continuous symptoms, especially with abdominal pain, a laparoscopic cholecystectomy was performed with a liver biopsy that showed subsequent granulomatous changes in September of 2015. The li"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year old male professional runner was transferred to our musculoskeletal tumor centre on recommendation from his team doctor. Currently a member of a national biathlon junior team, the patient was one of the best track and field athletes of his age group for mid-distance running disciplines (1500 m & 3000 m) on a competitive level at the time of initial diagnosis. Besides daily workout in the gym for strentgh and endurance, his training schedule included up to 4 h running 6 days per week. However, ongoing pain in both of his shins prevented the young athlete from training and competition despite intensive conservative treatment for 5 months. Before admission to our hospital, symptoms were treated for shin splints without success until MRI was conducted. Extensive cyst-like bone lesiosn were found in both diaphyseal tibiae (Figs. and ). Imaging was completed by plain radiography of both tibiae (Figs. and ).\nAs multimodal conservative treatment for MTSS demonstrated unsuccessful and MRI revealed the most likely reason for the patient’s symptoms, surgical therapy was indicated after thorough analysis of all clinical and radiological findings. In favour of a fast return to a competitive sports level we abandoned our standard surgical procedure for UBC consisting of open curettage and autologous cancellous bone grafting from the iliac crest. Due to the dimensions of both tibial lesions, this would have been associated with a long recovery and potential major donor site morbidity both seriously jeopardizing the young athlete’s competitive sports career. Based on promising reports of minimally invasive surgery for treatment of UBC of the humerus from Hou et al. [, ] we performed a customized surgical technique for the first time at the lower extremity beginning with the more symptomatic left lower leg. Surgery was conducted in a supine position without use of a pneumatic tourniquet to prevent possible muscular impairment. The exact dimension of the cyst and its distan"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male patient presented to the accident and emergency department with worsening central chest pain for 1 day. He experienced chest pain that was not related to exertion for 1 month, associated with night sweats. There was no history of fever, palpitations, or weight loss. He was a chronic smoker and had a history of childhood asthma. On admission, the patient was in respiratory distress, however, was hemodynamically stable.\nThe initial chest radiograph [] revealed a large soft-tissue opacity over the medial aspect of the left upper zone. In view of the clinical possibility of acute aortic dissection, urgent computed tomography (CT) angiography was performed. CT showed no evidence of dissection or an aneurysm in the thoracic aorta. There was, however, a lobulated heterogeneously enhancing soft-tissue mass seen in the anterior mediastinum, partially encasing the aortic arch, almost completely encasing the left common carotid artery and fully encasing the left subclavian artery []. No calcifications or fat densities were noted within the mass. The mass displaced the left upper lobe pulmonary artery laterally. No thrombus was seen within the pulmonary artery. This mass also displaced the trachea and esophagus to the right [ and ]. Blood tests including tumor markers were all unremarkable. Radiological differential diagnoses of anterior mediastinal mass including lymphoma, germ cell tumor, and invasive thymoma were made. Subsequently, an 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan was performed, showing the anterior mediastinal mass to be hypermetabolic with maximum standardized uptake values measuring 19.8 []. A hypermetabolic left cervical lymph node metastasis was also detected [].\nThe mediastinal tumor was considered unresectable since it encased the aorta and its branches. The patient underwent video-assisted thoracoscopic surgery and biopsy of the mediastinal mass was taken. Histopathological examination [] revealed sheets"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-year-old girl with the complaint of vague periodic abdominal pains mainly in the epigastrium and periumbilical region is referred to the children's hospital. There was not any correlation with feeding and almost having discomfort at night times. She had periods of constipation and diarrhea and symptoms of leg pains. She also used to take Propranolol for early morning headaches mostly in the frontal region for 2 years. The patient with a probable diagnosis of Familial Mediterranean Fever (FMF) was referred to the pediatric rheumatology clinic for further surveys when 0.5 milligram daily colchicine was taken without considerable clinical response. She also had both an intussusception experiment and a history of negative appendectomy since she was 2 years old and the initiation of abdominal pain since that time. She was never febrile during abdominal pains. General examination revealed a thin hemodynamically stable girl with no signs of acute abdomen; the weight and the length were 15 kg and 105 cm [body mass index (BMI): 14.5 kg/m2].\nShe had second admission within previous 15 days with similar complaints. The grey scale and color Doppler abdominal ultrasonography showed normal portal and splenic veins and there were no evidences of thrombosis. Stool calprotectin test was also requested for a probable inflammatory condition in the gastrointestinal tract. However, because of persistent symptoms, abdominal CT angiography was obtained, which revealed a decrease in aortic and superior mesenteric artery and aortomesenteric angle consequently to 5 mm and 14 degrees suggestive for superior mesenteric syndrome along with a gastric and duodenal dilation [].\nAnother confirmatory spiral CT scan of abdominopelvic region also marked distended stomach and the proximal part of duodenum which in context of CT angiography proposing SMA syndrome. In addition, she was in a malnourished state without adequate evidences supporting an autoimmune condition. Thus, according to persistent"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old male resident of a nursing home facility of Hispanic descent was brought to our emergency department (ED) for respiratory distress and altered mental status. He was intubated promptly on arrival to the ED. His past medical history was significant for intracranial aneurysm with bleeding following VP shunt placement, ischemic stroke with aphasia and paraplegia, and percutaneous endoscopic gastrostomy (PEG) tube placement. His vital signs and clinical laboratory results are presented in Table .\nThe clinical picture was suggestive of septic shock. We ordered a sepsis workup including two sets of blood cultures and urine culture. The patient was treated with aggressive intravenous fluid hydration and broad-spectrum antibiotics (vancomycin and meropenem).\nA non-contrast computed tomography (CT) of the chest, abdomen, and pelvis revealed bibasilar pulmonary atelectasis without focal infiltrate and the presence of a right-sided VP shunt catheter traversing the right neck, the right chest, and the right abdominal wall; the tip of the catheter was located within the gastric lumen and had likely entered through the PEG tube insertion site (Figures -). The PEG tube was outside the gastric lumen, terminating in the abdominal wall that was evidenced in the repeat CT scan confirmed that patient had abdominal wall cellulitis and localized abscesses around the PEG tube insertion site (Figure ). Medical records from another facility confirmed previously normal positioning of the PEG tube and normal intraperitoneal positioning of VP shunt catheter one year prior.\nGiven the malposition of the VP shunt inside the gastric lumen, we suspected VP shunt infection or meningitis/encephalitis and subsequently lumbar puncture was performed; the results of the cerebrospinal fluid (CSF) analysis were unremarkable. Blood cultures and urine culture results were negative.\nThe wound culture was positive for Proteus mirabilis sensitive to carbapenems and piperacillin/tazobactam. We debr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female with a known history of giant hepatic hemangioma was referred with one-year history of increasing abdominal pain associated with progressive nausea, 60 lbs weight loss and constipation. The hemangioma was initially diagnosed during a workup for lower back pain two years before the onset of abdominal pain. General surgical consultations were sought, and expectant management was advised. The patient had subsequently been treated conservatively for lumbar disk herniation and newly diagnosed irritable bowel syndrome. In our clinic, she appeared pale and malnourished with lumbar lordosis. The abdominal exam revealed generalized distention with a palpable liver edge below the right subcostal margin.\nMagnetic resonance imaging (MRI) of the abdomen revealed 18.5 (AP) × 19.2 (TV) × 25.3 (SI) cm mass located in the right posterior hepatic lobe consistent with giant hemangioma (). A review of radiological records indicated the hemangioma had grown steadily in a diameter from 13 cm in 2015 to 25 cm in 2018. Laboratory evaluation was significant for pancytopenia ().\nConsent for surgical resection was obtained. A surgical set-up has been described earlier. [] A midline incision with right subcostal extension was placed. The hemangioma arose from the right posterior lobe and was compressing the remaining liver and surrounding structures. Due to tumor size, the right lobe could not be mobilized and access to the vena cava was severely limited. It was therefore decided to proceed with “anterior approach” and resect the mass by creating a plane between the displaced right hepatic vein and the hemangioma. Monopolar coagulation and Cavitron Ultrasonic Surgical Aspirator (CUSA, ValleyLab, USA) were then used to transect the liver parenchyma just lateral to the right hepatic vein. Blood loss was limited through intermittent use of the Pringle maneuver in addition to low central venous pressure anesthesia. The mass was removed uneventfully with an estimated blood loss"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old female presented with sudden onset posterior neck and right shoulder pain with progressive right side weakness while falling asleep. During consult, she had reported taking anti-hypertensive medication for 20 years and was followed regularly for hepatitis C. She reported no trauma history or physical exertion for the past few weeks. Neurological examination resulted in alert mental status and the detection of right hemiparesis. Motor power of her right upper limb was grade III and ipsilateral hand grasping power was grade II. In her right lower extremity, motor power was grade IV, and her left whole extremities were intact. Right side hypoesthesia was also observed. Based on her medical history and clinical symptoms, the physician working at the emergency department ordered brain CT to rule out intracranial hemorrhage. However, brain CT did not show any positive findings (). Subsequent brain diffuse MRI was taken to rule out cerebral infarction, but it was also negative (). Cervical MRI was performed to rule out a cervical lesion based on the patient's report of posterior neck pain and revealed a mass like lesion in the right posterior epidural space at the C3-6 level compressing the right side of the spinal cord. The mass was isointensive to the spinal cord on T1WI and heterogeneously hyperintensive with central high signal foci on T2WI. At the C5 level, the MRI showed an ovoid, enhancing, nodular lesion, which was a suspected tumorous condition such as hemangioma or hemangiopericytoma (). Initial laboratory tests showed only severe thrombocytopenia (45,000/mm3). As her neurologic signs were getting worse with time, we decided to perform surgical intervention. Under general endotracheal anesthesia via light wand intubation, right C5 unilateral total laminectomy and C6 partial hemilaminectomy were performed. The mass lesion was pure hematoma and was removed (). We could find neither vascular malformation or an active bleeding point. She went into rehab"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old male patient presented to Emergency Department (ED) following a run over injury. The patient described the mechanism of injury as moving his body over his run over foot. On clinical examination, there was obvious deformity and swelling of the right ankle. Dorsalis pedis pulse was felt but weak compared to the contralateral side with a capillary refill time under 3 s. The posterior tibial artery could not be palpated because of the deformity. X-rays showed posterior ankle dislocation without associated fractures (Fig. ). Urgent reduction of the dislocation was done under sedation in ED. The knee was first flexed to relax the tendon Achilles then longitudinal traction with gentle forward force applied to the heel with immediate reduction of the deformity achieved. The foot was reassessed for vascular status. Triphasic pulse in both drosalis pedis and posterior tibial artery was detected with hand held Doppler. Ankle was immobilized in posterior below knee back slab to accommodate for swelling and check x-rays confirmed reduction of the ankle joint (Fig. ). CT scan was done afterwards to define any subtle incongruity or osteochondral fragments entrapped in the joint. CT did not show any associated fractures and showed congruent reduction of the ankle joint (Fig. ). Patient was mobilized touch weight bearing for first 2 weeks. The back slab was changed for weight bearing short leg cast and progressive weight bearing was allowed for the following 4 weeks. At 6 weeks follow up, plaster was removed and on examination patient still had moderate tenderness over the medial joint line and deltoid ligament area. Also, patient had limited range of plantar and dorsal flexion. Referral for physiotherapy was done for start of functional rehabilitation and range of motion exercises and in mean time MRI was done to delineate extent of ligamentous injury. MRI showed bone bruising of the lateral malleolus, medial malleolus and lateral talus (Fig. ). The anterior talufibul"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old man presented at the emergency room with complaints of retrosternal discomfort during swallowing for 7 days, and a history of tarry stool and hematemesis were found in the last 12 h. He gave a history of swallowing a bone by mistake. The patient felt dizzy and nauseous. There was no other digestive tract symptom or systemic symptom such as fever. He had a past history of alcoholism, but no history of chronic liver disease or peptic ulceration. His blood pressure was 105/70 mm Hg, pulse rate was 105 beats per minute and respiratory rate was 22 breaths per minute. He was administered 20 ml of 5% glucose and omeprazole 80 ml static push, 100 ml of 5% glucose and 40 mg omeprazole continuous infusion, 0.9% sodium chloride 500 ml plus 6 U insulin. No abnormality was detected on physical examination, except diaphoresis and mild pallor. Haematological investigations revealed mildly elevated white cell count 11.8 × 109/l, with neutrophilia of 10.34 × 109/l. His hemoglobin was 97 g/l. Standing chest and plain abdominal radiographs were normal. Computed tomography scan of the mediastinum showed indistinct esophagus middle, slightly higher density of the esophageal wall, the surrounding fat tissue had disappeared, part of the descending aorta showed aorto-esophageal fistula, and there was an esophageal foreign body. Emergency endoscopy revealed no upper esophageal FB. There was a fresh red thrombus at 26 cm, with no active bleeding. The foreign body was not visible. Foreign body was also not found during surgery with thoracoscopy. Then a second endoscopy examination was performed, and the blue cotton method was conducted after water washing, then a small piece of cotton was located at 26 cm, and a tiny part of a fish bone was found under the cotton (). The foreign body was extracted by the endoscope. The patient was discharged without any complications after 23 days."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old female of the Marshallese origin presented to the emergency department with complaints of nausea; nonbloody, nonbilious vomiting; and abdominal pain []. The patient denied any recent fevers, and no rash was reported. Review of systems was notable for the left ear drainage. Immunization status was unknown, and she was not reported to have been previously treated for any significant illness, though the history was limited by the patient's custodial circumstances. She lived in a small house in rural North Carolina with 21 other Marshallese immigrants and was cared for by relatives who had assumed care for her at the time of her immigration five years before.\nExamination during the initial hospital visit revealed dehydration and acute otitis media with rupture of the tympanic membrane. Laboratory results revealed leukocytosis, prerenal azotemia, elevated liver enzymes, and mildly elevated lipase (). Computed tomography (CT) showed scattered focal pulmonary infiltrates, splenomegaly, and a markedly distended stomach without an obvious focus of mechanical obstruction (). Cytomegalovirus and Epstein–Barr virus serology were requested with results suggesting prior exposure. She was admitted with a presumptive diagnosis of gastroparesis secondary to a nonspecific viral infection and possible mild pancreatitis. An NG tube was placed resulting in high volume output. Her symptoms gradually improved over several days with IV fluid support and bowel rest; her NG was successfully removed, and she was discharged home tolerating a regular diet.\nTwo days after discharge, the patient returned with recurrence of her prior symptoms. The patient appeared acutely ill with dehydration. On lung exam, scattered crackles were noted. She was also noted to have diffuse small nodular lesions most apparent on her hands, feet, lower legs, and face (). An advocate placed with the family reported her concern for additional symptoms of chronic weight loss and productive cough with postt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old female patient visited our hospital with bilateral weakness (left>right) which had suddenly developed and persisted for 15 days. She also had hypertension and unstable angina which had been treated with antihypertensive and antiplatelet medications for 10 years. She had no history of diabetes mellitus, hyperlipidemia, and smoking, etc.\nOn neurological examination, bilateral hemiparesis (left : Grade IV, right : Grade IV+) was detected. The brain computed tomography scan showed a low-density area only in the right post-central gyrus, and diffusion weighted-magnetic resonance imaging (d-MRI) showed bilateral anterior cerebral artery-middle cerebral artery borderzone infarction (), and MR angiography showed high grade stenosis of both proximal ICA ().\nCatheter angiography was performed 4 days after admission. Common carotid angiography showed 85% stenosis of the left ICA origin () and 90% stenosis of right ICA origin (). Vertebral angiography showed total occlusion of the right VA and multifocal stenosis of the left VA with faint flow to basilar artery (BA) (). PComAs on both sides were well visualized and filling to both posterior cerebral arteries (PCAs) (). However, retrograde flow to BA was not seen. Meanwhile, right occipital artery (OA) from right ECA supplied right VA and then BA to basilar tip ().\nWe performed stent-angioplasty for left ICA stenosis first under local anesthesia immediate after the catheter angiography (). During the procedure no remarkable events took place, and the neurologic symptoms of the patient remained unchanged after the procedure. Two days after stent-angioplasty for left ICA stenosis, treatment for right ICA lesion was performed under local anesthesia (). During the procedure no remarkable events took place, and the neurologic symptoms of the patient remained unchanged immediate after the procedure. After the 2nd session of angioplasty, we control the patient's systolic blood pressure (BP) about 120 mm Hg because of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old boy was referred for management of acute acquired comitant esotropia. His family noticed sudden inward deviation of his left eye 9 months ago, and as time passed, this deviation became increasingly noticeable. On first presentation, the angle of esodeviation was 50 prism diopters (PD) at distant and near fixation. The patient's visual acuity and sensory status were not checked, but he demonstrated alternate fixation. There was no lateral incomitance and no deficit of abduction bilaterally (). No difference in the size of the deviation was found with fixation of the right versus the left eye. The cycloplegic refraction with 1% cyclopentolate revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on fundus examination. No nystagmus was noticed, and there was no family history of strabismus or amblyopia. There was no preceding trauma or febrile illness before the onset of acute strabismus. Review of old photographs demonstrated that at 1 year of age, the patient's corneal light reflexes were centered.\nHe was referred to a pediatric neurologist, but the neurological examination did not reveal any additional pathological findings. A brain MRI revealed a 5 cm mass with an enhanced peripheral rim at the midline of the cerebellum as well as hydrocephalus (). The tumor was completely excised and a shunt was placed. Histological examination of the excision confirmed the diagnosis of pilocytic astrocytoma.\nThree months after neurosurgery the patient's visual acuity was 20/125 in each eye and the angle of esodeviaton increased up to 60PD at distance and near fixation without any deficit of abduction. Alternating six-hour occlusion therapy was initiated. Eight months after the initiation of occlusion therapy, the patient's visual acuity had improved to 20/50 in the right eye and 20/40 in the left eye. The angle of esodeviation was reduced to 50PD at distance and near fixation, and the esotropic angle did not show any sign of decrease.\nOne"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old Caucasian woman was referred due to gradual worsening of dyspnea with aggravation during a recent skiing trip. Her previous medical history included mild asthma and osteoporosis, surgical treatment for rectal cancer 30 years prior to presentation, and an evaluation for dizziness 4 years previously when a computed tomography scan of the cerebrum was without any positive findings.\nThe patient denied palpitations but reported occasional retrosternal oppression and two incidences of near syncope. Aside from age, she had no risk factors for ischemic heart disease.\nA physical examination revealed an arterial blood pressure of 132/70 mmHg, a heart rate of 40 bpm, normal oxygen saturation, normal body temperature, and no dyspnea at rest. Further examination revealed jugular vein distension while sitting upright in bed and a discreet systolic murmur. The electrocardiogram (ECG) showed atrial fibrillation and complete atrioventricular block. Blood tests were normal except from consistent low-grade elevation of the cardiac troponin I. An echocardiogram showed severely dilated left atria, mild mitral regurgitation, borderline dilated LV with near-normal systolic function and no hypertrophy. Acute coronary syndrome was not considered present and our patient underwent an uneventful implantation of a dual-chamber pacemaker (DDDR). Following discharge, the patient was followed by her private cardiologist. It was later noted that cardiac hypertrophy and a slight decrease in LV ejection fraction had developed, the latter possibly considered secondary to cardiac pacing.\nOver the next 5 years, our patient was repeatedly admitted to the emergency department with dyspnea. At our institution, the echocardiogram was repeated when our patient, at the age of 78 years, was admitted with severe respiratory distress interpreted as pulmonary edema. Her LV ejection fraction had decreased to 15% (Fig. ). A subsequent coronary angiogram was without any coronary artery lesions and she"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old male reported to the Department of Periodontology, HPGDC, Shimla, HP with a chief complaint of extruded and badly positioned mobile upper left front tooth. On examination the upper left lateral incisor was found to be below the level of the occlusal plane of adjacent teeth, was buccally drifted and had Grade II mobility with a 10 mm deep periodontal pocket. Radiographic evaluation revealed vertical bone defect extending until the middle one-third of root, there was no bone defects or loss of attachment in the rest of the dentition []. Endodontic consultation was taken to rule out any pulpal pathology. There was no medical history associated. A primary diagnosis of severe localized chronic periodontitis resulting in extrusion and misalignment of the affected tooth was made based on the clinical findings. A two-pronged treatment plan was devised with the main aim to preserve the tooth by treating the periodontal disease and promoting the regeneration, followed by orthodontic treatment to align the tooth in the arch for long-term maintenance and esthetic reasons. Clinical pictures and cast (models) were made and decision was taken to start the Phase I periodontal therapy which included SRP and oral hygiene instructions. Once the Phase I periodontal therapy was completed, it was noticed that vertical bone defects and clinical attachment loss were still persistent, therefore the decision to initiate Phase II periodontal therapy was taken to reconstruct the lost periodontal support. Open flap debridement using Kirkland flap was done under local anesthesia and the bone defect was filled using bio-oss* (Bone graft material). The flap was re-approximated and sutured. The sutures were removed after a week, and the patient was placed on a maintenance and recall program, which included a recall visit every 2 weeks for first 1-month, followed by every 3 weeks for 6 months postoperatively. At the end of 6 months, there was a gain in clinical attachment gain by 7 mm,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).\nTissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.\nOn the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.\nAn emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old woman with SCD presented frequently to the medical casualty department with severe pain due to sickle cell VOC. For the last 2 years, her sickle cell pain included intermittent pain in the left ankle. Her recurrent severe VOCs were treated with opioids, as they are the general treatment in such patients. She had experienced osteomyelitis in the right ulnar bone 12 years previously, which resolved after intravenous broad-spectrum antibiotic treatment. Additionally, she underwent splenectomy 4 years ago to reduce blood transfusion requirements because of her congenital hemolytic anemia. She was referred for a triple-phase bone scan and complementary bone marrow and infection imaging as part of the SCD research project. A plain radiograph of the left foot was normal, but SPECT-CT revealed an increased uptake in the shoulders, knees, and sternum on blood pool and delayed images, consistent with marrow expansion. A similar uptake pattern was seen during bone marrow study, confirming bone marrow expansion around the large joints. There was a mildly increased blood pool and bone uptake in the left ankle involving the proximal talus and the region of the medial malleolus, with focal increased uptake in the left talus. This nidus of activity appeared to correspond to a round lucent area surrounded by a dense sclerotic rim and sinus tract formation together with a fracture line in the proximal talus on CT. The WBC scan showed no evidence of significant uptake, and the bone marrow scan showed asymmetrical uptake between the two ankles without a cold lesion in the left talus, which is consistent with moderate bone marrow expansion. The CT and bone scan findings suggested Brodie’s abscess in the proximal left talus with possible surrounding chronic osteomyelitis. Intravenous antibiotics were administered for 10 days with no response. The abscess was then treated with surgical curettage under general anesthesia and antibiotic administration for 10 days. At 18 months"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-yr-old female visited our department in October 2002. She had a history of endotracheal intubation for a week to maintain her airway after an inhalation burn, and she then developed dyspnea after the treatment. Prior to the inhalation injury, she had no family history of disease or any notable medical conditions. On physical examination, the mobility of both vocal folds was found to be intact; however, we observed upper tracheal stenosis. The patient's airway was severely compromised with less than 30% of the normal function due to the stenosis. A neck computed tomography (CT) scan showed a tracheal stenosis lesion around the 6th cervical spinal level. The narrowest diameter of the lesional trachea was about 0.7 cm and the lesion length was about 3cm. Slight enhancement was also visible on the stenotic lesion, which most likely due to granulation tissue. We performed bronchoscopy and balloon dilatation procedures. The 10 mm balloon dilatation was initially successful, but further procedures could not be performed because of the patient's unstable vital signs. We decided to perform a resection with end-to-end anastomosis in November 2002. We performed a hyoid release and resection of a 2 cm segment of the trachea (from the 2nd to 5th tracheal rings) 2 months after the burn injury. Two months later, the dyspnea symptoms reappeared and the tracheal stenosis was found. Tracheal ballooning and stent insertion were then performed, but the stent was removed after 1 month due to displacement. Granulation tissue was observed a few months later at the previous operative site. LMS was performed next to remove the granulation tissue and mitomycin C was applied. In 2006, upper tracheal stenosis due to a fibrous stricture of the tracheal mucosa was found. A neck CT scan revealed a narrowed airway with hour-glass-shaped tracheal rings on the 6th cervical spinal level (). The narrowest diameter of the trachea was about 0.6-0.7 cm and LMS then was performed two more times. Five"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA Turkish 13-year-old boy was referred to our clinic fifteen days after a car accident. Clinically, the cooperation level of the child with the dentist was high, but oral hygiene was poor. After assessing medical history, the patient was examined for extraoral signs. He had no facial swelling, facial asymmetry, limited mouth opening, and pain on palpation. Intraoral examination revealed severe intrusive luxation in tooth 12 and moderate intrusive luxation in tooth 11. The tooth 11 was not mobile and did not interfere with the occlusion (). The patient was in the mixed dentition, had a deep bite, and tooth 13 was still erupting.\nAt the first appointment, pulp sensitivity of all anterior teeth was evaluated with an electric pulp test. Teeth 21 and 22 gave positive responses, while teeth 11 and 13 gave negative responses. Radiographs confirmed a complete root formation in all permanent anterior teeth, and periodontal space was absent (). Given that multiple severe luxation traumas, it was decided to perform surgical re-positioning. A photograph was requested from the family to see the anterior teeth positions. The patient and his parents were informed about treatment options and the expected prognosis of each procedure.\nThe difficulties encountered during surgery were i) reaching stability after re-positioning in adjacents multiple luxation teeth on the arch; ii) re-positioning of intruded teeth 11 and 12 in the alveolar socket due to the start of remodeling in the bone in 15 days. The teeth 11 and 12 were surgically extruded and stabilized in a position similar to the symmetrical teeth by 0.5 mm stainless steel splint (). Because the tooth 13 continued erupting, it was left to the spontaneous eruption and not included in the splint.\nAfter surgery, Augmentin (625 mg, 2*1), a penicillin-derived antibiotic, a mouthwash containing chlorhexidine, Parol, an analgesic agent, were prescribed for 7 days to the patient against the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old man presented with progressive left wrist pain and swelling, following a trauma one year back, in which he fell on his left upper extremity. He was operated by percutaneous pinning for the extra-articular lower end radius fracture. Post operative period was uneventful but then patient started developing pain and fullness over the operated wrist on removal of the cast 6 weeks post-operatively with loosening of pins, which were removed. Patient continued to have fullness with gradual & progressive loss of wrist movement. Patient was treated on the lines of CRPS by local physician with non-steroidal anti-inflammatory agents. No improvement was observed and the stiffness and pain progressively worsened for the last 9 months. Past medical history was non-significant. He had no history of tuberculosis (TB) or any other immune-suppressive disease. There was neither any family history of TB infection nor of any rheumatic or autoimmune disease. He had been immunized with BCG vaccine at birth. Constitutional symptoms such as fever, anorexia, fatigue and weight loss were absent. He was not receiving any regular medications. When seen in our institute, he had considerable pain and severely restricted range of motion of the left wrist. The rest of the musculoskeletal examination was normal.\nRoutine laboratory investigations including biochemical tests, complete blood cell count were all normal apart from an elevated ESR (42 mm in 1st hour; normal: <20 mm in 1st hour) and CRP (8.93 mg/L; normal: <5 mg/L). Serological tests for Anti-Nuclear Antibodies (ANA) and hepatitis viruses were negative. Tumour markers and HIV test, as well as test for Brucella antibodies were also negative. The result of tuberculin skin test (5 tuberculin units) was strongly positive with induration of 17 mm diameter. His chest x-ray was normal with no evidence of any active pulmonary disease.\nAn antero-posterior radiograph of the left wrist indicated soft tissue swelling, loss of joint"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.\nHer history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.\nEndemic Zika was identified in Haiti per the CDC early in the epidemic []. When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy []. She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.\nThe patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of 21-year-old female patient with a negative medical and surgical history. She presented to the gastroenterology clinic for chronic epigastric pain for several months, associated with postprandial episodes of nausea and vomiting. Her physical examination was insignificant. She was prescribed proton pump inhibitors and prokinetics.\nHowever, her symptoms didn't improve much, so a diagnostic upper esophagogastroduodenoscopy was done and showed normal mucosa but with external compression on the second part of the duodenum (\n). Computed tomography (CT) scan of the abdomen and pelvis was ordered due to characterize the external compressing mass. It showed a diverticulum at the second part of the duodenum (D2) measuring approximately 41 mm × 28 mm, filling the duodenal lumen (intraluminal diverticulum) and obstructing it (\n). Finally, an endoscopic ultrasound was done to delineate the diverticulum and have a clearer view of the surrounding structures. It showed again the intraluminal duodenal diverticulum (IDD) in D2, with a thin and regular wall. The endoscopic ultrasound also confirmed normal pancreatic appearance and normal Wirsung's duct and biliary tract.\nThe patient was presented with her options and after a surgical consult, and due to her intractable symptoms, it was decided to go with surgical treatment. Written consent was taken from the patient. She was prepared for the operating room.\nIntraoperatively, the duodenum was first completely exposed. Then, an intraluminal mass was palpated at the level of D2. Through a longitudinal duodenotomy, the intraluminal diverticulum was identified. The diverticulum was identified 20-mm proximal to the papilla. The papilla was intubated to avoid injury during traction of the mucosa. Excision of the diverticulum was then performed and the mucosa was approximated using absorbable sutures.\nThe postoperative course was unremarkable and the patient was discharged on day 6 after regaining bowel movement and tolera"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old woman presented with a lump in her neck, which had gradually increased in size during the previous two months. Physical examination revealed a firm nodular mass in the right lobe of the thyroid gland. Her past medical history was unremarkable. Thyroid function tests were within normal range. Ultrasonography revealed a round, relatively well-defined, mixed echoic nodule in the right lobe. The nodule had a markedly hypoechoic portion in the lateral side and had a slightly hypoechoic portion in the medial side. Color Doppler imaging showed increased blood flow within the markedly hypoechoic portion of the nodule ().\nThe fine needle aspiration in this nodule exhibited clusters of cuboidal cells with features of papillary carcinoma. The smear also contained spindle cell groups with non-cohesive arrangement among the tumor cells of PTC. The spindle cells were in a pale to eosinophilic background with associated lymphocytic infiltrate. They had vesicular nuclei, small nucleoli, and indistinct cytoplasmic membrane. Neither significant atypia nor mitotic figures were identified (). Total thyroidectomy with central lymph node dissection was performed.\nGrossly, the right lobe of the thyroid gland showed a well-circumscribed yellow to white, partially encapsulated mass, measuring 2.3×2.0×1.8 cm. Histologically, the tumor consisted of two distinct components: stromal and epithelial. The stromal component consisted of spindle-shaped cells arranged in interlacing fascicles and an abundant fibromyxoid matrix accompanied by thick collagen fibers. The stromal cells had neither nuclear atypia nor mitotic figures. Occasional lymphocytic infiltration or extravasated red blood cells were also identified in the center and periphery of the tumor stroma. Epithelial components had features of PTC (). The tumor was confined to the thyroid parenchyma. Metastatic tumor tissue was detected in four of five resected central lymph nodes without stromal components. Immunohistochemicall"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old Thai female G2P0A1 at 37+1 weeks of gestation presented with a 1-week history of pruritic erythematous papules and plaques starting on the lower abdomen. The rash spread to all extremities and the trunk; however, mucosa, palms, and soles were spared. Neither abnormal symptoms nor signs of systemic involvement or fetal distress were detected.\nShe had been receiving regular antenatal care since she was 8 weeks pregnant. Her medications were 1 ferli-6 tab per day and 1 g calcium carbonate per day, which she had been taking since an antenatal care visit. She had undergone an abortion during the eighth week of pregnancy 5 years earlier. There was no history of a similar skin condition. She denied any previous herpes simplex infection. Physical examination revealed generalized discrete and confluent erythematous papules and plaques with central dusky red areas (targetoid lesions) on the trunk and extremities (fig. ). Some tiny pustules and vesicles were noted on both arms and the chest wall. Conjunctiva and oral and genital mucosa were unremarkable.\nA Tzanck smear from the vesicle showed the presence of polymorphonuclear cells but the absence of multinucleated giant cells. Gram staining of the pustules showed no organisms. Direct immunofluorescent study was negative for herpes simplex virus antigen. Additionally, a skin biopsy taken from the targetoid lesions on the left forearm illustrated focal parakeratosis with scale crust formation, irregular acanthosis and focal spongiosis of the epidermis, superficial perivascular infiltration of lymphocytes, and eosinophils with red blood cell extravasation. Direct and indirect immunofluorescent studies (HG factor) were all negative. Due to the diversity of skin manifestations, excluding the cause of the targetoid lesions and the negative result of laboratory investigations, PEP was diagnosed.\nSystemic corticosteroids were prescribed at the patient's first visit because pemphigoid gestationis could not be excluded. H"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old right-handed Caucasian lady, known to have migraine with aura and type-2 diabetes mellitus presented to our emergency department center with dysarthria, left upper motor neuron facial weakness and left-sided hemiparesis affecting the upper limb more than the lower limb. The patient presented with signs of a right middle cerebral artery (MCA) stroke with an National Institute of Health Stroke Scale (NIHSS) of 10 and unfortunately was out of the window period for intravenous thrombolysis as it was a wake-up stroke and last seen well (LSW) was unknown. A MRI of the brain was obtained on an urgent basis which showed an established infarction in the anterior third of the right MCA territory secondary to the occlusion of the superior M2 branch of the right MCA ().\nUpon further workup, CTA showed a filling defect in the right V4 segment of the right vertebral artery which was suspected of being a dissection or a FFT, with normal flow in the left vertebral artery and the basilar artery and its distal branches ().\nThe attending neurologist in the referring hospital discussed the case with our neurovascular on-call team and the patient was then transferred urgently to our hospital for emergent endovascular therapy (EVT).\nThe patient was transferred to King Fahad hospital of the university the same night. An urgent angiogram was performed through a 5-F femoral sheath and a diagnostic catheter, under local anesthesia. The left ICA injection showed a normal flow into the MCA territory as well as the anterior cerebral artery (ACA) territory, with no cross flow to the right hemisphere. The right ICA injection showed the previously mentioned occlusion of the superior M2 branch with deficient collaterals to central MCA core territory. The left vertebral injection showed normal flow in its intracranial segment with no reflux into the right vertebral artery with normal flow into the basilar artery and its distal branches (). The right vertebral artery was accessed just a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old male patient was transferred to the emergency department after a road traffic accident. He had a fall from his bike and his right arm was crashed by the following car. On clinical examination, he had pain and obvious deformity in the shoulder while he was unable to move his arm in any direction, especially in external rotation. He had numbness in the regimental badge region of the axillary nerve and normal radial pulse at the wrist. Radiological examination showed an anterior shoulder dislocation with impaction of the humeral head underneath glenoid and associated fracture of the greater tuberosity (Fig. ). He had no other skeletal or visceral injuries. After conscious sedation, an effort for closed reduction (3 attempts) was performed in the emergency room but was unsuccessful. For reasons unrelated to the patient or the disease a CT-scan of the shoulder was not possible to be performed at that time. The patient was transferred immediately to the operative theatre for closed manipulation under general anaesthesia in order to reduce the dislocation and avoid further neurological compromise; a CT-scan and/or MRI has been scheduled for the next morning. Despite prompt sedation and muscle relaxation the shoulder was still unable to interpose. Open reduction was accomplished thereafter using the deltopectoral approach; the biceps tendon was found entrapped posterolateral between the humeral head and the tuberosity fragment preventing once again reduction of the glenohumeral joint. (Fig. ). Tenotomy and tenodesis of the frayed biceps at the level of pectoralis major was performed using a bone anchor; the transverse ligament at the bicipital groove had been torned. Next, the subscapularis was incised, 1 cm medial to its insertion at the lesser tubercle, and retracted medially after separated from the capsule. The latter was incised and the labrum was clearly visualized and was found to be intact inferomedially. Using longitudinal traction and finger manipula"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year old male patient reported to the Department of Oral Medicine and Radiology with a complaint of progressive flattening of left side of face since the age of 2 years which was continuous to date. Patient gave a history of pigmentation of his left face since birth which had been gradually fading over the years. No history of trauma or surgery was reported and there was no positive family history of facial atrophy. Neither was there a family history of consanguinity. His delivery was not assisted, per vagina. The medical history was not contributory, and he was not on any form of medication. Patient denied history of smoking or alcohol intake. Patient was moderately built and nourished.\nOn physical examination, he was conscious, oriented, and afebrile. His general condition was fair with vital signs within normal limits. On extraoral examination, facial asymmetry was detected due to hypoplasia of left malar region (). There was atrophy of left masseter muscle and fat with prominence of the left infraorbital ridge and zygoma. The right face appeared normal. Examination of the face revealed no sensory or motor deficits on both sides. The left eye appeared depressed in the socket (enophthalmos) due to loss of periorbital fat with minimal drooping of the left eyelid ( and ). Increased lacrimation was associated with enophthalmos. There was a deviation of mouth angle to the affected side at rest. Pigmentation was noticed on the left cheek which also involved the left palpebral conjunctiva (). Systemic examination of the central nervous system was normal. Fundus examination was also normal.\nBased on the clinical findings and history, a clinical diagnosis of Parry-Romberg syndrome was made. Routine blood investigations revealed all values within normal limits.\nAs a part of radiographic investigations, a panoramic radiograph was taken. The radiograph revealed no significant findings (). Axial and coronal computed tomographic (CT) images revealed hypoplasia of the left"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA five-year-old male child presented to the pediatric department with complaints of gradual abdominal distension developing since few months as well as fever and bluish discoloration of the limbs since few days. The mother complained that her son got tired easily on exerting himself during activities such as playing.\nUnder the routine admission protocol, the entire panel of blood markers was sent, electrocardiogram was performed, and the patient was then sent to the radiology department for an ultrasonographic evaluation and radiography. The hemoglobin was 9 gm/dL, and the packed cell volume (PCV), mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC) too were below the lower limit of normal. The total leucocyte count at 23,900/μL was significantly raised, and differential leucocyte count revealed eosinophils at 60%. The electrocardiogram revealed a right bundle branch block with right ventricular strain pattern.\nUltrasonography (USG) of abdomen and pelvis revealed an enlarged midline liver with two sets of dilated hepatic veins; multiple splenules were seen on the right side with empty left splenic region. Due to the enlarged liver, the right kidney was noted at a significantly lower position with respect to the left kidney (Figure ). There was intestinal malrotation with stomach located on the right side and small bowel loops clustered together on the left side; large bowel loops were clustered together on the right side; and sigmoid colon is noted in the lower half of right-side abdomen.\nThe radiograph revealed cardiomegaly with a cardiothoracic ratio of 0.7. In view of the above findings, an urgent two-dimensional echocardiography was performed, which revealed a severely dilated right atrium at the right ventricle with a moderate ostium secundum and bidirectional atrial septal defect; patent ductus arteriosus and severe tricuspid regurgitation and pulmonary artery hypertension too were observed (Figures , ).\nThe CT revealed visceral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn 2017, a 60-year-old female presented to her General Practitioner (GP) in Scotland with a slow-healing 1 cm wound on her right finger. She had sustained a minor burn to the finger 9 days prior to her attendance. A swab was taken by the attending clinician. This swab subsequently grew toxigenic . This result was telephoned to the out-of-hours local health protection team, 8 days after the case presented to her GP.\nThe case lived with her partner and owned two German Shepherd dogs. One dog had a history of a long-standing skin complaint, which had been documented as quiescent. The case worked in retail and had no recent travel history. She had not eaten unpasteurized dairy food nor visited any farms within the last 2 weeks. Her most recent diphtheria vaccination was in 2009.\nA nose and throat swab were collected from the patient and she was treated with diphtheria vaccine and a 2 week course of clarithromycin. She was excluded from work under the Public Health Act Scotland (2009) until completion of antibiotics and clearance swabs, one from each site (nose, throat and wound) were negative. Four close contacts were identified who required nose and throat swabs to assess for carriage of , of whom two were healthcare professionals who had dressed the wound. Contacts were all given diphtheria vaccine and a 1 week course of erythromycin. The two healthcare workers were excluded from work until nose and throat swabs were culture negative. One contact (husband) was identified as carrying in his nose and required a repeat swab following completion of antibiotics to check for clearance. His repeat swab was culture negative. Initial swabs for the fourth contact (a close friend) were negative.\nA local veterinary practitioner examined the dogs, which revealed one had an infected skin lesion, which was swabbed. Throat swabs were also collected from both dogs. Toxigenic was recovered in culture from the skin lesion and throat swabs of both dogs. They"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy presented to Fujian Medical University with giant scrotal elephantiasis and swelling of both lower extremities. The penoscrotal edema began fifteen years earlier, soon after his birth, and it resulted in bilateral lower extremity edema with the penis becoming buried by the scrotum. His scrotal size was massive, and for the past 5 years, the glans penis was not visible nor palpable (Fig. a–c). He had undergone circumcision 13 year earlier and had no history of travel in filariasis-endemic areas. There was also no family history of scrotal elephantiasis or known genetic disorders.\nUpon examination, the patient had a massively enlarged scrotum, with a volume of approximately 16 cm × 13 cm × 7 cm. The anatomical structures and urethral orifice were visible as a deep depression on the scrotum. Both lower extremities exhibited generalized swelling, which was especially noticeable on his ankles. His thigh circumference was 52 cm on the left and 56 cm on the right.\nTissue biopsy of the lower extremities was performed 13 years earlier and revealed lymphangioma and connective tissue hyperplasia. A urinary system ultrasound examination was performed 14 months prior to presentation at our hospital, which confirmed diseased subcutaneous scrotal soft tissues with no abnormalities in the bilateral testicular morphology and blood supply. The results of lower limb lymphoscintigraphy demonstrated that the lymphatic drainage of the lower extremities was obviously tardy. The development of bilateral inguinal and iliac lymph nodes was obviously tardy (Fig. ). The lower limbs and anterior pelvic position was imaged after injecting with the tracer (99mTc-SC) subcutaneously between the first and second toes. The images demonstrated that the lymphatic drainage in both lower extremities were unclear. In the early stage, the images showed that the bilateral inguinal and iliac lymph nodes were blurred, which was obvious on the left side. The concentration of imaging agent (99"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 36-year-old male, admitted to a specialist trauma center on 24 December, 2019, at 21:00, having suffered wounds caused by a cold weapon. He had exhibited hemodynamic instability during transport, but after fluid resuscitation he was stable when he arrived at the hospital. The most notable findings of the physical examination conducted in the emergency room were subdued vesicular murmur in the left hemithorax, heart rate of 125 bpm, mean blood pressure (MBP) of 70-75 mmHg, and multiple wounds to the anterior and posterior chest ().\nAfter administration of packed red blood cells and prophylactic antibiotics, angio-CT of the thorax was conducted (\n), showing contrast leakage from the thoracic aorta and left sided hemothorax. Left pleural drainage and arteriography of the thoracic aorta were performed.\nThe decision was taken to proceed directly to definitive endovascular treatment. Intraoperative aortography () was performed, confirming the damage to the thoracic aorta (at the level of T8) with adjacent tamponade, and a 20/20/82 mm straight thoracic endograft was deployed in the descending thoracic aorta. The endovascular intervention was conducted at 01:00 on December 25, 2019. Control aortography performed after implantation () showed no evidence of contrast leakage.\nThe patient remained in the intensive care unit during the immediate postoperative period. On the first postoperative (PO) day, the patient suffered acute myocardial infarction of the lateral wall, but without compromise to cardiac or hemodynamic function. He was discharged to the wards on PO day 3. The patient had a collection in the left hemithorax due to retained hemothorax, and underwent videothoracoscopy and decortication, conducted by the thoracic surgery team. His recovery was otherwise uneventful and he was discharged from hospital on the 10th day after admission. He is currently in outpatients follow-up with the specialties and is asymptomatic. He had a control chest angio-CT 30"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient 2 was a 7-year-old girl referred to our department for further evaluation of a hard tumor involving the right side of the face (). She was placed on an observation protocol after a thorough diagnostic workup ruled out any endocrinopathies or syndromes.\nNeither patient exhibited trauma and/or associated infections, and both had normal laboratory test findings. The facial CT images of patient 1 showed an expansive lesion with the ground glass appearance that involved the skull base and the right maxillary, zygomatic, sphenoidal, temporal, frontal, and mandibular bones ().\nInvolvement of the orbital bone resulted in a decrease in the socket volume and optic canal diameter, which explained the exophthalmia and vision loss. Bone scintigraphy showed osteogenic activity in the right craniofacial region, without involvement of other skeletal structures. The clinical features and laboratory and radiographic findings confirmed the diagnosis of MFD. The patient underwent osteoplasty of the affected maxillary, zygomatic, mandibular, and temporal bones for the restoration of facial harmony. The surgery was preceded by virtual planning ().\nIn case of patient 2, because of the early development and slight facial deformity, a clinical follow-up protocol was selected. During the growth spurt between 12 and 13 years of age, she developed significant occlusal alterations, facial asymmetry, and difficulty in supporting her eyeglass stem because of sharp growth in the right mastoid apophysis. Laboratory test findings were within normal limits, and bone scintigraphy showed intense osteogenic activity on the right side of the skull. CT revealed volumetric osteofibrous thickening of the maxillary, mandibular, zygomatic, sphenoidal, temporal, mastoid, and parietal bones, with preservation of the internal acoustic meatus, optic canal, and stylomastoid foramen.\nAt the age of 15 years, the patient underwent osteoplasty of the right mastoid and zygomaticomaxillary bones for esthetic com"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old Caucasian male presented with a 6-month history of a neglected rapidly growing lesion on the proximal left thigh. He had no relevant past medical history and took no medications, but admitted to binge drinking on weekends and a 10 pack-year history of smoking. He sought attention when the lesion became painful and malodorous. On examination there was a large approximately 30 x 30 cm geographic lesion centered in the left groin, with heaped edges lying 2 cm proud of the normal skin contour, and an ulcerated raised heterogeneous center. It extended superiorly to the lower abdomen, inferiorly 10 cm below the base of the buttock, laterally to the lateral aspect of the inguinal crease, and medially to involve the scrotum, penile base and contralateral perineum (). In addition there was 2 x 2 cm pigmented polypoid lesion at the dorsal penile base. He had stiffness within the proximal left thigh, had lost 25 kg over the last 6 months and had an ECOG performance status of one. CT of the abdomen and pelvis confirmed a large plate-like lesion lying superficial to the adductor muscle group and femoral vessels, as well as left inguinal and external iliac lymphadenopathy up to 5.2 cm in greatest dimension. A chest x-ray was normal. An incisional biopsy confirmed moderately differentiated squamous cell carcinoma, and he was staged as cT3 cN1 cM1. His disease was prohibitively large for either surgery or radiotherapy so he proceeded to palliative chemotherapy as follows: Cisplatin 75 mg/m2 and Docetaxel 75 mg/m2 every 3 weeks. He tolerated 7 cycles; the first 2 at full dose strength and the last 5 at 75% dose strength (55 mg/m2) due to myalgias, oral mucositis and 2 episodes of febrile neutropenia requiring hospitalization and G-CSF support. The visible lesion showed an early and sustained significant response to therapy (), however, after 7 cycles CT"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old female was admitted to the hospital due to severe suicidality. At the time of admission she complained about an irritating feeling in her nose, which made her constantly grimace in the area around the nose. She was excessively worried about having a serious illness of her nose (secondary hypochondriacal delusions) and was suicidal as a consequence. Her belief persisted even after any underlying medical condition of the nose has been ruled out by extensive medical examinations. She also presented with disorganized behavior, stereotypical movements, emotional instability and lability, and a below average level of intelligence during hospitalization. On the PANSS, her symptoms scored 29/23/70 (for the Psychotic, Negative and General Psychopathology Scale, respectively). Brief neurological examination revealed no abnormal neurological signs. As ascertained by the history taken from the patient and her mother, she had a history of school phobia that began at the age of 12 years, emotional disorders, normal cognitive and physical development, and a three-year history of chronic headache. She managed to complete primary and secondary education with the help of school counseling services given to her on account of school phobia. She had not received any psychiatric care before the described admission. A diagnostic evaluation for chronic headache at the University Children’s Hospital was undertaken a year before admission.\nCalcium, phosphate and parathyroid hormone blood levels were normal. Vitamin D levels were decreased with decreased calcium levels in the urine. No signs of calcium depositions in organs other than the described brain regions were determined by ultrasound. Ophthalmological, ear-nose-and-throat examination and electroencephalography were also normal.\nDetailed neurological examination revealed dysfunction of pursuit eye movement, dystonic positioning of both arms when stretched ahead, discrete ataxia of the arms and legs, and a pathological ext"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 60-year-old female who presented to the hospital with complaints of dull substernal chest pain. She had chronic atrial fibrillation, chronic obstructive pulmonary disease with home oxygen, osteoarthritis, and anxiety disorder as her comorbid conditions. On examination, she did have chronic dyspnea and was on home oxygen. She did not have any cyanosis, palpitations, paroxysmal nocturnal dyspnea, or orthopnea.\nShe was initially evaluated with a nuclear stress test that did not show any reversible ischemia but dilation of the right ventricle (RV); ejection fraction was identified to be 54%. The patient was further evaluated by a transthoracic echocardiogram (TTE) in order to evaluate the RV dilatation. TTE identified a complete absence of IAS and a CA (). The findings were confirmed with a positive bubble study (). Transesophageal echocardiogram (TEE) was performed that confirmed the absence of IAS, demonstrated free mixing of color flow, moderate to severe tricuspid regurgitation, normal mitral valve structure, normal left ventricular ejection fraction, and enlarged right atrium (RA) and RV.\nThe patient was evaluated with cardiac computed tomography angiogram (CCTA) that demonstrated the right coronary artery to be the dominant artery, all coronary arteries to be ectatic/aneurysmal and measuring up to 8-10 mm, a complete absence of IAS, marked dilation of CA and both ventricles, a coronary arteriovenous fistula (CAF) between the distal left anterior descending and coronary sinus, massive dilation of pulmonary arteries, and no mitral or aortic valvular abnormalities; left ventricular ejection fraction was measured to be 59% (Figures –).\nThe patient underwent an invasive angiography (IA) which demonstrated many abnormal findings. It showed that the patient had coronary artery aneurysms measuring 0.7 cm to 1 cm (). IA was instrumental in taking measurements regarding oxygen saturation and pressure at multiple levels identifying a large interatrial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man who previously had not undergone catheter examination or treatment presented with progression of chest oppression. He had no history of Kawasaki disease during childhood and other aneurysms. Cardiac catheterisation revealed double-vessel disease in the left descending artery (LAD) and right coronary artery (RCA), with a giant saccular coronary aneurysm of the LMT. Coronary artery CT (CACT) demonstrated a giant saccular CAA with a diameter of 40 mm on the posterior side of the main pulmonary artery. Blood flow was additionally noted from the RCA and the left circumflex artery into the aneurysm. According to the cardiovascular team’s assessment, the LMT site of entry of the aneurysm was too large to be treated by covered stenting and the margin was too short to touch up covered stenting at the LMT. There was also the problem of treating the feeding arteries. Therefore, surgery was recommended.\nThe patient underwent surgery to prevent rupture and angina (). Cardiopulmonary bypass (CPB) was established via cannulations of the ascending artery and both the vena cava. On the anterior surface of the pulmonary artery, meandering vessels that seemed to flow into the aneurysm were ligated. Coronary artery bypass was performed at the RCA and LAD with saphenous veins. Then, peeling of the adhesion off the surrounding tissue of the CAA was attempted; however, the pulmonary and ascending arteries were so severely adhered. As a result, the aneurysm was exposed just enough to access between the ascending aorta and the main pulmonary artery. Following aortic cross-clamping and cardiac arrest, the wall of the aneurysm was dissected at the right side of the main pulmonary artery. A large amount of thrombus filled the aneurysm. After removing the thrombus, the LMT site of entry of the aneurysm was examined by administering antegrade cardioplegia. The site of entry was of pinhole size, and therefore we were able to close it directly with 5–0 and 4–0 Prolene sutures wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA white 17-year-old male student was admitted to the ear nose throat department following referral from the accident and emergency department of our hospital. The patient presented with a 3-day history of dysphagia that was not associated with pain. He reported greater difficulty in swallowing solids than liquids. Furthermore, during the past weeks his sleep was disturbed due to a sensation of foreign body in the throat, causing him a nonproductive cough. This progressed to difficulty in swallowing his saliva on the day of presentation and prompting him to attend the accident and emergency department.\nPhysical examination showed a well-developed white male in good general health with no past medical history or allergies. Blood pressure was 145/77, pulse was 78, SaO2 was 98, respiratory rate was 16/min, and temperature was 36.4°C.\nOn examination of his oral cavity, depression of the tongue revealed a large oval, pale pediculate mass protruding from the upper pole of the right tonsil and partially obstructing the airway (). The rest of the oral cavity, nasopharynx, and laryngopharynx were normal. No significant neck lymphadenopathy was observed. Examination of head, ears, and nose was unremarkable.\nThe patient underwent a right tonsillectomy under general anesthesia. The tonsil and the pediculate mass were removed by dissection, and hemostasis was performed by diathermy and ligation. The specimen was sent for histology. There were no postoperative complications, and the patient was discharged the following day.\nHistological examination showed macroscopically a tonsil 28 × 22 × 8 mm in size with an exophytic polypoid nodule measuring 26 × 10 × 8 mm. The cut surface of the tonsil showed normal crypt architecture. Microscopy examination of the polyp showed a core of loose fibrous tissue with dilated vascular spaces containing proteinaceous material and lined by sparse bland endothelial cells. There were foci of well-organized lymphoid tissue. The pedicle showed some well"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n51 year old male presented with low back ache with radiation of pain to the right lower limb for 1 ½ months duration. He had pain at rest which aggravated on walking. He walked with a limp. Patient was given epidural injection 3 weeks before he presented to us at another center. There was no relief of pain post injection. Currently he did not have relief with analgesics and physiotherapy and had no relief from epidural injection. There was no history of any previous interventions to the spine or bowel or bladder symptoms. Ankle jerk was absent on the right side. Plantar reflex was equivocal on the right side and down going on the left side. There was no motor power loss or sensory deficit. MRI done showed hypointense lesion that appeared intraradicular in S1 root (arrow mark) with a clear layer of CSF all around the lesion (). Gadolinium MRI did not show any enhancement. There was a clear gap between the dura and the fusiform swelling in the nerve root with no evidence of disc prolapse. A diagnosis of nerve root tumor was made and surgery was advised. Surgery was done with a midline incision with patient in the prone position. Ligamentum flavum on the right side was removed.\nThe upper edge of the S1 lamina was nibbled and the swelling exposed. Due to the long intra spinal course of S1 root, the swelling could be very well exposed.\nThe swelling was seen at a distance from the dura with a definite segment of normal looking nerve root in between (). The swelling was opened longitudinally. Fluffy disc like materials came out from n between the nerve fibres (). No CSF came out from the incision. Material was sent for histopathological examination. The nerve sheath was repaired with 8-0 prolene under microscopic vision. Histopathology report was consistent with degenerated disc material with collagenous tissue showing characteristic cell clusters [] ().\nPost operatively the patient was relieved of his symptoms except for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year old man on home haemodialysis presented with a 6-h history of severe right-sided abdominal colic, non-radiating and associated with rigors and nausea but no vomiting. The pain had not been relieved by simple measures including a change of posture or over the counter analgesics. Twenty-four years previously he had undergone a panproctocolectomy and ileostomy for Crohn's disease. His ileostomy had been functioning normally with no recent change in content or output. He had been anuric for over 12 months prior to this presentation and described no new lower urinary tract symptoms.\nHe had developed end-stage renal disease secondary to chronic pyelonephritis at the age of 36 years and had been receiving home haemodialysis treatment for the preceding two years after a failed renal transplant. He was awaiting a parathyroidectomy for tertiary hyperparathyroidism. He had suffered an episode of right ureteric obstruction secondary to a calculus 11 years previously, when dialysis independent, which was treated successfully with a right nephrostomy. An antegrade nephrostogram at the time of nephrostomy insertion demonstrated a lucent filling defect in the upper third of the right ureter. A repeat nephrostogram one week later demonstrated clearance of the previously identified filling defect and the nephrostomy was removed. He had also presented two years previously while on dialysis with painless visible haematuria which resolved spontaneously. A computed tomography (CT) scan of the kidneys, ureter and bladder at that time demonstrated a 6-mm right-sided distal ureteric stone (Figure ). It was decided at that point to adopt a watchful waiting strategy and he remained completely asymptomatic for the following two years.\nOn examination he was afebrile, blood pressure 165/98 mmHg, heart rate 102 bpm. Abdomen was soft and non-distended but tender on palpation over the right flank with no signs of peritonism. Bowel sounds were normal, and a functioning ileostomy was noted"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old woman, known patient of UC on steroids for the past one year, presented with headache for one day. Next day she developed sudden onset of weakness of right upper limb and lower limb, associated with progressive inability to speak and comprehend. She did not have vomiting, seizures or loss of consciousness. She also complained of irregular bloody diarrhea and was on amino salycilic acid. There was no history of rash, joint pains or jaundice. She had unexplained first trimester abortions twice. On examination, she had pallor without significant lymphadenopathy. She was conscious and had global aphasia. She had right hemianopia, bilateral papilledema, right upper motor neuron facial nerve palsy and right hemiplegia with power of 1/5 in right upper limb and 2/5 in right lower limb. CT and MRI brain showed hemorrhagic infarct in left parietal region [Figures and ]. MR venogram revealed thrombosis involving superior sagittal sinus and right transverse sinus, later confirmed by digital subtraction angiography []. Other laboratory investigations revealed microcytic hypochromic anemia with hemoglobin of 8.5 g/dl. HIV, antinuclear antibody and anticardiolipin antibody was negative. Prothrombotic work up (APLA, Lupus anticoagulant, Protein C, Protein S, Antithrombin 3, ANA, homocysteine) was negative. Colonoscopy revealed multiple hemorrhage prone erosions involving the sigmoid colon. Initially she was started on Low molecular weight heparin for 24 h. As her clinical status continued to worsen, she was taken up for intra sagittal sinus thrombolysis. A catheter was advanced through the right femoral vein to the occluded sagittal sinus. After confirmation of catheter tip, intra sagittal sinus urokinase was given initially as a bolus of 100,000 units which was followed up with continuous urokinase infusion at the rate of 70,000 units per hour by keeping catheter in situ. Check venogram was done at 12, 24, and 48 h. Venogram at 48 h showed partial opening up of super"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old Caucasian male sustained diaphyseal fractures of the left radius and ulna three months prior to the presentation in focus. The fractures were managed surgically with closed reduction and 3.0 mm intramedullary elastic nailing of the ulna and open reduction and internal fixation (ORIF) of the radius with a 3.5 mm dynamic compression plate (DCP). Follow-up at two months confirmed satisfactory progress and radiological evidence of the union. The patient was scheduled for elective removal of the elastic nail at three months.\nOne week prior to metalwork removal the patient tripped and fell onto his outstretched left hand. He presented with severe clinical deformity of the forearm and severe distal neurovascular deficit (Figure ). The hand was pale with an absent radial pulse, prolonged capillary refill time (CRT) and no digital signal on pulse oximetry. Furthermore, both sensory numbness and motor weakness in the distributions of both median and ulna nerves were noted.\nEmergent closed reduction in the emergency department was only partially successful in restoring alignment, with restoration of the CRT but persistent neurological deficit. Post-reduction radiographs revealed persistent angular deformity of sixty degrees. Re-fracture of the ulna with plastic deformation of the flexible nail was again noted, as was a periprosthetic fracture at the distal margin of the radial plate (Figure ).\nIn view of the persisting neurological deficit, the patient was taken to the operating theater expediently. Further attempts at closed manipulation under general anesthesia were unsuccessful. The IM nail- though deformed- was intact allowing successful removal via the routine method from the proximal ulna entry point; however, satisfactory reduction could still not be gained. The radius was approached through the previous volar approach and re-plated, ensuring use of a longer 3.5 mm DCP to account for the previous screw holes. The ulna was then approached directly and inter"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).\nThe patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.\nWe performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n45 year old female patient was brought to our hospital with 4 months history of loss of interest in routine daily activities and inactiveness. The symptoms were insidious in onset with rapid progression over 4 months and sudden worsening in 1 week prior to presentation. There was no history of emotional lability, hallucinations or memory disturbances. There was no history of falls, and no sensory or motor deficits.\nHer general examination and vital signs were unremarkable. Neurological examination revealed severe apathy and impaired attention span and needed repeated coaxing to cooperate. Speech was hypophonic. She could follow single commands. Naming was normal but reading and writing were impaired. Mini Mental State Examination (MMSE) score was 18/30. Bilateral Papilledema and reduced abduction of both eyes was noted. The other cranial nerves were normal. There was evidence of rigidity in all four limbs and bradykinesia was present. Power was normal and all reflexes appeared exaggerated. Plantars were extensor. Gait was slow with narrow base and slow shuffling associated with body bradykinesia. There were no signs of meningeal irritation.\nHer baseline hematological and biochemical investigations were normal apart from peripheral blood smear which revealed microcytic hypochromic picture. Magnetic Resonance Imaging (MRI) brain was done () revealing diffuse deep white matter and periventricular T2 and FLAIR hyperintensities bilaterally which was followed by Digital Subtraction Angiography (DSA) (), which revealed torcular and Superior sagittal sinus DAVFs with arterial feeders from Internal Carotid Artery (ICA) via marginal tentorial artery and from External Carotid artery (ECA) through occipital and middle meningeal artery branches.\nIn view of the presentation with rapidly progressive dementia with parkinsonism and clinical findings of apathy, cerebral dysfunction, raised ICP and parkinsonism with features of pyramidal dysfunction all likely due to venous congestion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-month-old boy was referred for a right lower cheek mass and a left thoracic subcutaneous mass both present for 3 months. He was asymptomatic and healthy with no significant medical, surgical or familial history. The thoracic lesion was small (1,0 × 1,6 cm) and mobile. The cheek lesion presented as a deep and firm soft tissue submucosal mass adherent to the mandible (Fig. ).\nUltrasound (US) examination of both masses showed hypoechoic lesions with small calcifications and scant vascularization. Magnetic resonance imaging (MRI) of the neck showed a soft tissue mass of 3.4 (AP) × 2.2 (T) × 3.8 cm (CC), with lobulated contours and a cystic center (Fig. ). The lesion was located within the right buccinator and masseter muscles and showed bony invasion of the right mandible and peripheral enhancement with injection of gadolinium. To rule out other synchronous lesions, cardiac and abdominal US and brain MRI were performed and were negative.\nThe thoracic lesion was excised and the oral lesion biopsied. The histopathology was similar and showed spindle cell tumors with a storiform pattern (Fig. ) compatible with infantile myofibroma.\nThroughout the treatment, the conduct was coordinated by an adult head and neck oncology – reconstructive otolaryngologist and a pediatric oncologist. On multiple occasions, the patient was presented at a multidisciplinary pediatric oncology clinic for medical aspects and at a multidisciplinary head and neck oncology clinic for surgical aspects. The first surgery (debulking) was done jointly by an adult head and neck oncology - reconstructive otolaryngologist and a pediatric otolaryngologist. All other ablative and reconstructive surgeries were performed jointly by two adult head and neck oncology - reconstructive otolaryngologists. Surgical treatment of the mandibular tumor was initially judged too morbid and chemotherapy was started with Methotrexate and Vinblastine. After six cycles, the patient presented feeding difficulties. A computeri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman, with a history of double vessel coronary bypass surgery (CABG) in 1998, presented with five months of increasingly frequent exertional chest tightness and dyspnea. In 1998, the patient presented similarly with a few months' history of exertional chest heaviness, dyspnea, and jaw numbness. After a positive treadmill stress test demonstrating ST depressions, diagnostic coronary angiography was complicated by severe hypotension immediately upon catheter engagement of the left main artery, with blood pressure falling to less than 50 systolic and accompanied by severe chest pain. Limited angiographic images obtained demonstrated an 80% left main stenosis, with angiographically normal vessels in the remainder of the coronary tree. The patient was kept in hospital and sent for double vessel CABG, receiving a left internal thoracic artery (LITA) graft to LAD and saphenous vein graft to obtuse marginal. Since 1998, the patient had been relatively asymptomatic up until five months prior to current presentation.\nHer current symptoms were similar, though not identical to her initial presentation in 1998, but they were still provoked by activity and relieved with nitroglycerin spray and rest. She also reported a significant decrease in energy and her usual activities were limited due to exertional dyspnea. Review of systems was otherwise noncontributory. Notably, she was an active user of tobacco, smoking half a pack a day for the past ten years, was a social drinker, and had a mother who died from a heart attack in her early 60s. Her medical history was significant for gastroesophageal reflux, hypertension, dyslipidemia, and hypothyroidism. Her medications included atenolol, ezetimibe, rosuvastatin, paroxetine, and l-thyroxine. She had also recently been placed on topical nitrate patch. Her new-onset symptoms prompted a referral for repeat coronary and graft angiography, and possible percutaneous intervention if appropriate. Based on her cardiovascular hist"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old gentleman was admitted after he developed acute kidney injury and major upper gastrointestinal bleeding. His urea levels measured 50 mmol/L and creatinine levels 1500 µmol/L. A decision was made to commence haemodialysis. A temporary dialysis catheter was inserted into his right femoral vein initially, but it was then decided to change this to a temporary internal jugular dialysis catheter to minimize the likelihood of catheter-related infection.\nThe left internal jugular vein was punctured under ultrasound guidance and a temporary dialysis catheter was inserted without difficulty. There was good flow in both arterial and venous lumens of the dialysis catheter. A routine post-line insertion chest X-ray was performed (). The chest X-ray showed that the dialysis catheter was following an abnormal course by passing down the left side of the mediastinum rather than crossing the midline via the brachiocephalic vein to enter the superior vena cava on the right side. Aspirated blood gas analysis confirmed that the catheter was in a vein.\nA contrast venogram was requested to define the anatomy and ensure that the dialysis catheter remained safe to use. The venogram showed that the patient had a persistent left-sided superior vena cava (PLSVC) or possible double SVC and the dialysis catheter tip was in the distal part of the left-sided SVC. He was started on haemodialysis after the dialysis catheter position was confirmed with the venogram.\nAfter 4 h of haemodialysis in the dialysis unit, he was transferred back to the ward. Approximately 24 h after dialysis, the patient started complaining of breathlessness. An urgent chest X-ray () showed the presence of cardiomegaly, a new left-sided pleural effusion and subcutaneous emphysema over the left clavicle.\nAn urgent chest computed tomogram () was performed and showed the presence of bilateral pleural effusions (left more than right) and a 1.2 cm, presumed new, pericardial effusion. There was also left-sided basal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old female with hypertension, untreated hyperlipidemia, hypothyroidism, but without prior history of CAD or angina symptoms was referred to a cardiologist's office for a treadmill exercise test secondary to new onset palpitations. She denied any chest pain or pressure, shortness of breath, exertional dyspnea, or leg swelling. She quit smoking 36 years ago and has no family history of early cardiovascular diseases. She has a very distant cardiac work-up years ago, including a stress test and an echocardiogram, which the patient reported were unremarkable. Vital signs prior to the test were a blood pressure of 140/78, heart rate of 80, and a respiratory rate of 14. Physical exam was unremarkable except for a systolic ejection murmur that was graded II/VI at the base. EKG was at baseline with a normal sinus rhythm, normal axis, and occasional premature ventricular complexes (PVCs).\nThe patient underwent an exercise stress test using the Bruce protocol and was able to complete stage 1 with exercise for three minutes at a speed of 1.7 mph and a 10% incline. The test was terminated due to dyspnea and fatigue without chest pain. She reached a heart rate of 141 beats per minute which was 98% of predicted for her age. She accomplished 4.5 metabolic equivalents of exertion. With exercise, she had occasional atrial premature complexes and PVCs with a ventricular couplet in recovery. She started to notice tightness in her chest. Her peak blood pressure at the time was 218/90.\nThe patient was transferred onto a stretcher, and an IV line was started. She was given sublingual nitroglycerin, 325 mg of aspirin to chew, and one 5 mg IV push of metoprolol tartrate. She then received nitroglycerin paste and metoprolol tartrate IV every 5 min for two more doses. At that time, her EKG on the stretcher showed ST elevations in leads I, aVL, V5,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old man was referred to the department of Oral Medicine of the Isfahan University of Medical Sciences, Isfahan, Iran. He was complaining of exophytic painless mass in dorsal surface of his tongue. He expressed that the lesion had appeared 2 years ago and lasting ever since. The mass had negligible growth rate when he first noticed, but had grown rapidly over the past 2 months to attain the present size. The patient's chief complaint was his fear of speaking because it might make the relatives shocked and wonder and also his phobia of transmission to others or whether it might have a cancerous nature.\nMedical history of the patient showed history of epilepsy begining at age 10, taking anti-seizure medications since childhood, and his dental history showed multiple chronic oral ulcers diagnosed as drug-induced lichenoid reaction which were presumed to be related to anti-seizure medications. The list of medications included phenytoin sodium (300 mg/d) and carbamazepine (600 mg/d). It seemed that the patient was of a low socioeconomic status and had not followed his treatment and was taking his medicaments irregularly. Evaluating his laboratory tests revealed anemia, leucopenia, transient thrombocytopenia, folic acid deficiency, and increased liver enzymes. In the study of peripheral blood smear and bone marrow aspiration, mild relative erythroid hyperplasia was diagnosed for him. Symptoms of hirsutism due to phenytoin were evident in his head and face. Despite of long-term phenytoin consumption, there was no gingival hyperplasia.\nClinical examination revealed a reddish-yellow exophytic, pedunculated mass which centered on the dorsal surface of tongue, measuring 4 × 3 × 1 cm3 in size. The lesion was lobulated with a smooth surface. The base of the lesion was so tightly stuck to the bed that the interface was always slightly bloody []. Neither any traumatic factor in the oral cavity, nor palpable cervical lymph nodes were detected. The diagnostic hypotheses wer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 50-year-old male, 173 cm tall, and 85 kg in weight (body mass index (BMI): 27.7 kg/m2). He had a medical history of urinary tract cancer, type 2 diabetes mellitus, hypertension, and Hashimoto's disease. He underwent a robot-assisted radical cystectomy in lithotomy position. The total operation time was 419 min. The operative position was lithotomy position with his lower leg flexed and elevated by soft stirrups. Continuous compression devices on both calves were used for venous thrombosis prophylaxis throughout the procedure. No bleeding-promoting drug was used before and after the surgery.\nSixteen hours after the surgery, he complained of severe bilateral lower leg pain and swelling. Initial evaluation of lower extremities revealed foot drop, swelling and tightness of the anterolateral aspects, and stretch pain on passive ankle planter flexion. No remarkable finding was appreciated on the posterior aspects of his lower legs. Serum creatine kinase was elevated to at 28000 U/l. The compartment pressure was measured by an arterial line set with simple 18-gauge needle under the diastolic blood pressure of 98 mmHg. The measurement was performed at three places of each compartment, and the average value was recorded. The anterior and lateral compartment pressures in both legs had increased to 200 mmHg despite normal posterior compartment pressure (35 mmHg) or thigh compartment pressure (35 mmHg). Contrasting computed tomography (CT) showed swelling of the bilateral muscles in the anterior and lateral compartments without contrasting effect compared to the posterior compartments (). Based on these findings, WLCS localized in the anterior and lateral compartments was diagnosed.\nAn emergency fasciotomy was performed twenty hours after initial surgery. Anterior and lateral compartments were released with single incision (). Discoloration of the muscles improved within a few minutes after the fasciotomy (). Shoe-race procedure was added to prepare for second"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 71-year-old male diagnosed with renal AL amyloid nephrotic syndrome in March of 2007 and underwent a stem cell transplant in December of 2007, obtained an organ response with urinary protein falling from 10.5 g/24 h to 1.5 g/24 h. The patient developed congestive heart failure in July of 2013 and underwent an endomyocardial biopsy that demonstrated amyloid. Proteomic typing demonstrated that this patient had TTR cardiac amyloid, and genetic studies demonstrated the TTR gene to be wild-type, so-called senile cardiac amyloidosis. He died at the age of 79 of progressive heart failure 39 months following the diagnosis of TTR cardiac amyloidosis. Comment: This patient had two types of amyloidosis. He had AL amyloidosis successfully treated and had not relapsed after 9.5 years but subsequently developed age-related cardiac amyloidosis that could have easily been misdiagnosed as relapsing AL if cardiac biopsy and proteomic analysis had not been done.\nOver 15 years ago, it was common to identify amyloid in a patient with a monoclonal gammopathy and assume that this was AL type. However, in 81 patients with TTR amyloidosis, an M protein was found in 20 of the 81 and an abnormal free light chain ratio in 8 of the 81. A second study of wild-type TTR amyloidosis also demonstrated a monoclonal protein in 25% of patients. Finally, even when AL is diagnosed with proteomic analysis, this does not indicate whether the amyloidosis is localized or systemic. Attention must be given, particularly to those patients who present with amyloid in a skin biopsy, bladder biopsy, laryngeal biopsy, or at the edge of a colonic ulcer or polyp, that the amyloid may be a localized AL amyloidosis that requires no intervention.\nMany specialists, when encountering a patient with biopsy of an organ containing amyloid, refer to a cancer care provider uncertain of the type of amyloidosis. The first step for all biopsied tissues, shown in an algorithm (Fig. ), would be mass spectroscopic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old gravida 4 para 4 was referred to our centre for an abdominal and perineal mass that gradually enlarged over the past 3 years. She complained of abdominal distension, slow transit with 1–2 stools per week, and difficulty in voiding. There was no abdominal pain. She lost 8 kg over the past 3 years. On physical examination, the patient had a large, firm and indolent abdominal mass that emerged through an incisional hernia of the abdominal wall. We also noted a second mass, measuring 40 cm and occupying the internal part of the gluteal region. Its pedicle extended into the pelvis through the right ischiorectal fossa (). Perineal examination revealed a grade IV hysterocele. Computed tomography (CT) showed a huge, well-demarcated solid, homogeneous mass with moderate enhancement occupying the abdomen and pelvis herniating through the perineum (). The core needle biopsy findings were consistent with myxoid neurofibroma. Exploratory laparotomy showed a firm multilobed mass () that contracted intimate adhesions with the pelvic colon, right ureter and rectum. Resection was performed without organ involvement through a combined perineal approach. Tumour resection was macroscopically completed except in the perineum, where the tumour was left (R2 resection) to avoid anal sphincter injury. The operative specimen weighed 5.842 kg. Histological analysis showed a spindle cell tumour with a myxoid matrix without atypia or mitosis. On immunochemistry, the tumour was negative for PS 100 and CD 117 and positive for nuclear β-catenin and smooth muscle actin. It was diagnosed as a desmoid tumour. During the immediate postoperative period, wound infection and partial dehiscence were noted. Flatus and liquid stool incontinence were also observed. The incontinence completely improved during the 12th postoperative week. Adjuvant treatment with tamoxifen at an initial dose of 150 mg/day and indomethacin (100 mg per day) was given for the incomplete excision (R2). Tamoxifen was t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old female presented to the emergency room with a three-day history of right hip pain. She reported decreased range of motion and difficulty ambulating. She denied constitutional symptoms or fever. She had undergone intra-articular steroid injection of her right hip three days prior. Review of systems was otherwise unremarkable. Her past medical history was relevant for hereditary spherocytosis with splenectomy at age 14 and chronic right hip osteoarthritis. Her only medication was celecoxib as needed. She denied any drug allergy. She was unaware of her immunization history. She worked as a flight attendant, denied smoking or recreational drug use, and had not recently travelled outside of Canada. On initial examination she was afebrile and her vital signs were within normal limits. On examination of her right hip she had limitation of internal rotation with reproducible pain, but her physical exam otherwise was unremarkable. Her initial investigations showed elevation in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at 22.9 mg/L and 25 mm/hr, respectively. Her white blood cell count was not elevated. An X-ray of her right hip showed severe joint space narrowing with osteophytosis consistent with severe osteoarthritis. Arthrocentesis was performed and synovial fluid samples were directly inoculated onto solid culture media, including blood agar and chocolate agar. Two of three samples also underwent cytospin centrifugation and direct Gram stain. Gram-negative bacilli were observed in one sample though heavy neutrophils were observed in both. Synovial fluid analysis for cell count and chemistry was not performed due to insufficient sample. She was admitted to hospital for 24 hours of observation and was subsequently discharged with instructions to return to hospital if her symptoms worsened or if cultures subsequently grew a pathogenic organism.\nThree days later she was seen in a follow-up clinic. In the interim she had developed a fever"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 37-year-old man with a past medical history of hypertension, diabetes mellitus, extensive hypercoagulable history, and a remote history of exploratory laparotomy for an embolectomy of the superior mesenteric artery and a small bowel resection of the jejunum. He presented to the Emergency Department with an 8-hour history of worsening, crampy abdominal pain, nausea, vomiting, and multiple episodes of hematemesis. He had a bowel movement prior to arrival, but otherwise his review of systems was unremarkable. Physical examination was notable for hemodynamic stability and a mildly distended abdomen with epigastric tenderness but without guarding or rebound tenderness. Given his prior surgical history, a computed tomography (CT) of the abdomen was obtained, which showed dilated loops of bowel with a transition point in the region of the proximal ileum, just distal to his prior bowel anastomosis. The distended proximal small bowel loops contained fecalized material, and the distal small bowel loops were also decompressed without evidence of ascites, bowel wall enhancement, or free air ().\nThe patient was admitted and initially managed nonoperatively with fluid resuscitation, pain control, bowel rest with nasogastric tube decompression, and serial abdominal exams. Following return of bowel function, the nasogastric tube was discontinued on hospital day 2 but reinserted hours later due to persistent, new-onset vomiting, and worsening abdominal distention. Without significant improvement in symptoms, the patient was taken to the operating room urgently for an exploratory laparotomy. Intraoperatively, the small bowel was dilated to approximately the midjejunum, where an intraluminal obstruction was palpated and subsequently identified to be a phytobezoar. Consequently, a longitudinal enterotomy was performed to evacuate the phytobezoar measuring 4 cm by 3 cm and was closed in a transverse fashion in two layers (). The phytobezoar seemed to be composed of fibe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old female with diagnosis of Cushing's disease (ectopic ACTH syndrome) had undergone adrenalectomy in 2000. She was kept on low-dose steroids postoperatively. The patient started having pain in the left hip 2 years postadrenalectomy, for which she was given analgesics and calcium supplementation. Her BMD (T score: –3.3; lumbar spine and –2.6; proximal femur) and radiological examination suggested severe osteoporosis. She subsequently suffered pathological fracture neck of femur for which she was operated and valgus osteotomy was done. Postoperatively, she was advised alendronate 70 mg once a week with calcium supplementation along with low-dose steroid for post adrenalectomy supplementation. After 6 years, the patient again started having pain in the right hip and thigh. Her BMD was found to be improving (T score –1.1) and there was no radiological evidence of osteoporosis as well. She was advised analgesics, exercises, along with the previous treatment, but her pain did not subside. After 5 months, she had aggravation of pain and on radiological evaluation was found to be having pathological subtrochanteric fracture for which she was operated and internal fixation with long proximal femoral nail was done []. The fracture united at 10 months and pain in thigh and hip subsided []. The patient continued to take alendronate along with low-dose steroid for post adrenalectomy supplementation. Two years later the patient started having diffuse dull ache, insidious in onset, activity related pain in the right foot which did not subside completely with analgesics and physical therapy for 3 months. The radiographic evaluation showed incomplete, transverse, diaphyseal fracture of fifth metatarsal shaft with thickening of lateral cortex []. Patient's BMD showed normal mineral density (T score –0.7). She was advised plaster. Alendronate therapy was discontinued and teriparatide therapy 20 mcg subcutaneously was started and continued for 6 months. She improved and the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old woman was clinically monitored for primary hyperparathyroidism since 2005. She had a medical history of arterial hypertension and in 2015 she underwent a laparotomic left nephrectomy for hydroureteronephrosis caused by recurrent kidney stones.\nIn March 2017, she had a neck ultrasound showing a nodule with a size of 9 × 5 mm in the lower third of the left thyroid lobe, consistent with left parathyroid. Subsequent T99m single-photon-emission computed tomography (SPECT)/CT scans did not show any uptake of the radioactive tracer at the level of the lower left thyroid gland different from the surrounding glandular tissue. A left parathyroidectomy was scheduled and preoperative laboratory tests showed elevated PTH at 453 pg/ml, low Vitamin D at 25.1 ng/ml, elevated serum calcium of 12.9 mg/dl, slightly reduced level of phosphorus. A neck CT was performed, not showing solid growing mass in the cervical district, in the absence of observable thyroid or parathyroid lesions.\nIntraoperative PTH at the beginning of surgery was 440 pg/ml. The intervention started with a Kocher cervicotomy and cervical exploration at the left lower thyroid lobe. Here, there was a voluminous lesion with adipose appearance and texture. After identification and preservation of recurrent laryngeal nerve, the lesion was completely excised. On macroscopic investigation it was multilobulated, with a size of 7 × 7 cm, containing a little and poorly defined lump consistent with a pathologic parathyroid (). The sample was sent to obtain frozen sections and definitive histological examination. Frozen sections revealed the presence of adipose and connective tissue with tubular epithelial basaloid proliferation made of little cells without significant nuclear atypia, with focal areas of possible oncocytic differentiation. In those sections, the morphological features did not allow to distinguish between a thymic or parathyroid origin of the proliferation. After the excision intraoperative PTH dr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24 year old male was examined in the cornea services of our institute in January 2013 with the chief complaint of noticing a mass in the left eye for the last 6 months which was increasing slowly in size. He also complained of severe itching in both eyes for many years for which he had been prescribed various topical medications. He underwent a complete ophthalmic examination bilaterally. Ocular examination revealed an unaided visual acuity of 20/20 OU and intraocular pressures of 16 and 18 mm of Hg in OD and OS, respectively, by Goldman applanation tonometry. Anterior and posterior segment ocular examination OD was unremarkable except for the presence of papillae on the upper palpebral conjunctiva. There was no limbal involvement in the right eye. On eversion of the left upper lid, an intense papillary reaction was seen diffusely associated with several large “cobblestone” papillae measuring 1.5–2 mm in the centre and lateral side of the lid (). These were associated with a ropy discharge. The temporal limbus in the left eye revealed the presence of a reddish sessile papillary mass extending for 2 hours from 2 to 4 o'clock (). The surface showed the presence of multiple capillary fronds appearing as red dots, with focal areas of keratinization on the inferior border of the lesion (). The mass was freely movable and the temporal edge of the mass was associated with engorged conjunctival vessels. The rest of the limbus did not show any evidence of thickening, and anterior and posterior segment examination was noncontributory. The surface of the mass stained significantly with rose bengal. Clinically, the diagnosis of bilateral, though asymmetric, palpebral VKC (left eye being more involved than the right) was made. For the limbal mass in the left eye, the possibility of epithelial hyperplasia was entertained but OSSN could not be ruled out. Excision biopsy with wide margins was performed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old lady underwent an elective laparoscopic Nissen fundoplication. On the second postoperative day she deteriorated with persistent vomiting, pyrexia, and low oxygen saturations and was promptly admitted to the intensive care unit (ICU). Oesophago-gastro-duodenoscopy (OGD) was performed with dilatation of a tight gastro-oesophageal junction (GOJ).\nShe then continued to be hypoxic and hypotensive and a chest X-ray revealed a right sided pneumothorax which was managed with a right chest drain. Serial arterial blood gas samples did not reveal any acid-base disturbances at this stage. A gastrografin swallow ruled out any perforation in the oesophagus and was otherwise nonspecific. After a short period of noninvasive ventilation, she remained hypoxic and was consequently intubated. A second chest drain was inserted on the left side due to worsening bilateral pleural effusions on a subsequent chest X-ray.\nA repeat OGD revealed a normal GOJ with a rotated and distended stomach but there was no evidence of gastric outlet obstruction. As the patient continued to deteriorate, a computerised tomography (CT) scan was done () which confirmed herniation of the stomach into a congenital postdiaphragmatic space. At exploratory laparotomy, the anterior wall of the stomach was noted to be herniating into a congenital space behind the diaphragm pushing the liver and the inferior vena cava anteriorly. There was no evidence of a gastric volvulus. Following the retrieval of the herniating segment, the wrap was noted to be congested with an area of ischaemia which recovered promptly following reduction and no resection was necessary. The wrap was undone revealing a defect in the anterior wall of the stomach. The margins of the defect, which were of doubtful viability, were trimmed and the defect was closed with nonabsorbable sutures and covered with omentum. The stomach was then fixed to the anterior abdominal wall with nonabsorbable sutures. No defect was noted in the diaphragm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old woman visited our clinic with a 4-year history of tremor in both hands and a 6-month history of gait disturbance. The patient reported that the tremor in both hands and gait disturbance were progressively aggravated. On neurological examination, postural tremor was noted in both hands, but rest tremor was not observed. Rigidity was present in the extremities but not in the neck. On walking, arm swing was decreased. Mild bradykinesia was observed while the fingers were tapped, hands were closed and opened, and when foots were stomped on the floor. Facial expression was normal. Although postural tremor and rigidity were similar between both hands, brandykinesia was more severe in the left hand and arm swing on walking was more decreased in the left side. The patient showed independent walking with minor gait impairment and mild postural instability on the pull test; she recovered with 5 steps backwards for recovery without help. She complained of orthostatic dizziness but did not have orthostatic hypotension. Her consciousness was clear and orientation was well maintained. She revealed normal findings in the motor and sensory test, neurological tests for cerebellar function and eyeball movements, and deep tendon reflexes.\nThere was neither a notable history of medical disease nor a history of drug ingestion causing bradykinesia. Routine physical examinations including fundoscopy showed no abnormal findings. Nor were abnormal findings in the routine blood test, biochemical test, electrolyte test, thyroid function test, syphilis test, human immunodeficiency virus test, serum vitamins, serum cupper, serum ceruloplasmin, chest X-rays and electrocardiograms.\nThe patient was diagnosed with parkinsonism based on bradykinesia of both hands, rigidity and postural instability. Her score on the Unified Parkinson Disease Rating Scale was 22 points. Magnetic resonance (MR) images showed an ill-defined mass in the anterior third ventricle and hypothalamus, which had p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA nulliparous, 30-year-old female, presented to the infertility clinic with complaints of primary amenorrhoea and infertility, with chronic pelvic pain for more than ten years duration. The general physical examination was unremarkable with normal secondary sexual characters. The routine laboratory investigations for amenorrhoea and infertility were normal including normal hormonal profile. Pelvic examination revealed a normally developed vagina and cervix and anteverted nulliparous uterus. The patient had prior been investigated several times, including sonography of pelvis, outside our institution, with all inconclusive reports.\nThe patient underwent ultrasound in the radiology department of our institute, which demonstrated the presence of a normal sized anteverted uterus, oriented more toward the left side of pelvic cavity. The endometrial cavity was distended with echogenic fluid. The left uterine tube was dilated and filled with fluid of similar echogenecity. The cervix and left ovary were normal. A complex mass comprising of solid and cystic components was found on the right side. There was no separate visualization of right ovary. The patient was advised pelvic magnetic resonance imaging (MRI) to better characterise the ultrasound findings.\nMRI of the pelvis showed presence of two asymmetric uterine horns, smaller on the right side with thin myometrium and normal sized left with normal myometrium. Both endometrial cavities were distended with hemorrhagic contents and showed no communication to each other. There was associated hematosalpinx on either side. The cervix and vagina were normally developed, however there was no demonstrable communication between the endometrial cavity and the endocervical canal. Both the ovaries were normal. On the basis of MRI findings, a diagnosis of unicornuate uterus with cervical dysgenesis and a cavitated, noncommunicating rudimentary horn on the right side, was made [].\nThe patient was taken up for laprohysteroscopy. The ce"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43 years old, Latin American woman, right-handed, height 170cm, weight 106 kg, without relevant comorbidities except for obesity, suffered a pathological fracture of her right femur in May 2018. Consequentially she was treated with the resection of the fragment involved in the fracture and its substitution with a cylindrical-shaped implant of bone cement, stabilized with double carbon-PEEK fiber plates. The pathologist report was positive for malignant PECome tumor, a low-grade neoplasm, without any indication for further treatment. After a couple years of wellness, even though the function of the right low limb was reduced, the patient suffered in January 2020 a sudden atraumatic pain localized on the synthesized zone; After a radiological exam, implant failure was diagnosed (). As a routine follow-up was performed, a series of instrumental exams was carried out, comprehensive femur X-Ray, a PET-CT with FDG and chest CT scan in March 2020, which evidenced some pulmonary nodules of a probable metastatic nature. New surgical treatment was performed with distal femur resection and implantation of a megaprosthesis implant. The histological exam, in the latter case, was positive for malignant PECome tumor. During the hospitalization a specific anamnestic collection focused on the bone fragility and osteoporotic risk factors was performed in addition to routine laboratory tests for bone metabolism (protein electrophoresis, complete blood count, 24-hour urine calcium excretion and creatinine levels, serum level of calcium, albumin, phosphorus, vitamin D, alkaline phosphatase, blood urea nitrogen and creatinine) and densitometric bone evaluation of lumbar spine and both hips. It was also performed a biopsy from quadriceps muscle of both legs. No personal or familiar risk factors for generalized osteoporosis were highlighted. Laboratory test showed only a slightly increased PTH (43 ng/L ; normal values 8 ng/L -40 ng/L). Hand grip test was performed and no significant diff"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old female had experienced unstable gait for 3 months. Because her disability was gradually progressing, she consulted a local hospital. When she came to our hospital for further examination 1 week later, she could not move without a wheel chair. Neurological examination revealed cerebellar truncal ataxia without Romberg's sign. Magnetic resonance imaging (MRI) of the head showed a cystic lesion in the foramen of Magendie, which was compressing the inferior part of the vermis and the medial part of the cerebellar hemisphere without causing hydrocephalus [].\nShe had previously consulted her local hospital with a complaint of headache 3 years ago. MRI performed at that time revealed the same cystic lesion to be present. The intensity of the cyst was similar to that of the cerebrospinal fluid (CSF), and the cyst was divided into two portions, suggesting the presence of a multilobular cyst. Because the patient's symptoms were believed to attribute to the presence of this cystic lesion, surgical decompression was planned.\nMedian suboccipital craniectomy was performed such that after the dural incision, the cyst was exposed. The retromedullary cistern was open, but the cyst had not shrunk, and the cyst was found not to communicate with the surrounding cistern []. Most of the cyst wall was successfully removed. A small part of the cyst that was still attached to the choroid plexus at the foramen of the Magendie was allowed to remain [], and the fourth ventricle was not opened via the obex.\nPathohistological examination demonstrated that the cyst wall was composed of a collagenous membrane lined by multiple layers of arachnoid cells []. Chronic inflammation and hemosiderin pigmentation were absent on the wall. This result confirmed the diagnosis of the cyst as an AC.\nThe patient's postoperative clinical course was excellent and her neurological recovery was remarkable. She regained her mobility and could walk without a cane. MRI performed 2 weeks after the operati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman presented for a routine annual examination to her primary care physician. She had no significant past medical or surgical history. There was no family history of breast or ovarian cancer. Physical examination of the breast was unremarkable. She had never undergone routine screening mammography, so as part of her annual examination, a screening mammogram was ordered. The bilateral digital screening mammogram with tomosynthesis showed heterogeneously dense breast parenchyma, with calcifications in the upper central left breast, Breast Imaging-Reporting and Data System (BI-RADS) 0, for which diagnostic mammogram and breast ultrasound were recommended. A digital diagnostic mammogram showed heterogeneously dense breast parenchyma, with a single 5-mm area of calcifications in the upper outer quadrant of the left breast having very unusual morphology, with a lacy appearance (). The indeterminate calcifications were not typical for macrocalcifications and were not associated with ducts. The findings were assessed as BI-RADS Category 4, suspicious, and stereotactic biopsies were recommended. Ultrasound revealed no cystic or solid mass in either breast. Multiple left breast core needle biopsies were obtained under stereotactic guidance with vacuum-assisted needle biopsy. A specimen radiograph confirmed the targeted calcifications in the cores.\nPathologic findings: The core needle biopsies consisted predominantly of adipose tissue with only a few benign breast ducts and lobules. One of the core biopsies had 2 foci of OM with calcifications, each 0.5 mm, characterized by small anastomosing bony trabeculae without associated bone marrow elements (). These foci were located in benign adipose tissue, devoid of epithelial breast parenchymal components. Benign breast ducts and lobules were located in the same core, 4 mm from the hemangioma. Hemangioma with capillaries, postcapillary venules, and small veins lined by bland endothelial cells were present in the foc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old male with a history of nonischemic cardiomyopathy with a left ventricular assist device was admitted for expedited heart transplant evaluation. The evaluation included an elective colonoscopy in light of a family history of colorectal cancer in his mother who died at age 61 from the disease. The patient had his first screening colonoscopy at age 45 and was diagnosed with benign polyps, which were removed, and left-sided diverticulosis. The procedure was uncomplicated and he was advised to repeat a colonoscopy in five years.\nThe patient was without GI symptoms at the time of his colonoscopy. He denied tobacco, alcohol, or illicit drug use. His medications included amiodarone, aspirin, famotidine, levothyroxine, lisinopril, metoprolol, sildenafil, and intravenous heparin as well as torsemide, acetaminophen, docusate sodium, and melatonin as needed. On examination, he had a left ventricular assist device port entering at the upper abdomen, but otherwise the abdomen was soft and nontender to palpation with normal bowel sounds and no appreciable masses or ascites.\nThe patient underwent a standard bowel preparation which included a clear liquid diet the day prior to the procedure and 20mg of Dulcolax with 4 liters of polyethylene glycol the night prior to the procedure. Monitored anesthesia care sedation was administered with propofol. The colonoscopy was performed at night without difficulty with good bowel preparation. Abdominal pressure was briefly required to maneuver around the splenic flexure. The colonoscope was advanced to the cecum with identification of the appendiceal orifice and ileocecal valve. Findings included multiple sigmoid and descending colon diverticula and two, small (<5mm) sessile polyps that were removed using cold forceps.\nThe night of the procedure the patient had no pain or nausea and ate dinner and breakfast the following morning without incident. He then developed epigastric abdominal pain in the midmorning approximately 12-14 ho"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33 year-old woman presented with abdominal pain in 2018. Computed tomography (CT) imaging revealed a 3.9 × 3.7 cm heterogenous soft tissue mass in the ascending colon near the hepatic flexure with invasion of the right anterior pararenal fascia and the second/third portion of the duodenum. There were associated enlarged and necrotic portacaval and mesenteric lymph nodes and a 1 cm hypodense lesion in the right hepatic lobe. Colonoscopy with biopsy confirmed a diagnosis of adenocarcinoma, and subsequent immunohistochemistry (IHC) showed loss of MLH1 and PMS2 gene expression consistent with MSI-H/dMMR. The patient was started on 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX), but continued experiencing symptoms of partial bowel obstruction including severe nausea, emesis, abdominal pain and dizziness from hypovolemia. CT imaging at this time is shown in . Given no evidence of response to chemotherapy for 2 months, she was transitioned to pembrolizumab (anti-PD-1). Shortly after initiation of pembrolizumab, she developed a partial large bowel obstruction secondary to the tumor. This was relieved by placement of a percutaneous gastrostomy tube and she was started on total parenteral nutrition (TPN) and resumed immunotherapy. Following three cycles of immunotherapy, imaging was consistent with partial response in the primary tumor and associated lymph nodes and the patient was also able to transition to an oral diet. However, after 8 months on immunotherapy she developed complete bowel obstruction, though imaging showed continued response in the primary tumor and metastases. The bowel obstruction was thought to be from adhesions and inflammatory changes and not progression of the patient's primary disease. Following multidisciplinary discussions between the patient and her treatment team including Medical Oncology, Surgical Oncology, and Palliative Care, the decision was made to proceed with surgical intervention. She underwent an internal colonic bypass with ana"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAfter a multidisciplinary evaluation, at the end of November 2019, a 13-year-old girl attended the Pain Therapy Clinic of the Ospedale Pediatrico Bambino Gesù in Rome, where acupuncture is also practiced as an analgesic technique. She reported pain in the left wrist and hand, with intensity 10 on the Numeric Pain Rating Scale (NRS), pulsating, and always present, thus preventing any movement. Marked hypersensitivity and allodynia were present at the level of the left fingers, wrist and hand. Pain was present in both flexion and extension of the wrist and caused a marked reduction in strength in the left wrist and hand, making a handshake impossible for the girl. There was no redness but swelling and sweating at the level of the fingers of the left hand. The pain was so intense that it interfered with her regular attendance at school, generating social withdrawal phenomena, which are unfortunately very frequent in patients with chronic pain.\nPain began three months before the consultation, after an accidental fall with trauma to the left wrist. It gradually increased and did not respond to either NSAIDs or limb immobilization. The diagnostic tests performed at the time (X-ray, Doppler ultrasound and magnetic resonance imaging) were negative, as were the blood chemistry tests ( and ).\nFrom the age of 8, the girl was followed by a pediatrician in our hospital for a history of cramps and pain in the lower limbs, especially in the ankle and left knee, both in the absence of trauma or caused by frequent falls. In the following years, clinicians found bilateral flatfoot (with subsequent surgery), mild ligamentous hyperlaxity and vitamin D deficiency. In addition, borderline cognitive level with motor coordination disorder and executive function deficit, as well as stuttering, were then diagnosed. Elements of anxiety emerged from the administration of Self Administered Psychiatric Scales for Children and Adolescents (SAFA-A, D and S)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man was referred for resection of a cecal mass that was found on routine colonoscopy (Fig. ). The patient denied history of blood per rectum, change in bowel habits, abdominal pain, nausea or weight loss. The patient had a significant past medical history for prostate cancer for which he underwent prostatectomy and chemo-radiation therapy. He also underwent open repair of bilateral inguinal hernias in the remote past; the operative notes were not available to us. Tumor markers (CEA and CA19-9) and routine blood tests were unremarkable.\nThe mass was found in the cecum during routine colonoscopy (Fig. ); it had raised borders, did not have a stalk and was not associated with mucosal erythema or ulceration. Biopsies showed normal colonic mucosa. A computed tomography (CT) scan of the abdomen showed a 3.3 × 4 cm mass that compressed the wall of the cecum. There was no associated lymphandenopathy or liver lesions (Fig. ). Based on these findings, we could not conclude if the aforementioned mass was intramural or extramural to the cecum. Due to the uncertainty about the location of this mass (intramural versus extramural) and the inability to rule out a neoplasm, we proceeded with a diagnostic laparoscopy with the possibility of resection of the cecum. Intraoperatively, we found that the right inguinal hernia had been repaired using a plug-and-patch technique. The mesh plug was fixed in the preperitoneal space and had not violated the peritoneal layer. The ‘Plug’ had not fully deployed in the preperitoneal space and had retained a cone-like shape. The wall of the cecum appeared normal and there were no masses in its anterior wall. An intraoperative colonoscopy was done to confirm the absence of a mass; upon insufflation of the colon, it became apparent that the cecal wall was pressed against the non-deployed plug thereby creating the impression of a mass"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn January 2013, a 73-year-old man presented to the Department of Oral and Maxillofacial Surgery, complaining of a painful mass in the mandible on the right side. He had also a history of deep neck pain for 3 months, but it had been disregarded. A review of patient's medical history revealed that he had an acute myocardial infarction 2 years before, which was treated by percutaneous coronary angioplasty. The patient had a 30-year history of cigarette smoking and opium use. Physical examination showed a firm, well-defined swelling measuring about 3 × 3 cm in the body of the mandible on the right side. The skin over the mass was normal in color and texture. No palpable submandibular and cervical lymph node was evident. Intraoral examination showed that the involved mandibular area was edentulous and the mucosa over the mass was intact.\nAn orthopantomogram radiograph demonstrated an ill-defined radiolucent lesion in the body of the mandible causing pathologic fracture of the involved bone [].\nThe results of laboratory tests were normal with the exception of prostate-specific antigen (PSA) level which was 52 ng/ml.\nIntraorally, an incisional biopsy was performed under local anesthesia. Histological sections stained with hematoxylin and eosin revealed a metastatic tumor of epithelial origin; however, it was unclear from which primary site the metastasis occurred. Histologically, the neoplastic cells arranged in glandular patterns had low mitotic index and were composed of round hyperchromatic nuclei and acidophilic cytoplasm [].\nBecause of concern over raised PSA level and high suspicion of prostate malignancy, the patient was referred to an urologist for further evaluation. In pelvic ultrasonography, a significantly enlarged prostate was observed. A biopsy of the prostate was done; the histopathological examination was consistent with prostatic adenocarcinoma. Whole body skeletal survey using bone scintigraphy revealed a bone lesion of the right mandible plus a destruct"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male smoker presented in December 2013 at the CHU Sud Réunion with pain in his left ring finger and in the ribs, both secondary to indirect trauma a few weeks ago. Severe pain discouraged the patient from using his left hand in daily activities. He had no other complaints and was in good general condition. On physical examination of the hand, the left ring finger was edematous at the proximal interphalangeal joint (fig. ). The finger movement was restricted. His left ring finger measured 80 mm in circumference, while the contralateral healthy finger had a circumference of 55 mm.\nWe performed an X-ray of the rib cage, which showed a lytic lesion of the eighth rib. An X-ray of the left hand showed a lytic bone lesion with the destruction of the bone cortex in the proximal phalanx and a swelling of the surrounding soft tissue (fig. ). A CT scan of the chest showed several suspicious opacities, one in the left lung hilum, a stellar image at the apex of the right lung, and a lytic lesion of the anterior arc of the eighth rib (fig. ). The pneumologist performed a bronchoscopy, but the first biopsies were negative. Then a biopsy of the rib mass identified an infiltration of the parietal pleura and striated muscle tissue by a pulmonary adenocarcinoma, moderately differentiated TTF1+, KRAS mutant, BRAF wild type, EGFR wild type, and with no ALK rearrangement. The bone scintigraphy showed multiple bone metastases on the rib cage, the spine, and the left scapula. The patient's left ring finger was very painful. He was given a nonsteroidal analgesic. The pain was morphine resistant. The patient received radiotherapy for his left ring finger in March 2014 (dose of total 30 Gy/10 fractions, 5 fractions/week, 6-MV X-rays with 5-mm bolus). Over the next month, the left ring finger became much less painful. Analgesics were no longer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old Caucasian woman with chronic kidney disease, diabetes mellitus type 2, heart failure, previous nephrectomy due to clear cell renal cell carcinoma, and previous upper right lobectomy of the lung due to adenocarcinoma was admitted to the hospital because of acute hypercapnic respiratory insufficiency. She needed respiratory support with non-invasive ventilation. She was also hemodynamically unstable.\nCT angiography of the pulmonary arteries was performed. The CT scan revealed left-sided subsegmental pulmonary thromboembolism and a suspicious mass in the left atrium. She was treated for pulmonary embolism. The previous CT scan of her thorax, which she had undergone a couple of months before for her pulmonary carcinoma follow-up, had shown a normal image of the heart, proving the mass in the left atrium grew de novo. The transthoracic and transesophageal echocardiography discovered a massively enlarged left atrium, fibrous changes of the mitral valve and a mobile tumor formation measuring 2.8 × 3.6 cm that arose from the posterior annulus (shown in Fig. ).\nThe stem of the discovered formation was broad but did not reach the leaflet of the mitral valve. The tumor prolapsed through the mitral valve and caused severe mitral stenosis with minimal regurgitation. The tumor seemed to have caused postcapillary pulmonary hypertension as well. Cardiologists suspected it was myxoma and referred the patient to cardiac surgeons. A preoperative PET scan showed high metabolic activity in the left atrium that pointed to the possibility of the tumor's more aggressive origin, such as metastasis or a primary malignant tumor of the heart rather than myxoma. The patient underwent an open mitral valve replacement and extirpation of the tumor of the left atrium. At the time of open-heart inspection, the tumor was not encapsulated, but grew inside the atrial wall with root-like extensions. It hung on a stem that masked its appearance as myxoma on echocardiography. It did not over"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old Indian man with a medical history significant for CKD and hypertension presented to the ED after a witnessed episode of new-onset seizure at home that was followed by another episode of generalized tonic-clonic seizure in the ED. The seizures each lasted for less than two minutes and were followed by a postictal state. He complained of generalized body weakness, loss of appetite, nausea, and vomiting for the past three days, and there was no history of a fall or trauma. Patient assessment revealed a heart rate of 96 bpm and a blood pressure of 150/111 mmHg. He was alert and oriented with a Glasgow Coma Scale score of 15. However, we observed that the patient had a locked jaw and was unable to close his mouth. The patient also had tenderness of the right shoulder, and the range of motion of both his hips was reduced. His creatinine and urea levels were significantly elevated, and venous blood gas analysis revealed high anion-gap metabolic acidosis with hyponatremia, hypokalemia, and severe hypocalcemia. Therefore, he was moved to the resuscitation area of the ED for urgent hemodialysis (HD). The patient was consciously sedated, and his jaw was reduced using the traditional technique. Two attempts at closed shoulder reduction proved unsuccessful (Figure ). A central venous catheter was inserted into the right femoral vein, electrolytes were administered, and HD was started. The patient still had a complaint of bilateral hip pain; therefore, pelvic X-ray was performed. To our surprise, the X-ray showed bilateral femoral neck fractures (Figure ). Given the unexpected significant finding of bone injuries, we requested pan-CT to rule out other injuries. The pan-CT showed a single rib fracture and bilateral displaced femoral neck fractures (Figure ) but was otherwise unremarkable.\nThe patient was admitted to the surgical ICU, and the right shoulder dislocation was reduced under conscious sedation (Figure ). He underwent Permcath insertion, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old lady presented to the emergency room with acute onset left hemiparesis.\nThe patient had a history of hypertension and Chronic Obstructive Pulmonary Disease (COPD) but was otherwise healthy and functionally independent. She was being treated with 2 antihypertensive medications: 5 mg amlodipine OD and 50 mg valsartan OD.\nThe patient had experienced a slight weakness in their left arm and left leg on the morning of admission but had not contacted the emergency services before a gradual worsening of the symptoms later that same day.\nThe paramedics found the patient to be awake with a left hemiparesis, left facial palsy and a mild dysarthria. The paramedics suspected an acute onset stroke, and the patient was admitted to our hospital as a stroke code.\nUpon physical examination in the emergency room the patient had an National Institutes of Health Stroke Scale (NIHSS) of 11. The temperature was 36.7 °C, pulse of 90 beats per minute and blood pressure of 169/71 mm Hg. The initial prehospital oxygen saturation was 65% while on room air, subsequently increasing to 92% while breathing oxygen through a nasal cannula at a rate of 3 liters per minute. The respiratory rate was 22 breaths per minute.\nAn arterial blood gas obtained while the patient was receiving high-flow oxygen through a nasal cannula at a rate of 3 liters per minute showed a pH of 7.27, a partial pressure of carbon dioxide of 81 mm Hg (10.8 kPa), a partial pressure of oxygen of 60 mm Hg (8.0 kPa), a bicarbonate of 37.3 mEq per liter and a base excess of + 10.5 millimoles per liter.\nA CT scan was performed including a pre- and intra- cerebral angiography. A subsequent perfusion scan was also performed. The CT examination was performed using the Siemens Somatom Definition Flash using GE Healthcare Omnipaque intravenous contrast and standardized protocols for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old Caucasian man was admitted in 2012 to the Surgical Department of Iaşi Regional Institute of Oncology with a painless tumor mass of 6 cm in the left breast. The tumor had grown increasingly fast in the past 4 weeks and clinical examination identified inflammatory signs and skin invasion (Fig. ). No lymph nodes were identified in the left axillae or in other regional stations. The patient had no relevant medical, family, or psychosocial history. The most important diagnostic concern was to determine the benign versus malignant nature of the tumor, which is why we first performed a breast ultrasound that revealed a complex cystic tumor mass of 60 mm in the left breast, with both anechoic (cystic) and echogenic (solid) components, with ill-defined margin. The anechoic component was dominant and there was a clear invasion of the skin.\nAfter complete clinical staging, which showed no axillary lymph nodes and no systemic extension (cT3N0), the case was discussed in the multi-disciplinary tumor board (MDT). Because of the cystic character of the lesion, we decided to perform surgical resection and extemporaneous evaluation, rather than a tru-cut biopsy. The extemporaneous assessment showed a solid (invasive) papillary intracystic carcinoma which is a rare tumor composed of circumscribed large cellular nodules separated by bands of fibrosis.[ At this point, the surgeon decided to complete the resection and not to perform axillary lymph node dissection.\nThe histological report described 1 nodule with focal infiltrative margins, with a biphasic aspect due to the presence of 2 populations of cells. The lesion was composed of epithelial cells with oval-shaped nuclei, minute nucleolus, and eosinophilic cytoplasm. The epithelial cells were cuboidal or cylindric, and they were arranged in glandular-like structures, distorted, and compressed by the myoepithelial cells that were spindle or polygonal in shape with clear cytoplasm.\nIn some areas of the tumor, the myoepith"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 1-year-old girl presented with a large growth protruding from her oral cavity, gradually increasing in size since 5 months of age. Her feeding was poor. On examination, she weighed 3.6 kg (<3rd centile). A lobulated, spherical mass, 8 cm in diameter, was seen protruding from the oral cavity and seemed to arise from the maxilla. The mass was bony hard, immobile, nontender, and pigmented. It was an exophytic mass of bone with desiccated mucosa covering it. X-ray suggested dense calcification within the mass. Computed tomography (CT) scan revealed a large bone forming exophytic mass arising from the maxilla []. The initial plan was to amputate the exophytic portion for tissue diagnosis and to have satisfactory mouth closure. As intubation was difficult, a tracheostomy was done to secure the airway. At surgery, the mass was found to be made of extremely dense bone and required a powered instrument to amputate. A central area within the mass had a grayish soft fleshy tissue speckled with pigment. The solid mass was enucleated and sent for biopsy. A palatal flap was used to cover the bony defect. Oral feeding was rapidly re-established and tracheostomy was removed after 2 weeks. The biopsy showed a biphasic tumor with tubular or alveolar pattern with large melanin-containing cells with abundant cytoplasm and pale nuclei suggestive of MNTI. As the lesion seemed to arise from the right maxilla, a maxillectomy was planned and the reconstruction post resection was a challenge. The poor nutritional status, risks, and potential for poor cosmetic outcomes led to significant delays. During this time, the baby did really well. A review 3 months later showed no progression of the lesion. A plain X-ray showed a remarkable degree of bone remodeling toward normal. A CT scan 6 months later showed completely normal facial bones with no recurrence []. The child was counseled regarding the risk of recurrence and was kept on close follow-up"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old girl presented to the Emergency Department with a 1-week history of coryzal symptoms and severe headaches. In the week leading up to her presentation the headache intensity had continued to increase up to the point where she could barely move. The presence of bilateral periorbital swelling, particularly on the right side, and reduced range of motion indicated an emergency ophthalmology review within 24 hours.\nThe patient had a past medical history of recurrent headaches and dizziness which first presented 5 months ago, however an MRI brain taken during this period showed no pathological changes and at the time she was discharged.\nThe provisional diagnosis at the stage of initial presentation included preseptal or orbital cellulitis most likely secondary to pansinusitis, with a differential diagnosis of subperiosteal or orbital abscess.\nShe was admitted and started on intravenous antibiotics on admission: ceftriaxone, vancomycin, and metronidazole. The initial ophthalmology review indicated preserved optic function; however, this was associated with a significant soft tissue swelling along with reduced color vision. Both were seen in conjunction with diplopia and painful eye movements, which warranted close monitoring of her vision and further radiological investigation.\nAs shown in below, a CT scan of the head and sinuses indicated a 20 × 18 × 3 mm right subperiosteal orbital collection insinuating around the superior orbital margin, extending posteriorly into the orbit for approximately 14 mm. Furthermore, a right frontal intracranial, extradural collection, with a depth of approximately 5 mm was noted.\nThese findings were consistent with a diagnosis of pansinusitis and orbital cellulitis with abscess formation. Due to the presence of the abscess without apparent involvement of the cavernous sinus, a diagnosis of orbital abscess was made (Stage 4 as per Chandler’s Classification).\nThe results of a brain and sinus MRI in the subsequent week showed a re"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was an 87-year-old male in whom a mass accompanied by pressure pain was found in the left inguinal region (axillary lymph nodes) and who subsequently visited a hospital in Seoul on November 29, 2015 where he received PET-CT and CT scan as well as aspiration and biopsy of the bone marrow and right iliac crest. The PET-CT and CT scan results showed hypertrophy of multiple lymph nodes. In the subsequent bone marrow finding, a number of cells were in metaphase and, therefore, the metaphase quality was adequate. In the analysis of 20 cells in metaphase, no clone with chromosomal abnormality was observed and the karyotype was normal. Therefore, it was concluded that there was no evidence of bone marrow involvement of the lymphoma. Finally, the patient was diagnosed with atypical peripheral CD4 T cell lymphoma (follicular helper type, stage IIIA) and was recommended to receive chemotherapy at the hospital in accordance with the standard treatment guideline. However, first of all, his guardian and medical doctor suggested that the patient was unlikely to withstand chemotherapy, considering his age. Secondly, the patient was not within the normal range of standard body weight. Thirdly, the patient rejected chemotherapy due to unbearable pain and poor appetite and general weakness. Subsequently, the patient visited our hospital on December 23, 2015. At that time, there was no chief complaint caused by the diagnosis, and the patient complained of low energy and indigestion, among others. In the images he brought to our hospital, we found abnormal lymph node hypertrophy in the left intracarotid lesion, both cervical level II, left supraclavicular, both axillar, both mediastinal and interlobar, common hepatic artery, aortocaval, left iliac chain, right external iliac and inguinal lymph nodes. The blood pressure of the patient was 127/84 mm Hg, his temperature was 36.0°C, his pulse rate was 91, his respiration rate was 18, his weight was 47.95 kg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old man was referred to our outpatient clinic presenting with a small mass in his right nasal cavity. The lump, which the patient first noticed 5 years ago, had been growing insidiously over time and by the time of presentation had become visible at the right anterior naris. The patient did not complain of any symptoms but sought consultation as his wife was concerned by the cosmetic appearance of the mass.\nExamination revealed a large firm mass arising from the right side of the anterior nasal septum with approximately 0.5 cm attachment to the anterior cartilage of the septum. The left and right nasal cavities were otherwise unremarkable. Clinically, the mass had the appearance of a papilloma confined to the nasal cavity with an attachment to the septum only and therefore further imaging was not undertaken. The differential diagnoses considered at the time of presentation were: nasal polyp, squamous papilloma or inverted papilloma.\nThe patient subsequently underwent excisional biopsy of the right nostril mass under general anaesthetic using a circumferential subperichondrial incision with a small margin. Intraoperatively, the mass had the macroscopic appearance of a 0.5 cm × 2 cm × 2 cm calcified nodule. Due to a small 0.5 cm base, subsequent healing was achieved by secondary intention aided by the routine application of topical antibacterial cream. Histopathological analysis showed the nodule to contain cartilage and aneurysmal bone covered in stratified squamous epithelium with keratinisation (Figs. and ). Histopathological diagnosis was made using a haematoxylin & eosin stain. These findings were consistent with a diagnosis of a nasal chondromesenchymal hamartoma.\nThe patient was followed up in clinic and was discharged after 2 years having shown no signs of recurrence. Furthermore, a telephone interview was conducted 4 years post operation and the patient reported no recurrence of the nasal mass. He confirmed that he had no post-operative complication"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.\nAfter admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.\nThe radiographs of the left leg taken 10"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old male patient was admitted to the pain department due to cancer pain in the right lower abdomen and inguinal area. He was diagnosed as having hepatobiliary adenocarcinoma with retroperitoneal metastasis. He had received multiple anti-tumor treatments during the past 3 years, and had had a pain in the right side of the abdomen for 8 months. Imaging revealed enhanced soft tissue thickening around the right paraspinal site at T11–12 (Fig. A). Thus, the patient underwent paravalvular palliative radiotherapy at a dose of 25 Gy. However, the analgesic effect of radiotherapy was negative. He complained about a persistent dull, burning pain and soreness accompanied by paresthesia in the T11–12 dermatome, with an average VAS score of 6 points (8 points at its worst, 3 points at its least), and an average DN4 of 6 points. The patient received oxycodone (120 mg/day) and pregabalin (300 mg/day), but his pain scores were not reduced as a result of the treatment. In addition, his sleep quality was severely affected and he could not even lie on his right side. According to the diagnostic criteria of the expert consensus, we diagnosed the patient as having refractory cancer pain. Then, this case was introduced through our multidisciplinary channel, and further analgesic strategy for this patient was developed by multidisciplinary decision making and a comprehensive informed consent. We decided that the neuraxial neurolysis could be one of the best next analgesic approaches for him because the metastasis was indenting the thecal sac at the T12 level, which is a potential contraindication for intrathecal pumps. In addition, further palliative radio- and chemotherapy or surgery were infeasible according to the experts’ decisions. However, we are still concerned about the outcome of the neurolytic blocks because the tumor invades around the block target. Therefore, an ultrasound-guided paravertebral block with 1% lidocaine in 5 mL was first performed. Fortunately, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-yr-old man was admitted to hospital with community-acquired pneumonia on December 21, 2007. He had been suffering from dyspnea due to right fibrothorax associated with pulmonary tuberculosis. His baseline pulmonary function test revealed FEV1/FVC of 89%, FEV1 of 25%, and FVC of 18% predicted values. He was treated with mechanical ventilation for three months and received long-term care at the intensive care unit (ICU) for four months. After removal of the ventilator, the patient was transferred to a general ward for further planning of rehabilitation treatment. However, the patient suffered new-onset atrial fibrillation, after which his oral intake decreased. His general condition deteriorated and he became dehydrated. Therefore, a central venous catheter was placed in the right internal jugular vein for more intensive treatment, including bedside fluid and nutritional therapy, without imaging guidance. Three days after the procedure, he slept all day. When awakened, he answered only briefly with slurred speech. He tended to gaze toward the right. No movement of the extremities on the left side was seen. At this point, he had no circulatory impairment. DWI was performed to evaluate neurological problems and revealed extensive hyperintensity with decreased apparent diffusion coefficient (ADC) value in the right cerebral hemisphere suggesting acute cerebral infarction. There were mottled areas of low signal intensity within the acute infarct area, which were considered to be air bubbles (). With a diagnosis of suspected paradoxical cerebral air embolism, brain and chest CT were performed simultaneously. An extensive area of low attenuation suggesting acute infarction in the right cerebral hemisphere as well as air bubbles mainly in the border zone areas of the right hemisphere were observed on brain CT (), and free air was detected in the right atrium on chest CT (). Transesophageal echocardiography (TEE) revealed microbubbles in the aorta without visible intrac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female presented to our OPD with chief complaints of right superomedial eye swelling for last 2 years. The swelling was associated with excessive watery discharge and pain in right eye as well as pain in right frontal region. There was no history of diplopia or decreased vision from right eye. There was no history of nasal discharge or nasal obstruction. There was previous history of endoscopic marsupilization of mucocele by a private practitioner 2 months back but it recurred again. On physical examination, there was fluctuant swelling present in superomedial region above the right eye. There was mechanical ptosis due to swelling and the eyeball was pushed inferiorly and laterally. Vision was normal in right eye with full extraocular movements in all directions except in supero-medial direction. Pupillary reaction to light and accomodation were normal. Fundus examination was normal. On anterior rhinoscopy, nose was normal. On contrast-enhanced CT, there was large expansile cystic lesion was found to be present involving right frontal sinus containing hypodense contents with expansion of both anterior and posterior table of frontal sinus []. The swelling had so much eroded the anterior and posterior table of frontal sinus that frontal lobe of brain was in direct contact with the eyeball and it was compressing the eyeball and blocking the sinus ostia []. On MRI, the swelling was isointense on T1 and hyperintense on T2. The swelling was in close contact with both orbit and frontal lobes and was almost adherent to both these structures.\nThe patient was planned for surgery through the combined ENT-neurosurgical approach. A bicoronal flap incision was made and right-sided frontal craniotomy was done. The anterior and posterior wall of frontal sinus was eroded. The mucocele wall was adherent to dura and the supraorbital wall. Mucocele was dissected slowly from dura and orbit. Mucosa was carefully removed up till the frontal recess area. Complete removal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (\n). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.\nThe woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.\nTo better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (\n). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.\nThe following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.\nAfter a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (\n). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old female presented to hospital for new onset of double vision. The patient denied having a similar episode in the past. Additionally, she had persistent left ear ache for 5 months. The patient stated that the earache started as dull, achy pain that had been progressively getting worse requiring multiple office visits. She had been treated with oral and topical antibiotics without any significant relief. Her past medical history includes diabetes mellitus, hypertension, obesity, hypothyroidism, and fibromyalgia. The patient's presenting vitals were stable. The ear exam revealed granulation tissue on the left tympanic membrane and serosanguinous fluid was present. The patient had painful left external ear structure upon gentle traction. The neurologic exam findings were significant for inability to abduct the left eye beyond midline (). When looking left, the patient would have double vision. There were no other focal neurologic deficits, cranial nerve palsies, or abnormal cerebellar signs.\nA CT scan of the head was inconclusive (). A magnetic resonance image (MRI) of the brain showed an enhancement of left skull base that raised the suspicion for active infection (). These findings were further assessed with Gallium-67 citrate (Gallium-67 scan), which revealed a strong possibility of active infection (). Based on imaging and clinical findings, the patient was diagnosed with temporal bone osteomyelitis (TBO) due to malignant otitis externa. She was empirically treated with cefepime for possible Pseudomonas species infection. The patient underwent bone biopsy, which did not grow any organisms. The patient was treated with IV cefepime for 6 weeks. After the completion of antibiotic therapy, a repeat Gallium-67 scan showed improvement in the inflammation (). The patient was then treated with oral ciprofloxacin. The Gallium-67 scan five months after the initial scan showed complete resolution of the inflammation. Her diplopia has markedly improved (). The pati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man consulted us for visual disturbance with corneal opacity in his left eye (). He had received topical medication for chronic open-angle glaucoma for over 5 years. We did not obtain significant information on the etiologic factors related to neoplasm induction. His visual acuity was 20/20 and 20/200 in the right and left eye, respectively. Intraocular pressure (IOP) in his right eye was 14 mmHg, but IOP could not be precisely measured in his left eye due to the elevated lesion on the corneal surface. A whitish elevated, plaque-like isolated lesion without neovascularization was observed in the central area of his left cornea. The cornea of his right eye did not show any abnormality or signs of intraocular inflammation. The whitish plaque-like lesion was removed under topical anesthesia. The lesion was easily peeled off from the underlying basement membrane. The epithelial defect produced by the removal of the lesion was resurfaced by normal-looking epithelium in a couple of days. No recurrent lesion was observed after seven months of surgery (). Stroma beneath the neoplasm is opaque (). The removed lesion epithelium was fixed, paraffin-embedded, and subjected to histology/immunohistochemistry examinations with hematoxylin-eosin (HE) staining, direct fast scarlet 4BS (DFS) staining, and immunohistochemistry for intermediate filaments of mesenchyme and ocular surface epithelial cells such as vimentin, keratin 12, keratin 13, and keratin 14, as previously described [].\nThe epithelium of the lesion was occupied with atypical dysplastic epithelial cells as revealed by HE staining (). The specimen was not labeled for DFS staining and thus the lesion was not related to an amyloid disease. Immunohistochemistry of cell lineage-specific intermediate filaments, for example, vimentin of mesenchymal cells, keratin 14 of a basal cell of stratified epithelium, keratin 12 of corneal epithelium, and keratin 13 of conjunctival epithelium, showed that the dysplastic ce"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42 year old male presented to his primary care physician with a 20 pound unintentional weight loss over a 3 month period and new left axillary lymphadenopathy. A core biopsy of his axillary mass revealed metastatic malignant melanoma. He had no prior history of a primary melanoma. A staging PET/CT revealed abnormal FDG uptake in his left axilla and small bowel. A left axillary lymph node dissection was performed and revealed 2 of 19 lymph nodes involved with metastatic melanoma, BRAF wild type, the largest of which measured 10.1 cm. His medical history was significant for oligodendroglioma, which was surgically resected eight years prior to presentation, followed by radiation therapy for recurrence five years prior to presentation. He received four doses of systemic ipilimumab for his metastatic melanoma without incident. Post-treatment imaging revealed disease progression with new diffuse subcutaneous, lung, liver and bilateral axillary lymph node metastases.\nHe subsequently enrolled on a genetically engineered T-cell trial, targeting tyrosinase. He received fludarabine and cyclophosphamide as a conditioning regimen, then his engineered T-cells were infused, followed by one week of low dose IL-2, (72,000 U/kg IV q8 hours). Per the treatment protocol, unfractionated creatinine kinase (CK) levels were obtained just prior to and for two weeks after infusion of the genetically engineered T-cells. The CK levels were within normal limits during the course of this treatment. He initially experienced disease response, however, four months after his T-cell therapy, he again developed diffuse progression with new hilar lymphadenopathy and progression of his lung and axillary lymph node metastases.\nHe was next treated with three doses of pembrolizumab but post-treatment imaging again revealed disease progression in his lungs. CK levels were not checked during treatment with either ipilumumab or pembrolizumab. Despite multiple lines of therapy, the patient continued to have"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of Mrs. GO, a 38-year-old Para 2+0 with 2 living male children whose last menstrual period was May 22, 2019. She presented to the gynecological emergency department on July 19, 2019, with a history of amenorrhea of 8 weeks and 2 days. Her complaints on admission were vaginal spotting of 4-day duration and sudden onset of abdominal pain of 4 h. There were associated dizziness and fainting attacks but no loss of consciousness. She was brought to the hospital due to increasing fainting attacks. There was no history of the use of hormonal contraception, treatment of pelvic inflammatory diseases, or use of fertility-enhancing drugs. She had a history of two cesarean sections in her previous deliveries.\nOn examination, she was in painful distress and pale. Her radial pulse rate was 100 beats per min, and the blood pressure was 100/60 mmHg. Her abdomen was distended and tender on palpation with positive rebound tenderness and guarding and absent bowel sounds. Her vulva was blood stained. Speculum examination showed a bulging posterior fornix and blood trickling from the cervical os. Bimanual pelvic examination revealed a bulky uterus with cervical excitation and bilateral adnexal fullness and tenderness. The pouch of Douglas was full. A bedside serum pregnancy test was positive. Abdominopelvic ultrasound scan showed an empty uterus with thickened endometrium and left adnexal mass with a significant amount of free fluid in the abdomen and pelvis and normal right adnexa.\nA diagnosis of ruptured left tubal ectopic pregnancy was made. The diagnosis was explained to her. Intravenous access was secured in both arms, and blood samples were taken for laboratory investigations. Her hemoglobin concentration was 8 g/dl, and 3 units of whole blood were grouped and cross-matched and made available for her. She was resuscitated and taken up in emergency for exploratory laparotomy and partial left salpingectomy after written informed consent was obtained. Intraoperativel"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman presented in our neurosurgical emergency ward with severe headache accompanied by nonspecific radiating neck pain. The headache persisted for 3 days, and due to an exacerbation, the patient was admitted to the hospital.\nMedical history revealed that the patient fell in the last few weeks due to a known right-sided hemiplegia. The physical examination did not show any sign of external injury like abrasions, hematomas, etc. The neurological physical examination showed an oriented but aphasic patient with a preexisting high-grade right-sided hemiparesis (3/5). The aforementioned hemiparesis resulted from an earlier (around 1976) hemorrhage of an AVM on the left hemisphere with accompanied intraventricular bleeding. The pupils were equal in size, reactive to light, and there was no relative afferent pupil defect. Moreover, an exophthalmus of the left eye was revealed as well as a known strabismus divergens and a facial nerve paresis on the right side. Furthermore, signs of meningeal irritation in form of a stiff and painful neck were detected. A brain computed tomography (CT) imaging was conducted to investigate any intracranial pathology responsible for the headache symptoms as well as the hemiparesis. The results of the CT imaging were similar to those of 10 years ago, detecting no pathological findings. Thus, we proceeded with a cervical spine CT scan due to the accompanied cervical symptoms. The latter revealed an unstable fracture through the base of the dens, type II based on the Anderson and d’Alonzo classification []. There was no evidence of a spinal hematoma. Moreover, an extended osteolysis was revealed with reactive sclerosis of denses and axis’ endplate and margins, as shown in and . The dens fracture was evaluated as a pathologic fracture. The fall incident could not explain the expanded osteolysis. Our assumption, based on the conducted imaging processes, is that the fracture was caused by a large AVM, which extended from the right sid"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male with medical history significant for uncontrolled hypertension admitted to the hospital for acute onset bilateral hearing loss. Symptoms had started four hours prior to presentation while he was watching television. Initial admission computed tomography (CT) scan was negative for any acute infarcts or other intracranial processes. His initial physical exam was significant for mild gait impairment, with Weber and Rinne test consistent with bilateral neurosensory hearing loss. Patient was initially admitted as a possible stroke rule out. Work up for stroke including carotid ultrasound, Cardiac echo were all negative except for Magnetic Resonance Imaging (MRI) which showed some periventricular and deep white matter lesions demonstrating T2 hyper-intensity without enhancement consistent with questionable demyelinating disease as seen in Figure . Given the non-specificity of his symptoms and unknown sexual history, a decision was made to evaluate for syphilis. Rapid plasma reagent (RPR) test was ordered, and it came back positive with a 1:16 titer. A confirmatory Treponema pallidium fluorescent treponemal antibody absorption-Ab was also positive which confirmed the diagnosis of syphilis. A lumbar puncture was then performed prior to the beginning of treatment and cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) was positive with a 1:4 VDRL titer establishing the diagnosis of neurosyphilis. Considering the initial MRI scan in Figure below, was concerning for demyelinating disease, CSF protein analysis and oliclonal band was also obtained. Both CSF protein and oligoclonal band were noticed to be elevated, but in the setting of neurosyphilis and possible meningeal inflammation with increased likelihood for false elevation in CSF protein and negative family history, a decision was made to focus management on neurosyphilis. Patient was started on Penicillin G IV 3mmu (million units) daily for a total period of 14 days, and daily 30mg of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old man was admitted to our clinic with a sudden and progressive headache and binocular diplopia. His symptoms had appeared 2 months before his first visit to the clinic. He had also experienced a similar attack 6 months earlier, but he was in a good general condition. The neurological examination revealed right-sided abducens nerve palsy. A brain computed tomography (CT) scan was acquired, which showed a suspected lesion in the cerebellopontine angle. Brain CT angiography was also performed, which did not reveal any prominent findings. The brain MRI showed an extra-axial pontomedullary lesion with the classic appearance of a CM, that is, a reticulated salt-and-pepper core, surrounded by a halo rim []. With the diagnosis of brain stem CM with a history of multiple hemorrhages, progressive neurological deficit, and pial presentation of the CM, the patient was enlisted for the surgical resection of the lesion.\nThe patient underwent surgery using the suboccipital retrosigmoid approach with intraoperative neuromonitoring. The procedure was performed through general anesthesia as the patient laid in a lateral position, and his head was fixed in a three-pin Mayfield headrest. After opening the dura, a CM was detected, arising from the sixth cranial nerve, with no invasion to the brainstem or the surrounding tissues. Since the lesion could not be separated from the nerve and its integrity was unclear, we resected the CM by cutting the proximal and distal portions (before the Dorello’s canal) of the sixth cranial nerve []. Intraoperative monitoring was used to detect changes in the function of the nervous structure. Motor and somatosensory evoked potentials were normal during the surgery. Direct nerve stimulation of the sixth nerve was also performed during the surgery. The response to stimulation was normal when stimulating distal to the lesion and weak proximal to the lesion.\nThe greater auricular nerve (>3 cm) was harvested as an interposition nerve graft. An a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a trea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of severe pain in the left upper back region of the mouth since 3 days. Pain was continuous and aggravated with the intake of hot and cold beverages. Clinical examination revealed deep mesial caries approximating pulp with respect to tooth # 26. The tooth was not tender to percussion and palpation. Pulp vitality testing using an electric pulp tester (Parkell, Farmingdale, NY, USA) showed exaggerated response lasting for several minutes. Further, the maxillary lateral incisors were missing and the deciduous right maxillary first molar was overretained. Intraoral periapical radiograph of tooth # 26 revealed deep caries involving the pulp space []. Also, a single root with single canal was seen in relation to 26 and 27. Based on the clinical and radiographic findings, the diagnosis of acute irreversible pulpitis was made and patient was advised root canal treatment in relation to tooth # 26. After obtaining patient's consent, an emergency pulpotomy was performed at the same visit under local anesthesia. In order to confirm the apparent finding of the IOPA radiograph, the patient was referred for CBCT imaging of tooth 26 with 3D reconstruction. The results of the CBCT showed the presence of a single root with the Vertucci's type I canal configuration,[] and the same was observed for tooth 27 []. Thereafter, the root canal treatment was initiated. The tooth was isolated using rubber dam and access preparation was modified to completely de-roof the pulp chamber, which showed the presence of a single wide root canal orifice. Working length was calculated using an electronic apex locator (Root ZX II™, Morrita, Tokyo, Japan) as well as the radiographic method. Working length radiograph also suggested positioning of endodontic files in a single canal []. The coronal shaping was carried out using Gates Glidden burs (Dentsply, New Delhi,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year old Caucasian female with known NF1 presented herself in the emergency department of an outside hospital with acute symptoms of thoracic pain and dyspnea. Her history was otherwise significant for an extensive thoracic myelomeningocele and status post-surgical correction of a thoracic scoliosis using a tibia bone graft 27 years earlier.\nOn physical examination at the outside hospital, she was awake, afebrile, blood pressure of 80/40 mmHg and a heart rate of 100 beats per minute. The initial haemoglobin was 12.5 g/dl, quickly deteriorating to 8.4 g/dl in the following hour. Chest x-ray (Figure ) was performed 40 mins after admission and revealed an extensive mediastinal shift. Subsequent computer tomography (Figure ) was performed 1h later at the outside hospital and revealed a massive hemothorax on the left side. The patient was intubated orotracheally because of hemorrhagic shock and imminent cardiopulmonary arrest and received seven packed red blood cell concentrates. A thoracic drainage was inserted prior to transfer. 4 h 10 min after admission to the outside hospital the patient was transferred to our institution and arrived there 1h later.\nOn admission, she was highly catecholamine-dependent. We found one left-thoracic suction drainage installed using Monaldi technique with 50 ml of blood in the drainage bottle. During placement of venous and arterial lines she suffered a cardiocirculatory arrest. Resuscitation was immediately initiated and we proceeded with performing an emergency exploratory left antero-lateral thoracotomy in the intensive care unit. Thereupon 2 liters of blood exsanguinated spontaneously. Despite massive blood transfusions (16 packed red blood cells, 2 thrombocyte concentrates, and 4 fresh frozen plasmas) and intravenous fluid administration no sufficient circulation could be established. Due to massive bleeding and very difficult operative conditions it was not possible to perform either an exploration of the thorax or an open car"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old male with known Down syndrome and epilepsy and taking carbamazepine was brought by his family to the emergency room with a large protruded tongue within 30 minutes of the incident ().\nThe patient was vitally stable; however, he was slightly agitated. The otolaryngology team had been consulted immediately for further evaluation of the patient's status. History from the patient's family showed that they believed the patient was engaging in aggressive behavior, and he has a history of multiple tongue tractions leading to sudden severe tongue swelling. The examination was unremarkable, except for a huge protruded swollen tongue, which was diffused with no confined collection or sign of hematoma. Fixable nasolaryngoscopy relieved bilateral vocal cord movement, and there was no laryngeal edema. The neurology team was consulted to rule out active seizure, and they cleared him. The decision was to intubate the patient to secure the upper airway and then admit him to the intensive care unit (ICU). The patient consented to endotracheal intubation and possible tracheostomy in case intubation failed. The patient was successfully undergoing orotracheal intubation in the operating room. Then, a CT scan was done, which revealed some artifacts due to endotracheal intubation, with evidence of an enlarged diffused edematous hypertrophic tongue muscle protruded outside the oral cavity and deviated to the left side due to tube insertion from the right side (Figures and ). In addition, the CT scan showed no evidence of mass lesions, collection, abnormal enhancement in postcontrast series, or sizable lymphadenopathy. Thereafter, he was transferred while intubated to the ICU, and he was connected to mechanical ventilation. He was kept on midazolam, fentanyl, and dexamethasone at 8 mg intravenously for Q6h to relieve swelling, as well as pantoprazole for 4 days. Furthermore, a removable bite block was placed on the teeth to prevent tongue biting, and wet gauze was applied to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11 year old male child presented with a history of high grade fever with chills, right flank pain and progressive pyuria for two months. He had a prior history of surgery for vesical calculus and anterior urethral calculus for which he underwent open cystolithotomy and urethrolithotomy four years back. The chemical nature of the stone was calcium oxalate dihydrate. Medical work-up did not reveal any cause for the calculus.\nOn examination, the child was emaciated, febrile with pallor. There was diffuse tenderness in the right lumbar region with renal angle tenderness. X-ray showed radio-opaque shadow in the right lumbar region measuring 2 × 2 cm. Abdominal computerised tomography (CT) revealed a dilated pelvicalyceal system with necrotic debris at the lower pole of right kidney and a thrombus in the renal vein extending into the infrahepatic vena cava. Pyonephrosis, parenchymal calcification along with marked retroperitoneal and porta hepatis lymphadenopathy were also seen on the CT. Blood urea and serum creatinine were within normal limits. Gram negative bacilli, Pseudomonas aeruginosa were isolated from thick pus aspirated from the right renal pelvis. The urine culture was sterile.\nOpen nephrostomy was done which drained only pus and no urinary drainage. Following a renal biopsy diagnosed as chronic pyelonephritis (end-stage changes), the patient underwent subcapsular right nephrectomy. Kidney exposure was accomplished through the flank extraperitoneally using a 12th rib cutting incision. There were dense adhesions of the kidney and Gerota's fascia with the surrounding structures. It was decided to do a subcapsular nephrectomy. When the kidney was reached, the capsule was incised and is freed from the underlying cortex. The capsule was stripped from the surface of the kidney, and an incision was made all around the capsule where it was attached to the hilum. The vessels were protected by placing a finger in front of the pedicle while cutting the capsule. The adh"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase two was a 61-year-old female, who developed a huge retroperitoneal placeholder as indicated by examination. The patient had neither chest tightness, shortness of breath, difficulty in breathing, nor abdominal discomfort. Upon physical examination, the abdomen was flat and soft, with no palpable mass. Plain chest and abdominal CT scans showed a huge soft tissue mass shadow fused by multiple nodules of varying sizes on the right retroperitoneum, approximately 164 mm × 150 mm × 116 mm in size. Heterogeneous density and extensive low-density cystic areas were seen, with CT values of 25 to 40 HU, and clear boundaries with the surrounding organs. There was a shift in the heart, and the liver and right kidney were under compression, as well as the aorta and inferior vena cava. Varicose veins in the abdomen were also observed. The solid part of the mass in the arterial phase was moderately and heterogeneously enhanced, with a CT value of about 83 HU, and a plexiform disordered vascular shadow was visible (Figure A). The solid part of the scanned mass in the venous and delayed phases was more enhanced in a sustained and heterogeneous manner, with CT values of 99 to 123 HU. No enhancement was observed in low-density cystic areas although a significant enhancement in the envelope was visible. Multi-planar reconstruction displayed the tumor size, location, and relationship with the surrounding tissue more clearly (Figure B–D). Due to the high surgical risks as determined by consultation, a retroperitoneal tumor biopsy was performed under CT guidance. The tumor cells were in fusiform shape in a bundle-like, spiral arrangement under the microscope, rich in sinusoids, and interstitial collagen denaturation in the focus area (Figure E). Immunohistochemistry showed CD34 (++), bcl-2 (++), CD99 (++), F8 (+); CD117 (-), Desmin (-), S-100 (-), and CK (-). Because of the rich vascular supply and the potential risks of surgery, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-years-old Caucasian female was referred to our department, complaining of a 5-year history of intermittent pain in her right knee. She did not suffer from any medical condition, she was not on any medications and never smoked. Her symptoms started insidiously, following a minor soft tissue injury (no fracture). On clinical examination, she was found to have a right knee effusion and limitation of movement (ROM 10-90°). She had severe pain over her knee. She could weight bear with significant discomfort. Her blood tests were all normal, including the coagulation screen and all inflammatory markers. The X-rays performed were unremarkable (). An magnetic resonance imaging (MRI) scan was performed which suggested the presence of a suprapatellar fluid collection with cysts arising from the synovium. Following these results, an arthroscopy was performed. The cysts were excised and biopsied. The biopsies revealed normal synovium. Following the procedure, the patient remained asymptomatic for approximately 3 years. She then returned with similar symptomatology. A second MRI was performed showed the presence of a suprapatellar fluid collection measuring 4.7 × 2.1 cm at the suprapatellar area. No hemosiderin was noted within the collection and no local erosion. Surgical exploration was performed, and a poorly encapsulated vascular mass was encountered extending from the distal belly of the vastus intermedius to the knee. Excessive use of electrocautery and ligation of the numerous vessels were performed during resection. The histological examination of the mass revealed a dilated vascular space containing fibrous papillary projections and organized thrombus. It was suggestive of IPEH (Masson’s Tumor) ( and ). The patient’s symptoms recurred 2 years later. An MRI scan was repeated showing a 1 × 3 × 10 cm cystic lesion of the distal anterior thigh. The patient was then referred to the vascular department for embolization of the vascular supply of the tumor. Following this"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 72-year-old Caucasian female who underwent adjuvant chemoradiotherapy for a Grade 2 invasive ductal carcinoma of the left breast. She had no other significant past medical history, including dermatological history, and took no regular medications. She was a non-smoker and did not consume alcohol. Presenting from the national screening programme, she underwent a wide local excision with axillary lymph node clearance. Her tumor was estrogen receptor positive, HER2 negative and had 7/28 lymph nodes positive. Weekly paclitaxel treatments were stopped after four cycles due to anaphylactoid hypersensitivity. She underwent 40 Gy of radiotherapy in 15 fractions over 3 weeks to the left breast and left supraclavicular fossa. Before commencing radiotherapy, she had no noted skin changes.\nUpon routine review 8 weeks post completion of radiotherapy, oedema and erythema with blistering and desquamation of the skin were noted over the left breast and chest wall. There was also an area of desquamation on the patients’ back consistent with a radiotherapy exit field. The patient had been using simple moisturizers as instructed and managing pain with simple analgesia. The skin changes were first apparent 4 weeks after completion of radiotherapy. Initially, the skin lesions were confined to the radiotherapy field. She was afebrile with otherwise normal observations. Differentials included radiation-induced skin changes with superimposed cellulitis, autoimmune bullous disorder or a paraneoplastic process. An admission for further treatment was organized where intravenous antibiotics and antivirals were commenced alongside a regular skin treatment regimen. This consisted of Viscopaste and Tubigrip, Hydromol and Dermovate ointment as required. An initial superficial skin swab showed mixed skin flora only.\nDespite optimal medical management, her skin continued to deteriorate, with a new area of desquamation over the right hip. The patient also developed painful oral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 55-year-old, para 7, postmenopausal black African woman who was initially seen with a history of vulval itching of 3 years’ duration and at that stage there were no lesions to report and the itchiness was treated with topical steroids with an initial good response. Seven months prior to seeing a gynecologist she noted three warty-like lumps on her right labia majora. She then presented to a gynecologist and an excisional biopsy was done. Histology surprisingly showed infiltrating moderate to well-differentiated adenocarcinoma with malignant glandular structures that were lined by tall columnar epithelium with stratification and mucin production. The warty lesions eventually became florid as shown in Fig. .\nSince this was an unusual histological type for vulval cancer, immunochemistry was requested which showed mucin, strongly positive cytokeratin (CK) 20 and CDX2, and negative CK7. There was minimal patchy staining for p16 and features suggestive of large bowel or pancreatic primary tumor. Several years back, she had a hysterectomy for abnormal uterine bleeding and histology showed several leiomyomata and no evidence of uterine or cervical cancer. In view of the unusual histology, a mammography was done which showed a solitary benign lesion in her right breast. Computed tomography with contrast of her chest and abdomen showed multiple parenchymal shadows suggestive of metastasis in her lungs and there was rectal thickening of uncertain significance with no obvious large bowel or pancreatic lesions.\nShe underwent sigmoidoscopy; the findings were essentially normal. A biopsy of an enlarged left groin lymph node showed the presence of metastatic adenocarcinoma with an immunohistochemistry profile again consistent with spread from colonic or rectal adenocarcinoma. When she moved to Zimbabwe she presented to the gynecological clinic with a history of lumps on her vulva. These warty lesions were biopsied and sent for histology and immunohistochem"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old Asian woman had bilateral uneventful cataract surgery for central cortical opacity. Phacoemulsification via clear corneal incision and implantation of hydrophilic acrylic intraocular lens (IOL) with polymethylmethacrylate modified C-loop haptics were done in the left eye first and the right eye later with interval of 2 days. The left eye was operated first among three operative cases of cataract and the right eye was operated third among four operative cases of cataract. Preoperatively, the cornea was clear with normal specular microscopic finding, and inflammation was not detected in the anterior chamber of both eyes. The patient had not have any systemic or ocular disease other than diabetes that was controlled well under medication, and diabetic retinopathy was not presented in both eyes.\nOn postoperative day 1 of each eyes, right eye had grade 1+ white blood cells in the anterior segment with uncorrected visual acuity (UCVA) of 20/25, while left eye had trace of white blood cells with UCVA of 20/25. Levofloxacin and prednisolone acetate 1% eye drops were prescribed 4 times a day in both eyes. On postoperative day 7 of right eye, anterior inflammation improved and prednisolone acetate 1% was switched to fluorometholone 0.02% in both eyes. On postoperative day 11 of the right eye, the patient visited appealing mild right ocular pain, and the UCVA was dropped to 20/30 presenting diffuse corneal edema. Grade 2+ white blood cells and puff balls were shown in the anterior chamber and inflammatory plaques on the surface of IOL were also found []. However, the cell was not found in the vitreous and it was so clear enough to examine the retina []. Intraocular pressure of right eye was 17 mm Hg. In the left eye, cell reaction was not found in the anterior chamber and the vitreous. Since anterior segment inflammation had been controlled with prednisolone acetate 1% immediately after cataract surgery and the vitreous did not present inflammatory cells, the pat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female patient was known to have left-sided ulcerative colitis (UC) since 2005 under treatment with oral (2 to 4 g/day) and rectal mesalamine with good clinical and biological response. She presented flare up in 2013 and 2015 with rapid clinical and biologic response to steroid therapy. She was in clinical and biologic remission since 2016. On January 2018, after 13 years of initial diagnosis and while she was clinically asymptomatic, a screening colonoscopy for colorectal cancer showed diffuse superficial ulcerations surrounded by an erythematous inflamed mucosa from the rectum to the splenic flexure (), a solitary sessile well circumscribed polyp in the cecum with normal adjacent mucosa, not amenable to endoscopic resection (Figures , , and ). Histologic examination revealed mucosal extension supported by submucosa consisting of a variable mixture of inflammatory tissue, which is histologically consistent with an inflammatory pseudopolyp ()\nTwo weeks later, she developed moderate flare up with bloody diarrhea and diffuse abdominal pain with no signs or symptoms of obstruction. Laboratory findings showed normal hemoglobin, albumin of 3.7 g/dl, normal liver function tests, and C-reactive protein of 25 (normal < 5). Infectious causes including cytomegalovirus and clostridium difficile were ruled out; a rectosigmoidoscopy revealed diffuse superficial ulceration with pseudomembranes in the rectum and the sigmoid; upper limit of lesions was not seen. Biopsies showed architectural mucosal distortion with polymorph nuclear infiltrates and abscesses, compatible with active UC with no cytomegalovirus (CMV) inclusion. She was started on intravenous (IV) steroids as an induction therapy with marked clinical and biological improvement. Adalimumab infusion, subcutaneously, was initiated as a maintenance therapy at a dose of 160 mg followed by 80 mg after 2 weeks and then 40 mg every other week. Eight months later, a surveillance colonoscopy showed complete regress"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old woman visited our clinic with pain on the right inguinal area and lateral aspect of the thigh, which spontaneously started 3 months ago and had become aggravated a week before. The pain intensity in the visual analogue scale (VAS) was about 80 of 100. Her height was 164 cm and body weight was 62 kg. She was a caddie, and had no specific medical or trauma history. She was experiencing right groin and thigh pain precipitated by walking, which made it difficult for her to walk normally. Lumbar magnetic resonance imaging (MRI) done at a previous clinic showed otherwise normal (). In the previous clinic, lumbar epidural steroid injection was done twice in combination with medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants for 2 months; however, these failed to improve her symptoms. She has even had a gynecological examination to rule out the disorder such as pelvic inflammatory disease, yield to normal. On physical examination, she complained of tenderness over the right buttock and the anterolateral aspect of the thigh, as well as pain with flexion and internal rotation of the right hip joint. Both the straight-leg-raising test and the flip test were negative, as concordant with previous MRI showing non-specific finding. Motor weakness and sensory alteration on the lower legs were not observed. Her body temperature was 36.3℃, and laboratory findings such as complete blood count, erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor were normal. We checked the hip radiograph and found a small amorphous calcification near the right anterior inferior iliac spine (AIIS)-the attachment site of the rectus tendon-suggesting calcific tendinitis of rectus femoris. Additionally, it was more visible in frog leg lateral views around the bony structure (). On initial ultrasonography scanning on the tender area over the hip, oval- shaped calcification was seen with surrounding hyperechoic fat suggesting inflammatio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA male patient aged 47 years presented with a chief complaint of worn-out lower front teeth. A complete oral examination followed by a detailed medical and dental history was done and recorded. The oral hygiene status of the individual was fair [Oral hygiene index (OHI) score=1.5]. Medical history revealed that the patient was a known diabetic under medication Glipizide once daily (OD). He presented with a history of occasional grinding of teeth.\nIntraoral examination revealed, congenitally missing teeth in relation to 31, 41. All the remaining teeth showed signs of attrition, without any specific symptoms. Most of the posterior teeth showed class V fillings, which suggests that the lesions could be due to stress caused by the parafunctional habits like bruxism and clenching. Lower anterior teeth in relation to 32, 33, 42 and 43 were severely attrited with inadequate clinical crown length. Teeth numbers 11, 12, 21 and 22 were slightly palatally tilted, and the palatal aspects of these teeth also showed gross attrition, due to deep bite. Teeth numbers 21, 22, 32 and 33 were already endodontically treated as he had a history of pain and recurrent infections in relation to these teeth [Figures and ].\nEvaluation of vertical dimension of occlusion did not reveal any signs of loss of vertical dimension of occlusion (VDO). Occlusal analysis was done intraorally, and it revealed that there was no definite anterior guidance; and, thereby, absence of any mutually protected occlusion. Lateral movements of mandible showed that on the left working side, there was group function; and on the right nonworking side, there were interferences in the molar regions (46, 47 and 48). On the right working side, there were canine and premolar occlusions, with nonworking side on the left showing interferences in the second and third molars (37 and 38). Even with these clinical signs, the patient did not present"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old woman had noted moderate pruritus in the upper area of her left breast and sensed annoying mass in the same area, 15 months before she was referred to Al Zahra hospital where we took her history notes. One month after the initiation of pruritus, bilateral diagnostic mammography (4 films) showed a 1 cm spherical mass with spiculated edge in the upper zone of the left breast suspected to a malignant lesion and suggested fine-needle aspiration cytology for further studies according to breast imaging-reporting and data system (BIRAD V). Breast sonography revealed normal skin, nipple and subcutaneous fat but a 8.2 × 7.2 mm irregular contour, hypo echo lesion, 1 cm from nipple in the position of eleven o’ clock. Solid mass did not existed in the right breast. Due to these findings the patient underwent partial mastectomy and left axillary dissection 2 month after onset of mass sensation. Post operative pathobiopsy showed an invasive ductal carcinoma. Pruritus subsided immediately after surgery. Lung metastasis and post surgical collection were reported in multi 64-slice CT scan with contrast, 20 days after operation. Lungs were free from any pathologic infiltration. There were multiple pulmonary nodules (one 7 mm in the right upper lobe and three tiny foci in the left lung with mean size of 4 mm) in lung fields. No mediastinal or hilar lymphadenopathy, plural effusion and thickening were seen.\nDuring 6 sessions of chemotherapy and 31 sessions of radiotherapy, the patient had no considerable symptom or problem until 1 week after last session of radiotherapy when she presented with severe scattering pain of the whole left upper limb with a radiation to scapula. Multiform blisters appeared 1 week after, when the scattering pain was decreasing. The watery/vesicular blisters were in the distal flexor surface of the arm in different sizes, dominantly in the cubital area lasted for 3 weeks. These clinical manifestations were diagnosed as herpes zoster activation an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWritten informed consent was obtained to report the case. A 34-year-old G2P1 pregnant woman diagnosed with AS presented at the obstetric outpatient clinic at 18 weeks of gestation. She experienced back pain when she was 25 years old; these symptoms made walking difficult during her first pregnancy at 31 years old. Following her first vaginal delivery, she was able to walk although pain persisted to a lesser degree than during pregnancy. Radiography revealed osteosclerosis of the posterior surface of cervical vertebrae and osteoarthritis of the right hip with joint space narrowing (Figure ). The initial diagnosis of AS was made at 33 years of age.\nPain was managed by the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. After the present pregnancy was diagnosed, only acetaminophen continued to be administered, but pain increased during the present pregnancy. She complained of right hip pain, with a visual analog scale (VAS) score of 7/10. A dosage of 5 mg of oral prednisolone was administered daily from 18 weeks of gestation, and thereafter, the symptoms temporarily improved to 0/10 on the VAS. Unfortunately, the symptoms relapsed at 31 weeks of gestation. At 32 weeks of gestation, she complained of restricted neck mobility with difficulty gargling, restricted lumbar mobility that caused difficulties in bending her back, and restricted right hip joint mobility with a limitation of 10º of abduction, which also affected internal and external hip rotation. Peripartum management was discussed and planned by obstetricians and anesthesiologists. Given that only hip abduction and rotation, but not flexion, were limited, it was considered that an attempt of vaginal delivery would be possible when spontaneous labor occurred. However, if an emergency cesarean section (CS) was necessary during labor owing to other obstetric complications such as nonreassuring fetal status, special anesthesia management may be required because of the possible fai"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 27-year-old Saudi male who had been bed-bound with a history of congenital anomaly of severe kyphoscoliosis, bilateral lower limbs deformity with paraplegia, and a ventriculoperitoneal shunt since early childhood. He was brought to the emergency department (ED) with right flank pain associated with fever and difficulty in breathing. The patient had no complaints of chest pain, palpitations, cough, rhinorrhea or nausea, and vomiting. He could not comment on symptomatic urinary issues due to his baseline paraplegic status. The patient had a past medical history of recurrent urinary tract infection (UTI) characterized by up to two incidences per year and renal stones. He had been discharged four days prior to this admission from a different hospital's ICU, with a diagnosis of sepsis. On physical examination, his vitals were as follows: temperature of 38 °C, heart rate of 165 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 144/95 mmHg, and oxygen saturation of 94% on room air. Cardiovascular examination revealed a normal S1+S2, no added sound, and intact peripheral pulses without peripheral edema. Chest examination showed bilateral decreased air entry with restricted chest movement due to kyphoscoliosis. Abdominal examination revealed a soft and lax abdomen with right upper quadrant tenderness. Lab investigations showed elevated WBC, metabolic acidosis, coagulopathy, elevated inflammatory markers (Table ), and a positive urinalysis for UTI. His ECG demonstrated sinus tachycardia and pulmonary hypertension, and tricuspid regurgitation was found on his transthoracic echocardiogram. CT imaging of his chest and abdomen was performed with negative results for a pulmonary embolism but showed a mass on the right kidney suggestive of XGP (Figure ).\nThe patient was started on 1000 mL of 0.9% normal saline IV, paracetamol 1 g IV, and ceftriaxone 1000 mg IV in the ED. He was referred to the urology department as a case of severe uro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nFemale patient, white, 20 years old, with no systemic history, attended the dental clinic in 2005 reporting a slow, painless increase in volume in the mandible region (right side) over the last 5 years, producing facial deformity. During physical examination facial asymmetry was observed due to an increase in the size of the mandibular body on the right side, of solid consistency, pain-free, and without adenomegalies. Intraoral examination showed a hard-textured increase in the alveolar ridge on the right side; the adjacent mucous tissue was normal. A panoramic X-ray was done () in which alteration was observed in the pattern of the cancellous bone in the right hemimandible; it was then decided to do an incisional biopsy, resulting in a definitive diagnosis of fibrous dysplasia. Bone gammagraphy was indicated plus an endocrinological study to eliminate polyostotic forms which produced a negative result. Monostotic fibrous dysplasia in the right hemimandible was diagnosed. The treatment options were discussed jointly and it was decided to carry out monitoring with a sequence of imaging studies, with the patient being recalled for control.\nWhen the patient returned for control four years later, in 2009, she expressed interest in treating the facial deformity produced by the pathology. She reported that she had received surgical treatment to remove two teeth which were retained in the mandible on the right side. After clinical examination, a panoramic X-ray was done () in which it was observed that pieces 4.5 and 4.8, which were retained, had been removed. Furthermore there was a radioopaque area of the image with the appearance of ground glass in the right hemimandible. A more detailed examination by cone-beam computed tomography (CBCT) not only confirmed the existence of the bone lesion in the right hemimandible (), but also allowed the location and extent of the tumour to be determined precisely, from which the surgical procedure indicated could be"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn November 2012, a 30-year-old woman presented for evaluation of bilateral thyroid masses. A 4×5 cm hypoechoic nodular lesion was detected on the right and a 6×7 cm hypoechoic nodular lesion was detected on the left. The lesions were diagnosed as papillary thyroid carcinoma, and we recommended total thyroidectomy. However, the patient did not wish to undergo total thyroidectomy because she was afraid of the large surgical scar that would remain on her anterior neck. Two years earlier, the patient had been in a traffic accident, as a result of which she had a 10 cm keloid scar on the left lateral neck area (). For this reason, she had a growing fear of skin incision that we planned to perform endoscopic total thyroidectomy via a keloid scar incision.\nUnder general anesthesia, the patient was placed in the supine position. The neck was extended to a greater degree than with the conventional transcervical approach to provide sufficient working space (). A skin incision was made on the lateral keloid scar about 10 cm in length (). A skin and subcutaneous dissection was carried out from the incision line toward the thyroid area, carefully retracting the sternocleidomastoid (SCM) muscle (*) inferiorly and strap muscle superiorly (). We then met the left thyroid gland, preserving the recurrent laryngeal nerve and parathyroid gland around the thyroid (). Thereafter the left thyroidectomy was done (). In frozen biopsy, the left thyroid mass was confirmed to be papillary thyroid carcinoma.\nAfter that, the subcutaneous flap (including the strap muscle) and the SCM muscle were pulled with a retractor to make a tunnel to approach the right thyroid. As the size of the thyroid was large, it could be identified easily while approaching it laterally. A flexible endoscope (10 mm, 0 degrees; Olympus, Tokyo, Japan) was inserted through a subcutaneous tunnel, which provided a good view of the right thyroid area. The assisting surgeon kept the endoscope"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male, heavy goods vehicle driver was referred by his general practitioner with a 5-month history of frequency of micturition and a right groin swelling. He reported that pressure exerted on the groin swelling made him void more urine after he had finished his initial void. On examination, the right groin swelling was indeed noted to decrease in size when compressed after voiding.\nAn ultrasound scan of the renal tract and right groin demonstrated a right inguinal hernia containing the urinary bladder [Figure and ]. The findings were subsequently confirmed by a magnetic resonance imaging (MRI) scan of the abdomen and pelvis, which suggested a right inguinal hernia, containing a large bladder diverticulum []. At flexible cystoscopy, a large bladder diverticulum with a narrow neck was noted. The patient was offered an elective laparoscopic right inguinal hernia repair and excision of the bladder diverticulum.\nThe procedure was performed under a general anesthetic with antibiotic prophylaxis. Four ports (2 × 12 mm and 2 × 5 mm excel bladeless trochars) were inserted after establishing pneumoperitoneum via Hassan's technique. Laparoscopy revealed a large direct right inguinal hernia containing the bladder diverticulum. Following right inguinal dissection, herniotomy was attempted via traction and external pressure. This was unsuccessful; therefore, a small incision was made laparoscopically in the conjoint tendon which enabled the hernia to be reduced.\nThe neck of the diverticulum was identified and confirmed by simultaneous flexible cystoscopy. The diverticulum was subsequently transected using a 35-cm harmonic scalpel (Ethicon harmonic ace). The bladder defect was closed with 4.0 vicryl in a continuous running suture. Flexible cystoscopy confirmed no leak of urine from the bladder following which an 18 Charriere silver-coated urethral catheter was inserted. A 10 × 15 cm Dacron mesh (Cousin Biotech) was tacked over the inguinal defect. This type of mesh was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65 year old woman, presented with stuffiness and headache, referred to our clinic. She has had these symptoms for three years and increasing for three months especially at the right side of her face. The patient had no associated symptoms such as; epistaxis, rhinorrhea, diplopia, cerebral or the other opthalmologic symptoms. She had no history of surgery, trauma or chronic infection. At physical examination there was no deformity on her face. Anterior rhinoscopy showed bilateral inferior conchal congestion and a mass at posterior of the right inferior concha. A solid mass with smooth surface that extend to the choana was found in right nasal cavity on endoscopic examination (). Other physical examinations were normal. A paranasal sinus computerized tomography (CT) scan revealed a 4x3 cm lesion of osseous density arising from the right lamina papyracea and extending to the choana, posterior ethmoid air cells and frontal reses (). Except from the lamina papyracea, there were no insertion of the mass to the lateral wall. There was a soft tissue density in the right maxillary sinus secondary to the ostium obstruction.\nAn endoscopic excision planned under general anesthesia. After uncinectomy and anterior ethmoidectomy, the margins of the osteoma evaluated. The bony medial orbital rim were cut by a drill without excision of the lamina papyracea and the mass was mobilized. Posterior part of the nasal septum was resected for excision of the osteoma. It was pushed to the choana and got out from mouth. Merocel package was done for hemostasis. After removal, the giant osteoma was found to measure ~ 4×3×2 cm (). There was no complication after surgery and the lamina papyracea was intact. Meroceles were got out two days later, there was no hemorrhage and the patient was discharged. The histopathologic report confirmed a diagnosis of osteoma with osteoblastic and osteoclastic activity. An endoscopic examination and CT showed that the patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 34-year-old gravida II para l woman, with a gestational age of 26 + 3 weeks at admission, who had a relatively healthy 4-year-old child with her 40-year-old husband of non-consanguineous marriage. She had been on injectable contraception for 2 years and had regular menses for 6 months before the pregnancy. She had antenatal care at a local health center and was vaccinated with tetanus toxoid once and supplemented with iron for 3 months. She was screened for retroviral infection, hepatitis, and syphilis and it was documented nonreactive. She had no anatomic scan at early gestation. She came to Felege Hiwot Referral Hospital with the chief complaint of severe and persistent headache of a day’s duration which was occipital in location associated with blurred vision and generalized body swelling of 1 week’s duration. She had no other danger signs in pregnancy. Her past gynecologic history, medical history, and surgical history were uneventful. She is Amhara by ethnicity. She had no known family history of hereditary or chromosomal disorders.\nHer blood pressure at admission was 180/120 mmHg and pulse rate was 84 beats per minute; her respiratory rate was 22 breaths per minute and she was afebrile. She had pink conjunctiva and non icteric sclera, 24 weeks-sized gravid uterus, no abdominal tenderness, no organomegaly, no sign of fluid collection in her abdomen, and the fetal heart beat was positive. She had no vaginal bleeding or discharge. She had pedal and pretibial edema. She was conscious and oriented to person, place, and time. Her deep tendon reflex was +2 and her motor and sensory examinations showed no motor or sensory problems. Other parts of systemic examinations were normal.\nHer hypertension was controlled with intravenously administered hydralazine 5 mg two doses at our emergency department. In her complete blood count her white blood cells were 7300 cells/micL,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 29-year-old G3P2002 woman at 39-week and 1-day gestation, who was referred from a health center for management of fetal demise. She had attended 03 antenatal visits at the same health center wherein the fundal height was documented at each visit and routine care given. Except for occasional painful fetal kicks, she was otherwise well throughout the antenatal period. Three days prior to admission into our service, she experienced reduced fetal movements for which she consulted at the said health center and a diagnosis of fetal demise was made. On admission to our unit, she had stable vital parameters. There was no abdominal tenderness and an apparent fundal height of 32cm was measured, fetal parts were not easily palpable, and fetal heart tones were not perceived. There were no signs of per vaginal bleeding. Her cervix was long, posterior, firm, and closed. An emergency ultrasound scan was requested which confirmed fetal demise (gross cranial deformation was noted) but failed to diagnose an intra-abdominal location.\nCervical ripening was started with 50µg of misoprostol vaginally every 6 hours and after 4 applications; the cervix remained unchanged. A decision for operative delivery was made, indicating failed induction and in a bit to reduce the risk of disseminated intravascular coagulation. The intraoperative findings were a third-degree macerated female fetus floating freely in the peritoneal cavity, weighing 2650g with a tight cord round neck and with no amniotic sac (). The uterus was about 14 weeks () and the fallopian tubes and ovaries were normal. The placenta was implanted on the ascending colon and mesocolon. The placenta was left in place. No intraoperative complications were encountered. Postoperatively, she was placed on ampicillin, gentamycin, and metronidazole parenterally for five days. She also received 50mg of methotrexate every other day (04 doses) with 5mg of folinic acid each day proceeding the methotrexate. She was discharged o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-month-old female infant was admitted due to a fast-growing tumor of the right side of the maxilla, disfiguring the right cheek, nose and upper lip. The first symptoms occurred when the girl was 6 weeks old, when a tooth within the hard palate surrounded by a small, hard, non-painful bulge was found by the mother (). It was diagnosed by a GP as a neonatal tooth and a decision was made to wait and see. However, during the next two weeks, the mass rapidly increased in size. Magnetic resonance (MR) displayed a pathological, well defined, solid mass measuring 23 × 22 × 18 mm, located within the alveolar process on the right side of the maxilla, reaching the midline. The bud of the right incisor was visible within the mass. The tumor bulged outside in the region of the nasal alar and invaginated into the mouth. No evidence of destruction of the hard palate, penetration into the orbital or nasal cavities and no evidence of enlarged lymph nodes (LN) were found ().\nThe tumor was resected in the otolaryngology department; however, clear margins were not achieved. The histopathological examination revealed MNTI with typical morphology and immunophenotype (). Three weeks after the surgery, a local recurrence was observed and the patient was referred to the department of Pediatric Oncology. MR revealed a mass measuring 16.5 × 16.5 × 22 mm visible in the postoperative area (). The mass was invading the nasal concha and reaching the medial angle of the right eye; however, it did not penetrate into the orbit. Because the tumor was deemed unresectable without severe mutilation, a neoadjuvant CHT was introduced to reduce its size and extent. The patient received several courses of CHT according to the protocols for neuroblastoma (NBL) and sarcoma. The responses to particular courses of CHT varied () but eventually, after eight courses, a partial regression of the tumor was achieved which enabled its complete non-mutil"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old male patient reported with the chief complaint of swelling and mobility in lower posterior teeth since six days. On examination there was a periodontal pocket of 7 mm and 8 mm on distal aspect of 46 and 47 respectively [Figure and ]. Radiograph showed infrabony defects distal to 46 and 47 [Figure ]. The treatment plan was to perform an open flap debridement in 46, 47 region and utilize autogenous bone procured from maxillary tuberosity to fill the osseous defect.\nA mucoperiosteal flap was raised from the 45-48 regions using simplified papilla preservation flap[] to achieve maximum coverage of the grafted site. No vertical incisions were given and the flap was extended to one tooth on either side for adequate reflection [Figure ]. A thorough debridement was carried out and after complete removal of granulation tissue, 5.5 mm and 5 mm defects were present distal to 46 and 47 respectively [Figure and ].\nThe site selected for procurement of the autogenous graft was the right maxillary tuberosity. A mucoperiosteal flap was raised and site exposed with adequate reflection []. Autogenous chips were collected from the site [] and placed into the defects []. The flaps were sutured with close approximation of both the flaps using interrupted sutures starting from the distal aspect of 47 and last suture placed between 45 and 46.\nThe patient was instructed on proper plaque control in all areas except the quadrant of surgery where he was instructed not to brush. A 0.12% Chlorhexidine mouthwash was prescribed for rinsing twice daily. The sutures were removed 10 days after surgery and the patient was advised to continue the Chlorhexidine mouthwash for two weeks. After this he was advised to start mechanical plaque control in the operated quadrant using soft brush and roll technique.\nThe patient was put on regular recall at 1,3,6,9 and 12 months. The clinical picture had improved considerably at the time of three-month"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old Caucasian lady presented to the Maxillofacial outpatient clinic via her general practitioner with a 12-month history of tenderness around the left side of the oropharynx. She reported painful swallowing mostly with solid foods and felt it was getting worse. She also reported that she was unable to lie flat due to severe pain. Based on these symptoms, the patient had been diagnosed with gastroesophageal reflux and had been placed on regular proton pump inhibitor (esomeprazole) by her general practitioner. This medication failed to control or improve her symptoms. It was also noted from her medical history that she had previously suffered with a tonsillar carcinoma on the left side and had been treated with surgery and radiotherapy years earlier.\nPhysical examination revealed an edentulous patient with an irregular red lesion in the left side of the soft palate with a bony hard, slender mass protruding into the mouth covered by mucosa (Fig. ). There was no evidence of ulceration, induration or any other lesions present in the mouth. Extraoral examination was completely normal with no clinical evidence of cervical lymphadenopathy. An orthopantomogram demonstrated an elongated styloid process.\nThe patient was clinically diagnosed with an elongated, medially deflected and symptomatic styloid process. The proposed management plan was for surgical reduction of the protruding process via an intraoral approach.\nUnder a general anaesthetic, a mucosal incision over the protruding process was made with monopolar diathermy. Periosteal elevators were used to free all the soft tissue attachments off the styloid process (Fig. ). Once cleared, 2.5 cm of the styloid was removed with a Rongeurs bone nibbling forceps. This was judged clinically to be a sufficient length to clear the oral cavity of any interference from the protruding styloid process. Bleeding was controlled with bipolar-diathermy forceps and the mucosal incision closed with 3.0 vicryl interrupted sutures."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old African man presented to our surgical emergency with a week history of bleeding per urethra following nocturnal penile erections. He admitted to have introduced a broken transistor radio antenna into his urethra a week before to serve as an improvised ‘itchstick’ to ease a bothersome itchy urethral condition. The object subsequently migrated proximally out of reach. He made several unsuccessful attempts at self-retrieval prior to presentation and remarkably reported no difficulty with voiding. He had no history of psychiatric disorder, alcoholic or drug intoxication and had no prior history of similar or other self-injurious behaviour. He, however, had a bothersome perineal and itchy urethral condition which was worse at nights.\nPhysical examination revealed a hard rod-like mass in the proximal part of the penis extending to the perineum; the mass had only minimal mobility. A pelvic X-ray done showed a rod-like radio-opaque foreign body in the region of the penile and bulbar urethra []. A diagnosis of foreign body in the male urethra was made. After obtaining informed consent, removal of the foreign body was planned. Under caudal regional block with 2% Xylocaine gel instilled into the urethra, an attempt at ‘milking out’ the foreign body was made but failed. Endoscopic removal was considered but deemed inappropriate as the distal end of the object was jagged (irregular) and appeared impacted in sub-urethral tissue. External urethrotomy of the anterior urethra was performed with the incision made into the proximal penile urethra at the distal tip of the foreign body which was then easily extracted []. The extracted foreign body, an aluminium tube transistor radio antenna measured 13 cm in length [], urethral swab for microscopy and culture was taken and urethrotomy closed over a 16 Fr Foley's catheter. The patient was discharged after 48 hours and the catheter removed after a week at the clinic. The urethral swab"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male volleyball player presented to the clinic with a three-week history of lower back pain. The patient was otherwise healthy, with no history of trauma. Spinal extension with his arms overhead during jumping elicited lower right back pain (Figure ).\nA review of systems did not reveal any other pertinent findings. On examination, the patient showed normal responses to the straight leg raise test and no neurologic signs. His range of motion was normal with extension and flexion of the lumbar spine, but associated pain occurred over the paravertebral muscles. Palpation of the proximal lumbar spine vertebrae revealed mild tenderness. Paraspinal spasms were noted. No signs suggestive of inflammation were evident. The stork test caused mild pain over the lower back (Figure ).\nConservative treatment was initiated which included rest for two weeks and icing of the painful area of his back for 15-20 minutes a day, up to three times a day. The patient was also advised to avoid any activities and positions that might lead to back pain. He was advised to take ibuprofen as needed for pain and cyclobenzaprine as needed for spasms. He was referred to physical therapy for local modalities and core-strengthening exercises. His back pain had resolved by the two-week follow-up. Approximately three weeks later, he was pain-free, even during activities.\nDiagnosis\nIn this athlete, treatment was geared towards mechanical back pain and spasms, and it appeared to be effective. The patient had expressed desire at the time of the consultation to participate as soon as possible in a college-level volleyball competition. The lengthy symptomatology (three weeks) in this adolescent collegiate athlete who performed repetitive hyperextension as a volleyball player who was planning to participate in an upcoming competition, combined with the physical examination findings and positive stork test, indicated a need for radiography due to increased suspicion of spondylolysis [-]. An"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA-40-year old female, previously fit and well, presented with pain and swelling of the left side of her neck of four days duration, in association with a sore throat and chest tightness. The pain radiated to the left axilla and shoulder. There was no history of fever or night sweats, and she had lost about 8 lbs in weight in the previous 3 months. She had no cough, and clinical history was otherwise unremarkable. She had no relevant past medical or surgical history and was not taking any medications.\nOn examination, there was diffuse tender swelling on the left side of neck with marked engorgement of the superficial veins over this area, also involving the upper part of chest and upper left arm. There were a few scattered small tender lymph nodes in the posterior triangle of the left side of the neck. The remainder of clinical examination was normal.\nInitial laboratory investigations showed a normal full blood count, with a raised erythrocyte sedimentation rate of 58 mm and elevated C-reactive protein of 45 units (normal range is 0–10 units). Urea and electrolytes, liver function tests, and thyroid function tests were normal, and chest X-ray was also unremarkable. A thrombophilia screen was negative, and serum ANA was weakly positive.\nShe was referred initially for ultrasound examination of the neck which demonstrated extensive thrombosis of the left internal and external jugular veins (Figures and ).\nUltrasound also demonstrated enlarged lymph nodes in the left supraclavicular fossa which were suspicious of malignancy ().\nShe was initially treated with intravenous antibiotics and was anticoagulated with low molecular weight heparin followed by warfarin. Subsequently she underwent computed tomography (CT) of the neck, chest, abdomen, and pelvis which confirmed venous thrombosis of the left jugular veins. CT also showed multiple enlarged left supraclavicular nodes, an enlarged right retro-crural lymph node, and extensive portal and para-aortic adenopathy extending do"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old gentleman was diagnosed as a case of left-sided RCC in June 2004, which was treated with radical nephrectomy and adjuvant radiotherapy at an outside hospital. In October 2006, he presented to our hospital for second opinion in view of progressive metastatic deposits in both the adrenals, lungs, and mediastinum. He was started on interferon (INF-α, 5 MIU daily subcutaneous doses), which he continued till December 2007. Subsequently, he presented with swelling in throat in March 2009. It was biopsied and confirmed to be metastases from RCC. He was advised external beam radiotherapy for the base tongue lesion but refused treatment due to personal reasons. In December 2009, he presented again with increasing difficulty in swallowing and alteration in voice. He was barely able to swallow liquids orally and had lost 2-3 kg of weight. On clinical examination, he had a large (5 × 5 cm) exophytic swelling in the oropharynx with epicenter in the right base of tongue []. It involved the tonsillar fossa and adjacent soft palate on right side, crossing midline. Tongue mobility was normal. There was no palpable cervical lymphadenopathy. Computerized tomography (CT) scan of the face, neck, thorax, abdomen, and pelvis was suggestive of widespread visceral and osseous deposits apart from the base tongue lesion []. No adenopathy was noted (which corroborated with secondary from RCC as it is uncommon for large oropharyngeal primary of squamous carcinoma to present without neck nodes). In view of predominant symptom of dysphagia and exophytic growth, he was first planned for palliative radiotherapy with escalating doses followed by Sunitinib. The patient received radiotherapy to a dose of 50 Gy in 25 fractions over 5 weeks with limited portals. Protracted regimen (prolonged fractionated course of radiotherapy over 5 weeks as compared to the most commonly used short course of palliative radiotherapy) was chosen expecting sustained and relatively quicker relief of symptoms."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old and 60 kg weight male patient was admitted in kidney transplant unit with a history of end-stage renal disease (ESRD) and on maintenance hemodialysis twice weekly since 21 months. He was having type 2 diabetes mellitus since 7 years and was on oral hypoglycemics. He was also hypertensive since 18 months and was on nifedipine retard 20 mg TID, clonidine 100 μg TID, metoprolol 50 mg OD, and furosemide 40 mg BID. During preoperative evaluation, the patient was New York Heart Association Class III having a history of breathlessness and dyspnea on exertion. Jugular venous pressure was raised. Mild ascites was present without evidence of organomegaly. His daily urine output was around 500 ml. His 12-lead electrocardiogram (ECG) showed left ventricular hypertrophy with strain pattern. Two-dimensional echocardiography revealed moderate mitral regurgitation, moderate tricuspid regurgitation, dilated left ventricle with global hypokinesia, and LVEF of 15% with moderate pulmonary artery hypertension (right ventricular systolic pressure = right atrial pressure + 44). Coronary angiography was normal. His routine blood investigations were within normal limits except hemoglobin of 8.7 g% and a serum creatinine of 6.9 mg/dl on preoperative visit. His creatinine value before starting of dialysis 21 months earlier was 9.4 mg/dl. His chest radiograph showed cardiomegaly with cardiothoracic ratio of 0.7. On airway examination, his mouth opening was 3 cm with normal dentition. He was Mallampati Class 2 with a full range of neck movements and a thyromental distance of 7 cm. All antihypertensive medications were continued as prescribed. Heparin-free hemodialysis was done 24 h before surgery. A written informed consent for surgery and anesthesia was obtained along with high risk of cardiovascular events and postoperative mechanical ventilation.\nIn the operating room, an 18-gauge intravenous (IV) cannula was secured in the right upper limb and 5-lead ECG, noninvasive blood pre"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old undernourished boy presented to our outpatient department with a 1-month history of progressive breathlessness on exertion. He had a history of intermittent fever of mild to moderate grade and dry cough since 4 months. His breathlessness had progressed relatively rapidly over 1 month and now limited his daily activities. He also had associated anorexia and weight loss. He had been treated symptomatically by his local physician and later underwent investigations for the persistence of symptoms. A chest X-ray [] showed a complete white-out of the left lung with ipsilateral mediastinal shift suggesting complete lung collapse. A contrast-enhanced computed tomography of the thorax showed an endobronchial lesion in the left main bronchus with complete collapse-consolidation of the left lung; it also showed an endobronchial lesion in the right lower lobe []. He underwent a fibreoptic bronchoscopy which confirmed a left main bronchial growth and a right lower lobar bronchial growth and a guided biopsy of these endobronchial lesions [] was done. The histopathology report of the left sided lesion was necrotic tissue and the right sided lesion was reported as a neuroendocrine tumor (carcinoid tumor).\nSubsequent to these investigations, he was transferred to our hospital for increasing the severity of his symptoms. He presented to our hospital in respiratory distress and required endotracheal intubation with mechanical ventilation. We performed a bronchoscopy which confirmed the outside report and repeated endobronchial biopsies. Review of these and the external biopsies showed a high-grade malignant tumor composed of sheets ofhighly pleomorphic cells containing a moderate amount of eosinophilic cytoplasm and eccentrically placed hyperchromatic nuclei and prominent nucleoli. Few cells showed wreath like/horseshoe-shaped nuclei []. On immunohistochemistry (IHC) the tumor cells were strongly and diffusely positive for leukocyte common antigen, while negative for cyt"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old man was found to have early gastric cancer during his yearly check-up by gastrointestinal endoscopy. He was 158 cm in height and weighed 62 kg. Gastrointestinal endoscopy showed a depressed lesion that was diagnosed as early gastric cancer by pathological examination of biopsy specimens. He underwent LADG with regional lymph node dissection (D1 including the nodes surrounding the origin of left gastric artery). A 12-mm trocar for the laparoscope was placed in the umbilicus. Pneumoperitoneum was then established with carbon dioxide and the intraperitoneal pressure was maintained at 10 mm Hg. Two more 12-mm trocars were inserted in the midclavicular line below the costal margin and 2 cm above the umbilicus on each of both flanks and were used for active surgical instruments. All trocars used were the non-bladed type. The specimen was removed through a small medial incision which was 55 mm in length placed after resection of the stomach, and then Roux-en-Y reconstruction (RY) was carried out (Fig. ). A tubular shaped drainage tube 10 mm in diameter was inserted and placed through the upper trocar site made on the right flank. Wound defect at the umbilical port site was sutured completely including the peritoneum with 0 absorbable suture and fascial incisions at all other trocar insertion sites were closed with 2-0 absorbable sutures. Surgical duration was 263 min, and the volume of blood loss was less than 50 mL with no blood transfusion.\nPostoperatively, the patient complained of an acidic feeling in his stomach; however, there were no remarkable abnormalities on biochemical examination of serum. Radiological findings did not suggest bowel obstruction until 3 days postoperatively, although mild symptoms such as general malaise and vague abdominal pain were reported on day three. However, on day 4, the patient started to complain of upper abdominal pain and developed a high grade fever (38°C). Complete obstruction of the small bowel and leakage"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male referred to Shahid Beheshti Maxillofacial Pathology Department with a two year history of generalized proliferative gingival maxillary lesions with palatal right side swelling and mandibular labially gingival lesions ().\nThe lesions were asymptomatic, without any bleeding or purulent discharge. The right submandibular lymph node was palpable and the patient noticed this swelling after the extraction of the third molar one month prior to his visit to our department. The gingivally lesions were red and soft with irregular surfaces, and the palatal swelling had a purple-gray appearance with intact overlying mucosa ().\nRadiographic examination revealed a moderate bone loss similar to a periodontal disease.\nLaboratory test results were normal, so the patient’s diagnosis was stated as inflammatory and reactive hyperplastic lesions.\nThe patient’s teeth were extracted. Only 2 maxillary central incisors were preserved for esthetic. Tissues needed for histopathologic evaluation were obtained from the gingivectomy of gingivally proliferative masses and with a full thickness flap from the palatal swelling.\nSoft tissue specimens were fixed in 10% neutral buffered formalin and embedded in paraffin blocks. For standard pathological examination, the sections were prepared with H&E stain.\nThe slides of both gingival and palatal specimens showed a dense cellular infiltration under the epithelial layer in deeper portions.\nThe cells were mononuclear which showed pleomorphism with moderately amount of cytoplasm and round to oval nucleus with prominent nucleoli. These cells did not have a characteristic phenotype. Therefore, a series of differential diagnosis such as large cell lymphoma, plasmacytoma, poorly differentiated carcinoma and lymphoblastic leukemia was suggested (-).\nFor the final diagnosis, a panel of antibodies was applied using the Immunohistochemistry (IHC) method. The tumor cells were diffusely positive with antibodies against LCA, negative with CD20, C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male presented with 6 months of radiating pain and numb to right leg. Physical examination revealed a positive straight leg raising test at 40°on the right side. There was weakness of the ankle and great toe dorsiflexion (muscle strength graded IV and III, respectively). MRI revealed a herniated disc compressed on the right nerve root and right lateral recess stenosis at L4-5 (Fig. ). The surgical protocol was set as L4/5 PELD.\nAfter the general anesthesia, the patient was placed in a prone position on a soft cushion for spinal surgery. C-arm fluoroscopy was used for anteroposterior and lateral view to ensure L4-5 intervertebral space. The position of the fluoroscope and the height of the operating table should be checked for convenience for the operating team. The patient was marked for puncture orientation and prepped and draped in standard sterile procedure. 0.5 wt% of lidocaine was used for local infiltration anesthesia around the skin, fascia, and the facet joint. Aided by C-arm fluoroscopy, a puncture needle is inserted into the intervertebral foramen of L4/5 by layers. The tip was confirmed in the anteroposterior position at the inner margin of the vertebral pedicle, while the lateral position was in the posterior and upper margin of vertebral pedicle of L5 (Fig. ). After the intraformational infiltration anesthesia was completed in the right intervertebral foramen, the guide wire was inserted along the puncture needle. A 7-mm cut was made in the center of the puncture point on the skin. The guide wire was inserted along a tapered cannulated dilator to enlarge surgical access, as well as an ongoing dialogue with the patient. The working sleeve was implanted along tapered cannulated dilator to separate the surrounding soft tissue (Fig. ), then the protective sleeve of trephine was also inserted. The soft tissue was expanded step by step using the protective sleeve until its tip was at"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old Saudi boy of Arab ethnicity, with no past relevant medical, surgical, family, or psychosocial history, presented to the King Saud Medical City emergency department with bleeding per rectum and mild abdominal pain 3 days after blunt abdominal trauma while playing football. On examination, his abdomen was slightly tender and bowel sounds were present. Initially, focused assessment with sonography for trauma (FAST) showed mild intraperitoneal fluid in his pelvis. A subsequent computed tomography (CT) scan of his abdomen revealed mild pelvic hemoperitoneum, but there was no definite solid or hollow visceral injury. So, he was admitted to the general ward for serial abdominal observation. On admission to the surgical ward, he was stable with a heart rate (HR) of 86 beats per minute (bpm) and blood pressure (BP) of 100/70 mmHg. His hemoglobin (Hb) was 9.6 gm/dl. We kept him nil per mouth and a nasogastric tube was inserted. The intake and output chart was regularly calculated. Serial Hb monitoring showed a continuous fall in his Hb level during the following days. He continued to have altered rectal bleeding. On day 3 his Hb dropped to 6.1 gm/dl, despite having received 2 units of packed red blood cells (PRBC). He started to develop a mild fever with a temperature of 37.8 °C, tachycardia with a HR of 140 bpm, and the BP dropping to 70/40 mmHg. He was resuscitated and stabilized with intravenously administered crystalloid fluids and 2 units of PRBC. He did not require any inotropes or vasopressors. Due to this clinical deterioration, he was urgently taken to the operating room for further diagnostic and therapeutic management. The nasogastric tube revealed bile without hematemesis. After initiating general anesthesia, an on-table colonoscopy was performed to identify the bleeding site. There was altered blood within the whole colon and terminal ileum without a definite bleeding site. Therefore, we proceeded to a laparotomy."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fas"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAll patients in our case series were Caucasian male between 32 to 47 years old when the symptoms started (). However one patient presented to us at the age of 70 years and another at 61 years of age. All of our patients presented with slowly progressive ataxia and 2 had fall on multiple occasions. Only one person had family history of undiagnosed ataxia. All of them were referred by either the GP or the peripheral hospitals as the cause of their symptoms were unclear.\nAll of them demonstrated spasticity in the lower limbs. First three patients revealed some degree of horizontal ophthalmoplegia (). The third patient had asymmetric ptosis in addition to ophthalmoplegia. All of them had signs of cerebellar ataxia.\nAll 4 patients were subject to routine bloods, B12, folate, thyroid function test, copper, nerve conduction studies, etc. Then all had routine genetic testing for ataxia including spinocerebellar ataxia, Friedreich’s ataxia (Frataxin) Fragile X Associated Tremor/Ataxia syndrome (FRXTA) (). They subsequently had next generation sequencing of 21 gene panel for hereditary spastic paraparesis.\nThe Magnetic resonance imaging (MRI) showed some degree of cerebellar atrophy in first three patients. However the last patient had significant pan-cerebellar atrophy in MRI scan (). None of them showed any evidence of cord compression, demyelination or space occupying lesion in whole spine magnetic resonance imaging. The genetic screening for spinocerebellar ataxia (SCA 1,2,3 and 6) were negative for all. Patient 4 had additional testing for mutation in SCA 7 which turned out to be negative.\nThe next generation sequencing involving 21 genes in the spastic paraparesis panel revealed autosomal recessive hereditary spastic paraparesis due to the mutation in Spastic paraparesis 7 gene (SPG 7) in all of them with a novel mutation in one of them (). All these mutations were comfirmed by conventional Sanger sequencing.\nAll the patients were informed approximately their"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3.5-year-old girl was referred to pediatric neurology department with ataxia and dancing eye movements starting since 1.5 years ago. The patient was admitted for further evaluations. Initial laboratory workups including hematological and biochemical parameters were in normal range. The 24-hour urinary vanillin mandelic acid (VMA) concentration showed an increase. Imaging studies including chest and abdominal computed tomography (CT) scan revealed a tumoral lesion located in posterior mediastinum extending from T6 to T10. The patient was scheduled for thoracotomy and the mass was resected as much as possible.\nSurgical specimens were submitted to the histopathologic laboratory. Microscopic evaluation was compatible with poor stroma, undifferentiated neuroblastoma. N-myc was amplified to more than 10 copy numbers using fluorescence in situ hybridization (FISH). Bone survey study was performed and show no abnormality. Bone marrow aspiration and whole body Tc-99 m was unremarkable and brain CT scan was normal.\nChemotherapy started referring to N6 protocol []. Within the first weeks following chemotherapy patient's symptoms and signs remarkably alleviated except opsoclonus-myoclonus syndrome which was the main complaint of the patient. It was planned to prescribe corticosteroids and clonazepam to treat the syndrome. After about 4 weeks, the debilitating problem for the patient was ataxia which showed no acceptable improvement. It was decided to prescribe intravenous immunoglobulin (IVIG) 1 g/Kg, monthly to improve ataxia and opsoclonus. After 2 courses of IVIG for 2 consecutive months, no obvious change was observed. Finally rituximab 375 mg/m2 as the last recognized option was considered to control patient's symptoms.\nOMS Evaluation Scale was applied to evaluate clinical outcome of the patient as previously described []. A significant improvement in patient's ataxia and eye movements was observed after first dose of rituximab. About 3-4 weeks later the symptoms returne"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old woman (gravida 2, para 2) was referred to our hospital complaining of a lower abdominal mass and pain. Her medical history was unremarkable. She was initially diagnosed with a uterine leiomyoma by transcervical needle biopsy. CT revealed a large heterogeneous tumor occupying the pelvic cavity and an intravascular tumor within the dilated left internal iliac and ovarian veins (Figures and ). Her preoperative cervical cytology results were negative for intraepithelial lesions and malignancy. The endometrial cytology and needle biopsy results were also negative. Thus, the preoperative diagnosis was IVL, with extension of the tumor into the left internal iliac and ovarian veins.\nIntraoperatively, multiple myomas were found within the uterine corpus and cervix, and the tumor extended to the parametrium and paracolpium. Detachment of the tumor from the left ureter and vaginal wall was very difficult. Intravenous tumors in the left internal iliac and ovarian veins could be palpated. The left internal iliac vein forming the common iliac vein was transected at the bifurcation region. In addition, TAH and bilateral salpingo-oophorectomy (BSO) were performed, resulting in the complete surgical resection of the tumor (operative time, 11 hours; blood loss, 8462 g). The resected uterus and adnexa weighed 897 g (Figures and ). There was no residual tumor detected in the venous resection stump.\nThe nodule resected from the uterus and the internal iliac and ovarian veins consisted of a proliferation of spindle cells. There was no nuclear atypia and the mitotic index was low. In addition, vessel endothelium cells and a vascular smooth muscle layer covered the IVL (Figures and ). The tumor cells stained positive for Alcian blue (pH = 2.5) and the staining disappeared after hyaluronidase digestion. However, compared to that in Case 1, the intensity of the staining was weaker and less diffuse (Figures and ). Similar findings for hyaluronan expression were obtained using th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old woman, gravida 1 para 0, underwent the routine prenatal examinations in our hospital from 6 gestational weeks. Till 30 gestational weeks, the prenatal course was unremarkable, including systemic prenatal ultrasound diagnosis and the routine fetal cardiac screening (at 24 gestational weeks). Fetal growth was within the normal process and the alpha fetal protein was 23.91 U/ml (the normal reference value:0–25 U/ml).\nAt 30 gestational weeks, the B-mode ultrasound revealed that the liver of the fetus was enlarged with a heterogeneous solid mass located in the right quadrant of the fetal abdominal cavity, with a close relationship to the liver. The mass measured 5.8cmx4.7cmx5.2 cm and pushed the portal vein and gall bladder. The lesion seemed to have an ill-defined margin, irregular shape, partial capsule with multiple cystic cavities inside, and maximal diameter of 2.1 cm. The portal and hepatic veins were not dilated. In the color Doppler ultrasound, the mass appeared to be highly vascularized (Fig. ) and RI was 0.67. The three-dimensional power Doppler ultrasound showed the feeding vessels were mainly around the lesion but there were less vessels inside it (Fig. ). Due to the rapid enlargement of this mass and the imaging features of ultrasound, the diagnosis of HBL was highly considered. But IHH, mesenchymal hamartoma or other rare liver tumors such as hepatic cysts or adenomas could not be ruled out.\nAccording to the pediatrician, the final diagnosis depended on the postnatal biopsy of the hepatic lesion and the prognosis of HBL was uncertain. Finally, the parents chose to give up this fetus because of the uncertain outcomes involving tremendous emotional and economic impacts on the family. Furthermore, they refused to take any further prenatal examination, like fetal MRI. A male fetus was aborted, weighing 1409 g and measuring 36 cm long.\nMedical ethics committee of West China Second Hospital of S"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old female G4P1112 at 34-week and 1-day gestational age dated by last menstrual period presented to the outpatient clinic for her first obstetrical visit. She was referred for evaluation of a large vaginal mass by an outside provider over concern of potential malignancy. There were also vulvar lesions which were punch biopsied showing squamous vaginal mucosa with some reactive cellular changes. A transvaginal ultrasound detailed the presence of varicosities within the vaginal wall. The patient had no prior history of vaginal varicosities. Her obstetrics history was significant for 2 prior C-sections, 1 ectopic pregnancy, and diet-controlled gestational diabetes. The patient had been complaining for the past 2 months of yellow vaginal discharge, dysuria, and discomfort made worse with walking. She had been treated unsuccessfully with fluconazole for this pain in the past. Fetal anatomy survey at 26 weeks and 2 days demonstrated no maternal anomalies of the cervix. The fetus was found to have mild bilateral hydronephrosis at 4 mm.\nOur patient began menarche at age 12 and has been regular with a moderate flow lasting approximately 3 days. She has no known history of gynecologic diseases; STI screening with her last pap smear and HPV test were negative for abnormalities in October 2016. She has no history of past varicosities, coagulopathies, or hepatic disease. The patient had a significant past surgical history of laparoscopic cholecystectomy and hernia repair in 2014. She denied any personal or family history of cancer.\nOn physical exam, significant anterior and lateral vaginal wall clusters of soft varicosities were noted. The varicosities filled the vagina and protruded beyond the hymenal ring (Figures and ). A second opinion obtained by a Gyn-Onc physician confirmed large vaginal varicosities by clinical exam. The patient was sent back to referring provider to continue prenatal care. The oupatient OB/Gyn consulting physician recommended repeating C-secti"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a weight of 2659 g and Apgar scores of 9 and 9 at 1 and 5 minutes, respectively; arterial cord pH was 7.26. No extension of the hysterotomy was noted following delivery of the infant. Following repair of the hysterotomy, the bladder was noted to be distended and edematous, despite the presence of a patent Foley catheter. This finding prompted a vaginal exam to assist in evaluating the integrity of the lower uterine segment behind the bladder due to concern for an occult uterine rupture or dehiscence. The vaginal exam revealed a spontaneous detachment of the anterior rim of the cervix from approximately 9 to 3 o'clock. The avulsed portion of cervix appeared necrotic () and there was no bleeding noted at the site of cervical detachment. The cesarean delivery was completed, and an attempt was made to repair the site of the detachment vaginally, at which time the entirety of the cervix completely detached. No excessive bleeding was noted and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old female with a prior history of hypertension, was diagnosed with Stage IIIC high-grade serous ovarian carcinoma (HGSOC) nearly 5 years ago. The patient received neo-adjuvant chemotherapy with paclitaxel and carboplatin every 3 weeks for 3 cycles. A repeat scan done post 3 cycles showed partial response to treatment and patient underwent a cytoreductive surgery at an outside center. The surgical pathology was consistent with Stage IIIC disease noted earlier with lack of good response to carboplatin and paclitaxel given neoadjuvantly. Hence treatment was switched to gemcitabine, cisplatin and bevacizumab during adjuvant therapy for 3 cycles. A repeat scan done post completion of treatment showed complete resolution of disease.\nThe patient remained disease free but had a relapse with the PET scan showing FDG avid lesions in the liver and pouch of Douglas after 3 years. The patient was started on second-line chemotherapy with gemcitabine, cisplatin and bevacizumab. However, bevacizumab was discontinued after first dose as the patient developed internal bleeding in the operative bed. Next two cycles of chemotherapy were continued with gemcitabine and cisplatin alone without bevacizumab. A CT scan done post completion of 3 cycles of treatment showed response to therapy. The patient did not continue any further chemotherapy at this time due to toxicity issues. No PARP inhibitor was offered due to BRCA negative status on germline testing at the time. The patient developed progressive disease after 9 months and underwent a second surgery with excision of the vaginal vault and the pelvic mass and omentectomy. Histopathology was suggestive of metastatic HGSOC. For the ideal therapeutic options, the sample was sent for multi-analyte Exacta® analysis. The overview of the treatment given is summarised in ().\nThe integrative, multi-analyte Exacta® test includes molecular analysis of comprehensive gene expression, DNA mutation profiling, chemosensitivity assay, immunoh"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47 year-old-man, human immunodeficiency virus negative, with a recent diagnosis of central nervous system lymphoma presented with perianal skin lesions and nonbloody diarrhea. The skin lesions began as nodules that progressed to a roughened plaque and in the minority, ulceration. The lesions began eight weeks prior to presentation, were multiple, scattered in the perianal area and upper thigh bilaterally, and three centimeters at the widest diameter (). A more distinct lesion with irregular border was present over the sacrum consistent with a decubitus ulcer. The patient had been diagnosed with a CNS lymphoma six weeks prior to admission when he presented to another hospital with lower extremity weakness, saddle anesthesia, and fecal incontinence, and was found to have a L1-L2 intramedullary spinal mass. He had emergent surgical resection of the mass and was treated with high-dose dexamethasone and further radiation therapy. He was additionally found to have a right temporal lobe mass that was resected and pathology was consistent with a B-cell lymphoma with T-cell infiltration. He had no other significant past medical history or immunocompromising condition. The lower extremity weakness persisted and primarily confined him to bed. For ongoing fecal incontinence and the nonhealing sacral decubitus ulcer, he ultimately had a diverting colostomy. Two weeks prior to presentation, his bowel movements became more liquid in consistency and increased in frequency. He denied abdominal pain. The perianal skin lesions were not painful, but the initial loss of sensation from the compressive spinal mass had not recovered. He remained on a dexamethasone taper and was transferred to this hospital for further evaluation for chemotherapy. His complete blood count was notable for a normocytic anemia, and his liver function tests for an elevated alkaline phosphatase. An excisional biopsy of one of the skin lesions from the upper thigh was obtained and sent for pathological examinat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old postmenopausal lady (Patient A) and a 32-year-old homemaker (Patient B) presented with history of exertional dyspnea of 1-year duration and 6-month duration, respectively. Both gave history of occasional cough with expectoration. They also gave history of recurrent respiratory infections. However, neither of them had a history of tuberculosis or associated comorbid illness like diabetes mellitus. On presentation, both were clinically stable and maintained normal saturation at room air. On examination, they had mild deviation of trachea to the left with reduced breath sounds in the left hemithorax and laterally placed apex beat. Their chest X-ray (CXR)/scanogram demonstrated shift of the mediastinal structures to the left and hyperlucent right lung []. A possibility of left lung collapse/left lung hypoplasia was considered. Contrast chest computed tomography (CT) showed hypoplastic left lung with bronchiectatic changes in the left lower lobe with herniation of right lung. Mediastinal structures were to the left []. Further on CT, Patient A had a rudimentary left pulmonary which was interrupted/abrupt termination within 1 cm of origin from the main pulmonary artery. The diameter of the left pulmonary artery and main pulmonary artery of Patient A are 7 and 23 mm, respectively. Patient B CT showed a left pulmonary artery of about 9 mm in diameter but was also abruptly terminated within 1 cm of origin from the main pulmonary artery. A possibility of left-sided pulmonary artery agenesis with left lung hypoplasia was suspected and both the patients underwent a perfusion scan which revealed no perfusion in the left lung with normal perfusion in the right []. Fiberoptic bronchoscopy showed narrowed segmental openings of the left lung. The left main bronchus and lobar bronchus were normal. Bronchial washings were collected from all the narrowed segments, but no organism was isolated. Patient B also had a more distally placed right upper lobe bronchus probably du"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case report describes the fracture of a temporary femoral hemodialysis catheter during placement in an old man with gastric carcinoma and extensive abdominal and retroperitoneal metastasis, in an attempt to draw lessons from and nurture experience among practitioners.\nA 76-year-old man was admitted with acute kidney injury and anuria. He underwent a subtotal gastrectomy for gastric carcinoma 7 years ago. Three months prior, he had a similar admission with anuria which required temporary hemodialysis. At that time, a computed tomography and magnetic resonance imaging of his abdomen revealed an atrophic right kidney, extensive intra-abdominal metastasis, and retroperitoneal involvement causing bilateral hydronephrosis. A temporary double lumen dialysis catheter was inserted in the right femoral vein for acute hemodialysis. A double J stent was placed in the left ureter. His urine volume gradually returned. The dialysis catheter was removed after 7 days. During his second admission with acute oliguric kidney injury, ultrasonography of his bilateral femoral and iliac veins revealed no stenosis or thrombus in femoral and distal iliac veins. A 19.5 cm/13.5 Fr acute dual lumen dialysis catheter [Mahurkar, Covidien, Minneapolis, MN] was placed into right femoral venous using universal Seldinger technique. The procedure was relatively straightforward although the patient experienced some moderate, transient pain during the advancement of the catheter. At the end of the procedure, there was no flow in one of the two lumens.\nSubsequent radiography showed that the end of the catheter had doubled back and the first 4 cm of the catheter had fractured (Fig. ). Venography showed a stenosis in the middle of his right iliac vein (Fig. ). The stenosis was thought to have veered the curve end of the guide wire back toward the direction of advancement, and “misguided” the catheter which subsequently broke off. A second dialysis catheter was inserted successfully in the right intern"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old woman, gravida 3 para 0, presented for a routine prenatal visit at 34 weeks and 5 days with complaints of constant right upper quadrant pain, headache, and visual disturbance. Serial readings of her blood pressure were all in the normal range and there was minimal proteinuria. Workup revealed an elevation of alkaline phosphatase at 2365 U/L (normal range 35–115 U/L). The patient did not have a history of bone, liver, or renal disease. Past pregnancies were remarkable for a spontaneous abortion and therapeutic abortion requiring dilatation and curettage. Prenatal lab work was unremarkable and the patient was Rh negative. She received RhoGAM during her prenatal care and in the postpartum period. An abdominal ultrasound was performed and failed to show any biliary stones or biliary duct dilatation. To identity the cellular source of the alkaline phosphatase, it was fractionated and showed that 97.8% of the alkaline phosphatase was placental in origin.\nDuring workup the patient was also found to have an elevated glucose tolerance test and was confirmed to have gestational diabetes several days later. The patient was closely monitored for the remainder of the pregnancy and noted to have good glycemic control with dietary modification alone with a hemoglobin A1C of 5.5%. Her alkaline phosphatase was serially monitored and noted to rise to a peak of 4053 U/L (35x upper limit of normal) on the day of delivery. The patient was induced at 40 weeks and 2 days of gestation and had an uneventful vaginal delivery of a vigorous baby boy. Shortly after delivery the infant was noted to have significant bruising and petechiae. A complete blood count was obtained six hours after delivery and revealed significant thrombocytopenia with a platelet count of 20,000. The infant was eventually diagnosed with neonatal alloimmune thrombocytopenia with the parents having an incompatibility in the HPA-1a (PlA1) and HPA-5b (Bra) platelet antigen systems.\nSubsequent postpartum monito"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old man, who was diagnosed with advanced primary HCC with right atrial metastasis and sought medical treatment, was admitted to our hospital. A computed tomography scan revealed a large mass (approximately 7.6 × 7.6 cm in size) in the right lobe of the liver and intracavitary metastasis to the right atrium, an extremely rare secondary cardiac malignancy of primary HCC metastasis (Fig. ). According to the classification of IVCTT as previously described,[ the present case was intra-cardiac type III IVCTT with a cardiac TT above the diaphragm that extended to the right atrium of the heart. The patient underwent surgical treatment on September 25, 2018, during which time right atrial metastasis in the heart was actually observed, extending from the right liver via the IVC to the right atrium (Fig. A); the gross specimen of resected cardiac mass is shown in Figure B.\nAfter full assessment, surgical treatment, consisting of hepatectomy, resection of the involved IVC and right atrium thrombus, and reconstruction of the resected IVC, was performed in this patient. After blocking the right Glisson pedicle and marking the ischemic line at the junction of the left and right half liver, the liver was split along the line under the blocking of the first hepatic hilar and subhepatic IVC. The right Glisson's pedicle was then dissected. Subsequently, the chest was opened, the mediastinum and the diaphragm muscles around the hepatic IVC were cut, the pericardium was opened, allowing fully exposure of the heart, and cardiopulmonary bypass (CPB) was performed in the patient. In the following operative procedures, the right atrium was cut, the right half liver was removed at the root of the right hepatic vein; a longitudinal 8-cm long incision was made on the surface of the superior hepatic IVC, followed by complete removal of the IVCTT and secondary thrombosis. The right atrium incision was closed and the resected IVC was then reconstructed in which autologous pericardial tu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man was admitted to our hospital because of liver dysfunction during a screening examination. Enhanced abdominal computed tomography (CT) revealed a hypervascular mass of 35 mm in diameter in the descending portion of the duodenum (Fig. ), and the left three sections of the liver were occupied by multiple cystic tumors with contrast enhancement of the cystic wall, 13 cm in diameter (Fig. ). A duodenal tumor was identified on gastrointestinal endoscopy (Fig. ), and a biopsy revealed a NET. The serum levels of insulin, gastrin, and glucagon were within normal ranges. CT did not initially reveal evidence of pancreatic invasion between the tumor and the pancreas; however, irregularities of the duodenal wall and swelling of the lymph nodes around the pancreatic parenchyma were observed. Thus, the patient was diagnosed with non-functional duodenal NET with multiple liver metastases, T2N1M1 stage IV (UICC 8th). In addition, CT revealed the anatomical variation of the CHA, which branched from the SMA and ran fully through the head of the pancreatic parenchyma (Fig. , Additional file Figure S1). The CHA branches into the left hepatic artery (LHA), the middle hepatic artery (MHA), and the right hepatic artery (RHA) (Fig. a, b). Furthermore, a developed gastric arterial arcade, 4 mm in diameter, was found between the left gastric artery (LGA) and the right gastric artery (RGA). The RGA was branched from a distal portion at a distance of 10 mm from the root of the LHA (Fig. ). Incidentally, we did not observe stenosis of the celiac axis due to compression by the median arcuate ligament. We planned PD and left trisectionectomy with caudate lobectomy combined resection of the tp-CHA with the preservation of the gastric arterial arcade in order to maintain arterial flow of the remnant liver, preserving the route of the celiac artery to the right posterior hepatic artery ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old woman was evaluated for abdominal pain in another hospital. A mass was seen between the pancreatic head and duodenal wall on ultrasound examination of abdomen. She was referred to our institution for further evaluation. EUS confirmed a 5.5 cm × 4.5 cm hypoechoic mass between pancreatic head and duodenal wall. The mass appeared to be outside the duodenal wall. No calcifications or vessels were seen inside the mass. Multiple small nodes were seen around the lesion. No vascular involvement was seen. The possibilities considered on EUS were gastrointestinal stromal tumor, lymphoma, and solid and papillary epithelial neoplasm (SPEN) of pancreas. EUS FNA was done. Air dried and alcohol fixed smears were prepared from the FNA material. Material was also procured in formalin for cell block preparation.\nMay-Grunwald Giemsa and Papanicolaou stained smears were examined. Smears were of good cellularity. The cells were present dispersed singly, in small groups and fragments. In few fragments, cells were seen adhering to fibrovascular cores []. The cells were round in shape and monomorphic. The nuclei had fine nuclear chromatin and small nucleoli. The most striking feature was that the cytoplasm of almost all the cells had multiple fine vacuoles imparting a foamy appearance to the cells. Most of the cells had eccentric nuclei [Figures and ]. At low power examination, these cells were almost indistinguishable from foamy histiocytes. Occasional bare nuclei were seen in the background. Hematoxylin and eosin stained sections from cell block showed small nests of similar foamy cells entrapped in blood clot. The cells had well defined cytoplasmic membranes []. Keeping in view, the cytologic features of the tumor, location of the tumor, and the young age of the patient possibilities of neuroendocrine tumor (NET) with clear cell change and SPEN with clear cell change were considered. Other differentials considered were primary clear cell adenocarcinoma, metastatic clear ce"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old lady was referred to the emergency department with chest pain occurring during her twelfth cycle of carfilzomib infusions (56 mg/m2 received on Days 1, 2, 8, 6, 15, and 16 of every 28-day cycle) as a treatment for her multiple myeloma. She had been receiving this therapy for the preceding 12 months but reported 3 months of similar intermittent chest pain. She described her pain as localized, central chest tightness with radiation to her right arm and the right side of her neck. The pain would typically last 5–10 min before spontaneously resolving. This could occur at rest or with exertion and did not have diurnal variation. She also described associated dyspnoea on exertion for the preceding 3 months without orthopnoea, paroxysmal nocturnal dyspnoea, or leg swelling. She had no traditional cardiac risk factors but was referred for cardiovascular assessment given the nature of her presentation. Clinical examination revealed a slim, normotensive woman with a normal cardiopulmonary exam.\nIntercurrent medications included dexamethasone, thalidomide, and trimethoprim/sulfamethoxazole in addition to carfilzomib as part of her treatment for multiple myeloma. She was on no other regular medications.\nThe differential diagnosis at this time included obstructive coronary artery disease, disorders of coronary vasomotion including microvascular and/or vasospastic angina, congestive cardiac failure, and pulmonary emboli.\nAn electrocardiogram while pain free in the emergency department demonstrated sinus rhythm at a rate of 70 b.p.m. There was poor R wave progression and ischaemic T wave inversion through the anterior leads without conduction abnormalities (Figure ). High sensitivity troponin T was 8 ng/L (reference range <16 ng/L). A transthoracic echocardiogram demonstrated normal left ventricular size and function with no regional wall motion abnormalities. There was no evidence of pulmonary hypertension or valvular disease. She was discharged from the emergency d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old man was referred to our hospital in 2014 for a suspected right bronchogenic cyst. He underwent a trans-esophageal biopsy to confirm the diagnosis. After a few days, he started to complain of fever and acute chest pain. A contrast-enhanced CT scan revealed a massive pleural effusion in the right hemithorax with complete atelectasis of the ipsilateral lung (Fig. ).\nA right thoracoscopy was performed, in order to achieve a complete debridement and drainage. During the procedure, no esophageal perforation was seen. The following clinical course was normal, so the patient was discharged on postoperative day 15.\nIn December 2019, the patient was referred to our Emergency Department because of the sudden onset of fever (39 °C) with acute chest pain. He underwent a CT-scan which revealed a suspected esophageal perforation with acute mediastinitis and right pleural effusion. A subsequent gastroscopy showed, at 35 cm from dental arch, an erosion of the esophageal wall 1,5-cm long and a 2-mm perforation with a small leak of purulent liquid. Furthermore, an endoscopic ultrasound revealed the presence of the bronchogenic cyst just outside the erosive area. Thus, a right thoracotomy with intraoperative endoscopy was performed. An esophageal perforation at the level of the cyst was found, so the right hemithorax was cleaned, the cyst was opened in order to better understand its margin, and then resected, while the esophageal wall was closed with two interrupted, absorbable stitches. A 24-Ch drain was left in place. After 2 days, salivary material appeared into the drain, so the patient underwent an EGDS, which revealed a 7-mm hole of the esophageal wall at the level of the previous suture (Fig. a). Thus, an E-Vac therapy was placed directly into the perforation (Fig. b) only during the first placement, with the aim of cleaning the mediastinum and healing the esophageal wall, which was locally compromised by the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old man came to our attention in October 2018 due to the appearance of a right frontotemporal swelling with progressive growth for about a month and a half. In anamnesis, he had a single kidney. The patient’s neurological exam was negative. Contrast-enhanced brain magnetic resonance imaging (MRI) revealed a large lesion (28 x 20 x 38 mm) in the right frontotemporal cranial theca. The lesion had caused complete bone lysis involving the full thickness of cranial planking and extending widely into the subcutaneous soft tissues while extending approximately 4 mm into the extradural space. In the T1 sequence, the lesion was homogeneously intense and, after administration of contrast, it was characterized by inhomogeneous enhancement (Figure ).\nAs metastasis was suspected, the patient preoperatively underwent a total body computed tomography (CT) scan, which showed the presence of diffuse thickening of the left postero-lateral bladder wall and a solid endoluminal protrusion at the ureteral outlet, characterized by irregular endoluminal margins and discrete enhancement (Figure ). Urinary cytology showed the presence of carcinoma cells (Figure ).\nThe patient gave informed consent for the surgery and to the use of the data for scientific purposes. During the operation, which took place on July 11, 2018, the patient underwent gross total removal (GTR) of the head lesion and subtotal resection (SR) of the bladder lesion. The cranial lesion was of a hard-elastic consistency and was resected en bloc, involving bone margins apparently without disease. The dura mater was infiltrated so it was removed keeping very wide edges. Dural plastic surgery using NeoDura and cranioplasty with titanium mesh were performed. The temporal fascia and epicranial tissue over the lesion were removed.\nDuring the transurethral cystoscopy, in the left postero-lateral bladder wall, a solid lesion of about 2 cm with a large implant base with significant periwound edema was identified. The lesio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old woman presented to a local hospital after she began to experience right upper quadrant pain, nausea, and vomiting. Abdominal ultrasonography showed marked dilatation of the intrahepatic bile duct (IBD) in the left lobe of the liver and common bile duct with intraductal stones.\nShe was diagnosed with cholangitis and then referred to our hospital in May 2011 for further investigation and treatment. She underwent laparoscopic left lobectomy for a left IBD stone and choledocholithotomy with t-tube drainage for a common bile duct stone. After one year, follow-up computed tomography (CT) showed no definite abnormalities, but laboratory data showed elevated serum levels of cancer antigen 19-9. Thus, CT scan was performed at three-month interval and a mass was observed at the atrophied right posterior segment of the liver. In addition, a palpable mass was found at the t-tube site and histologic diagnosis of the lesion by excisional biopsy was interpreted as adenocarcinoma (stage IV).\nShe was referred to our department for palliative chemo- therapy and received treatment with gemcitabine and cisplatin. She neither consumed any alcohol nor smoked and she reported no family history of illness. After eight cycles of gemcitabine and cisplatin (days 1 and 8: cisplatin 25 mg/m2 followed by gemcitabine 1,000 mg/m2; repeated every three weeks), the follow-up CT showed progressive disease, showing an interval increase in the size of the metastatic lesion in the abdomen, thus, the regimen was changed to cisplatin 60 mg/m2 on day 1 and 5-fluorouracil 1,000 mg/m2 on days 1-5.\nHowever, two months after the first infusions of cisplatin and 5-fluorouracil, the patient developed gait disturbances on day 6 of the third infusion. She could not maintain a standing position with her eyes open, and a tandem gait was impossible because of severe positional imbalance. Brain magnetic resonance imaging (MRI) with T2-weighted images (-) and diffusion-weighted images (-) showed high sign"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old healthy man who lived in a major urban area in Japan admitted to our hospital with complaints of sore throat and abdominal discomfort and diminished appetite persisting for 2 months. Sore throat and nasal congestion appeared 2 months before the date of admission (day 0), at which time the patient visited a otolaryngology department of local hospital (Hospital A) and was prescribed amoxicillin following a diagnosis of pharyngitis. The patient's throat symptoms persisted, and abdominal pain appeared. Body temperature measurements taken at home consistently remained at approximately 37℃. Eighteen days later (day 18), the patient was seen by the gastroenterology department of Hospital A due to persistent abdominal symptoms and was prescribed a proton-pump inhibitor. Three days later (day 21), the patient developed malaise, accompanied by chest and abdominal pain, and was transferred to another medical facility (Hospital B) via ambulance. The patient presented with a fever of 38.3℃ at the time of transfer, and the electrocardiograph, blood tests, and chest computed tomography scan yielded no noteworthy results. He was subsequently placed under observation and then released, free to return home. The patient's symptoms were found to persist after an additional week of monitoring. Although abdominal ultrasonography and urinalysis had also been performed at Hospital A, no issue was flagged. One month after the initial onset of symptoms (day 31), the patient underwent another blood test as well as an upper gastrointestinal endoscopy at another medical institution (Hospital C), but no abnormalities were detected. After another four weeks (day 58), the patient underwent an abdominal CT at Hospital C. As a result, he was diagnosed with functional dyspepsia (FD) and was prescribed Acotiamide and Bifidobacterium. From that day onwards, the patient began to experience glossodynia, difficulty consuming food, and he visited our clinic on day 59. Except for slight sign o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male was referred to our hospital in May 2008 due to severe traumatic brain injury caused by a traffic accident and was diagnosed as brain dead shortly after admission. Dextrocardia was found during physical examination and situs inversus totalis was verified by further X-ray and ultrasonic inspection. During the retrieval of donor organs, it was found that the liver, pancreas, and stomach were located in the opposite positions. The descending aorta was located directly in front of the spine and the inferior vena cava was found in the front left of the spine. Organ procurement was smoothly performed without great difficulty even though the procedure took a little longer due to the operator's habitual thinking about the anatomy. During preparation of the donated liver, the anatomical relations were clearly identified, that is, liver artery locating in right side and common bile duct in the left, and portal vein still being behind common bile duct and liver artery. The hepatic superior and inferior vena cava was cut to angle well in preparation for vascular anastomosis.\nA 58-year-old female recipient was diagnosed with end-stage liver disease caused by type B hepatitis. Preoperative condition was evaluated with Child-Pugh (class A) and MELD (4.3). The liver transplantation was performed in May 2008. The incision was made double subcostally. Following isolation of porta hepatis and hepatic ligament, the retrohepatic inferior vena cava was partially clamped and then the diseased liver was removed preserving the inferior vena cava. The right hepatic vein was suture ligated while preserving the left and middle hepatic veins. At the point of left hepatic vein entering the hepatic superior and inferior vena cava, a transection was taken on an anterior wall of the interval between the left and middle hepatic veins, and meanwhile, the anterior wall of inferior vena cava was cut downward 2 cm, thereby forming a “T” type anastomotic rim in preparation for hepatic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old primigravida woman in her third trimester of pregnancy presented to the obstetrics department with severe itching. Examination of the patient confirmed a single, live intrauterine pregnancy of 33 gestational weeks. A widespread erythematous rash was also evident, with tense fluid-filled blisters accompanied by severe itching. The patient indicated these symptoms had begun two weeks previously. The patient was referred to the dermatology polyclinic, where examination showed erythematous maculae scattered over the arms, legs, trunk, and neck (Figures , , , , and ), some with burst and crusted tense blisters on them. The patient's personal history was unremarkable. Routine hemogram and biochemical tests produced normal results, and vitamin B12, folic acid, thyroid hormones, and antibody levels were all within normal ranges. Anti-BP 180-NC16 could not be obtained because this test could not be carried out in the biochemical laboratory of our hospital. Subepidermal disintegration was detected by means of punch biopsy (). Direct immunofluorescence showed linear C3 deposition () and weak IgG deposition () at the basement-membrane zone. A diagnosis of PG was made from these findings. Systemic corticosteroid treatment was initiated at a dose of 40 mg/day prednisolone. Since a regression was observed in the lesions of the patient after two weeks, the prednisolone dose was reduced gradually. No new blister formation was observed during hospitalization. Prednisolone treatment was started at a dose of 10 mg/day on the 15th day of hospitalization and the patient was then discharged. The patient had a mild relapse after 10 days, prednisolone dose was increased to 20 mg/day, and an improvement was observed. The dose was reduced after one week and maintained at 10 mg/day. The remaining follow-up period of the pregnancy was uneventful and the patient gave birth to a live baby measuring 3600 g in weight and 50 cm in length through vaginal delivery in the 39th gestational"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old Vietnamese boy presented to our emergency department with bilateral knee pain and swelling. The mechanism of injury was sustained as a result of tripping with bilateral knee strikes on the ground while playing sports at school. The subject and his parents denied jumping in relation to the injury or any knee pain prior to the injury. The history revealed immediate pain and the inability to mobilise or bear weight.\nOn physical examination, the boy had an athletic constitution. There was significant appreciable bilateral knee swelling with a fixed flexion deformity on observation with pain being the limiting factor disabling knee extension. Generalised tenderness and an intra-articular effusion were present on palpation with the predominant source of pain at the tibial tuberosities. Any attempt of motion provoked severe pain. Given the pain, it was difficult to assess the integrity of the cruciate and collateral ligaments; however the limited examination did not reveal obvious instability. Neurovascular examination was normal and compartments were soft.\nInterestingly, the boy's past history was significant for a type IIIA left knee avulsion fracture that he sustained 13 months priorly. This happened via a different mechanism (jumping) where pain was felt while pushing off. On that occasion an MRI showed an injury to both ends of the patella ligament with some avulsion of the patella proximally and some lifting up of the tibial tuberosity distally. He was managed conservatively on that occasion in a hinged-knee brace locked in extension for six weeks with physiotherapy to progress ROM thereafter. The paediatric orthopaedic surgeon who reviewed him in the outpatient clinic made a specific note in his letter stating that “this injury will have changed the relative length of his patella by a small amount”, going on to say that “we will need to take this slowly in terms of protecting this.”\nOn this presentation, plain radiographs (Figures and ) showed bilatera"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPresentation and diagnosis\nOur patient is a 62-year-old Caucasian man who went to a health fair at his church where abdominal sonograms were being performed. After receiving a sonogram the patient was told to see his primary care provider about possible kidney stones. The primary care physician performed an additional sonogram and confirmed kidney stones with an incidental finding of gallstones. The patient was referred out for a CT scan for workup of kidney stones. The patient underwent stent placement and lithotripsy. Soon after lithotripsy, the patient developed fever, and a CT with contrast was performed. This scan showed incidental findings of masses on the gastric fundus. An endoscopic exam was performed with a biopsy taken which showed spindle cells, and the first diagnosis of GIST was made.\nTreatment\nThe patient underwent a cholecystectomy, during which time the surgeon also removed the gastric masses. A light tan nodular mass, 4.5 x 2.2 x 1.8 cm, was removed from the posterior stomach, with histological findings as noted in Figure . We also obtained a light pink and tan wedge-shaped sample measuring 2.9 x 2.5 x 2 cm from the anterior stomach. Samples were sent to pathology where they showed spindle cell neoplasms composed of interlacing bundles of spindle cells with rounded to tapered nuclei. The mitotic count was low, with only one mitotic figure found in an examination of 15 high powered fields. Calcifications were seen and the edge of the tumor was well-demarcated with a thin fibrous membrane.\nFollow up\nThe patient was sent home to recover, and roughly three weeks after the procedure returned for a kidney/ureter/bladder x-ray, which had no relevant findings. Follow up with his primary care provider showed well healing surgical incisions, improved energy and positive affect regarding his own health. We advised the patient to have follow-up visits every six months for the next five years to check for a possible resurgence of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old man was admitted to Matsushita Memorial Hospital, Osaka, Japan because of an abnormal electrocardiogram. The patient had noticed exertional chest discomfort for a few months, but did not seek medical care because his symptoms improved with rest and had not changed in frequency or severity over time. One day before admission, he had a 30-minute episode of chest discomfort at rest in the morning. The next day, his chest symptoms reportedly recurred during rest in the morning and lasted for approximately one hour. The patient visited his physician in the afternoon and was found to have an abnormal electrocardiogram. He was transferred to the emergency room of the hospital, when his symptoms had already disappeared. The patient had a history of hypertension but had taken no drugs. He was a current smoker with a 25 pack-year history.\nHis physical examination was normal, other than a blood pressure of 189/130 mmHg. An electrocardiogram showed normal sinus rhythm, a heart rate of 65 beats per minute, ST-segment elevations in V1 and V2, and negative T waves in anterior and lateral leads []. His chest radiograph was unremarkable. His troponin T level was 1.74 ng/mL (reference, < 0.1 ng/mL). Echocardiography demonstrated borderline abnormalities of wall motion in the ventricular septum. A diagnosis of acute myocardial infarction was made, although the infarcted area remained undetermined.\nIntravenous administration of isosorbide dinitrate, followed by heparin (5000 units), did not alter his electrocardiogram. Emergency coronary angiography, which was performed after initiation of aspirin (200 mg) and clopidogrel (300 mg), revealed no significant stenosis with a delayed flow in the second septal branch of the LAD []. Intravascular ultrasound was done in the second septal branch for further examination because the delayed flow in the second septal branch of the LAD did not improve after administration of intracoronary isosorbide dinitrate, intravascular ultrasound"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn eighty-one-year-old male visited the clinic complaining of abdominal pain along with pulsating mass. He had been diagnosed with infrarenal aortic aneurysm and this was treated with EVAR 6 years previously. After EVAR, a gradual increasing of the aneurysm sac was found without evidence of any type of endoleak. Eventually, the aneurysm reached a diameter of 9.7 cm on the computed tomography (CT) angiography and abdominal pain redeveloped. CT angiography showed a huge aortic aneurysm without evidence of endoleak, and it was considered that this was due to endotension.\nCT-guided sac aspiration was performed through the translumbar puncture of the aneurysm sac, and 400 mL of a dark brown-colored liquid was aspirated (). CT scan was performed the day after the puncture and the sac shrunk back to its original size (). Abdominal pain subsided and the palpating mass disappeared. One month after the aspiration, a CT scan was retaken, and the scan showed that the aneurysm sac increased back to the size before the aspiration (). Additionally, the scan showed no signs of endoleak. A second aspiration was performed again, and a further 300 mL of the dark brown colored fluid was aspirated. During the second aspiration, small amounts of contrast media was administered through the lumbar puncture site in order to search for the presence of collateral flow induced endoleak and to detect any possible rupture of the aneurysm sac. But no contrast media leakage from the sac was found, and no endoleak was found. So it was concluded that the increase of the aneurismal sac was due to endotension.\nFinally, with the consent of the patient, the endovascular relining technique was performed on the patient to treat the endotension. Since the diameter of the main body of the original endograft was 28 mm, it was planned that the relining process would be carried out by inserting two customized, tubular stent-grafts each of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old man presented at our hospital with a thyroid nodule in the neck region, which the mass had been detected during a routine medical check-up. FNA were performed twice prior to the visit to our hospital, but the results of the cytological evaluations at both instances were atypia of undetermined significance (AUS). The patient had no clinical symptoms and the laboratory results were in normal range. Ultrasonography, performed at our hospital, revealed the presence of a relatively well circumscribed mass (2.2 cm in diameter) with microcalcifications on the right lobe of the thyroid gland (Fig. a). Additionally, another FNA conducted at our hospital. The cytologic evaluation showed some follicular cells with enlarged nuclei and pale chromatin pattern. However, the cytologic findings were not sufficient to diagnose a specific tumor, thereafter we diagnosed the cytologic specimen as AUS (Fig. b). Subsequently, the patient underwent right hemithyroidectomy for diagnostic and treatment purposes.\nThe results of the cytology could not confirm whether the mass was benign or malignant. Hence, histologic evaluation of a frozen section using hematoxylin-eosin (H&E) staining was performed. A relatively well-circumscribed mass comprising cells that were mostly arranged in a trabecular or solid sheet-like pattern and intersected by homogenous eosinophilic material was noted (Fig. ). The tumor cells consisted of amphophilic cytoplasm and round to oval-shaped nuclei with condensed chromatin and indistinct nucleoli (Fig. b). The eosinophilic material was suspected to be amyloid deposition and the mass was diagnosed as a medullary thyroid carcinoma. Neck lymph node dissection was additionally performed due to the results of the frozen biopsy. And the patient has been warned that if the results of permanent biopsy was confirmed to medullary thyroid carcinoma as of the frozen biopsy, total thyroidectomy is necessary.\nSubsequently, a permanent section obtained from the patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA-17-year-old previously healthy female presented to THP with a history of fever for 2 days associated with body aches and nausea. She didn’t have any abdominal pain, bleeding manifestations or postural symptoms. On examination, she was flushed and febrile but was not pale or icteric. She was mildly dehydrated. Blood pressure was 100/70 mmHg, pulse rate 100 beats/min and capillary refilling time (CRFT) was less than 2 s. On abdominal examination, there was no free fluid. Lung fields were clear on respiratory system examination. Other systems examination was normal.\nHer NS1 antigen was positive and serotype was identified as DEN1. She was managed as dengue fever with continuous monitoring. On the 3rd day of fever, she complained of retrosternal chest pain and undue tiredness. At that time her cardiovascular system examination was normal and electrocardiogram (ECG) showed acute T wave inversion in V2-V5 leads. Troponin I was negative and 2D echo showed global left ventricular hypokinesia and mild impairment of LV function. Ejection fraction was 40–45%. She was treated as having dengue fever complicated by myocarditis. Intravenous hydrocortisone 200 mg 8 hourly was administered for 2 days to reduce myocardial inflammation. On the 4rd day following admission, she complained of abdominal pain and ultrasound scanning revealed free fluid in hepato-renal pouch. Blood pressure was 100/70 mmHg, pulse rate 70 bpm, and CRFT was less than 2 s. She was taken to High Dependency Unit (HDU) and was managed as having DHF complicated with myocarditis with continuous monitoring and with careful administration of fluid to avoid fluid overload. She was discharged on day 7 of illness after recovering from critical phase of dengue fever. She was advised on limiting physical activities. During the follow up on day 14 of the illness, ECG showed reversal of T inversions. Echocardiogram showed improvement of left ventricular function with an ejection fraction of 55"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 83-year-old man with headache was referred to our clinic. He had a history of a chronic headache with different degrees of severity and changing patterns that continued for 2 weeks before his admission. The headache was global. Besides, it sometimes localized to the back of his head and neck. There was no association with nausea, vomiting, seizure, or fever. Physical examination did not demonstrate any neurological deficit. The patient was also suffering from a severe renal disease.\nBrain magnetic resonance imaging (MRI) showed a well-defined epidural mass lesion in the left side of posterior fossa, with severe compression of the cerebellum. Opacification of adjacent mastoid air cells was seen. Craniocervical junction and upper cervical cord signal and thickness were normal []. These findings considered with an extradural posterior fossa mass lesion. Gadolinium images were not performed because of the presence of severe renal disease.\nGross total resection of the tumor was performed via the left retrosigmoid craniectomy. The tumor was a well-defined, large intracranial and completely extradural cystic lesion with a thin layer of a white capsule, containing yellow cheesy material. The cyst including the capsule and its contents was totally resected. The tumor eroded the inner surface of the skull at that site. Gross involvement of dura mater was not seen. The surface of the dura was shaved and coagulated, and eroded bones were removed. Microscopic examination showed interosseous epidermal inclusion cysts, filled with keratinous needle-like material []. The patient had a satisfactory recovery after the surgery.\nTwo months after the operation, the patient came back with a chief complaint of watery discharge from the surgery site. He also suffered from increased severity of headache, neck pain, and bulging site of surgery. Physical examination showed that the bulging was very loose. Fluid collection and leakage of clear to xanthochrome liquid via an orifice on the su"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe first case shows a 30 year old female. Clinical and radiographic examination showed a skeletal Class II pattern with an anterior open bite and a transverse maxillary deficiency with a lateral posterior crossbite on the right and the tendency to a lateral crossbite on the left (Fig. ).\nThe treatment plan involved a first stage of maxillary expansion with SARME to correct the transverse discrepancy followed by the leveling of the dental arches with lingual fixed appliances and finally two jaw surgery to correct the open bite as well as the Class II malocclusion.\nImpressions of the upper and lower arches were obtained for the lingual appliances.\nDuring the planning for the production of the lingual brackets, it was noted that a surgically assisted rapid maxillary expansion takes place. In the set-up, therefore, the transverse width of the upper jaw should be adapted to the lower jaw.\nFour Benefit mini-implants were inserted: two in the anterior area of the T-Zone and two 12 mm distally on each side of the midpalatal suture. A silicon impression was taken and the laboratory analogues were placed on the transfer caps. The maxillary expansion appliance was manufactured using a Hyrax screw anchored only to the four mini-implants, named the Quadhyrax.\nDuring the same appointment the lingual appliance was indirectly bonded using a dual cured composite (Fig. ) and the Quadhyrax was inserted and attached to the mini-implants using Benefit fixation screws. The first lower arch wire 14 NiTi was placed while the upper brackets were securely ligated with a continuous steel ligature in each quadrant to prevent accidental dislodgement during surgery (Fig. ).\nThe surgery for SARME was performed on all three patients according to the same procedure: First Le Fort I osteotomy with an oscillating saw. After that, the sutura palatina mediana was chiseled up for the midpalatal split. The tuber region was also"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4 year old female presented with huge abdominal swelling first noticed by her parents at 2 years of her age (See Figure ). The swelling had increased in size since then to occupy almost whole of the abdomen. Right labia had a swelling which increases in size on standing and decrease on lying down. On examination abdomen was found to be distended, felt tense with flanks full. The swelling over the labia was reducible on manipulation suggesting its continuity with the abdominal swelling.\nUltrasound abdomen showed 30 × 20 × 20 centimeters huge, multiloculated, multiseptate, lesion extending from xiphisternum to pelvis with extension into the right labia majora. Lesion was causing lateral and posterior displacement of bowel loops and compression of liver and both kidneys. A provisional diagnosis of omental, mesenteric or ovarian cyst was made. CT scan was done to throw some more light on the site of origin. Non-contrast film showed the cyst filled with clear fluid possibly arising from the mesentery. Contrast film was suggestive of multiloculated cyst. Pelvic films proved the labial extention of the cyst (See Figure ), but still the exact site of origin remained unclear.\nPatient was taken up for exploratory laparotomy and midline vertical incision was kept. After opening the peritoneum a thin walled cyst was seen popping out of the skin incision (See Figure ). On exploration it was found attached to the greater omentum (See Figure ).\nCyst was deflated partially by aspiration and we found the swelling over labia majora got reduced as we deflated the cyst and no adhesions were found between the cyst wall and labia. Complete excision of the cyst wall along with part of omentum was done. Histopathological report of the cyst wall showed endothelial cell lining, foam cells, lymphatic spaces, lymphoid tissue and smooth muscles which are diagnostic of lymphangiomatous cyst (See Figure"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old female presented initially to our cancer center, after being diagnosed with ACC of the right parotid gland. She was complaining of a mass in the right side of her neck, which was associated with jaw discomfort. Her symptoms worsened gradually over 6 months. Head and neck computed tomography (CT) scan revealed soft tissue mass in the right side of the face, destroying the mandibular ramus and extending to the right sphenoid bone and inferior temporal lobe. A head and neck magnetic resonance imaging (MRI) scan showed a parotid tumor with extension into the foramen ovale and destruction of the right mandibular ramus. The patient underwent a fine needle aspiration biopsy, which showed ACC of salivary glands. The mass was deemed to be unresectable, and the patient was referred to radiation oncology department where she was treated with neutron beam radiotherapy. The parotid neoplasm responded well to treatment, and she had disease remission confirmed with follow up MRI.\nA year later she developed right sided hip pain. After an unremarkable plain X-ray, she underwent a right femur and pelvis MRI that showed an osseous mass within the right ilium extending inferior to the acetabulum concerning for metastatic disease. CT of the abdomen and pelvis showed an abnormal lucency in the right acetabulum and a larger area of the right ilium, which measured 3.3 cm in maximum transverse dimension, as well as hepatic hypo-densities suggestive of metastatic disease. CT scan of the chest revealed numerous bilateral noncalcified lung nodules scattered throughout both lungs () and a lytic bone lesion in the right scapula measuring 3.1 × 3.6 cm. This was followed by a bone scan that revealed uptake within the medial right ilium and the right inferior and superior pubic rami. There was also uptake within the right frontotemporal calvarium, right scapula, and anterior left third rib.\nSubsequently, she underwent right ilium biopsy, which confirmed the diagnosis of recurrent meta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nD.N. is a 75-year-old Caucasian man with a history of malignant melanoma of the left shoulder resected in 2011, who presented with progressive dysphagia. An upper endoscopy revealed a gastric mass, and biopsy specimens demonstrated a poorly differentiated malignant neoplasm. Staging CT of the chest, abdomen, and pelvis demonstrated numerous pulmonary nodules bilaterally and scattered liver lesions consistent with metastatic disease. Biopsy of a liver lesion confirmed metastatic melanoma, negative for BRAF mutations. A brain MRI was negative for intracranial involvement. Pertinent medical history included acetylcholine receptor (AChR) autoantibody positive myasthenia gravis (MG) diagnosed at age 64. At that time, he had primarily ocular symptoms and AChR binding antibodies were positive at a titer of 2.1 nmol/L (normal range = 0.0-0.4 nmol/L). Over the years, his MG progressed and he developed other symptoms such as dysphagia, chewing fatigue, dyspnea on exertion, and neck and limb weakness. He responded well to prednisone and was eventually transitioned to mycophenolate mofetil. Just before the metastatic melanoma diagnosis, his MG was asymptomatic with mycophenolate mofetil 750 mg daily and pyridostigmine 60 mg 3 times daily.\nFor lack of a more robust treatment option, and after discussing the potential side effects with the patient and the neurologist, pembrolizumab was started at 2 mg/kg every 3 weeks. The dose of mycophenolate mofetil was decreased to 500 mg daily and pyridostigmine was continued unchanged. After his second dose, the patient developed symptoms of diplopia and worsening bilateral ptosis concerning for an exacerbation of MG. Pembrolizumab was held, and pyridostigmine was titrated up to 180 mg 3 times daily, along with prednisone 30 mg daily. The patient’s condition continued to deteriorate, and he was admitted to the intensive care unit with respiratory distress and worsening dysphagia, where he required noninvasive ventilation and gastrostomy tub"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of 70 years old female, with no known co-morbidities, who presented to the Otolaryngology clinic with complaints of increased somnolence and reduced appetite for past the 3–4 years. These complaints were not associated with any other associated symptoms. Her past medical history and family history were unremarkable. She had a history of the cesarean section under spinal anesthesia 30 years ago. On examination, she was well oriented to time, place, and person. She had a heart rate of 64 beats per min, a respiratory rate of 16 breaths per min, a blood pressure of 110/70 mm Hg, and she was afebrile. Her general physical and systemic examination was also unremarkable. Her serum calcium was 14.1mg/dl (8.8–10.6) and serum parathyroid hormone showed a value of 457mg/dl (7-53). Her vitamin D level, serum albumin, and creatinine were all within a normal range. 24-hour urinary calcium and phosphorus were also within normal limits. She underwent neck ultrasonography which showed a complex solid and a cystic nodule on the left side close to the lower pole of the thyroid measuring 3.6 × 2.8 cm ().\nThe clinical picture was suggestive of a parathyroid adenoma and she was admitted electively for its resection. After relevant investigations and anesthesia fitness, she underwent complete excision of the left parathyroid lesion and left lobectomy of thyroid gland under general anesthesia. Intra-operative findings were enlarged left parathyroid gland which was inseparable from the multi-nodular left lobe of the thyroid gland. A recurrent laryngeal nerve was identified and saved. Neck drain was placed and the sample was sent for histopathology (). The lesion was not involving any other structure other than the thyroid gland. No level VI lymphadenopathy was observed intraoperatively.\nThe patient remained hemodynamically stable with no signs of recurrent laryngeal nerve palsy. Her post-op serial serum calcium monitoring was done which decreased to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Caucasian male was referred to our hospital with 3 weeks of abdominal distension and worsening right lower quadrant pain. He was diagnosed with IgG kappa multiple myeloma four years prior to presentation. He was initially treated with bortezomib/dexamethasone with monthly zolendronic acid with good response initially; however, a year after diagnosis, he was found to have disease progression which manifested as a right radius fracture. His regimen was switched to lenalidomide with dexamethasone with good response and clinically depressed levels of paraproteins. After completion of 9 months of therapy, he underwent autologous stem cell transplant with high-dose melphalan. 7 months after bone marrow transplant, his disease progressed with involvement of pericardial fluid. Salvage therapy was initiated with pomalidomide, bortezomib, and dexamethasone which was discontinued a year later due to peripheral neuropathy; however, at the end of treatment, there was no evidence of ongoing disease.\nWhen the patient presented to our hospital, he had an acute abdomen. Initial blood work revealed a normocytic anemia with hemoglobin of 8.4 g/dl and elevated ESR of 44. He also had acute kidney injury with creatinine of 3 mg/dl (baseline of 1.9 mg/dl). CT scan of the abdomen and pelvis revealed extensive stranding seen throughout the abdomen within the peritoneal space with edema in the mesentery ().\nHe underwent an exploratory laparotomy which revealed induration of the entire base of the mesentery and retroperitoneum. He had an IgG level of 4407 units with predominantly kappa light chains whose level was 4833 units (kappa to lambda ratio 540). Pathology revealed extensive mesenteric infiltration by kappa restricted plasma cells positive for CD138 on immunohistochemistry, without evidence of amyloidosis. Bone marrow biopsy revealed a 30% involvement by plasma cells (Figures –). Cytogenetics showed 1q22 duplication, trisomy 7 and 15, and gain of 8q24.1. The skeletal surv"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old woman was referred to our interventional radiology department for investigation of a palpable mass and irritating audible bruit on her right neck. Two months prior to this visit, she had developed an acute exacerbation of chronic renal failure secondary to viral gastroenteritis and underwent temporary hemodialysis using a central venous catheter placed in her right jugular vein. Upon arrival at our hospital, a 50 × 30 mm soft mass was palpable over the right side of her neck, and systolic bruit was heard during auscultation. Laboratory data showed elevated levels of serum creatinine and blood urea nitrogen at 155.6 μmol/L and 10.0 mmol/L, respectively. Duplex ultrasonography evaluation of the neck was performed, which showed a 48 × 27 × 46 mm aneurysmal sac that connected the craniomedial side of the thyrocervical trunk via a short narrow neck approximately 3 mm in length and 2.5 mm in diameter (). The aneurysmal sac also continued to the internal jugular vein, and the cranial aspect of the internal jugular vein was occluded by a thrombus. Computed tomography angiography of the neck showed a high-density-flow jet of contrast agent shunting from the thyrocervical trunk into the aneurysmal sac via the short neck in the arterial phase (Figures and ). Continuity between the aneurysmal sac and internal jugular vein was also noted (). Based on these findings, the diagnosis of iatrogenic PsA of the thyrocervical trunk with an AVF involving the internal jugular vein was made. We discussed surgical versus endovascular intervention with the patient, and the latter was elected. A 4-Fr sheath (Terumo, Tokyo, Japan) was inserted through the right brachial artery, and the right subclavian artery was selectively catheterized by a 4.2-Fr Judkins Right 4.0 angiographic catheter (Goodman, Nagoya, Japan). Selective digital subtraction angiography of the right subclavian artery showed a PsA originating from the thyrocervical trunk root; the PsA"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old Japanese man, who had undergone esophagectomy with gastric conduit reconstruction via the antesternal route for spontaneous esophageal rupture 28 years previously, was hospitalized due to redness of the precordial skin, which had persisted for 1 month (Fig. a). Gastric juice was discharged from the gastric conduit through the skin fistula. He had taken low-dose aspirin due to a past history of left carotid artery obstruction and stenosis of the right carotid artery but had not taken proton pump inhibitors (PPIs). Laboratory studies showed mild inflammatory findings (WBC 9200/ul, C-reactive protein 5.7 mg/dl). No evidence of Helicobacter pylori infection was seen.\nComputed tomography (CT) revealed a fistula between the thickened gastric conduit and skin (Fig. ). He was diagnosed with a gastric conduit ulcer that penetrated through to the chest wall and was managed conservatively with fasting, the administration of a PPI and antibiotics, and continuous compression of the gastric conduit over the skin with a cotton ball. Upper gastrointestinal fiberscopy on day 14 revealed the ulcer was located at the anterior wall of the middle gastric conduit (Fig. a). An esophageal biopsy revealed no evidence of malignancy.\nThe fistula healed with conservative management. Although the fistula relapsed twice on the 37th and 58th days, respectively, it healed with conservative management.\nOn the 174th day from the onset, discharge was recognized again. A fistula of 1.5 cm in diameter was observed on the operation scar of the precordium at the nipple line, from which the gastric mucosa was seen. The skin around the fistula was reddish (Fig. b). On the 196th day, when the infection was completely controlled, resection of the refractory cutaneous fistula was performed with the transfer of a pectoralis major muscle pedicle flap and a split-thickness skin graft.\nFirst, a skin incision of 3 cm × 2 cm in size was made on the fistula. The area around the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old Japanese woman was referred to a clinician in April 2013 because of a 5-month history of occasional epigastric pain, 2-month history of intermittent abdominal pain/watery diarrhea, and a recent loss of appetite and worsening of watery diarrhea. Enhanced computed tomography (CT) revealed a thickening of the ascending colon and rectum. She was diagnosed with ileus and admitted to a local hospital. Fasting initially alleviated her symptoms. Eventually, she was discharged on the fifth day of hospitalization after she was able to eat without the recurrence of abdominal pain.\nA week later, she experienced abdominal pain and watery diarrhea. Gastroenteroscopy and colonoscopy did not detect any abnormalities, and positron emission tomography/CT revealed no significant uptake of the tracer. Considering that a previous CT study had revealed the presence of gall bladder stones, cholecystectomy was planned after a provisional diagnosis of cholecystitis. On June 20th, her abdominal pain and watery diarrhea worsened, she was unable to eat, and she suffered from intermittent severe abdominal pain, predominantly in the upper abdomen; she was then referred to our hospital. She did not give history of travel abroad or consumption of uncooked meat, fish, or seafood in the recent past.\nThe patient gave a past history of two episodes of ileus, first in her twenties and then at 41 years of age. She had undergone laparotomy without an alimentary tract resection for both episodes. In addition, when she was in her thirties, she had been treated with a 10 mg/day dosage of prednisolone for 1 year because of the preliminary diagnosis of idiopathic thrombocytopenic purpura (ITP), on the basis of the decreased platelet counts. At the age of 54 years, she was referred to a rheumatologist because of elevated titers of autoantibodies against Ro/SSA and La/SSB and was diagnosed with Sjögren's syndrome. Serological testing at that time had revealed hypocomplementemia, but no other colla"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male patient discovered a left axillary palpable nodule like a jujube in size when bathing in October 2011, but the patient was not concerned because of busy work. In January 2012, he went to a local hospital for medical checkup. Ultrasonography (US) revealed multiple hypoechoic solid masses with irregular margins in the left axillary cavity; the largest mass was 2.2 cm in diameter and color Doppler US showed that the mass had internal vascularity. He was then referred to the surgical department for further examination and therapy.\nPhysical examination showed a rigid, nonmobile mass measuring 3.0 cm in diameter in the left axillary; the skin covering the mass was normal and there were no significant enlargement of other superficial lymph nodes. No masses were palpable in either breast or other organs. On imaging examination (Figures and ), computed tomography (CT) scan for ostiomeatal unit, chest, abdominal, and pelvis, and ultrasound for thyroid, breast, genitourinary, and gastrointestinal fail to reveal any malignant or occult primary lesions but the axillary masses with a maximum dimensions of 2.5 × 1.7 cm. The magnetic resonance imaging (MRI) of breast showed that both mammary glands were free of lesions whereas it demonstrated multiple swollen lymph nodes in the left axillary. Positron emission tomography(PET) showed several increased lesions in the left axillary and the metabolic activity of the bone marrow also mildly increased, but did not discover any malignant lesion. Imaging examinations exclude other possible anatomic sites of origin despite hematology system, which was also ruled out by bone marrow puncture.\nDetailed pathologic examination of the lymph nodes was recommended, the patient underwent incisional biopsy on February 29, 2012. Upon incision of the left axillary cavity, multiple confluent swollen lymph nodes were seen. Postoperative hematoxylin and eosin staining demonstrated moderately differentiated adenocarcinoma with solid nest"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female attended the gynecology outpatient department for abnormal uterine bleeding. The patient was a follow up case of right-sided clear cell RCC that had been operated 3 years back by the procedure of radical nephrectomy. She had also been operated for meningioma right sphenoid wing () by the procedure of craniotomy 6 years back following which, the patient developed recurrence. The removal of residual tumor was done by gamma knife therapy. On histopathological examination, the tumor showed features of transitional meningioma (WHO grade I). During follow up, the patient started developing right-sided lumbar pain for 3 months. Ultrasonography revealed a hypoechoic lesion measuring 6.7×6.9 cm in the middle pole of right kidney with displacement of the pelvicalyceal system. CT scan revealed features suggestive of RCC () which was proven on histopathology, when the tumor was removed by the procedure of radical nephrectomy. A Technetium99 MDP bone scan revealed no metastatic foci. Also VHL gene sequencing studies did not show any evidence of mutation.\nPatient has been under constant follow up since then, when she started developing abnormal uterine bleeding. On ultrasonography, an echogenic lesion was identified on the right side of pelvis. Intra-operatively, a 5×4×3 cm ovarian mass was identified. The ovarian mass was solid with yellowish-grey and hemorrhagic areas with tiny cystic spaces ().\nA frozen section examination was done along with intra operative cytology in the form of imprints and scrape smears. Cytological smears showed cells dispersed singly along with focal clusters of clear cells. There was mild nuclear pleomorphism and presence of prominent nucleoli in some of the cells, however no mitosis or necrosis was identified. Frozen sections showed clear cells arranged in cords, nests as well as tubular pattern with mild nuclear atypia. A diagnosis of malignant epithelial tumor was given. A Total abdominal hysterectomy with bilateral salphingooph"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old female patient presented with a history of persistent pain, redness accompanied by bilateral visual loss since the past one and one half years. Previous significant medical history included surgery for pituitary macroadenoma 26 years ago. Previous investigations included a mantoux test that had been reported as “positive” but the patient had declined to start antitubercular therapy.\nHer best corrected visual acuity was counting fingers at 6/12 in the right eye and 6/36 in her left eye. Slit lamp examination of her right eye revealed multiple fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber had a normal depth but there were extensive posterior synechiae with a complicated cataract. similar findings were seen in the left eye.\nThe disc and the retina were normal in either eye. The intraocular pressure was 10 and 12 mmHg.\nSystemic evaluation revealed palpable cervical and axillary lymph nodes. A repeat mantoux test showed an induration of 22× ×25 mm. Her total and differential blood counts, tests for serum creatinine, serum calcium, serum angiotensin converting enzyme and serological tests to detect human immunodeficiency virus (HIV) infection were normal.\nA 18 FDG-PET scan revealed several metabolically active, bilateral level 5 lymph nodes in the neck, the largest on the left side measuring 1.6 ×1.8 cm with SUV max 5.5 and the largest on the right measuring 1.4 cm with a SUV max 5.2. The lungs and mediastinum were clear. Several metabolically inactive nodes were seen bilaterally in the axilla.\nShe underwent an ultrasound guided biopsy of a right posterior cervical lymph node suggested by the PET/CT scan. The microscopic examination revealed several medium sized epithelioid granulomas with occasional central necrosis suggestive of tuberculosis.\nShe was started on standard four drug therapy along with topical and periocular corticosteroids. Two months later there was a marked red"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78 year-old male was diagnosed with central non-small cell lung cancer 12 months earlier. The primary lung cancer was located in the proximal right upper lobar bronchus associated with postobstuctive atelectasis of the right upper lobe. However, at the time of diagnosis, the patient refused all the curative means. He had exhibited cough and increasing blood tinged sputum in the previous 4 months. We performed CT imaging on outpatient clinics, which showed a completely obstructed right upper lobar bronchus by a tumor with postobstructive pneumonia of the right upper lobe. The wall of the right main bronchus and bronchus intermedius was thickened and the lumen of the right main bronchus was almost narrowed by tumor infiltrations. Metastatic lymphadenopathy was observed in the right lower paratracheal and subcarinal area (). Nine days after the CT scan, the patient was hospitalized and underwent bronchoscopy. A bronchoscopic examination demonstrated that orifice of the right main bronchus was nearly completely obstructed by the endoluminal mass and there was diffuse bleeding from the right main bronchus. The patient received urgent external beam radiotherapy to control bleeding from the friable endobronchial tumor and bleeding gradually decreased for several days. However, eleven days after the radiation therapy, a sudden onset of dyspnea developed. Chest radiography showed that the right lung had totally collapsed and bronchoscopic examination revealed complete obstruction of the right main bronchus with diffuse bleeding.\nBronchial artery embolization could not be considered as a treatment option for hemoptysis because bleeding conditions were not because of active arterial bleeding and there was no prominent contrast enhancement of the mass as seen on the CT scan. We decided that bronchial stent insertion in the right main bronchus was necessary to both, re-open the airway and to control the bleeding of tumor through the tamponade effect. After the bronchogram, whi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 55-year-old female, was admitted in the hospital on July 5, 2019, because of the discovery of an abdominal mass that had been present for more than 4 months. Approximately 4 months prior, the patient inadvertently found a hard upper abdomen mass but reported no associated pain. The patient self-reported the tumor to be about the size of an egg but reported no nausea, vomiting, abdominal pain, diarrhea, haematemesis, blood in the stool or other discomfort. A local hospital computed tomography (CT) enhancement scan revealed a solid cystic mass in the upper abdomen, and the initial segment of the jejunum was unclear, suggesting the possibility of a stromal tumor. The patient was physically healthy. The examination upon admission revealed a soft abdomen that allowed the abdominal mass to be palpated. The mass was hard and appeared to contact the upper left abdominal area, and the size was approximately 5 × 6 × 5 cm. The patient's level of activity was good, and there was no tenderness. After admission, the relevant examinations were completed, and no obvious abnormalities were found in the laboratory tests, which included routine blood tests, biochemistry tests, and tumor marker analyses.\nThe upper abdomen enhanced CT showed the following: an abnormally dense shadow was present across the upper abdomen, but the side was clear, and the tumor size was approximately 6.2 × 5.8 cm. There was an uneven density within the lesion, with obvious visible enhancement present in 1 area and a cystic nonenhanced area. The lesion was closely related to the intestinal tract of the small intestine (beginning approximately at the jejunum), and a small arterial branch was seen inside. There were no obviously enlarged lymph nodes beyond the retroperitoneum (Fig. A–C).\nFirst, the patient underwent ultrasound-guided abdominal biopsy, and the postoperative pathology results showed the following: the cells showed alveolar and trabecular growth and were of a consistent shape, with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old man with a complicated past medical history of chronic kidney disease and small bowel transplant status post colonoscopy leading to ischemic bowel presented to the emergency room with homicidal and suicidal ideations. The patient had the small bowel transplant nearly 3 years prior to the emergency room visit. He had been maintained on tacrolimus to prevent bowel rejection, but otherwise was on few medications and in otherwise good health. According to his wife, he had never exhibited such behavior in the past and there were no obvious precipitating factors to this sudden attitude change. His erratic behavior was exhibited by the patient taking ∼24 lorazepam tablets throughout the day prior to admission and firing shots from a gun in their home, leading to police involvement. He had also complained of back pain for several days prior to the emergency room visit. He had no exposure to other drugs and his medications, including his tacrolimus, had not changed.\nOwing to this bizarre behavior, a workup was started. Laboratory work in the emergency room revealed a serum creatinine of 1.6 mg/dl, but was otherwise unrevealing. Ultimately, an MRI was performed (Figure ). Imaging revealed several contrast-enhancing lesions within the diploic space of the calvarium, the largest of which was a 3.6 × 3.6 × 1.8 cm plasmacytoma in the right parietal calvarium near the vertex. The mass extended through the inner table leading to displacement of the underlying left parietal cortex, and extension through the outer table contributed to involvement of the overlying soft tissue of the scalp. Multiplanar and multisequence imaging of the cervical and thoracic spine with and without contrast indicated multiple enhancing foci within the left T6 pedicle and T4, T5, T7 and T8–T12 vertebral bodies. Lumbar spinal imaging also revealed areas of altered marrow signal in the L2–L5, S1 and S2 bodies, giving the overall impression of metastatic disease"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman with gravida 2 Para 1 Living 1 with previous caesarean section at 29 weeks four days of gestation was referred with diffuse pain abdomen and giddiness. The pain was diffuse and present for the past 20 days which was partially relieved by symptomatic treatment by local doctors, and she also received antibiotics suspecting urinary tract infection. However she presented then with history of giddiness and one episode of vomiting with no history of diarrhoea and was referred. She was married for 10 years. Her first pregnancy was three years back when she underwent caesarean section for placenta previa. She continued to have episodes of pain abdomen in the postnatal and interpregnancy period for which she received symptomatic treatment by local doctor. She was pale on examination. Her vital signs including temperature were normal. There was no guarding or rigidity except mild tenderness on abdominal examination. The uterus was corresponding to 28-week gravid uterus size and was showing occasional contractions but no scar tenderness. Foetus was in breech presentation having regular heart rate. Her investigations showed mild anaemia with haemoglobin of 8.7 g% and neutrophilic leukocytosis (WBC 20900/c mm). Obstetric ultrasound showed single live intrauterine foetus corresponding to 29- to 30-week gestation. Suspecting chorioamnionitis the tocolysis was not administered. She went into spontaneous preterm labour. She was posted for emergency caesarean in view of previous caesarean with breech presentation under spinal anaesthesia with the coverage of antibiotics. On opening the abdomen, multiple pockets of pus were noted in the peritoneal cavity, and the coils of intestine and omentum were found adherent to the fundus and anterior upper surface of the body of the uterus. Lower segment caesarean section was done, and live male baby weighing 1.37 kg was extracted as breech. Then the general anaesthesia was induced, and the exploration was done by extending t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old female patient presented to the radiotherapy department in July 2008 with complaint of unrelenting hoarseness of voice for the last 1 year. She developed it gradually over a period of time. Initial treatment was directed to common cold but was of no help. There was no associated sore throat, otalgia, localized pain or tenderness over thyroid cartilage, dysphagia or features of airway obstruction. The patient is a nonsmoker and is nonalcoholic and without any history of past or present marijuana smoking. There was no history of prior neck irradiation. An incidence of cancer in the family could not be elicited from a detailed history. An indirect laryngoscopy was performed, which showed both vocal cords to be mobile. There was no visible growth over any of the vocal cords. Contrast-enhanced CT scan of the neck was performed, and it showed a small irregular lesion over the left vocal cord at the junction of anterior one third and posterior two thirds []. Thickening of left true vocal cord with loss of paraglottic fat is seen, suggestive of a neoplastic lesion. The normal paraglottic fat on the right side is seen as black area just deep to the thyroid cartilage (seen as white). The airway is seen as black oval structure. There is no visible neck node. Fiber-optic laryngoscopy confirmed the CT scan finding, which also showed irregular lesions along the medial margin of the left vocal cord []. Both CT scan and fiber-optic laryngoscopy showed an otherwise normal picture. Microlaryngoscopic removal of the mass was performed. Histopathological examination under low-power and high-power fields showed severe dysplasia and full-thickness replacement of epithelium with dysplastic cells and diagnosed it as carcinoma in situ [Figures and ]. However, the risk of a micro-invasive carcinoma could not be ruled out. A second biopsy was advised to obtain deeper tissue, but it was refused by the patient. So from the available documents, we considered it carcinoma in situ of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 88-year-old woman with dementia was brought to our emergency department (ED) due to two rapidly growing painful nodules on her right lower leg. Due to her dementia, the medical history was mostly obtained from her son, and the informed consent for this case report was signed by her son. She had poor performance status and was capable of only limited selfcare (Eastern Cooperative Oncology Group Performance Status Scale grade 3). She was confined to the bed or chair most of the time and was normally cared for at a nursing home. According to her son, the nodule on her right anterior lower leg appeared about 3 weeks previously, and she had begun to complain of right lower leg pain. The other tumor was located at the medial aspect of her right lower leg, and it had appeared only 1 week previously. The two nodules had grown rapidly, with increasing pain. She denied experiencing fever, night sweats or weight loss in recent months. She had been seen at a local clinic prior to her ED presentation. At the clinic, antibiotics had been prescribed and a needle aspiration of the larger skin lesions was attempted. No pus or fluid could be aspirated, and despite antibiotic treatment, the lesions were getting larger. Thus, she was transferred to our ED for further evaluation and treatment.\nPhysical examination revealed two red and violaceous skin lesions over the right lower leg, ~9 and 3 cm in size, respectively. The lesions were erythematous, had ill-defined borders and were tender on palpation. Local heat and swelling of the skin around the lesions were also noted. Laboratory data, including a complete blood count and biochemical studies, revealed no significant findings. Contrast-enhanced computed tomography of the lower limbs revealed an abnormal space-occupying lesion about 9 cm × 7.5 cm × 3.3 cm in size, at the anterior aspect of the right lower leg. It showed heterogeneous density, heterogeneous contrast enhancement, and involvement of the subcutaneous area, superficial f"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male with a 20-year history of ulceration over the lateral and medial aspects of his left ankle presented with a two-month history of pain. In 1993, he had developed chronic ulceration on either side of the ankle from friction caused by his shoe. The wounds were originally treated with saline irrigation by a rural doctor. The patient worked in a paddy field and had poor economic circumstances.\nPhysical examination revealed a 4.5-cm-diameter ulcer over the medial aspect and a 5-cm-diameter ulcer over the lateral aspect of the left ankle. A Marjolin's ulcer with similar histological characteristics occurring in different parts of the body simultaneously is a rarely reported occurrence. The crater-shaped ulcers were dirty, necrotic and malodorous, with surrounding tissue proliferation ( and ).\nRadiography showed areas of dense cortical bone and new periosteal bone formation in the middle and distal parts of the left tibia and fibula, and in the calcaneus and talus. There was a small area of bone destruction in the distal part of the tibia, with signs of chronic osteomyelitis and surrounding soft tissue swelling (). Bacterial cultures of the wound surface revealed Proteus penneri.\nIn September 2012, the patient underwent partial resection of the lesions. Pathological examination showed well-differentiated squamous cell carcinoma in the two lesions (). PET-CT showed abnormal uptake in the lymph nodes of the left popliteal fossa and left inguinal region, but it was unclear whether this represented wound infection or tumor metastasis ().\nIn September 2012, the patient underwent below-knee amputation of the left leg for these aggressive lesions. Two weeks after surgery, PET-CT still showed increased uptake in the lymph nodes of the left popliteal fossa and inguinal region, indicating possible metastasis. The patient then underwent B-mode ultrasound-guided biopsy of the left popliteal and inguinal lymph nodes. Examination of the biopsy specimens showed metastas"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old male with history of congenital membranous ventricular septal defect (VSD) developed tricuspid valve endocarditis following a dental procedure in 2007 and subsequently underwent VSD closure and bioprosthetic tricuspid valve replacement. His left ventricular (LV) ejection fraction prior to surgery was normal. In 2009, he presented with heart failure symptoms and was found to have severe LV systolic dysfunction. Since LV dysfunction persisted despite optimal medical therapy, he was referred to electrophysiology for consideration of a primary prevention ICD in 2010.\nHis 12-lead electrocardiogram at baseline () showed sinus rhythm with a QRS pattern consistent with ventricular pre-excitation over a right free wall accessory pathway (AP). The QRS duration was 193 msec. A transthoracic echocardiogram showed normal LV size with evidence of abnormal septal wall motion and an LV ejection fraction of 35%. The bioprosthetic tricuspid valve showed normal function and there was no evidence of residual VSD. A cardiac CT revealed normal coronary arteries and a cardiac MRI showed no evidence of delayed enhancement. We felt that the ventricular preexcitation pattern mimicking left bundle branch block could potentially contribute to his cardiomyopathy by causing dyssynchrony [,]. Therefore, the patient underwent electrophysiology study with a plan for catheter ablation of the AP.\nBaseline rhythm was sinus with a preexcited QRS complex of 193 msec. The HV interval was negative. The antegrade and retrograde AP block cycle length were 270 and 280 msec, respectively. Retrograde atrial activation was entirely eccentric with the earliest local activation in the area of the antero-lateral tricuspid annulus. The antegrade AP effective refractory period (ERP) was 320/600 msec. No significant changes in QRS duration or pattern were noted during atrial programmed stimulation and decremental pacing (). The retrograde AP ERP was ≤ ventricular ERP (240/600 msec). No arrhythmia could"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old man with a history of chronic alcoholism presented with abdominal distension. The previous day, the patient had presented to a local hospital with anal bleeding and abdominal pain after an incidental insertion of barbecue skewer per anus in the drunken state; subsequently, he had undergone sigmoid loop colostomy for rectal perforation. However, after the operation, the patient had become hemodynamically unstable. At presentation, his systolic blood pressure was 90 mmHg and the pulse rate was 135 beats/min. Although there was no gross rectal bleeding, the digital rectal examination revealed a penny-sized anterior rectal wall defect 6 cm from the anal verge (AV). Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with active bleeding in the pelvic cavity and a pseudoaneurysm in the anterior wall of the rectum (). Since the patient was hemodynamically unstable, an emergency operation was performed. During the operation, a massive subperitoneal hematoma in the rectovesical pouch and large amount of blood in the peritoneal cavity were found. After evacuation of the hematoma and blood, oozing continued in the rectovesical pouch (). Thus, compression with gauze was performed for 30 min until the oozing stopped. The Hartmann procedure was performed with the suspected bleeding focus included, but the perforation site was not included.\nAlthough the postoperative course was uneventful and there was no evidence of recurrent bleeding on the follow-up CT on the 7th postoperative day (POD), a focal enhancing lesion in the anterior wall of the rectum indicating a residual pseudoaneurysm was noted (). On the 11th day POD, his hemoglobin decreased from 11.6 g/dL to 7.9 g/dL, and the follow-up CT revealed recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity and the residual pseudoaneurysm (). Following the diagnosis of recurrent bleeding from the residual pseudoaneurysm, an angiography was performed. However, the angiography failed to localize the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-month old boy presented at a hospital in a south western state of Nigeria, with a swollen left upper arm adjoining the chest, low-grade continuous fever (38.1 °C), frequent passage of loose watery stool and persistent cries for more than 3 h. Child had been immunized about 24 h earlier. The mother reported that the symptoms were observed 2 h after the child was vaccinated with the measles vaccine at a private hospital. The child was one of three children reported to have been vaccinated with measles vaccine at a private hospital during the immunization clinic session.\nOn examination, he was mildly pale, febrile and anicteric. He was moderately dehydrated; mildly dyspnoeic with normal heart sound, heart rate of 148 beats/ min, breath sound was vesicular and respiratory rate of 54 cycles per minute. He was well nourished as the weight was appropriate for age. There was extensive swelling with skin discolouration (hyperemia) involving the entire left upper arm, sparing the distal third of the forearm and hand. There was also swelling of the upper part of the anterior chest wall. The swelling was firm and mildly tender. There was no history of adverse reaction to immunization or any form allergic reaction.\nA day after admitting the child, extensive erythema of the left upper arm and anterior area of the chest was observed with extensive scalded skin lesion involving the deltoid area, the upper chest wall and arm (Fig. ). Desquamation of the affected areas was observed presenting like severely burned skin from a hot liquid. There was darkening and hardening of the skin over the affected area on the arm with eventual severe necrosis up to a depth of about 5 mm thereafter (Figs. and ). A diagnosis of severe necrotizing fasciitis was made.\nRadical debridement of necrotic tissues was carried out under general anaesthesia. Child was also transfused with blood. Daily dressing of the wound was done and antibiotics administered were intravenous metronidazole (20 mg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old female presented with a 2 months history of progressive intermittent claudication of the right calf. She had no history of limb trauma but exhibited hypertension, hyperlipidemia, and paroxysmal atrial fibrillation that were well controlled. Her maximum walking distance was approximately 500 meters, but she did not experience rest pain at the time she presented to our hospital. On physical examination, the right posterior tibial or dorsalis pedis arteries were not palpable. The ankle-brachial index on the right leg was 0.70. Her vital signs were stable, with no significant laboratory findings. Enhanced computed tomography showed an occlusion of the right popliteal artery with a 60-mm-long circular cystic arterial lesion but preservation of arterial flow below the knee by collateral circulation (). The left popliteal artery and aortoiliac region showed no signs of arteriosclerosis. She was diagnosed as having ACDPA. Because she was symptomatic, with a 500-m intermittent claudication caused by the occlusive lesion, we decided upon surgical treatment. Under general anesthesia, in the prone position and through a posterior approach, a 60-mm-long intramural cyst of the right popliteal artery was exposed. No popliteal arterial pulse was noted below the knee. The cyst was punctured to reveal tenacious mucoid material, although there was no improvement in arterial flow. We then incised the cyst for drainage and decompression (), but the right popliteal arterial flow remained diminished on intraoperative angiography. Finally, we resected the affected popliteal artery with interposition using a right great saphenous vein graft. The operative time was 3 h 56 min, and blood loss was 170 mL. The ankle-brachial index after revascularization improved to 1.10 in the right leg, and the right posterior tibial and dorsalis pedis pulses became palpable. On the 13th postoperative day, she was discharged from our hospital. Histopathological examination revealed that the muco"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA forty-five-year-old female patient was admitted to our Clinic for symptomatic gallstones and laparoscopic cholecystectomy was performed without any drainage placement. On the second post- operative day the patient had abdominal pain on the right side; ultrasound showed a small subhepatic fluid collection compatible with laparoscopic surgery. Next day the patient was discharged without any problem.\nBecause of severe abdominal pain, the seventh postoperative day the patient referred to our Clinic.\nOn admission laboratory tests were performed and showed slightly elevated values of liver transaminase and alkaline phosphatase. Ultrasound identified minor subhepatic fluid collection. On the third day after admission the patient presented increase in body temperature of 38 degrees. Abdominal computer tomography revealed abundant free fluid in all the recesses, and in particular sub-hepatic, so a biliary fistula was suspected. The same day urgent laparoscopic revision was decided and intraabdominal bile collection with biliary peritonitis was found. After careful washing and drainage placement, an endoscopic retrograde cholangiopancreatography (ERCP) showed contrast spreading from the cystic duct. Sphincterotomy (PST) and 10-French endobiliary stent placement were performed.\nIn the course of the next few days, the patient was treated with antibiotic therapy and was pain free. After three days she developed fever and the amount of drainage output increased. Computer tomography revealed abdominal free fluid and two subhepatic and perigastric collection, respectively 69x31 mm and 61x27 mm. A laparoscopic peritoneal toilette was performed and four drainages were placed.\nDuring the following days, bile flow through the external drainages did not decreased in spite of fasting; an ERCP allowed visualization of contrast spreading upstream of the stent (). After its removal a contrast spreading from the cystic duct was noticed too (). A nasobiliary tube was placed at the biliary b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male complaining about a “wound in the mouth” was referred to Goiás Oral Medicine Center, Federal University of Goiás Dental School, Goiânia, Brasil, for diagnosis and treatment. The patient reported that the lesion had approximately 6 months of evolution and that he was asymptomatic and had not experienced any bleeding. His medical and dental history did not show any significance or any relation to his lesion. The patient had been a smoker for 33 years. Intraoral examination revealed a destructive ulcerative lesion around the upper left first and second molars, which showed mobility and poor dental conditions, including dental caries, gingival recession and bone loss (Fig. a). A panoramic radiograph revealed a radiolucent area in the periapical region of the upper left first molar, suggesting an osteolytic lesion (Fig. b). According to the clinical and radiographic features, the main diagnostic hypotheses were periodontal disease associated with oral squamous cell carcinoma. The patient reported that there was no cancer in his family history. The results of laboratory analyses, including blood and urine studies, were within the normal range. We also performed a biopsy to provide histopathological analysis. At this time, the patient took prescribed antibiotics for 7 days and underwent surgery of the upper left primary molar. Microscopic findings showed an inflammatory infiltrate rich in plasma cells that is commonly present in periodontal disease, without the presence of any atypical cell in this specimen of oral mucosa. Based on these findings, periodontal disease was considered as the diagnosis and the patient underwent periodontal therapy twice without remission of the initial injury. During follow-up, it was observed that the lesion increased considerably.\nSince the lesion was increasing in size, a second biopsy was performed on a deeper level of histological plan. It showed a proliferation of cells resembling histiocytes with an occasional pale nu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old woman was referred to the Department of Oral and Maxillofacial Surgery at Tokyo Medical University Hospital for a closer evaluation and treatment of an asymptomatic firm mass in the left posterior maxillary site. Intraoral examination revealed a palpable mass located in the posterior lateral region of the left maxilla (Fig. a). The overlying mucosa was intact and normal in color. The firm mass was not movable. Laboratory data were within the normal limits. Computed tomography (CT) scan of her head and neck showed a clear circumscribed solid mass measuring 28 × 23 mm in size between the lateral aspect of the posterior maxilla and the anterior region of the masseter muscle with no evidence of maxillary bone involvement (Fig. b). There was no lymphadenopathy in the cervical region. Magnetic resonance imaging scans revealed homogeneously enhanced signal intensity on T1-weighted images after gadolinium administration (Fig. a) and high signal intensity on Short T1 Inversion Recovery images (Fig. b). Incisional biopsy demonstrated benign lymphoid tissue. CT examination was conducted in the chest and abdominal region taking into consideration Castleman’s disease as a differential diagnosis. However, systemic lymphadenopathy was not recognized. The submucosal mass was completely excised under general anesthesia. In the course of the surgical resection, the mass was observed to be adjacent to the buccal fat pad.\nGross examination showed a solid mass measuring 38 × 23 × 17 mm in size, which was encapsulated with fibrous tissue (Fig. ). Microscopic examination revealed lymphocytic tissue composed of scattered lymphoid follicles with germinal centers and predominant small well-differentiated lymphocytes in the parafollicular area (Fig. a). The follicles showed various sizes of the germinal centers surrounded by well-defined mantle zones consisting of small lymphocytes (Fig. b). The germinal center contained a mixture of centrocytes and centroblasts with occasional"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOn November 2009 a 33-year old woman with no significant previous medical history was referred to her gynecologist due to complaints of pelvic pain. A right ovarian cyst was diagnosed upon examination. However, due to persistent pain, a CT scan was performed that revealed a right pelvic mass. On 12 November 2009 the patient’s gynecologist performed laparoscopic surgery during which a sub peritoneal lesion likely to start from the bladder was found. The mass was removed but ruptured during surgery, with intraoperative spillage of mucinous material. A cystoscopy was performed postoperatively, which showed a reddish lesion of the dome of the bladder. The intraoperative histological diagnosis was mucinous adenocarcinoma. This was then confirmed by the final histological examination.\nThe patient was referred to our hospital, Istituto Nazionale Tumori (National Tumors Institute), Milan, Italy, a referral center for the treatment of oncological disease in Italy, and a histological review was performed by our genitourinary pathology expert. The immunohistochemical analysis was positive for CDX-2 and CK20 and negative for CK 7, suggesting a diagnosis of mucinous adenocarcinoma originating from the urachal ligament. We then performed a whole body CT scan that showed two metastases in the right lung, one at the lower lobe and one in the middle lobe, with a diameter of 15.6 and 8.5 mm, respectively, and one lesion anterior to the bladder wall and the dome that extended through the bladder wall, protruding into the lumen. Serum CEA was 15.39 ng/mL (normal <5), CA 19.9 was 70.1 U/mL (normal <37), CA 125 negative, CA 15.3 negative.\nWe discussed the case of the patient with the urological surgeon and, given the extension of the disease, we decided to treat the patient with systemic chemotherapy rather than performing surgery.\nThe histological type, the strong mucinous component and the phenotypic similarities with a cancer of gastroenteric origin, rather than urothelial, prompted u"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 74-year-old male who was admitted to the hospital after presenting to the emergency department (ED) with the chief complaint of right arm weakness and difficulty in speaking. His past medical history included diabetes mellitus, hypertension, persistent atrial fibrillation on long-term anticoagulation with rivaroxaban, heart failure with reduced ejection fraction of 30% and aortic stenosis with two previous bioprosthetic surgical aortic valve replacements in 2004 and 2014. Two months prior to admission, he was diagnosed with IE caused by Group B Streptococcus involving the aortic bioprosthetic valve. Initially, he presented with complaints of intermittent febrile episodes and night diaphoresis for approximately 8 weeks. At that time, the decision was made to treat him conservatively with oral antibiotics and close clinical monitoring. Blood cultures were negative in two different occasions, and the patient was discharged on stable conditions. However, a day prior to his second hospital admission, the patient noted sudden onset right upper extremity weakness (MRC power grade 3) and dysarthria. Upon further evaluation in the ED, a magnetic resonance imaging (MRI) of the brain revealed multiple embolic strokes ().\nTransthoracic echocardiography and computed tomography angiography (CTA) of the chest revealed nonspecific structural changes with images compatible with a possible aortic perivalvular abscess/pseudoaneurysm (). Transesophageal echocardiography (TEE) confirmed a perivalvular cavity around the aortic root, and this cavity was communicating with the aorta. Furthermore, the cavity was also in communication with the left ventricle (LV), creating a dynamic of retrograde flow, with blood passing from the aorta to the LV through the fistulous tract (). As a result, the patient developed an ACF due to perivalvular endocarditis, which resulted in symptomatic severe aortic valve regurgitation.\nThe patient was transferred to a tertiary care cente"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old man presented to our otorhinolaryngology outpatient department with the symptoms of persistent odynophagia and hoarseness for 1 week after ingesting a fish bone. There was neither dysphagia nor dyspnoea. At first, he sought medical consultation in a local clinic and cervical X-ray was done. However, it was not conclusive, and there was no sign of presence of foreign body in the pharynx. Due to the worsening of his symptoms, he presented to our clinic on 25 August 2016. Flexible pharyngolaryngoscopy was done, and it was noted that there was left vocal cord immobility, oedematous left aryepiglottic fold, and left pyriform fossa with secretions in it. We could not find any foreign body in his pharynx nor in larynx. However, based on his history, the presence of fish bone impaction in the larynx was suspected. The patient was then admitted to the hospital, and urgent computed tomography (CT) scan of the neck was done and revealed a 3 cm linear foreign body embedded in the soft tissue medial to the left thyroid cartilage with surrounding hypodense soft tissue swelling causing mild indentation of the left vocal cord extending into the supraglottic region up to the left pyriform sinus and downwards minimally extending to the infraglottic region causing mild asymmetric narrowing of the involved laryngeal segments and causing mass effect on the glottis and supraglottic airway causing mild asymmetric narrowing ().\nThe diagnosis of inflammation of the paraglottic region and vocal cord immobility secondary to fish bone impaction in the paraglottic space was made. The patient was then shifted to the operation theatre (OT), and rigid direct laryngoscopy was performed under general anaesthesia. It revealed oedema in the left pyriform fossa and left supraglottic region, and no foreign body was visualized. Also, rigid oesophagoscopy was performed, and it showed the same findings as the laryngoscopy. Therefore, foreign body retrieval endoscopically has failed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old woman arrived in the emergency department complaining of acute right lower quadrant abdominal pain and vomiting. She did not report any weight loss or diarrhea. She had no history of abdominal surgery or any other allergic disease. She denied taking any drugs or herbal medicines. A physical examination of the abdomen revealed tenderness with rebound tenderness in the right lower quadrant of her abdomen. Initial laboratory investigations showed a white cell count of 14,400/mm3 with 75% neutrophils, 16% lymphocytes, 3.3% monocytes, and 4.3% eosinophils (an absolute eosinophil count of 619/mm3). Other laboratory tests and stool examination for ova and parasites were within normal limits. Based on her physical examination, a laparoscopic appendectomy was performed for a presumed diagnosis of an acute appendicitis; however, it revealed bowel edema and a moderate amount of ascites in the abdominal cavity without gross evidence of appendicitis. The appendectomy specimen showed eosinophilics were infiltrating the muscular and subserosal layers of the appendix wall (). Ascitic fluid analysis showed exudative ascites with predominant eosinophils (a white cell count of 3,150 cells/µL with 75% eosinophils) and no evidence of malignant cells. Postoperatively, the degree of peripheral eosinophilia progressed to 1,729/mm3. Tests for antinuclear factor, rheumatoid factor, antineutrophilic cytoplasmic autoantibody, and skin prick test were all negative.\nA gastroscopy showed marked edema of the gastric antrum and narrowing of the pyloric ring. The duodenum also showed mucosal edema with erythema. Biopsies of the gastric antrum and proximal duodenum revealed inflammation with eosinophilic infiltration (). A colonoscopy showed normal mucosa without eosinophilic infiltration. Although an abnormal skin lesion was not observed, a punch biopsy of the central abdominal skin revealed diffuse perivascular and interstitial inflammation with marked eosinophilic infiltration (). Th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old man was admitted at the emergency department of a general hospital after experiencing painless hematuria which was his only symptom; he had a history of smoking and hypertension. Laboratory tests showed results within normal limits: creatinine levels were 0.9 mg/dL and he had a glomerular filtration rate (GFR) greater than 60 mL/min. Urological ultrasonography revealed a 4 cm tumor on the right posterolateral wall of the bladder which appeared to be invasive.\nComputed tomography (CT) of the abdominal and pelvic area showed a mass in the urinary bladder corresponding to stage 3 (cT3b) with apparent infiltration into the fat but without lymph node involvement. Cystoscopy and transurethral resection (TUR) of the tumor was carried out but residual tumor remained. Pathological examination confirmed a urothelial carcinoma with evidence of invasion into the muscular layer.\nThe patient did not receive neoadjuvant chemotherapy but surgical treatment was planned which consisted of radical cystectomy and Bricker-Wallace reconstruction. Histological examination of the resected specimen described a grade 3 urothelial carcinoma with infiltrations into the adjacent fat tissue. Twenty-two tumor-free lymph nodes were also removed, and the tumor was staged as a pT3bN0. The tumor margins as well as the urethers were microscopically negative and there was no in situ carcinoma. After surgery creatinine blood levels were 1.2 mg/mL and the GFR was higher than 60 mL/min.\nThe patient remained disease-free for 18 months until a single, newly-formed 1.6 cm lung nodule was discovered which was not accessible for biopsy using standard techniques. No mediastinal lymphadenopathies were found and there was no evidence of disease in any other location. At this point, the patient underwent resection of the mass and the histo-pathological examination revealed a 1.2 cm metastatic lesion from a urothelial carcinoma with tumor-free edges. No chemotherapy was administered after surgery.\nTwe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA thirty eight year old lady was admitted with complaints of worsening breathlessness and low grade fever of one month duration. This was associated with pleuritic type of chest pain on inspiration and orthopnea for past three days. She had developed multiple skin ulcers on her lower back over one month duration. Two of these were discharging serous fluid over past two weeks. She had undergone right knee surgery seven years ago and incisional hernia repair three years ago. There was no history suggestive of tuberculosis in the past. She had been treated unsuccessfully with antibiotics for suspected folliculitis with abscesses on the back, at another centre for one week prior to admission in our hospital. On examination, BCG vaccine scar was seen on the left deltoid. There were multiple, nontender skin ulcers on bilateral lumbar areas, some oozing serosanguinous discharge and few others with scarring []. Respiratory system examination revealed restricted right sided respiratory movements, stony dull percussion note in right hemithorax and absent breath sounds on right side in all lung fields. Other system examinations were normal.\nChest X-ray was suggestive of right sided pleural effusion []. Pleural fluid aspiration and analysis was done. Results are detailed in . Pleural fluid was exudative in nature with 99% lymphocytes and adenosine deaminase level of 108 IU/L, suggestive of tuberculous etiology. Other blood investigation results are given in . Echocardiography was normal. Intradermal Mantoux (1 TU PPD with RT 23 Tween 80) was positive (12 mm) at the end of 48 hours. Skin biopsy was taken from the edge of the ulcer and histopathological examination was done. It was reported as granulomatous inflammation suggestive of tuberculosis. The biopsy specimen contained multiple granulomas composed of epithelial cells and langhan’s giant cells; areas of necrosis and dense lymphocytic infiltrate []. It did not stain for acid fast bacilli. Diagnosis of pulmonary tuberculosis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.\nThe patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of delivering the baby. The rest of the case was uneventful. No blood product transfusion was necessary. After"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old female motorcyclist presented to our emergency department with a 3-h history of severe abdominal pain following blunt abdominal trauma after bumping by a car. She denied any medical or surgical history. We evaluated this patient according to the advanced trauma life support algorithm. The airway was patent, and bilateral breath sounds were clear. The heart rate was mildly elevated to 100 bpm without low blood pressure. She was conscious and clear without any neurologic deficits. No obvious open wounds were observed, except for an erythematous bruise on the right middle abdomen, measuring 3 × 3 cm in size. Contrast-enhanced computed tomography (CT) revealed pneumoperitoneum with mild ascites and a retroperitoneal hematoma in zone 1 (Figs. and ). We performed an emergency exploratory laparotomy suspecting hollow organ perforation and retroperitoneal hematoma. On midline laparotomy, we noted that a considerable amount undigested food had spilled out of the distended stomach onto the gastrohepatic ligament and lesser sac. A transverse full-thickness laceration on the lesser curvature of the stomach was observed, measuring approximately 10 cm in length (Fig. ). On retroperitoneal exploration, we used the Kocher maneuver to examine the first and second portions of the duodenum and observed them to be intact. We then opened the lesser sac to examine the pancreas and fourth portion of the duodenum, which were intact as well. No bilious ascites or active bleeding was noted during retroperitoneal exploration. Therefore, we performed a primary repair of the perforated stomach and sent the patient to the intensive care unit for further resuscitation. However, on the second postoperative day, peritonitis presented again, and the drainage tube showed bilious content. Hence, a second laparotomy was performed. This time, however, we observed bilious ascites in the lower abdomen. The repaired perforated stomach was intact. We then performed a complete right medial visc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-year-old Syrian boy presented to the dermatology clinic with complaints of a widespread yellowish-white subcutaneous nodule on his right thigh. During 2 years of follow-up, other lesions had appeared gradually on the forearm, elbow and brachium (). Then the lesions showed chalky discharge (A) and no similar lesions were observed elsewhere in the body. There had been no increase in the number of lesions since the last visit. Clinical examination revealed palpable firm nodules below the skin. There were no signs of inflammation, joint pain or photosensitivity. His past medical history did not reveal any underlying diseases, including metabolic, autoimmune, malignant or traumatic events. There was no family history of similar complaints.\nWe did full blood count for the patient and all values were within normal ranges (). serum calcium and phosphate levels as well as parathormone, vitamin D hormone levels (vitamin D was checked to exclude high levels and hypercalcemia); alkaline phosphatase levels were within normal limits. Also, a 24-hour urine collection test showed normal calcium and phosphate levels. Erythrocyte sedimentation rate and Rheumatoid Factor tests were done at first to investigate inflammatory and immunological causes and the results came negative (). Then we did more specific tests to screen the most common conditions associated with the disease, Anti-Jo1 for dermatomyositis and it was negative (4.3), serological tests for systemic lupus erythematosus (SLE) and scleroderma, including antinuclear antibody (ANA) and anti-dsDNA were negative.\nThe possibility of familial hyperphosphatemia is unlikely because we checked-up parent’s calcium and phosphate blood levels and the results were normal. Plain x-ray revealing calcification around the elbow and brachium separate from the adjacent bone (B).\nSurgical excision was performed and histological examination of one of the nodules revealed thick, chalky discharge at the time of the procedure and microscopic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is the case of a 29-year-old female patient, G2P1001, at 12 weeks + 4 days, referred to us for management of giant splenic artery aneurysm. History goes back to 11 months prior to presentation when the patient had severe left upper quadrant pain during the 8th month of her first pregnancy. Her pain was then attributed to uterine contractions and thus she was delivered by Caesarean section with no further investigations carried out at that time.\nDuring her subsequent pregnancy and few days before presentation, she developed the same left upper quadrant pain. Ultrasound was performed showing: enlarged spleen 15.5 cm, well-defined rounded heterogeneous lesion of 7.6 × 6.8 cm in favor of a splenic artery aneurysm. MRI was performed for better evaluation (Figs and ), revealing a single aneurysm 7.5 × 7 × 6.5 cm in the distal portion of the splenic artery with an intramural thrombus, abutting the splenic hilum.\nLaboratory studies performed were normal.\nAt this point, open aneurysmectomy was decided for the following reasons: the large size of the aneurysm, its location in the distal third of the splenic artery, the extensive involvement of the splenic hilum, the potential need for a formal splenectomy, the fact that our patient was pregnant, and the potential risk of rupture in endovascular repair.\nA left subcostal incision performed, entering the lesser sac by division of the gastrocolic ligament and liberation of the splenic flexure. The aneurysm could be palpated over the distal pancreas and splenic hilum, dissection and control of the splenic artery proximally. Dissection of the gastrosplenic ligament and ligation of the short gastric vessels. The aneurysm was adherent to the pancreatic tail, and exhibiting a severe desmoplastic reaction. Thus, a distal pancreatectomy was warranted. Ligation and division of the splenic artery proximally and distal pancreatectomy was thus performed. Ligation and division of the splenic vein, liberation of spleen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-day-old Pakistani boy was admitted to hospital in June 2005 for bleeding from the left nipple. His parents are first cousins. He has two siblings aged 8 and 6 years. There was no family history of bleeding diathesis. The mother had a normal pregnancy with full antenatal care. Mode of delivery at term was an elective Caesarean section due to previous Caesarean sections. His birth weight was 2.7 kg. 1 mg of Vitamin K was given intramuscularly at delivery. His first neonatal check was normal. He had a small amount of self-limiting bleeding from the umbilical cord on day 3 of life. He went home on day 4.\nOn day 6 of life he had mild spontaneous left sided nipple bleeding, which presented as spots of blood stains on the left side of his baby dress.\nOver the next 7 days he had two further episodes of a similar nature. Baseline biochemistry and full blood count were normal but a coagulation screen showed a prolonged prothrombin time of 41 s (control 14 s), a prolonged partial thromboplastin time of 132 s (control 33 s) and normal thrombin time of 15 s (control 14 s). In view of the mild nature of bleeding, the child was only treated with 1 mg of i.v. vitamin K. Subsequent coagulation assays revealed a plasma factor V activity of less than 0.01 IU/ml (normal range 0.50–1.50 IU/ml) determined by factor V clotting assay with all other coagulation factors in the normal range. Hence the diagnosis of congenital factor V deficiency was made. A cerebral ultrasound done at this stage was within normal limits. Oral transexamic acid at a dose of 15 mg/kg/dose 3 times daily was started.\nMother was found to have a plasma factor V activity of 0.44 IU/ml (normal range 0.5–1.50 IU/ml) and the father of 0.52 IU/ml by factor V clotting"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old man with a past medical history of nonischemic cardiomyopathy who initially underwent OHT in 1994 (biatrial anastomosis) was referred for pacemaker lead revision. His posttransplant course had been complicated by transplant vasculopathy, and he ultimately required a second heart transplant in 2002 (bicaval anastomosis). He also developed ESRD and underwent deceased donor kidney transplantation in 2004. He developed ehrlichiosis in 2011 in addition to cryptococcal pneumonia and histoplasmosis requiring chronic treatment with antifungals. In 2013, he had syncope leading to a subarachnoid hemorrhage and was diagnosed with sinus node dysfunction in the setting of intermittent sinus bradycardia to less than 20 beats per minute. He underwent dual chamber pacemaker placement in 2013 (Medtronic ADDRL1) with a Medtronic 5076 lead in the ventricular position and a Medtronic 5592 lead placed in the right atrial appendage after an active fixation lead was deemed to be unstable.\nHe was admitted for volume overload three years later, and pacemaker interrogation revealed undersensing on the atrial channel due to a gradual P wave amplitude decrease from 4.7 mV at implant to ~0.4 mV, leading to asynchronous ventricular pacing and failure to recognize atrial arrhythmias. No change in lead position was detectable on chest X-ray. An atrial lead addition was planned. However, the left subclavian vein was occluded. He underwent extraction of the atrial lead to obtain venous access. A 12 French Spectranetics SLS II laser sheath was advanced over the lead, and minimal application of laser energy was used to free adhesions. Countertraction using a snare was also employed from the femoral vein. The lead was removed, and subclavian access was retained. A Medtronic 3830 lead was implanted in the right atrium. The patient tolerated the procedure well, and he had no complications within the next 30 days. However, he was admitted with cryptogenic encephalopathy two months later whic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old female patient (bodyweight 50 kg, height 160 cm) presented with syncope. Severe arterial hypertension was diagnosed (178/147 mmHg left arm, 102/83 mmHg left leg). She reported previous episodes of exercise independent headaches and nose bleeds. Auscultation revealed no cardiac murmurs, but an accentuated second heart sound and reduced pulses in the lower limbs. There were no clinical signs to suggest Alagille or William’s syndrome or clinical evidence of neurofibromatosis. Blood tests showed normal inflammatory markers and normal creatinine. The urine dip showed no markers for blood or protein. No regular medication was taken at the time she presented. The electrocardiogram showed normal sinus rhythm, no significant signs of left ventricular (LV) hypertrophy or abnormal repolarization. Echocardiography detected a severe concentric LV hypertrophy (14 mm diastolic septal diameter, 15 mm diastolic diameter of the LV posterior wall) and a long hypoplastic segment in the abdominal aorta with massive arterial collateralization. Cardiac catheterization confirmed the diagnosis of a midaortic syndrome with a minimum diameter of <1.5 mm and a gradient of 50 mmHg between the aortic arch and the femoral arteries (Figure ). The narrow part began directly under the diaphragm above the truncus coeliacus and continued down to the bifurcation of the arteriae iliacae including the renal arteries, with reversed flow in the caudal aorta up to the renal arteries. Because of the extraordinary length of the hypoplastic segment of 23 cm, we decided for a stepwise interventional therapy with a paclitaxel covered balloon. No additional computed tomography scan or magnetic resonance imaging (MRI) was performed. Consultation with our surgeon, supported the interventional approach. The proposed procedure was reviewed and approved by our institutional review board, extensively discussed with the patient’s family, and informed consent was obtained before proceeding.\nAfter balloon in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male was hospitalized for a 4 months complaint of worsening difficulty in swallowing, predominantly to solids, accompanied by mild loss of weight. Hematology and biochemistry laboratory tests were within normal limits, and standard chest radiography did not reveal any lung or mediastinal lesions.\nContrast-enhanced computed tomography of the chest showed a well-defined 3 × 3.5 × 4 cm homogeneous mass on the right side of the distal esophagus, proximal to the gastro-esophageal junction (Figure ). Transesophageal ultrasound was not available, but upper gastrointestinal endoscopy showed a smooth submucosal bulge in the distal segment of the esophagus, resulting in evident localized narrowing of the esophageal lumen. The overlying mucosa was intact.\nDecision was made to perform elective excision of this mass lesion and, since the distal esophagus is usually more accessible from the left, this was carried out employing a left-sided video-assisted thoracoscopic surgical (VATS) approach. Using three 5-mm ports, the lower esophagus was dissected and the mass was identified (Figure ). Attempts to enucleate the mass were unsuccessful and, upon incising the mass to perform a frozen section procedure, thick creamy fluid leaked out confirming its cystic nature (Figure ). Consequently, layers of the decompressed cyst were dissected off the esophageal musculature with ease, the cyst was excised, and the specimen was retrieved through a limited thoracotomy incision. The continuity of the esophageal mucosa was confirmed by infusing methylene blue solution into the esophageal lumen while occluding the esophagus at the gastro-esophageal junction (Figure ). The muscular edges of the esophagus were reapproximated, and the resection site was buttressed with the mediastinal pleura.\nThere were no postoperative complications. The patient returned gradually to full oral intake and was discharged home on the fourth postoperative day in an excellent general condition. He remains s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old Japanese woman presented to our clinic with a 4 month history of bilateral groin pain and right buttock pain. Her right hip was more painful than her left hip. There was no history of trauma, alcohol abuse, or steroid use. Her medical history included iron-deficiency anemia diagnosed 2 years earlier, after which she had been on iron supplements. She had no fracture episodes, including fragility fractures.\nHer height, body weight, and body mass index were 155 cm, 42 kg, and 18.7 kg/m2, respectively. She was able to walk for approximately 10 minutes without a stick, albeit at a slow speed. Limitations in the passive motion of her bilateral hip joint were observed thus: flexion, 100°, internal rotation 5°, external rotation 15°, and abduction 20°, on both sides. She was able to perform a straight-leg raise of the right limb with substantial pain. The neurovascular status of both lower extremities was intact. The Japanese Orthopaedic Association scoring system for the evaluation of hip-joint function (JOA hip score) was 46 points for her right hip and 56 points for her left hip. The score was based on a total of 100 points, comprising 40 for pain, 20 for range of motion, 20 for the ability to walk, and 20 for activities of daily living [].\nStandard radiographs of both hips (Fig. a–c) demonstrated no characteristic findings such as the crescent sign, sclerotic band pattern, and collapse of the femoral head, and no joint space narrowing was seen in either femoral head. MRI of both hips (Fig. d, e) presented a low signal line in the subchondral region of the femoral head in the T1 weighted image and high signal region in almost all of the femoral head in the short tau inversion recovery (STIR). The oblique axial views of the proton density-weighted image showed a low-signal sinuous line in the anteromedial region"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year-old girl presented to our orthopaedic clinic, with main complaint of a mass which was getting bigger on her upper back. Her parents noticed that she has already had the mass since six years. The initial mass size was around 1 cm in diameter (like a marble) located just below the tip of both scapulae. Subsequently, more masses appeared on the left lateral side of vertebrae. It was accompanied by difficulty in moving both shoulders and neck since 4 years. Because of these complains, her family tried various traditional medicines without improvement.\nSix months prior to admission, she fell down on her back, and since then the masses grew progressively. She also felt pain around the masses. Meanwhile her neck and shoulder movement were becoming more limited than usual. She was brought to a district hospital in other province and then referred to our hospital to get more appropriate treatment. There was no history of similar disease in her family.\nOn physical examination, general condition was good and no abnormality was found in other organ. We found multiple bony prominences measuring about 2 cm in diameter at paravertebral region from cervical to lumbar and posterior thoracic wall. They made bone bridges starting from inferior occipital bone to cervical spine and extending to paravertebral lumbar region. We also found multiple masses at both axilla. Cervical lordosis and thoracic kyphosis were diminished. All the masses were hard in consistency. There was no tenderness, and the masses were fixed to the bone. The shoulder, cervical, and thoracal spine ranges of movement were limited ().\nRadiograph of the cervical spine showed new bone formation starting from occipital bone, cervical, until upper thoracal spine. Chest and shoulder radiographs also showed new bone formation at both humerus bridging to the tip of scapulae, with subluxation of both humeral head superiorly. The radiologist saw it as mustiple exostoses (osteochondroma lesion) with the differential d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. ().\nRadiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement (). Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.\nThe patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding so"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 56-year-old female who complained of swelling over the right side of forehead for 15 days. Magnetic resonance imaging (MRI) brain showed lytic lesion involving left frontal bone with erosion of inner and outer tables suggestive of plasmacytoma. Laboratory work-up revealed an elevated β2-microglobulin level of 3018 ng/ml, raised kappa-lambda ratio- 29.640 and presence of multiple myeloma band. Bone marrow examination confirmed the diagnosis of plasma cell neoplasm with 42% plasma cells. Under the suspicion of MM, the diagnosis was proved histopathologically by specimen from tumour attached to the dura that revealed hypercellular marrow with increased plasma cells. Diagnosis of MM, stage III (International Staging System) was made. Further work-up with FDG PET/CT imaging demonstrated multiple hypermetabolic lytic osseous lesions suggestive of mitotic osseous involvement.\nSix cycles of Inj. Bortezomib 2 mg weekly along with Inj. Dexamethasone 40 mg weekly, and T. Thalidomide 100 mg (VTD regimen) were administered. She came to our hospital 1 year after the first treatment with relapse of MM. At this time, she was treated with 4 cycles of VTD regimen and achieved complete marrow remission. Further plan was to proceed with the HSCT.\nHowever, just before her planned transplant date, she developed weakness of both lower limbs, low backache which progressed to difficulty in walking over a couple of days. MRI Brain showed two lobulated extra-axial dural based soft tissue lesions in left frontal and parietal regions measuring 47 x 15 mm and 10 x 8 mm, respectively with perilesional edema. Whole spine screening showed diffuse altered signal intensity of all visualized vertebrae with ill-defined focal lesions and a soft- tissue component at the S3 – S5 level in the presacral region, extending into the left S3 and S4 neural foramina. There was similar soft tissue component in the left paraspinal region on left side at S"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).\nIt also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.\nThe patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old male (height 5'2”, weight 50.9 kg) with a history of severe idiopathic pulmonary fibrosis with two spontaneous pneumothoraces and a persistent bronchopleural fistula underwent a successful leak repair via pleurodesis. Following the procedure, the patient developed acute respiratory failure with persistent hypoxia requiring intubation and mechanical ventilation. An echocardiogram showed right ventricular strain with an EF of 78%, right ventricular systolic pressure of 115 mmHg, and enlarged pulmonary arteries, suggestive of obstructive shock from a pulmonary embolism or pulmonary hypertension. Limited improvement prompted the need for monitoring beyond that provided with transesophageal echocardiogram. Initiation of a right heart catheterization with a pulmonary artery catheter allowed continuous real-time monitoring of hemodynamics and assessment of pulmonary capillary wedge pressure, to further guide therapy towards a potential lung transplant.\nA critical care fellow, under the supervision of an attending physician, used an ultrasound-guided technique to successfully place a 9 Fr introducer sheath [Arrow International, PA, USA] in the right internal jugular vein, through which the pulmonary artery catheter [Edwards Lifesciences, CA, USA] was inserted. During the initial attempt to float the catheter, right atrial, and ventricular wave forms were confirmed with the catheter advanced 20-30 cm, and a pulmonary artery wave form was confirmed at about 40-50 cm. Pulmonary artery pressures were measured varying between 100/30 mmHg, but wedging of the catheter was unsuccessful. Subsequent attempts confirmed appropriate right atrial and ventricular wave forms but failed to advance through the pulmonary artery. During the final attempt, the catheter was advanced to about 40-50 cm without acquiring a pulmonary artery wave form, but upon attempted removal, it stopped at approximately 30 cm, without any possible further retraction. The inability to remove the cath"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old man, weighing 65 kg, was admitted to our hospital to evaluate a murmur in the routine examination. He had complained of mild shortness of breath on physical exertion for one month. Physical examination on admission revealed a systolic murmur in the left para-sternum, trans-thoracic echocardiography showed a subarterial VSD with a diameter of 8 mm, left to right shunting, pressure gradient via the defect was 70 mmHg. The left ventricle dilated mildly with left ventricle end-diastolic diameter was 57 mm and left ventricular ejection fraction was normal range. Pulmonary artery systolic pressure was 33 mmHg at rest. Mild aortic regurgitation was present.\nThe patient was conducted under general anesthesia with a single-lumen endotracheal tube and placed in supine position as for standard median sternotomy with two arms along the body. Defibrillation pads were placed on the right and left chest before sterile draping. The femoral artery and vein were dissected in preparation for cannulation with a 2–3 cm oblique right groin incision. A 4 cm left parasternal thoracotomy was used to enter the thorax via the third intercostal space (ICS). The left internal thoracic artery was preserved carefully. The third costal cartilage was divided close to the sternum, without resection, to increase exposure. The ribs were slowly spread with a mini-thoracic retractor. The pericardium was opened longitudinally and suspended with stay sutures. The femoral artery cannula was inserted directly into the common femoral artery. A multi-stage venous cannula was inserted using the Seldinger technique with the tip of cannula advanced to the superior vein cava under transesophageal echocardiography guidance. After femoral arterial and venous cannulation, cannulas were secured, and cardiopulmonary bypass (CPB) initiated. CPB was initiated with vacuum-assisted venous drainage and body temperature maintained at approximately 34 °C A long cardioplegia needle (Livanova, London United Kingd"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman with left femoral nonunion following periprosthetic fracture after bipolar hip arthroplasty was referred to our department. She had undergone bipolar arthroplasty for left femoral neck fracture (Figures and ) and had been treated for osteoporosis with alendronate for 27 months after the bipolar arthroplasty. Her medical history included rheumatoid arthritis since the age of 60 years and diabetes mellitus diagnosed at the age of 83 years that was being treated using voglibose. She noticed thigh pain 36 months after the operation, which worsened 2 months later without any episode of injury. According to her, she felt pain at first and then fell because of the pain. A periprosthetic simple transverse fracture at the level of the distal end of the stem was found (). Internal fixation with a locking plate was performed at the hospital (). The remaining gap between the fragments was evident. To promote fracture healing, low-intensity pulsed ultrasound and teriparatide administration were started six days and two months after the surgery, respectively. Despite these treatments, the fracture did not heal in nine months; she was therefore referred to our department. The retrospective radiographic analysis revealed that a periosteal thickening of the lateral cortex at the stem tip level had existed at least two months before the fracture ().\nOn admission to our hospital, she could hardly walk due to the left thigh pain. Radiographs showed a nonunion fracture with osteosclerotic changes in the left femoral shaft at the level of the stem tip (). Radiographs of her contralateral femur showed lateral bowing but no features of AFF ().\nThe implant was replaced with a longer stem (Exeter; Stryker, Tokyo, Japan) using the cemented technique. The implant of bipolar arthroplasty was not loosened. Osteosynthesis was performed with a locking plate for the distal femur (NCB Periprosthetic Femur Plate; Zimmer Biomet, Tokyo, Japan) and a cable system ().\nShe regained th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old man with abdominal pain and diarrhea was admitted to the in-patient service at a Department of Gastroenterology in September 2014. The symptoms had reportedly been present for 2 months. The frequency of defecation was 3 or 4 times a day, and there was no mucus or blood in the stool. No family history of inflammatory bowel disease was reported by the patient. His body mass index (BMI) was 15.8 at the time of admission. Follow-up workup included computed tomography (CT) enterography (CTE), colonoscopy, and regular blood tests. The erythrocyte sedimentation rate (ESR) was 42.4 mm/h, serum C-reactive protein (CRP) was 65.2 mg/L, the leukocyte count was 11.64 × 109/L, and hemoglobin was 111 g/L. In CTE the ascending colon was thickened, and there was effusion and enlarged lymph nodes around the colon. Segmental lesions were detected via colonoscopy. Polypoid proliferation was found 45 to 48 cm from the anus and was more severe at 60 cm. Bowel stenosis was found approximately 70 cm from the anus. Chronic inflammation was evident in multiple biopsies. No erosions or ulcers were detected via peroral small bowel endoscopy. A diagnosis of CD was made, with a Clinical Disease Activity Index (CDAI) score of 240. The patient refused to take corticosteroids or biological agents reportedly based on consideration of potential side effects. Mesalazine was then administered at a dose of 1 g 4 times a day for 2 years. His abdominal pain was relieved, but his defecation pattern was similar to that on initial admission.\nThe patient was readmitted to the in-patient service in September 2016 due to severe abdominal pain and ongoing fever that he reported he had been experiencing for 1 week. His temperature was >39 °C. Masses could be felt via palpation at the right groin area and right posterior superior iliac crest. ESR and CRP were substantially"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-yr-old addict man was referred to our institution with an 8 month history of chronic pain in both groins aggravated by weight bearing sometimes keeping him awake at night. He had previously normal activities without specific sport or job program. By disease onset, His activities were restricted because of the pain and decreased range of motion. About 4 months before operation, the patient was visited by a physician who took a plain pelvic radiograph which revealed displaced left and non-displaced right femoral neck stress fracture (Fig-).\nAfter 8-month, because of low socio-economic state and not appropriate follow-up by him, finally, the patient was referred to us with displaced bilateral hip fractures (Fig-).\nOn examination, his weight was 65 kilograms and both active and passive motions were painful and restricted. Active straight leg raise was not possible on either side. No limb-length discrepancy was observed because of symmetrical nature of the deformity.\nThere was no evidence of any underlying metabolic or endocrine disease affecting the bone strength in physical examination or family history.\nIn laboratory tests, CBC, ESR, alkaline phosphatase, serum calcium, phosphorus and serum total protein levels were normal. Normal Parathyroid, thyroid, renal, gonadal and liver function tests were detected. 24-hour urinary excretion for calcium and phosphorus was also within normal ranges.\nBecause of long period of immobilization and lesser activities, which decreased bone density, we did not consider bone densitometry for him.\nSkeletal bone scan with TC-99m showed no other abnormal findings except bilateral femoral head osteonecrosis and bilateral femoral neck fracture (Fig-).\nSurgery was performed using general anesthesia with the patient lateral on a conventional operating table for both right and left hips at one section choosing posterolateral minimal incision approach. The cartilage of the acetabulum was intact and heads of the femurs were decided to be repl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year old asymptomatic male was admitted to our institution after referral from his cardiologist in an outpatient care clinic, where he was monitored because of a dilated aortic root (46 mm). This was an incidental finding by transthoracic echocardiography (TTE) 6 months earlier at presentation due to non-specific chest pain. Except for hypertension, the patient had no other history of disease. Now 6 months later, the most recent TTE did not only show an increase in the aortic root diameter (50 mm), but also a hypo-echogenic structure in the right ventricular cavity (). The latter was interpreted as a right ventricular thrombus, position-wise possibly related to the tricuspid valve. Moreover, because of the rapid increase of the aortic diameter (4 mm in 6 months), the patient was referred to our hospital where a regular non-gated computed tomography angiography (CTA) scan was performed for acute aortic pathology. At the initial evaluation of the scan there was no suspicion of acute aortic pathology besides the dilation. After this CTA, the patient was discharged home with the intention to perform magnetic resonance imaging (MRI) a week later to determine the nature of the right ventricular structure. However, upon review of the CTA the next morning there was a suspicion of aortic dissection, based upon a possible tear in the aortic root. The patient was readmitted urgently for a new and dedicated electrocardiogram-gated (ECG-gated) cardiac computed tomography angiography (CCTA) scan () on which a structure of hypodense tissue was observed to derive from the sinus of Valsalva of the NCC bulging into the right ventricular cavity with involvement of the perimembranous septum. This suggested it to be a SVA filled with thrombus. As there was no continuation of contrast from the aortic root to the right ventricular cavity, a rupture was highly unlikely. However, given the potential risk for rupture with the rapid increase in aortic diameter and the thrombus suggesting"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy presented to Fujian Medical University with giant scrotal elephantiasis and swelling of both lower extremities. The penoscrotal edema began fifteen years earlier, soon after his birth, and it resulted in bilateral lower extremity edema with the penis becoming buried by the scrotum. His scrotal size was massive, and for the past 5 years, the glans penis was not visible nor palpable (Fig. a–c). He had undergone circumcision 13 year earlier and had no history of travel in filariasis-endemic areas. There was also no family history of scrotal elephantiasis or known genetic disorders.\nUpon examination, the patient had a massively enlarged scrotum, with a volume of approximately 16 cm × 13 cm × 7 cm. The anatomical structures and urethral orifice were visible as a deep depression on the scrotum. Both lower extremities exhibited generalized swelling, which was especially noticeable on his ankles. His thigh circumference was 52 cm on the left and 56 cm on the right.\nTissue biopsy of the lower extremities was performed 13 years earlier and revealed lymphangioma and connective tissue hyperplasia. A urinary system ultrasound examination was performed 14 months prior to presentation at our hospital, which confirmed diseased subcutaneous scrotal soft tissues with no abnormalities in the bilateral testicular morphology and blood supply. The results of lower limb lymphoscintigraphy demonstrated that the lymphatic drainage of the lower extremities was obviously tardy. The development of bilateral inguinal and iliac lymph nodes was obviously tardy (Fig. ). The lower limbs and anterior pelvic position was imaged after injecting with the tracer (99mTc-SC) subcutaneously between the first and second toes. The images demonstrated that the lymphatic drainage in both lower extremities were unclear. In the early stage, the images showed that the bilateral inguinal and iliac lymph nodes were blurred, which was obvious on the left side. The concentration of imaging agent (99"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4.5-month-old female presented to hospital with a 2-day history of watery diarrhea and fever developed in the 12 hours before admission. The infant was reported to have had 10 watery stools over the previous 24 hours, during which she became quite unsettled, crying a lot, whilst drinking half her usual amount of liquids. There was no history of vomiting.\nHer medical history revealed delivery at term via emergency cesarean section due to severe fetal distress, with a birth weight of 2910 g. Her Apgar score was 0-1 at one and five minutes, respectively, after delivery requiring tracheal intubation and transfer into neonatal intensive care unit. She was put into induced coma and active hypothermia for 72 hours. The infant was extubated on the fourth day of life, followed by reestablishment of enteral nutrition by day 5. She was fed exclusively on formula milk from birth. An MRI performed on day 5 showed signs of severe hypoxic-ischemic encephalopathy. Followup after discharge was very irregular and the infant did not receive any vaccines up until the current hospitalization episode. Her weight curve was a reason for concern; indeed, her weight two weeks before the current admission to hospital was 4390 g.\nOn the day of presentation, physical examination revealed an alert but irritable and ill-appearing infant with a temperature of 39.9°C, heart rate between 170 and 190 beats/min, respiratory rate between 40 and 80 breaths/min, blood pressure of 102/55 mmHg, and oxygen saturation by pulse oximetry of 100%. The child's weight at admission into hospital was 3990 g, meaning she lost 10% of the previous reported weight. The skin was pale grey, tenting skin turgor, dry lips and dry buccal mucosa, normal looking eyes but reduced tears, soft fontanele, and capillary refill time of 3 seconds. The urine output was also decreased. Heart and lung examination were normal except for tachycardia; the abdomen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 83-year-old man underwent surgical excision of a malignant peripheral nerve sheath tumor (MPNST) at the right knee at another hospital and was then referred to our hospital for further chemotherapy. Three months after the start of chemotherapy, the patient complained of severe pelvic and low back pain. A PET CT was performed which showed multiple bony lesions with a variable (moderate to high) degree of metabolic activity raising suspicion that these were metastases. The lesions, however, had a very unusual appearance and evolution as seen on CT.\nInitially, the lesions presented as small rounded lytic lesions with a well-defined sclerotic margin (Figure ). They exhibited a rapid growth but the initial appearance of central lysis and surrounding sclerotic margin was preserved. Follow up PET CT scan was performed after seven weeks to evaluate the response to chemotherapy. It revealed a second concentric band (halo) around some of the lesions. This band (halo) had a ground-glass appearance and was surrounded by a second sclerotic rim. This rim was thinner and less sharply demarcated than the more central rim (Figure ). The multiple lesions were in different phases of evolution and as such had a different appearance at any given time.\nPresence of multiple lesions, a known primary tumor and moderate to high uptake of FDG tracer on PET scan (Figure ) suggested metastatic disease, despite the unusual appearance of the lesions.\nOther bony metastases were also evident on CT. Some were entirely sclerotic and a few had an ill-defined lytic appearance. Collapse of a vertebral body and fracture of the upper endplate of another vertebra due to metastases were also present.\nBone biopsy of a lesion with the above described doughnut appearance located in the left pubic bone was performed. A biopsy was obtained in the central lytic area and another biopsy in the peripheral halo (Figure ). Histological evaluation of both the samples showed infiltration of bone marrow by malignant s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman presented with acute memory disturbance and headache. During the afternoon of the day of presentation, she did not have any complaints while she was at work. After finishing work, she drove home. By the time she arrived at her home, she developed a headache and nausea. Her husband noticed that her memory was severely disturbed and called an ambulance.\nIn the emergency department, she complained of headache and nausea but denied any visual disturbances. Her blood pressure was 187/100 mmHg, and her pulse rate was 77 beats per min. The remainder of the physical examination was normal. Neurologically, she was alert and oriented with respect to place and person but disoriented with regard to time. She was unable to acquire new information and to recall the events that occurred during the same or previous day. She repeatedly asked the same questions. Her remote and working memories were intact, and she showed no loss of personal identity. Her speech and reasoning were intact. There was no visual field defect, and the other neurological examinations were normal.\nHer laboratory tests, including those of the cerebrospinal fluid, were normal, and her brain magnetic resonance image (MRI) () was interpreted as normal. She was suspected of having a diagnosis of TGA. However, because we were concerned about her high blood pressure along with the headache and nausea, we treated her hypertension with nicardipine, observed her in the emergency ward, and planed a follow-up MRI looking for punctate high intensity spots in hippocampus on diffusion-weighted images (DWIs), the diagnostic finding for TGA. Subsequently, over the next 9 h, her blood pressure returned to normal, and her amnesia improved. She no longer had nausea. By the next morning, her amnesia had completely resolved, although there was a gap in her memory during the episode. The DWIs () of the brain MRI on the same day were normal, but the fluid attenuation inversion recovery ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old woman presented to her gynecologist with 6 months of increasing abdominal cramping and marked distention despite a 35-pound intentional weight loss. She denied other systemic or gastrointestinal symptoms. Her medical history was notable for in vitro fertilization resulting in twin pregnancy 7 years prior. She was otherwise healthy with a body mass index of 27 and not taking any medications. Physical examination was remarkable for a non-tender, but firm and distended abdomen with palpable findings suspicious for a large mass. Lower extremity edema was not identified in either leg suggesting that the mass was not compressing the iliac veins and likely superior to the pelvis. All laboratory testing, including serum hCG, was within normal limits.\nComputed tomography (CT) scan of the abdomen and pelvis revealed a large heterogeneous, hypodense mass measuring 27 cm x 20 cm x 13 cm with irregular, central solid-enhancing components (Fig. a, b). Based on cross-sectional imaging, the mass appeared distinct from the uterus, without associated ascites or lymphadenopathy. An ultrasound-guided core biopsy demonstrated an admixture of mature adipocytes and spindle cells. Immunohistochemical staining showed diffusely positive for smooth muscle actin, desmin, and estrogen receptor, but was negative for HMB-45 (Fig. c–g). Taken together with the imaging findings, the histopathological characteristics confirmed a diagnosis of lipoleiomyoma.\nGiven the symptomatic nature of the mass, the patient underwent exploratory laparotomy to resect the tumor. Upon entering the peritoneum, the mass was immediately identified and encompassed most of the abdominal cavity. The tumor appeared to originate below the inferior border of the stomach with attachments to the mesentery and omentum and displaced the transverse colon into the pelvis. The tumor was well vascularized with feeding arteries from the mesentery and a large draining vessel to the superior mesenteric vein. Grossly, the t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.\nHis vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 52-year-old man who presented to our outpatient clinic complaining of a painful lump in his left lateral abdominal wall. The patient noticed the development of a small nodule about one year ago, and he also stated that the lump was gradually increasing in size. The patient did not refer any previous abdominal trauma or any further pathologies. Palpation revealed a 4 × 5 cm nodular mass protruding through the left upper lateral abdominal wall. The mass was firm, tender, and not fix to the skin of the abdominal wall.\nComputed tomography (CT) scan of the abdomen with contrast revealed a 32 × 45 mm cystic mass located between the external and internal oblique muscles (). Abdominal Magnetic Resonance Imaging (MRI) demonstrated a well-circumscribed 4 × 5 cm cystic mass, arising in the abdominal wall. The lesion was hyperintense on T2 (), and fat-suppressed sequences suggested cystic degeneration (). Clinical appearance and radiological findings were not specific for a particular entity. Our differential diagnosis included a chronic haematoma or a cystic tumor of the abdominal wall.\nThe patient underwent total resection of the mass under local anaesthesia (). The choice of local anaesthesia was based on the patient's preference, the small size of the tumor, and the fact that it was located at the abdominal wall. During the operation, the tumor was intermuscular and found between the external and the internal oblique muscle. The mass was not strongly attached to the surrounding tissues and was easily mobilised and excised in healthy margins. He was discharged the following day in excellent clinical condition.\nMacroscopic examination of the resected specimen revealed a well-circumscribed nodular mass measured 6.5 × 4.5 × 3.5 cm (). Histopathology findings were characterized by interlacing bundles of spindle cells of varying cellularity and peripheral lymphoid cuffs (Figures –).\nThe neoplastic cells were immunoreactive with S-100 protein () and vimentin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 10-year-old boy with a 1-year history of a restrictive eating disorder with agitation during meals. He had no noteworthy developmental history. He showed body image distortion and obsessive fears of being fat, but he did not exhibit depressive mood, hallucinations, or delusions. Physical examination was normal with the exception of emaciation. Laboratory investigations, echocardiography, head computed tomography (CT), chest CT, and abdominal CT demonstrated no abnormality. In September 2009, he was hospitalized because he was refusing all meals and his weight had fallen from 26 kg to 22.8 kg (71% of ideal body weight [IBW] for his height of 134.2 cm). We consequently started enteral feeding. He gained 7 kg and maintained his weight; however, he became agitated during enteral feeding and continued to refuse to eat. We started olanzapine for the body image distortion and agitation during meals but discontinued it in December 2009 because of over-sedation.\nIn April 2010, we started risperidone 1 mg/day. Thereafter, the agitation during enteral feeding and his complaints based on body image distortion diminished. After 1 month (6 months after hospitalization), he resumed meals. No side effects of risperidone were observed and his growth was good in the month after it was started. However, we stopped risperidone in June 2010 at his mother's request. One month after doing so, the patient's abnormal eating behaviors deteriorated and he stopped eating meals. In July 2010, we resumed risperidone 1 mg/day and his abnormal eating behaviors diminished. One month later, he resumed meals. No side effects were observed and his growth was good during the next two months. However, after this period he refused risperidone because he believed it was making him fat. His abnormal eating behaviors deteriorated again, and after one month he again stopped eating. In October 2010, we started RLAI 12.5 mg/2 weeks, as he refused to take risperidone orally but accepted the in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMrs D was a 36-year-old female patient diagnosed with metastatic triple negative breast cancer (stage T4b N3 M1). The patient had undergone 7 cycles of chemotherapy before being referred to and managed by the pain and palliative care team. Metastases had spread to her cervico-dorsal, lumbar and sacral vertebrae and bilateral pelvic bones. On presentation to the pain control out patients department (OPD) she had severe pain in her head and neck, and was admitted to the inpatient palliative care unit for analgesic titration and control of nausea and vomiting.\nThe patient was already on anti-sickness medication (Ondansetron); further management of nausea and vomiting included the introduction of a proton pump inhibitor (Pantoprazole) as well as advice on diet and patterns of eating.\nThe management of the patient's pain was more complex, and can be framed in the context of total pain [].[]\nPhysical pain control was managed as per the WHO pain ladder.[] The patient was already on step 3 of the ladder, so her morphine dose was increased from 20 mg every 4 h to 30 mg every 4 h. Due to her head and neck pain, an MRI was done. This was discussed at a cross-disciplinary meeting with the radiologists to clarify what the progression of the disease was and what would be the most appropriate way to move forward with management. Although the progression of disease was such that treatment was no longer an option, a decision to give radiotherapy was taken as a palliative measure in order to prevent spinal cord compression and its complications, as well as to relieve pain and preserve function.[] As an adjunct to this, the physiotherapists provided advice on movements of the head and neck, and also a neck brace.\nThe patient's social problems had started when she first fell ill. She had to leave her job of making clothes and therefore lost some of the family income. Her brother and husband were also missing"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n34 years old patient, Gravida 6 Parity 3, previous 2 miscarriages (18 weeks & 12 weeks), was seen first at 23 weeks 4 days of pregnancy. She had undergone previous 3 cesarean sections and an evacuation of retained products of conception by curettage in 2013 for partial hydatidiform mole. At 27 weeks 5 days, she was admitted for vaginal bleeding. On further evaluation by ultrasound (), the diagnosis of placenta percreta was made (later confirmed by MRI). At 29 weeks, she had constipation with 2 episodes of urinary retention and she was put on continuous bladder drainage. She developed urinary tract infection and treated with appropriate antibiotics based on culture sensitivity. She continued to have repeated bouts of vaginal bleeding of varying amounts and severe constipation from 31 weeks of gestation.\nAt 32 weeks 4 days, patient underwent cystoscopy, which had shown signs of cystitis with no definite infiltration. She underwent classical cesarean section under combined anesthesia (Epidural + General). The umbilical cord was tied near insertion and the placenta was left in situ because there was no spontaneous separation. Then, the uterus was closed. Prophylactic temporary bilateral internal iliac artery balloons were inserted and inflated earlier. Uterine artery embolization was performed post cesarean section and selective angiograms confirmed adequate positioning. The patient required large volume of particles and still had incomplete embolization with the lower part of the uterus still showing some unblocked branches on both sides.\nPost-operatively, she was transferred to labor ward and within 4 hours, she developed clinical features of pulmonary embolism (PE). Some of her symptoms included drop in O2 saturation to 81%, tachycardia, chest pain, peripheral cyanosis, and signs of respiratory distress. Then, she was transferred to ICU and was initiated on heparin infusion. On chest X-ray, she had no atelectasis, pneumothorax, or pleural effusion. An immediate CT sc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA female patient aged 58 years presented to a tertiary cancer care unit with a history of bleeding from the vagina and low back ache since 4 months. On clinical evaluation, patient’s general condition was good, and per vaginal examination revealed a cervical growth with left parametrial involvement not up to the pelvic wall. Biopsy of the cervical growth showed a nonkeratinizing squamous cell carcinoma []. Her cystosigmoidoscopy was normal. Final diagnosis was carcinoma of the cervix, FIGO – International Federation of Gynecology and Obstetrics – stage 2B. The patient received external beam radiotherapy 50 Gy/27 fractions followed by high dose rate intracavitary brachytherapy (3 sessions each of 7 Gy) from October 31, 2008, to January 23, 2009. The patient was cured on clinical and radiological evaluation and was on regular follow-up.\nFour months after the treatment, on follow-up evaluation the patient gave a history of lump in the left breast. On examination, a lump measuring 8 × 7 cm was palpable in the upper outer quadrant of the left breast with no evidence of skin or chest wall invasion. Mammographically, a high-density mass with ill-defined margins was noted in the upper outer quadrant; no calcification was noted. On ultrasonographic correlation, the mass was hypoechic with internal vascularity. Tru-Cut biopsy of the lump was done and histopathological examination showed features suggestive of an infiltrating ductal carcinoma with negative estrogen and progesterone receptors. Her primary site was clinically evaluated and was normal. A diagnosis of breast carcinoma as second primary was made and the evaluation was initiated on the same lines.\nAs a part of metastatic work-up and to know the status of the primary carcinoma, a positron emission tomographic scan was done which showed uptake in the left breast and left lung. Her bone scan and ultrasonography (USG) of the abdomen were normal. Chemotherapy for metastatic breast carcinoma was planned. The patient recei"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male was admitted to the emergency department with complaints of acute onset severe abdominal pain and vomiting for three days. He was earlier evaluated and treated at a local hospital where he was kept on conservative management with insertion of nasogastric tube for 24 hours. But his symptoms were further aggravated with increased bouts of vomiting; as a result he was referred to our institute for further management. The patient had no history of similar attack in the past. He did not report any fever, dysuria, and change in bowel habit or hematochezia. There was no history of any comorbid illness, past surgical intervention, or trauma. On general examination, pulse rate was 98/minute and blood pressure was 130/80 mm of Hg. Patient was afebrile and tachypneic. Abdominal distension and tenderness were detected on abdominal examination. Bowel sounds were decreased. Digital rectal examination was normal. Rest systemic examination revealed no abnormality. Abdominal radiography in the upright position showed dilated small intestinal loops with multiple air-fluid levels suggesting intestinal obstruction. Ultrasonography of the abdomen revealed gaseous distension of the bowel loops. Routine blood investigations were within normal limit.\nThe patient was planned for exploratory laparotomy in view of acute intestinal obstruction. On laparotomy, a loop of ileum was found to enter the retroperitoneum through a hernia gate (defect of 2.5 cm) located lateral to the sigmoid colon in the left paracolic gutter (Figures and ). The small intestinal loop was incarcerated at the neck of the hernia sac which was reduced after widening the hernia gate. The segment of intestine was found to be viable after reduction for which resection was not required. The hernia gate was closed with nonabsorbable interrupted suturing (). There was no malrotation of the gut. Postoperative recovery was uneventful and the patient was discharged on the sixth postoperative day. He is now on fo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old female patient reported to the Department of Periodontics, People's College of Dental Science and Research Centre, Bhopal, with a history of swelling in the upper lip and gums since last six years. Patient gave history of trauma during playing six years back, which resulted in laceration of upper lip, for which a local doctor was consulted. This was followed by appearance of swelling in the upper lip which increased gradually in size and was constant since the last two years. Patient also gave a history of swelling and spontaneous bleeding from the gums, because of which she refrained herself from oral hygiene maintenance.\nIntra oral examination showed generalized gingival hyperplasia with maxillary arch with a typical bluish purple gingiva at the interdental areas of 11 and 21; associated with grade I mobility Also, localized gingival enlargement was present in relation with mandibular incisors and canine [Figures –]. Generalized bleeding was observed at slightest provocation of gingiva. No abnormalities were detected on general systemic examination, and hematological investigations which included a coagulation profile. Orthopantomogram was also inconclusive [].\nPeriodontal treatment which was initiated with phase I therapy using hand instruments resulted in spontaneous brisk bleeding which was difficult to control. The bleeding site was suctioned and severe hemorrhage was controlled by digital pressure which took no less than 20 to 25 minutes. Because of the severe nature of hemorrhage encountered, some type of vascular abnormality was suspected and the patient was referred to physician for opinion.\nUltra sonography of the upper lip was performed which showed marked thickening of upper lip with multiple dilated vascular channels in the submucosal layer of upper lip. Dilated and enlarged arteries were seen with marked increase in systolic and diastolic flow predominantly on left side of midline. The findings were suggestive of post traumatic AVM [].\nA"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male patient was presented to us with a huge swelling measuring 35 cms in greater dimension arising anteriorly from the neck more on the left side which was hanging up to the umbilicus (). The swelling was painless, slow growing and had acquired the present size in approximately 20 years. There was no history of treatment in the past. Patient was completely asymptomatic, except for ulceration of the overlying skin. On palpation, the swelling was smooth, painless and non-tender. Skin over the swelling was stretched, shiny and showed ulceration over the lower most part. There was no lymphadenopathy or any other palpable mass.\nENT examination of the patient was normal. Thyroid hormonal evaluation showed no abnormality. On ultrasound, the “mass” was iso-echoic with subcutaneous fat. It laid in front of the left lobe of the thyroid which was normal in size and echogenicity and moved freely with swallowing under the mass. The mass appeared to have an ill-defined capsule with several thin echogenic septa seen coursing through the substance of the mass. The ultrasound findings were suggestive of a soft tissue lesion. Computed tomography (CT) scan of the neck showed a hypodense mass in the left side of the neck with fat density, measuring 17×9 cm with multiple internal septations.\nIt originated in the left anterior triangle of the neck and extended up to the upper chest cavity. The mass was seen to be causing mild pressure effects with displacement of left parapharyngeal and oropharyngeal spaces. The trachea and the major vessels were displaced to the right and both the lobes of the thyroid seemed normal. Findings were suggestive of a soft tissue lesion possibly lipoma. A fine needle aspiration was performed and samples were taken from multiple levels of the swelling for adequate and representative cytological material.\nAll cytological smears yielded mature adipose tissue fragments. In view of ultra-sonographic finding and CT evaluation, a diagnosis of giant su"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 24-year-old male, Igbo by tribe, and an undergraduate, resident in Enugu, Southeast Nigeria. He was referred from the Enugu State University Teaching Hospital staff clinic on account of persistent hiccups of 4 days and confusion of 2 days' duration. The patient was in apparent good health until about 14 days before presentation when he was involved in a road traffic accident, in which he sustained minor blunt injuries, bruises, and lacerations but no fractures. On presentation, he was seen, admitted, and managed by the General Surgical Unit of University of Nigeria Teaching Hospital, Enugu, Nigeria. Four days into the hospital admission in the surgical unit, he developed progressive weakness and worsening of the body pain, and hiccups which became so severe that the patient could not eat without fear of discomfort. As a result of the weakness, he was unable to walk around or bath himself. Two days later, the patient developed nausea and recurrent vomiting, which smothered on until he developed progressive confusion and altered sleep pattern. The patient later developed facial puffiness which was closely followed by bilateral swelling of the legs. The leg swelling progressed to the thigh; he had no associated fever or seizures. His urine volume was noticed to have reduced and a collected urine sample turned dark brown after 6 h. There was no history of hematuria or frothy urine. He had no bleeding from any orifice. There was no history of hypertension or diabetes mellitus. He had no known risk factor for muscular disease from history obtained, and there is no family history of muscular disease.\nPhysical examination revealed an acutely ill-looking young male. He was in respiratory distress, was afebrile (temperature 37.1°C), not pale, and not anicteric. There was no significant peripheral lymphadenopathy. He had bilateral pitting lower limb edema. Asterixis was present.\nThe significant observations on examination of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41 years old Egyptian male with an unremarkable past medical or surgical history presented to the King Saud medical city emergency department, with two days history of abdominal pain, associated with nausea, vomiting, and abdominal distention. The pain was colicky and started gradually without any bowel motion or flatus for two days. The drug and family history was unremarkable. Patient had tachycardia, with normal blood pressure and oxygen saturation of 100 % in room air. The abdomen was found to be distended and tender all over with an empty rectum by digital rectal examination (DRE). Upright chest and abdominal X-ray showed multiple air fluid levels with no air under the diaphragm (). CT abdomen showed a dilated proximal small bowel loop and a picture of SBO at distal ileal loops (). The patient resuscitated with intravenous (IV) fluids and kept nil per os (NPO). A nasogastric tube was inserted, and the patient was shifted to the operating room. Laparoscopic exploration showed dilated small bowel loops with collapsed distal ileum and an inflammatory band was found 20 cm from ileocecal junction originating from a small bowel diverticulum with no palpable intraluminal masses (). The inflammatory band was present at the distal part of the diverticulum and was adhered to a small bowel segment leading to obstruction. The band was released, and wedge resection of the diverticulum was performed at its base by gastrointestinal anastomosis (GIA) on healthy tissue, about 2 cm from the inflamed segment, which is a standard surgical approach for MD. The postoperative period was uneventful. The patient was initially kept at regular surgical floor bed and then discharged on the second postoperative day, when he passed good bowel motion. The histopathology result on follow up visit showed MD with Schistosoma infection, most likely by Schistosoma mansoni. The patient was referred afterwards to the infectious disease department for initiation of praziquantel, which is the drug"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a 25 years old Malay girl with learning disability and no significant past medical history, who started noticing a sacral mass since August 2015. The mass was painless and gradually increasing in size. The family members of this patient brought her to a traditional healer. They did not seek any medical treatment until late 2017. By this time, the mass over the sacrum was extremely large. Family members claimed the mass was preventing the patient from lying down flat supine. The patient was also unable to ambulate for the past 2 years. Hence, she was bedbound most of the time. It was difficult for her to sit on the wheelchair. She also felt tired to move because the mass was quite heavy. The family members claimed when the patient was lying down flat, she had to flex her hips and knees to achieve a more comfortable position. In addition, she often slept either in prone position or in supine with multiple pillows below her body. The mother also claimed over the last 2 months, the patient’s body had been getting thinner despite her physical weight was increasing due to the increase in size of the sacral mass. The patient had been passing stool and urine in pampers. There was no past medical history and no family history of cancer. Socially, the patient lived with her mother and siblings. The mother was the main care taker. Her father passed away 10 years ago because of heart attack. The patient previously attended a special needs school, but she stopped going to school since 2015 after developing the sacral mass.\nThis patient was managed in the Southern Region referral centre for Orthopaedic Oncology in Malaysia. On clinical examination in the Orthopaedic Oncology ward, the patient appeared cachexic, she had slightly pale conjunctiva, but she was not dysmorphic. Vital signs were Blood Pressure 142/90, Pulse Rate 98 beats per minute and Temperature 37 degrees Celsius. There was a large mass 40 cm × 30 cm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old woman presented to our outpatient clinic complaining of a small indolent tumor on the tip of the nose which was slowly progressing in size. She did not mention any other symptoms ().\nThe clinical examination showed a nodule measuring about eight millimeters which was located on the upper border of the right nostril where the medial crus of the alar cartilage bends to reach the lateral crus. There was an additional subcutaneous expansion towards the tip of the nose and the columella. The lesion was hemispherical, immobile, sharply demarcated, nonirritated, and indolent. Further head and neck examination including laryngopharyngoscopy and cervical sonography did not reveal any other disorder.\nThe absence of irritation was not consistent with an acute infection. Because of the sharp demarcation, the smooth surface, and the lack of ulceration a primary malignancy was also unlikely. For a better diagnostic classification a histopathological diagnosis was necessary. Using local anesthesia we performed an excision biopsy. Via a small incision, a complete resection of the tumor and its surrounding capsule was possible. Crossing the midline, the lesion expanded into the subcutaneous tissue between the medial walls of the alar cartilages. However, the tumor did not macroscopically infiltrate the surrounding structures. After primary closure and uncomplicated postoperative wound healing the local status was cosmetically unremarkable.\nThe histopathological examination revealed fibrous connective tissue which was partly covered by an intact nondysplastic squamous epithelium. The corial connective tissue was infiltrated by nonkeratinizing squamous cells with pleomorphism of size and nuclei. These findings corresponded to a moderately differentiated squamous cell carcinoma ().\nThe clinical and histopathological findings, especially the nodular form, the intact epithelium covering the lesion, and the missing infiltration, were not consistent with a primary malignancy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 53-year-old male who worked as a coal miner. In spring of 2017, he noticed enlarging scalp nodules and right hip pain. He also complained of fatigue but was otherwise asymptomatic. Because of the hip pain and nodules, he came to the emergency department where a CT scan showed an enlarged right frontal scalp mass that measured about 4 cm (). MRI also revealed a right frontal scalp mass and extensive vasogenic edema localized to the right frontal lobe with a 5 mm midline shift at the foramen of Monroe (). A subsequent CT chest, abdomen, and pelvis was performed and showed a lytic lesion in his ilium and a single enlarged right hilar lymph node (not shown). A follow-up nuclear medicine bone scan demonstrated multiple areas of increased uptake concerning for metastasis (). One of the largest areas was in the right frontal scalp. After discussion with the patient and the need for a definitive diagnosis, he was consented for subtotal resection of the right frontal scalp mass.\nHe was taken to the operating room where a right frontal scalp incision was performed for subtotal resection of likely metastatic cancer. The mass was primarily located within the right frontal scalp but extended through the skull into the right frontal cortex. It did not however appear to be involved with the brain parenchyma. The resection consisted of removing scalp mass and taking a core biopsy from the specimen. Histopathology of the biopsy showed a diffuse and monotonous infiltrate composed of small cells with irregular nuclei, condensed chromatin and inconspicuous nucleoli (). On immunohistochemistry, the cells are CD20 positive B-cells and co-express CD10 and Bcl-2 but do not express CD3, 5, 23, 43 and cyclin D1 (). CD21 was present highlighting a disrupted follicular dendritic cell meshwork. Ki-67 proliferation rate was low (less than 20%). By flow cytometry, a dim kappa light chain-restricted B-cell population was identified expressing CD10. The FISH assay revealed t(14;"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male patient reported to our institution with a complaint of pain and swelling in the lower right jaw region for the past 3 months, which was increasing in size. No history of trauma was elicited. Extraoral examination revealed a nontender, diffuse, hard swelling of size 6 cm × 2.5 cm on the right side of the jaw extending 2 cm from the midline till 2 cm anterior to the angle of the mandible. Paresthesia was present in the same region. Intraoral examination revealed a swelling in the vestibular region which was soft, fluctuant and nontender.\nRadiographic examination revealed a well-defined unilocular radiolucency of size 3.5 cm × 4 cm having irregular margin extending from 43 to 46 region. Another well-defined radiolucency of size 2.5 cm × 2.5 cm was seen on the left parasymphysis region extending up to 35 region []. Both the lesions were enucleated and specimens were sent for histopathological examination.\nHistopathological examination of the lesion on the left side of the jaw showed multinodular proliferation of spindle-shaped and cuboidal cells. Numerous scattered duct-like structures were also seen which were lined by cuboidal to columnar cells and lumen filled with eosinophilic material exhibiting characteristic histological findings of AOT.\nHistopathological examination of the lesion on the right side presented unusual features. The lesion showed a large cystic lumen surrounded by odontogenic epithelium, predominantly cuboidal cells showing ductal or glandular pattern []. Numerous follicles lined by cuboidal and columnar cells with centrally placed stellate reticulum-like cells with thin rim of eosinophilic material were seen []. Anastomosing cords of epithelial cells with peripheral tall columnar cells intermingled with areas of spindle-shaped cells were also seen []. Supporting connective tissue was highly vascular containing large areas of extravasated red blood cells, few chronic inflammatory cells and numerous multinucleated giant cells peri"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old Korean male was admitted due to 3 days′ history of hematochezia. Two weeks earlier, he had visited the outpatient clinic due to intermittent dull left lower quadrant pain and loose stool of 3 months′ duration. He had mild exertional dyspnea. Faint pansystolic murmur was audible along his left sternal border. A firm tender mass of 3–4 cm in size was palpable at his left lower abdomen. Colonoscopy revealed a small pedunculated polyp on the cecum and another small sessile polyp on the sigmoid colon The two polyps were removed with polypectomy. The mucosal folds were hypertrophic and the lumen was slightly narrow over a long segment of the sigmoid colon. Histologic examination of the removed polyps revealed lymphoid polyps. Mucosal biopsy from the narrow segment of the sigmoid colon disclosed only mild infiltration of chronic inflammatory cells.\nOn admission, his vital signs were stable. Hemoglobin was 11.0g/dl. Upper GI endoscopy was unremarkable. Colonoscopy revealed a small shallow ulceration at the previous polypectomy site on the cecum, and any evidence of recent bleeding could not be noted. Four days later, he experienced mild hematochezia again without any significant change in blood pressure and heart rate. Urgent sigmoidoscopy revealed fresh blood up to the splenic flexure, but the bleeding point was not clear.\nSelective inferior mesenteric arteriography demonstrated abnormal vasculature involving the sigmoid and distal descending colon without active bleeding (). Echocardiography and right cardiac catheterization demonstrated a ventricular septal defect with Qp/Qs ratio of 1.99. On the next day of the cardiac catheterization, he experienced a sudden massive lower GI bleeding and became hypotensive. On urgent laparotomy, a long abnormally hard thickened colonic segment with dilated tortuous vasculature involving the distal descending colon, sigmoid colon and upper rectum was found. Segmental colectomy, including the involved segment, was done. Pos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year old woman was free climbing with her boyfriend near Gunnison, Colorado. Both were wearing a helmet and a harness for safety. The girl had 20 years of experience of rock climbing, being taught early tricks by her father at the age of 8 years. The ascent consisted of three pitches of 90-100 feet (ca. 30 m) each. The climbing distance was defined by the climbing rope which had been fixed at a defined length. The girl took the lead on the third pitch, to a total height of 300 feet (ca. 90 m). After securing the anchor at that height, the rope - which was lacking a security knot - slid through her harness. She then fell a total of 300 feet, with a first impact at 200 feet onto a flat rock surface, and a further fall for about 100 feet. Based on this falling height, the velocity at the time of impact is estimated around 75-80 mph. Her boyfriend witnessed the entire fall, climbed back down and provided first aid at the scene. The patient was awake and moaning, but not responsive to verbal or painful stimuli. She was intubated at the scene and transported to a local level IV trauma center, where she was resuscitated and transfused with 4 units of packed red blood cells (PRBC). Due to ongoing hypotension and transfusion requirements, a decision was made for transfer to our regional level 1 trauma center. On arrival, the patient was intubated and sedated. She was hypotensive, with systolic pressures in the 80s. She was successfully resuscitated with crystalloids and blood products, using a standardized institutional massive transfusion protocol with point-of-care thrombelastography-guided resuscitation [,]. The patient was managed according to the ATLS guidelines for initial assessment and management, and by our institutional \"damage control\" protocols, including the initial spanning external fixation of femur shaft fractures [,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old woman presented to the surgery outpatient department (OPD) with clinical history of right upper abdominal lump for 6-7 years, which was gradually increasing in size. It was associated with dull aching type of pain, which was on and off in nature. There was no history of fever, weight loss, altered bowel habits, or urinary symptoms. Her menstrual history was within the normal limits. There was no history of twin birth or teratoma in the family. Her general physical examinations were within the normal limits. On abdominal examination, as done in surgery OPD, there was a lump involving the right upper quadrant of the abdomen. It had ill-defined margins with soft to firm consistency and irregular surface. It was not moving with respiration. On evaluation, beta-human chorionic gonadotropin (β-HCG), alpha fetoprotein (AFP), and routine blood investigations were found within the normal limits. For further diagnostic evaluation, ultrasonography (USG) was done. Prior imaging examinations were not done in this patient. USG showed a large, ill-defined heterogeneous mass in the right side of the abdominal cavity adjacent to the liver, having multiple hypoechoic areas and echogenic structures with no internal vascularity. With inconclusive diagnosis, she was admitted in surgery ward for further evaluation.\nLater, contrast enhanced CT scan of the abdomen and pelvis revealed a large heterogeneous retroperitoneal mass in the right side of the abdomen, measuring approximately 22.5 × 14.1 × 12.5 cm having cystic areas, fat attenuating areas, foci of calcifications, malformed skeletal parts resembling long bones, ribs and vertebrae, and heterogeneous soft tissue fetal components. Soft tissue components showed minimal peripheral enhancement. The mass was lying predominantly in the posteroinferior aspect of the right lobe of the liver causing its displacement anteriorly and to the left side and extending superiorly up to D8 vertebral body causing superior displacement of t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old Javanese woman presented with urinary incontinence following an abdominal hysterectomy with bilateral salpingectomy 3 months earlier. She is a housewife with no history of routine drug use and no prior history of hypertension, diabetes, allergies, or other chronic disease. She does not smoke tobacco and does not consume alcohol.\nA physical examination revealed that her general condition was good and her vital signs were: blood pressure 112/74 mmHg, heart rate 89 beats per minute, respiratory rate 18 times per minute, and temperature 36.6 °C. There were no abnormalities in her chest and abdomen, or in musculoskeletal and neurological examinations. In a genitalia examination using a speculum, we identified fistulae above her vagina wall that were 1 cm in size. All laboratory findings (that is, complete blood count, liver functions, renal functions, and urine analysis) were within normal limits.\nAfter discussion with our patient regarding the risks and benefits of an open abdominal procedure and laparoscopic approach, we discussed the similarities and differences between the two procedures were her. We chose surgical management using laparoscopic approach with the considerations that it could facilitate precise dissection, offer good visualization, and be minimally invasive, thereby enabling faster recovery.\nOur patient was placed in the lithotomy position and received general anesthesia. A cystoscopy was performed to confirm the fistulae orifice and a stent was inserted into the fistulae tract from her bladder to her vagina. A tamponade was inserted into her vagina up to the vaginal apex, to be able to identify the vagina and prevent loss of pneumoperitoneum. A transperitoneal approach was performed with trocars distributed as follows: The camera was placed through a 12 mm port with 30° down lens located superior to the umbilicus. Two ports for the surgeon were placed on the right side (Fig. ).\nShe had adhesions; therefore, adhesiolysis was performed, us"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old male presented to the Department of Periodontics, Manipal College of Dental Sciences, Manipal, India, with recurrent swelling and pain in the maxillary anterior teeth over the previous 6 months. The pain was dull and slightly increased whenever he used that particular tooth for biting. The patient had fair oral hygiene and was otherwise healthy.\nOn examination, the maxillary right central incisor was found to have a 5 mm pocket mesiolabially and a 6 mm pocket mesiopalatally. The tooth was noncarious and was slightly extruded and proclined []. The incisal edge in the center of the tooth had a notch (abraded). The tooth showed no evidence of fracture and was not tender on percussion. There was no abnormal mobility. The incisal edges of the lower right and left central incisors also showed notching.\nRadiographic evaluation revealed the presence of a vertical defect [] mesial to the right central incisor. An orthopantomogram revealed no periodontal involvement of any other tooth in the arch. When the clinical findings were correlated to the radiographic findings, it was evident that the cause of such localized destruction was either trauma or an endodontic-periodontic lesion. Since the tooth was not discolored and not tender on percussion, we sought for history of possible trauma.\nEnquiries related to his work as an electrician revealed that he often used his incisors to strip the outer rubber coating off electrical wires. He would hold the wire between his maxillary anterior and mandibular anterior teeth and pull the wire, thus removing the outer tubing and exposing the tungsten core.\nIn view of the localized destruction and the recurrent attacks of periodontal abscess, it was evident that the lesion was related to his occupation. Based on the history and the clinical and radiographic findings, we made a diagnosis of chronic periodontal abscess.\nThe relationship between the recurrent attacks of periodontal abscess and periodontal destruction and his profe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old female presented to our health service with one month history of acutely worsening abdominal distention and pain, on a background of six months of non-specific gastrointestinal symptoms which was investigated with an abdominal ultrasound that did not detect any abnormality. Relevant medical history includes vaginal hysterectomy secondary to fibroids, type 2 diabetes mellitus, hypothyroidism, hypercholesterolaemia and hypertension.\nOn history, the main symptoms were abdominal distention and pain with no features of bowel obstruction. The vital signs were within normal limits. On examination, the abdomen was grossly distended with focal tenderness in the upper abdomen. There was a palpable cystic mass which appears of pelvic origin, however, the gynaecological examination was normal.\nRoutine laboratory investigations were normal. Tumour markers, including CA 125, CA 15-3, CA 19-9 and CEA, were all within normal limits.\nA contrast-enhanced CT scan of the abdomen and pelvis was performed, which revealed a large intra-peritoneal cyst measuring 21 × 25 × 26 cm3, containing simple fluid (Fig. ). There were a few thin septations along the periphery with no appreciable nodular or soft tissue components within. The origin of the cyst was not able to be determined due to gross displacement of surrounding viscera. There was associated splaying of the bowel loops without resultant bowel obstruction. No pathologically enlarged abdominal, pelvic or inguinal lymph nodes were noted and there was no vascular compromise. On pelvic ultrasound, the majority of the lesion appeared simple cystic in nature. There was no obvious internal colour flow. Both ovaries were identified and appeared separate from the cyst.\nA laparotomy was performed to resect the cyst for diagnostic and therapeutic purposes (Figs and ). The cyst was noted to originate from the sigmoid mesocolon. No other viscera required resection. The patient made an uneventful recovery.\nMacroscopically, there was a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old female presented to the ED with six days of nausea and vomiting. She also noted feeling progressively weak with xerostomia and lower abdominal pain for several days prior to presentation. Further history revealed that she was a previous vegetarian who over the prior 22 days was attempting to lose weight by eating solely meat and eggs. She reported a 17-pound weight loss over the time period and noted that she was consuming only minimal carbohydrates. She took no medications and denied chronic alcohol use.\nHer vitals upon arrival were as follows: temperature 97.1 degrees Fahrenheit, heart rate 77 beats per minute, respiratory rate 16 breaths per minute, blood pressure 160/106 millimeters of mercury, and oxygen saturation 97% on room air. She weighed 73 kilograms with her stated height of 5 feet 6 inches and had a body mass index of 26. The physical exam revealed dry mucous membranes and a benign abdominal exam.\nThe patient was given two liters (L) of normal saline intravenously (IV) and four milligrams of ondansetron IV for nausea. Labs were drawn due to a concern for abnormal electrolytes as well as her change in diet. Labs revealed an anion gap acidosis with ketosis ().\nIn the ED she received antiemetics, two L of normal saline and an infusion of D5NS at 150 cubic centimeters (cc) an hour, and her symptoms greatly improved. By the time she was admitted to the hospital, her gap had closed to a level of 12. She continued to receive an infusion of 5% dextrose in normal saline (D5NS) at 150 cc an hour as well as insulin subcutaneously on a sliding scale after admittance to the hospital. Her anion gap remained within the normal limits while in the hospital and her insulin was discontinued. After returning to a normal diet, her glucose remained stable and she was discharged after three days with only potassium supplement prescriptions. Since discharge"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old male was referred to the department of oral and maxillofacial surgery for evaluation and management of a left facial mass. He had no other medical problems and no known food or drug allergies. At the age of 15 years, he noticed a mass on his left cheek eminence, which was excised and was told that it was a sebaceous cyst. Three years later, he had a local recurrence of the facial mass that was surgically excised again showing the same pathology. A third recurrence in the same area occurred 4 years later and was excised with the overlying skin. However, at this time the pathology specimen proved to be pilomatrixoma. The mass recurred again few years later and has been growing slowly over the past 3 years prior to presentation.\nClinical examination of the face showed a firm, nontender mass infiltrating the overlying skin of the left buccal subunit measuring about 5 × 3 cm. The overlaying skin had bluish discoloration (). There was no limitation of the mandibular range of motion. Cranial nerve exam was grossly intact. The neck was supple with no palpable masses or cervical lymphadenopathy. Intraoral exam was unremarkable.\nAnother incisional biopsy was done under local anesthesia, which confirmed the diagnosis and ruled out malignant transformation. A contrast enhanced magnetic resonance imaging (MRI) study showed a heterogeneously enhancing mass in the subcutaneous tissues overlying the left platysma muscle at the level of the mandible (). The adjacent musculature and bone marrow maintained their normal signal intensity. The mass was surgically excised including the overlying skin with a safety margin of 1 cm. About 6 × 5 cm skin was marked over the pilomatrixoma and was included in the specimen. The incision was carried through the skin, subcutaneous tissues, and the superficial musculoaponeurotic system (SMAS). The buccal and marginal mandibular branches of the left facial nerve were identified and preserved. The resulting cheek defect measured about 6"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old female patient with a diagnosis of locally advanced invasive ductal carcinoma of the left breast was referred for a staging CT scan of the abdomen and pelvis. The scan was done using a Philips Brilliance 64 slice multidetector CT scanner. Nonionic contrast media (Ultravist 300) in a volume of 100 mLs were administered via pressure injector at a rate of 3.5 mL/min. The liver was found to be normal; however, she had evidence of metastases to the spleen, several vertebrae, and the pelvis.\nAn incidental finding of abnormal arterial branching was noted at the upper abdominal aorta (Figures and ). The left gastric artery originated directly from the anterior surface of the abdominal aorta shortly after it entered the abdomen through the diaphragmatic hiatus. Thereafter, it followed its normal course along the lesser curvature of the stomach. At the level of the first lumbar vertebra, there was a large arterial trunk originating from the anterior surface of the aorta, consistent with the celiacomesenteric trunk described by Ishigami et al. []. After coursing 2.5 cm, the celiacomesenteric trunk bifurcated into the superior mesenteric artery and the coeliac trunk that was unusually long and tortuous (). The splenic artery coursed to the left over the superior mesenteric artery and vein toward the splenic hilum where it divided into segmental arteries to supply the spleen in normal fashion. The left hepatic took an early origin directly off the common hepatic artery and travelled up toward the hilum in a plane superficial to the portal vein but in a more medial position than usual. The right hepatic artery took its origin from the distal gastroduodenal artery behind the pancreatic head to course superiorly in the free end of the gastroduodenal ligament, posterolateral to the portal vein. The bile ducts were normal in calibre and were not well visualized on CT scans. At the hepatic hilum, the left and right hepatic arteries branched in the usual fashion to supply"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old male presented initially to the plastic surgery clinic with a right thumb lesion that had been present for approximately 2 years, and underwent a wide excision with flap closure. Final pathology revealed invasive porocarcinoma, measuring 1.3 cm, with positive margins and dermal lymphatic involvement, and consisted of nests and cord of atypical, mitotically active epithelial cells involving ulcerated epidermis, dermis, and subcutis without bone involvement. The cells exhibited marked nuclear pleomorphism and focal comedonecrosis. Some epithelial nests contained luminal structures, a distinguishing feature between porocarcinoma and squamous cell carcinoma (). Lymphovascular invasion was prominent and extended beyond the main tumor mass to involve the proximal margin.\nWithin weeks of his original surgery, the patient developed a new nodular recurrence at the suture line and subsequently underwent a partial amputation at the distal interphalangeal joint demonstrating persistent porocarcinoma with lymphatic involvement. At that time, a palpable right axillary node was detected and fine-needle aspiration was positive for malignant cells.\nA complete metastatic workup revealed no evidence of distant disease, and he underwent a radical axillary lymph node dissection including nodal levels 1–3; 2/28 nodes were positive with the largest node measuring 3.7 cm. Given the burden of nodal disease, he went on to receive 4800 cGy in 20 fractions of adjuvant axillary external beam radiation.\nSurveillance CT scans at 6 months post lymph node dissection did not reveal any evidence of new metastatic disease; however; within 7 months of surgery, he developed multiple cutaneous lesions with a papular, cystic appearance, located on the right hand and chest ().\nA biopsy confirmed metastatic porocarcinoma. A re-staging CT did not demonstrate any visceral metastasis. Given the new diagnosis of cutaneous metastasis, he was then treated with palliative intent carboplatin and pacli"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old Caucasian female patient was referred to the respiratory clinic with a 6-month history of exertional breathlessness. She gave a history of yearly chest infections, particularly in winter months. She, however, had no history of childhood respiratory problems or any significant respiratory symptoms during her adult life. She had a 30-pack-year smoking history but she quit 25 years prior to presentation. She worked as a nursing auxillary at a local hospital and had no prior asbestosis. She was on a 1 mg maintenance dose of prednisolone for polymyalgia rheumatica. Otherwise, she had no significant medical condition and was not on any regular medications. Her exercise tolerance was unlimited and she enjoyed a good health.\nHer O2 saturation was 95% on room air and her spirometry showed obstructive pattern with FEV1 1.14L (55%), FVC 2.09L (83%) and FEV1/FVC ratio 54%.\nAn initial chest radiograph 2 years prior to presentation suggested an increased radiolucency of the left lung but this was not investigated further (). Serial CXRs 2 years later showed a relatively unchanged appearance of the left hemithorax with progressively increased opacification in the periphery of the middle and lower zones, and accompanying reduction in lung volume, on the right side ().\nThe patient underwent a contrast-enhanced CT of the chest in view of the repeated chest infections and lack of complete resolution to rule out the possibility of an adenocarcinoma in situ or endobronchial lesion, respectively. Cross-sectional imaging was also carried out to assess the possibility of an underlying bronchiectasis in the presence of the recurrent chest infections and to further assess the interstitial changes seen on the CXR on the right side.\nHer CT showed hypoplastic left pulmonary artery (; arrow), attenuated peripheral pulmonary artery branches on the left (: arrows), hyperinflated left lung with air trapping and cystic bronchiectasis of the lingua and left lower lobe (). Features"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old woman with a 6-month history of swelling in the left floor of her mouth was referred to our institution. Although she experienced slight difficulty in swallowing, she did not experience pain or tongue paralysis. Her medical and family histories were unremarkable.\nIntraoral examination revealed a well-defined 3.5 × 3 × 2 cm-sized solid, spherical submucosal nodule adjacent to the sublingual gland; the nodule was covered with light bluish smooth mucus (Fig. ). The patient experienced slight pain when pressure was applied to the tumor. Mobility and sensory functions of the tongue were normal, and no lymphadenopathy in the submandibular region was detected on palpation. All relevant laboratory test results were normal. Enhanced computed tomography revealed a 2.8 × 1.8 × 2.1 cm-sized well-defined, solid, heterogeneous nodule that did not appear to involve the mandible (Fig. ). In addition, a three-dimensionally reconstructed image showed a nodular lesion occupying the left floor of the mouth with abundant blood flow (Fig. ). No enlarged lymph nodes were found in the submental or submandibular regions.\nThe initial clinical impression was a benign salivary gland tumor, dermoid cyst, or benign connective tissue neoplasm. The patient was scheduled for surgery via an intraoral approach. First, an elliptical incision was made around the periphery of the sublingual gland through only the oral mucosa, and a full-thickness tissue flap was prepared along the lingual aspect of the sublingual gland. After the sublingual gland was freed from its surrounding tissue with blunt dissection, a well-circumscribed tumor without capsular extension was found beneath the body of the sublingual gland and located above the submandibular gland duct and lingual nerve. The submandibular gland duct and lingual nerve were carefully freed from the tumor surface, and the complete tumor was excised along with the sublingual gland (Fig. ). The tissue sample was fixed with 10% formalin and s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nSusan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.\nWhen she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.\nIn May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.\nIn August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old woman with no significant medical history presented with abdominal pain for one week. She was tender in the left costovertebral angle and had frequent voiding symptoms without gastrointestinal problems. Routine urinary analysis showed many red blood cells and 20-29 white blood cells per high power field of microscopy indicating renal stone disease. Other laboratory tests were unremarkable. Chest computed tomography (CT) was performed for evaluation of a nodular lesion in the right lower lung field that was detected on routine chest radiography leading to the incidental discovery of a low-density lesion in the left hepatic lobe. While she was admitted to the hospital for treatment of left renal stone disease, further evaluation of the incidental low-density lesion in the left hepatic lobe was performed. Ultrasonography (US) of the upper abdomen demonstrated a 3.1 cm-sized mixed-echoic nodular lesion in segment IV with a hyperechoic rim (). The right portion of the lesion was anechoic (solid arrow) while the left was hyperechoic. An abdominal CT scan revealed a lobulated mass with a cystic component in the right portion of the mass and delayed enhancement in the left which was thought indicate solid component (). Magnetic resonance imaging (MRI) of the liver was performed for further evaluation of the mass. The right side of the mass was seen as low signal intensity while the left side was enhanced on gadolinium-enhanced T1-weighted image (), thus matching to the CT features. However, T2-weighted images showed bright high signal intensity throughout the whole lesion () suggesting that the lesion was composed of aggregated cysts rather than solid tissue. For confirmative diagnosis, the patient underwent gun biopsy using US-guidance, the results of which demonstrated microscopic findings of a sponge-like lesion composed of microscopic cysts lined by attenuated cells resembling those in normal lymphatic ducts (). In addition, the lining cells showed stainin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old Korean male underwent distal gastrectomy for stomach cancer in 1999. Pathology report revealed early gastric cancer. Adjuvant treatment was not offered to the patient. The patient had multiple serious comorbidities including end-stage renal disease, for which patient was on hemodialysis and liver cirrhosis, which was associated with underlying viral hepatitis. The patient underwent regular surveillance with esophagogastroduodenoscopy (EGD) biannually. The patient was also under surveillance with serum alpha fetoprotein, liver function panel, and either ultrasonography or computed tomography (CT) scan of the liver following the Korean national guideline for high-risk patients with hepatocellular carcinoma. There were no signs of recurrence as of November 2016 when the patient had both EGD and CT. On July 2017, the patient visited the emergency room due to a sudden onset of melena. Emergency EGD revealed a 2 cm sized nodular mass in the greater curvature with bleeding (Figure ). Biopsy report showed moderately differentiated adenocarcinoma, identical to initial pathologic diagnosis. Stomach CT revealed a 2-cm sized cancer in the remnant stomach. Primary lesion on CT was suspicious for muscularis propria invasion. However, there was no evidence of lymph node or distant metastasis. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed diffuse hypermetabolism in the stomach without evidence of metastasis elsewhere (Figure ).\nRemnant total gastrectomy was planned for this clinically staged T2N0 recurrent stomach cancer. On open laparotomy, however, severe adhesion was found. Due to high risk of incomplete resection and bleeding risk due to multiple comorbidities, further surgical exploration was not sought. The attending medical oncologist recommended against palliative chemotherapy. The underlying rationale was that the risk of adverse events from the anticipated treatment, including fatal hepatic failure, outweighed the survival benefit. After m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old woman with no relevant past medical history suffered a CA with asystole after collapsing in a shopping mall and falling down a few steps. Spontaneous pulse was recovered after 15 min of advanced resuscitation manoeuvres. She was sedated with propofol, intubated and transferred to the emergency room. The first electrocardiogram (ECG) after hospital admission following adrenaline injection 1 mg was sinus rhythm (). Pupils were symmetric, miotic, and reactive to light. Brainstem reflexes were preserved. Response to pain was absent except for withdrawal in the left foot. Plantar cutaneous responses were neutral.\nThe patient was admitted to the coronary care unit because of suspected cardiogenic CA and a hypothermia protocol was initiated. Acute myocardial infarction or other cardiac disorders were not diagnosed as the troponin curve was negative, angiography ruled out significant coronary lesions and echocardiography was normal. A thoracic computed tomography (CT)-scan ruled out pulmonary thromboembolism. There was no intracranial haemorrhage or other abnormalities on brain CT-scan.\nOn the 4th day post-CA, propofol was stopped but the patient remained in coma. Pupils were miotic and reactive. Other brainstem reflexes were preserved. Motor response to pain was absent. An EEG recorded diffuse delta–theta slowing with frequent irregular bilateral frontal sharp waves every 2–10 s. Median nerve SSEP demonstrated bilateral absence of thalamocortical N19 response and bilateral irregular low-amplitude cervicomedullary junction N13 waves with preserved peripheral potential (Erb point response) ().\nOn the 5th day after CA, a brain magnetic resonance imaging (MRI) showed absence of acute hypoxic–ischaemic lesions but an upper cervical spinal cord injury was unexpectedly noticed. A cervical MRI confirmed a fracture with luxation of the odontoid with severe cervical spinal cord hyperintensity (). The cervical spinal cord was immobilized and an orthopaedic consultation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient in this case was an otherwise healthy 6-year-old male who presented to the emergency room with a right elbow deformity from an injury sustained while playing football. He reported being tackled and falling back, leading to a direct impact onto his flexed right elbow. Examination demonstrated his right arm to be neurovascularly intact despite having a closed gross deformity at the elbow joint. X-ray evaluation revealed an anteromedial elbow dislocation with fracture of the radial head (). Two attempts were made at closed reduction in the emergency room under ketamine sedation with no appreciable reduction or improvement in alignment. Given the lack of success with closed reduction, the decision was made to take the patient to the operating room urgently for closed versus open reduction and possible fixation. Once under general anesthesia and with muscle relaxation employed, another closed reduction maneuver was attempted again with no success (). A direct posterior approach to the elbow was then performed with exposure carried around to the subcutaneous border of the ulna. It was noted that the olecranon apophysis remained in its anatomic position despite the ulna being anteriorly dislocated. Interestingly, the proximal ulna was found to be buttonholed through the anterior joint capsule, thus preventing reduction of the joint. The radial head was also noted to have an angulated Salter-Harris II fracture which was realigned with direct pressure application. No epicondylar fracture was noted with direct inspection. Once the entrapped proximal ulna was freed from the anterior capsule, it was easily reduced into its anatomic position (). Braided suture was used to reattach the olecranon apophysis to the proximal ulna through two drill holes in a figure of eight fashion. Final clinical exam and fluoroscopy images through a full range of motion revealed stable reduction of both the elbow joint and olecranon apophysis. The patient was splinted for approximately"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 58-year-old female patient with a large recurrent ventral hernia. Six years before, the patient had been operated on for the umbilical hernia, with the simple repair without a mesh. The patient was an active smoker who suffered from morbid obesity with a body mass index of 43 kg/m2 and COPD as comorbidities relevant for this case report.\nThe patient was introduced to the surgeon during hospitalization at the gastroenterology department where a diagnostic workup due to a clinical picture of chronic small bowel obstruction was conducted. While taking the anamnesis, the patient reported frequent abdominal cramps, swelling, and pain in the area of the hernia that had intensified in the last few weeks. The physical examination revealed a large irreducible ventral hernia in the lower abdomen that was quite painful on palpation, but soft and, at that time, without signs of incarceration or strangulation. Taking into account the clinical picture with threatening hernia incarceration, the surgeon did not opt for preoperative optimization of the patient in terms of smoking cessation and starting a weight loss program but made an indication for semielective surgery.\nOn operative procedure, greater omentum, part of the transverse colon, and a cluster of small bowel loops with signs of chronic obstruction were found as hernial content. After adhesiolysis hernial content was reduced into the abdominal cavity. Hernial defect measuring about 7 cm in diameter and about 15 cm in the vertical line with significant rectus diastase in the supraumbilical part of the abdomen was revealed. Using the Rives-Stoppa technique a wide retromuscular space was created. Lateral dissection boundaries of this space were perforating neurovascular bundles in the area of the lateral edges of the rectus muscle on both sides. The posterior fascia was easily closed using also a portion of the hernia sac to bridge the defect between the posterior rectus sheaths. A 30 × 25 cm polypropy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female presented for a routine clinic visit with her primary care physician and was found to have an elevated blood pressure of 150/100 that was sustained on repeat measurement. Upon further questioning, the patient reported history of elevated blood pressure readings over the past 7 years and was lost to follow-up. Past medical history was significant for migraine headaches and the patient had no past surgical history. Current medications included rizatriptan and ibuprofen were used as needed for headaches, approximately 2–3 times per year, and levonorgestrel IUD for contraception. Family history was notable for maternal and paternal grandparents with hypertension and mother with hypothyroidism. The patient was a nonsmoker with occasional alcohol use. BMI was 19. Physical exam was unremarkable.\n24-hour ambulatory blood pressure monitoring was performed and confirmed the diagnosis of hypertension. Due to the patient's age, a secondary hypertension workup was initiated. Laboratory evaluation included complete blood count, basic metabolic panel, and thyrotropin that showed no abnormalities; plasma aldosterone and renin were within normal limits at 2.9 and 1.069, respectively; urinalysis showed 1+ protein with protein/creatinine ratio 0.44. Renal ultrasound was performed and showed presence of left accessory renal artery and the appearance of bilateral renal vein congestion. Bilateral main renal arteries showed no signs of stenosis. Renal CT with contrast was recommended for further evaluation of renal vasculature due to appearance of renal vein congestion and showed ostial stenosis of the left accessory renal artery (Figures –). In addition, compression of the left renal vein between aorta and superior mesenteric artery was also noted, consistent with nutcracker syndrome (Figures and ).\nThe cause of hypertension in this 31-year-old female was suspected to be due to stenosis of the left accessory renal artery that was identified on imaging. Interventional"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man manual worker with a 13-year history of gout in his right hallux presented to his general practitioner with right knee pain, stiffness, and giving way with no history of trauma. He had been taking allopurinol for 11 years. He drank 10 to 12 units of alcohol per week and his body mass index was 24.4. On examination, he had anterior knee pain and crepitus was felt from the patellofemoral joint. He had a range of motion from 0 to 90 degrees.\nA magnetic resonance imaging (MRI) was performed and reported a grossly abnormal patella tendon showing heterogenous characteristics with areas of architectural distortion and altered signal in all sequences. The appearances were not typical for a tendinosis but more in keeping with findings seen in gout (\n).\nThe patient was commenced on anti-inflammatory medication in addition to his regular allopurinol and referred to an orthopaedic knee surgeon. At assessment, he was found to be significantly compromised by his knee. He was unable to ride a pushbike, walk with his dog, or even get out of a chair. Plain films showed calcification within his patellar tendon (\n).\nA multidisciplinary discussion with rheumatology and radiology consultants confirmed that the likely diagnosis was a tophaceous gouty deposit within the patella tendon. His uric acid level was 560 μmol/L (above the target of <300 μmol/L set by the British Society for Rheumatology [BSR])\nand estimated glomerular filtration rate was 52 mL/min. He was referred to rheumatology who advised increasing the dose of allopurinol. A subsequent ultrasound (US) scan showed the superficial fibers of the patellar tendon relatively intact, but within the deep fibers, there were multiple hyperechoic areas with distortion of the tendon architecture. There was no significant cyst. A computed tomography (CT) scan demonstrated a markedly thickened patellar tendon with areas of mineralization within the tendon itself (\n). He was seen in a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male presented to the outpatient department with a complaint of pain and swelling in his upper right back tooth region since 15 days. The patient gave a history of pain in relation to 14 and 15 for which he underwent inadvertent root canal therapy, followed by apicectomy and extraction of 12, 3 weeks earlier at a local dental hospital. Posttreatment, the pain and swelling did not subside which lead the patient to revisit his local dental surgeon, where he was advised to undergo biopsy.\nOn extraoral examination, there was a significant facial asymmetry caused by an approximately 5 cm × 4 cm mass involving the right maxilla. No pulsations were detected, and overlying skin was normal in color. Intraorally, an ulceroproliferative mass of 4 cm × 5 cm in its greatest dimension was observed protruding from the gingivobuccal sulcus from 15 to 11 tooth region obliterating the vestibule. The lesional mass was reddish, firm in consistency, with ulcerated surface and tender on palpation. The lesional mass extended around the upper gingival area near right central incisor to right first premolar, completely masking the associated tooth surface and also obliterating the gingivo buccal sulcus. There was no evidence of tooth mobility and pus discharge []. The computed tomography scan of the paranasal sinus revealed an enhancing mass lesion in the right gingivobuccal sulcus and nasolabial fold extending into maxillary sinus, with destruction of anterior wall of the sinus, and erosion of the alveolar margin []. Right cervical lymphadenopathy was observed with 6–20 mm right Level IB and IIA. A provisional diagnosis of soft-tissue tumor was given. The differentials included nodular fasciitis, malignant peripheral nerve sheath tumor (MPNST), fibrosarcoma, and rhabdomyosarcoma.\nAn incisional biopsy was subsequently performed and subjected to histopathological examination. On microscopic examination, the hematoxylin and eosin-stained sections exhibited loose, hypercellular s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man was referred for treatment of a massive infected tumor situated in the left lumbar region, 12 months after left nephrectomy for squamous cell carcinoma of the kidney. On clinical examination the mass was located on the lobotomy scar and measured 15 cm ().\nThe abdomino-pelvic CT scan showed a mass in the left lumbar region, measuring 95 × 75 × 65 mm and invading the 11th rib. This mass extends to the ipsilateral latissimus dorsi muscle which seems to be invaded in the lower part and to the iliopsoas muscle ().\nThe biopsy revealed a squamous cell carcinoma. Recurrence of the renal tumor was evoked, and surgery was indicated.\nThe tumor was removed through a circular incision, section of the lower insertion of the latissimusdorsi, the quadrates lumborum, the iliopsoas, and the two obliquus muscles. The peritoneal cavity was opened. The distal part of the 11th rib was removed with a pleural wound which was repaired. The excised tissues included also a nodule located at the superiorpart of lobotomy scar, and a second one was situated in the left retrocolic area (Figures and ).\nThe LD outline was marked as well as its upper limit. The paraspinal perforators were outlined about 5 cm from the midline, and the penetration of the perforators through the muscle was estimated about 9 cm from the vertebral column (). No Doppler ultra soundor arteriography was performed (not available in the center). All the benchmarks were taken based on the literature.\nAn oblique incision was made from 10 cm down to the axilla to the defect. The LD was identified (). The thoracodorsal artery, vein, and nerve were exposed, tied off and then detached (). After section of its humerus insertion, the LD was harvested carefully in order to preserve the segmental pedicles.\nWe found three large perforators originating from the ninth,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 67-year-old female patient of the present study had previously been diagnosed with transitional cell cancer of the urothelium (non-invasive, pT1N0M0), which had been treated with total cystectomy, ileal conduit diversion and urostomy at the age of 63. The patient had smoked 10 cigarettes a day between the ages of 30 and 60 and had then quit. The patient had no documented hypertension or diabetes mellitus. Subsequent to the finding of an abnormal shadow in the right upper lung, based on X-rays taken during the follow-up post-operative testing in April 2012, the patient visited the Department of Respiratory and Infection Control (Tokai University Hachioji Hospital, Tokyo, Japan) for a detailed examination. No such shadow had been detected in the lung during testing the previous year.\nThe patient’s blood pressure was 156/93, the heart rate was 79 bpm and regular, percutaneous oxygen saturation was 95% (room air) and there were no cardiopulmonary symptoms such as coughs and sputum. The patient had previously undergone a urostomy in the right lower abdomen. The blood tests, including those for tumor markers, were normal except for a slightly elevated white blood cell count. The aspergillus antigen and antibody were not present, and the β-D glucan level was also normal. The sputum culture detected no fungus or mycobacterial colonies throughout an 8-week incubation period. The chest CT showed a cavitary lesion that was 3.5 cm in diameter, with fungus ball-like shadows and air crescent signs next to the pleura in the right upper lung (). No nodular density was noted in the other lung fields. No pleural effusion or enlargement of the mediastinal lymph node was found. Based on the clinical and imaging findings, the patient was temporarily diagnosed with aspergilloma with a cavitary lesion and fungus ball-like shadows in the right upper lung.\nThe primary treatment of aspergilloma is surgical removal, and the differentiation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-year-old boy presented with complaints of frequent cough and fever since the age of 5 years. The child was initially investigated elsewhere and diagnosed as a case of pulmonary tuberculosis. He had received antitubercular treatment for 1 year. After temporary relief, his symptoms recurred and the sputum showed presence of acid fast bacilli. The child was restarted on antitubercular treatment, which was administered for 2 years. Radiological investigations revealed the presence of a left intrathoracic mass. The child underwent thoracotomy and biopsy elsewhere. The biopsy was suggestive of inflammatory myofibroblastic tumor of the lung. The child was started on prednisolone but remained symptomatic. Subsequently, the child was referred to our institution for definitive treatment. His general condition was good and there was no evidence of respiratory distress. On examination, the movements of the chest wall were diminished on the left side. The left hemithorax was dull on percussion and the air entry was absent. The right side was normal. Chest radiograph showed the presence of a homogenous opacity in the left hemithorax with large areas of calcification in the hilar region. A contrast enhanced CT scan of the chest revealed a large soft tissue mass in the left lung with dense calcification and collapse of the lung. The child underwent thoracotomy; there was a soft tissue mass arising from the left lung and densely adherent to the pericardium, aorta, and thymus. Large mediastinal lymph nodes were present and the left pulmonary vein and artery were encased by the mass. Complete excision of the mass along with the involved pericardium and left pneumonectomy was performed. The child suffered a cardiac arrest during surgery but was revived immediately. Postoperatively, the child required ventilator support for 7 days. The child was subsequently discharged in a stable condition with no neurological deficit. The histopathological examination confirmed the diagnosis of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old previously healthy girl presented 2 weeks after an uncomplicated laparoscopic appendectomy for non-perforated acute appendicitis in a regional hospital. The girl complained of gradually reducing urinary frequency to twice per day and prolonged hesitancy. The micturition stream was initially weak and slow before becoming interrupted. Straining did not produce stronger urinary stream. She had never suffered from urinary tract infections (UTIs) or constipation and opened her bowels daily.\nFollowing an episode of acute cystitis 2 months later, she completely lost her ability to void. She was put on indwelling Foley urinary catheter, and her cystitis was successfully treated with antibiotics. After every attempt to remove the urinary catheter, she had to be catheterized again with 300 to 1200 mL of urine volume registered. She noted loss of urge to urinate and felt only dull pain in suprapubic region and right iliac fossa on extreme bladder distention. The girl was kept on indwelling urethral urinary catheter and referred to a tertiary center to determine the etiology of her urinary retention.\nShe was examined with normal clinical findings and no obvious pathology on abdominal and pelvic ultrasound scan (USS). A pediatric neurologist found nothing abnormal, and magnetic resonance imaging (MRI) of the brain and spine, electromyography (EMG) of the lower extremity, somatosensory-evoked potentials (SEP) of tibial nerve, electroencephalogram (EEG), and lumbar puncture were with no pathology. On USS, the gynecologist described multiple follicular cysts on ovaries bilaterally and found no pathology explaining her urinary retention.\nOur pediatric urologist performed an examination under general anesthesia including a free calibration of the urethra up to 26F followed by normal findings on cystoscopy. Videourodynamic study (VUDS) showed an asensitive and hypotonic bladder. The bladder filling had to be stopped at 360 mL due to the patient's discomfort. Maximum intr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old gentleman with end-stage kidney disease due to hepatitis C with focal segmental glomerulosclerosis, on hemodialysis for seven years, underwent deceased donor renal transplantation. The donor kidney had a KDPI of 60%. There was a 4 antigen HLA mismatch with Class II panel reactive assay (PRA) of 62.31%. Class I PRA was 0%. His donor specific antibody testing was positive for an antibody to DQ7. The donor had died as a result of anoxic brain injury following cardiopulmonary arrest resulting from anaphylactic shock. The cold ischemic time was 12 hours, 7 minutes and the warm ischemic time was 51 minutes. Basilixumab was used for immunosuppression induction and the patient underwent early steroid withdrawal. His maintenance immunosuppression was tacrolimus (targeting trough levels 5-8) and mycophenolate sodium 720 mg BID.\nThe patient's postoperative course was complicated by delayed graft function, necessitating continuation of renal replacement therapy. He was hemodynamically stable throughout his hospital course. A renal allograft ultrasound showed good blood flow to the entire kidney with a resistive index of 0.64. A repeat flow crossmatch was negative, but he remained positive for a persistent low-level donor specific antibody to DQ7 (1000 MFI). He underwent a renal transplant biopsy on his 4th day postoperatively. This showed extensive acute tubular necrosis with associated peritubular capillaritis and interstitial nephritis (). Oxalate crystals were seen in several tubules. One large caliber artery showed active endothelialitis, but no tubulitis or glomerulitis seen. C4d staining was negative in the peritubular capillaries. Electron microscopy revealed minimal effacement of podocyte foot processes. The patient received methylprednisolone 500 mg x 3 doses to treat moderate acute cellular rejection. His tacrolimus dose was also optimized as his trough levels had been running low at between 3.5 and 6. He continued to take mycophenolate sodium at a dose"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA four-year-old febrile healthy male child presented with a lump in the right parotid region. On examination, the swelling was about 6 × 5 cm in size, nontender, irregular, and firm to hard in consistency with obvious proptosis. Swelling extended superiorly up to zygomatic region, inferiorly up to mandible, anteriorly up to maxillary region, and posteriorly up to retromandibular space. Radiological examination showed a large solid ill-defined lesion along the ramus of the mandible extending into masseteric space and until skull base of the right side. Involvement of nasopharynx, posterior ethmoid, and sphenoid sinus with sinus wall remodelling was suggestive of neoplastic mass (). Clinical differential diagnosis of rhabdomyosarcoma, lymphoma, and primitive neuroectodermal tumour was suggested. Routine investigations were all within normal limits, and evaluation of complete blood count was normal except for anaemia. On microscopic examination of the processed biopsy, tissue sections showed mainly tumour tissue infiltrating into normal parotid gland (). Tumour cells seen were mostly round to oval with high N/C ratio and hyperchromatic with irregular nuclear membrane and at some places with angulated nuclei also (). Increased number of eosonophilic precursors were also noted along with few neutrophils and lymphoid cells. No evidence of acinous formation or lymphoglandular bodies was found which helped in ruling out carcinoma of parotid gland or lymphoma. Histopathological diagnosis of Langerhans cell histiocytosis (LCH) versus granulocytic sarcoma was considered. To confirm the histologic diagnosis and to rule out clinical diagnosis, immunohistochemistry was performed, and a panel of markers were used as described in and . Peripheral blood smear showed increased number of blast cells, morphologically mostly monoblast and myeloblast in myeloperoxidase staining (MPO). The bone marrow smear taken showed increased number of blast cells (more than 20%) which were myeloperox"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old female with a past medical history of morbid obesity [body mass index (BMI) of 58.4 with a height of 1.6 m and weight of 149.5 kg] presented with right-sided abdominal pain. The abdominal pain had been present and consistent for several weeks but had increased acutely over the last few hours. She denied fevers, chills, chest pain, palpitations, shortness of breath, cough, nausea, and vomiting. Her past medical history was significant for multiple cardiopulmonary comorbidities including heart failure with preserved ejection fraction, chronic obstructive pulmonary disease requiring 3 L of oxygen per minute at baseline, myocardial infarction, and type 2 diabetes mellitus. Her surgical history was significant for a remote history of a hernia repair, but the patient was unclear of when it occurred.\nAt the emergency department (ED), her respiratory rate was 32 breaths/minute with an oxygen saturation of 88% on 3 L of oxygen. The rest of her vitals were unremarkable. There were no significant abnormalities on the cardiac exam. She had decreased breath sounds in the lower lung lobes bilaterally with mild diffuse wheezing throughout all lung fields. An abdominal exam revealed moderate tenderness to palpation in the right upper and lower quadrants. A hernia was palpated in the right lower abdomen.\nPertinent lab values included a white blood cell count of 12,400 cells per microliter with negative blood and urine cultures. Basic metabolic panel and lactic acid were unremarkable. Liver tests were within normal limits (Table ). Chest X-ray was inconclusive because of poor penetration due to the patient’s body habitus.\nCT of the abdomen and pelvis with contrast showed distension and thickening of the gallbladder wall, pericholecystic stranding, and a fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe (Figure ). The gallbladder was located in the right lower quadrant of the abdomen due to the mass effect from"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2.5-year-old boy was referred to the pediatrics clinic with severe self-mutilating injuries to his hands, feet, tongue and oral mucosa caused by unconscious biting ().\nHe is the second child of cousin parents and the product of a term, normal vaginal delivery with a birth weight of 3300 gr.\nAt two-months of age, he was admitted to the hospital as a result of fever and convulsion. The patient continued to have fever throughout his hospital stay and evaluation for the etiology of prolonged fever was done and abnormal results were not seen in any of the diagnostic tests including blood culture, CSF analysis and culture, urine analysis and culture, echocardiography, blood smear, bone marrow aspiration and culture, Wright and Vidal test, abdominal sonography and brain CT scan. Finally, he was discharged from the hospital on phenobarbital medication, but episodes of hyperthermia and unexplained fever recurred.\nHis parents found him never sweating after birth and he did not tolerate warm weather or sun exposure and he was irritable and cried with appropriate tearing in such situations. The parents also complained that the child showed no response to any kind of injury including pinpricking, burning, hitting and cutting. The boy had never complained of painful sensation and his hands or feet were burned by heater flame or hot water repeatedly.\nHe had a right third metatarsal fracture without reason when he was 2.5 years old that was managed on an outpatient basis and caused edema and deformity in his right foot.\nTeething had started at seven months of age, but because of biting and ulcerative lesions in the gums, his teeth had started to shed at 1.5 years of age.\nOn examination, he had 12 kilograms weight (10th percentile), 92 centimeter height (75th percentile) and 48 centimeter head circumference (10th percentile) and a normal blood pressure without orthostatic hypotension. Ulcerative lesions were seen in his fingers"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old male had a history of road traffic accident 18 months back with severe head injury and pelvic fracture. He remained in the referring hospital for three months. After discharge he remained reasonably well except for occasional episodes of anterior chest pain and dyspnea on moderate exertion.\nRecently he was admitted again through the emergency department with complain of severe chest pain along with shortness of breath. CT chest with intravenous contrast showed large aneurysm of the descending thoracic aorta distal to the origin of left subclavian artery causing compression on the origin of the left main bronchus, and on the right and left pulmonary arteries with no evidence of dissecting or contrast leak; however, the patient referred to the vascular surgical unit in our institute for further management.\nAfter admission he complained of mild shortness of breath. His vital signs and his routine blood investigation were within normal limits. His chest radiograph showed normal bilateral lung fields.\nHe underwent endoluminal thoracic aortic stenting under general anesthesia. Postoperatively the patient started to complain of severe dyspnea and was desaturating. His immediate post-procedure routine chest X-ray revealed complete collapse of the left lung []. An urgent CT chest with intravenous contrast showed endovascular stent in place, but the aneurysmal sac was completely occluding the left main bronchus with complete collapse of the left lung but with adequate perfusion. The aneurysmal sac also had a mass compression on the adjacent right main pulmonary artery, which was compressed and stretched maximum at its proximal portion [].\nPatient was stable hemodynamically and with relatively acceptable arterial blood gases.\nHe was monitored closely for possible emergency intervention with an endobronchial stent.\nAlthough placement of an endobronchial stent in the left main bronchus can open the collapsed left lung, at the same time it may increase the pressure"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old woman was transferred to our emergency department following a road traffic accident. The patient was a restrained passenger of a car, the driver lost the control of the vehicle and the car fell into a ditch at the side of the road. The patient lost consciousness at the impact but was found alert and oriented at the time of the arrival of the ambulance. Patient observations were stable and there were no signs of other bone injuries. Patient had no neurological deficits and cranial nerves were intact. Past medical history of the patient included acute glaucoma and visual impairment.\nA routine trauma series CT-scan was performed and showed a type II odontoid fracture with anterior displacement (Figure ). Patient was referred to our spinal unit and, after appropriate counselling, elected a non-operative treatment. Cervical spine was stabilized with a Philadelphia collar and patient was discharged home 3 d after the injury. The first outpatient clinic appointment was booked at 2 wk after discharge and patient was seen at regular intervals thereafter. Six months following the injury the patient was still complaining of significant axial neck pain requiring regular pain killer. An interval computed tomography (CT) scan at 6 mo after the injury revealed a non-union at the fracture site, distance between fracture fragments was 4 mm and there was evidence of sclerotic bone margins at the level of the fracture (Figure ). Surgical options were discussed with the patient at this stage, but she again refused any surgical intervention.\nPatient was maintained in rigid collar and was offered off-label therapy with daily subcutaneous injections of Teriparatide (rhPTH1-34) 20 μg/d which she accepted. This is the same regime used for treatment of osteoporosis in post-menopausal women. The anabolic treatment with Teraparatide was monitored through periodic examinations and regular measurements of serum levels of calcium, phosphorus, vitamin D, parathyroid hormone and alkal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year old white English male was presented to the vascular outpatient clinic with history of a lump behind his right ankle on inner aspect over a year. Apart from the presence of a lump, he denied any other complaints including any violent or repeated trauma. He also suffered from diet controlled Type II diabetes mallitus and gout and had tonsillectomy and manipulation of colles’ fracture in childhood. He was not taking any antiplatelet or anti-coagulation medications and denied any use of tobacco. On examination, there was 3 × 3 cm size lump just behind the right medial malleous which was non-tender and non-pulsatile. The peripheral pulses were easily palpable on either side. There was no evidence of aneurysm anywhere else in the body on clinical examination. He underwent Doppler ultrasound which confirmed 1.4 cm size aneurysm of posterior tibial artery with presence of mural thrombus. The distal and proximal parts of posterior tibial artery, anterior tibial artery and popliteal artery were reported normal. He underwent an elective operation in the form of excision of aneurysm (Figure ) followed by reversed vein graft from the same leg (Figure ). Histology confirmed the true aneurysm of posterior tibial artery with mural thrombus attached to the intima of the vessel with normal arterial wall pattern without any evidence of connective tissue disorders, arteritis, necrotizing vasculitis, infection or inflammation (Figures , , and ). The bacteriology examination neither revealed any organisms nor grown any organisms in the culture media. He recovered well postoperatively and was discharged the next day. At follow up at one year, he did not develop any complications and colour Doppler revealed patent posterior tibial artery.\nFalse aneurysms are more common in comparison to the true aneurysms of infrapatellar blood vessels. There have been only very few case reports of true aneurysms of posterior tibial artery published [,]. The precise aetiological factors are not"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 83 year old female patient presented with a two week history of a self detected lump in the upper outer quadrant of the left breast. Clinically there was a 15 mm suspicious lump in the left breast, mammography did not reveal any abnormality (R1) and ultrasound scan findings were consistent with the diagnosis of breast cancer (U5). Clinical and ultrasound examination of the axilla was unremarkable. Core biopsy of the lesion confirmed the diagnosis of invasive ductal carcinoma.\nDuring review of her past medical history, it was noted that in 1996 she had a cardiac PM inserted for persistent sinus bradycardia. In 2003 this was replaced with a St. Jude Medical dual chamber PM (St. Jude Medical Inc., St. Paul, MN, USA). The pacemaker was programmed to VVIR 70 bpm, hysterises 60 bpm in single chamber mode due to an atrial lead failure. The dominant rhythm was atrial fibrillation with intermittent ventricular pacing. The patient’s heart rate varied between 60–107 bpm. The patient had been self caring and a recent transthoracic echocardiogram showed a normal ejection fraction and left ventricular size. Anatomically, the PM was located in a subcutaneous tissue pocket in the upper pole of the left breast 9 cm away from the primary tumour (Figure , Figure ).\nAfter discussion at the multidisciplinary meeting, we recommended wide local excision and sentinel node biopsy. In view of the size of the tumour and presence of the PM, it was also decided to offer the patient intraoperative radiotherapy using the TARGIT technique.\nPrior to surgery, the details of the PM were obtained from the implanting hospital and the distance from the tumour to the device was measured at an assessment session. During surgery, after harvesting the sentinel node and wide local excision, intraoperative radiotherapy was performed using the Intrabeam™ device (50 kV, Carl Zeiss Surgical, Oberkochen, Germany). A 3 cm diameter applicator was used, delivering approximately"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man presented with a 2-month history of intermittent epigastric pain. At the time of presentation, the patient had hypertension that was controlled with medication, and he had no other remarkable past medical history. The physical examination and laboratory tests were unremarkable.\nAfter admission, the patient underwent an upper gastroduodenal endoscopy examination and the result was normal. We then performed ultrasonography (US) and computed tomography (CT) examinations to further evaluate the abdominal pain. Based on the US findings, a large well-defined anechoic mass was identified and it was located in the posterior aspect of the splenic vein. The lesion was seen with posterior acoustic enhancement that suggested the presence of a cystic or necrotic mass (). Helical CT was performed using a multidetector-row CT (MDCT) scanner (LightSpeed VCT; GE Healthcare; Milwaukee, WI) with 64 detectors. The abdominal CT axial and coronal images () showed an approximately 5 cm sized, well-defined, necrotic mass with an even peripheral wall in the retroperitoneal area. The mass was located between the left renal vein and the splenic vein and the mass compressed the adjacent pancreas without evidence of direct invasion. There was no calcification detected in the mass. Several abnormal enlarged lymph nodes in the left gastric area were also noted. Based on these imaging findings, metastatic lymph nodes, tuberculosis lymphadenitis and an unusual form of Castleman's disease were considered in the differential diagnosis. The main necrotic mass and abnormal enlarged lymph nodes were removed by surgical excision. On a gross specimen, the mass showed extensive internal necrosis that correlated to the image findings seen on US (). Spindle to ovoid cells that made up fascicles were identified on a light microscopic examination of the resected mass and lymph nodes. The tumor cells had slightly eosinophilic plump cytoplasm with an indistinct cell border and small nuclei ()."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old gentleman was admitted to the emergency room for unstable angina. He underwent coronary artery bypass grafting 6 years prior to current admission and also had persistent atrial fibrillation on rate control and anticoagulation. His ejection fraction was 65%. Coronary angiogram showed occlusion of all vein grafts but patent left internal mammary graft to left anterior descending artery with severe native multivessel disease. There was severe stenosis of the native left circumflex artery (); the proximal right coronary artery was completely occluded, and it was supplied distally by bridging collaterals and collaterals from the left circumflex artery. After extensive discussion with the patient, decision was made for percutaneous coronary intervention (PCI) of the native left circumflex artery. Serial balloon dilation to the mid circumflex artery was performed: first with a 2.5 mm × 15 mm balloon but a waist was noted (), followed by a noncompliant 2.5 mm × 12 mm balloon but a residual waist was still observed, and finally with a 2.5 mm × 10 mm scoring balloon (AngioSculpt, Spectranetics, Milwaukee, Wisconsin, USA) inflating up to 20 atmospheres (). The stenosis gave way, and repeat angiogram noted Ellis Class III perforation ().\nThe operators immediately inflated a 3.0 mm balloon to 8 atmospheres at the site of perforation followed by deployment of a 2.5 × 24 mm covered stent. However, repeat angiography still showed extravasation from perforation site and a second 2.5 × 12 mm covered stent was deployed, but there was continued extravasation. Protamine sulfate was given, and prolonged balloon inflation was then performed. Subsequent angiography showed that the circumflex artery was thrombosed.\nImmediate bedside transthoracic echocardiogram showed very small 4 mm pericardial effusion. Pericardiocentesis was attempted but was unsuccessful. The ejection fraction was normal, and there were no other echocardiographic features of cardiac tamponade.\nThe patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old female patient, known to have arterial hypertension and coronary artery disease and on aspirin therapy, was admitted to the hospital for elective total thyroidectomy with a symptomatic non-toxic multinodular euthyroid goiter.\nPhysical examination revealed palpable neck swelling. The neck ultrasound showed an enlarged thyroid gland with multiple nodules on both sides; the thyroid volume was 22 ml. The preoperative thyroid function test, parathyroid hormone and serum calcitonin were within normal ranges.\nThe patient underwent a total thyroidectomy. The parathyroid glands and recurrent nerves were recognized and preserved. After meticulous haemostasis and an intraoperative Valsalva manoeuvre, the wound was closed. No drain was placed. The patient was sent to the recovery room and then to the normal ward.\nThe neck circumference was regularly measured at different intervals as follows: the preoperative measurement was 37 cm; immediately postoperative, 38 cm; 30 min, 38 cm; 60 min, 38 cm; 90 min, 39 cm; 120 min, 39 cm, 4 h, 39 cm; 6 h, 40 cm; and 8 h, 41 cm. At this point, the patient experienced a pressure sensation and tightness in her neck but no respiratory distress or hypoxia.\nThe patient was transferred immediately to the OR. No difficulties in intubation were reported by our anaesthesiologist. After surgical draping, the wound was opened and cervical exploration was carried out, which revealed a haematoma deep to the strap muscles. Blood clots were removed, the surgical bed was irrigated and bleeding was identified from the small venous branch of the middle thyroid vein. After ligation of the bleeder and meticulous haemostasis, drains were placed in the thyroid bed. The patient was extubated and shifted to the recovery room and later to the surgical ward. The postoperative course was uneventful. Oral intake was gradually increased as tolerated. The drains were removed on postoperative Day 2. Histopathology returned benign. The patient was discharged o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old female Arab, a known asthmatic, presented to the emergency department of our hospital with complaints of chest pain and a nonproductive cough of 1-hour duration. She was conscious and well-oriented to the surroundings but had mild dyspnea. There was no history of receiving assisted mechanical ventilation. There was no previous history of pulmonary tuberculosis, recent trauma, surgery, or other intervention.\nVital parameters were stable, and body temperature was normal. There was subcutaneous emphysema involving the right side of the neck. Auscultation of the chest did not reveal any significant abnormality. A chest radiograph was obtained, which revealed surgical emphysema along the upper part of the right lateral chest wall and the right side of the neck. Minimal pneumomediastinum was also noted with air within the superior mediastinum on the right. A loss of volume of the right lung was noted with a shift of mediastinum to the right and elevated right diaphragmatic dome (). No lung consolidation, pneumothorax, or pleural collection was noted. The patient collapsed immediately after the chest radiograph was obtained. She was intubated and given intravenous fluids and vasopressors to control the hypotension. Her condition stabilized after 2 hours. The portable bedside chest radiograph revealed increased severity of pneumomediastinum, surgical emphysema, right lung collapse, and mediastinal shift to the right ().\nComputed tomography (CT) imaging of the thorax was also performed, which confirmed the dissection of air into the mediastinal and subcutaneous spaces (). A CT scan also revealed air within the posterior spinal extradural space in the thoracic spine ( and ), minimal pneumothorax on the right, and obstruction of the segmental right upper lobe bronchus by mucus plugs ().\nShe was hospitalized and treated with antibiotics, bronchodilators, oxygen inhalation, and other conservative measures. A bronchoscopic removal of mucus plugs and thick secretion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female presented in July 2007 to a peripheral general hospital with progressively enlarging mass in the anterior abdominal wall of one-year duration. On physical examination, she was well built with normal vital signs. A 7 x 6 cm firm irregular subcutaneous mass was felt in the right lower para-umbilical area of the anterior abdominal wall. On palpation, the abdomen was soft and lax with no intra-abdominal masses. There were no palpable lymph nodes. Her cardiac and respiratory examinations were unremarkable. Computerized Tomography (CT) scan of the abdomen revealed a mass within the abdominal wall. Her laboratory investigations were within normal limits. A plain chest X-ray was unremarkable.\nWide local excision with safety margins of the tumor was done. The postoperative period was uneventful, and she was discharged on the second postoperative day in a satisfactory condition.\nGross examination of the specimen showed an ellipse of skin that measured 13 x 10 cm with subcutaneous fatty tissue measuring 11 cm in thickness. On cut section, a well-defined nonencapsulated grayish yellow mass measuring 7 x 6 cm with foci of necrosis was seen. No skin infiltration or abdominal skeletal muscle involvement was noted.\nMicroscopic examination revealed well-defined but nonencapsulated subcutaneous mesenchymal neoplasm composed of irregular islands of large cells with mostly round to oval pleomorphic vesicular nuclei, with markedly granular cytoplasm, and several large eosinophilic globules (). The nuclear cytoplasmic ratio was variable, with several cells having large nuclei. The tumor nests were surrounded by bands of fibrous connective tissue ().\nMany foci of tumor necrosis and scattered mitotic figures, 4 per 10 HPF at a magnification of 200, were identified (Figures and ). Margins of resection were free of tumor.\nImmunohistochemical stains show the tumor cells to be strongly positive for vimentin, S100 and CD68 (Figures , , and ). Stains for cytokeratin (CK), sm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year old, right-handed male patient presented in the emergency room after a motorcycle accident. The patient collided with a car while grasping the handlebars with both of his hands but could not remember the exact mechanism of injury. After excluding any life threatening organ injuries the patient was referred to the Department of Plastic Surgery for further evaluation of the left hand. The clinical examination revealed severe swelling and tenderness of the left hand. Tenderness was reported especially over the snuffbox, proximal to the base of the second metacarpal bone and distally to the distal radio-ulnar joint with a skin laceration and superficial abrasions on the dorsum of the hand. Additionally, a skin laceration with a diameter of approximately two centimeters was located at the area above the lunate on the dorsum of the wrist. The perfusion and sensibility were without any pathological finding.\nX-ray showed a dorsal dislocation of the lunate with no clear signs of fracture or dislocation of other bony structures ().\nSince lunate dislocations often come along with additional carpal bone injuries and pain over trapezoid persisted, a computed tomography (CT) of the left hand and wrist was carried out immediately. It confirmed a dorsal dislocation of the lunate and interestingly also a compound sagittal fracture of the trapezoid ( and ). Furthermore, air pockets in the dorsal wrist indicated an open trauma.\nUnder general anesthesia, a closed reduction of the lunate was performed by pushing the lunate to proximopalmar direction while applying longitudinal traction to the fingers with the wrist fixed in a neutral position. The intraoperative x-ray confirmed anatomical reduction of the lunate. Since no tendency of lunate re-dislocation, neither in neutral nor in hyper-flexed or extended wrist position was seen on x-ray image intensifier dynamic screening, no open ligament reconstruction was carried out. Due to slight carpal instability without confirmed by"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female presented with history of sudden onset weakness of right upper and lower limb for 1 day with deviation of angle of mouth to the left side. There was no history of headache, vomiting, seizures, or previous history of stroke or transient ischemic attacks. Also there was no history of chest pain, palpitations, or any cardiac disease. She is not a diabetic or hypertensive and there was no other comorbid illness. Her general examination revealed a pulse rate of 180/ min, regular, low volume, and blood pressure of 130/80 mmHg. The central nervous system examination showed normal higher mental functions, right upper motor neuron facial nerve palsy, and muscle power of 3/5 in upper limbs, 2/5 in lower in lower limbs with right extensor plantar response. The examination of other systems was normal. The laboratory investigations revealed normal liver and renal function tests. The serum calcium, magnesium, and potassium levels were normal. The serum troponin T and creatine phosphokinase levels were normal. The CT brain revealed left middle cerebral artery territory infarct measuring around 2×3 cm.\nOur patient presented to the emergency medical services department within 8 h of acute stroke. Her ECG showed regular narrow QRS complex long RP tachycardia at a rate of 186 beats per minute (bpm) with inverted p waves in lead III []. She had a normal study on echocardiography without structural changes or thrombus. On intravenous injection of 6 mg of adenosine, the patient transiently developed complete atrioventricular block but the atrial rate was persisting at the same 186 bpm with regular p waves separated by isoelectric baseline [] which reverted back to AT within a minute []. A diagnosis of atrial tachycardia was made and she was started on verapamil 40 mg three times daily orally. Following one dose of verapamil she developed sinus bradycardia (50 bpm). So verapamil was withheld and she was monitored in intensive care unit. In the following 1 week, she di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old woman was referred for evaluation of back pain and worsening left lower extremity pain, which included neurogenic claudication. She gave a history of a fall from standing height, with onset of low back pain. Around a month later, her left leg pain became a prominent feature, with a symptom duration of approximately five months at the time of injury. She did not experience lumbar epidural or intrathecal injections. She reported no history of fever and no difficulty passing urine. Significant medical history included mild hypertension, of note, and there was no history of malignancy and no history of use of anticoagulant drugs. Both platelet count and prothrombin time were in the normal range. On examination, there was full power and symmetrical reflexes in both lower extremities. Patchy reduction in sensation to the left lower limb was noted. She was given a left L5 nerve root block which was only effective for 3 days. The patient and/or her families were informed that data from the case would be submitted for publication and gave their consent.\nA lumbar MRI without gadolinium (Gd) had been performed prior to evaluation (4 months after symptom onset) in a previous hospital (). The MRI showed a posterior mass at L4/5. On T1-weighted images (), the mass was isointense, with a few hyperintense areas within. On T2-weighted images, the mass was hyperintense in the center and hypointense in the periphery (). We suspected the spinal tumour and carried out a 2nd MRI with Gd. On the 2nd MRI of the same area (Figures –), after a 2-week interval, a newly isointense mass was present within the anterior part of the previously identified lesion on T1-weighted image () and the hyperintense area in the lesion was a little extended on T2-weighted imaging (). There was no significant enhancement with Gd-based contrast (Figures and ). Her symptoms were not changed between the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 13-month-old female presented to the emergency department for urinary retention. She was born at 35 weeks gestation in Mexico with an unknown postnatal hospital course. She was known to have mild gross motor developmental delay diagnosed several months before; caregivers stated that she pulled to stand but did not cruise or walk and babbled but did not have any words. She had no additional past medical history or previous surgeries and no known previous trauma. Upon presentation, the adoptive parents with whom she has lived since very early in her life provided the history. Adoptive parents reported about 2 weeks of fussiness and decreased ability to bear weight on her lower extremities. Parents denied any known trauma at that time. Her weight was <3rd percentile with a Z score of −3.36. She was thin appearing but without signs of dehydration or malnourishment. Examination was notable for 0/5 strength, hypotonia, and areflexia in the bilateral lower extremities as well as hypotonia of the trunk. In addition, she was found to have significant head lag and very severe thoracic kyphosis or gibbus deformity. The patient was first evaluated by outpatient urology after referral from the primary care office for urinary retention. A renal ultrasound was performed and was notable for bilateral moderate hydronephrosis and bladder distension. She was sent to the emergency department for further workup. Laboratory studies in the emergency department yielded normal creatinine for age at 0.3 mg/dl, and urine culture obtained by in and out bladder catheterization grew >100,000 CFU/mL of Enterococcus faecalis. Complete blood count and basic metabolic panel were unremarkable, and thyroid stimulating hormone was within normal range. The patient's creatinine kinase was >1200 U/L, six times the upper limit of normal. Spinal CT demonstrated complete retrospondylolisthesis of T12 vertebra (). MRI was also performed and showed marked compression of the spinal cord resulting in inability"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male with a chief complaint of pain during chewing and swallowing was referred to our department He mentioned a history of trauma to his right mandibular angle during an assault four months previously. The patient did not have any neurosurgical signs, loss of consciousness (LOC), dizziness or vomiting. The Glasgow coma scale (GCS) of the patient was 15 when he was referred to our department.\nThe main complaints of the patient were pain on the right side of the neck and lower jaw during chewing and swallowing. Although the patient experienced pain during mandibular movements and yawning, no limitation of jaw movements was observed. The nature of the pain was sharp and intermittent and lasted a few seconds every time the patient turned his head or upon chewing. The maximum mouth opening (MMO) was about 46 millimeters and there was no deviation in mandibular movements. On clinical examination, there was neither extra-oral swelling nor tenderness of temporomandibular joint (TMJ) or masticatory muscles. Intra-oral examination did not show any occlusal problems or premature contact. The patient did not mention any surgical history or tonsillectomy. He did not complain of symptoms mimicking glossopharyngeal neuralgia.\nA panoramic radiograph was obtained from the patient (). The radiographic view of the jaws showed elongated SP in the left side whereas the right SP was normal in size but displaced. The right displaced SP on panoramic view suggested fracture of this process without mandibular condyle fracture. Computed tomography (CT) was obtained for more evaluation and to detect other possible fractures. The CT views confirmed right SP fracture ().\nThe treatment plan for the patient was conservative treatment and follow-up. He was instructed to restrict neck movements. An anti-inflammatory (Naproxen 500 mg for every 8 hours for two weeks) and muscle relaxant (Tizanidine 2 mg twice a day for two weeks) drugs were prescribed to reduce the pain during the mastic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year old man was referred to our clinic for the sudden onset back pain with weakness in both legs and sensory change. The pain was located at mid thoracic area, and was positively related to motion. It started 5 days prior to the visit and the neurologic changes occurred the following day. Neurologic examination revealed grade IV motor power on both legs and hypoesthesia was present below the level of the xiphoid process. The patient was able to walk with the aid of a cane. He had been taking anti-arrhythmic medications for a year, and had no other past medical history.\nPlain radiographs and magnetic resonance imaging (MRI) taken from the other hospital revealed a T8 acute compression fracture with cord compression (). Under an impression of the T8 pathologic fracture, we ran a series of tests to find the primary origin of the spinal metastasis. All laboratory tests including tumor markers were within normal limits. Chest and abdominal computed tomography scans did not show any mass lesions in solid organs. We discussed the plan for diagnosis with oncologists. Since the patient presented with neurologic symptoms in both lower extremities, we came to an agreement that planning an early spine surgery of T8 decompression and stabilization and making the pathologic diagnosis through tumor tissue removed during the surgery would be reasonable. Further systemic work ups such as whole body positron emission tomography was planned after confirmation of the pathologic diagnosis. No steroid therapy was performed during the preoperative period.\nA spinal embolization was performed prior to the operation. As a small size of the ASA was visualized on the left T8 segmental artery angiography (), only the right T8 segmental artery was embolized. On the following day, we carried out a total laminectomy of T8 and pedicle screw fixation from T6 to T10. Tumors located at the ventral side of the dura sac were partially removed to achieve circumferential decompression of the spinal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nChest X-ray findings during a medical checkup of a 70-year-old man showed an abnormal shadow. Chest computed tomography (CT) revealed a nodule on the side of the left lower lobe or posterior mediastinum (A). The patient's medical history showed that he had multiple rib fractures and traumatic left hemopneumothorax due to falls 17 months before the first visit to our hospital. In addition, he had undergone chest tube insertion at another hospital. Three days after insertion of that tube, there was no leakage, and the amount of daily drainage was decreasing. Chest X-ray revealed improvement in the left hemothorax and the chest tube was removed. At this point, he had evidence of left lower pulmonary lobe contusion; however, no nodule was identified.\nContrast-enhanced chest CT of our hospital revealed a nodule in the left lower lobe (S10). The nodule was 27 × 18 × 16 mm in size and was elliptical with well-defined margins. It showed no contrast effect (B). Furthermore, 18F-fluorodexyglucose positron emission tomography/CT (FDG-PET/CT) revealed a little uptake (the maximum standardized uptake value = 1.66) in the lesion (). Chest CT performed 4 months after the first visit showed that nodule size had not changed. The patient had no history of malignancy, making a metastatic tumor unlikely. Taking the shape of the nodule and his history together, we suggested that the differential diagnosis was a benign lung tumor, a neurogenic tumor in the posterior mediastinum, a low-grade malignant tumor such as a pulmonary carcinoid. The resection surgery for diagnostic treatment was planned to rule out a malignant tumor.\nPartial resection of the left lower lobe was performed by thoracoscopic surgery. Intrathoracically, the white pleural change was at the left lower lobe. This pleural change was considered as the nodule that was visualized in the image, and a partial resection was performed (). The intraoperative pathological diagnosis was not a malignant finding, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 76-year-old woman with both multiple myeloma (MM) and myelodysplastic syndrome (MDS), was seen in the haematological outpatient clinic for a planned blood transfusion. The patient had no history of GI disease apart from minor GI bleedings, and no implants or history of alloplastic surgery. The most recent surgery the patient had undergone was an operation for a rotator cuff lesion 7 years previously. Six days earlier she had received two red blood cell transfusions and one transfusion of pooled platelets. The patient was diagnosed with light-chain MM 7 years ago. During the following years she received several lines of treatment with alkylating chemotherapy, glucocorticoids, immunomodulatory drugs and radiation therapy. Two years ago, she developed transfusion-dependent anaemia and thrombocytopenia and a new bone marrow biopsy and cytogenetic karyotyping revealed therapy-related MDS. Treatment with 5-azacytidine and recombinant erythropoietin or thrombopoietin was ineffective. Subsequently the patient was put on supportive treatment with oral 12.5 mg prednisolone daily and supportive transfusion therapy. She was in partial remission for her MM at the time of infection. Due to severe thrombocytopenia and prednisolone treatment the patient had had several prior episodes with minor GI bleedings before the time of the infection. The patient had also previously been examined for infections several times before the time of infection. Sixteen days before the positive blood culture with was drawn, the patient was discharged from the hospital after an admission because of suspected tonsillitis. Blood cultures were negative, and the patient was found to be negative for influenza virus A and B and respiratory syncytial virus. No other microbiological tests were performed. The patient was treated empirically with intravenous piperacillin/tazobactam and was discharged with oral penicillin and pivmecillinam. Two months before the present case story the patient had"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old right-handed male presented to the emergency department with right wrist pain and decreased range of motion of the forearm following a friendly grappling match. On history, he was mildly intoxicated by alcohol at the time of the injury. His friend had performed an arm-bar holding the patient's right arm between his legs while pulling on the forearm with his hands. The patient tried to escape the maneuver by forcefully pulling and pronating his forearm. He immediately felt pain in his right forearm and was unable to use it afterwards. His past medical history was significant for alcohol, tobacco, and cocaine use. He was not known to be suffering any other medical conditions and had never suffered any injury to his right wrist or forearm in the past. On physical examination, the forearm was locked in supination, with no passive or active pronation elicited. There was loss of the dorsal ulnar prominence, and a palpable and tender solid mass was felt on the volar aspect of the wrist, which was presumed to be a volarly dislocated ulnar head (). The skin was intact, and the neurovascular status of the hand was normal. Radiographic examination of bilateral forearms confirmed our suspicions, displaying overlap between the radius and ulna on the anteroposterior view and volar displacement of the ulnar head relative to the distal radius on the lateral view. A CT scan was performed, completing the clinical picture by revealing impaction of the ulnar head on the distal radius ().\nAfter obtaining informed consent, closed reduction was planned under procedural sedation. The reduction was first attempted by pronating the forearm while applying a posteriorly directed force to the ulnar head. After an unsuccessful first attempt, a second attempt was performed with an assistant applying pressure on the interosseous membrane (IOM) of the forearm using the palm of both of his hands, in an effort to free the impacted ulnar head from the distal radius (). With the ulnar hea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old female patient presented to our orthopedic outpatient department with a rapidly enlarging ulcerated right upper arm swelling which was growing gradually over the past six months. She recalled that it had been a pea-sized lesion and had remained the same size over the past 30 years. No history of preceding episodes of trauma or local irritation was found. The initially asymptomatic lesion had recently become painful and pruritic with slight bleeding. On examination, a large nodulo-ulcerative plaque was noted on the right upper arm, measuring approximately 12 cm × 6 cm in size (). Magnetic resonance imaging (MRI) revealed a mass measuring 12 cm × 6 cm × 1.5 cm, invading the deltoid and triceps brachii muscles (). Examination of the needle biopsy specimen demonstrated the proliferation of spindle cells in a storiform arrangement in the dermis. Results of tests for CD34 and factor VIII were negative, suggesting the possibility of a benign tumor. However, the clinical findings, which included muscle invasion, large tumor size, and rapid enlargement, suggested the possibility of malignancy, prompting the need for wide resection and myocutaneous flap-plasty. Intraoperatively, the tumor was found to have invaded the deltoid and triceps brachii muscles, as well as the cutaneous and subcutaneous tissue. Wide resection was achieved with a 3 cm margin. A latissimus dorsi musculocutaneous flap was needed to close the skin defect. The postoperative period was uneventful. Histopathological examination following hematoxylin and eosin stain revealed spindle cell proliferation with a vague storiform growth pattern and basal cell hyperplasia in the overlying epidermal cells (). The tumor tested negative for CD 34 on immunohistochemical staining but tested positive for SMA, CD 68, and factor XIIIa (Figures –). Mitoses were inconspicuous in the lesion, and the Ki 67 labeling index was also low, at 1 to 2%. These findings were consistent with a diagnosis of dermatofibroma."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male presented to the Cardiology department due to edema of the legs, erythema, pain, abdominal swelling, and was hospitalized with pulmonary hypertension, right heart failure, atrial fibrillation, chronic obstructive pulmonary disease, and cellulitis. The patient had a history of appendectomy when he was 20 years old and had been stabbed in the abdomen when he was 35 years old. He had been stabbed twice, and 1 h after the stabbing, he had been successfully treated by general surgery. The patient had been discharged 1 week postoperatively. The patient also had a 4-year history of smoking during his adolescent period. Five years earlier, the patient (age 45 years) had presented to the Cardiology outpatient service and was diagnosed with New York Heart Association (NYHA) Class II shortness of breath. On echocardiography (echo), his right heart cavity dimensions were mildly increased and pulmonary artery systolic pressure was found to be 45 mmHg. After treatment, his complaints regressed completely. Three years earlier (age 47 years), he had been admitted to the Pulmonology department with abdominal and bilateral leg swelling, and shortness of breath (NYHA Class III) complaints. CT thorax was performed and he was diagnosed with right heart failure. But dilated IVC was missed or might have been accepted as secondary dilatation to pulmonary hypertension and right heart failure. Intravenous diuretics, steroids, teophylline, and inhaled bronchodilator treatment had been administered. Subsequently, his complaints regressed. His echo findings at that period of time were as follows: Left ventricular ejection fraction 65%, Grade I diastolic dysfunction, normal left heart cavities, significantly enlarged right heart cavities, pulmonary artery systolic pressure 70 mmHg, and Grade 2–3 tricuspid failure. He was being closely monitored by the pulmonologist for pulmonary hypertension. One year earlier (age 49 years), he had been admitted to the Pulmonology department d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn April 1996 this 78-year-old woman was diagnosed with a poorly differentiated lobular carcinoma in the upper outer part of the left breast. Clinically it measured 15 mm. She was treated with conservative breast surgery and level III axillary node clearance. Tumor margins were clear and all lymph nodes were negative. Tamoxifen was commenced at 20 mg OD.\nA course of postoperative radiotherapy was arranged due to breast conservation surgery. She received 46 Gy in 23 fractions over 35 days using paired glancing megavoltage fields. This treatment was completed in July 1996 and was followed by a boost to the site of excision of a further 12 Gy in 4 fractions over 7 days using 9MEV electrons. Chemotherapy was discussed but the patient did not want to pursue this option.\nShe remained in regular follow up with no evidence of local or regional recurrence. In June 2005 during a routine follow up appointment she reported a 2 cm area of purple skin lesion at the lower inner quadrant of the left breast (figure ), with a history of it being there for about 3 months. It was associated with peau d'orange and soft tissue thickening extending from the lower inner quadrant across the midline. Mammography was not performed, as she was too tender. Ultrasound showed no evidence of a lesion deep to the abnormality. Freehand core biopsies were taken of the area. Pathology demonstrated the presence of malignancy in keeping with high-grade angiosarcoma.\nStaging investigations including CT chest and abdomen, CXR and bone scan none showed any evidence of metastasis. She had wide surgical excision and reconstruction with a Vertical Rectus Abdominus Myocutaneous flap (VRAM flap). She has completed her first year follow up without any recurrence.\nHistological examination following routine processing and staining with haemotoxylin and eosin shows malignant tumor (figure ). Although this tumor is predominantly solid, comprising highly pleomorphic cells (figure ) and areas with spindle cell morphol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-year-old male child presented to the outpatient clinic with a painless swelling and deformity over the left scapular region which was insidious in onset and gradually progressing over the past 3 months. The child was first born, with no siblings and there was no history of a similar condition in any of the family members. The child had developmental milestones appropriate for his age. There was no history of trauma and no swelling elsewhere in the body. There was no history of fever or weight loss.\nOn clinical examination, the left scapula looked asymmetrical as compared to the right, with the medial border of the left scapula seeming prominent and elevated from the thoracic cage (). A swelling was palpable 5 × 4 × 4 cm in size which was non-tender, immobile, arising from underlying bone and non-adherent to the overlying skin. It was non-fluctuant and non-compressible. Skin overlying the scapula was intact. Range of motion of shoulder and cervical spine was normal and unrestricted. On neurological examination, the sensory, motor, and reflex testing of bilateral upper limbs were within normal limits. There was no sign of compression of nerves, vessels, or lymphatic system.\nPlain radiographs and computed tomography (CT) scan (, , ) were done. The radiograph showed a bony lesion and the CT scan demonstrated a well-corticated bony excrescence arising from ventral surface of the left lower part of body of the scapula, 3 cm proximal to inferior angle and no associated fracture of the bony stalk.\nIn this case, we had a skeletally immature 2-year-old male child who was asymptomatic apart from a painless mass over the scapula with no associated complications, and hence, was planned to be managed conservatively and followed up regularly at 6 monthly intervals till skeletal maturity. This was planned keeping in mind the fact that a benign ventral scapular osteochondroma ceases to grow after the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 40-year-old man who presented to the Mycetoma Research Centre (MRC) in Khartoum, Sudan with a painful left shoulder mass lesion and multiple sinuses discharging purulent discharge and black grains. He experienced increasing pain and loss of shoulder function over 3–4 months, alongside nausea, vomiting, and anorexia.\nFourteen years earlier, the patient recalled a laceration to the left shoulder during a traditional sword dance. This penetrating trauma may well relate to the current infection. The clinical course of the laceration infection lasted six years. He presented to his local rural medical centre six times, undergoing two surgical incisions and curettage procedures with subsequent physiotherapy. These achieved good functional restoration, but a definitive diagnosis was not achieved. The swelling recurred sometime later. At his fifth local consultation, four months before presenting to the MRC, a differential diagnosis of mycetoma was raised and he was started on oral itraconazole. Two months later he returned for his sixth consultation at his local health centre when it was noted the swelling had increased in size, accompanied with pain, discharging sinuses, and the systemic features noted above. He was admitted to the local health facility for 11 days and treated with intravenous benzyl penicillin, cefuroxime, and analgesia. Blood test at this time showed raised erythrocyte sedimentation rate (ESR) (110/hour). No surgical biopsy or cytology smears were taken from the lesion, but, following discharge, he was referred to the MRC to be seen one month later with subsequently admission to Soba University Hospital.\nHe had an appendicectomy one year prior to presentation, keloid scars over the xiphisternum following cautery, traditional treatment for back pain, a snake bite resulting in fixed flexion of the right fourth finger, and childhood abdominal surgery to evacuate traumatic haematomas. There was no family history of mycetoma. The patient was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old male patient with no specific medical history was admitted to University Hospital for paraparesis and sensory disturbances in both lower extremities, caused by a fall 3 months prior to admission. He was diagnosed with CES, due to a L3 burst facture and spinal canal compression. Thus, posterior lumbar interbody fusion was performed (). After surgery, paraparesis improved progressively and no specific symptoms were reported, except neuropathic pain. The patient was transferred to a rehabilitation hospital for conservative treatment of the neurogenic pain and gait training; no specific complication was found during treatment.\nThe patient was transferred to our emergency department with fever and general weakness for 7 days. A complete blood count indicated leukocytosis, and Klebsiella pneumoniae was isolated from blood and urine culture tests. By abdominal ultrasonography, edema was observed in the bilateral renal parenchyma with hyperechogenicity, indicating renal failure, caused by acute pyelonephritis. No local lesion in the renal parenchyma, decreased blood perfusion, or extension of the renal pelvis or renal calyx was observed. After diagnosing sepsis, caused by acute pyelonephritis, meropenem was administered intravenously. After antibiotic treatment for 13 days, vital signs were stable and laboratory findings returned to normal. Antibiotics were stopped on the 15th day.\nThe patient was transferred to the rehabilitation medicine department for comprehensive management of his CES on the 16th day of hospitalization. In the Medical Research Council Manual Muscle Test, muscular weakness was observed in both lower limbs, with hip flexor 4/4 (right/left), knee extensor 3/3, ankle dorsiflexor 3/3, hallucis extensor 3/3, and ankle plantar flexor 2/2 grades. The patient complained of tingling sensations, allodynia, hyperalgesia, and decreased sensations below the third lumbar segment.\nSitting and standing up could be performed independently according to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male presented with a two month history of difficulty urinating and was found to have a fungating penile mass involving 50% of his penis. The mass was hard and fixed and extended from the glans proximally up the shaft. He also had bilateral palpable inguinal lymphadenopathy. There were no associated constitutional symptoms. Given there was a high suspicion for malignancy, the patient underwent partial penectomy within a month of presentation. Biopsy results confirmed a pT2 tumor with invasive keratinizing squamous cell carcinoma, poorly differentiated, and tumor size of 5 × 4 × 2.5 cm, with corpus spongiosum and lymphovascular involvements.\nFollowing the procedure, the patient had PET-CT for staging, and imaging revealed enlarged hypermetabolic bilateral axillary lymph nodes concerning for metastatic disease. In addition, there was a large centrally necrotic lymph node conglomerate in his left groin that had increased FDG avidity. The patient had left inguinal and bilateral pelvic lymph node dissections revealing metastatic squamous cell carcinoma in multiple lymph nodes. The left inguinal mass was also found to be metastatic well-differentiated SCC. His diagnosis was staged at T2N3M0.\nAfter his surgical procedures, patient was started on adjuvant chemotherapy. He began first line chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP). He underwent 4 cycles of TIP but eventually developed disease progression on repeat imaging. At this point, the patient was started on cetuximab given EGFR amplification on tumor analysis with the FoundationOne testing platform. However, the patient had an allergic reaction to cetuximab, so his treatment was changed to panitumumab. The patient had stable disease and a progression-free survival of 6 months with anti-EGFR treatment, which is clinically significant given that this treatment was given in the second-line setting for an aggressive tumor type that other than chemotherapy there is no other approved drug t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMr. B.C. is a 35-year-old male patient who presented with a six-month history of right lower quadrant pain and weight loss of 20 pounds. He also complained of constipation with a decrease in bowel motion frequency from once per day to two per week.\nOn examination, B.C. was noted to be cachexic. Palpation of the abdomen revealed tenderness in the right iliac fossa; however, no signs of peritonitis were elicited. Complete blood count and renal and liver function tests were normal.\nComputed tomography (CT) of the abdomen and pelvis with intravenous contrast showed a thick-walled (6.3 mm) caecum with fat stranding and a small volume of adjacent free fluid (see ). These findings were reported as being consistent with inflammatory bowel disease.\nThe patient subsequently had a colonoscopy which showed a mass at the caecal pole with edematous, inflamed tissue and pus (see ). Random biopsies were obtained from the inflamed colonic mucosa. Attempts at intubation of the ileocecal valve were unsuccessful. The rest of the colon appeared normal. Histology of the biopsy showed a marked increase in the number of chronic inflammatory cells dominated by tissue eosinophilia, consistent with a diagnosis of eosinophilic colitis. The specimen revealed no evidence of malignancy.\nConsidering the CT and histology findings, the patient's age, and the absence of a family history of malignancy, the findings at colonoscopy were interpreted as an inflammatory mass secondary to eosinophilic colitis. Stool microscopy showed no ova, cysts, and parasites. In conjunction with a gastroenterologist, the patient was started on an empiric course of albendazole and mesalamine.\nOne month after his first presentation, Mr. B.C. represented reporting no improvement in symptoms, further weight loss of 10 pounds, and intractable abdominal pain. At this time, the patient was tender in the right lower quadrant of the abdomen with guarding. Repeat CT scan showed a fluid collection surrounding the ca"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old hypertensive, obese, diabetic, male patient with short neck presented with episodic falls, difficulty in walking, and brief loss of consciousness to our hospital. Weakness of both hands and progressive weakness of all four limbs were present since 1 week. The patient was diagnosed as complex partial seizures clinically. There was no history of trauma at the presentation or in the past. The patient had a history of subarachnoid haemorrhage 6 months back for which conservative management was done elsewhere. Magnetic resonance (MR) imaging of the brain showed mild effacement of the sulcal spaces on T1 weighted images (T1WI) and T2 weighted images (T2WI) (Figures and ). There was a positive phase shift and blooming along the sulcal spaces on phase contrast and maximum intensity projection (MIP) susceptibility weighted images (arrow heads in Figures and ) suggestive of superficial siderosis. There was no evidence to suggest the possible source of haemorrhage in the MR images of the brain. The remainder of general physical and systemic clinical examination was also unremarkable. Screening of the spine was done to locate the possible source of the bleeding leading to superficial siderosis.\nCervical spinal magnetic resonance imaging (MRI) revealed an intradural extramedullary mass occupying the anterior intradural space which displayed hypointense signal on T2WI and hyperintense signal on T1WI (Figures , , , and ). Contrast enhancement of the mass was not evidently revealed by visual assessment on postcontrast fat saturated T1 weighted images () due to strong T1 hyperintensity of the mass on unenhanced images. Mild peripheral heterogeneous enhancement of the tumor was verified by the subtracted images (). The lesion was compressing and displacing the spinal cord posteriorly (arrow in Figures , , and ). The PET CT images showed moderately FDG avid extramedullary intradural mass (arrow in ) and no other foci of FDG avidity were noted elsewhere in the body"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old female, not known to have any chronic illnesses, presented to the urology department after the patient developed sudden hematuria six hours after a lower abdominal cesarean section. Her medical history was insignificant with one previous child who was delivered by CS and no allergies or medications confirmed. Meanwhile, social history was negative for tobacco, alcohol, or any illicit drug use. Upon examination, the patient was afebrile, vitally and hemodynamically stable, while systemic review was unremarkable. Moreover, local examination showed a full flank with mild abdominal distention and mild generalized tenderness without any signs of peritonitis. Regarding her investigations, complete blood count was within normal limits while Renal Function Test (RFT) showed elevated creatinine (3.42 mg/dl) (Table ). A non-contrasted Computed Tomography (CT) was ordered and a finding of a large amount of intraperitoneal fluid accumulations was reported (Figure ). After normalization of serum creatinine and glomerular filtration rate (GFR), which was achieved by a foley catheter drainage, a CT cystogram showed a defect in the dome of the urinary bladder with extravasation of contrast to intraperitoneal space (Figure ).\nThe choice of taking a non-invasive approach was determined after the patient's refusal for any further surgical interventions to be done. Afterwards, tapping off the intraperitoneal fluid was done with an abdominal fluid drain insertion which was inserted under local anesthesia and under the guidance of ultrasound and complete aseptic conditions rather than the standard surgical approach for the removal of the intraperitoneal fluid collection. Moreover, a 6.5 French pigtail catheter was inserted for 14 days to allow for maximum fluid drainage with a plan for surgery in case there is further deterioration. Fluid chemistry showed high creatinine levels (377 mmol/L), indicating the presence of urine in the abdominal area within less than 24 hours. T"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old gentleman reported with inability to lift his right upper lid following the development of a painless swelling in the right brow region of two weeks' duration. There was no history of any diplopia, or visual disturbances and nor was there any concurrent dental, ear, nose, throat (ENT) or significant systemic illness. The patient had sustained deep lacerations of the scalp and forehead due to a road traffic accident a year earlier. There was no history of loss of consciousness, bleeding ENT or any visual disturbances at the time of injury. He had been treated elsewhere with wound suturing and antibiotics novoclox and metrogyll for five days, following which he recovered well and had remained symptom-free till the present illness.\nClinical examination revealed a firm, non-tender, finely nodular swelling 2 cm × 4 cm in size, in the superotemporal region of the right upper lid, with an accompanying moderate grade mechanical ptosis. Skin over the swelling was normal and the mass seemed to be continuous with the supero-temporal orbital rim but not with the lacrimal gland []. The frontalis muscle was acting normally. Both eyes were normal with a visual acuity of 20/20 in each eye. Exophthalmometric readings were normal. Dental, ENT and systemic examinations were also normal.\nOrbital X-rays revealed a soft tissue shadow anterior to the orbital margin. There were no bony abnormalities seen. Magnetic resonance imaging (MRI) revealed an ill-defined extraconal lesion at the superior and lateral aspect of the right orbit which seemed to involve the lacrimal gland. The radiologist's report suggested the presence of a pseudotumor orbit or lymphoma [Figs. and ]. Consequently, tissue samples from three different areas of the mass were obtained by fine needle aspiration cytology (FNAC), through both skin and conjunctival approaches. The FNAC was reported as organizing infected hematoma, although the infective organism was not identified. As treatment with intravenous ce"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man presented to our institution with a 3-year history of pain in the left throat and trismus caused by pain. Magnetic resonance imaging in the Department of Neurology revealed an abnormal shadow above the hyoid bone. The patient was referred to the Department of Otorhinolaryngology, where no abnormal signs other than trismus were found. Computed tomography (CT) revealed that the left styloid process was connected to the hyoid bone, had a total length of 70 mm, and was approximately 10 mm thick along almost its entire length (Figures and ). Five years earlier, the patient had been transferred to our emergency clinic with a facial injury, and cervical CT images taken also revealed elongation of the styloid process. At that time, the styloid process had been approximately 5–7 mm thick, and its enlargement in the subsequent 5 years was evident ().\nThe patient was diagnosed with Eagle syndrome and treated initially with analgesics. However, the treatment with analgesics had not improved his pain, so he underwent transcervical resection of the styloid process under general anesthesia. A horizontal skin incision was made in the upper part of the neck, and the submandibular gland was removed to ensure a wide surgical field (). The styloid process was firmly connected to the hyoid bone on the dorsal side of the hypoglossal nerve, and a 40 mm portion was resected from the attachment to the hyoid bone. No invasion of the surrounding tissue was found intraoperatively, and it was easy to separate and resect the bone. Pathologic examination revealed that the lesion consisted of bony tissue with a bone marrow component and a cartilaginous component in contact with the trabecular bone. There were no signs of active inflammation or malignancy. The symptoms such as pain and trismus disappeared completely. Preoperatively, the patient scored pain on opening his mouth and pain on swallowing as 8 on a visual analog scale, and both scores improved to 0 postoperatively. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old man with spastic tetraplesia diagnosed with CLS at age 3 was referred to our hospital. One year before admission, the patient's parents noticed that he could not walk long distances and had a spastic gait. His gait disturbance became worse over time. One month before admission, the patient could not walk even several meters and had decreased upper extremity locomotor activity, such as an inability to elevate his arms. At the time of admission, he could not get up and could only make slight movements of the distal potions of his extremities.\nThe patient's appearance was consistent with previous descriptions of patients with CLS. He had a prominent forehead, coarse faces, broad nose, thick septum, wide mouth, and tapering fingers (Fig. ). He could emit a groan but could not have a conversation. We were unable to perform assess sensory function on physical examination. He could move his neck but not his trunk or extremities. Spastic weakness and very brisk muscle stretch reflexes were observed in all 4 extremities, and Babinski sign was observed. A balloon-catheter was placed because of dysuria. We suspected his symptoms were caused by cervical spinal cord damage, and performed imaging studies.\nComputed tomography (CT) showed hypoplasia of the posterior arch of the C1 vertebra, and continuous calcification of the YL from C2 to T3 (Fig. ). Magnetic resonance imaging (MRI) revealed that the cervical spinal cord from C1 to T1 was compressed by the calcification (Fig. ). Image quality for MRI was low because the patient reacted poorly to anesthesia and moved during the examination. Although diagnostic information was limited, we diagnosed acute exacerbation of cervical myelopathy, and performed emergency surgery.\nUnder general anesthesia in the prone position, the C1 to C7 laminae were exposed. Twenty millimeters of the width of the C2 to C7 laminae were removed using a high-speed drill. Adhesion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old female presented with a chief complaint of left hip pain of 5 months’ duration. The patient had been seen approximately 10 months prior to presentation, shortly after experiencing a “clunk” in her right hip. She reported that her pain was stable and had not increased since that episode. Relevant history included a left primary THA approximately 25 years ago. The patient also reported a right primary THA at the age of 33 years, followed by a head and liner exchange 10 years later due to poly wear and broken tine. A right total knee arthroplasty procedure was performed approximately 1 year ago. Comorbid conditions reported included degenerative joint disease, thrombocytopenia, cirrhosis of the liver, lumbar spondylosis and anemia. The patient had been managing any ongoing hip pain with anti-inflammatories and routine monitoring of poly wear with annual radiographs.\nOn physical examination, a pain-free range of motion (ROM) of the affected hip was noted, although the patient demonstrated hesitation at the extremes of motion. Slightly reduced ROM was noted with internal and external rotation when compared with the right hip. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. Radiographs were obtained and revealed severe polyethylene wear and asymmetry in the left hip (). Some acetabular and proximal femoral lysis was noted, although there was no change in the acetabulofemoral component interface.\nThe pre-operative plan for this patient was to exchange the polyethylene liner only; however, during surgery, it was observed that the locking mechanism on the poly component was incompetent. Furthermore, intraoperative measurement with the navigation system indicated anteversion of 5° (radiographic definition), revealing a cup component significantly more retroverted than the 18° indicated by the pre-operative radiograph (). A decision was made to exchange both the liner and the cup component ().\nSurgery was successful, and post-operat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA three year-old girl presented with abdominal pain and jaundice of one month duration. The pain was epigastric in origin, and worsened after eating. Her history was unremarkable except for blunt trauma following a car accident. The child was sitting on her father’s lap while he was driving whenthe accident occurred.After trauma the child was visited by a physician because of vomiting. When ultrasound and physical examination of the child was normal she was discharged and given metoclopramide drops. Over the next three days, she had nonbiliary vomiting which stopped thereafter. The child complained of occasional abdominal pain which was finally complicated by icterus. She appeared healthy and tolerated feeding well, although occasionally complaining of postprandial abdominal pain. She did not have a fever and her vital signs were normal. The physical examination showed a soft abdomen with no tenderness but revealed jaundice. The laboratory data results wereas follows: WBC = 12600 mm3, Hb = 12 g/dL, ESR = 25 mm/h, total bilirubin = 8.4 mg/dL, conjugated bilirubin = 6.9 mg/dL, aspartate aminotransferase (AST) = 559 IU/L, alanine aminotransferase (ALT) = 475 IU/L and alkaline phosphatase = 938 IU/L. A new ultrasound examination showed remarkable dilatation of the common bile duct to 8 mm with a terminal stricture. Barium meal showed a normal stomach and an open duodenum. Magnetic resonance cholangiopancreaticography (MRCP) demonstrated severe dilatation of the both intrahepatic and extrahepatic bile ducts ().\nThe patient was operated with a diagnosis of obstruction of the end of the common bile duct. The severe dilatation was obvious upon operation. The common bile duct was explored. A small catheter was passed with difficulty which pointed to severe stricture and fibrosis,not amenable to dilatation. The patient underwent choleducoduodenostomy. On the third day postoperatively, the patient started oral feeding. On the fifth day postoperatively, the serum bilirubin decr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old girl was referred to the Oncology Section of the Endocrine Unit of the University Hospital of Pisa, Italy, for suspected MTC based on the presence of both thyroid nodules and elevated serum levels of calcitonin (Ct).\nThe medical history of the child showed that she was born after a caesarean section at 38 weeks with a weight of 2400 g as well as with newborn jaundice and biliary vomiting. Because of the failure to pass meconium, congenital intestinal dysganglionoses or cystic fibrosis was hypothesized, but at that time, both were ruled out by a rectal biopsy and sweat test, respectively. The patient continued to experience biliary vomiting and failure to thrive; for this reason, she was fed using a nasogastric tube for a long period of time. When she was 2 years old, pyloric stenosis was suspected, and the girl underwent digestive system scintigraphy that demonstrated slowed gastric emptying. On the basis of this test, the patient underwent dilatation of the pylorus but did not achieve any clinical benefit. During gastroscopy, an irregular and small duodenum associated with esophagitis was documented. Magnetic resonance imaging (MRI) demonstrated an abdominal solid massive and expansive lesion (14 cm at the largest diameter) that extended down to the pubic region and surrounded the urethra and the bladder, without any cleavage plans, thus causing mild hydronephrosis. She underwent laparotomy with debulking of the lesion since it was unresectable. The histology described a ganglioneuroma. Over the years, she developed vesicoureteral reflux and recurrent pyelonephritis due to an increasing pressure of the pelvic mass on the bladder that forced her to practice intermittent catheterizations. At 6 years of age, urological control demonstrated high-grade (grade III) vesicoureteral reflux with markedly decreased excretive functioning bilaterally.\nAt 7 years of age, a serum calcium level of 11.3 mg/dl with a serum parathyroid hormone (PTH) level of 49 pg/ml was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old man with liver cirrhosis and ulcer of the stomach in his medical history was found to have a T3N1M0 squamous cell carcinoma in the floor of the mouth between teeth 33-43. The tumor was surgically resected, and the patient was reconstructed with a free anterior lateral thigh (ALT) flap. At the same procedure, a neck dissection region 1-5 right side and region 1 left side was carried through since fine needle aspiration cytology had confirmed a regional metastasis in region 1, right side. The patient received antibiotics the same day as the surgery and regularly the days after surgery. However, the patient developed a redness on the neck and on the flap donor site 5 days after surgery, and pus started to leak from the neck wound.\nThree years previously, the patient had been diagnosed with left-sided tonsil cancer and ipsilateral metastases on the neck. He then received full-dose (68Gy) radiotherapy. At the 3 months follow-up, a CT scan was routinely done and showed remaining lymph nodes with suspicious appearance. A neck dissection of the ipsilateral side regions 1-5 was carried out. Three days after surgery, a redness and suspected infection on the neck was found and clindamycin was ordinated. The patient was dismissed from the hospital but returned 13 days after surgery since the neck did not improve (Figure ). The neck showed alarming redness and the surgical wound was purulent. The patient was put into the ward and ordinated intravenous cefotaxime and later, cloxacillin, since a swab showed s aureus. Despite adequate antibiotics, a flap necrosis developed, and the neck was closed a month after the neck dissection with a transposition flap. The flap area got red after surgery, and a local swab showed presence of enterococcus and coagulase-negative staphylococcus. The patient was treated with several courses of antibiotics, and the flap eventually healed without necrosis about a month after the flap surgery (Figure ).\nAfter"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old woman presented with a one-month history of a perianal lesion. She had a CD4 count of 18 cells/µL. Herpes simplex virus (HSV) and Cytomegalovirus (CMV) inclusions were both present in the perianal biopsy (). No serological testing for HSV or CMV were performed.\nInfection with HSV2 typically presents as genital ulcers. There is a strong association between HIV and HSV2 infection. Individuals infected with HSV2 have sixfold higher odds of HIV infection compared with those uninfected with HSV2, and 68% of patients with genital ulcers caused by HSV2 were found to be co-infected with HIV. Locally, HSV2 remains the leading cause of pathogen detectable genital ulcer disease. Histologically, cells infected with HSV2 show intranuclear inclusions with a glassy appearance, margination of chromatin and multinucleation. Infected keratinocytes are best demonstrated at the ulcer edge (). However, in hypertrophic or tumourous HSV2 lesions, the dense inflammatory cell infiltrate may obscure the viral inclusions. Careful search of multiple levels through the tissue block and immunohistochemistry may be required to identify the virally infected cells. Sparse infected cells within the deep dermis derived from ruptured hair follicles may be seen. It has been postulated that the florid inflammation noted in these hypertrophic lesions is due to immune reconstitution. Tissue may be submitted for drug resistance testing in those cases not showing clinical response to standard therapy. Cells infected with HSV and varicella-zoster virus show identical features on histological examination. Immunohistochemical stains are available to help distinguish among them.\nCharacteristic intracytoplasmic and intranuclear CMV inclusions were also seen in case 6 (, inset) but atypical histological features are well documented. Immunohistochemistry can also be used in those cases that are densely inflamed. The role of CMV that is detected in mucocutaneous lesions is controversial. It is thought"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 49-year-old Japanese woman with a history of NF1. There was no family history. She had brown spots on the skin and multiple dermatofibromas, and she was diagnosed with sporadic NF1 by biopsy in her teens. After small intracranial aneurysms (< 2 mm) were found in the right middle cerebral artery 2 years ago, she underwent annual magnetic resonance imaging (MRI) follow-up (Fig. left). In addition, she was orally administered phenytoin for the treatment of genuine epilepsy. There were no aneurysms anywhere other than in the brain. She also had a history of untreated hypertension. She had no other complications, such as intracranial neurofibroma and brain tumors.\nShe was transported to our hospital because of acute headache and disturbance of consciousness and was diagnosed with subarachnoid hemorrhage by computed tomography (CT) (Fig. A). Regarding the disturbance of consciousness, she had a score of 13 on the Glasgow Coma Scale, grade III in the Hunt and Kosnik grading system, and grade II in the World Federation of Neurosurgical Societies grading. Blood pressure was over 200 mmHg. Computed tomography angiography revealed multiple intracranial aneurysms (Fig. B, and C). Based on the distribution of hematoma, we suspected that one of the aneurysms in the peripheral branch of the left middle cerebral artery, rather than known intracranial aneurysms in the right middle cerebral artery, was the source of hemorrhage. These multiple small intracranial aneurysms in the left middle cerebral artery were considered de novo aneurysms because they were not found on brain MRI in the previous year (Fig. right). Accordingly, she underwent emergency surgery on the day of admission. After a left frontotemporal craniotomy, the Sylvian fissure was opened, exposing the superior and inferior trunk (M2) of the middle cerebral artery. We found small intracranial aneurysm (< 2 mm) in the bifurcation of the left middle cerebral artery. During surgery, only one small aneurysm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68 year old female, known case of hypertension and osteoporosis presented to the emergency department with complaints of absolute constipation for five days, abdominal distension for three days and vomiting for one day. Abdominal distention was gradual in onset and generalized. Vomitus was feculent and large in quantity. Apart from an uneventful caesarian section 35 years prior, she had no other past surgical history. On examination, the abdomen was tense, tympanatic and mildly tender on the right side on deep palpation. DRE revealed collapsed ano-rectal canal with no fecal staining. Her Xray abdomen supine shown below () demonstrated dilated small bowel and cecal distension with fecal loading and no gas under the diaphragm was seen in the chest x-ray (). She had history for similar complaints one year back, for which she was managed conservatively. She was on medications for osteoporosis, and had family history of Chron’s disease.\nCT scan with IV contrast demonstrated marked diffuse dilatation of small bowel loop and the cecum with abrupt point of transition at the junction of cecum and the ascending colon. Mild ascites was seen in the peri-hepatic region, in the pericecal region and the pelvis (, ).\nBased on radiology, no proper cause of intestinal obstruction could be identified. The patient was offered colonoscopy before laparotomy but she chose to get operated. Surgery was performed by consultant surgeon and senior registrar. Patient was counselled for right hemicolectomy, diversion and stoma formation.\nOn laparotomy, around 200 ml reactionary fluid was aspirated. The cecum and small bowel were distended but healthy looking. Cecum was found rotated anteriorly upon itself (). Distal to the caecum, the large bowel was collapsed. There was no other obvious pathology observed. Liver and peritoneum were normal. Cecectomy was done with end to end ileo-colic anastomosis.\nPost operatively, the patient was kept in the general ward, and she developed ileus ("}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old male was admitted to another hospital in March 2014 with symptoms of hematemesis and tarry stool. He had a history of hypertension, cardiac infarction, and aortic regurgitation. Laboratory data collected on admission revealed anemia (hemoglobin concentration, 6.4 g/dl), and he received a transfusion of four units of packed red blood cells. A CT scan showed the presence of irregular dilated arteries in the pancreatic head, and he was diagnosed with pancreatic artery pseudoaneurysm presenting with multiple arterial feeder vessels.\nThe patient was referred to our hospital for treatment. On admission, a CT scan showed the presence of meandering irregular dilated vessels in the pancreatic head (Fig. ) and an early appearance of the portal vein at the arterial phase (Fig. ). Further evaluation using 3D imaging showed feeder vessels from the superior mesenteric, celiac, and splenic arteries (Fig. ). Magnetic resonance imaging showed the strong enhancement of the conglomeration in the pancreatic head (Fig. ), and reformed maximum intensity projection imaging showed feeder vessels from the superior mesenteric and celiac arteries with an early appearance of the portal vein at the arterial phase (Fig. ). Selective angiography showed the proliferation of a vascular network in the pancreatic head and early visualization of the portal vein at the arterial phase (Fig. ). Color Doppler imaging revealed a mosaic-like structure comprising pulsatile waves. The preoperative diagnosis was AVM of the pancreatic head.\nThe intraoperative examination revealed that there were no abnormal vessels and/or collateral vessels on the surface or around the pancreas except dilated drainage veins at the top of the pancreatic head (Fig. ). But, serial sections of the resected specimens revealed dilated and tortuous vessels in the pancreatic head (Fig ). Four feeder arteries from the superior mesenteric artery and two feeder arteries from the common hepatic artery were detected during the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man who had had diabetes and hypertension for the last 15 years presented with a history of right-sided weakness which progressed slowly over a period of 2 weeks. A week before presentation he had also developed headache, vomiting, and difficulty in swallowing. At presentation, he had loss of speech followed by altered sensorium. The patient had also been having cough with minimal sputum off and on and loss of weight for the last 3 months.\nThe patient had a focal lesion on a brain MRI, along with a left pleural effusion on a chest radiograph, and had been treated for tuberculosis. When he was finally seen in our hospital, the patient was afebrile and had a raised pulse rate and blood pressure. The liver was mildly enlarged. Respiratory and cardiovascular system examination was unremarkable. He had altered sensorium, with aphasia and complete weakness of the right side of the body (grade 0/5 power in both upper and lower limbs). The plantar was upgoing on the right side and there was gaze preference to the left. Fundus examination revealed a few microaneurysms at the macula, a few cotton wool spots, and mild arteriolar attenuation in both the eyes.\nThe laboratory examination revealed normal red blood cell and renal function parameters, with normal sodium and potassium levels. The total leucocyte count was reduced.\nContrast-enhanced CT of the head [] revealed conglomerate, ring-enhancing lesions in the left parietal lobe, with significant surrounding edema and contralateral shift. There was no abnormal meningeal enhancement. Contrast-enhanced MRI of the brain revealed perpherally enhancing conglomerate lesions in the left parietal lobe [], with significant surrounding edema. These lesions showed central hyperintense signals with low signal intensity walls on the T2W images []. On T1W images, the central contents appeared hypointense. USG of the abdomen showed a small right pleural effusion and hepatomegaly. Contrast-enhanced CT scan of the chest revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old lady presented to the Accident & Emergency (A&E) department immediately after a fall from standing height with a painful deformed right elbow. Initial radiographs demonstrated a dislocation of the elbow with no associated fractures (). The joint was manipulated by the A&E staff and the arm was placed in an above elbow plaster back slab with 90° flexion. Postmanipulation radiographs confirmed the reduction albeit with some subluxation of the radio-capitellar joint (). The patient was discharged home. Four days later she was reviewed at the fracture clinic by a locum doctor who also did not appreciate the importance of subluxation on the post-reduction film and did not repeat the radiographs. The arm was placed in an above elbow complete cast and a review was scheduled in a further two weeks. At this review, three weeks following her injury she was in severe pain and the elbow was noted to be obviously clinically dislocated with extensive bruising and swelling. Fortunately the hand remained neurovascularly intact. Radiographs confirmed the now chronic dislocation (). At this point the soft tissues prevented further closed reduction.\nThe patient had significant medical comorbidities: ischaemic heart disease with previous coronary stents; left ventricular failure; complete heart block with a permanent pacemaker; type 2 diabetes; a BMI > 35 and emphysema treated with long-term steroids. She was discussed in the departmental trauma meeting and due to her high anaesthetic risk, poor soft tissues and general frailty she was assessed as not suitable for our standard operative treatment with collateral ligament repair and stabilisation with a hinged external fixator. The options suggested by the consultant body at the trauma meeting were to offer either non-operative treatment (pain control medications and a brace) or percutaneous trans-articular pinning. Both these options have significant drawbacks in terms of functional outcome. We have previously described a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 79-year-old man presented to his local hospital in May 2007 with a 2-month history of a chronic non-productive cough, weight loss of 1.5 stone (9.5 kg) over 1 month, anorexia and general malaise. Other gastrointestinal or respiratory symptoms were absent. Examination was consistent with the finding of a left-sided pleural effusion and of note, abdominal exam was normal. An admission chest X-ray showed a left-sided pleural effusion with basal collapse. His inflammatory blood markers were also elevated (WCC 21.3, CRP 286). He was commenced on intravenous antibiotics but showed little improvement after 3 days of treatment, at which point a computed tomographic (CT) scan of the thorax and abdomen was performed. The CT showed a loculated pleural effusion consistent with an empyema plus thickening of the pleura and diaphragm as well as an abnormal thickened splenic flexure adjacent to the diaphragm (Figure ). The patient was subsequently transferred for further management.\nOn the day of transfer, the patient was taken to theatre for pleural decortication. A posterolateral thoracotomy was performed and the abscess collection was evacuated. A small perforation of the diaphragm was also found and it was established that the abscess cavity was extending through the diaphragmatic defect (Figure ). At this point a laparotomy was performed. It was found that the patient had a locally perforated splenic flexure tumour, which had formed a collection that communicated with the thorax and also invaded the spleen. The tumour, along with the adherent spleen was removed (Figure ) and a transverse colostomy and distal mucus fistula were fashioned. An omental patch was used to close the defect in the diaphragm.\nThe patient made an uneventful postoperative recovery and was discharged from hospital 15 days after the operation having received the relevant vaccinations. Pathological assessment showed a Dukes B moderately differentiated adenocarcinoma with the pathological staging of T4"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old male without any previous medical history presented to our emergency room (ER) with multiple traumas from a 10 meter fall in a construction field. Physical examination revealed a male patient with a body mass index in the normal range and an acutely ill looking appearance. His right lower leg and ankle were swollen and bruised, and he had a 2 cm laceration wound on the plantar aspect of his right foot. The patient's right ankle had limited range of motion due to pain. The patient had tenderness at the right anterolateral aspect of the mid lower leg and anterior aspect of the ankle. There was grade 1 anterolateral instability of the left ankle. The neurologic examination was normal. Based on the patient's clinical history and physical examination, the orthopedic surgeon suspected a fracture of the right fibular diaphysis and ligament injury of the right anterolateral ankle.\nInitial radiographs of the ankle in the anteroposterior and lateral views showed fractures at the diaphysis at the fibula and anterior lip of the tibial plafond (Fig. ). The patient was not able to undergo ankle Mortise view because of his limited range of motion due to extreme pain. In a subsequent lower extremity computed tomography (CT), the orthopedic surgeon in the ER noticed a segmental fracture of the right fibular shaft and the anterior lip of the tibial plafond.\nTo evaluate the ankle ligaments, a turbo spin-echo (TSE) two-point mDixon technique applied to an ankle MRI (Table ) was performed after procuring written informed consent. In addition to the fractures of the right fibular shaft and tibial plafond, this MRI demonstrated a tiny chip fracture of the lateral talar dome. A tiny wafer-shaped talar dome chip fracture fragment about 7 (anterior–posterior diameter) × 3 (head to toe diameter) mm was clearly delineated only in the sagittal T2-weighted mDixon opposed-phase MRI (Fig."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male had continuously visited the Department of Oral and Maxillofacial Surgery at Yonsei University College of Dentistry for MRONJ which had primarily developed after zoledronic acid and capecitabine administration for previous bone metastasis of medullary thyroid cancer. Pain, bone exposure, and pus discharge in the right mandible and left maxilla first occurred 5 years after discontinuing bisphosphonate and capecitabine administration. At that time, the patient was going through chemotherapy with another antineoplastic drug, everolimus. Clinical, radiological features of both jaws, and pathological evaluation of the mandible confirmed the diagnosis as MRONJ.\nSymptoms of the left maxilla started as chronic apical abscess with tooth mobility in the left premolars. Primary bone exposure with osteonecrosis at the left maxilla was observed after extraction of these teeth in a local clinic. The remaining sockets showed delayed bone healing with pus discharge and incomplete soft tissue covering.\nRadiologic examination by CT () revealed that there was an irregularly mixed radiolucent/radiopaque area in the left maxilla with discontinuity of the cortical barrier adjacent to the left buccal vestibule, palate, nasal cavity, and maxillary sinus. Mucosal thickening was seen in the left maxillary sinus and nasal cavity. These radiologic features persisted in the additional CT views taken 2 years later (data not shown).\nAfter a year of conservative treatment and another year and a half without periodic follow-up, the patient re-visited the hospital for recurrent bone exposure in the left maxilla with pus discharge. An ill-defined radiolucent/radiopaque lesion with definite alveolar bone loss was seen at the left maxilla on panoramic views (). The exposed sequestra were removed and sent for pathological evaluation.\nOn pathological examinations, the tissue specimen revealed mostly several necrotic bone fragments with surrounding nonspecific bacterial colonies and nec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old woman underwent a lower segment cesarean delivery for her fourth pregnancy two years before; she was transfused two units of blood for continuous vaginal bleeding. After delivery she failed to lactate, did not resume cycles and complained of fatigue. Three months before admission she complained of cough and intermittent fever with night sweats. She was seen at a primary health center where sputum was found positive for acid fast bacillus on multiple occasions, with no findings suggestive of tuberculosis on chest radiograph. The patient was started on antiitubercular treatment (ATT) in the form of isoniazid, rifampicin, ethambutol and pyrazinamide in appropriate doses. She felt more fatigue and weakness in the first week after starting ATT. On the tenth day she was found to be unconscious in the morning and was brought to the hospital. Examination in emergency revealed a sick, pale looking lady with a feeble pulse rate of 100 beats per minute and unrecordible blood pressure with a temperature of 99°F. She had breast atrophy and sparse axillary and pubic hair. She also had a systolic murmur at the mitral area suggestive of mitral regurgitation. Her deep tendon jerks revealed a marked delay in relaxation suggestive of hypothyroidism. In view of her postpartum hemorrhage (and need for blood transfusions), lactation failure, secondary amenorrhea, hypotension and features of hypothyroidism, a clinical diagnosis of Sheehan syndrome with adrenal crisis was made. The patient was given emergency treatment in the form of oxygen inhalation, intravenous fluids and a nasogastric tube was inserted. After taking a blood sample she was started on hydrocortisone 100 mg every 6 hours, levothyroxine 100 μg through the NG tube and ATT was continued. She regained consciousness after an hour and her blood pressure rose to 80/60 mm Hg. Investigations revealed a hemoglobin of 9.2 g/dL, total leukocyte count of 3.2×103/mL with polymorphonuclear leucocytosis, a platelet count of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53 year-old man was transported from another hospital with the high suspicion of a traumatic aortic rupture after acute blunt thoracic trauma. Following a high speed car accident he was admitted in another hospital with injuries in the chest and fracture of the left femur. A thorax-CT scan was performed without contrast medium because of a known chronic renal failure (creatinine levels = 2.2 mMol/L). It showed hemothorax on the left, minimal left lung contusions (of the posterior segments), rib fractures and a periaortic hematoma at the level of the isthmus area (figure ). Because of a high-suspicion index of thoracic aortic rupture, we decided to do an emergency aortography. It revealed an interruption of the normal contour of the thoracic aorta in the aortic isthmus area. A protrusion of the aortic lumen in the corresponding inner curve of the aorta supported our suspicion for the disruption of the intima and the initiation of a pseudoaneurysm's process (figure ). Therefore, an emergency operation (the interventional management was abandoned because of technical reasons) by using partial right femoro-femoral bypass for aortic isthmus repair was decided. Surprisingly, and after a postero-lateral thoracotomy at the 4th intercostals space, we inspected an \"intact\" outer thoracic aortic wall, without haematoma or related pathology at the aortic isthmus area. However, because we did not totally exclude a possible limited disruption of the intima, or even another pathology (see discussion), we decided to check from inside the thoracic aorta. Following proximal and distal dissection of the aorta, a partial cardiopulmonary bypass was initiated with flow level 2-2.6 L/min to restore a distal aortic pressure of >55-60 mm. After double clamping and vertical opening of the aorta wall, an intact endothelium was observed. In the inner curve of the aortic isthmus area and in the site of occluded ligamentum arteriosum, a local vestigial dilatation 0.5 × 0.8 cm with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 25-year-old male who presented with complaint of clawing of his left great toe. The patient had sustained a left-sided distal tibia fracture treated with open fixation of the tibia fracture 3 years ago. The implant was removed 18 months after the procedure due to the patient’s preference. After 6 months, the patient initially noticed clawing of his left great toe when he climbed stairs barefoot. He also complained that he had started to find it difficult to sit cross-legged, squat, as well as ride his bicycle due to the tightness he felt in his toes with certain ankle movements on examination, the patient walked with a normal bipedal unassisted gait. He had well-healed surgical scars and a plantigrade foot. Active dorsiflexion of the ankle joint produced an exaggerated flexion of the great toe. With the ankle held in dorsiflexion, it was not possible for the patient to actively or passively fully extend any of the toes (Figs. and ). The diagnosis of checkrein deformity of the left great toe was made and attributed to the previous fracture of the distal tibia resulting in scarring or ischemic injury to the toe flexors. The possible patterns of injury could have been an isolated injury to FHL muscle or tendon causing fixed flexion of the great toe. The patient elected for surgical intervention and surgical exploration of FHL tendon at the level of the midfoot was planned. Exploration at the midfoot would give easier access to both tendons free from scar tissue making correction easier. The patient was suitably consented and the exploration was performed under spinal anesthetic with an inflated tourniquet at 250 mmHg. The tendon of FHL was identified (). Subsequent z-plasty of FHL tendon gave a full correction of the great toe flexion contracture (). The patient made an uncomplicated post-operative recovery and after final review, 3 months post-surgery had"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old woman was presented with complaints of diarrhoea for 3 years. She had no medical history. Colonoscopy revealed slight extrinsic compression of the hepatic angle. CT examination showed a right retroperitoneal mass of 65 × 60 × 90 mm. The well-defined solid lesion was located in the right retroperitoneum, posterior and inferior to the duodenum, on the right side of the cava, and anterior to and on the left side of the right kidney. Based on these findings, the differential diagnosis was between a neurogenic tumour and a mesodermal tumour.\nBlood tests for tumoural markers, chromogranin A and urine metanephrines, were negative.\nAt a sarcoma multidisciplinary meeting, surgery was favoured over biopsy. Due to the inconclusive diagnosis, a conservative laparoscopic approach treatment was decided.\nWith the patient placed in left lateral decubitus position, four trocars were placed in a semicircular line in the right hemiabdomen. The right angle of the colon was mobilized to locate the tumour in the right side of the duodenum and the cava. The tumour was then dissected by ultrasonic shears and by blunt dissection from the cava; the right gonadal vein and the ureter were found to be in contact with the tumour but without infiltration.\nDissection indicated the tumour arose from the gonadal vein, and this was therefore clipped and divided. The tumour was maintained and completely removed by an accessory incision in the right flank.\nEn bloc resection was ruled out in view of the uncertain diagnosis. Postsurgical recovery was uneventful. Oral intake was started on the fourth day because she had nausea and vomiting in the immediate postoperative period. She returns slowly to a regular diet and was discharged on the ninth postoperative day.\nThe histological report confirmed a high-grade leiomyosarcoma (grade 2), with areas of focal necrosis, dystrophic calcification, and positive resection margins (R1). The tumour was described as a fusocelular sarcoma with crossed bu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old male patient reported to the dental clinic with the chief complaint of unesthetic appearance of the gums and hypersensitivity in relation to his upper right canine. No significant medical history and habits were reported.\nOn clinical examination, he had relatively fair oral hygiene. Periodontal examination revealed localized gingival inflammation in relation to maxillary right canine, with a probing pocket depth of 2 mm and clinical attachment loss of 5 mm with deep/wide Class I gingival recession []. The keratinized tissue (KT) thickness was around 2 mm which was measured at the center of an imaginary line from mucogingival junction (MGJ) to marginal gingiva, using an endodontic file with stopper after anesthetizing the region. Intraoral radiograph in relation to the tooth concerned showed no bone loss.\nConsidering the height (3 mm) and width (5 mm) of the defect, the treatment decided on was root coverage using an epithelial embossed graft technique. The treatment plan was explained to the patient, and a duly signed written consent was obtained. Oral prophylaxis was done 2 weeks before surgery.\nUnder local anesthesia, a sulcular incision was made in the right canine region, also involving mesial aspect of the first premolar and distal aspect of the lateral incisor as described by Raetzke.[] Envelop flap was raised without making vertical incisions []. Thorough root planing was done. The connective tissue graft was procured from the contralateral side of the palate between the left first and second premolar region. A tinfoil template was cut fitting the defect size precisely and transferred to the palate from where the donor tissue was to be obtained. It was placed in relation to the upper left premolar palatal region, and an incision was made around the tinfoil which extended 3 mm close to the gingival margin on either side []. The epithelium was undermined 3 mm from the incision. Releasing incision was given so that only the connective"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old right hand dominant male suffered a blast injury from a stick of dynamite. He was complaining of left hand, forearm, and elbow pain. Patient also endorsed significant numbness and tingling in the left hand. On physical exam, there was significant degloving of the palm and partial amputations of the second and third distal phalanges. Radial pulses were intact, with no evidence of an arterial bleed. A photograph of the hand on presentation can be seen in . Figures and are the initial radiographs of the hand and elbow, respectively, showing the extent of the injury.\nThe patient went for emergent washout and exploration by hand surgery. He was found to have complete obliteration of the superficial and deep palmar arches. Approximately half of the flexor tendons were intact. The thumb was attached via a single flexor tendon and remnant skin. The median nerve was completely severed at the level of the wrist. Open reduction and internal fixation (ORIF) of the distal radius and the distal ulna was not performed because of a lack of viable soft tissue coverage secondary to the traumatic injury from the blast effect as determined by the hand surgeon intraoperatively. The amputation level was partially based on the level at which viable soft tissue coverage was available for coverage of bone. The hand surgeon proceeded with a transradial amputation.\nClosed reduction of the ulnohumeral joint was performed by the orthopaedic team once hand surgery was done with their part of the procedure. The patient required 90 degrees of flexion at the elbow to maintain reduction due to gross instability. 3D reconstructions from the postreduction computerized tomography (CT) scan are seen in Figures and showing the terrible triad injury of the elbow.\nTwelve days after the initial injury, the patient returned to the operating room for definitive fixation. A Kaplan approach was used, which demonstrated rupture of the lateral collateral ligament (LCL) as well as a comminuted radial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second patient (PT2), a black female, was a 43-year-old non-smoker with weight of 300 lbs and height of 6–2\" at the time she presented for care at the clinic. She was diagnosed in New York in 2000 with right upper extremity lymphedema (Figure ) following treatment for breast cancer in 1998 including mastectomy, axillary dissection of 24 lymph nodes, radiation, and chemotherapy. A side effect of the radiation was fibrosis of the lateral chest wall and breast tissue. The patient's first CDT began in 2002 after the lymphedema progressed with increased discomfort and recurrent infections. Between 2002 and 2006, she had four episodes of cellulitis treated with multiple antibiotics. She received three courses of intensive CDT, including two to three visits weekly for three months. In 2004, she began using the programmable ProACT 1 pump (Fore Tech Medical, Williamstown, NJ; HCPC code E0652) intermittently for temporary relief of pain when her symptoms were most bothersome. This device did not provide treatment of her truncal lymphedema.\nIn 2006, she stopped using the ProACT 1 pump due to development of a fibrotic cuff (at the limb root nearest the axilla), skin irritation, and lack of sustained reduction of lymphedema. She then moved to Georgia and in March 2007 began a fourth course of CDT, which required treatment five days a week for four months. At the time she began this treatment, arm volume measurements showed that the affected arm had 31% greater volume than the unaffected arm.\nThe patient's self-MLD was not successful, because she was unable to reach all affected areas and did not have anyone at home to assist with her care. The FT system was recommended because, in addition to treating her affected arm, it treated the chest wall, trunk, and shoulder areas that the patient could not reach. In December 2007, she began using FT for in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old woman was on a flight and suffered from a sudden onset of right temporal pain for 30 min, followed by a tingling sensation on the right cheek. After she arrived at her destination, she experienced a throat blockage for approximately 20 min; therefore, she visited an ear, nose, and throat (ENT) doctor as well as a neurologist at another hospital. Neurological examination only revealed a tingling sensation in the area of the second branch of the right trigeminal nerve (the maxillary nerve). Otolaryngological examinations were unremarkable, except for percussion pain from the upper right central incisor to the first molar and gingival sensory disturbance in those regions (Fig. ). The patient was examined using head magnetic resonance imaging (MRI), which detected inflammatory findings in the right ethmoid sinus and slight fluid retention in the right sphenoid sinus (Fig. ). No pathological findings in or around the brainstem and cisternal portion of the trigeminal nerve were noticed. Under a diagnosis of idiopathic trigeminal neuralgia, the woman received conservative treatment. Because her symptoms persisted, the patient revisited the neurologist 1 month after the onset, and an additional MRI scan revealed chronic sinusitis in the right sphenoid sinus (Fig. ).\nSeven weeks after onset, the patient's symptoms continued, such as a tingling sensation from the right side of her nose to around her upper lip, and, therefore, she visited our hospital for a further workup. During the entire period, she noticed no febrile episodes. Neurological examinations revealed only sensory disturbance on the second branch area of the right trigeminal nerve. Other cranial nerves were intact, and a blood examination revealed no abnormal findings. The CT examination indicated sphenoid sinusitis with a small amount of fluid retention. And the coronal thin-sliced bone CT revealed the absence of the bony boundary between the sizeable sphenoid sinus and maxillary nerve (Fig. ).\nAcc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old female patient presented with a sudden left-side motor disorder and loss of consciousness. The patient was otherwise in good health and had no history of hypertension or diabetes. During the physical examination, she appeared lethargic and manifested left limb paralysis with level zero muscle strength and a positive pathological reflex.\nHead computed tomography findings showed lesions with hemorrhage occupying the right temporal lobe space, compression of the ipsilateral ventricle, and the midline structure offset to the contralateral side (Fig. A,B). Further, magnetic resonance imaging examination revealed a right temporal lobe space-occupying lesion with an uneven signal surrounded by an edema and a vascular flow signal. After contrast agent enhancement, lesions were observed in the enhanced vascular image. Inside the lesion, low signals of filling defect were detected suggesting thrombus (Fig. C,F).\nIntracranial lesion resection was undertaken because the patient was diagnosed with a right temporal lobe tumor with hematoma. The operation was performed under general anesthesia using a right temporal operative approach. A reddish cystic mass was observed on the surface of the brain the dura was opened. It felt tough and had a large number of nourishing arteries on its surface. Because the lesion was considered to have a vascular structure, we immediately closed the skull and transferred the patient to the catheter room for digital subtraction angiography. The angiography showed that the lesion was a PAVF fed by the right middle cerebral artery. Blood flow was through the lateral fissure vein and Labbé vein to the sigmoid sinus (Fig. ).\nThe PAVF was completely embolized with endovascular treatment using coils and onyx (Fig. ). Subsequently, the patient was transported to the operating room for removal of the PAVF and release of the mass effect. During the surgery, it was observed that the PAVF mainly comprised blood clots, and these structures, includi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.\nHis vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old African-American man, with history of renal insufficiency, diabetes, hypertension, severe peripheral vascular occlusive disease, and a 100 pack-year tobacco history, was incidentally found to have an abnormal chest radiograph showing bilateral large lower lobe airspace opacities. Images taken three years previously were reviewed; the abnormalities were present at that time and had not changed in size significantly. The patient was lost to follow-up after that initial abnormal radiograph. He was experiencing only mild respiratory complaints of dyspnea on exertion and occasional dry cough. There were initially no symptoms of hemoptysis, fever, chills, weight loss or night sweats. No laboratory abnormalities were discovered. A history of diagnosed autoimmune disease, cancer or family history of lung disease was not present. A computed tomography (CT) scan of his chest confirmed dense consolidation with air bronchograms involving several segments of his bilateral lower lobes. No mediastinal lymphadenopathy was seen (see Figure ). Our patient underwent bronchoscopy with a transbronchial biopsy. The pathology of the biopsy specimen showed extranodal marginal zone B-cell lymphoma of BALT (see Figure and ). Further staging with positron emission tomography-CT and bone marrow biopsy revealed stage IV disease involving the subcarinal lymph nodes as well as the bone marrow.\nOur patient was treated with single-agent rituximab and received four total doses, one dose given weekly. His clinical course remained stable with no evidence of progression and some improvement on CT imaging post-treatment. Our patient was seen every three months by his oncologist after his initial diagnosis. Two years after the diagnosis and treatment with rituximab our patient's clinical course worsened. He described new symptoms of worsening shortness of breath, weight loss, night sweats and fevers. He had elevated lactate dehydrogenase at 350IU/L, uric acid measuring 10.0 mg/dL and creati"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old male patient reported to the department of Pedodontics complaining of pain in the lower lip that began 15 days before. The patient’s medical history revealed traumatic injury to the upper anterior teeth in addition to a lower lip laceration due to a fall while playing approximately 10 months previously. However, at the time, no attempt was made to locate the fractured tooth fragment at the site of the accident neither by the patient nor by his parents. The patient consulted a nearby general medical practitioner for the soft tissue injury, and the lip laceration was sutured by the medical practitioner. Subsequently, the patient did not receive any treatment for the fractured upper teeth. For approximately 10 months, the patient did not feel any discomfort in the lip. Fifteen days before presenting at the clinic, the patient began to have pain in the lower lip. Clinical examination showed scarring and discoloration of the skin to the right of the midline of the external aspect of the lip [Figure ]. On palpation, a small hard mass was felt in the lip mucosa. Intraoral examination revealed an Ellis and Davey class II fracture involving the permanent maxillary right central incisor. Suspecting a foreign body, a radiograph of the lip was taken, which showed a radiopaque structure similar to that of the fractured tooth fragment [Figure ]. Based on the patient’s history and on clinical and radiographic findings, the present case was diagnosed as a case of embedded fractured tooth fragment in the lip following trauma. The embedding of the tooth fragment in the lower lip was explained to the patient, and its removal under local anesthesia was planned. A small incision was made under local anesthesia in the proximity of the hard mass, which exposed the embedded tooth fragment [Figure ]. The tooth fragment was completely removed followed by suturing with 3−0 black silk suture [Figure ]. Examination of the tooth fragment [Figure ] confirmed that it"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-month-old girl without specific past medical history was admitted to the hospital due to nausea and diarrhea. On physical examination, a firm mass was detected in the left upper quadrant of the abdomen. Abdominal computed tomography (CT) revealed a 6.8×5.8×5.3 cm sized left renal mass without lymph node enlargement (). There were no suspicious metastatic lesions in chest CT. Laboratory data showed leukocytosis. Radical nephrectomy with lymph nodes dissection was performed. Gross examination revealed a well circumscribed, ovoid, firm mass in the lower pole of the kidney (). The mass was abutted on the renal capsule, and the surface of the mass was whitish gray with multifocal hemorrhages. The remaining renal parenchyma was unremarkable. Microscopic findings revealed that the tumor was a highly cellular neoplasm composed of tumor cells of varying size with prominent nucleoli and abundant cytoplasm (). Histological examination was consistent with the diagnosis of malignant rhabdoid tumor. Immunohistochemistry showed loss of INI1 protein staining ().\nOne week after the operation, weakness of both lower extremities and voiding failure were noted. On neurological examination, she failed to respond to pain in both legs. Brain magnetic resonance imaging (MRI) did not show evidence of metastatic disease, but lumbar MRI revealed a 6.5×1 cm sized intradural extramedullary tubular mass with heterogeneous enhancement at L1-S1 level (). On the next day from onset of symptoms, laminoplastic laminotomy was performed by a neurosurgeon to remove the tumor and decompress spinal cord. Conus medullaris was displaced by the hypervascular tumor with yellowish color, however the upper margin of the tumor was clear (). The tumor was densely adhered to the left side of L5 nerve root. Near total removal of the tumor was performed using cavitron ultrasonic surgical aspirator, and there was no root injury during the surgery (). The pathologic findings were consistent with metastatic malign"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 51-year old man with CD. He was initially diagnosed with CD at 23 years old. He had undergone ileocecal resection, owing to a stricture of the terminal ileum, at 36 years old, and the residual small intestine was 230 cm long. After the initial operation, he was prescribed 5-aminosalicylic acid and home parenteral nutrition. He did not accept a recommended colonoscopy examination, owing to anal pain.\nIn August 2008, the patient complained of difficulty in defecation and consulted a physician at our hospital. A colonoscopy examination showed a pedunculated rectal polyp, 4 cm in diameter (Figure ) and an anal stricture due to proctitis. Histological examination of the biopsy from the lesion showed an adenoma; no dysplasia was detected around the polyp. A transanal resection of the polyp was performed for treatment and final diagnosis (Figure ). The pathological findings revealed that the polyp was an adenoma with well-differentiated adenocarcinoma without lymphatic or vascular invasion with negative margin of cut end, and that no dysplasia or inflammation was present around the polyp; thus, the polyp was diagnosed as a sporadic adenocarcinoma in an adenoma, rather than a colitis-associated adenocarcinoma (Figure ). Consistent with the results of the biopsy, an endoscopic exploration showed no dysplasia in the rectal mucosa, and immunohistochemistry showed no p53-staining of the crypt base. These findings were not consistent with colitis-associated CRC (Figure ). In July 2010, follow-up colonoscopy showed a longitudinal ulcer scar from the descending colon to the ascending colon and stenosis of the ileocolic anastomosis. We did not find any apparent lesion in the rectum.\nThree years after the second surgery, in August 2011, colonoscopy examination revealed a reddish, elevated lesion in the rectum (Figure ). This lesion was located at a different site from the initial lesion. A colonoscopic biopsy revealed a signet ring cell carcinoma. We performed an a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old Caucasian male patient presented to our dental office with a 1 year history of recurrent swelling on the buccal aspect of lower right mandibular region. He reported pain/tenderness on chewing over the past year. Medical history was unremarkable and there was no contraindication to dental treatment. There was no history of trauma to the teeth and jaw; a previous dental root treatment in the lower right region was reported.\nClinical examination revealed that the first right lower molar was tender to percussion and had a large coronal restoration; the adjacent premolar and molar teeth were vital and intact with no signs of caries or anomalies such as occlusal tubercle. The buccal soft tissue of lower molar teeth was normal. The probing depths were within normal limits. The molar tooth had no mobility. Radiographic examination showed a large circumscribed radiolucency at the apex the mesial root of first mandibular molar (). However, lamina dura surrounding the root of second premolar was apparent circumferentially. Further history revealed that the molar tooth had been endodontically treated 5 years ago and restored with an amalgam restoration. The obturation was deemed inadequate and a diagnosis of persistent AP due to inadequate root canal filling of lower right first molar was ascertained. After full explanation the patient consented to nonsurgical endodontic retreatment, followed by coronal restoration with amalgam.\nFirst, patient was asked to rinse with 0.2% chlorhexidine mouthwash. After administering local anesthesia, and isolation with rubber damn, the amalgam restoration was removed using a water-cooled high-speed fissure bur and straight line access to the root canals was made. Working length was determined radiographically, confirmed by electronic apex locator and using hybrid instrumentation (mixed technique) the canals were shaped and cleaned; copious irrigation with 5.25% NaOCl solution was carried out. Canals were dried and obturated by lat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old Japanese woman consulted a doctor because of back pain, and UPJO was detected after an examination. She was referred to our department and agreed to undergo laparoscopic surgery. A renogram showed that the function of her left hydronephrotic kidney was maintained to some extent, and surgery was thought to be effective. However, CT data revealed that the network of arteries and veins was very complicated. Therefore, we decided to use our simulator before surgery, and our patient agreed.\nCT data were saved in the DICOM (Digital Imaging and Communications in Medicine) file format. CT was performed with slices of 1mm in thickness from the chest to the pelvis, and its DICOM file was reconstructed to obtain three-dimensional (3D) volume data. The reconstructed organs were shaped with 3D mesh by using computer graphic techniques. After 3D conversion, the data were transmitted to our simulator, and relations and locations of organs were set. Fibrotic tissue and fat were added appropriately around the organs, and reconstruction of the body was completed (Figure\n).\nDuring the simulation, we first placed the camera and trocars on the body surface and obtained a virtual view of the abdominal cavity. When we changed the position of the trocar, the virtual view of the abdominal cavity also changed. Thus, we could choose a better position of the trocar in this pre-operative simulation. There were four renal arteries, two renal veins, and one gonadal vein that bifurcated in the middle. The lumbar vein was not important during surgery and therefore was not depicted.\nDuring surgery, we chose the right flank position and four trocars. The pneumoperitoneum pressure was 10mmHg. We approached the retroperitoneum from the lateral aspect of the descending colon. We found the gonadal vein and ureter and then reached the renal hilum. We found an anonymous vein that tightened the ureter. We removed the target vein and ureteral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a 59-year-old male who presented to a fracture clinic with a 7 month history of an infected surgical site wound overlying the left tibia, which was thought to be complicated by underlying osteomyelitis. During his initial consultation, the patient reported that, 7 months prior, he was hit by a motorcyclist while crossing a road in Bangkok (Thailand), where he had sustained a displaced spiral fracture of the left distal tibia. He was subsequently operated on in Thailand, where he underwent an open reduction and internal fixation. Upon return to the UK his surgical site wound began to discharge, over the course of a 7 month period prior to presentation to our institution. The patient reported that he had received multiple empirical courses of antibiotics for a non-healing surgical site wound. He had no significant past medical history, nil reported allergies and was fully mobile prior to this incident.\nThe patient was admitted to hospital (Day 1) for further management of his infected surgical site wound. Initial laboratory analyses including a full blood count, liver function tests and serum urea and electrolyte tests were conducted upon admission. All results were unremarkable. An X-ray of the left tibia and fibula performed on admission indicated periprosthetic lucencies. There was no evidence of healing at the site of the proximal fracture aligning with the initial clinical presentation of osteomyelitis.\nThe patient was subsequently taken to theatre on Day 4 for removal of all metalwork (including 12 screws), debridement and deep tissue and bone sampling for bacterial culture. During this operation vancomycin was incorporated in bone cement and intravenous (IV) ceftriaxone (2 g/q24h) was initiated pre-operatively. Purulent discharge was encountered from the skin and deeper skin layers from the distal tibia during the procedure. A CT scan of the left lower leg was performed the following day and suggested osteomyelitis of the medial aspect of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old woman, gravida 1, para 1, visited the internal medicine department at another hospital with a complaint of abdominal fullness and weight loss of 10kg during the last year. A huge abdominal mass was palpated, and she was referred to the gynecology department to search for a tumor of uterine origin. She was premenopausal and had no significant past medical history. Physical findings revealed a large elastic hard mass extending from the xiphoid to the pubic bone. The magnetic resonance imaging (MRI) examination revealed a huge tumor on the uterine corpus, and a number of dilated vessels were observed between the tumor and the myometrium. Therefore, the tumor was suspected to derive from the uterus. The tumor showed an uneven signal on T2-weighted sagittal section (), and the enhanced MRI study showed that the tumor edge but not the center was enhanced (). As such, necrosis was suspected to have occurred in the center of the tumor. Uterine sarcoma was primarily suspected due to the large size, degeneration, and necrosis on MRI imaging. Computed tomography (CT) examination showed no lymph node swelling or distant metastasis. Preoperative laboratory testing revealed anemia (hemoglobin level, 5.6g/dl). We transfused 18 units of RCC before surgery. CT examination and ultrasonography on lower extremities indicated an absence of thrombosis. Preoperative serum levels of CEA, CA 19-9, CA 125, and LDH were within normal limits. A biopsy of the endometrium was not collected as the sounding examination of the endometrium was unsuccessful due to a deviated uterine cervix. At this point, preoperatively, we suspected the tumor was a leiomyosarcoma or leiomyoma with degeneration.\nThe patient underwent laparotomy, where we identified a huge tumor occupying a space from the pelvis to the diaphragm. The tumor surface was smooth and hard with many dilated veins (). A massive tumor with a diameter of 30 cm was observed arising from the posterior uterine wall with a smooth con"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman, gravida 3, para 2, was referred to our center at 15 + 0 weeks of gestation for suspected TTTS in a monochorionic-diamniotic pregnancy []. Our center serves as the national referral center for fetoscopic laser surgery for TTTS in the Netherlands. Ultrasound examination showed a normal amount of amniotic fluid (deepest vertical pocket (DVP) 4 cm) in one twin (twin A) and a reduced amount of amniotic fluid (DVP 2 cm) in the other twin (twin B). Both twins had normal bladder filling. Diagnostic criteria for TTTS were thus not fulfilled. The estimated fetal weight (EFW) of fetus A was p50, biometry of fetus B revealed growth <p10. Doppler ultrasound revealed intermittent absent end-diastolic flow in umbilical artery in the smallest twin. These findings suggest a type III selective intrauterine growth restriction (sIUGR) []. After counseling, the parents opted for expectant management and no interventions were performed. Ultrasound examination was repeated weekly. At 17 + 1 weeks of gestation, mild pericardial effusion was seen in the larger twin, in a furthermore normal heart. At 19 + 1 weeks, the pulmonary valve in the larger twin had a normal diameter for gestational age, but they showed echogenic valve cusps and a mildly elevated peak systolic velocity across the pulmonary valve (1 m/s). Two weeks later, at 21 + 3 weeks of gestation, the abnormalities progressed with myocardial hypertrophy of the right ventricle and a peak systolic velocity across the pulmonary valve of 1.75 m/s. The antegrade flow was combined with mild insufficiency at the beginning of the diastole (). In addition, tricuspid regurgitation was present and the ductus arteriosus showed retrograde flow. The right ventricle had a normal size. The myocardial hypertrophy progressed during the pregnancy, the other cardiac abnormalities remained stable until birth.\nThe patient was admitted to our hospital at 34 + 3 weeks of gestational age for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a 40-year-old male with a history of chronic back pain and a recent, acute progression of bilateral lower extremity paresthesias and weakness. Over a seven-day period prior to presentation, the patient experienced a sudden onset of bilateral leg numbness, with no history of trauma or another precipitating event. The right leg was affected more severely than the left, traveling primarily in a distribution down the lateral leg into the dorsum of the foot and great toe. He eventually began having a shooting pain in this same distribution. He also reported a progressive weakness with bilateral ankle and toe dorsiflexion and five days duration of perineal numbness and mild urinary retention. On exam, he was unable to dorsiflex his ankles or great toes against gravity and had reduced sensation in the lateral aspect of both lower legs and the dorsum of bilateral feet. The patient’s Achilles reflexes were also diminished bilaterally, though reflexes were present and brisk at the knee. It is also pertinent that no upper motor neuron signs were present.\nMagnetic resonance imaging (MRI) of the lumbar spine revealed a somewhat heterogeneous, but predominately T2-weighted, hyperintense mass in the left lateral and dorsal epidural spaces (Figure ). There was significant lumbar stenosis present at the level of L4-5 secondary to the mass, with the rightward displacement of the thecal sac. There was no clear connection to the adjacent facet joint although the dorsal mass did seem to be contiguous with the dorsal aspect of the L4-5 disc (Figure ).\nDue to the acute onset of symptoms, as well as the severity of neurologic involvement, the patient was taken to surgery for exploration and removal of the epidural mass. An L4-5 laminectomy was performed, which revealed a very large dorsally migrated disc fragment that erupted as soon as the ligamentum flavum was removed. The large mass, which was displacing the thecal sac"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nKathy (this is a representative composite case that does not reflect any single patient) was a 67-year-old woman who suffered an out-of-hospital cardiac arrest. She received 5 min of cardiopulmonary resuscitation and defibrillation by emergency medical services at the scene before the return of spontaneous circulation. In the hospital, she was diagnosed with an ST-elevation myocardial infarction and underwent thrombolysis, followed by 24 hours of induced therapeutic hypothermia, a treatment intended to reduce the risk of brain injury after cardiac arrest. Unfortunately, Kathy sustained severe anoxic brain injury and remained comatose after restoration of normal body temperature.\nAdditional tests were done to help determine her neurological prognosis. These tests showed mixed results. On the one hand, an MRI scan showed no structural abnormality, and somatosensory evoked potentials were bilaterally present with normal latency and amplitude. While the bilateral absence of the N20 somatosensory evoked potentials response indicates a poor prognosis, its presence does not predict neurological outcome. On the other hand, Kathy displayed persistent seizure activity on her electroencephalogram, which is associated with increased mortality following cardiac arrest.\nThe neurocritical care team met with Kathy’s husband and son and explained that they were uncertain about her likely outcome and needed more time and information to develop a clearer picture of Kathy’s prognosis. The care team was aware of an ongoing research study at the hospital involving functional MRI for which Kathy was eligible. The study involved recording brain responses to stimuli and comparing patient responses with eventual outcome to determine if functional MRI could be a useful prognostic test for future patients. Functional MRI shows promise as a candidate prognostication method in patients with acute brain injury.\nThere are ethical issues associated with enrolling patients like Kathy in functional M"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n61-year-old female patient with multiple comorbidities, including diabetes mellitus, hypertension, and diverticulitis, presented with pelvic abscess, small bowel obstruction, and sepsis, requiring emergent exploratory laparotomy. She had left upper extremity single lumen PICC, placed two weeks ago for antibiotic therapy which was now inadequate for her resuscitation needs, vasopressors, and central venous pressure monitoring. Right internal jugular (RIJ) vein cannulation was considered due to its straight course and ease of insertion. PICC was not removed before attempting central venous cannulation as that was our only venous access. We used standard Arrow® 7 French triple lumen Kit with soft spring J-tip guidewire, introducer needle puncture was guided by peripheral vascular ultrasound, vascular anatomy was found to be normal, needle placement was uneventful with free back flow, j-tip guidewire was introduced using Seldinger technique, wire position was confirmed with ultrasound, guidewire was advanced smoothly to about 15 cm at the needle hub, 9 cm into the vessel after which it encountered resistance, and we tried manipulating guidewire by changing angle of insertion, but it was not possible to advance further. Hence, left internal jugular (LIJ) vein cannulation was attempted, which was also met with resistance to guidewire insertion approximately 17 cm at needle hub or 11 cm into the vessel, and right internal jugular access was successfully cannulated at 2nd attempt with manipulation of guidewire. Patient did not have history of previous internal jugular cannulations, thoracic surgery, or any other condition predisposing to central venous stenosis or thrombosis. Postprocedure chest X-ray was obtained, which shows CVC in appropriate position, in proximity with PICC, with approximate 45-degree angle at convergence of two catheters and no evidence of complications (). PICC was removed after radiological confirmation of optimal CVC placement. Patient remained crit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA fourteen-year-old girl presented with history of fever, painful subcutaneous nodules with ulcerations in both the lower limbs for two months, and digital gangrene of the right index finger for one-month duration. There was no history of purpura, Raynaud's phenomenon, recurrent oral ulcers, hair loss or malar rash. The history of throat pain, jaundice or past tuberculosis was negative. The general physical examination showed normal vitals with multiple subcutaneous ulcers predominantly distributed over both the lower limbs [Figures and ] and bluish black discoloration of distal phalanx of the index finger. The laboratory investigations are shown in . The renal function and liver function tests were normal. The peripheral smear showed elevated total count and Anti-streptolysin O (ASLO) titer was elevated. The throat and urine culture showed no growth of bacteria. The ultrasonography of the abdomen and echocardiography of the heart were normal. The deep incisional skin biopsy taken from the subcutaneous nodule revealed leukocytoclastic vasculitis of the dermal vessels [Figures and ]. The patient was treated with methyl prednisolone (three pulses doses of 750 mg/day) followed by oral prednisolone of 1 mg/kg/day. She also received a course of oral penicillin for antecedent streptococcal throat infection. The skin lesions completely healed over a period of six months with scarring [Figures and ], and patient was on regular follow up for one and half year after which she lost to follow up and treatment.\nShe presented to us again in July 2010 (three years after the initial episode in December 2007) with similar complaints of bluish black discoloration of left middle finger and subcutaneous nodules. The skin biopsy was repeated which showed leukocytoclastic vasculitis of the dermal vessels suggestive of CPAN. There was no systemic involvement by clinical examination and investigations. The ASLO titer was normal. The patient was treated with injection cyclophosphamide 750 m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn 2002, a 52-year-old asian woman underwent a lumpectomy for a stage II infiltrating duct carcinoma over her right breast, followed by four cycles of adjuvant chemotherapy combining doxorubicin, cyclophosphamide and paclitaxel. Chemotherapy was followed by locoregional radiation. Eight years after the completion of chemotherapy, she found a slowly growing mass on her right neck. Positron emission tomography (PET) scan revealed large infraclavicular mass and a supraclavicular adenopathy of the right neck and right nasal cavity. Analysis of biopsy samples from both masses was consistent with metastatic carcinoma and suggestive of the metastasis having arisen from primary breast cancer. She underwent removal of the right supraclavicular and infraclavicular masses at that time, followed by adjuvant chemotherapy. However, one year after the surgery, she found a mass in the upper outer quadrant of her right anterior chest wall. Ulceration and bleeding of the mass caused her to have a painful disability of her right upper limb. A computed tomography (CT) scan (Figure a) revealed a mass in the upper outer quadrant of her right anterior chest wall. The mass had invaded the ribs and pleura. Magnetic resonance imaging (MRI, Figure b) revealed that the mass involved the axillary artery and occluded the right lateral subclavian vein and axillary vein.\nAfter a multimodality assessment followed by discussion of the available options and risks, benefits and subsequent rehabilitation associated with forequarter amputation with the patient and her family, she consented to the amputation. Surgery revealed a fungating tumor in the anterior superior chest wall that involved the right first, second and third ribs. This tumor had adhered to the right lung as well as the brachiocephalic-subclavian vein and artery.\nDuring surgery, the patient was placed in a semi-lateral position on her left side with her right side elevated at a 45° angle. An incision was made over her sternocleidomastoid"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male patient reported with mild swelling and pain in the left zygomatic region. The history of present illness revealed that the patient had noticed the swelling in the last few weeks and it also had an associated intraoral ulcer. The patient was a known diabetic who was under medication. He had a habit of smoking cigarettes for the past 15 years. He smoked almost 15 cigarettes per day. The clinical examination revealed a firm swelling in the left zygomatic region measuring approximately 3 cm to 5 cm. It was mildly painful on palpation. The left maxillary region had significant paresthesia, nasal obstruction, and episodes of pain. A palpable left submandibular lymph node was present, which was also tender and fixed. The cervical lymph node on the left side was also palpable (Figure ). The intraoral examination revealed an ulceroproliferative growth measuring 4 cm to 6 cm in dimension.\nThe lesion was extending in relation to teeth 23, 24, and 25. The ulcer was covered with necrotic slough. Purulent discharge and bleeding were present in the lesion. The other teeth in the quadrant were missing (Figure ). A panoramic radiograph revealed extruded teeth 23, 24, 25.\nThere was increased radiopacity in the left maxillary sinus (Figure ). Water’s view showed the opacification of the entire left maxillary sinus.\nAn intraoral extension of this mass was also evident. The inferior, posterior, lateral, and medial walls of the left maxillary sinus appeared to be destroyed (Figure ). A computed tomography (CT) scan showed a lesion extending into the maxillary space and the nasal cavity. A heterodense soft tissue lesion showing heterogeneous contrast enhancement in the left maxillary sinus and hard palate with the destruction of the posterolateral wall, medial wall, and floor of the left maxillary antrum, extending into the adjacent retro maxillary space and medially extending into the left nasal cavity, obliterating all meati with the destruction of nasal turbinates."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old lady presented with history of gradually progressing, painless swelling of the left lower eyelid of 1 year duration. She was diagnosed as chalazion elsewhere for which she had undergone incision and curettage twice following which the swelling recurred to the present size. There was a history of gradual increase in the size of the swelling following incision and curettage. There was no history of similar lesion anywhere else in the body. There was no significant family history. On clinical examination there was a firm, nodular mass measuring 10 × 10 × 8 mm (). The mass was fixed to the underlying tarsus, nontender and nonmobile. On eversion of the eyelid there was an area of scarring in the tarsal conjunctiva and the overlying skin was normal (). The examination of rest of the anterior and posterior segment was unremarkable. The right eye was essentially normal and systemic examination revealed normal findings. Full thickness excision biopsy was done under local anesthesia and eyelid defect was repaired by Tenzel's semicircular flap. The specimen was sent for histopathological examination.\nOn gross examination, it was a pentagonal full-thickness segment of the eyelid measuring 11 × 9 × 9 mm consisted of a nodular mass lesion with smooth overlying surface. Cut section revealed a unilocular cyst measuring 9 mm in diameter. Cyst was filled with yellowish homogenous solid material with focal gritty white areas ().\nMicroscopic examination showed lining keratinized stratified squamous epithelium of eyelid skin. Subepithelium showed a cyst, wall of which was composed of epithelial cells with absence of clearly visible intercellular bridges. The epithelial cells close to the cystic cavity appeared swollen filled with pale cytoplasm. The peripheral layer of cells showed distinct palisade arrangement. Cyst was filled with homogeneous, amorphous keratinous material. Patchy calcification of this keratinous material was noted. Cholesterol clefts were seen at places"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old lady presented with complaints of headache and vomiting from past one and half months; headache was increasing in severity and there was relief on vomiting. She had no history of blurring or diminution of vision or seizures. There was also no history of motor or sensory disturbances. On examination, no abnormality was detected. The patient underwent computed tomography (CT) scan of brain, which showed space occupying lesion in the right frontal lobe, measuring about 6×6 cm []. Fundus was normal. She underwent near total excision of the lesion. Postoperative period was uneventful. Histopathology of the specimen showed features suggestive of papillary carcinoma of choroids plexus. There was increased cell density, increased mitotic figures (greater than 5 per 10 high-power fields), nuclear pleomorphism, and necrosis. Diffuse invasion of the adjacent brain parenchyma was present []. On immunohistochemistry, it was positive for glial fibrillary acidic protein and negative for epithelial membrane antigen []. Since the diagnosis of papillary carcinoma of choroid plexus is very rare in adults, patient was worked up to rule out any primary disease elsewhere in the body. Thyroid scan, chest X-ray, and ultrasonography of abdomen and pelvis were normal. Stool for occult blood was negative. Complete blood count and peripheral smear was normal. Cerebrospinal fluid (CSF) was examined for the presence of malignant cells and it was found to be negative for malignant cells. The patient received radiation to whole brain on telecobalt unit, using German helmet technique, with two lateral portals. Initial dose was 4000 cGy/20 fractions (200 cGy/fraction). Later, she received boost to the primary tumor bed, using antero-lateral wedge pair technique, to a dose of 2000 cGy/10 fractions. Along with radiation, the patient also received four cycles of intrathecal methotrexate (12 mg), cytarabine (50 mg) and hydrocortisone (20 mg) weekly. The patient tolerated the treatment well"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man was admitted to our clinic with ear discharge, pain, and hearing loss. From otoscopy, a mass was identified, covered by skin and protruding from the postero-inferior wall of the entrance to the external auditory canal. The passage of the canal was significantly narrowed by the tumor, and the tympanic membrane was not visible. After 1 week of topical treatment (ciprofloxacin, dexamethasone), the patient’s symptoms and clinical findings were observed to improve. Audiological tests and a computed tomography (CT) scan were performed. The pure tone audiogram indicated conductive hearing loss with a mean air-bone gap of 25 dB. The CT scan showed a soft tissue density mass protruding from the postero-inferior wall of the entrance to the external auditory canal and obstructing the canal with no invasion of other tissues (). Fine-needle aspiration biopsy was performed; however, an insufficient number of specialized cells were present in the pathological samples to permit diagnosis.\nOne month after the appearance of symptoms, surgical excision was scheduled under local anesthesia. Under microscopic view, after transcanal lateral circumferential skin incision, a skin flap was elevated and the encapsulated tumor with a diameter of approximately 20 mm was seen and excised en bloc. The skin flap was replaced to cover the surgical area and two Merocel® ear packs were placed in the external ear canal. After surgery, the patient was prescribed analgesics (paracetamol, 3 × 500 mg/day) for 7 days.\nThe tumor was off-white in color with the dimensions of 20 × 12 × 15 mm3. Microscopic examination showed glandular structures which were composed of two cell layers: epithelial and myoepithelial. The inner layer consisted of middle-sized cylindrical or cuboidal cells. Abundant eosinophilic cytoplasm, arranged in a columnar to cuboidal shape, was seen in the luminal cells. The outer layer consisted of spindle cells with elongated nuclei. Neither atypia nor mitotic activity w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male presented to the ED with his wife and followed shortly by their daughter for evaluation of dyspnea which began approximately six hours prior to arrival. He had an associated nonproductive cough which had been worsening over that time period. He reported a subjective fever, chills, and myalgias. He had taken Robitussin and Aleve prior to arrival without relief. He stated that the symptoms began 1-2 hours following the cleaning of an exotic coral which he identified as a species of Zoantharia from his home aquarium. He had cleaned the coral using hot tap water in his basement sink. He identified the coral as a Zoantharia species of coral. He had not previously cleaned that particular coral and did not use any protective equipment while cleaning it. Both his wife and daughter were present in the home while he was cleaning the coral. His wife was in an adjoining basement room and his daughter was upstairs on the first floor of the home. Both presented to the ED with similar but less severe symptoms with the degree of severity commensurate with the distance from the location where the coral was being cleaned.\nThe patient's past medical history was significant only for hypothyroidism, hyperlipidemia, and psoriasis for which he was taking levothyroxine, rosuvastatin, and glucosamine chondroitin. Social history was significant for prior tobacco use, with a 20 pack-year history, with cessation one year prior to this encounter.\nVital signs included tachycardia at a rate of 112, a blood pressure of 155/83, respiratory rate of 18 with an oxygen saturation of 96% at room air, and a temperature of 102.6°F taken orally. On physical examination, bilateral expiratory wheezes with normal chest excursion were noted, with normal chest excursion. The patient had no evidence of respiratory distress. Cardiac examination revealed a regular tachycardia without murmurs, rubs, or gallops. The patient"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male patient was first admitted to the emergency department of our hospital 12 years ago with recurrent episodes of collapse and a documented ventricular fibrillation (VF) arrest requiring emergency cardioversion by the paramedic team. The patient gave a 5-day history of general malaise and fever and a 24-hour history of an itchy vesicular rash. He had no relevant past medical history, but both his children had been diagnosed with chicken pox two weeks ago.\nOn examination, he was apyrexial, with a normal cardiovascular examination. He had multiple widespread erythematous, vesicular lesions approximately 2 mm across with some weeping that involved all limbs and his trunk. The haematological and biochemical investigations were normal, apart from a C-reactive protein (CRP) of 70 mg/L (normal ≤ 5 mg/L). The resting electrocardiogram (ECG) was within normal limits with a QTc interval of 403 msec. Transthoracic echocardiography confirmed normal biventricular structure and function with no regional wall motion abnormalities and normal cardiac valves. Intravenous amiodarone was administered for 24 hours, and no further arrhythmias were detected. In addition, he was treated with intravenous acyclovir for 10 days. He made an uneventful recovery. The patient took his own discharge a few days following the acute presentation.\nHe represented 8 years later with a further syncopal event lasting for less than a minute. He was on treatment with citalopram 20 mg od prescribed by his general practitioner for anxiety. He had a normal clinical examination, and the biochemical investigations were within normal limits. The resting ECG confirmed sinus rhythm with a normal QTc interval of 430 msec. The cardiac magnetic resonance imaging (MRI) confirmed normal biventricular function but also mild mid-wall myocardial enhancement at the basal inferior and inferolateral walls consistent with myocarditis and no evidence of inducible ischaemia (Figures and ). He was reviewed by the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old female presented to a local hospital with severe left lower extremity pain and oral thrush. In the emergency department, laboratory data revealed anemia, thrombocytopenia of 10,000 platelets/microliter, and elevated white blood count of 235,500 leukocytes/microliter with 97% blasts concerning for leukemia. Bone marrow biopsy confirmed a new diagnosis of acute myelogenous leukemia (AML). She was subsequently transferred to a major tertiary referral center for management.\nOn further evaluation, she continued to have worsening left lower extremity pain with physical exam notable for cyanosis of all five toes, erythema to the midshin, and decreased sensation to touch but intact posterior tibial and dorsalis pedis pulses detected using a Doppler device. Bilateral lower extremity ultrasound revealed a left popliteal artery occlusion at the level of the popliteal fossa and acute bilateral deep vein thrombosis (DVTs). The patient was started on a heparin infusion for acute DVT and given nonopioid adjuvants (scheduled oral acetaminophen, scheduled oral gabapentin, lidocaine patch, and ketamine injection as needed) as well as oral and intravenous opioids to control her pain. Despite escalation of pain regimen up to 200 oral morphine equivalents (OME), she continued to experience 10/10 pain at rest and was unable to sleep at night. Palliative care service was consulted for further management.\ntGiven her worsening pain, a regional anesthetic technique was considered. Due to her critical thrombocytopenia and continuous heparin infusion, she was not a candidate for neuraxial anesthesia. Consideration was given to the patient's multiple risk factors for peripheral nerve block including bleeding, infection due to severe immunocompromised state, and potential for masking a developing compartment syndrome or a worsening of her CLI. After an extensive discussion with the patient and her family regarding the high risk nature of an invasive procedure, the decision was made"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 7-year-old male child was presented to the Pediatric Department in Shatbi University Hospital with recurrent chest infections since 1 year. Repeated chest X-ray showed left pleural effusion. The child was managed conservatively and discharged from the pediatric department. During the course of follow-up for the respiratory condition an abdominal ultrasound was ordered to investigate a new onset minor abdominal discomfort. An abdominal cyst was found which, otherwise, was not clinically palpable during abdominal examination. Subsequent computed tomography (CT) scanning of the abdomen and pelvis with intravenous contrast revealed a retroperitoneal thick-walled fluid filled mass, measuring approximately 11.5 × 13 cm in close relation to the main pancreatic duct with inflammation of the adjacent pancreatic tissue. Provisional reports indicated a pseudo-pancreatic cyst with further extension into the posterior mediastinum through one of the diaphragmatic hiatus (\n). Serum amylase and lipase were markedly elevated (amylase: 45,630 U/I and lipase: 180,000 U/I).\nThe decision after surgical consultation was to perform laparotomy. The child was prepared for the operation. Through an upper midline incision, the abdomen was explored. This revealed a large, smooth, and fluctuant mass behind the stomach extending up to the posterior mediastinum through the esophageal hiatus, mostly arising from the pancreas. Aspiration of the coffee ground contents was done followed by a drainage procedure by anastomosing the posterior wall of the stomach to the anterior wall of the cyst wall (cystogastrostomy) using running 4/0 vicryl sutures. A Penrose drain was inserted in the left upper quadrant followed by a layered closure. The postoperative course was uneventful. Nasogastric suction and intravenous fluids were continued for 5 days, after which oral feedings were gradually given. The drain was removed after 5 days and the child was discharged from the hospital on the 9th postoperative day"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old male was assaulted by four persons, and remembers that some of them jumped on his left knee. He was not sure about the exact mechanism of injury, as he stated that he was under the influence of alcohol. The patient presented with swelling of his thigh and inability to weight bear on the left leg. There was bruising and a palpable depression (Fig ) of the left quadriceps tendon. The patient was able to extend the knee, but not against gravity, with an extensor lag of 30°.\nThe patient reported that, 27 years before the present injury, he had been involved in a road traffic accident sustaining ipsilateral femur and comminuted patellar fractures. The femur underwent intramedullary nailing. The patella was removed, and primary repair of the extensor mechanism was performed. Six years later, the intramedullary femoral nail was removed. In the patient's past medical history, there were no other significant problems to note, and there was no history of quinolones intake. The patient had been generally fit and well.\nPlain radiographs of the knee showed a depression in the soft tissue shadow anterior to the distal femur, extraosseus calcification along the tendon, and absence of the patella (Fig ). Other imaging investigations were not performed, as the clinical signs were classical.\nWe elected to perform a primary quadriceps repair within 24 hours of the injury. A midline incision was made over the previous scar. A complete quadriceps rupture was noted approximately 3 cm proximal to the patellectomy site with a 2.5 cm gap (Fig ). The previous extensor mechanism repair site was well healed. The medial and lateral retinaculums were intact. An end to end repair was performed using continuous, locked heavy absorbable sutures (size 1 Maxon-Monofilament polygyconate synthetic suture, United States Surgical, USA) in multiple layers (Fig ). The ragged margins of the tendon were excised and sent for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old female presented to the ED with left-sided back pain upon waking up in the morning. She reported that the pain was located in the left posterior lower ribs, about the inferior portion of the left scapula. The patient denied associated fevers, trauma, or rashes. She stated that her pain was worse with movement and taking a deep breath, and when reaching her left arm across the right side of the body. She denied any associated numbness or weakness. Her past medical history was notable for hypertension, but she could not recall the name of her anti-hypertensive medication. She had no allergies and had no other significant past medical or social history, although she did smoke e-cigarettes.\nOn examination, her vital signs were within normal limits. There was no hypoxia, tachypnea, or tachycardia. Pertinent physical exam findings revealed that the patient was experiencing moderate distress secondary to pain. She had a normal cardiac and pulmonary auscultation, and her skin was normal. Neurologically, her strength and sensation were intact in the upper and lower extremities. On musculoskeletal examination, the provider noted pain with forced adduction of the left arm across the body, and back exam was notable for tenderness in the left paravertebral muscles of the thoracic spine. The provider initially reported concern for pulmonary embolism, which was excluded with the Pulmonary Embolism Rule-out Criteria, as well as concern for pneumothorax and occult rib injury. A chest radiograph with dedicated left-sided rib views revealed no acute abnormality.\nGiven that the patient’s pain appeared to be myofascial in origin, a physical therapy consultation was obtained. The physical therapist was specifically trained in myofascial manipulation and trigger point release. The patient was diagnosed by the physical therapist with muscular spasm of the left quadratus lumborum muscle, and was treated with manual trigger point therapy, which completely released the spasm in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman, who had been treated for mental development delay and schizophrenia, was admitted to the intensive care unit of the Department of Traumatology and Critical Care Medicine after a fall during a suicide attempt 30 minutes previously.\nShe was alert on arrival and her extremities did not have any neurovascular deficits. On physical examination, she was unable to move her right arm and leg, and an approximately 3 cm open wound was noted in the anterolateral thigh region.\nRadiographs showed fractured femoral neck and shaft, an acetabular fracture (Figures and ), and a humeral shaft fracture on the right side. Whole body computed tomography showed right pulmonary contusion, liver contusion, and type B3 acetabular fracture, according to the AO classification system (). Additionally, her injury severity score was 29.\nShe was transferred to the operating room 5 hours after the fall. First, she underwent antegrade intramedullary nailing for the right humerus fracture and retrograde intramedullary nailing for the right femoral shaft fracture simultaneously. Then, she was placed on a traction table and underwent multiple screw fixation with cannulated cancellous screws for the right femoral neck fracture (). The operating time was 5 hours, and the intraoperative blood loss was 500 mL.\nPostoperatively, her condition stabilized and she recovered. Seven days after the initial operation, a second operation was performed for the acetabular fracture. First, the transverse fracture was exposed using the modified Stoppa approach and was anatomically reduced and fixed using a reconstruction plate. Then, using the Kocher-Langenbeck approach, posterior wall fixation was performed with a reconstruction plate (). The operating time was 5.5 hours and the intraoperative blood loss was 540 mL.\nThe early postoperative course was uneventful. Eight weeks after the second operation, partial weight-bearing was allowed. After partial weight-bearing, she complained of right hip and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman presented to our hospital with low back pain. Trauma history was vague except for falling 40 cm from a bed a month earlier. She had a past history of eosinophilic granulomatosis with polyangiitis and was treated with prednisolone (40 mg/day) 3 months before presenting at our hospital. Her bone mineral density in the hip had a T-score of −4.7, and bisphosphonate and vitamin D were initiated to treat osteoporosis. She underwent computed tomography (CT) and was diagnosed as having a left vertical sacral fracture and treated conservatively. Three weeks after her initial diagnosis of sacral fracture, her low back pain worsened and she started to have radiating left posterior thigh pain with symptoms of stress urinary incontinence, constipation, and loss of anal sensation.\nOn examination, she had weakness of dorsiflexion of her left ankle and flexion of both great toes, in which the muscular power was grade 3/5 and 4/5, respectively, as measured with manual muscle testing (MMT). Sensation to pinprick on her S2 receptive field was impaired. Lumbosacral magnetic resonance imaging using a short inversion time inversion recovery (STIR) sequence revealed an H-shaped fracture in the sacrum, but there were no abnormal findings such as spinal stenosis in her lumbar spine potentially explaining for her neurological symptoms (). Repeated CT demonstrated slightly aggravated displacement of the sacral fracture compared with previous CT ().\nWe consulted a urologist, and the patient was diagnosed as having stress incontinence because of poor function of pelvic floor muscles or the sphincter. However, we speculate that both the weakness of dorsiflexion of the ankle and great toes and loss of anal sensation could be attributed to SIF and recommended that she undergo surgery. She underwent lumbopelvic fixation from L3 to the ilium using a minimally invasive technique with a percutaneous pedicle screw system () []. Her radiating leg pain, motor weakness in her ankles, a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old female visited the hospital with progressive severe dyspnea class III (New York Heart Association) for 1 year. She had a history of MVR and tricuspid annuloplasty (TAP) for mitral and tricuspid valve regurgitation 20 years ago. She had been taking warfarin, since the mechanical mitral valve was inserted. A chest X-ray showed marked cardiomegaly and evidence of a median sternotomy. Transthoracic echocardiography (TTE) revealed huge enlarged bi-atria without visible intracardiac thrombi, a mechanical mitral valve with mild paravalvular leakage, and severe tricuspid regurgitation (TR) due to coaptation failure with moderate pulmonary hypertension (Fig. ). Coronary angiography showed no significant stenosis of the coronary arteries. A chest CT also revealed marked cardiomegaly and bi-atrial enlargement, evidence of a median sternotomy, and a replaced mechanical mitral valve (Fig. ). No pulmonary abnormalities that cause dyspnea were detected on the chest CT. No abnormal laboratory findings were observed, including inflammatory markers. TVR was planned for severe TR under general anesthesia with cardiopulmonary bypass as an elective operation with heparin bridging therapy.\nGeneral anesthesia was induced uneventfully. The arterial line was inserted before induction of general anesthesia, and a Swan-Ganz catheter was inserted through the right internal jugular vein. We inserted the TEE probe to evaluate cardiac status preoperatively. We identified almost the same findings as with the previous TTE. However, a floating, 1-mm-diameter hyperechoic signal was found in the left atrium, which was not mentioned on the preoperative TTE (Fig. ). We discussed the existence of an intracardiac foreign body with the cardiac surgeon, and the surgeon performed an additional left atrial incision to identify the foreign material prior to the main operation.\nA long thin foreign body was observed in the right pulmonary vein to the left atrium. It was tied at the right upper pulm"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male patient was brought by his parents to a genetics clinic with complaints of developmental delay and tremor. He was a full-term infant with an uneventful delivery. He started walking around 18 months of age, spoke his first words at the age of two. Other problems included nervousness, immature behaviors, lack of eye contact during conversations, and aggressive behavior. His mother reported that he began to have a tremor in the hands around three years of age. Diagnostic workup included magnetic resonance imaging (MRI) of the brain, urine organic and amino acids, lactate, pyruvate, and lead levels along with chromosomal and DNA analysis for fragile X which were all unremarkable. His family history was significant for mental retardation. Maternal grandmother had three mentally retarded brothers with tremors, two of whom died in their forties. The patient’s brother also seems to have a speech delay along with tremors since the age of three.\nHis tremors worsened gradually, and he started to have difficulties with fine motor control including difficulty with drinking out of a cup along with increased aggression and behavioral changes. His teachers reported that he was biting, kicking, spitting and getting into conflicts with other children. He was seen by a child psychiatrist at that time and was started on risperidone, valproic acid and Adderall (amphetamine and dextroamphetamine) which seemed to help with his behaviors.\nOn examination, he has high nasal bridge, slightly down-slanting palpebral fissures, long philtrum, and thin upper lip. On neurological exam, he has slightly increased deep tendon reflexes throughout. Babinski sign was positive on the right, but a normal plantar response was noted on the left side. Bilateral hand tremors were noted, both at rest and in action. He was walking slowly without much arm swing and had a slightly stooped forward posture. A full psychological evaluation was done which showed a Leiter scale IQ of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-week gestation preterm male delivered through precipitous vaginal delivery in the emergency department to a 21-year-old G2P1 female presenting with acute onset of labor with rupture of membranes at home. Birth weight was 1870 g and Apgar scores were 7 at 1 min and 8 at 5 min. Due to immediate respiratory distress, the infant was intubated and mechanically ventilated. One dose of surfactant was given and he was transferred to the neonatal intensive care unit. Caffeine was administered for apnea of prematurity, and ampicillin and amikacin were initiated for concern of neonatal sepsis due to preterm labor and delivery. Within hours, the infant became hypotensive requiring normal saline boluses and a dobutamine drip, prompting an increased concern for sepsis and the addition of cefepime. However, after 3 days, blood cultures were negative, and the clinical condition had improved. Therefore, the antibiotics were discontinued.\nOn the day of life three, a routine cranial ultrasound was found to be normal. Echocardiogram was also normal with no structural abnormalities. The initial cranial circumference was 31 cm, and the neurological examination after resolution of hypotension was normal with no focal findings. On the day of life six, significant abdominal distention occurred with pain elicited on examination. Necrotizing enterocolitis was suspected, so empiric intravenous vancomycin and meropenem were initiated. However, pneumatosis intestinalis and portal venous gas were not observed on serial abdominal X-rays, and blood cultures never isolated a pathogen. Due to clinical severity, 2 weeks of antimicrobial treatment was given with clinical improvement and enteral feedings by nasogastric tube were started.\nOn the 18th day of life, the cranial circumference suddenly increased 34 cm. On examination, the anterior fontanelle was bulging, despite the child being alert and active with a normal neurological examination. Cefipime was initiated out of concern of neonatal seps"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man presented with prolonged dull back pain for 3 months. One year prior to being referred to our hospital, he underwent BCG intravesical instillation therapy for bladder cancer. Computed tomography (CT) at a neighboring hospital revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed enlargement of both aneurysms. The saccular-shaped thoracic aneurysm enlarged from 39 × 35 mm to 52 × 47 mm, and the size of the abdominal aneurysm also increased from 26 × 23 mm to 41 × 34 mm. The surrounding tissue showed typical findings of inflammation, such as thickening of the adventitia and faint contrast effect (Fig. ). Although he had no symptom except for dull back pain, laboratory tests showed only a slight increase in the inflammatory response (C-reactive protein 4.95 mg/dl, procalcitonin 0.127 ng/ml), and blood culture was negative, he was diagnosed with an impending rupture of both infectious thoracic and AAAs and was referred to our hospital. Considering the risk of rupture and the possibility of infectious aneurysms, urgent surgical treatment was planned. Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient who had a poor general condition due to prolonged dull back pain. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed.\nUnder general anesthesia, the AAA was exposed through a midline abdominal incision. Prior to abdominal aortic replacement, a stent-graft (GORE C-TAG: W. L. Gore & Associates Inc. Flagstaff, AZ) was inserted via the left femoral artery and deployed at the level of the saccular TAA. After confirming the precise placement of the endograft and no endoleak, the abdominal aorta was clamped, and the aneurysmal sac was opened. The aneurysmal wall was quite thin and fragile."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male with abdominal wall mass presented for excision of an anterior abdominal wall mass, adjacent tissue transfer, and flap graft under general anesthesia. His past medical history was significant for coronary artery disease status after three stents, hypertension, dyslipidemia, obstructive sleep apnea using home CPAP, and being a chronic smoker. His medication included clopidogrel (stopped 3 weeks before surgery), aspirin (stopped 5 days prior to the procedure), atorvastatin, hydrochlorothiazide-losartan, and metoprolol. He had no known allergies. His body mass index was 38 (height 183 cm and weight 129 kg). Intraoperative monitoring included continuous electrocardiograph (EKG), pulse oximetery, temperature, and automatic blood pressure monitoring with a large size adult blood pressure cuff (cuff size 16 cm width × 36 cm length and blood pressure monitor calibrated every 6–12 months) placed on his left upper arm, and possible pressure points were not found during a secondary survey. General anesthesia was induced through a 20 gauge intravenous catheter placed on the dorsum of the right hand. The patient was positioned supine with the head neutral and both arms placed neutrally alongside the body and secured on the arm board. Arm abduction was less than 90 degrees with padding of the pressure points. Intraoperatively, noninvasive blood pressure was measured every 5 minutes, and it ranged from 160 to 87 mm Hg systolic and from 104 to 51 mm Hg diastolic ( shows the trend of blood pressure measurements). Surgery lasted for about 9 hours (630 minutes). Throughout the surgery, the patient's temperature was maintained normothermic by using warm fluid, a forced air warming device, and maintaining the room temperature between 24°C and 26°C. At the end of the surgery, patient was extubated and transferred to the recovery room. In the recovery room, after two hours, the patient complained of left forearm swelling, pain, and wrist drop. Postoperatively, blood pre"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man, with a background of recurrent outbreaks of herpes labialis approximately once every 2 years and childhood varicella, noticed vesicles on the lower lips. Five days later, a skin eruption developed on the right side of his face. Although he had no history of atopic dermatitis, Kaposi varicelliform eruption with secondary bacterial infection was suspected at another hospital, so he was treated with oral acyclovir and levofloxacin for 2 days. The patient subsequently presented to our outpatient clinic for consultation after the lack of symptomatic improvement.\nOn examination, erythema and small vesicles were present on the right side of the face in the dermatome innervated by the maxillary branch of the trigeminal nerve; the dorsum nasi, philtrum and upper lip were also affected. Crusting of these lesions was observed, and the right eyelids were red and swollen. Small vesicles were also noted at the bottom of the lower lip (fig. ). Vesicles with red halos were scattered on the trunk and extremities. Laboratory investigations revealed an elevated level of C-reactive protein of 2.4 mg/dl, suggesting a mild inflammatory reaction; however, other blood tests, including immunoglobulin levels and HIV antibody results, were either normal or negative. No evidence of immunological dysfunction was seen. A small number of coagulase-negative staphylococci were identified on bacterial culture of a swab taken from a skin lesion.\nThe differential diagnosis included disseminated herpes zoster, varicella, herpes simplex and impetigo. We performed the LAMP assay (Eiken Chemical, Tokyo, Japan) using swab samples taken from the following areas: an erosion on the right cheek, vesicles on the upper and lower lips (fig. ; arrows 1, 2 and 3) and a vesicle with a red halo on the right thigh. HSV-1 and VZV were detected by LAMP in samples taken from all 3 sites on the face, and VZV was detected in the sample taken from the vesicle on the right"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 1: Kidney trauma\nAn 11-year-old girl got injured during a fall with a bike. A day later, she started to experience abdominal pain and nausea. She has had a fever (38°C) and a sore throat for a few days before the injury. The inflammatory markers were increased [C-reactive protein (CRP) 133 mg/L]. The physical exam found tenderness in the costovertebral angle and the left upper quadrant of the abdomen. A therapy with co-amoxiclav was started. The B-mode US examination showed a hyperechogenic change in the left kidney located between the upper and middle thirds of the kidney (Figure ). A subcapsular hematoma was also described. Color Doppler showed blood flow only in the middle and lower thirds of the kidney (Figure ), pointing towards a laceration and infarction of the upper pole of the kidney.\nA day after admission, the patient's inflammatory parameters began to rise (CRP 187 mg/L), and microscopic hematuria was detected. Chest radiograph and urine culture tests ruled out respiratory and urinary tract infections, and the focus of possible infection was not found. Co-amoxiclav was replaced with ceftriaxone. A control CEUS examination showed a devascularization of the upper third of the kidney parenchyma, which was confirmed by the MRI of the abdomen. Approximately 40% of the kidney parenchyma was affected, and the increase in CRP was presumed to be due to the ischemia/necrosis of the damaged part of the kidney. The patient was followed clinically and with US until discharge.\nIn this case, CEUS showed the extent of laceration a lot more clearly than B-mode and Doppler US. The approximate area of the injury was detectable by color Doppler, but CEUS demonstrated the lesion better and helped to evaluate the degree of organ injury (Figure ). Renal parenchyma has very high blood flow, and thus, large quantities of contrast are visible quickly []. Due to the absence of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was born prematurely (34 weeks and 1 day of gestation) at an outside hospital to a 29-year-old woman by elective cesarean section. The pregnancy had been complicated by preterm premature rupture of the membranes at 28 weeks and 2 days of gestation as well as prenatal diagnoses of cystic hygroma, pericardial and pleural effusions, left renal artery duplication, and bilateral ventricular hypertrophy with worsening myocardial function. This conglomeration of symptoms was later confirmed to result from Noonan syndrome. Specifically, this patient was found to have a PTPN11 gene mutation (c.923A>C; p.N308T).\nAt 12 hours of life, the patient became hypotensive and did not respond well to fluid resuscitation. Given the constellation of complications, the decision was made to transfer her to the tertiary care children's hospital for genetic assessment and cardiologic consultation. Upon arrival, the patient remained in respiratory distress and was hemodynamically unstable, and the placement of an umbilical catheter was attempted. A portable chest radiograph demonstrated a caudal loop of the catheter prior to ascending to the superior abdomen, so the catheter was assumed to be within an umbilical artery. However, the tip of the line was ultimately located to the right of the vertebral column (). Given this unusual position of the catheter, a cross-table lateral radiograph was performed. This demonstrated the tip of the umbilical line projecting over the expected location of the right atrium, at the level of the lower thoracic spine, and anteriorly and to the right of the expected position of the aorta (). A subsequent portable radiograph was obtained the following morning, redemonstrating the atypical position.\nAn ultrasound with Doppler assessment was performed to accurately determine the positioning of the line. The aorta was found to be unremarkable and without an intraluminal catheter. Instead, the catheter was identified within the inferior vena cava, with the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old male was diagnosed to have type I truncus arteriosus (TA) during infancy. He underwent palliative main PA banding at the age of four months. No following corrective surgery was performed at his family’s choice. He had an uneventful childhood. At 26, he presented with Streptococcal Gordonii endocarditis with severe truncal valve regurgitation. This was complicated with septic emboli to his lungs and kidneys. At the same time, he was found to have left sided pulmonary hypertension due to migration of the PA band to the right PA (RPA) on the computed tomography of the chest (Fig. ). He survived from a stormy hospital stay which required intubation and mechanical ventilation, and completed 5 weeks of antibiotics. A decision was made not for surgery at that point of time in view of the high surgical risk and uncertain surgical outcomes at this age [].\nHe remained relatively well in New York Heart Association (NYHA) functional class I for 3 years, subsequently, his functional class deteriorated to NYHA II. On annual echocardiographic follow up, there was evidence of increase in size and decrease in systolic function of the left ventricle (LV). At 32 years old, he was hospitalized for worsening heart failure. On physical examination, he was thinly built with pectus carinatum, finger clubbing, raised jugular venous pressure and pitting edema over bilateral lower limbs. He had displaced apex beat, first and second heart sounds were present. There were ejection systolic murmur and early diastolic murmur at the left parasternal edge. The oxygen saturation was 90 % on room air. Blood investigation were unremarkable except for elevated hemoglobin of 17.9 g/L and serum creatinine of 105 mmol/L. Electrocardiogram revealed right ventricular (RV) hypertrophy with strain pattern. Chest radiograph showed an enlarged heart with prominent pulmonary trunk.\nTrans-thoracic echocardiogram showed type I TA (Fig. ). The LV was severely dilated with ejection fraction of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old man presented with multiple nodular lesions over the pubic region with ulceration and excoriation over the penile skin for the previous 2 months []. The lesions had been increasing in size and number over a period of time. The patient first consulted a dermatologist who referred him to a surgeon, given the history of malignancy in this patient with suspicion of cutaneous metastases. He had complaints of severe and intractable pain over the lesions. He had a 2-year history of carcinoma of the rectum with liver metastases. According to the American Joint Committee on Cancer Tumor-Node-Metastasis Staging System, the disease was Stage 4, so surgery was not feasible. A colonoscopy performed 9 months previously had revealed an ulceroproliferative lesion in the rectum 8 cm from the anal verge. Since a biopsy proved it to be an adenocarcinoma, a repeat biopsy was not performed. He underwent a colostomy 9 months previously because of obstructive symptoms. He received chemotherapy with three series of combinations of irinotecan, oxaliplatin, 5-fluorouracil (5 FU), and leucovorin (LV) (FOLFOX). A positron emission tomography-computed tomography scan revealed liver metastases, and he was encouraged to receive further chemotherapy, which he refused. Two months later, the patient returned to the surgery department and was found to have extensive new skin lesions involving the pubic region and external genital area. The cutaneous lesions were not close to the colostomy wound. His vital signs and laboratory investigations were normal. A hard, ulcerated lesion was felt on rectal examination. Histopathological examination of a biopsy from the skin nodules and the penile region revealed metastatic adenocarcinoma []. The tumor was assessed to identify histological features suggestive of high-frequency microsatellite instability which was negative in the index case. Palliative radiation therapy was advised, but the patient refused any further treatment. He also did not rec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48- year-old Chinese woman, gravida 4, para 2, was admitted to our hospital due to abdominal pain for 1 month. The clinical features of the patient at baseline were summarized in Table . The patient had a history of tubal ligation and denied asbestos exposure.\nFifteen years ago, the patient was diagnosed with a uterine myoma, which was about 8 cm in diameter. Instead of undergoing surgery, she opted for regular check-ups. One month ago, she developed abdominal pain and ultrasonography showed a 12 × 11.4 × 9.8 cm heterogeneous mass behind the uterus, with a cystic dark area of 3.4 × 2.3 cm (Fig. ). Ultrasound suspected as degeneration of uterine myoma. A further CT examination also considered it as a myoma fatty degeneration (Fig. ). Therefore, the patient underwent exploratory laparotomy.\nIntraoperative observations were described as below: There was a small amount of viscous fluid in the pelvic cavity. The uterus was enlarged to the size of 2 months gestation. There was a mass about 12 cm in diameter behind the uterus with a pedicle attached to the uterus. The mass was multilocular cystic with myxoid fluid. The surface of the left ovary was dotted with minute neoplasms. No obvious metastatic lesions were observed elsewhere.\nThe mass was removed and a quick-freezing examination was performed. The results indicated that it was a mesenchymal tumor and adenomatoid tumor was possible. We treated her with a total hysterectomy and bilateral adnexectomy. The final pathology of paraffin confirmed it as localized well-differentiated benign mesothelioma (Fig. A). The results of immunohistochemistry showed that the 3 molecules Calretinin, D2–40, CK were positive, while p53, EMA were negative (Table ). The tiny neoplasm on the surface of the ovary was also thought to be mesothelioma involvement. In addition, a small nodule with a diameter of about 2 cm was found in the myometrium, and the pathological"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 35-year-old male presented to the ER with right craniofacial trauma due to an occupational injury caused by falling of a plastic pipe on his head. He was awake and aware at the time of arrival. The initial assessment revealed a GCS level of 14. Signs of traumatic injuries in the right side of his face included swollen eyelids due to trauma to the soft tissue of the right periorbital and frontal area along with right superior eyelid laceration, redness, and tenderness. The visual acuity in his right eye was almost no light perception. Right optic neuropathy was evident with a relative afferent pupillary defect (RAPD) of 4+. The eye movements of the right eye were restricted in all directions, but the other side was normal. Other examinations revealed no further abnormal findings.\nCT-Scan depicted a small focus at the level of the right Sylvian fissure in favor of a pneumocephalus and a hyperdense structure in the right orbital cavity, posterior to the globe, suggestive of a bony material (Figs. , , and ). As we were not sure about the origin and material of hyperdense structure demonstrated on CT-Scan, use of MRI was waived in order to prevent subsequent complications in case of metal object foreign body. However, initial assessments of patient’s images amplified the suspicion of skull base fracture, regarding the foci of pneumocephalus, especially at the region of the right superior orbital wall. Based on these findings, the patient was admitted to the trauma section of the neurosurgery ward and received initial necessary supportive care. Antibiotic therapy was commenced for surgery preparation and preventing probable meningitis, with Cefepime and Vancomycin. A consult with ophthalmologists was performed, and regarding their evaluation, both ophthalmologists and neurosurgeons were agreeing with choosing a craniotomy approach. The procedure was performed by using the method of “extra-dural orbitocranial approach to the anterior cranial fossa” cranio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old nulliparous woman presented with 24 h of increasing left lower quadrant pain, worsened with movement and temporarily relieved with narcotic medications given by the emergency room provider. She had a past medical history of PCOS and a surgical history of a right salpingectomy secondary to a right paraovarian cyst resulting in an isolated necrotic torsed fallopian tube at 13 years of age.\nPhysical exam revealed an obese female with normal vital signs. Abdominal exam was significant for left lower quadrant pain on deep palpation, with no rebound or guarding present. Bimanual examination revealed similar pain at left adnexa but otherwise benign with no vaginal bleeding, cervical motion tenderness or otherwise palpable masses. Of note, the physical examination was performed after patient had already received 975 mg of acetaminophen, 600 mg of ibuprofen and three doses of 2 mg morphine by emergency room providers.\nLaboratory evaluation was significant only for a white blood cell (WBC) count of 12.85 × 109/l with an otherwise normal complete blood count, comprehensive metabolic profile and urinalysis. Transvaginal and transabdominal ultrasound revealed a simple left adnexal cyst 1.5 × 1.2 × 1.4 cm and a 4 × 3.8 × 4.1 cm mildly complex cyst, both of which appeared to be extraovarian. Arterial and venous waveforms were documented for both ovaries. Fluid in the endocervical canal was also noted.\nThe patient's surgical history was significant for a similar presentation to the emergency department at 13 years of age. Upon review of the medical record that was available, a nurse at triage noted the patient was complaining of right lower quadrant pain that worsened over the day and stated that the patient was “doubled over in triage”. Unfortunately, no provider note could be found regarding physical examination and history of presenting illness. A CT examination of the abdomen and pelvis had revealed a 5.1 × 4.4 cm right ovarian cyst with trace"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 21-year-old female patient reported to us with the chief compliant of swelling in gums in the upper and lower anterior tooth region. These swellings were increasing in size for the past 15 days and were associated with bleeding gums, purulent discharge, and intermittent pain that were increased on chewing food. She had also noticed increase in gaps between her front upper teeth with slight mobility with the same. The patient was concerned for her compromised esthetics. Her medical history was suggestive of abnormal menstrual cycles and her drug history revealed that she was on hormonal supplements for reducing her body weight. She had a waist circumference of 102 cm and weighed 91 kg. All her vitals were within normal limits.\nThe patient was cooperative and had no reported tissue abuse habits. No abnormality was detected during her extraoral examination. Her intraoral clinical examination revealed soft and edematous gingiva which bled spontaneously on probing. It was associated with purulent discharge with a marked halitosis. There were multiple reddish granulomatous swellings in relation to tooth no. 12, 11, and 21 in the upper arch and 31, 41, and 42 in the lower arch []. There was an associated localized gingival overgrowth covering at least one-third of the clinical crown height on the labial surfaces of teeth. Lesions had pedunculated base, varying from 4 mm × 3.5 mm in 11 and 21 regions to 5 mm × 4 mm in 12 region. A provisional diagnosis of PG was made. The differential diagnosis of the lesion included fibroma, irritational fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, and hemangioma.\nThe gingiva was painful to touch and the associated teeth were tender on percussion. Periodontal probing was done after administration of local anesthesia. Anterior teeth revealed deeper probing depth measuring around 9–10 mm []. Grade I mobility was also seen with 11 and 21. Radiograph showed presence of angular bone loss in all anterior teeth []. Th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n16-year-old girl presented in the orthopedic clinic with a swollen right middle finger associated with occasional pain of one month duration. There was progressive increase in size. The middle phalanx was diffusely swollen, with mild tenderness. She did not have any lesions over the skin. Plain films of the right middle finger showed an expansile lesion with thinning of the cortex and intralesional calcifications. []\nHer complete blood count was normal. Considering her age and the radiological features a diagnosis of enchondroma was made. Computerized tomographic scan[CT scan] showed a central oval round area of geographic destruction in the medullary canal at the metaphyseal region of the middle phalanx of the right middle finger. There were dystrophic calcifications with bulbous expansion of the bone with cortical thinning. There was no soft tissue involvement. As shown in the plain films and the CT scan. []\nWith a provisional diagnosis of enchondroma she was operated under general anesthesia. The mass was approached through a curvilinear dorsolateral approach under tourniquet. Dark- brown jelly like contents of the tumor was curetted out. There was break in the volar cortex. The defect in the bone was packed with cancellous grafts harvested from the proximal tibia.\nHistopathology showed grey and dark brown tissue, with sections showing fragments of tissue composed of many perforating capillary sized blood vessels that are lined by plump endothelial cells with abundant cytoplasm and vesicular nuclei. Some cells showed vacuoles. At places there was hobnail appearance of the endothelial cells. These were admixed with numerous eosinophils, lymphocytes and few plasma cells. Occasional scattered giant cells also were seen. Immunohistochemistry for vascular markers showed CD31 positive in cords of cells and cells lining blood vessels, many CD 68 positive cells were also seen. Features were consistent with epitheloid hemangioma. [ & ]\nAt one-year follow up, there was no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old man was referred to our hospital complaining of having had bloody stools five to seven times/day for 1 month. He had no noteworthy medical or familial history, including inflammatory bowel diseases. Colonoscopy showed moderate mucosal inflammation throughout the rectum to the sigmoid colon and multiple erosions from the sigmoid colon to the cecum. The findings also included a well-circumscribed raised tumor, which was revealed to have a type IV to VI pit pattern, 15 mm in diameter, in the sigmoid colon (Figure ). Step biopsying was performed at 18 points from the rectum to the terminal ileum, there being no findings of dysplasia lesions microscopically. The pathological findings revealed UC Matts’ grades 3 to 4 in the rectum to the sigmoid colon and Matts’ grades 1 to 2 in the left-sided colon to the cecum. He was given mesalazine (2,400 mg/day) as the initial medical treatment. Endoscopic mucosal resection was also performed to remove the sigmoid colon tumor at 1 month after the initial diagnosis. Histological examination showed a 15 × 10-mm well-differentiated adenocarcinoma with submucosal deep invasion (4,000 μm) that detect diffusely p53 protein accumulation in immunostaining. There was no intravenous or lymphatic invasion microscopically, and the horizontal and vertical margins were negative. The circumference mucosa around the cancer lesion did not show dysplasia, and the circumference and unaffected UC mucosa were considered negative for the p53 protein overexpression because only a few weakly positive cells were detected (Figure ).\nFor this case, additional surgical resection with lymphadenectomy was required because of the submucosal deep invasion. At 3 months after the initial diagnosis of UC, the bloody stools had disappeared, and clinical improvement was attained with mesalazine (3,600 mg/day) and prednisolone (15 mg/day). Also, an endoscopic examination showed improvement and Matts’ grade was 2 to 3 in the rectum to the sigmoid colon path"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA forty-four year old woman presented to us with a five days history of multiple painful papulo vesicular lesions distributed along the right D9 dermatome. She had no known co-morbidities prior to the onset of the skin lesions. She was clinically diagnosed a case of HZ. Tzanck smear performed from the lesions revealed multinucleated giant cells confirming the diagnosis. Other investigations were found within normal limits. Acyclovir therapy was deferred as she had presented on the fifth day after the onset of the lesions. She was managed symptomatically with analgesics and topical soothing agents. Lesions started healing with crusting and post inflammatory pigmentary changes.\nTwo days later, she reported again with multiple erythematous itchy papules all over the body. In view of dissemination of lesions, the possibility of HZ with dissemination was kept. However, on closer examination, it was observed that some of the lesions were targetoid papules and plaques with central hyper pigmentation and at places fluid filled vesicles ().\nTherefore, in view of morphology of lesions, provisional diagnosis of EM secondary to HZ was kept. She was in good health without any sign and symptom of immunosuppression. There was no mucosal involvement or lymphadenopathy. She was clinically suspected to have EM secondary to HZ. Tzanck smear prepared from new lesions did not reveal any multinucleated giant cell. Other Investigations revealed leukocytosis of 10,000/mm3 with 70% neutrophils, 1% eosinophils, and 29% lymphocytes. The C-reactive protein was of 5.9 mg/dl. Her liver function test and urine analysis were within normal limits. Her serology for Human immunodeficiency Virus, cytomegalovirus and mycoplasma were found negative. Antinuclear antibodies were also found negative. Histological examination of a skin biopsy showed a sub epidermal bulla with eosinophilic necrosis in the epidermis. A few inflammatory cells were present in the necrotic epidermis. There was a slight perivascu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn elderly lady in her late fifties, was referred to the endodontic department of a private dental clinic with her chief complain being dull tight pain on the left side of her face. She stated that she had been experiencing this sensation of pain for the past two weeks. On clinical inspection no facial discrepancy and swelling was noticed. Oral examination revealed a maxillary first molar on the left side that had an extensive amalgam filling and was extremely sensitive to percussion and palpation of the periradicular area. She mentioned previous root canal therapy of this tooth five weeks earlier. Radiography was indicated and revealed a phenomenon that was supposed to be the cause of all these discomforts (). The mesiobuccal root was perforated in many zones and the perforation sites were over obturated with gutta-percha. Surprisingly she was told that her tooth had five canals and was extra-charged for these canals.\nThe situation was discussed with the patient and extraction/implant placement was indicated. Patient had too much anxiety and refused to accept the situation stating that she could not take that due to recent complications in her personal life. She insisted on an alternative approach. Thus, she was referred to another endodontist for evaluation of possibility of intentional replantation. It was later decided to approach through trial and error; if the replantation was not successful the tooth would be extracted. On the very same session the procedure was initiated. Unfortunately, the mesial root was separated during extraction and the clinician had to extract the tooth.\nOne week later, she appeared with persisting pain on the left side of her face. This time she mentioned that this pain worsened when she became more stressful. She was not satisfied because she expected the pain would vanish after losing one tooth. As she was explaining her disapproval, it was observed that her face was blushing and she was sweating allover. The patient also mentioned"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old woman, para 1-0-0-1, was diagnosed with invasive squamous cell carcinoma of the cervix at 12 weeks of gestation and she was referred to the University of the Ryukyus Hospital. Specular examination showed a sessile tumor measuring approximately 2 cm in diameter on the anterior lip of the cervix. At 15 weeks of gestation, magnetic resonance imaging showed a lesion consistent with cervical carcinoma FIGO stage IB1. Both the patient and her husband were informed about the treatment options and the possible consequences of such treatments on the pregnancy. The couple was also informed about the option to perform radical abdominal trachelectomy (RAT) as a relatively new surgical procedure and all the possible consequences were discussed. The patient was told that the outcome of this procedure could not be guaranteed because not enough procedures had been globally performed to yield reliable conclusions. The patient wished to maintain the pregnancy, and both parents signed a written consent agreeing to RAT. The institutional review board of our university approved this treatment.\nThe patient underwent RAT with pelvic lymphadenectomy under general anesthesia in August 2013 at 17 weeks of gestation. To prevent uterine contraction, 50 mg of indometacin sodium rectal suppository was administered on the morning of the surgery; 25 mg of indometacin sodium rectal suppository was immediately administered after surgery and every 6 h thereafter (4 times in total). In addition, 250 mg of 17-alpha-hydroxyprogesterone caproate was intramuscularly administered 60 min immediately before the surgery and administered once a week thereafter until 36 weeks of gestation. An enlarged pregnant uterus prevented the operative field; therefore it was secured by manually putting aside the uterus because indomethacin sodium and sevoflurane were effective enough for the softening of the uterine muscle.\nIn our case, pelvic lymphadenectomy was performed. The frozen section of the lymph no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old man was referred to gastrointestinal surgeons for pancreatic mass pointed out by an abdominal ultrasonography in a medical check-up. The patient did not show any symptoms. Abdominal contrast-enhanced computed tomography (CT) revealed dissection from the CA (), DPA, and splenic artery (SA). This aneurysm was not seen on an abdominal unenhanced CT taken 6 years ago in a medical check-up. The enhancing inner lumen of the DPA was derived from false lumen and that of the SA was derived from true lumen. The stenosis of proximal side of SA, an aneurysm measuring 2.5 cm on DPAA with unenhanced mural thrombus, and the connection of the distal side of the DPAA to transverse pancreatic artery (TPA) with stenotic change were confirmed (). A connection with DPA and the superior mesenteric artery (SMA) was undetermined. The current diagnosis was the dissection of the CA to DPA and SA, resulting in DPAA and SA stenosis. After the diagnosis was made, the patient was referred to the department of radiology by a vascular surgeon for the consultation of endovascular surgery to prevent aneurysm rupture because open surgery was thought to be quite invasive as it required distal pancreatectomy with splenectomy and CA repair. He had received medications for hypertension. There were no remarkable findings in his initial laboratory data. We planned to embolize DPAA, SA, and dissected area of CA that allow to preserve vascular supply to hepatic artery from SMA via peripancreatic arcade and to distal side of SA via gastroduodenal artery (GDA) to TPA. An angiography from the CA revealed the enhancing inner lumen of DPAA from false lumen of dissected CA connecting to TPA (). TPA was revealed between the peripancreatic arcade from GDA and pancreatic tail artery that connected to the distal side of SA. A 4.5 Fr. Shepherd hook–type guiding sheath (Parent Plus 45: Medikit, Tokyo, Japan), carrying a triple coaxial system, consisted of a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female was referred to our medicine dental department in UHC Sahloul, Sousse, for treatment of tooth #46. She suffered from major coronal destruction and needed to have her first molar restored. The medical history was noncontributory. Radiographic and clinical examinations were performed initially, and an extensive glass ionomer cement restoration of a nonvital tooth (46) was identified (Figures and ). The tooth was treated endodontically. The patient had an acceptable oral hygiene and a favorable occlusion. After removing the restoration, an endocrown restoration was recommended because of the amount of remaining tooth structure and the thickness of the walls (). The prosthetic decision was to restore tooth (46) with an endocrown fabricated from lithium disilicate ceramic (IPS e.Max CAD). The preparation for the endocrown is different from the conventional complete crown. This monolithic, ceramic adhesive restoration requires specific preparation techniques to be suitable for especial biomechanical needs.\nThis is aimed at achieving achieve an overall reduction in the height of the occlusal surface of at least 2 mm in the axial direction and to get a cervical margin or “cervical sidewalk” in the form of a butt joint. The cervical margin has to be supragingival and enamel walls less than 2 mm have to be eliminated.\nDifferences in levels between the various parts of the cervical margin should be linked by a slope of no more than 60° to escape a staircase effect. We used a cylindrical-conical diamond bur held parallel to the occlusal plane, to reduce the occlusal surface. Then we used a diamond wheel bur to control the orientation of the reduction and to guarantee a flat surface thanks to its shape.\nWe used a cylindrical-conical diamond bur with a total occlusal convergence of 7° to create continuity between the coronal pulp chamber and endodontic access cavity. The bur was orientated along the long axis of the tooth; the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man was admitted to our hospital because of a bulge in the left inguinal region. He had no pain and no urinary symptoms. Physical examination revealed a non-tender, reducible bulge in the left inguinal region. His body mass index (BMI) was 19.0 kg/m2. Laboratory data were all within the normal range. Computed tomography (CT) performed 5 years before admission for other disease showed a left indirect inguinal hernia. In addition, a small protrusion of the adipose tissue into the left femoral canal and a portion of the bladder pulled to the left femoral ring were observed retrospectively (Fig. ). Preoperative imaging studies were not performed. Based on a diagnosis of left indirect inguinal hernia, we planned for TAPP.\nThe patient was placed in the supine position under general anesthesia. A urinary catheter was inserted before the operation. A 10-mm port was placed for the laparoscope at the umbilicus and two 5-mm ports were placed at each flank. Laparoscopy and intraperitoneal observation revealed a left indirect inguinal hernia with sliding of the surrounding tissue. There were no other peritoneal indentations (Fig. a). We incised the peritoneum and dissected the preperitoneal space toward the Retzius space along the vesicohypogastric fascia. We found a mass covered with the vesicohypogastric fascia that was pulled into the femoral ring (Fig. b). The mass was confirmed to be a portion of the bladder; the mass expanded when we injected saline through the urinary catheter (Fig. c). We first dissected the protruding bladder all around from the preperitoneal tissue sliding with the bladder because the protruding bladder had developed severe adhesion to the hernial orifice. Then we reduced the protruding bladder carefully without causing injury. The length of the herniated bladder in the femoral canal was about 1 cm. The diameter of the femoral ring was 1 cm. An aberrant obturator artery was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old male patient visited our emergency room due to melena of duration one week. History taking revealed no particular issues other than antihypertensive medication after a diagnosis of hypertension five years previously. He did no smoke, but consumed a small amount of alcohol regularly. No specific features arose from his family or social history. He did not experience nausea or vomiting at the time of hospitalization, and only complained of mild indigestion. Furthermore, he showed no epigastric soreness, abdominal pain, or weight loss, and his vital signs at hospitalization were stable. His physical examination was uneventful. His hemoglobin was 10.4 g/dL, and renal and liver function, as determined by blood tests, were also normal. No lesions were found in the esophagus or stomach by esophagogastroduodenoscopy. However, an exophytic tumor with a bleeding surface ulcer was observed luminally in the ampulla of Vater in the second portion of the duodenum (Figure ). An endoscopic biopsy was performed on the tumor and bleeding from the ulcer was controlled endoscopically. And abdominal computer tomography (CT) and magnetic resonance imaging (MRI) revealed a hypoattenuating mass of diameter 1.6 cm in the second portion of the duodenum. The pathological result later revealed atypical chronic inflammation and regenerative atypia. Although no malignant cells were observed, surgery was performed based on the judgment that gross findings indicated that the possibility of malignancy was high. During surgery, a papillary 2.5 × 2.0 × 0.7 cm sized mass was found in the ampulla of Vater. Distant metastasis or any of lymph node enlargement were not observed. Pylorus preserving pancreaticoduodenectomy (PPPD) was performed. The pathological result of the excised specimen showed that the tumor was limited to the mucosa and proper muscle layer and had not invaded the pancreas or common bile duct. Furthermore, no lymph node metastasis was detected. The submucosal tumor was fo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn January 2010, a 51-year-old female presented to a rural hospital with a one month history of left lower and upper abdominal quadrant pain. The patient was admitted to the hospital with the preliminary diagnosis of pancreatitis. After admission, the patient developed gross hematuria. It was discovered that the patient had a past medical history significant for a stab injury in 1998 to her left kidney with involvement of the left renal artery. At that time, the patient underwent a transabdominal/transperitoneal partial nephrectomy. Due to the patient's complicated past medical history and her present gross hematuria, the decision was made to transfer the patient to our service for a higher level of care.\nAfter admission to our hospital, a transurethral catheter was placed, which showed gross hematuria. Upon further evaluation, the decision was made to perform a cystoscopy and evacuation of blood clots. The urethrocystoscopy showed no gross pathology in the urethra and bladder. The left and right orifice were normal in size, place, and configuration. In order to locate the source of bleeding, bilateral ureteroscopy was performed. The right ureter and renal pelvis were found to be unremarkable. The left ureter also appeared to be free of pathology. However, at approximately the level of the ureteropelvic junction, a papillary mass was noted that appeared to extend into the left renal pelvis. A biopsy was unable to be obtained due to significant bleeding. After the blood clots were evacuated, and taking into account the past history of hematuria with a small, atretic kidney, it was deemed necessary to pass a stent into the left ureteral pelvis. The patient tolerated the procedure well. The results of the cystoscopy were discussed with the patient, and a nephrectomy was being considered to remove the tumor. However, after cystoscopy the patient developed an ileus. She was also very malnourished. Once her bleeding and ileus resolved, the decision was made to allow her t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old man visited another hospital with chief complaints of generalised weakness, pallor and intermittent rectal bleeding for 2 years prior to his presentation. Physical examination was unremarkable. His haematological profile showed low haemoglobin levels (8.5 g/dl). The rest of the laboratory parameters including total serum protein and erythrocyte sedimentation rate were within normal limits. Stool culture was negative for pathogenic organisms. Colonoscopy revealed pseudopolyps along with multiple erythematous and eroded mucosal lesions in the rectum []. He was diagnosed clinically as ulcerative colitis for which he received oral aminosalicylic acid followed by prednisolone for 6 months. However, the patient was non-responsive to this medical therapy. He was also transfused blood on two separate occasions along with hematenimics because of persistently low hemoglobin. One year after the initial treatment he was admitted to our hospital because of worsening of symptoms, which were now accompanied by mucous diarrhoea, straining at defecation and rectal prolapse (feeling of mass protruding out from rectum). Laboratory data at the time of present admission also revealed low hemoglobin (8.0 g/dl) however, remaining hematological investigations were within normal limits. On digital rectal examination, multiple soft elevated lesions were palpable. Contrast enhanced computed tomography of the lower abdomen and pelvis showed multiple rectal polyps and thickening of the rectal wall with a maximum wall thickness of 12 mm along with its abnormal inferior descent [].\nAs the patient was non-responsive to medical therapy, low anterior resection of the rectum was done. Intra-operatively, multiple sessile polyps were noted in the rectum along with erythema of the surrounding mucosa. An intra-operative diagnosis of inflammatory polyposis was considered. The post operative course of the patient was uneventful.\nGross examination of the resected specimen revealed multiple ses"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male patient presented to his primary care physician complaining of a dry cough and recurrent bouts of bronchitis as well as frequent orthostatic dizziness. At the age of 20 years, he had undergone repair of CO-A through a left thoracotomy using an interposition Dacron graft between the left SCA and the mid thoracic aorta. His chest radiograph raised suspicion of AN of the thoracic aorta. Computed tomographic angiogram then confirmed the presence of two large anastomotic PANs at both ends of the graft (\n) as well as an occluded right SCA, stenosis of the left vertebral artery, and bovine origin of the carotid arteries (\n).\nIn view of this complex anatomy, the decision was made to use a hybrid approach to address these findings. In a first stage, a right carotid artery to right SCA bypass was done using a short segment of Goretex graft (\n). Next, using single lung ventilation, a right posterolateral thoracotomy was performed and the chest entered through the fifth intercostal space. With the diaphragm retracted inferiorly, the pericardium, posterior to the phrenic nerve, was gently lifted with a long clamp, thus allowing exposure of the distal most portion of the thoracic aorta, medial to the inferior vena cava (IVC). After heparinization, the aorta was partially clamped and a 22 mm Hemashield graft anastomosed in an end-to-side fashion to an appropriate aortotomy using a continuous suture of 5–0 Prolene (\n). The graft was then brought posteriorly to the IVC and anteriorly to the right hilum, then anastomosed in an end-to-side similar fashion to the partially occluded ascending aorta through a vertical pericardial opening (\n,\n).\nThe immediate postoperative course was uneventful, and 5 days later, the patient was brought to the hybrid operating room for completion angiogram. This confirmed patency of the extra-anatomic graft as well as the presence of a 4 cm proximal left SCA anastomotic PAN with close extension"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old girl was referred to the Department of Periodontics with the chief complaint of gingival overgrowth and mobility in her teeth for the last 2 years. She reported that the problem has begun in lower anterior and progressed involving both the arches. Patient appeared fit and indicated no current or previous systemic disease during her medical history interview.\nIntraorally, severe diffuse gingival enlargement of both the arcades (more pronounced on the right side) was observed covering almost all the surfaces of teeth and projecting into the vestibule [Figure –]. Gingiva was bright red, friable, fibrous as well as edematous in consistency. The erythema was disproportionate to the amount of plaque and calculus remaining on the dentition panoramic radiograph demonstrated generalized alveolar bone loss []. Probing depth ranged from 10 mm to 12 mm with an attachment loss of 7-9 mm and was more in the right molar region. Grade 2 mobility was present around the mandibular and maxillary first and second molars and grade 1 around the mandibular right premolars.\nLaboratory tests revealed no evidence of any systemic disease such as leukemia, scurvy and hormonal disorders.\nInternal bevel gingivectomy was performed in the maxillary arch and left mandibular region[]. Adjunctive amoxicillin (500 mg, 3 × 1) plus metronidazole (400 mg, 3 × 1) for 7 days was prescribed to treat AgP. Patient could not continue her treatment for personal reasons and when she reported after 1 year, the recurrence of gingival enlargement was noticed [Figure –]. Periodic panoramic radiographic examination revealed progressive alveolar bone loss, which was more pronounced on the right lower molars []. Biopsy showed hyperplastic stratified squamous epithelium along with ulceration of epithelium at places. Sub-epithelial tissue revealed a large number of normal plasma cells, few eosinophils and inflammatory granulation tissue [Figure and ]. A diagnosis consistent with PCG was made. To clarify whe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female gravida 2 para 1 was referred to our hospital with a 1-week history of mild vaginal bleeding. She had already been diagnosed with a cesarean scar pregnancy via transvaginal ultrasonography and magnetic resonance imaging (MRI) that showed the pregnancy 2.5 mm from the bladder wall. Two years prior to presentation, the patient had had a cesarean delivery for macrosomia without complications. Repeat ultrasound at the current presentation showed a single viable gestational sac corresponding to 7 weeks’ gestation at the cesarean scar site (). Endometrial thickness was 12 mm, and blood was seen in the uterine cavity at the level of the fundus. Abdominal examination was unremarkable. Speculum examination revealed minimal blood in the vagina. Laboratory workup showed normal hemoglobin level, platelet count, white blood count, and C-reactive protein. After the risks of cesarean scar pregnancy and benefits of treatment were explained, the couple chose termination of pregnancy; informed consent was obtained.\nThe patient was positioned similarly to infertility patients for office-based ovum pickup. A transvaginal probe fitted with a suction double lumen needle (Kitazato Corp) was introduced into the vagina, and the sac content was aspirated until no cardiac activity was detected. Methotrexate 50 mg was injected into the sac, and a 25-mg methotrexate injection was administered intramuscularly. The patient was hospitalized for 1 week after the procedure. During the first 2 days postoperatively, the patient had minimal vaginal spotting associated with mild lower abdominal pain. Her vital signs were stable throughout her hospital stay, and she was discharged on postoperative day 7.\nOne week after the procedure, transvaginal ultrasound showed a well-defined soft tissue mass that was inhomogeneous in texture with surrounding vascularity at the site of the cesarean scar and a small collapsed gestational sac without a yolk sac or embryo (). Beta human chorionic gon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old woman first noticed double vision 2 years prior to hospitalization. It had been present periodically, mostly in the evenings, and did not disturb the patient sufficiently to seek medical attention. Three months later she noticed leg weakness with walking difficulties, especially when climbing and walking down stairs, and walking instability resulting in consecutive falls. Six months later weakness of the arms appeared that caused difficulties in washing and combing her hair. After seven months she noticed difficulties in swallowing and nasal speech after prolonged talking. All of these symptoms had a fluctuating course and were more pronounced in the evenings.\nA neurological examination revealed diplopia due to the weakness and fatiguability of the rectus superior and rectus lateralis muscles of the left eye as well as of the rectus inferior of the right eye, moderate weakness of the facial muscles, mild dysphagia with nasal speech, mild weakness of neck muscles, and weakness and fatiguability of proximal limb muscles. Very mild active and percussion myotonia were observed, but the patients had not been aware of it prior to hospitalization. The patient's mother had been diagnosed with DM2 at the age of 48 years and her maternal grandfather had cataracts.\nA diagnosis of MG was confirmed in our patient by clear positive results in the neostigmine test and decremental responses in the repetitive nerve stimulation test (RNST) (); these were 43% and 26% in the deltoid and nasal muscles, respectively. Anti-acetylcholine receptor (AChR) antibody titer was elevated (8.8 nmol/L, normal <0.2 nmol/L). A chest CT scan showed a persistent thymic tissue in the upper anterior mediastinum, and a pathohistological examination of the thymus after thymectomy revealed thymic hyperplasia. Electromyography during relaxation demonstrated diffuse episodes of myotonic discharges () in multiple muscles, while during voluntary muscle activity a mild myopathic lesion was revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old Japanese woman in her second spontaneous pregnancy was referred to Takeda General Hospital at 17 weeks of gestation and diagnosed with a MCDA twin pregnancy. She was admitted to our hospital at 30 weeks' for management of potential premature delivery. She was regularly monitored by conventional ultrasound to assess growth and amniotic fluid volume, and by Doppler ultrasound of the umbilical artery (Table ). No TTTS complications were observed during hospitalization. The final routine monitoring before delivery was performed at 35 weeks and 5 days of gestation; and the maximum vertical pockets of the MCDA twins were observed to be 4.2 and 3.6 cm, respectively, with cardiotocography showing reassuring fetal status patterns for both. However, she complained of diminished fetal movement at 35 weeks and 6 days of gestation (approximately 12 h later; at the final confirmation of normal cardiac sound for both twins by fetal Doppler ultrasonography), and the IUD of one fetus was confirmed by ultrasonography. Emergency cesarean section was performed, and the patient delivered a 2306 g surviving twin male infant, and a 1994 g dead twin male infant without any definite anomalies. No autopsy was performed as consent could not be obtained from the parents. The surviving infant's hemoglobin was 13.9 g/dL, and ultrasonography of the head revealed no abnormal findings at birth. Although he showed no cardiac or renal dysfunction after birth, he was diagnosed with large cystic periventricular leukomalacia (PVL) on the basis of magnetic resonance imaging findings at 13 days after birth (Fig. ). His placenta was peculiar in that both UCIs were observed to be centrally located and in close proximity on the placenta (Fig. A). We did not observe any specific placental and umbilical cord findings during the fetal period. The placenta was 24 × 19 cm and weighed 778 g. The umbilical cords were found to be of unusual thickness and of 45 and 48 cm in length, respectively. Both um"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old woman (5′6″; 144 lb) was referred to a cardiologist by her primary care practitioner for evaluation of exertional dyspnea and chest pain upon walking a few feet. Her medical history included hypertension, hypothyroidism, and osteoarthritis. Her medications included nebivolol, levothyroxine, aspirin, and citalopram. Cardiolite stress test revealed no ischemia, and a 2-dimensional echocardiogram demonstrated normal left ventricular systolic function with no wall motion abnormalities, no significant valvular heart disease, and no pericardial effusion. An electrocardiogram showed normal sinus rhythm, and no acute changes were noted.\nBased on her history of continued symptoms, the patient underwent 2 cardiac catheterizations. The first catheterization revealed normal right-sided heart pressures and 80% stenosis of the left circumflex artery and was followed by percutaneous coronary intervention. The second catheterization occurred 2 months after the first and revealed a patent left circumflex artery stent, but 70% stenosis of the right coronary artery, for which the patient again received percutaneous coronary intervention.\nThe patient continued to experience exertional dyspnea and chest pain, and she subsequently developed dysphagia to solid foods and episodic dizziness. Consultations with a pulmonologist, gastroenterologist, and otolaryngologist revealed no underlying cause for these symptoms apart from evidence of esophageal dysmotility. Her dysphagia persisted despite treatment with a proton pump inhibitor and a histamine H2 receptor blocker. A cardiac event monitor showed no evidence of significant bradycardia or tachycardia, although the patient reported 1 episode of low heart rate (35 beats per min).\nShe was subsequently referred to an electrophysiologist for evaluation of presumed bradycardia. Orthostatic evaluation found a supine blood pressure of 150/80 mmHg with a heart rate of 70 beats per min. Upon standing for 3 min, the patient’s blood press"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old girl with a previous diagnosis of MFS was admitted in our Pediatric Surgery Unit with sudden onset of chest pain and shortness of breath after sneezing. Her past medical history revealed two previous left spontaneous pneumothorax (two and three months prior to this hospital admission), managed with conservative measures and pleural drainage.\nUpon examination, both physical and radiographic findings were compatible with a pneumothorax recurrence on the left side. A thoracic CT scan showed bullous pulmonary dysplasia (). Thoracoscopic treatment included resection of the pneumopleural adhesions and bullae. The procedure was performed with the patient in a lateral decubitus position. Three valved ports, ranging in size from 3 to 5 mm, were used. The first port was placed in the mid to the anterior axillary line in the fifth interspace to determine the position of the major fissure and evaluate the lung parenchyma. The position of the fissure dictates the placement of the other ports. The working ports were placed in the anterior axillary line above and below the camera port. Lung resection, including the parenchymal area involved in the lesion, was performed using the LigaSure® device. A lung specimen was removed using a protective specimen endobag through a 5 mm port. No postsurgical drainage tubes were positioned. The patient was discharged on the eighth postoperative day.\nOne week later, a pneumothorax recurrence necessitated a second thoracoscopic intervention. Further pulmonary resection of the atypical upper left lobe was performed using a stapling device. Two patches (9.5 × 4.8 cm) were cut from the adhesive/foam complex (TachoSil®), rolled and inserted into the 5 mm trocar, and subsequently stretched over the sutures. No drainage tubes were inserted. The postoperative period was uneventful, and the patient was discharged one week later. Gross findings showed severe emphysematous involvement in the upper lobe with marked bulla formation (). Microsco"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old female, with a typical presentation of carpal tunnel syndrome in the right hand, presented initially with numbness in digit IV and V a year later. A few months later, she developed numbness in all five fingers on the left side. Furthermore, the patient mentioned that she had had a burning sensation in both feet for a few years. Another few months later she complained of weakness in all four limbs and was sent for a neurological consultation with electromyography. Clinical examination revealed a Hoffmann-Trömner reflex on the left side, mild loss of strength in both hands, loss of vibratory sense and hypoesthesia in the distal end of all four limbs and loss of proprioception in both legs. The electromyography showed disturbed sensorimotor signals in the left hand and mildly disturbed sensorimotor signals in the right hand. The disturbed electromyography was attributed to carpal tunnel syndrome, which was presumably less severe on the right side due to treatment with long acting corticosteroid injections. The paresthesia in digit IV, digit V and both feet, however, could not be explained with the diagnosis of carpal tunnel syndrome. Therefore, magnetic resonance imaging (MRI) of the cervical spine was performed. Imaging showed an extra-dural soft tissue mass posterior to the odontoid process of the axis. The mass extruded through the transverse ligament of the atlas with severe compression of the myelum and myelomalacia at the level of C1 (Figures , and ).\nA plain radiograph of the cervical spine was performed to check for atlanto-axial instability. The radiograph during flexion shows a slightly widened atlantodental interval, measuring 4 mm (normal value: <3 mm) (Figure and ).\nPre-operative imaging of the cervical spine also revealed an anatomical variant of the craniocervical junction, atlanto-occipital assimilation of the massa lateralis bilaterally (Figure ).\nThe patient was treated with laminectomy of C1 to decompress the spinal canal followed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA five-month-old boy of Caucasian ethnicity presented at our pediatric emergency unit. He had suffered acute paroxysmal abdominal pain and bilious vomiting for nine hours. His general condition and vital signs were normal.\nDuring physical examination, an abdominal mass was noted in the upper right quadrant - there was no blood in stools in the rectum. Biological examinations did not yield significant results, but an ultrasound scan revealed a target sign in the form of an opaque mass under the liver. An air enema reduction was performed and identified a loop in the transverse colon that was refluxing under air pressure. This procedure did not result in a complete reduction of the assumed intussusception even after two attempts under midazolam infusion. An ileocolic intussusception of 2 cm was diagnosed during the laparoscopic exploration and a reduction was carried out by applying gentle traction. The adjacent small intestine and the ascending colon had a normal color and the child had normal peristalsis. The procedure was finished on these reassuring signs. During the night, the boy suffered repeated episodes of vomiting and had blood in his stools. An ultrasound scan performed in the morning revealed an intussusception, a swelling of the distal small intestine and the presence of a mass in the pouch of Douglas. It was difficult to determine with confidence whether the intussusception was ileocolic or ileoileal.\nA second laparoscopic procedure determined that the intussusception was not ileocolic. The cecum was in its usual location, and there was no inflammation of the appendix. The small intestine was examined more closely and an intussusception was found, located 40 cm above the ileocolic junction. A reduction attempt failed even with the help of a third forceps. A right hemitransverse abdominal incision was performed but the reduction attempt failed. Palpating the ascending colon revealed a diffuse induration with no signs of wall necrosis. The small intestine"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old woman with a past medical history of sarcoidosis underwent an endoscopic examination owing to dysphagia. The endoscopic examination revealed a circumferential tumor with ulceration in the cervical esophagus. Biopsies obtained during the endoscopy indicated squamous cell carcinoma. Contrast-enhanced CT showed extensive tumor growth with suspected tracheal invasion and enlarged lymph nodes extending from the cervical region to the upper mediastinum. FDG-PET/CT revealed abnormal FDG accumulation in the primary lesion (SUV max: 23.1) and lymph nodes (SUV max: 5.45) from the cervical to upper mediastinal region (Fig. ). However, it was difficult to determine whether the multiple lymphadenopathy was benign or metastatic because of her past medical history of sarcoidosis. Therefore, and also for the purpose of preserving the larynx, we initiated definitive chemoradiotherapy. The patient was administered 2 cycles of 45 mg cisplatin and 700 mg 5-fluorouracil with 60 Gy/30 fr radiation therapy over 2 months. In each cycle, 8 mg dexamethasone was administered to prevent side effects of chemotherapy. After completing the chemoradiotherapy, we observed complete disappearance of FDG uptake in the primary cancer in the esophagus, and only a slight reduction in FDG uptake in the mediastinal lymph nodes (SUV max: 3.26; Fig. ), which indicated that the lymph nodes were affected by sarcoidosis. The primary lesion of the esophagus relapsed 3 months later. Then, the patient underwent thoracoscopic and laparoscopic total laryngopharyngoesophagectomy with gastric tube reconstruction via the posterior mediastinal route. The pathological diagnosis was moderately differentiated squamous cell carcinoma in the cervical esophagus. The resected lymph nodes demonstrated no tumor metastasis. However, some lymph nodes showed granulomatous reactions and contained several small epithelioid cell granulomas (Fig. ), suggesting the presence of sarcoidosis. The final stage was determined as"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old gentleman complained of swelling and progressive pain in his left big toe after falling foot first into a drain. From his description of the fall, it seemed like the big toe suffered from an axial loading and hyperdorsiflexion injury. He visited the emergency department of another institution where he was given symptomatic treatment and had dorsoposterior (DP) and oblique radiographs of the left great toe performed (). He was told that the radiographs did not reveal any acute fracture and was advised to rest and to attend at the Orthopaedic Surgery Specialist Outpatient Clinic 2 weeks later. The patient felt symptomatically better after a few days and had returned to running and playing field hockey. Three weeks from the initial injury, there was recurrence of pain and swelling in the left great toe and this was limiting the function of the patient. This prompted him to seek attention at our Specialist Outpatient Clinic.\nOn examination, the affected big toe was shortened and dorsally dislocated as compared with the contralateral side. There was tenderness and swelling at the IP joint. While walking, the plantar side of the great toe did not touch the floor. There was lack of active movement of the affected IP joint. The IP joint could not be maneuvered passively too. Normal motion was maintained over the left metatarsophalangeal joint. Plain radiography was repeated and showed obliquity of the IP joint line with an interposed sesamoid bone (). Dislocation of the IP joint of the left big toe was suspected based on the clinical presentation as well as subtle features appreciable on the radiographs as discussed with our radiologists. Manual reduction was attempted but was unsuccessful. In spite of advice for surgical reduction, patient was not keen initially as the prescribed analgesics were efficacious in treating the pain and patient was still able to walk and jog without severe symptoms. However, the patient returned 1 week later (4 weeks from initial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old woman with a history of root canal treatment of the upper maxillary (left) central incisor was referred to our department from a private clinic. The root canal treatment had been initiated 4 months prior but could not be finished. A clinical examination revealed a temporary filling on the palatal surface. The coronal part of the tooth was discolored, and multiple visible cracks were present on the buccal surface (). The tooth was asymptomatic; the mobility was normal, and the probing depth at all sites was ≤ 3 mm. A periapical radiograph revealed a lesion around the apex and an enlarged and clearly irregular root canal (). When specifically asked, the patient denied knowledge of any previous dental trauma. Upon checking the electronic documentation of the faculty of the institution, we found that the patient had visited the department 2 years prior for other reasons, and X-rays were taken at that appointment. From a comparison of the periapical X-rays, it was clear that something must have happened since her last visit (). After gaining her confidence, the patient and her mother admitted that the patient had suffered from domestic abuse at the hands of her boyfriend, but that had been taken care of by the police. At this point, a small-field-of-view high-resolution cone-beam computed tomography (CBCT) scan was taken to investigate the extent and irregularity of the lesion. The scan confirmed the presence of a periapical lesion, which had destroyed most of the buccal bony wall around the root. The scan also showed massive internal resorption inside the root canal (). The patient was informed of the findings and the poor prognosis of the tooth, but since she desperately wanted to keep her tooth, she provided consent for endodontic treatment, which was initialized at a later appointment. The patient was also informed that due to the irregular nature and more pronounced buccolingual extent of the resorptive lesion and the massive destruction of the buccal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA one-and-a-half-month-old boy of Caucasian origins was referred to our hospital for an assessment of his feet. He was born with talipes equinovarus, or clubfoot, on his right foot. Figure shows his right foot postoperatively, after the correction to his clubfoot. On his left foot he had developed pes cavus and he had curly toes on both feet (Figure ). He had also been treated for a left hip dislocation.\nThere is no information with regard to the pregnancy itself but the birth was troublesome because he was lying in a lateral position and had to be born with vacuum extraction.\nHe was born to nonconsanguineous parents and has an older sister who is healthy.\nIt was found necessary to operate on his right foot and the operation, which went as planned, took place when he was just three months old. It was noted that there was an eczematous rash corresponding to the medial-dorsal skin furrow, which was exactly where the intended incision was to be made. The eczema was described as exuding, with fluid slowly seeping out, but not as a complete epidermis lesion. He was subsequently prescribed peri-operative antibiotics (dicloxacillin) two times per day for the course of one week after the operation, and the eczema was not considered an issue for the success of the operation and healing process.\nTen days after the surgery he was admitted urgently to our hospital because the bandages were foul-smelling and he had failed to thrive for the previous two days. Necrosis was seen around the cicatrix and it was found necessary to revise the wound under general anesthesia. Afterward, he was monitored for a month every other day when he had his bandages changed and the wound healed well. He was fitted with a dynamic splint to support his right foot.\nA week after the last control, he was referred from"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case report of a 41 year old male patient who suffered a knife inflicted injury to the face. He was referred to our department 20 months after the incidence complaining of persistent discomfort with downward gaze of the left eye. He reported being agitated and feared a possible sight-threatening condition after the alleged assault. He was transferred to an emergency department where he was examined by an ophthalmologist who reassured him that his globe was intact and sutured the deep cut wounds related to his upper and lower eyelids. He was reassured that the facial edema would subside and the neurosensory deficit he was suffering from would eventually recover. Empirical antibiotics, Analgesia and tetanus prophylaxis were prescribed and the patient was discharged from the emergency department. He was unsatisfied with the resultant scar in his left eyelids and six months later was re-examined by a plastic surgeon that performed blepharoplasty. The persistent complaint of discomfort related to his left eye led him to seek medical advice again before being referred to our department.\nSystematic thorough clinical and radiographic examination was performed. Upon inspection, it was noted that the left globe was displaced superiorly with increased scleral show (a). Bimanual palpation was done and a hard object could be felt behind the orbital rim of the left eye; although it was not visible externally. No evidence of diplopia was noted by ophthalmological examination. Plain radiography (Paranasal sinuses view (P.N.S) and lateral skull view) revealed a radiopaque foreign body (FB) lodged inside the orbital floor and directed downward & posteriorly (b and c). Computed tomography (CT) scan was ordered to precisely localize the foreign body and its relation to the surrounding structures. The foreign body was found penetrating the facial skeleton at the level of the orbital floor and transgressed the maxillary antrum and its tip reaching the pterygoid plates of maxill"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old, previously healthy male was admitted to our intensive care department after suffering a motor vehicle accident. His injuries included: skull base fracture; diffuse axonal brain injuries, bilateral lung contusions with left side diaphragmatic rupture and dissection of descending aorta.\nOn admission to ICU he was sedated and mechanically ventilated. His blood pressure was 134/54 mmHg and pulse was 69 beats/min. Due to a potentially high risk of rupture and bleeding from the aortic dissection, the patient underwent urgent endovascular stenting. The procedure was completed successfully uneventfully.\nFor the following two weeks the patient was treated for severe traumatic brain injury. Despite adequate sedation and analgesia the patient had become extremely hypertensive (blood pressure 215/100 mmHg). CT imaging and ICP monitoring did not reveal any signs of elevated intracranial pressure, or signs of herniation.\nA detailed clinical workup was performed, and included a repeated abdominal CT, which demonstrated a remarkable subcapsular hematoma of the left kidney (), with no active bleeding. There was no biochemical evidence of kidney dysfunction or reduction in GFR.\nThe patient was started with and angiotensin converting enzyme inhibitor and an alpha-beta blocker Labetalol. Due to persistent hypertension, despite optimal medical treatment a surgical approach (capsulotomy or nephrectomy) was considered. Due to refusal of the patient's proxy, surgery was not performed. Thus, ultrasound guided hematoma drainage was done with a total of 80 mL of sanguinous fluid withdrawn. Gram stain analysis did not detect any microorganism. Antihypertensive therapy was continued after the procedure. Further workup for primary hypertension which included a cardiac echocardiogram and vascular ultrasound did not reveal abnormalities.\nAfter one month of ICU hospitalization the patient was discharged for rehabilitation for rehabilitation. The patient remained dependent on anti-hy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old boy reported to the department of oral and maxillofacial surgery with a complaint of painless multiple swelling over the right massetric region since 2 years, which was obvious only after clenching. The patient was healthy without any medical and dental abnormalities. He could not recollect any incidence of trauma to the affected site.\nOn examination facial asymmetry with swelling at the right mandibular angle region was evident only on clenching []. Palpation revealed superficial well-circumscribed, well-defined, discrete, painless masses of different sizes (2 × 3 mm, 2 × 2 mm, 1 × 2 mm, 1 × 1 mm, approximately). They were not adherent to the underlying structures and freely movable in all directions. Routine blood investigations were within normal range. Serum calcium and phosphorous were also within normal limits. Panoramic radiograph reveals multiple well-defined radio-opaque masses scattered over the lower border of the right mandibular angle region below the mandibular third molar []. Axial view of CT scan examination revealed a multiple hyperdense masses located in the region of the right mandibular angle over the right masseter muscle [].\nMyositis ossificans, osseous calcified nodules and osseous choriostoma were considered in the differential diagnosis. Intraoral excision was planned under general anesthesia. The incision was placed in the buccal vestibule opposite to the first molar extending along the anterior border of the ramus toward coronoid notch []. Blunt dissection was carried supraperiostally extending toward the masses till it was identified []. The head was fixed in position with proper retraction throughout the procedure which was important. The assistant fixed the masses from outside while dissecting.\nThe whole bunch of nodules was excised []. While dissecting intraorally care was taken to prevent injury to the facial artery and vein. During the procedure, bleeding was encountered due to injury to the facial vein, which was manag"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old Caucasian female with a history of lupus presented for elective left total knee arthroplasty following the development of osteoarthritis that had failed conservative measures. The patient had a history of previous left knee ACL reconstruction approximately 25 years ago using the Arthrotek bone mulch screw and WasherLoc system []. She underwent removal of the tibial WasherLoc approximately 10 years later, in the early 2000's ().\nThe patient was positioned supine; standard incision with a medial parapatellar arthrotomy was performed. A measured resection technique was then performed with an intramedullary guide placed in the femur. The femur was cut in 6 degrees of valgus and 3 degrees of external rotation. A size 4 femoral prosthesis was placed and noted to overhang both medially and laterally on the condyles. At this time, it was decided to downsize the femoral component. The 4 in 1 femoral cutting block was then placed back on the femur and was noted to be in contact with the bone mulch ACL screw. The bone mulch screw was located and identified in the lateral femoral condyle; a curette was used to clear the head of the screw, and it was removed. The proximal tibia was then prepared using an intramedullary guide with 3 degrees of posterior slope. A size 3 tibial component and a 9 mm poly were placed; the knee was noted to be tight in both flexion and extension. An additional 2 mm resection was performed on the proximal tibia. It was noted at this time while trying to trial the prostheses that the lateral femoral condyle was fractured. Conversion to a stemmed femoral component with a cruciate stabilizing prosthesis was attempted. The femoral canal was reamed, and the femoral box cut was made. However, during trialing, the medial femoral condyle was now noted to have a fracture as well. An intraoperative consultation with an adult reconstruction trained orthopaedic surgeon was performed. Immediate surgical correction was not possible due to improper impl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was 32 years old when he was referred to our center, and he was complaining of infertility. Pregnancy and delivery were normal. He was born at term with standard measurements. On physical examination, his weight was 74 kg, his height was 190 cm, and also body mass index (BMI) was normal at 20.5 (20 < normal values < 25). In clinical examination, Semi-Klinefelter characteristics such as tall stature (190 cm), teeth dysmorphology, history of respiratory disease, low total body hair, long length of fingers and toes, partial deformity of the joints and nails, likewise mental health problems were obvious in this patient. Meanwhile, there was no similar features or history reported within the patient's family members. After consultation, we decided to accomplish karyotype analysis to make sure about chromosome numbers and aberrations that was needed for early diagnosis and then choose appropriate treatment strategies.\nThe patient's blood samples were cultured, and their chromosomes were analyzed and studied by the G-banding method. A total of 85 cells were counted of which 81 cells had 48 chromosomes, two had 46 and two had 47.\nAll of the 85 counted cells without exception illustrated three Y sex chromosomes (the cells containing 46 and 47 chromosomes were probably caused by random chromosomal additions or losses from cell breakage). The construction of the cells with 48 chromosomes is thought to be 48, XYYY. The supplementary chromosomes were Y chromosomes because they had the subsequent characteristics in common: The long arms of the chromatids usually remained equal through their length, they never contributed in satellite association, and almost always appeared on or around the border of the metaphase spread, and simultaneously there are no clinical signs attributable to aneuploidy of other G group members.\nHis karyotype was therefore reported as 48, XYYY (Fig. ). Cytogenetic examination of his wife was normal (46, XX). In order to validate our results, we"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year-old neutered male Labrador retriever was referred to the medical oncology service for evaluation of a mass on the left rostral maxilla and dorsolateral muzzle. On presentation, the swelling had a diameter of 3.3 cm, round and firm. The mass could be appreciated intraoral at the apex if 204 and extraorally ~1.5 cm caudal to the nasal planum. The patient was placed under general anesthesia for head and thoracic CT as well as incisional biopsy and regional lymph node aspiration. Regional lymph node aspiration showed reactive lymphoid tissue and the thoracic CT showed atelectasis, consistent with general anesthesia, with no evidence of pulmonary metastasis or intrathoracic lymphadenopathy. Head CT revealed a 4.6 cm soft tissue attenuating mass along the left dorsolateral maxilla extending from the mesial aspect of the left maxillary canine tooth to the mesial aspect of the left maxillary second premolar tooth. The dorsal extent of the mass was 1.5 cm from the dorsal midline of the muzzle and ventrally involved the alveolar margin of the left maxillary canine tooth. Results of histological examination revealed a histologically low-grade FSA with mild bony infiltration. Based on the clinicopathologic correlation, the tumor was determined to be a histologically low-grade, biologically high-grade FSA (H/L FSA).\nThe case was referred to the dentistry and oral surgery service for surgical treatment. A composite resection utilizing a combined intra- and extraoral approach was performed. The soft tissue resection extended from 1 cm rostral to the medial canthus of the left eye and extended into the left lateral nasal planum. From dorsal to ventral, the resection extended from the dorsal midline of the muzzle to approximately 3.5 cm from the mucocutaneous junction. The osseous resection extended from the mesial aspect of the left maxillary second incisor tooth to the furcation of the left maxillary fourth premolar tooth. The palatal extent of the resection was the media"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old woman presented with a 2-month history of mild dyspnea on exertion. A computed tomography (CT) scan showed a low-attenuation defect in the lumen of the right main pulmonary artery (). Pulmonary artery thromboembolism was suspected. Anticoagulation therapy with apixaban was administered; however, the defect in the pulmonary artery did not improve after 4 weeks of anticoagulation treatment. A positron emission tomography (PET) scan revealed the uptake of fluorine-18 fluorodeoxyglucose (FDG) in the intraluminal defect with a maximum standardized uptake value (SUVmax) of 4.35, suggesting a malignant tumor. To confirm the diagnosis and selection of a treatment, we performed endovascular catheter aspiration biopsy of intravascular mass using a 6 Fr Envoy catheter (Codman, Raynham, Massachusetts, USA). Vacuum suction of the mass was performed several times by careful manipulation (). Histological examination revealed pulmonary artery sarcoma. No distant metastasis was identified. A right pneumonectomy with arterioplasty of the pulmonary arterial bifurcation with the use of cardiopulmonary bypass was planned.\nThrough median sternotomy, the surgery was performed. The tumor completely filled the right main pulmonary artery. No invasion to extravascular tissues was identified. Cardiopulmonary bypass was established with standard techniques using cannulas placed in the ascending aorta and the right atrial appendage. The main pulmonary artery was incised. The solid tumor filled the right main pulmonary artery and extended to the main pulmonary artery trunk. The right pulmonary artery and a part of the main pulmonary artery from the supravalvular to the left main pulmonary artery were resected. Macroscopically, the surgical margin was negative. The main pulmonary artery trunk and left pulmonary artery were reconstructed with bovine pericardium. The patient was successfully weaned from the cardiopulmonary bypass, and a right pneumonectomy was performed. The operation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old right-handed female was admitted to our hospital because of a pulsatile mass at the right side of the neck, below the angle of the mandible. The patient reported that she had noticed the mass for the first time 13 years ago and has been followed up regularly. There was no history of any infective lesion, trauma, or any family history of aneurysm disease. There was no palpable lymphadenopathy. Initially, she has treated conservatively and due to the appearance of the symptoms such as enlargement of the size of the mass and dyspnea on exertion. She had been managed with endovascular treatment as parent vessel occlusion 4 years ago []. There was shrinkage of the size of the mass and improvement of the symptoms. Over the past 6 months, the size has again started to enlarge and also the appearance of the symptoms and its pulsatile nature became more evident. Clinical examination showed a pulsatile mass on the right side of the neck. No neurologic symptoms occurred in the patient. Examination of the cranial nerves showed no anomalies. A computed tomography (CT) angiography followed, verifying the presence of a fusiform giant aneurysm of the right ICA, measuring 5 cm in diameter. To further define the right EICA and the remaining cerebral circulation, CT angiography was performed with three-dimensional (3D) reconstruction. The 3D reconstruction confirmed a fusiform aneurysm arising from the proximal right EICA []. Despite the patient had undergone endovascular management 4 years ago in the form of parent vessel occlusion, we could see the minimal flow in the EICA which may be due to recanalization. No intracranial aneurysmal disease was identified. The aneurysm measurements were 25 mm × 30 mm, with a cranial-caudal length of 50 mm and a wide neck. An aneurysm extended from 2 cm after the carotid bifurcation nearly to the base of the skull. The patient elected for surgical correction, as she was finding her symptoms troublesome and was keen for a “definitive”"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old male with a history of a distended abdomen presented to the emergency department (ED) after outpatient imaging studies were significant for an abdominal mass. He initially presented to his gastroenterologist with a 2-week history of intermittent epigastric pain that, worsened after each meal. He also developed early satiety and his parents reported increased distention. Review of systems was otherwise negative. Of note, the patient had a protuberant abdomen starting at 3 years of age. Two ultrasounds were completed at that time and both were reportedly negative for any findings; the images were not available for review. Over the years, his abdomen gradually became more distended.\nHe underwent an abdominal X-ray, which was significant for an abdominal mass. He was then sent for a CT of the abdomen and pelvis, which again noted an abdominal mass 27 x 33 x 15 cm in size that displaced the majority of his abdominal contents posteriorly and that appeared to be mesenteric in origin (). He was instructed to go to the ED after the CT findings. On physical exam, his vital signs were within normal limits and his abdomen was soft, non-tender to palpation, and distended. There were no palpable masses in the abdomen or palpable lymph nodes. His blood work was also unremarkable.\nHematology/oncology was consulted, and a CT neck and chest were obtained to look for potential metastatic disease, both of which were negative. The patient was admitted and underwent surgical resection of the mass the following day. On exploration, the mass was tan-yellow in color, firm with a rubbery consistency, involved a segment of small bowel, and was connected via a single vascular pedicle (). The vascular pedicle was ligated, and the involved segment of small bowel was resected along with the entire mass. Abdominal exploration revealed no other abnormalities. The patient did well postoperatively, resuming a liquid then regular diet, had return of bowel function, and was discharged"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old female was admitted to the operating theater for aortic valve replacement. During the operation and in the first hours in the intensive care unit (ICU) the patient had to undergo TEE in order to assess postoperative left ventricle performance status. Soon after, in the ICU, the patient presented hematemesis. Gastroscopy revealed a corkscrew esophagus along with a bend before the gastroesophageal junction. A deep 2 × 1.5 cm ulcer covered with blood thrombus was found approximately 2 cm above the gastroesophageal junction. Blood oozing was clearly seen from the ulcer edges. Despite thorough irrigation the thrombus could not be removed. Endoscopic therapy with 10 ml NaCl 0.9% solution successfully stopped bleeding. The rest of the endoscopy was unremarkable. Within the next 48 h, thoracic and abdominal CT scans were ordered twice to rule out esophageal perforation. Only a few blood clots were found in the area between the stomach and the left liver hilum, but no signs of mediastinitis or free intra-abdominal air. The patient remained in the ICU hemodynamically stable and on nil by mouth.\nFour days later, as the patient became febrile, a second gastroscopy was performed. A 2 × 1.5 cm perforation was seen at the same site of ulcer with no bleeding (fig. ). Abdominal X-ray confirmed subdiaphragmatic air. Due to the patient's clinical condition and the size of the gap, an endoscopic intervention was decided. A new 12-mm clip (OTSC®; Ovesco Endoscopy, Tübingen, Germany) was engaged. The clip is made of nitinol and approximates large perforation margins like a surgical clamp. It is preloaded over a transparent cap attached to the scope tip. The perforation size was endoscopically assessed with a biopsy forceps. The edges of the perforation were approximated by using a specific endoscopic double grasping forceps and applying suction through the cap. Thus, the tissue was pulled into the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old girl was referred to a tertiary metabolic bone disease unit for premature loss of primary teeth with roots intact and low serum ALP activity (123 IU/L; reference range: 230–700 IU/L) []. Routine genetic testing revealed compound heterozygosity (c.350A > G, p.Y117C, c.400_401AC > CA, p.T134H) for different TNSALP missense mutations in exon 5 of the ALPL gene, confirming the diagnosis of HPP. On presentation, radiologic assessment of the left hand and arm showed tongue-like lucencies projecting into the metaphyses consistent with childhood HPP. She did not have any clinical features of skeletal involvement of the lower limbs and no motor developmental delay except for a mild waddling gait as a younger child. The patient had a relatively asymptomatic clinical course until she presented at age 11 years with swelling and tenderness of the left ankle that was nonresponsive to paracetamol or ibuprofen. An MRI scan of the ankle suggested a diagnosis of chronic recurrent multifocal osteomyelitis, which was subsequently confirmed by biopsy. The symptoms of pain and swelling of the lower limb joints showed spontaneous transient improvement at age 13 years. Recurring at age 14 years, the symptoms fluctuated and caused significant pain and disability. These symptoms eventually stabilized when the patient was transitioned to adult care at age 17 years. At age 18 years, she successfully underwent radiofrequency ablation for Wolff-Parkinson-White Syndrome, a cardiac disorder unrelated to HPP. The patient is now 27 years of age and has experienced an episode of metatarsal stress fracture; she also suffers from generalized aches and pain.\nOver 22 years, this patient was hospitalized 3 times for a total of 19 days (Table ). Only 1 hospitalization exceeded 3 days, when the patient was admitted for 14 days to receive intravenous antibiotics for suspected osteomyelitis (Table ).\nOutpatient specialist visits, outpatient procedures, and day case procedures represent the majori"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old Dominican woman presented to emergency room with complaints of five hours of vomiting and profuse diarrhea in summer 2011. Symptoms started within 3 hours after eating chicken sandwich and salad, which were prepared at home. While frequency of vomiting decreased, she reported diarrhea, which later occurred and was too often to count. Subsequently, her urine output decreased. The patient denied fever or blood in the stool. She had previously been healthy and was not taking any medications. She had no known allergies. Her last travel to Dominican Republic or outside the US was more than 3 years ago. She lived with her husband and son. She consumed alcohol occasionally and did not smoke or use illicit drugs. Her family and friends who had the dinner together had been well. She had no history of similar symptoms in the past. She denied recent use of antibiotics or hospitalization. She had gastric bypass surgery in 2005 and abdominoplasty in 2007. At presentation, she was afebrile with pulse rate of 103 beats/minute. Her blood pressure was 89/52 with orthostatic changes. Her mucous membranes were dry; the remainder of the examination was unremarkable. Laboratory test results were significant for anionic gap metabolic acidosis with acute kidney injury and severe hypokalemia. There was no leucocytosis. Liver enzyme tests showed mildly increased aminotransferases. The laboratory data at presentation are presented in . The patient was admitted to the critical care unit due to acute renal failure with severe electrolyte abnormalities. Human Immunodeficiency Virus test was negative. She had central line placement for close monitoring of central venous pressure. She had a total stool output of 40 liters by the end of 5 days. Later, her stool color changed to green. Stool ova and parasites and Clostridium difficile toxin were negative. Computed tomography scan of abdomen showed normal bowel pattern without any dilated loops of bowel and unremarkable pancreas (). Sh"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60 year old man, who was under regular haematological follow-up because of myelofibrosis, presented at a routine clinic visit complaining of increasing shortness of breath, weight loss and lethargy. Clinical examination of the chest was normal but a chest x-ray (CXR) showed multiple lung lesions consistent with metastatic deposits (figure ). A staging computed tomography (CT) scan done shortly afterwards showed marked splenomegaly, causing displacement of the left kidney medially. In the left kidney, there was a 5 cm soft tissue mass arising from the middle of the kidney with characteristics of primary renal cancer (figure ). The staging CT chest showed multiple pulmonary metastases in both lungs.\nThe patient underwent laparoscopic cytoreductive nephrectomy without complications and agreed to have immunotherapy with alpha-interferon. Histology revealed clear cell renal cell carcinoma. Six weeks following the operation, just prior to commencing immunotherapy, he attended the haematology clinic as routine follow-up. His initial symptoms had completely resolved and a repeat chest radiograph on that day showed clear lungs with no evidence of metastatic deposits (figure ). Although no histological confirmation of the metastatic nature of the lung lesions was obtained, it is highly likely that his pulmonary metastases had regressed spontaneously as the patient had not received any immunotherapy in the meantime. The patient remains well five months after the operation.\nRenal cell cancer accounts for 2% of all cancers and its incidence is steadily rising. It usually presents in late adult life and is more common in males than females. Although they are associated with Von Hippel-Lindau disease, adult polycystic kidney disease and multicystic nephroma, most renal cell cancers develop spontaneously [].\nThe patient may present with urological symptoms such as haematuria or flank pain or with an abdominal mass or alternatively with systemic manifestations, such as anaemia and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old male patient had road traffic accident dated January 2018, was taken to a nearby orthopedic surgeon, where he was diagnosed as having intra-articular distal radius fracture of the right side, and was operated 2 days after injury with anatomical distal radius locking plate. He was doing fine for 6 months after the index surgery; thereafter, he noticed a swelling in his lateral aspect of the right forearm for which he consulted his index surgeon, was advised course of oral antibiotics with regular follow-up. However, his swelling did not subside and was slowly increasing in size which made him to visit his index surgeon again where he was advised removal of implant.\nOne month following removal of implant, he again noticed swelling now on his inner aspect of the right forearm which was also slowly increasing in size; he was advised ultrasonography and fine-needle aspiration cytology (FNAC). Sonographic findings were non-specific, but FNAC report suggested soft-tissue sarcoma and was finally referred to our tertiary care hospital for further management.\nClinically, the patient was afebrile with no history of weight loss. Non-tender, ill-defined, and firm swelling was located on inner aspect of his right forearm; overlying skin was free with normal texture and normal temperature. Swelling was not fixed to underlying structure and regional lymph nodes were not enlarged. Routine laboratory and biochemical parameters were within normal rage except for mild raised erythrocyte sedimentation rate. Radiograph revealed malunited fracture of distal radius with evidence of screw holes of previous implant. Soft-tissue shadow was noticed adjacent to ulna with no evidence of bone erosion and/or periosteal reaction (). Here, the patient was advised contrast magnetic resonance imaging (MRI), which reported calcified soft-tissue mass measuring 8.3 cm × 1.6 cm × 10 cm situated in medial aspect of lower third ulna extending to ventral compartment of the right forearm, appear"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n1: A-39-years-old male referred to our General Hospital with sensation of giving away and unable to extend on the right knee after car accident 1.5 years ago. He had history of close fracture of lateral condyle right femur. The patient complain of irreducible patellar dislocation during flexion and extension of the right knee joint. He underwent 4 times surgery of his right knee by other orthopaedic surgeon. The first surgery result still unreduced fragment fracture, and we done open reduction and internal fixation (ORIF) also PCL reconstruction. The right knee became valgus knee after fracture union and instability sensation on the medial knee joint. On physical examination, the right knee had 18° of valgus deformity, moderate instability to valgus stress, complete lateral dislocation of the patellae during extension and flexion, and tenderness at the lateral joint line (). Range of motion was 0–110°.\nDuring radiographic examination, the standing knee radiograph showed mild arthritic changes on the lateral compartment of the right knee that were not observed on the left knee. The long-leg weight-bearing standing radiograph showed 18° valgus on the right knee and 5° valgus on the left knee with depression of the lateral tibia plateau and a mechanical axis passing outside the lateral compartment, and the weight bearing line locates lateral to Fujisawa point. The anatomical lateral distal femoral angles of the right and left knees were 105° and 82° respectively (normal value is 81° and 62°, respectively); the medial proximal tibial angles were 94° and 93° respectively (normal value is 87° and 63°, respectively). This result confirmed valgus deformities of both knees. A skyline view radiograph showed complete lateral dislocation of the patella () [].\n2: A-26-years-old obese female came into outpatient clinic with chief complain of left patellar dislocation. She had history of left knee surgery for dislocation at age 5 years old. Her left knee never felt comfortable and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-years-old female presented to our outpatient department (OPD) for the assessment of multiple non-healing ulcers present bilaterally on the dorsal aspect of hands, posterolateral aspect of elbows, and inner knees (Figures -). The patient had severe pain at the sites of the ulcer which was present throughout the day. The patient first noticed a hard-elevated lesion on her left elbow two months ago. The lesion first began as a small pustule. It increased in size and became pus-filled to form a blister which later on burst to leave behind a raw area that turned into an ulcer. Several such lesions developed gradually on other parts of her body that progressed similarly. The lesion progressed to her right elbow, advanced further to both knees, and then lastly to the dorsal aspect of both hands. All the lesions turned into painful pus discharging ulcers over time. The patient initially consulted a private practitioner and was prescribed antibiotics along with an analgesic. The patient was unresponsive to this treatment following which she was referred to our tertiary care centre. On initial examination, the lesions were painful that discharged pus. Margins were raised, irregular, and showed bilateral symmetry. A few differentials were suggested like cutaneous tuberculosis, vasculitis, deep fungal infection, and PG. To rule out cutaneous tuberculosis, investigations were done which turned out negative. Further, a skin biopsy from the left elbow ulcer was sent to rule out other differentials.\nThe biopsy report showed epidermal and dermal ulceration with necrosis, vascular proliferation, granular tissue formation with polymorphs, lymphocytes, plasma cells, and macrophages. The adjacent epidermis showed spongiosis, while there was mild hyperplasia and peri adnexal mixed inflammatory infiltration in the dermis. These histological features were consistent with the clinical diagnosis of pyoderma gangrenosum. Antinuclear antibody (ANA) profile and rheumatoid factor (RF) were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old right hand dominant gentleman presented to our orthopaedic clinic with a six-month history of an unusual, progressive, painful, and fixed external rotation deformity of his left shoulder (Figures and ).\nOne year previously, he was diagnosed with oesophageal adenocarcinoma, which was treated with a course of neoadjuvant chemotherapy followed by oesphagectomy. Preoperative staging CT had shown no evidence of distant metastases. Histology revealed a poorly differentiated adenocarcinoma with focal perineural invasion but clear resection margins. He had declined adjuvant chemoradiotherapy.\nThe patient initially experienced reduced range of movement in his left shoulder six months following his oesphagectomy and began to notice that self-hygiene was becoming troublesome. He was referred to the physiotherapists who noted a progressive permanent external rotation deformity of his left shoulder with a fixed abduction of 30 degrees and a maximum abduction of 90 degrees. He complained of a continuous pain from the shoulder radiating to his elbow, and was slightly tender over the infraspinatus muscle bulk, although no mass was palpable. The awkward position of his arm increasingly interfered with washing and dressing. The external rotation deformity worsened and became fixed at 40 degrees, at which point he was referred to the orthopaedic clinic where he presented a great diagnostic challenge.\nAs the shoulder pain and deformity progressed, CT and MRI were performed to aid the diagnosis. These showed a discrete mass measuring 4 × 4 × 4 cm in the infraspinatus muscle (Figures and ).\nBiopsy subsequently confirmed metastatic oesophageal adenocarcinoma with the histology showing infiltration of the infraspinatus muscle by poorly differentiated adenocarcinomatous cells with calcific deposits. Further imaging revealed local recurrence of the primary. The decision was made in liaison with the patient and oncologist to have palliative radiotherapy to his shoulder to help w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe combined surgical and electrochemotherapy technique proposed was adopted to treat a 72-year-old male patient with an RRC developed in a long-standing ulcerative colitis of the rectum. In 1991, the patient underwent surgery for intra-abdominal total colectomy with terminal ileostomy for acute severe UC. In 2018, he noticed the appearance of right ischial-rectal abscess associated with a perianal fistula with evidence of rectal adenomatous villous lesion with high-grade dysplasia. So, the patient went to surgery with proctectomy in November 2018 for adenocarcinoma G2 infiltrating the muscle tunic (pT2 pN0 M0 sec. ajcc 2017). The surgical resection margins were free from neoplastic localization.\nAfter a multidisciplinary consult, an adjuvant chemotherapy and pelvic radiotherapy treatment was proposed to the patient, but he refused and avoided to undergo oncological follow-up until October 2019 when he noticed the appearance of a hard-wooden swelling in the soft tissue of right perineal region (6–7 cm in diameter). After a CT scan () and MRI that confirmed a local recurrence of cancer, following a multidisciplinary discussion between surgeons, radiation oncologists, radiologists and oncologists, a surgical resection indication was given.\nHowever, the CT investigation documented a close relationship between the neoplastic lesion and the root of penis and urethra, with consequent difficulty in obtaining the certainty of disease-free margins without a major demolition procedure that the patient firmly refused.\nTo increase the chance of best treatment of the margin and perform a local remediation of the tissue adjacent to the neoplasm, it was decided to associate resective surgical treatment to ECT.\nIntraoperative time I: the mass infiltrated the perineal muscles and appeared anteriorly tightly close to the prostate plane and root of penis. Removal of the neoformation was made en-bloc with a portion of skin and perineal muscles.\nIntraoperative time II: after intravenous"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15 years old boy with ESRF due to rapid progressive GN (on peritoneal dialysis) and growth retardation, underwent living related kidney transplantation (from his father), commenced on protocol of triple immunosupression including Tacroluimus, MMF/ Cellcept (750 mg BID) and Prednisolon (to be tapered over three months period to 5 mg) and on bacterial prophylaxis (Bactrim) and CMV prophylaxis (Ganciclovir). On day 22 from the transplant he presented to our emergency department with acute sever colicky right upper abdominal pain and high fever with no similar previous attack. On physical examination he had abdominal distension with generalized tenderness more on the right upper quadrant. His blood work showed leukocytosis (17,000), liver enzyme (including Alkaline phospatase) and renal function were within normal range also CMV antigenemia was negative. Empirically he was started on broad spectrum antibiotics suspecting bacterial peritonitis from the peritoneal dialysis catheter (PDC) and it was connected to gravity drainage (the output fluid was serous). Few hours after admission the abdominal pain start to subside and the PDC drainage became bloody and mixed with bile but the output was decreasing. Then the WBC count went up to 31,000. Repeated ultrasound showed collapsed gallbladder compared to preoperative one with no stones. Further imaging with CT scan confirmed perforated gall bladder (). Under US guidance, a 7F pig tail cholecystostomy catheter and another pig tail tube in the left iliac fossa were inserted. Both tubes were draining biliary fluid (). Patient responded dramatically to this and the pain, fever and leukocytosis subsided gradually over 3 days. One week later the peritoneal pigtail tubes removed after confirming nil output. His Cellcept dose readjusted to 500 mg bid and discharged on the same dose. Three months later the cholecystostomy tube and PDC were removed after confirming no bile leak or collection (). Another follow up imaging after six mo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman presented with mastalgia and yellowish discharge from her right breast. She reported family history (maternal lineage) positive for cancer. Her mother was diagnosed with BC at 33 and died, and maternal grandmother at 65 years, also from BC. Uncle who had been a smoker died of lung cancer at the age of 70. She has no other live relatives and siblings and has one 3-year-old son. Radiologic imaging found no suspicious lesions in the breast nor enlarged lymph nodes but showed solitary mediastinal mass which was surgically removed. Patohistological examination revealed fibrous tumor with increased mitotic activity, positive for CD34 and STAT6 by immunohistochemistry staining (Fig. ). Both tumors/breast cancer and solitary fibrous tumor have stained negative for p53 protein.\nNo further treatment was indicated and after 4 years of follow-up, a lesion in the upper left quadrant of the right breast was discovered. Needle biopsy suggested a luminal B-like invasive BC so she underwent mastectomy and axillary dissection. Surgical pathology specimen showed pT1bN1 grade 3 carcinoma (ER 100%, PR 80%, Her2 negative, Ki 67 26.5%, micrometastasis in 1 out of 11 lymph nodes).\nFour cycles of adjuvant treatment with doxorubicin and cyclophosphamide was administered followed by radiotherapy and tamoxifen with ovarian function suppression. The testing for BRCA1/2 was carried out and found no mutations.\nOne year later, during preoperative evaluation for breast reconstruction surgery, 4 pulmonary nodular lesions were discovered on chest computed tomography (CT) scan. A CT-guided biopsy of one of the suspected metastases was performed and pathohistological examination was consistent with metastasis of malignant fibrous tumor. Tamoxifen was switched to exemestane due to its possible proliferative effect on fibrous tumor. Chemotherapy for stage IV sarcoma with temozolomide and bevacizumab was initiated given the prior anthracycline chemotherapy.\nIn the light of the two know"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old female sustained a twisting injury to her left knee as she was descending a spiral playground slide. She presented to the ED with her leg locked in extension and experiencing severe pain. She was unable to bear weight on her left leg. The patient had no other injuries but did complain of tingling in the lower left leg. She had no muscle weakness and no loss of sensation from the knee distally. On physical examination, the patella was obviously mal-positioned and was rotated 90°, facing perpendicular to its natural plane (). The performed radiograph confirmed a rotation of the patella of 90° about its vertical axis, positioned within the trochlear groove between the femoral condyles (). The Orthopaedic Service was consulted and evaluated the patient in the Emergency Department. Given the patient’s thin body habitus, the patella could be easily palpated and it was determined that the articular surface was facing laterally. A reduction was attempted in the Emergency Department under conscious sedation with etomidate. The patella was successfully reduced via vertical traction to lift the medial side and lateral pressure on the anterolateral edge of the patella to allow it to rotate back to its anatomic position. Reduction was confirmed with radiographic imaging () and restoration of normal motion of the knee passively. After waking from sedation, the patient reported that her pain had markedly improved. A knee immobilizer was placed after reduction and she was discharged from the ED.\nUpon follow-up in clinic, an MRI was ordered and revealed medial patella and anterolateral femoral condyle bone contusions, mild femoral trochlear dysplasia, and medial patella femoral ligament sprain. There were no osteochondral defects or loose bodies detected in the MRI. The knee immobilizer was then transitioned to a hinged knee brace and she was able to begin range of motion exercises. She was referred to physical therapy for strengthening and patella stabilization. At fo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old female came to our observation due to a limitation in mouth opening range. She also reported crepitus sounds at the left TMJ as well as pain, exacerbated by function (e.g., chewing) and increasing in intensity over the past three months. Clinical assessment showed a limited mouth opening (i.e., 22 mm) and pain with palpation at the left joint and all the main masticatory muscles, more severe on the left side. At the first appointment (T0), mandible manipulation was performed to achieve a forced opening of about 40 mm. A magnetic resonance (MRI) was prescribed to assess the disc-condyle relationship as the possible source of limitation in mouth opening and to gather some pictorial evaluation of the presence of joint effusion (). Despite the clinical suspicion of TMJ arthritis, computerized tomography was not prescribed at this stage due to the expected low impact on treatment planning decisions.\nMRI showed a regularly shaped condyle, with an anteriorized disc at closed mouth. At the maximum mouth opening, the condylar translation is reduced and the disc is not recaptured. Joint effusion of severe entity is also present. A conservative approach to provide pain relief and to manage muscle tension was provided, based on counseling, a home program of self-exercise and a stabilization appliance to wear at night. After three months, symptoms improved only partially, with a reduction of pain with muscle palpation but a steady pain at the left joint.\nBased on that, a cycle of five arthrocentesis plus viscosupplementation with hyaluronic acid (Sinovial, IBSA) has been performed weekly. Clinical data has been recorded at each time point before each injection and 15 days after the last one ().\nAfter one month from the last arthrocentesis plus viscosupplementation, the patient still showed some pain and, more important, still felt a limitation in the unassisted mouth opening and right laterotrusion. A diagnosis of TMJ intermittent locking on the left side was thus"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old male was struck by a truck while riding a motorcycle and consequently impacted a guardrail. He was reportedly conscious, ambulatory, and unable to bear weight on his left leg at the scene. His pelvis was temporarily stabilized at an outside hospital, and he was transferred to our facility. A pelvic X-ray and a computed tomography (CT) scan of the chest, abdomen, and pelvis from the outside hospital demonstrated diastases of the left pubic symphysis and a fracture involving the left sacral wing extending to the left sacroiliac joint and a ruptured bladder. On arrival, he underwent a retrograde cystogram during Foley catheter placement, which demonstrated extraperitoneal bladder rupture.\nThe patient underwent an additional CT scan with contrast enhancement of the chest, abdomen, and pelvis with reconstructions of the thoracic and lumbar spine. At the same time, a CT scan of the head and cervical spine was performed. The images demonstrated extensive hyperdensity within the spinal canal subarachnoid space related to extravasation of contrast material, which was not previously observed on the outside hospital imaging [].\nThe imaging suggested that the contrast material extravasated out of the bladder into the extraperitoneal space []. Because of extensive fracturing of the left sacral pelvic tube with violation of the left sacral nerve roots, the contrast agent entered the subarachnoid space at the left sacral ala predominantly through the left L5 and S1 nerve roots [].\nThe patient underwent emergent repair of the bladder by the urological surgeon, and the pubic symphysis was secured with plates by the orthopedic team. Two days later, the patient underwent open reduction and internal fixation of the left sacrum and percutaneous pinning of the left sacroiliac joint by the orthopedic surgeons. The dural tear and cerebrospinal fluid leak were treated conservatively.\nThe patient was discharged home 13 days after presentation with family support, physical thera"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn eight-year-old female spayed Saint Bernard dog presented to the emergency department of a referral hospital for evaluation of nonproductive retching and lethargy. Abdominal radiographs confirmed the presence of GDV, and emergency surgery was performed to correct the GDV and perform an incisional gastropexy. No history of prior neurologic disease was noted by the owner. The patient recovered uneventfully from anesthesia. The dog was placed in a large kennel with deep bedding, and instructions were to walk or change the dog's position every four hours.\nTwelve hours later, significant gait abnormalities involving the right pelvic limb and a small (approximately 1 cm) wound on the dorsum of the right paw were noted. A neurological examination indicated paresis of the right pelvic limb and conscious proprioceptive deficits leading to knuckling and dragging of the right hind foot. The right hind limb had a mild plantigrade stance and notably decreased hopping compared to the left hind limb. The withdrawal reflex was decreased on the right pelvic limb, but the lateral digits elicited a better response than the medial digits. Patellar reflexes were intact bilaterally. The patient's recovery plan was updated to include more frequent leash walks, and a crib mattress was placed in her cage to minimize the potential compression of the sciatic nerve while recumbent. A sports medicine consultation had similar findings to the neurologic examination. The patient was discharged four days after admission with instructions for rehabilitation exercises to perform at home. The patient returned two days later for a recheck of the neuropraxia and for a bandage change on the right hind foot. The paresis of the right hind limb noticed previously was improved, and no knuckling-over was seen. The right tarsus remained dropped compared with the left, but withdrawal reflexes were present in both hind limbs. The owners noted significant improvement with the patient's stability. She was discha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn July 2017, a 13-year-old Chinese male experienced intermittent abdominal pain lasting about 10 minutes per stint. The pain could be alleviated without treatment. No fever or diarrhea were observed. The patient subsequently developed vomiting, notably a coffee-like substance, which could not be alleviated by drugs. Gastroscopy results revealed gastric mucosal inflammation, but the patient refused to undergo further systemic examination. On the 30th of July 2017, the patient was diagnosed with an acute intestinal obstruction, with the abdominal CT scan indicating obstruction of the lower intestine and thickening of the splenic flexure (). He underwent an emergency colostomy with a colon tumor resection. No lymph node dissection was performed because of the operation under emergency condition and considering the boy’s young age. Intraoperative findings revealed that an irregular 5cm x 3cm tumor within the intestinal wall near the splenic flexure was the cause of the obstruction. The proximal bowel tube was dilated and multiple lymph nodes were enlarged. The proximal colon was removed 5cm from the edge of the tumor as well as a small mesenteric lymph node. The patient was healthy prior to the surgery with no history of infective diseases, or allergies to food or drugs. His maternal uncle also had colorectal cancer.\nFrom August 2017 to December 2017, the patient underwent six cycles of combined mFOLFOX6 chemotherapy which consisted of oxaliplatin, leucovorin, and 5-fluorouracil. During chemotherapy, the level of CEA and CA199 was stable. An abdominal CT scan evaluation showed that the disease was stable and remained stable after the completion of the mFOLFOX6 chemotherapy regimen (). Oral administration of capecitabine was adopted from January 2018. The disease-free survival (DFS) was 8 months. On April 23 2018, the level of CA199 was significantly higher than before, and the abdominal CT scan suggested the presence of multiple nodules in the greater omentum and perit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMan, aged 57, farmer, smoker, and previously healthy, referred to the GP in February 2015 due to left upper limb pain, most severe in the elbow, persistent since January. He could not deny the injury (perhaps at work on the farm). Neither swelling nor redness were found. He received Profenidum 2 × 100 mg for 1 week with slight improvement. He was referred to the Department of Neurology with the diagnosis of neuropathy of the ulnar nerve. The clinical picture suggested neuroborreliosis (radicular syndrome), as the patient was the resident of endemic area for tick-borne diseases and was exposed to tick bite. During the following days numbness of fingers of the left upper limb appeared. The straightening of the upper limb at the elbow was not feasible due to the severe pain.\nX-ray of elbow joints and bones of the forearm revealed osteolytic lesions. Brain CT presented cyst (28 mm × 40 mm), with inhomogeneous marginal contrast enhancement in the right occipital lobe with the vast area of hypodension in the parietooccipital region of the lobe, the area of similar nature (36 mm × 27 mm) in the right hemisphere of the cerebellum with hypodense zone of edema, metastases. Hyperdense area (11 mm × 7 mm) in the midline at the base of frontal lobes, with heterogeneous contrast enhancement suggested meningioma. Midline brain structures were displaced by 9 mm to the left side, the right lateral ventricle and the fourth ventricle were narrow, and left lateral ventricle was extended. The grooves of the right hemisphere were oppressed and had edematic characteristics. Features of intussusceptions were observed. Chest X-ray showed nodular shade in the upper right lung.\nOn admission to the Department of Lung Diseases and Tuberculosis patient complained of pain and weakness of left upper limb. Chest CT showed enlarged lymph nodes in the mediastinum. In the top of the right lung heterogeneous mass of irregular lumpy shape with uneven"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 84-year-old woman with a history of syncope was referred to a general hospital by her primary doctor. Sick sinus syndrome was diagnosed and a ventricular demand pacemaker was implanted via the left axillary vein. The tip of the implanted lead (5076-52 cm, Medtronic, Minneapolis, MN) was a screw type. The lateral chest X-ray film obtained just after pacemaker implantation demonstrated that the tip of the lead was in the correct position () and the pacemaker threshold was normal. Two days after implantation, she complained of the sudden onset of pain in the left precordial region. On the fourth day after implantation, a bulge appeared in the left sixth intercostal space at the site of the pain. A lateral chest radiograph obtained on the same day demonstrated displacement of the pacemaker lead (). Transthoracic echocardiography did not identify a pericardial effusion, but the position of the lead tip could not be seen accurately. Computed tomography (CT) confirmed penetration of the lead though the RV into the subcutaneous tissues of the left thoracic cavity (). There was no pericardial effusion, pneumothorax, or pleural effusion. The patient was sent to our hospital for emergency treatment. Because transvenous removal of the pacing lead was thought to be risky, surgical removal and RV repair were performed. Median sternotomy was chosen as the approach because it would be easy to establish cardiopulmonary bypass if required. There was no pericardial effusion, but the pacing lead was seen protruding through the anterior wall of the RV apex and penetrating the pericardium (). When the left pleural cavity was opened, the pacing lead was found to be embedded in the anterior visceral pleura, but the left lung was not injured in agreement with preoperative CT findings. A purse string suture was placed around the lead in the RV wall and a pledgetted mattress suture was added for reinforcement. Then the part of the lead protruding from the RV was grasped with forceps and cu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was an 80 year old man admitted to the ER with abdominal pain. At admittance, the patient was unable to walk and described an increased difficulty with movement and coordination of the lower limbs, tendency to fall, extensive fatigue, and pain. Six months earlier, the patient had full movement of his lower limbs and could walk unaided. He described an increased intensity and duration of symptoms during the last three months. He was also confused and was unable to answer correctly on orienting questions. Blood serum samples taken at the ER showed a slight thrombocytopenia and mild kidney insufficiency. An arterial blood gas showed hypercalcemia. His condition was deemed to be a combination of somatic pain and confusion. He was therefore treated as a mild trauma patient. Computer tomography (CT) of the abdomen was performed and a surgical consult ruled out any surgical pathology. A pelvis CT showed deterioration of the right hip and an orthopedic consult diagnosed right-sided hip arthritis. The patient was admitted to the orthopedic trauma ward for one day before being transferred to the geriatric clinic for mobilization and pain optimization. He was placed at the neurogeriatric ward to due to space constraints caused by Covid-19.\nAt the neurogeriatric ward, clinical examination revealed several neurological abnormalities including apraxia, dysdiadochokinesia, intentional tremor, clonus, and parkinsonism. Both sides of his body were affected although the left side showed more pronounced symptoms than the right. He was paraspastic and there was parkinsonism in his upper extremities with cogwheel rigidity bilaterally. There was hyporeactivity in his triceps, biceps and brachioradialis tendon reflexes. His lower body display mixed neurological symptoms with peripheral rigidity and hyporeactivity in quadriceps tendons reflexes. He admitted no pain sensation in his left lower leg and foot, though both proprioception and sense of vibration were preserved. He had"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient's mother was 36 years old, with a total of 5 pregnancies and 1 live birth. Eleven years ago, she gave birth to a healthy boy via cesarean section. She previously had 2 artificial abortions and 1 spontaneous abortion, with no family history of hereditary diseases. Ultrasound test result was normal at gestational week 6. At gestational week 12, nuchal translucency of 1.3 mm was observed, with no positive findings. Non-invasive DNA analysis showed low trisomy 21 risk, low trisomy 18 risk, and low trisomy 13 risk. At gestational week 24+5, ultrasound examination showed abnormal development of the long bones of the limbs (the length of the long bones was shorter than 1% controlled to the same gestational week of normal fetus), thick metaphysis in the right lower limb, irregular vertebral arrangement, and a narrow and small thorax (Fig. A–D). The patient's parents decided to terminate the pregnancy at 27 weeks of gestation considering this as a lethal skeletal dysplasia.\nAfter the termination of pregnancy at week 27, the gross examination of the fetus showed a flat face and nose bridge, short limbs, asymmetric short lower limbs, and bilateral clubfeet with bilateral ankle joint contracture (Fig. A, B). The autopsy report indicated that the left humerus bone was 2.5 cm long; the right humerus bone, 2.0 cm; the left femur, 3.0 cm; and the right femur, 2.2 cm; all were significantly shorter than 4SD measured at the same gestational age. In addition, the shapes of T3 to L3 were abnormal, the vertebral bodies appeared fused, the thorax was small with a maximum circumference of 16 cm, and the abdominal circumference was 26 cm. The autopsy also found subcutaneous edema in the head and face and thick metaphysis in the lower limbs. X-ray imaging showed short femur and humerus bones, a narrow and small thorax, thick metaphysis with a thick “splashed paint"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 35-year-old man with a penetrating dorsolateral thoracic injury. The patient was injured by a knife through a street quarrel and brought to the emergency department (ED) by ambulance. The knife had entered the thoracic cavity from lateral to the left mid-clavicle line posteriorly at the level of the third intercostal space with about 4 cm of the blade inside the body (). Hematoma was detected at the site of the injury. Despite an elevated pulse rate (110 bpm), the patient was stable with the arterial blood pressure of 110/70 mmHg, respiratory rate of 18 and oxygen saturation of 96% in room air. We evaluated the patient by extended focused assessment with sonography in trauma (e-FAST)protocol which revealed possible pneumothorax, but no sign of hemothorax was observed. There was no abdominal free fluid and we did not detect any sign of pericardial effusion. The knife at the injury site did not allow performing anterior-posterior Chest X-Ray (CXR), therefore, a hemi-lateral CXR was taken to evaluate the extension of the injury. The radiograph was taken using a portable X-ray machine ().\nConsidering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. We intended to have a better vision of the injury and remove the knife with thoracoscopy, and avoid wide thoracotomy, which is the routine treatment for patients with penetrating thoracic injuries.\nAt thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space (). There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. After removing the knife, we observed the site of the injury directly via"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old second-gravida was referred to a tertiary care center at 30 weeks of gestation for evaluation of a right lung mass in the fetus. The mother had no significant complication in her previous pregnancy and no other antenatal problem was reported in this pregnancy before 30 weeks of gestation. A 32×31 mm, well-defined calcified hyperechoic mass in the right thorax with hypoechogenic right pleural effusion was detected on antenatal ultrasonography at our hospital, which was initially suspected to be a teratoma (). The fetal thoracic mass increased in size up to 39×32 mm and the amount of right pleural effusion increased during 3 weeks of evaluation (). Fetal hydrops including 7 mm deep ascites and generalized subcutaneous edema developed at 33 weeks of gestation (). No other significant defect in fetal structure was found. Fetal surveillance tests, including biophysical profiling and non-stress test were conducted. Minimal variability was noted on the non-stress test.\nA male baby weighing 2,780 g was delivered through an emergency cesarean section owing to non-reassuring fetal heart beat patterns, and admitted to the neonatal intensive care unit with Apgar score 3 at 1 minute and 5 at 5 minutes. No metastatic lesion was found in the placenta and umbilical cord. Initial neonatal hemoglobin from arterial blood was 12.6 g/dL, neonatal hemoglobin dropped to 9.4 g/dL after thoracentesis. Initial neonatal red cell distribution width was slightly increased (18.9%), which suggests fetal anemia was due to the hemorrhage of the tumor. Bone marrow biopsy revealed no metastasis to bone marrow.\nContrast-enhanced computed tomography of the chest revealed a 40×40×30 mm enhanced tumor in the right thorax with bilateral hemothorax causing mediastinal shifting to the left, which was considered a posterior mediastinal teratoma or neurogenic tumor (). Moreover, multiple hepatic metastases were suspected on magnetic resonance imaging () and abdominal ultrasonography. The neuro-s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 10-year-old boy when dental treatment under moderate sedation was first planned. He had a medical history of a sudden cardiac arrest during separation surgery for syndactyly, from which he had been rescued by immediate cardioversion. He had received a diagnosis of long QT syndrome. The QT interval of the patient was prolonged above the normal range in an electrocardiogram (ECG) (). He had been taking beta-blockers (Atenolol) as a routine medication.\nAt a regular visit, ICDAS 5-6/+ () mesial proximal dental caries at the right mandibular permanent first molar and ICDAS 4/+ caries at the right maxillary permanent first molar were observed. The right mandibular first molar tooth was thought to require endodontic treatment (). Profound local analgesia must be achieved before endodontic treatment because the treatment is often very painful and uncomfortable. Emotional stress can also induce arrhythmia in patients with long QT syndrome, therefore treatment under sedation was planned. On the day of the treatment, we first administered N2O at a concentration of 40 vol % before intravenous cannulation. We attached a bispectral index (BIS) sensor to his forehead. Propofol was infused with a computer-controlled drug delivery system after intravenous cannulation. We adjusted the propofol effect-site concentration to maintain a BIS value in the range of 70-80. The effect-site concentration of propofol was maintained in the range of 0.6-1.2 µg.ml-1 during the treatment period. There was no fatal arrhythmia during propofol sedation. Composite resin restoration of the right maxillary first permanent molar and an endodontic treatment on the right mandibular first permanent molar were successfully performed under propofol sedation. Local anesthesia was achieved with lidocaine without epinephrine.\nAbout 10 months after the first sedation, new dental caries of ICDAS 2-3/+ () were observed on all second permanent molar, all of which required restorative dental treatmen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a female in her 40s who underwent a repeat renal transplantation that was complicated by acute tubular necrosis, delayed graft function, and Pseudomonas sepsis with a right upper lobe pneumonia (Figure ). The patient was admitted and treated with an extended course of piperacillin-tazobactam for the Pseudomonas infection. She continued to experience dyspnea following the completion of treatment and had a persistent right upper lobe opacity identified on chest X-ray (Figure ) and the subsequent computed tomography (CT) scan (Figures -). CT scans demonstrated a large opacity (10 cm x 4 cm) with adjacent areas of mixed ground glass opacity, airspace opacity, and thickening of the interlobular septa. The combination of the ground-glass attenuation with superimposed interlobular septal thickening and reticular thickening-specific opacifications was consistent with a “crazy paving” pattern. Given the history of immunosuppression, infectious, inflammatory, and neoplastic lesions were considered in the differential. A follow-up CT scan two months later demonstrated a persistent lesion with little change from the previous imaging. Given the failure of this lesion to resolve, the patient underwent a surgical lung biopsy to exclude an atypical infectious or neoplastic lesion.\nA video-assisted thoracoscopic surgery (VATS) was performed and an abnormal right upper lobe with a nodular and cheesy appearance was identified. A representative wedge biopsy was sent for intraoperative consultation. The cryosections showed interstitial pneumonitis with calcification and no evidence of malignancy. Given that this appeared to be a benign process, a lobectomy was not performed, but additional wedge biopsies were sent for permanent sections along with material for culture. As shown in Figures , , , , sections of the lung biopsy were composed of extensive multifocal calcifications, highlighted by a von Kossa stain (Figures , , , ) . The calcifications ranged in size from small"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old female with a 24 h history of acute, worsening abdominal pain with associated abdominal distension and bilious vomiting was referred by her GP to the general surgical admissions unit. The patient reported no other gastrointestinal symptoms and there was no prelude to the presentation.\nThe patient had an extensive surgical history. She had undergone a Billroth I gastrectomy in 1977 for peptic ulcer disease, a splenectomy following blunt trauma in 1989 and further gastric surgery for a cancer in 1999. During a therapeutic endoscopy for a benign stricture 4 months previously, the patient had suffered an iatrogenic perforation. This was treated endoscopically with the deployment of a Hanaro-antireflux covered stent, covering the defect that was identified at 35 cm. The stent was deployed at 32–41 cm. These margins were chosen in order to give a ±3 cm cover of the perforation. The extra 2 cm distal cover was because the stent was the only suitable stent available that would be both wide enough to remain in situ and long enough to give adequate cover of the perforation. There were no concerns regarding the apposition of the stent, and the stent was not sutured in place. Routine follow-up was arranged for 4–6 weeks; however, for an unconfirmed reason, this follow-up never took place.\nOn presentation, her physiological observations were stable and she was apyrexial. The abdomen was very distended, tympanic and tender on palpation. Bowel sounds were not present.\nBlood results on admission, including liver function, urea and electrolytes, CRP, amylase, lactate and full blood count, were within normal limits.\nAbdominal X ray showed multiple distended loops of small bowel with a migrated stent inside small bowel Fig. .\nFollowing the diagnosis of mechanical small bowel obstruction due to oesphageal stent migration, the patient was booked and consented for a laparotomy. At laparotomy, distended small bowel was found, with the cause of the obstruction being"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man was referred to our cardiovascular center with previous history of hypertension for 5 years and a 2-month history of worsening dyspnea on exertion that motivated him to seek medical attention. Atrial fibrillation was detected during a recent medical check up at a local clinic, and the patient was referred to our hospital and admitted for closer examination. The laboratory data was unremarkable. His electrocardiogram revealed new-onset atrial fibrillation compared with previous data. A chest X-ray film revealed no particular anomalies. Two-dimensional transthoracic echocardiography (2D TTE) showed 1.04×0.87 cm nodular mass attached to the aortic valve. The echogenic mass originated from the ventricular side of the non-coronary cusp of the aortic valve (). Based on these findings, a papillary fibroelastoma of the aortic valve was suspected. Because of his old age and atrial fibrillation, scheduled surgery was performed to avoid systemic embolization. After aortic cross clamp, the aorta was opened. Inspection of the aortic root revealed a normal structure. A mass was found on the ventriclular side of the non-coronary cusp. The mass was successfully excised from the aortic valve (). The tumor measured 1.5 cm and had a smooth surface with a spherical shape. The aortic valve was repaired rather than replaced after tumor resection. Intra-operatory transesophageal echocardiography showed normal left ventricular outflow without regurgitation and no residual mass.\nHistopathological examination of the tumor revealed a benign soft tissue tumor mass. The margin of the mass was irregular but was easily distinguishable from the normal valve tissue. The tumor consisted of plump gray purplish myxoid stroma and slender and long spindle stromal cells. The stromal cells had eosinophilic scanty cytoplasms and dark small nuclei. Fibrocollagenous bands of aortic valve tissue were also noted in the myxoid stroma (Hematoxylin and eosin; ×200) (). The final pathologic diagn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old Hispanic man with known history of obesity and hypertension presented with a 3-month history of abrupt episodes of weakness and altered mental status. He referred severe psychomotor symptoms as well as anxiety, aggressiveness, agitation, weakness, diaphoresis, and decreased visual acuity occurring at any time of the day and improved by eating. Upon further questioning, our patient, who worked as a truck driver and whose symptoms had reflected poorly in his workplace, also expressed overall discomfort with life and wishes of death due to the intensity of his symptoms. He had no history of tobacco smoking or excessive alcohol consumption. Medications taken prior to admission included candesartan 16 mg and hydrochlorothiazide (HCTZ) 12.5 mg once a day for hypertension.\nDuring the following weeks, the symptoms increased in severity and frequency, with continued unremitting anxiety and weakness accompanied by loss of consciousness and extreme burning sensation in his entire body. After this acute episode, he was evaluated by a primary care physician in a local hospital and hospitalized for 4 days, where he continued to present recurrent episodes of irritability and aggression to self and others. He was discharged and referred for psychologic evaluation by mental health services at another institution. No specific diagnoses were given.\nUpon release from mental evaluation, he was evaluated by a third physician, who performed a 3-hour postprandial blood glucose test which revealed a blood glucose level of 58 mg/dL. Suspecting an insulinoma, our patient was admitted to a third-level hospital, and upon arrival his vital signs were: afebrile (37 °C), heart rate of 93 beats per minute, blood pressure of 161/84 mmHg, respiratory rate of 19 breaths per minute, and oxygen saturation of 98% on room air. A physical examination revealed an oriented, well-nourished, and hydrated patient, without any stigmata on skin, a normocephalic and atraumatic head, and no masses or"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman with a heavy medical history of arterial hypertension, sarcoidosis, hypothyroidism, and bilateral optic nerve atrophy was referred to the Emergency Department for severe headache, vomiting, and alteration of consciousness. Her Glasgow Coma Score on admission was 15/15 but the patient had a slurry speech and exhibited choreic movements of the upper limbs. The admission brain computed tomography (CT scanner) revealed a Fisher grade 4 SAH with initially mild intraventricular bleeding uncomplicated by hydrocephalus. Angiographic examination confirmed the presence of a saccular aneurysm at the junction of the left pericallosal and callosomarginal arteries, which was successfully treated by coiling. The neurological status worsened a few hours after the procedure and an early follow-up brain CT scanner was performed with increased hydrocephalus and the de novo constitution of a subpial hematoma collected at the upper border of the corpus callosum (). Extubation was possible soon after surgery for intraventricular drainage. The neurological examination showed spontaneous eye opening and some spontaneous movements of the upper and lower limbs with a mild left hemiparesia. When stimulated, the patient remained completely mutic but demonstrated some orientating reactions toward the source of intense verbal and/or auditory stimulation. A brain magnetic resonance imaging (MRI) performed on day 6 failed to reveal vasospasm or ischaemic injury in both ACA territories (Figures -). In contrast, there was a significant impingement by the mass effect of the subpial hematoma on the superior border of the corpus callosum. Expectedly, major haemorrhagic contamination of the whole ventricular system was still present.\nEvent-related evoked potentials were recorded on days 13 and 28, using an auditory oddball paradigm (at least two independent acquisitions of 100 stimuli, consisting of an 85 dBHL binaural tone burst at 500 Hz for the frequent stimulus and 750 Hz for the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 56-year-old female with history of syncope due to third degree atrioventricular heart block presenting initially with onset of stroke symptoms six days after pacemaker placement and two days after hospital discharge. At 5 PM she developed abrupt onset of left facial droop along with left upper and lower extremity weakness. The patient was initially treated at an outlying hospital and received alteplase at 6:35 PM for treatment of acute ischemic stroke.\nA chest radiograph performed at the outlying hospital prior to alteplase administration demonstrated an enlarged cardiac silhouette when compared to prior radiographs showing only borderline cardiomegaly. Upon administration, the patient reported mild chest pain and was given nitroglycerine and morphine. Her chest pain resolved and she was transferred to our comprehensive stroke center for admission. The patient presented to our emergency department at 10:10 PM with a heart rate of 122 beats per minute (bpm) and a blood pressure of 109/41 millimeters of mercury (mmHg).\nAt 11:20 PM the patient went for a computed tomography angiogram (CTA) after an initial assessment by the emergency physician in consultation with the stroke-team attending physician. After CTA at 10:28 PM, she was documented to have a blood pressure of 49/25 mmHg and heart rate of 109 bpm. She was returned to the resuscitation bay for re-evaluation. Cardiac tamponade was suspected due to the extreme hypotension in the setting of thrombolytic administration after recent pacemaker placement.\nOn reassessment, the patient had become confused with a Glasgow Coma Scale of 14. The emergency physician performed a POCUS, which demonstrated a pericardial effusion with features of cardiac tamponade including diastolic collapse of the right ventricle (). At that point the diagnosis of cardiac tamponade was made. The patient was alert and responsive, so an intravenous bolus of normal saline was given while a stat surgical consult was obtain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn April 2018 a 23-year-old Caucasian man presented to the general practitioner for the appearance of a rapidly increasing palpable mass in the proximal part of the left thigh in the last month. His clinal history was negative, as well as his oncological family history. He worked as a plumber and did not report any traumatism. He was a light smoker (less than 5 cigarettes per day for 3 years) and denied the consumption of alcohol or drugs. The clinical examination revealed only a solid lesion of 6 cm of the upper third of the left thigh which was hard, fixed on the deep plane and not painful. A magnetic resonance imaging (MRI) scan was performed, showing an enhancing solid lesion of 50 × 45 × 60 mm localized between the rectus femoris and the tensor fasciae latae muscles, associated with enlargement of homolateral inguinal lymph nodes, radiologically suspected for reactive lymphadenopathies, but not clinically palpable for the presence of the main lesion in the proximal part of the thigh.\nIn May 2018 a biopsy of the mass was performed, revealing an initial diagnosis of nodular fasciitis, and consequently the patient was addressed to follow up. In consideration of the clinical dimensional increase of the mass, a new MRI was performed in July 2018 confirming the increase of the left thigh lesion (54 × 64 × 75 mm). A surgical approach was, therefore, planned but the pre-operative blood tests reported an important elevation of serum transaminases values (GOT = 145 U/L, GPT = 440 U/L, GOT/GPT = 0.32). According to the suspicion of liver metastases, a staging Total Body (TB) computed tomography (CT) scan was performed in November 2018, but no secondary lesions were shown. According to the hepatological consultation, the transaminase elevation was not amenable to a viral or autoimmune disease, but a paraneoplastic syndrome.\nThe radical surgery was, therefore, planned in February 2019 but the pre-operative 18F-FDG"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old man, with a weight of 105 kg, admitted to our hospital with chest pain symptom. After the diagnosis of myocardial infarction, he underwent coroner angiography emergently and he was treated by percutaneous transluminal coroner angioplasty. When he was admitted to the hospital, the platelet count was 391 × 109/L. The prothrombin time was 11 s (reference range: 11–13 s). LMWH (enoxaparin sodium 6000 Anti-XA IU/0.6 ml) twice a day was administered subcutaneously by the cardiologists as anticoagulation. On the 5th day of LMWH therapy, the patient complained of prolonged pain at the both upper and lower extremities and the control platelet count was 154 × 109/L. There were no significant changes in the other parameters of the complete blood count at the time of admission to the hospital and at the 5th day of LMWH treatment. The control prothrombin time was 13 s. There was no history of thrombophilia, protein C and S deficiency. The fingers were swollen with tenderness and warmness. Doppler ultrasonography assessment of both upper and lower extremities showed arterial and venous thrombosis at the radial and ulnar arteries and veins of both upper extremities, and tibialis posterior and dorsalis pedis arteries and veins of both lower extremities. HITS was diagnosed by significant decrease in platelet count, physical examination, enzyme-linked immunoassay (ELISA) test against the PF4/heparin complex, and Doppler ultrasonography. The optical density of the ELISA test was >1.0. No confirmation test was performed as it indeed requires a specialized laboratory for platelet aggregation tests. As a result, the diagnosis of HITS was only based on high clinical probability and the positive screening ELISA test. The 4-T test which scores four parameters such as platelet fall, timing of platelet fall, thrombosis, and other causes for the thrombocytopenia is high correlation with HITS with the scores between 6 and 8 []. In our patient, this score was 6. After the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old female who was previously diagnosed with Glanzmann’s thrombasthenia had undergone laparoscopic aspiration of the ovarian cyst three weeks back at another center. She was on synthetic progesterone and tranexamic acid which is an antifibrinolytic agent for menorrhagia. She presented to us with lower abdominal pain, fever, loose stools, and intermittent rectal bleeding. Her blood picture revealed low hemoglobin of 8 gm/dl, increased white cell count of 14000 cells per cubic millimeter, normal platelet count, and normal prothrombin time and partial thromboplastin time. Contrast-enhanced computed tomography (CECT) of the abdomen showed pelvic collection with an air pocket and thickened sigmoid colon (Figure ). Colonoscopy was performed as she had persistent bleeding per rectum with low hemoglobin and it showed multiple colonic mucosal hemorrhages and a fistulous opening in the sigmoid colon, probably an iatrogenic perforation which happened during prior laparoscopic cyst aspiration. She was planned for computed tomography (CT) guided drainage of the pelvic collection under platelet cover as she was hemodynamically stable and the CT showed only localised collection. Since source control with radiology-guided drainage was inadequate and the patient had persistent fever with loose stools, she was taken up for laparotomy and pelvic abscess drainage. A sigmoid colectomy with proximal end colostomy was also performed as there was a sigmoid perforation which resulted in pelvic abscess and dense adhesions. She received single donor platelets and irradiated packed red blood cells during surgery. In the postoperative period, she had a surgical site hematoma and her hemoglobin dropped to 5.6 gm/dl. Irradiated packed red cells and human leukocyte antigen (HLA) matched single donor platelets were transfused. Thromboelastography (TEG) was performed pre- and post-platelet transfusion to assess the response as she had previously received platelet transfusions and the risk"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old asymptomatic man was found to have multiple intestinal masses by computed tomography (CT) done as part of his routine medical examination in December 2011. Surgical resection (R0) was performed in December 2011. The resected specimen consisted of a mass measuring 10.0 ×10.0 cm in maximal diameter. Final pathologic diagnosis revealed a high-risk GIST according to the Armed Forces Institute of Pathology (AFIP) criteria (). The patient was not treated with adjuvant treatment after surgery in the local hospital because he had difficulty paying for adjuvant imatinib therapy. On routine follow-up visit in May 2012, local recurrence and metastasis were confirmed by imaging. He was then referred to West China Hospital in May 2012.\nBeginning in May 2012, this patient received first-line imatinib orally with a dose of 400 mg/day resulting in a partial response. Disease progression occurred after the continuation of imatinib for 54 months. The patient was then treated with cytoreductive surgery combined with imatinib and showed a PFS of 7 months. New biopsy of an abdominal metastasis yielded a KIT mutation in exon 11 as well as in KIT exon 13 (V654A), confirming the clinical observation of secondary imatinib resistance (). In May 2017, this patient received second-line sunitinib. After 11 months of treatment, sunitinib was discontinued due to disease progression. The patient refused biopsy for additional mutational analysis for personal reasons.\nAlthough regorafenib had been approved for the third-line treatment of patients with advanced GISTs by China Food and Drug Administration at that time, the patient refused the agent due to the cost and budget constraints. In the meantime, there was a medical-product-donating project for apatinib that patients could get support since they were enrolled in a clinical trial. After signing informed consent, the patient was treated with apatinib 500 mg daily beginning in April 2018. Abdominal CT scans before apatinib therapy s"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old woman was referred to the authors' hospital for evaluation of a corneal ulcer in her left eye. With the patient's consent, a review of the clinic record was conducted. Ten years previously she received an allogeneic hematopoetic stem cell transplant for treatment of myelodysplasia syndrome. Her course was complicated by the development of cGVHD affecting the liver, skin, esophagus, mouth, and eyes. Severe keratoconjunctivitis sicca had been treated with a PROSE lens for more than 2 years prior to developing this corneal ulcer. Her medical status was compromised by systemic steroid dependence and by steroid induced diabetes mellitus.\nAfter presenting with a corneal ulcer in her left eye, the patient was empirically treated with topical 0.5% moxifloxacin (Vigamox, Alcon) that was applied 6 times a day (once before the PROSE lens was inserted in the morning, 4 times during the day inside of the PROSE lens reservoir, and once again at night after the PROSE lens was removed). After failure to improve on 4 days of this treatment, she was referred to Massachusetts Eye and Ear Infirmary for additional corneal ulcer evaluation, culture and modification of treatment. Upon presentation, the central cornea was opaque and neovascularized with tissue loss of approximately 60% of the corneal thickness. There was an epithelial defect that measured 2.5 mm by 1 mm, with an underlying 2 mm by 1 mm infiltrate. Microbiological smears and cultures were performed with the specimen from corneal scraping. No bacteria or fungi were evident with Gram stain or Calcofluor white stain. At the time, frequency of application of topical moxifloxacin was increased to every 2 hours while awake (approximately 8 times per day), delivered as one drop added to the PROSE reservoir after removal and cleaning reinsertion of the device and replenishment of the reservoir with preservative free saline (B).\nFour days after culture and modification of antibiotic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 59-year-old male with a postoperative union of a left tibial plateau fracture who, after open reduction and internal fixation, underwent surgery for implant removal at a local hospital (Fig. ). The first day after surgery, at approximately 9 a.m., he complained of severe pain in the wound region and developed a fever in which the highest temperature reached was 39 °C. Upon examination, the patient was conscious without chills and other discomfort, and the incision was severely swollen and filled with hemorrhagic content. Analgesic therapy was given, but the patient did not feel pain relief. Early on the second morning, the patient started to become irritable and apathetic and the incision was inflamed. The following afternoon, at approximately 3 p.m., the patient felt increasing pain out of proportion to the physical findings accompanied by progressive swelling, numbness, and weakness of the limb. The skin around the wound was darkened, and tension blisters were visible (Fig. ). The patient was delirious on the third morning after surgery, the systemic skin turned yellow, and there was a large amount of dark red, bloody discharge drainage from the incision with bubbles of gas, and a foul, sweetish, unpleasant odor was smelled in the incision. A physical examination revealed subcutaneous crepitus extending along the length of the limb, roentgenograms revealed the accumulation of gas in soft tissue (Fig. ), the lower limb skin temperature decreased, the dorsal artery of the foot could not be touched, and the patient had no response to pain in the lower extremities. Anaerobic infection gas gangrene was highly suspected, and the patient was transferred to our hospital at approximately 7 p.m.\nLeft lower extremity incision decompression was carried out immediately. Upon incision, the musculature was found to be extensively necrotic and crepitant, the appearance of the affected muscles was purplish red and brown with a characteristic foul odor,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male presented with complaints of chronic, intermittent abdominal pain. The patient had a 20-year history of mild-to-moderate amount of alcohol consumption. There was no history of jaundice, fever or weight loss. His laboratory tests revealed no significant abnormal findings. Serum amylase and lipase, and tumour markers [CA 19-9, carcinoembryonic antigen (CEA)] were within normal limits. The patient was subjected to a CT examination. On unenhanced CT image, a poorly defined soft tissue mass was seen in the pancreaticoduodenal (PD) groove with a hypodense cystic lesion within the mass (). On post-contrast study, the lesion showed minimal enhancement in the portal venous phase ( and ), but delayed imaging at 2–3 min showed mild persistent enhancement of the lesion compared with the pancreatic parenchyma that was consistent with scar tissue () and a non-enhancing cystic lesion within the lesion. The lesion showed poorly defined fat planes with the adjacent second part of the duodenum on its right side and pancreatic head on the left side. Mild thickening of the wall of the second part of the duodenum adjacent to the lesion with variable luminal narrowing was noted. The common bile and pancreatic ducts appeared grossly normal. The pancreatic body and tail were normal. In order to clearly delineate the ductal system and the periampullary region, and to know the extension of the lesion, the patient was also subjected to an MRI examination. Axial two-dimensional fast imaging employing steady-state acquisition () sequences showed soft tissue signal intensity lesion in the PD groove with a cystic lesion within the lesion and the aforementioned CT scan findings. MR cholangiopancreatography sequence () revealed smooth and regular tapering of the pancreatic and common bile ducts. The gallbladder was distended and the cystic duct was normal. Incidentally, a few simple cysts (Bosniak 1) were noted in both the kidneys. The patient was advised further surgical interve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old man, presented to our hospital in February of 2010, about five months after the occurrence of soft tissue swelling on the right laterocervical area that had gradually increased in size. An ultrasound and a CT scan of the neck showed an inhomogeneous and irregular lesion in the right laterocervical area. A biopsy of this lesion was performed, indicating a carcinoma ex pleomorphic adenoma of the right parotid gland.\nThe patient underwent adjuvant radiation therapy consisting of 1.50 Gy in 25 fractions and a boost of 2.10 Gy in 5 fractions to the right parotid area.\nAfter a staging CT scan and a total parotidectomy with ipsilateral laterocervical lymphadenectomy, a CXPA of the right parotid infiltrating the skin surface and the next muscle tissue of stage pT4a pN0 M0 was confirmed. Histologic examination showed a poorly differentiated malignant epithelial component originated from a pleomorphic adenoma. Immunohistochemically, cells were positive for p63 and a cocktail of cytokeratins. Moreover, Ki67 labeling index was 50% (Figure ).\nThe patient underwent adjuvant radiation therapy consisting of 1.50 Gy in 25 fractions and a boost of 2.10 Gy in 5 fractions to the right parotid area.\nIn March of 2011, during a surveillance CT of the neck an irregular and inhomogeneous lesion measuring 4 cm in the right supraclavicular region was detected. The patient underwent dissection of right supraclavicular lymph nodes with histopathological confirmation of a secondary localization of CXPA of salivary glands. The patient was subjected to radiation therapy consisting of 50 Gy in 25 fractions to the right supraclavicular region.\nFollow-up of the patient demonstrated no locoregional recurrence or distant metastases; however, in February of 2013 the patient underwent a surveillance CT scan showing a low-density nodular lesion measuring 1.2 cm in the apical segment of the upper lobe of the left lung and another similar lesion measuring 2.5 cm in the superior-medial portion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old Indian female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of yellowish discoloration and poor appearance of her teeth with the rehabilitation of the same. Family history and medical history was non-contributory. Patient was unmarried, well qualified medical student and there was no history of similar condition in the family. Her parents and siblings were fine and no other family member presented with similar dental findings. Her past dental history disclosed that she underwent root canal treatment of 36 due to caries involvement. Extra-oral examination disclosed normal mouth opening and no temporomandibular joint problems. The patient was healthy with no co-morbidities.\nOn intraoral examination, the enamel thickness was highly thinned down and partially flaked off from few surfaces of teeth. Teeth revealed well defined pitted surfaces along with yellowish brown discoloration. Surfaces of teeth were rough with minimal enamel present. The teeth also revealed short clinical crowns with multiple spacing between teeth. The occlusal plane was uneven worn-down posterior teeth. On frontal view, the patient presented with deep bite with less horizontal overlap. Dentin which was exposed were brown in color. The periodontal examination revealed normal healthy gingiva with no abnormalities (Fig ).\nRadiographic examination included full mouth Orthopantomogram (OPG) and Intraoral periapical radiograph (IOPA) showed features of AI. (Fig ) Occlusion was assessed after obtaining the diagnostic casts. Based on clinical and radiological examination, it was diagnosed as hypoplastic type of amelogenesis imperfecta. Based on the arrived diagnosis, a full mouth rehabilitation was planned. A well formulated treatment plan involving endodontic, and prosthetic department was charted out to furnish a functional occlusion with good esthetics and further prevent the tooth loss. The entire treatment plan was explained to the p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old male with a history of autism along with cognitive, language, and behavioral delays presented to the emergency department after falling 4 feet from a window. Head computerized tomography (CT) revealed a 5 × 5 × 4 cm AC of the left frontal convexity with subjacent mass effect. Before the fall, he had delays in cognitive advancement with difficulty following commands, naming objects, and making eye contact. He was able to ambulate with assistance but unable to climb stairs. He also banged his head against walls frequently while screaming and it was unclear if this was secondary to headaches. The patient received physical, occupational, and behavioral therapy through early intervention therapies with no real improvement. On neurological examination, he made no eye contact, did not follow commands, was not cooperative, did not speak or verbalize, but did demonstrate symmetric movement. The patient’s family stated that he had undergone neuropsychiatric testing which diagnosed autism but the patient’s family did not provide reliable follow-up with us; we were unable to obtain this report. The patient was lost to follow-up for 6 months, and on representation, a magnetic resonance imaging (MRI) was obtained which demonstrated a 5.6 × 5.2 × 4.5 cm left frontal AC with associated mass effect on the adjacent parenchyma and frontal horn of the left lateral ventricle. Ophthalmological assessment revealed no papilledema. The patient underwent a left frontal craniotomy for microsurgical fenestration of the AC with excision of the cyst wall without complication. At 10-day follow-up, his parents reported much calmer behavior with no further labile outbursts and less head banging. At 1 month follow-up, his parents reported significant improvement in cognitive function whereby he was following instructions in computer games and solving multistep problems. His behavior was completely altered and more appropriate for 3 years old and he was making eye contact and interacting"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old woman was referred for low abdominal pain after TOT procedure in a private gynecologic clinic. Abdominal pain lasted for 7 hours after procedure and she went to our emergency care center. On arrival, she appeared pale and acute illness. Her blood pressure was 102/75 mmHg and heart rate was 95/min. She complained lower abdominal tenderness and rebound tenderness. Vagina and cervix were no specific findings in pelvic examination. Vaginal bleeding was scanty. After arrival, her hemoglobin was 12.6 g/dL and coagulation factors, electrolytes, chemical batteries were within normal range. Abdomen and pelvis CT showed a 10-cm-sized hematoma in left pelvic cavity with extravasation of contrast. Abruptly, her blood pressure dropped to 96/63 mmHg. Hemoglobin dropped from 12.6 to 10.9 g/dL. During resuscitated with intravenous fluid and two units of packed red blood cells, we made a diagnosis as retroperitoneal pelvic hematoma with active bleeding. She was taken to operation room for evacuation of hematoma and bleeding control. We found a large amount of hematoma in abdominal cavity and undertook hematoma removal. Although we tried to find bleeding focus but we couldn't, and bleeding persisted at pelvic wall. We sent her to our angiographic room for embolization to confirm pelvic vessel injury. Left iliac artery angiography showed extravasation of contrast from pubic branch of Left obturator artery (). After use of glue, post embolization angiography showed remained bleeding foci. Left external iliac artery angiography showed extravasation of contrast from Left inferior epigastric artery (). After insertion of microcoil and use of gelfoam, extravasation of contrast was stopped. After embolization, her vital signs stabilized and hemoglobin was 11.4 g/dL. Patient was given 8 units of packed red cells during her hospitalization. Since the overall amount of vaginal bleeding diminished, she had no longer complained of leakage symptom. She was discharged on postoperativ"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old man was referred to our gastroenterology department for the specialized management of persistent symptoms such as intermittent epigastric and lower abdominal pain that had begun approximately 7 months earlier. The pain had developed gradually and tended to aggravate after meals.\nOne month prior to his referral to our department, the patient had visited a primary outpatient clinic several times and was administered medication to control symptoms, but his symptoms did not improve. The patient was later admitted to a primary hospital for 1 week, where gastroduodenoscopy, colonoscopy, abdominal sonography, and laboratory testing was performed to identify the cause of the symptoms. On the basis of these examinations, he was diagnosed with IBS and administered medication. However, because of poor symptom control, the patient was referred to our hospital for specialized management of IBS. The patient had no medical history, including drug history, and had lost approximately 5 kg over the previous 7 months. The patient had a history of 5 pack-years of smoking and social alcohol consumption. The patient's father was diagnosed with pulmonary tuberculosis 1 month earlier and was receiving medication. The patient was employed as a cell phone salesman, but helped with work on his father's farm every weekend. His associated symptoms were frequent nausea with vomiting and diarrhea-like loose stools.\nPhysical examination findings were nonspecific and he showed chronic rather than acute illness. He had no tenderness or rebound tenderness on his abdomen. Laboratory test results of peripheral blood, blood biochemistry, and serum electrolytes were all within the normal ranges. Urine analysis and stool occult blood test showed no abnormal findings. Because of his weight loss, we tested his glucose and thyroid-associated hormone levels. His fasting blood glucose level was 87 mg/dL and the results of the thyroid function test were normal. We reviewed the imaging studies perf"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male patient presented with sudden blurring of vision in the right eye that had persisted for 2 days. He reported that discomfort and redness had occurred in the eye, along with periorbital skin rashes over the affected side, almost 2 weeks prior to the visual obscuration. He had no history of systemic illnesses such as diabetes mellitus or bleeding disorders. He had not been in contact with persons with any skin disorders, and he had no history of drug abuse.\nOn examination, his best corrected visual acuity was hand motion in the right eye and 6/6 in the left eye. Crusted skin lesions were distributed along the ophthalmic division of the trigeminal nerve on the right side, as well as on the tip of the nose (Hutchinson's sign). A corneal dendritic ulcer accompanied by reduced corneal sensation was found in the right eye. The same eye showed a positive relative afferent pupillary defect []. Fundus examination of this eye revealed a cherry-red spot surrounding pale retinal nerve fiber layers, box-carring over the superotemporal arcade, and attenuation of the retinal arteries []. Anterior and posterior segment examinations of the left eye revealed no significant abnormalities. The intraocular pressure (IOP) in both eyes was 14 mmHg. The patient's blood pressure was 106/75 mmHg, while his random blood sugar was 7.0 mmol/L.\nHZO with CRAO was diagnosed in the right eye. Intermittent ocular massage and breathing into a paper bag were performed. Oral acetazolamide (500 mg) and topical timolol (0.5%) were initiated immediately. The patient was also started on oral acyclovir (800 mg, 5 times daily) as well as acyclovir ophthalmic ointment in the affected eye (5 times daily). The next day, the vision in his right eye improved to counting fingers at 1 foot.\nA number of investigations were performed during the patient’s first presentation. Laboratory analyses showed a white"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old male with a history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, and persistent atrial fibrillation was brought to hospital after being successfully resuscitated following a brief pulseless electrical activity (PEA) cardiac arrest. During his convalescence, he had a second PEA arrest, from which he was again successfully resuscitated. Telemetry revealed atrial flutter with atrioventricular conduction that slowed markedly to ventricular rates as low as 34 beats per minute. A balloon-tipped temporary pacing catheter was floated in via left internal jugular vein until adequate ventricular capture was observed. Fluoroscopy was not used during insertion. A follow-up chest X-ray confirmed appropriate placement of the lead, which revealed the lead in the right ventricle with redundant lead slack forming a loop ().\nThe patient subsequently had a PPM implanted. The PPM was implanted without complication using a standard left cephalic vein access. The lead was advanced under fluoroscopic guidance. Implantation of the PPM lead was carried out without difficulty with active fixation to the right ventricular septal wall. The lead pin was attached to a pacemaker pulse generator which was then placed in a pocket located in the prepectoral plane below the left subclavicular fossa.\nThe TVP was then removed under fluoroscopic guidance. The large loop of redundant wire was noted, but it exited the cardiac silhouette without any resistance or interaction with the newly implanted PPM lead. However, significant resistance was noted when attempting to pull the tip of the TVP lead out through the introducer sheath. This resistance was only encountered when the TVP lead tip was at the level of the skin; fluoroscopy was not performed at this stage to determine the cause of resistance. The resistance was overcome and the TVP lead was successfully removed. It quickly became evident that the reason for the resistance was that the TVP lead had"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man manual worker with a 13-year history of gout in his right hallux presented to his general practitioner with right knee pain, stiffness, and giving way with no history of trauma. He had been taking allopurinol for 11 years. He drank 10 to 12 units of alcohol per week and his body mass index was 24.4. On examination, he had anterior knee pain and crepitus was felt from the patellofemoral joint. He had a range of motion from 0 to 90 degrees.\nA magnetic resonance imaging (MRI) was performed and reported a grossly abnormal patella tendon showing heterogenous characteristics with areas of architectural distortion and altered signal in all sequences. The appearances were not typical for a tendinosis but more in keeping with findings seen in gout (\n).\nThe patient was commenced on anti-inflammatory medication in addition to his regular allopurinol and referred to an orthopaedic knee surgeon. At assessment, he was found to be significantly compromised by his knee. He was unable to ride a pushbike, walk with his dog, or even get out of a chair. Plain films showed calcification within his patellar tendon (\n).\nA multidisciplinary discussion with rheumatology and radiology consultants confirmed that the likely diagnosis was a tophaceous gouty deposit within the patella tendon. His uric acid level was 560 μmol/L (above the target of <300 μmol/L set by the British Society for Rheumatology [BSR])\nand estimated glomerular filtration rate was 52 mL/min. He was referred to rheumatology who advised increasing the dose of allopurinol. A subsequent ultrasound (US) scan showed the superficial fibers of the patellar tendon relatively intact, but within the deep fibers, there were multiple hyperechoic areas with distortion of the tendon architecture. There was no significant cyst. A computed tomography (CT) scan demonstrated a markedly thickened patellar tendon with areas of mineralization within the tendon itself (\n). He was seen in a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 27-year-old woman with four previous pregnancies resulting in two births and two abortions. She had no history of appreciable disease. She was diagnosed with class IIIa high-grade squamous intraepithelial lesion by a cervical smear conducted at 14 weeks of pregnancy and diagnosed with squamous cell carcinoma by punch biopsy. She was referred to our hospital at 16 weeks and 6 days of pregnancy for further examination and treatment. No clear macroscopic abnormality was recognized by colposcopy. She was admitted for conization at 18 weeks and 3 days of pregnancy. An exophytic papillary tumor was observed by colposcopy at the time of admission; it may have grown rapidly before admission. We fully explained to the patient and family members that the cancer had advanced and when the baby would be able to survive outside the uterus if the patient continued the pregnancy. The patient and her family desired surgical treatment and termination of the pregnancy. A radical hysterectomy with pelvic lymphadenectomy was conducted at 19 weeks and 0 days of pregnancy ().\nPostoperative pathological diagnosis revealed the following: uterine cervical carcinoma (pT1b1N1MX), squamous cell carcinoma with a keratinizing type, lymph vascular space positive for invasion, vaginal stump negative for invasion, and lymph nodes metastases (right external iliac lymph nodes, right inguinal lymph nodes, and right obturator lymph nodes).\nMetastasis to the para-aortic lymph nodes was detected on positron emission tomography/computed tomography (PET-CT) performed postoperatively. Additional treatment options were discussed and explained. The patient and her family desired treatment that could be administered by visiting the hospital; therefore, chemotherapy was chosen. Weekly TN therapy (taxol 80 mg/m2, nedaplatin 25 mg/m2, i.v., once weekly) was conducted. Most of the metastases disappeared on PET-CT three months postoperatively and after the completion of nine cycles of chemotherapy."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female with past medical history significant for type 2 diabetes mellitus, hypertension, and dyslipidemia and family history of breast cancer in her brother and maternal aunt presented to the emergency room for recurrent chest pain. She also reported fatigue for the past few months and was being evaluated for worsening anemia by her primary care physician. Her hemoglobin was 6 gm/dl with iron panel consistent with anemia of chronic disease. Her electrocardiogram (ECG) at arrival showed an “RSR pattern” in V1 and V2 leads but was otherwise normal. She underwent a stress myocardial perfusion imaging (MPI) which was negative for cardiac ischemia. A transthoracic echocardiogram revealed a 1.6 cm × 1.5 cm atrial mass attached to the anterior wall of the left atrium, which appeared to cross the mitral valve in ventricular diastole. The left atrial mass was further characterized by a transesophageal echocardiogram (TEE) as a solid, irregularly shaped, partly mobile mass attached to the atrial septum and extending to the anterior mitral valve leaflet (). The segment attached to the septum measured 2.6 cm × 1.43 cm, and the segment attached to the valve measured 1.4 cm × 2.22 cm. In addition, MRI of the heart with gadolinium was done preoperatively which confirmed the circumscribed hypodense mass with speckled appearance which originated at the atrial septum and extended along the anterior mitral valve leaflet (). The mitral valve flow was normal with no evidence of obstruction, stenosis, or regurgitation. The patient underwent a minimal incision valve surgery for resection of the mass which was presumed to be myxoma due to its location. Intraoperatively, on open examination of the left atrium, it was noted that the mass originated from the fossa ovalis region of the interatrial septum and infiltrated the atrial wall down onto the entire anterior leaflet of the mitral valve. A fibrotic density that surrounded the tumor was also noted. The mass along with a port"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn October 2012, a 46-year-old woman was referred to our center for the presence of a large mass (50 × 70 mm) in the superior lobe of the left lung with homolateral pleural effusion. The patient was never smoker, without family history of cancer and without comorbidity. The cytological diagnosis was made using a CT-guided fine needle aspiration of the primary tumor and revealed an adenocarcinoma of the lung (TTF1+, CK7+) with the EGFR ex19del mutation. A PET-CT demonstrated the presence of liver and bone metastases and a nodule in the right breast, confirmed as a metastasis by fine needle aspiration. The patient received zoledronic acid 4 mg every 28 days and gefitinib 250 mg daily since November 2012 obtaining a partial response (PR). In August 2013, a disease progression (PD) was documented, with an increase in size of the primary tumor and size and number of liver metastases. A brain MRI revealed the presence of two cortical nodules, which were treated with stereotactic radiotherapy. The patient was enrolled in the IMPRESS trial and received 6 cycles of cisplatin and pemetrexed plus gefitinib obtaining again a PR that lasted until June 2014. Thereafter, a new lung metastasis appeared in the superior lobe of the left lung and the mammary nodule increased in dimensions. From June 2014 to December 2014 the patient received erlotinib 150 mg daily obtaining an initial stabilization of the disease (SD); however, within 6 months, she experienced again a PD with the increase of the mammary nodule and the appearance of a new bone metastasis in the sacrum. In December 2014, EGFR ex19del and T790M mutations were detectable in a new needle biopsy of the primary tumor; only at this time a digital PCR-based method was available for the analysis of circulating tumor DNA (ctDNA). Briefly, the method was optimized in order to recover a suitable amount of ctDNA for molecular analysis from 3 ml of plasma using the QIAmp Circulating Nucleic Acid Kit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old male patient reported to the Department of Periodontology Government Dental College, Calicut with a chief complaint of bleeding from gums and bad breath of 3 months duration. On clinical examination, generalized moderate to deep periodontal pockets and bleeding on probing was noticed. Radiographic examination revealed generalized bone loss. Based on the history, clinical and radiographic findings, the patient was diagnosed with chronic generalized periodontitis. Six weeks after performing thorough scaling and root planning and following a strict plaque control regime, the case was reevaluated. Since the pocket depth was 7 mm distal to 36, it was decided to proceed with flap surgery [].\nAfter giving block anesthesia in the left mandibular posterior area, internal bevel incision was given, and a full thickness flap was raised. Meticulous defect debridement and root planing was done to remove subgingival plaque, calculus, and inflammatory granulation tissue. A deep two wall defect was observed distal to first molar, heavy ledges were noticed extending bucally from second premolar to the second molar area []. First it was decided to remove the ledges as a part of osteoplasty procedure and then utilize the removed bone to fill the two wall defect. For this purpose, a sharp sickle scaler (PDT Cruise Scaler U15-33 R113, PDT Inc., US) [] was used in a scrapping motion with sufficient force such that the bone was essentially shaved off []. The harvested bone was carefully collected in a dappen dish and then transferred to the defect with a periosteal elevator [Figures and ]. The flap was repositioned, single interrupted sutures were placed and periodontal dressing was given [Figures and ]. The patient was reviewed after 1-week, the healing was found to be uneventful. The sutures were removed, and the area was irrigated with saline. The patient was put on the maintenance phase with oral prophylaxis performed every 3 months. Radiographs were taken"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female with pain in her right ankle and paresthesia along the medial plantar aspect of the foot reported to our outpatient clinic. No history of trauma was reported. Last 8 years, she was regularly monitored by a rheumatologist due to Raynaud's syndrome. Since the ankle symptoms started about a year ago, she significantly gained weight due to medications and inactivity. She was initially examined in an emergency department regarding her ankle pain. No definitive diagnosis was set at the time, and she was referred to a rheumatologist for further assessment. Her symptoms persisted after the initial conservative therapy with NSAIDs and rest. She was further treated with high doses of intravenous corticosteroids despite unremarkable capillaroscopy and regular laboratory work-up for immune diseases. As the pain persisted, sulfasalazine was added to therapy with no effect on symptoms. She was further referred for a three-phase bone scan and ultrasound (US) of the ankle, which were also unremarkable. At that moment, she was diagnosed with complex regional pain syndrome, and lidocaine patches were added into therapy. In the meanwhile, she was referred to a physical therapy specialist, and physical therapy for alleviation of pain was scheduled. Rheumatologist referred her for an MRI of the right ankle, which was reported as unremarkable by a musculoskeletal radiology specialist. As symptoms persisted, she was further referred to a pain management clinic and for an orthopedic surgeon's examination. Opioids and pregabalin were introduced into therapy, and the patient was referred for hyperbaric chamber therapy. Following hyperbaric chamber therapy, she noticed an improvement in sensation in her foot while ankle pain persisted. In the meantime, she presented to our outpatient clinic, where an orthopedic surgeon issued a plain radiograph of the right ankle, and a dense area was noted in the right calcaneus (). Requested computerized tomography (CT) scan of the righ"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11 year-old right-handed girl was referred to our clinic for her painful and swollen left wrist. The patient was a successful student and there was no relevant family history. She had painful wrist without swelling for past two years and had no history of antecedent trauma. The pain was constant, dull and more intense at nights and was not activity-related, so she referred to a health medical center where the general practitioner took an X-ray from her left wrist and referred her to an orthopaedic surgeon because a lytic lesion was in her carpal scaphoid bone (). At that time, the patient was advised for a complete work up but her parents refused further investigation. In spite of constant pain, the patient did not take any pain killer or anti inflammatory agent to subside the pain. Gradually the wrist started to swell and pain became worse and finally two years later she was referred and admitted to an orthopaedic surgery unit in a university hospital where a complete work up was done. At this time, left wrist was swollen, there was a tumor with hard consistency on dorsal and wrist palmar especially on radial side with mild tenderness. The wrist was stiff with minimal motion range and grip power was de-creased. Physical examination otherwise was normal. New X-ray revealed marked osteopenia of the wrist and adjacent bones and an osteolytic expansile lesion with opacities in its matrix in the scaphoid area ().\nBone scan showed increased uptake in the scaphoid area. CT scan revealed lytic expansile lesion with internal calcification in scaphoid ().\nMRI of wrist reported a relatively welldefined heterosignal mass lesion in the scaphoid bone, which was surrounded by edema in adjacent soft tissues with central signal void foci, which could be calcification, hemosiderin or flow void vascular structures and no evidence of fluid-fluid level. Chest X-ray and blood tests were normal. The patient underwent a biopsy through volar approach and specimen sent to histology revea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old man presented to the emergency department with an 8-hour history of an acutely painful enlarged right hemi-scrotum and obstipation. His medical history includes a previous left inguinal hernia repaired laparoscopically at another institution nine years prior. He had noticed an enlarging but easily reducible right groin mass for the past 2 to 3 years, for which he had not sought care. During this current presentation, he appeared in significant discomfort, and diaphoretic. Heart rate was 110 beats per minute but he remained afebrile with normal blood pressure. There was a mass present in the right groin which extended into the right hemi-scrotum measuring approximately 15 cm in size. The mass was firm, tender, and non-reducible. His scrotum had overlying skin erythema. His abdomen was diffusely tender with mild distension but no peritoneal signs.\nA diagnosis of an incarcerated right inguinal hernia with concern for strangulation was established immediately after a physical exam. Further imaging or laboratory evidence was deemed unnecessary based upon his clinical findings and concern for strangulation. Intravenous fluid resuscitation and antibiotics were initiated, and the patient was brought immediately to the operating room for open inguinal hernia repair. A large indirect hernia sac was identified and dissected from the cord structures. The hernia sac was then opened revealing markedly dilated necrotic bowel. A gentle retraction did not result in adequate mobilization of the necrotic bowel to the operative field as the bowel appeared to be fixed in the right groin. Therefore, a lower midline laparotomy was made. The bowel was reduced through the hernia defect and examined through the midline incision. A 20 cm segment of necrotic bowel was identified, including a large Meckel’s diverticulum measuring approximately 15 cm in length (). There was no perforation. A wound protector was inserted (not shown), and a bowel resection of the necrotic segment and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old male, with no known comorbidity, presented with an episode of urticaria along with shortness of breath. According to the patient, the urticaria had started from the extremities, progressed to the trunk, and was associated with generalized itching and swelling of lips. This was accompanied by shortness of breath and a cough that progressed from dry to productive with white sputum. He had a history of undocumented weight loss over the last few months. The rest of the symptom review was unremarkable. The patient was a long-term smoker who had recently quit smoking in the past six months and was currently an active betel nut chewer. He had no known allergies, no prior hospitalizations or surgical procedures, and was not on any routine medications. His family history was unremarkable.\nA chest radiograph revealed a left-sided pleural effusion. A pleural tap showed a predominantly lymphocytic exudate. The pleural effusion was recurrent and had not settled despite repeated pleural taps. A subsequent computed tomography (CT) scan of the chest revealed a large, left-sided pleural effusion, as well as a large soft tissue mass in the posterior mediastinum in a paravertebral location without extension into the spinal canal, as can be seen in Figure .\nBiopsy attempts had proven inconclusive. Routine laboratory investigations were unremarkable. The patient was advised tumor excision. A left posterolateral thoracotomy was done, in which a large posterior mediastinal mass was seen adherent to the left lung, as seen in Figure .\nThe mass was completely excised, as shown in Figure .\nThe patient had an uneventful postoperative recovery. Histopathology of the mass, which measured 12.5 x 8.5 x 7.5 cm, showed it to be a giant, predominantly cystic Schwannoma, with medium- to large-sized, congested hyalinized vessels with surrounding hemorrhage, as well as dense acute and chronic inflammatory changes without evidence of malignancy. The S-100 immunohistochemical"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old female patient reported to our institute with a complaint of swelling in the left side of lower jaw since 2 months []. Post its onset, the swelling gradually increased in size over a period of 2 months. The swelling was associated with dull pain. The patient is a known diabetic since 5 years and is under oral anti diabetic medication. Concurrent with the history of swelling, the patient gives a history of weight loss in past 2 months. No history of cold, cough or fever.\nExamination revealed a swelling of 9 × 4 cm in size which extended anteriorly 1 cm in close proximity to chin on left side and posteriorly in line with the ear lobe []. Skin over the lesion was pinchable, normal in color and texture. Margins were well-defined and the swelling was firm, fixed to underlying tissues and non tender on palpation. There were no signs of paresthesia. No local rise of temperature was seen in the concerned area. Left submandibular lymph node was 0.5 cm in size and mildly tender on palpation. A provisional diagnosis of benign tumour of left submandibular salivary gland was given. Few differential diagnoses such as Sarcoidosis, Sjogren's syndrome, Lymphomas and Mikulicz disease were considered. Sarcoidosis was ruled out because only one of the submandibular glands was involved. Generally, all the salivary glands are involved. Sjogren's syndrome was ruled out as there was no history of dryness. In both Sarcoidosis and Sjogren's syndrome, the patient did not give any relevant history. Mikulicz disease is an autoimmune disease and thus was ruled out.\nThe following investigations were done:\nFNAC gave an impression of chronic non specific lymphadenitis. No evidence of cytological atypia seen Ultra sonography report showed a circumscribed mixed area of 3 × 1.5 cm in the anterior region of left submandibular gland. Moderate blood flow was seen and the region showed two enlarged lymph"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old premenopausal Caucasian woman presented in December 2009 during a multidisciplinary tumour board for nonpalpable lesions. Mammography revealed microcalcifications and gentle densities suspicious for invasion in the area of 6 × 8.6 cm in her left breast (Figure ). An ultrasound showed indistinct hypoechoic lesions with posterior acoustic shadows. A core biopsy revealed high grade DCIS with calcifications. Due to the extensive microcalcifications, the patient was recommended to undergo a mastectomy and immediate breast reconstruction with expander implant. The surgery was performed on 23 March 2010. The mastectomy specimen weighed 238 g and measured 13 × 12 × 3 cm. Grossly, in the upper lateral quadrant of the breast a suspicious area was found. The suspicious focus measured around 2 cm in the largest diameter and consisted of somewhat harder yellow-whitish tissue of granular appearance. In the other parts, the breast tissue was mainly fatty without macroscopically suspicious changes. Careful sampling of the suspicious area and surrounding parenchyma was performed. Altogether, 12 tissue blocks were taken from that area. Besides, one paraffin block was taken from each quadrant and central part of the breast. Microscopic examination revealed massive, high grade DCIS with multiple foci of microinvasion that measured up to 0.1 mm in the largest diameter. Deeper sections from the paraffin blocks with microinvasion were also performed, but no invasive focus ≥1 mm was found. DCIS was located mainly in the upper lateral quadrant but multicentric foci of DCIS were present in all breast quadrants. The dimension of the DCIS was approximately 8 cm. Surgical margins were free (the basal margin was 6 mm). Tumour cells were negative for oestrogen (expressed in less than 1% of cells) and progesterone receptors (0%). Testing for HER2 status was not performed. In the pathologist’s opinion, the invasive clusters were too small for a reliable determination of HER2 status. I"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman was admitted to our hospital for fever and headache. She was hospitalized in the Infectious Disease Department for observation and study. Chest X-ray and abdominal ultrasound examination were normal. Magnetic resonance imaging (MRI) with gadolinium revealed a right frontobasal brain abscess, compressing the homolateral frontal horn of the lateral ventricle, with a second mass partially occupying the right orbital cavity (Figure ). She presented also with inflammatory sinusopathy involving the right frontal, ethmoid and maxillary sinuses. After 14 d of clinical observation and intravenous broad-spectrum antibiotic therapy, nasal culture was performed on day 14 of hospitalization, which showed evidence of low levels of Candida albicans. Ophthalmological consultation revealed visual loss from her right eye, and contrast computed tomography (CT) showed an increase in abscess size, so the patient underwent prompt surgery with right frontobasal craniotomy (Figure ). Thanks to neuronavigation and under operative microscopy, the abscessual capsule was opened widely, in order to drain its content, and it was coagulated to avoid damage to nervous structures, given that the cerebral parenchyma in the right orbit appeared to be involved in an inflammatory reaction. Some of the mass content was sent for microbiological examination in Bactec broth and, 8 d after surgery, R. ornithinolytica was isolated by conventional microbiological tests. On the basis of an antibiogram, determined according to the European Committee on Antimicrobial Susceptibility Testing, and after consulting an infectious diseases specialist, the patient started intravenous therapy with metronidazole and ceftriaxone, four times and twice daily, respectively (Table ). She received a basal CT scan that showed no residual or recurrent brain abscess.\nHer general clinical conditions were improved but, on day 30 in hospital (approximately 2 wk after surgery) she developed right-side pneumonia wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman presented to our hospital with left-sided abdominal pain. The patient had no significant past medical history. An abdominal examination revealed left flank fullness. Abdominal sonography and a CT scan of the abdomen revealed a large left (10 × 12 cm) upper pole hydatid cyst in the left kidney. The remaining blood tests and urine examination were normal. No serological test was done and a diagnosis of renal hydatid cyst was made from the typical radiological finding. The patient was given albendazole for three weeks, preoperatively.\nThe patient had undergone sonography guided PAIR (puncture, aspiration, injection, re-aspiration) via the retroperitoneal route, by percutaneous means, on two occasions. Thus we decided to use the transperitoneal route, with necessary precautions, to avoid peritoneal contamination. The patient was given general anesthesia and placed in a supine position, with the left side elevated at 60 degrees. Pneumoperitoneum was established using a veres needle and CO2 insufflation. The retroperitoneum was exposed by mobilizing the left colon. The cyst was demonstrated and exposed all around by blunt dissection. The cyst was then isolated on all sides by packing it off using betadine-soaked gauze pieces (10% povidon iodine), to avoid contamination of the peritoneal cavity even if spillage occurred. A trocar was inserted into the cyst under vision, with due care taken to avoid spillage. The contents of the cyst were aspirated using an aspiration needle, and hypertonic saline was instilled for 10 minutes. The scope was inserted into the cyst to confirm complete evacuation. This was followed by cystotomy, and the endocyst was removed completely. This was introduced into an endobag. Partial cystectomy was carried out using a harmonic scalpel. Complete hemostasis was achieved. Omentoplasty was performed. The drain was kept in the retroperitoneum. The procedure lasted for 90 minutes. There were no intraoperative or early postoperative c"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old boy with normal birth and developmental history and no history of febrile seizures or encephalitis-like illness had a history of seizure onset at the age of 2.5 years. The seizures were automotor in type with ictal speech and were, therefore, localized at the nondominant temporal lobe. Video-electroencephalography (VEEG) was suggestive of ictal onset from the right anterior temporal region. It was concordant with the finding of right mesial temporal lobe sclerosis on magnetic resonance imaging (MRI). Ictal single-photon emission computed tomography (SPECT) revealed hypoperfusion in the right mesial temporal lobe. There was no history of any psychiatric comorbidity. The seizures remained refractory to the medical treatment; therefore, the patient underwent a right selective amygdalohippocampectomy. He remained seizure-free following the surgery. There were no symptoms of anxiety, depression, or psychosis during the first 2 years after the surgery but the patient had two episodes of nonepileptic events after 2 years. The patient developed feelings of constant sadness and worthlessness, along with feelings of guilt and suicidal ideations 2 years after the surgery. He also started excessive alcohol consumption. At that time, he was on valproate, oxcarbazepine, and clobazam as a part of his antiepileptic treatment. He was diagnosed with major depression as per the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV) criteria, and was started on oral escitalopram at a dose of 10 mg/day, to which he responded adequately within 2 months, and the medication had to be continued for the next 1 year. He developed features of mania with inflated ideas 5 years after the surgery. The development of mania coincided with tapering and then withdrawal of sodium valproate, which had been part of his AED treatment, which we had decided to taper very slowly. He was restarted on sodium valproate and initiated on antipsychotic treatment with risperid"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old male presented for evaluation of known moderate to severe PVR with symptoms of progressive dyspnea on exertion, orthopnea, and weight gain 2 months after coronary artery bypass surgery and aortic valve replacement at another institution. His past medical history included nonsmall cell lung cancer, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and 3-vessel coronary artery disease. The patient had originally presented after a non-ST elevation myocardial infarction with severe aortic stenosis and severe coronary artery disease. At the time of his 3-vessel coronary artery bypass grafting and open surgical aortic valve replacement the surgery was complicated by inability to advance a 23 mm sizer through the sinotubular junction due to severe calcium, which resulted in the placement of an undersized 21 mm Magna valve (Edwards, Irvine, California). At the completion of the surgery, intraoperative imaging revealed moderate to severe aortic regurgitation, but the calcium was felt prohibitive for repair and the patient was referred to our institution.\nOn presentation, the patient was wheelchair bound with New York Heart Association Class IV symptoms and was hypoxic requiring supplemental oxygen. Examination identified a diastolic murmur, 4 + lower extremity edema, and bibasilar rales.\nTEE revealed a left ventricular ejection fraction of 55% to 60%, grade III diastolic dysfunction, and moderate PVR with two distinct jets in the noncoronary sinus (Figure ). The patient improved clinically with careful diuresis and further imaging with computed tomography suggested his aortic annulus actually measured 2.2 x 2.6 cm, larger than the 21 mm valve placed at surgery. Based on this, the PVR was felt to be due to the placement of an undersized 21 mm valve. Given excessive open surgical risk for this bedridden patient, transcatheter options were considered. This magna valve true inner diameter of 19 mm. ViV TAVR with balloon fracture of the surgical valve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old male patient, with a history of smoking (30 pack-years) and no known medical or surgical history, was admitted in our department for a spontaneously resolved inferior ST elevation myocardial infarction (STEMI). The intra-hospital treatment included enoxaparin 0.6 ml twice a day, clopidogrel 75 mg once a day, aspirin 100 mg once a day, bisoprolol 2.5 mg once a day and atorvastatin 40 mg once a day. The coronary angiogram (performed at day 3 through the right radial artery) showed a severe thrombotic lesion of the distal circumflex. The patient underwent an ad-hoc successful angioplasty of the circumflex with a drug eluting (everolimus) stent. Initial laboratory tests at admission were normal except elevated troponin. Echocardiography showed a 65% left ventricular ejection fraction. The patient was discharged after 5 days of anticoagulation by low molecular weight heparin (enoxaparin). Laboratory tests were not controlled during the hospitalization. The discharge treatment included clopidogrel 75 mg once a day, aspirin 100 mg once a day, bisoprolol 2.5 mg once a day and atorvastatin 40 mg once a day.\nOne week later, the patient was referred again to our department for both chest and right lower limb pain. The electrocardiogram showed an inferior STEMI and the physical exam of the right lower limb found ischemic signs with absence of the femoral pulse. There was no history of aspirin or clopidogrel discontinuation. An urgent coronary angiogram (performed through the left femoral artery) showed total thrombosis of the circumflex stent (\n). The patient underwent a successful primary angioplasty of the circumflex by simple balloon (\n). Urgent lower limb contrast-enhanced computed tomography was performed immediately after the angioplasty, revealing total acute thrombosis of the right common femoral artery (\n). The patient underwent an urgent successful thrombectomy with Fogarty catheter. Immediate evolution was favorable with total regression of coronary and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old man, working in a furniture confection plant, experienced severe “tearing” chest pain upon heavy lifting. On presentation in another health facility, a chest computed tomography (CT) scan, with incomplete imaging of the iliofemoral axis, revealed a type A aortic dissection (DeBakey type I). Following transfer to our center, physical examination showed a pulseless left femoral artery, while no sign of acute limb ischemia was present. The patient underwent a mechanical Bentall procedure with hemiarch replacement under circulatory arrest for a total procedure time of 7 hours, 45 minutes. The immediate postoperative course was uneventful. The femoral pulses were symmetrical and well palpable once the patient rewarmed. Thirty-six hours after surgery, the patient was extubated and complained of severe pain to his left buttock. The lower limb pulses were present and no sensory or strength deficit was found. The left limb was normal, while the buttock was tense and painful especially upon flexion and adduction of the hip. A GCS was suspected. A CT angiography scan of the pelvis showed a dissection flap ending proximal to the iliac bifurcation without direct involvement of the iliac arteries. The false lumen was thrombosed and preferentially oriented toward the common left iliac artery. The opacification of the left internal and external iliac arteries was good. Preoperative CT angiography showed left gluteus muscle swelling (\n). This was likely related to a malperfusion following thrombotic or embolic occlusion (\n). The patient was diagnosed with GCS, further supported by a peak creatine kinase of 91 865 U/L.\nA Kocher-Langenbeck procedure (\n) was performed under general anesthesia with the patient placed in a right lateral decubitus position, with his legs bent at a 30° to 40° angle. An incision was made from the posterior superior iliac crest up to 5 cm of the greater trochanter and then to the lateral aspect of the femoral shaft."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old Caucasian woman was referred to a private practice specializing in periodontics, dental implants and advanced restorative techniques to replace a 'failed' implant. The author informed the patient that the soft and hard tissues around her implant (tooth position 34 according to the World Dental Federation notation) showed evidence of peri-implantitis. The implant had been placed 20 months prior to her visit (to the current practice), and the crown fitted 4 months after the implant surgery. She reported a problem-free implant surgery and subsequent healing period; however, she reported that from the day the crown was fitted, the crown and adjacent gum had never felt 'comfortable.' The patient completed normal hygiene visits during her dental check-ups, but since the crown was fitted onto the implant in position 34, she had visited a hygienist every 3 months for help with this implant site. During visits to the hygienist, topical antibiotics were inserted on several occasions into the pocket to treat infections and pocket/implant surface debridement was carried out. The referring dentist had already warned the patient that the implant should be removed. Upon visiting our office, the patient described feeling very unsatisfied with the loss to her buccal tissue and bone at the implant site and asked if the implant could be replaced. Additionally, the tooth anterior to the implant (position 33) had also suffered extreme recession, which she felt was attributed to the development of peri-implantitis at position 34. The patient had no contraindicating medical condition. Clinical examination showed a very pronounced loss of attachment at positions 33 and 34 (). The patient was diagnosed as having a mixed 'thin and thick' gum phenotype. The width of keratinized gingivial tissue (KGT) in the lower arch varied between 0 and 6 mm. We performed a radiographic examination that produced periapical, panoramic and linear tomograms (). The initial diagnosis was controlle"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 4-day-old Asian Chinese female newborn was admitted to our department because she presented with six round, soft, multiple, pedunculated swelling masses with two on her upper anterior ridge and four on her lower anterior ridge. The size of the largest mass was 3.5×3cm (Figure ). No family history of hereditary diseases was reported. The baby was delivered in the 38th week of gestation via Cesarean. Her birth weight was 2650g. She was unable to close her mouth and thus feeding was not possible. Her respiration was normal. The size of the swelling masses increased slowly after birth. Because of the feeding problems, an immediate surgery was planned. General anesthesia was placed in spare to manage intraoperative complications including blood asphyxiation and other airway-related problems. The feeder vessels were seen to originate from the alveolar ridge. Hence, a transfixion suture was placed slightly away from the lesion on the alveolar ridge so as to achieve pre-excision hemostasis and minimize the chances of intraoperative bleeding, which could endanger the airway.\nAll lesions were well defined, firm, round, smooth and pink in color on the cut surface. All alveolar masses were excised surgically without complications under general anesthesia on the sixth day after the birth of the baby, who was discharged on the third postoperative day. Postoperative recovery and surgical site healing were satisfactory.\nThe excised masses were fixed in 10% neutral buffered formalin. The tissue was submitted for histopathological examination. Immunohistochemical analyses were also carried out using a panel of antibodies, including vimentin, Ki-67, smooth muscle actin (SMA), synuclein (Syn), neuron-specific enolase (NSE) and S-100. Corresponding positive and negative controls were performed in parallel for all the antibodies tested.\nMicroscopic examination showed a benign tumor composed of sheets of closely packed, large, rounded polygonal cells with abundant granular, eosinophilic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old woman visited the emergency room with confused mental status after a few generalized tonic-clonic seizure attacks. She had been treated for spinal cord glioblastoma for 4 years. She had undergone surgical removal of a spinal cord tumour and had been on concomitant chemoradiation therapy, which was terminated 2 weeks before the visit. CSF tap was not performed due to an intracranial space occupying lesion.\nBrain MRI performed 3 months before the visit showed extension of the tumour from the brainstem to the upper thoracic spinal cord and another lesion at the right temporal pole.\nFigure on presentation, she was drowsy and vital signs were as follows: blood pressure, 125/65 mmHg; body temperature, 36.4 °C; pulse rate, 100 per minute; respiratory rate, 19/min. The emergency medical faculty immediately gave her intravenous LEV 1000 mg; however, there was one more generalised tonic-clonic seizure without mental recovery. Video-EEG monitoring was initiated 2 h after the end of LEV loading; at that time, she started to show choreoathetoid movements in her face and bilateral limbs (see Additional file ), but no epileptiform discharges were noted on concomitant electroencephalography (EEG) as seen in Fig. . Laboratory findings including complete blood counts, electrolytes, blood urea nitrogen, creatinine, and arterial ammonia levels were normal. Review of her medical history revealed that she had been treated with solifenacin, esomeprazole, baclofen, and escitalopram for more than 3 months. She was not on concomitant drugs such as dopamine receptor blockers or antipsychotic agents. Considering the temporal relationship between the onset of involuntary movements and administration of LEV, further treatment with LEV was withheld. Chorea movement continued for about 30 min. She could communicate with her caregiver and physician until the end. After administration of 4 mg of lorazepam and 1200 mg of phenytoin, the involuntary movements ceased gradually. The next da"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old, asymptomatic female with no significant past medical history was diagnosed to have a mass in the left atrium (LA) on routine cardiac evaluation. Transthoracic echocardiography revealed a mass of size 1.5 cm × 2.6 cm in LA attached to the interatrial septum (IAS). Considering patient's age, coronary angiography was done which showed normal coronary arteries and a tumor blush due to feeding arteries supplying the LA mass. Coronary angiography also showed feeding arteries arising from the left circumflex (LCX) and left anterior descending vessels (LAD) []. The patient was posted for excision of LA mass.\nThe patient was induced as per the standard anesthesia protocol and a TEE probe was introduced without any difficulty. Precardiopulmonary bypass (CPB) TEE examination demonstrated a homogenous and irregularly-shaped mass in the LA of size 2.4 cm × 2.2 cm arising not only from IAS [] but also seen attached to the roof of LA, without prolapsing through the mitral valve. The aforementioned findings were confirmed by the surgeon intraoperatively.\nUnder standard hypothermic CPB with cold blood hyperkalemic cardioplegia, the LA mass was excised through the right atrial approach, and IAS was reconstructed using pericardial patch. The patient was weaned from CPB without any pharmacological support. Postprocedure, TEE showed complete excision of LA mass and absence of flow across IAS. However, an unusual single continuous jet with a peak velocity of 0.9 m/s was seen from LA roof into the LA chamber near the opening of right pulmonary vein [ and ]. With a suspicion of CCF, the coronary arteries were looked at, for any dilated course by direct visualization on the surface of the heart as well as on TEE and found that the coronary arteries were not dilated. The possibility of tumor-feeding vessel draining into LA was considered and protamine was administered with simultaneous monitoring of the continuous jet using TEE. Thirty-five minutes after administration of prot"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was 24 years-old male, born in Maua, Sao Paulo, Brazil. He was the eighth child of a 32 year-old woman, who had two miscarriages, did not do prenatal care and smoked during pregnancy. His parents were not consanguineous and he was delivered through vaginal delivery without perinatal complications, and born at term with adequate weight.\nHis neurodevelopment was normal until five years of age, when the patient, previously healthy, presented with vomiting and diarrhea lasting about a month, staying in hospital at the beginning of the clinical features to correct dehydration.\nAfter this episode the mother told that he started to lose weight and ceased growth. He no longer understood commands and the difficulty to communicate worsened slowly. He had major mood swings, with periods of agitation, aggression and insomnia.\nSince the age of six he used hearing aids. At the age of nine he was transferred to a “special school” where he remained for two years, however, he had no progress in learning.\nHe had several hospitalizations for diarrheal episodes and bronchopneumonia. He underwent bilateral orchiectomy at 12 years of age due to cryptorchidism.\nHe presented diagnosis of bilateral allergic conjunctivitis and myopia on the right eye. Dental agenesis was observed in the second premolar bilaterally and the right maxillary central incisor.\nAbsence of subcutaneous fat was noted on his general physical examination. Skin and hair were undernourished. He had dry and aged appearance with multiple nevi on the face and trunk (Figure \n). His lips were thin and ears were prominent. He had teeth in bad condition. He had clinodactyly on hands and feet (Figure \n). There were no pulmonary, cardiac and abdominal alterations.\nOur patient could keep contact with the environment through sight and hearing (a hearing aid in use). He had poor language, speech difficult to understand, in a hoarse and high voice"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old woman presented to the Provincial Maternal and Child Health Care Hospital (Changsha, China) in March 2017 because of irregular vaginal bleeding for more than 1 year and presence of a lower abdominal mass for 4 mo.\nThe patient was nulliparous and overweight (body mass index = 28.1), with a 15-year history of primary infertility. Her age at menarche was 12-years-old, and the menstrual period lasted for 10 d. She got married at 20-years-old, and had been married for more than 15 years to date. Several characteristics were observed, including nulliparity, limited sexual activity (intercourse 1-2 times a year) in recent years, and irregular vaginal bleeding for 2 years without a pathological report. In April 2017, the patient found a palpable lower abdominal mass in the supine position, but there was no tenderness in the local area. By February 2018, the mass had increased in size, with the patient experiencing occasional lower abdominal pain and discomfort.\nThe patient denied a history of hepatitis, tuberculosis, typhoid fever, and other infectious diseases, as well as chronic hypertension, diabetes, coronary heart disease, and other chronic diseases.\nThe patient was born in Guizhou Province, China. She did not have a history of smoking or drinking. Her occupation was housewife and the working conditions of such were general. She denied contact with toxic chemicals, poisons, or radioactive substances. She had married at the age of 20 and they were separated at the time of her case management. She reported her experience of sexual frequency in recent years as approximately every half year. She also reported not using contraception and never having been pregnant.\nFindings from the gynecological examination revealed an enlarged uterus, similar to the uterus size in the fourth month of pregnancy, and the uterine wall was relatively hard.\nLaboratory tests showed a white blood cell count of 7.7 × 109/L,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previous healthy 43-year-old woman was seen for evaluation of swelling in the right submandibular region. The patient first noticed the mass 2 months before visiting the hospital. She had no pain, trismus, or discomfort during eating, but complained of cosmetic problems. The mass was very soft and movable within the submandibular region; no tenderness was reported during physical examination.\nUltrasonography (USG) showed that the mass was of a relatively heterogeneous, hypoechoic nature, with ill-defined margins compared to typical submandibular glands. The tumor was located in the superficial and deep portions of the normal submandibular gland and extended externally to the gland (). A computerized tomography (CT) image revealed a fatty mass with an irregular margin. Multiple soft tissue density was seen inside the mass in the right parapharyngeal space and submandibular region (). Because the mass was located at the superior and medial aspect of the submandibular gland, the residual gland was displaced inferolaterally, creating the cosmetic problem about which the patient complained. As we had no previous experience with sialolipoma, our clinical impression of the mass was that it was a simple lipoma of the submandibular gland.\nTumorectomy with preservation of submandibular gland was performed under general anesthesia via submandibular incision. A marginal mandibular branch of the facial nerve was identified and preserved. Because the tumor was well-encapsulated, it could be easily dissected from the main submadibular gland. The tumor measured 4 cm in its largest dimension and had a fatty consistency like a simple lipoma. Gross examination revealed that the tumor was well-circumscribed, soft, yellowish, and had a well-demarcated light pink-colored nodular component surrounded by fatty tissue. Ill-defined brown lesions were scattered around the nodule; histological examination identified these as an oncocytic nodule and glandular tissue ().\nMicroscopic examinatio"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn 2013, an 11-year-old Japanese boy was referred to our department for painless bone expansion in the right maxillary alveolus, delayed eruption of the permanent second molar teeth, and altered occlusion. He had no significant medical or family history. A panoramic X-ray showed a unilocular cystic lesion in the right maxilla containing a calcified large mass associated with an impacted tooth (Fig. ). Computed tomography showed a cystic lesion of size 3.6×3.1×2.7 cm that included calcified structures (Fig. ). A horizontal view showed right maxillary bone expansion (Fig. ).\nIn 2013, the patient underwent tumor extirpation combined with impacted tooth extraction. The incisional line was started from the labial mucosa in the right maxillary central and lateral incisor area. It extended to the gingiva in the right maxillary lateral incisor and canine area by arch-like incision, and to the gingiva of the right maxillary second molar by crestal incision with distal releasing incision. The goal of this procedure was to make a mucoperiosteal flap from the lower border of the pyriform aperture, vertically to the infraorbital foramen and surrounding areas, and horizontally to the lower border of the zygomatic bone. The infraorbital neurovascular bundles were preserved. Upon opening of the sinus from a thin plate of bone in the canine fossa and surrounding areas in the anterior wall of the right maxilla (the same level as the lower border of the pyriform aperture), bone-like hard tissues that were strongly adhered to the maxilla were found. When these tissues were separated from the surrounding areas and removed using a fissure bar, a solid, bone-like, hard odontogenic tumor (similar to a complex odontoma) was found to have occupied almost the whole sinus. The mass was too large to remove from the opening.\nFor complete removal of the mass including the tumor capsule, which was adhered to the surrounding bone, the tumor was divided into several pieces using a fissure"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy male in his 30s presented to the emergency department with a 2-day history of pain and swelling in his right upper extremity after striking a heavy bag with an uppercut punch. At the time of event, the patient felt a sudden sharp pain radiating from the wrist to the elbow, which eventually localized to the elbow. Over the next 2 days, the patient gradually developed swelling and diffuse erythema from the proximal aspect of the right arm to the wrist, tension, and decreased elbow, wrist and finger mobility. He reported a history of compartment syndrome requiring fasciotomy in his right distal arm and proximal forearm due to an automobile accident-induced crush injury 10 years prior. On exam, he was tender to palpation, weak to grip, but had intact sensation and vasculature. Initially, cellulitis was suspected, partly because of the appearance of his extremity and an unlikely traumatic mechanism for ACS. Radiographs were unremarkable for fractures. Magnetic resonance imaging (MRI) revealed extensive edema in the proximal brachioradialis muscle and extensor carpi radialis longus muscle, as well as increased signal in the extensor musculature at the dorsal aspect of the arm, but no fracture or tendinous, ligamentous or muscular tear (Fig. ). Ultrasound showed a non-occlusive thrombus in the right axillary and brachial veins, for which the patient was eventually started on anticoagulation. All initial labs were unremarkable except the CPK of 973 and the patient was subsequently admitted.\nOn hospital Day 4, due to lack of improvement on antibiotics, worsening of pain and growing suspicion for ACS, the patient was taken to the operating room (OR). After dissection of the fascia, it was found that the muscles of the mobile wad had a dark and dusky appearance along with an associated hematoma, consistent with the diagnosis of ACS. The hematoma was evacuated and vacuum assisted closure of the wound was performed (wound VAC). Four days later, the wound was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA male patient aged 65 years reported to the Department of Periodontics, K. V. G Dental college and Hospital, Sullia, on September 29, 2011 complaining of bleeding and swollen upper and lower gums with pain since six months. On clinical examination, the gingiva was red in color, soft, and edematous in consistency with spontaneous bleeding on probing. The size of the gingiva was enlarged with severe calculus deposit and probing pocket depth measuring 6 mm with exudation on digital pressure. Routine intraoral photographs were taken []. The patient's oral hygiene was poor with no significant history of medication. The case was diagnosed as Generalized Chronic Periodontitis. The patient was advised to rinse his mouth with chlorhexidine 0.12% mouth wash and was advised to carry out the following hematological investigation like fasting blood sugar, bleeding time, clotting time, differential count, and total count. The test was advised prior to the treatment so as to rule out any systemic condition and patient was advised to report to the department for the necessary periodontal treatment next day.\nOn September 30, 2011, the patient reported as per the scheduled appointment. The blood investigation results were normal. On extraoral examination, face was symmetrical with no palpable lymph nodes. On clinical examination, gingiva was covered with a loosely adherent yellowish white slough on the attached gingiva extending from lower canine to canine on the labial surface []. The lesion extended apically to the alveolar mucosa up to the vestibule with erythematous margins. The patient reported with severe pain. These findings were absent on the previous day. The affected area was gently cleansed and irrigated with betadine and saline. History about placement of any tablet or medicine or application of any medicament was elicited. On detailed questioning, the patient disclosed that he had visited a local physician for the routine general check up on the previous day. He also ca"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old boy, Greek, presented in the emergency department with abdominal pain, abdominal distension, diarrheas and fever. A physical examination revealed multiple palpable painless abdominal masses that were mainly confined to the lower abdomen and around the omphalic region. He had a history of acute abdominal pain and anaphylactic reaction with urticaria rash 2 months previously, but this had regressed without medical therapy.\nAn ultrasound and computed tomography examination revealed a cyst containing a “floating membrane” in the spleen and numerous unilocular cysts in the peritoneal cavity, measuring from a few millimeters to 3 cm ( and ) Floating membrane in the splenic cyst and multiple cysts in the peritoneal cavity). Laboratory data were within normal limits except for the eosinophil count (12%) and antibodies against Echinococcus granulosus (1/4096). The diagnosis of multiple hydatid disease was established based on imaging findings and positivity for anti-echinococcal antibodies.\nWe applied chemotherapy (albendazole, 10 mg/Kgr/day) for 6 months, since the spread of the disease into the peritoneal cavity and the multiplicity of lesions were strong contraindications for a radical surgical approach. At around 3 months the cysts in the peritoneal cavity had disappeared and the splenic cyst had reduced in size. However the echinococcal antibody titers, (which were measured monthly), did not fall noticeably throughout the 6-month chemotherapy period.\nOur fundamental concerns on exploration were to avoid spreading the disease and to preserve the spleen. A wide trocar was used to open the splenic cyst and suck the contents out. The result was negative since the contents appeared to be gelatinous rather than watery. The splenic cyst cleared and drained externally. The exploration of the abdominal cavity revealed a myriad of cysts, measuring from a few millimetres to 3 cm located only in the great omentum () numerous cysts in the great omentum). The surgical h"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old female patient presented to our clinic with complaints of a mass located medially on her left upper eyelid which had increased in size over the previous 4 years (). The mass was movable and painless on palpation. The patient had no diplopia, and there was no erythema or warmth in the skin overlying the mass. Visual acuity was 20/20 in both eyes on Snellen chart, and intraocular pressure as measured by noncontact tonometry was within normal limits. The patient’s eye movements were unrestricted. Direct and indirect light reflexes were normal. No pathology was detected on the skin over the mass on slit-lamp examination. Anterior segment structures and fundus examination were normal in both eyes.\nThe patient first noticed the mass 4 years earlier and since then its growth was documented by annual follow-up with orbital magnetic resonance imaging (MRI) with contrast ( shows orbital MRI of the cystic mass from January 2014). It was documented as a dense cystic mass lesion with smooth borders, approximately 12x8x7 mm in size, located anteromedially to the left eye. It appeared mildly hyperintense on T1-weighted images and markedly hyperintense on T2-weighted images, and showed no enhancement pattern.\nTo surgically excise the mass, a cutaneous incision was made medially in the fold of the left upper eyelid and the mass was exposed by blunt dissection through the orbicular muscle and septum. Excision was continued by careful blunt dissection in order to avoid capsule rupture and the cystic mass was removed from the surrounding tissues. Following the total excision of the mass (), it was sent for pathologic analysis. Macroscopically the mass was 15x15x6 mm in size and whitish-pink in color with translucent margins; microscopically the mass was determined to be a benign cystic formation lined with a single layer of columnar epithelium. Immunohistochemically, the mass did not exhibit ki-67 staining, while histochemical staining with Alc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 51 year-old white female with a 5-year history of ulcerative colitis. She has been taking mesalamine 1.2 gram (2 tablets two times a day) for 1 year with no complications that were reported. No history of allergies and no history of smoking or alcohol abuse were present. Past medical history was only remarkable for ulcerative colitis and there was no significant past surgical or family history. Around March 2018, she started having increased watery diarrhea with occasional blood (10-12 bowel movements per day from a baseline of 1-2 bowel movements per day) as well as cramping abdominal pain. She went to see her gastroenterologist in clinic. On physical examination, she had diffuse tenderness to palpation of her abdomen. Stool studies including stool cultures, stool ova, and parasites were sent which were negative. ESR and CRP levels were elevated. Therefore, she was thought to be in a moderate to severe ulcerative colitis flare based on the current criteria and was prescribed budesonide multimatrix (MMX) 9 mg once daily. Her abdominal pain improved but the diarrhea persisted. She then received a course of oral prednisone 40 mg daily for one month without any improvement of her symptoms and was subsequently started on infliximab therapy. Prior to initiating infliximab therapy, an interferon gamma release assay, hepatitis panel, varicella zoster antibody, and HIV tests were done which were negative. On 4/13/2018, she received her first dose of infliximab 500 mg based on her weight of 100 kg (5mg/kg). Her symptoms got better during the first week after the infusion; however during her second week, she complained of nonradiating chest pain located at the midsternal region, shortness of breath, and worsening fatigue. She went to a hospital where she was admitted. Her initial vitals were significant for low to normal blood pressure and a persistent tachycardia of up to 110. EKG was negative for any acute changes and a CT-PE"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old Caucasian woman consulted her doctor with symptoms of asthenia, anorexia and weight loss 15 days after they first appeared. In her physical examination, pallid skin and mucous membranes were observed. Her abdomen was soft and yielding and tender to deep palpation of the left hypochondrium, where a mass could be felt.\nIn the medical tests carried out, the only altered parameters were hematocrit 24%, hemoglobin 8 g/dL, red blood cell count 2,500,000/mm3 and blood glucose 152 mg/dL. An abdominal ultrasound revealed a mass with a diameter of approximately 10 cm at the area between the tail of the pancreas, the left adrenal gland and the upper pole of the left kidney. An abdominal CT scan confirmed the presence of a large retroperitoneal tumor measuring 10 cm × 15 cm that seemed to have its origin in the left adrenal gland, which was surrounded by the tumor, although the possibility of another type of primary retroperitoneal tumor could not be excluded (Figure ). On the basis of these findings, an intravenous pyelogram with contrast dye was obtained, which revealed only a slight displacement of the left kidney in relation to the described tumor. A chest X-ray did not reveal any significant alterations.\nWe decided to perform surgery with the patient under general anesthesia. We made a bilateral subcostal incision and found a large retroperitoneal tumor in the left hypochrondrium with a grooved surface and a diameter of approximately 15 cm. The tumor was removed, including the kidney and left adrenal gland, together with the spleen and greater omentum. The patient recovered without any post-operative complications.\nThe anatomopathological study corresponded to a tumor weighing 625 g and measuring 16 cm × 11 cm with a nodular, fleshy appearance and areas of hemorrhage and necrosis. The microscopic study showed a tumor with fusiform and ephithelioid cells, with frequent multi-nucleation, monstrous nuclei, intra-nuclear inclusions, prominent"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old immunocompetent male patient presented to the outpatient department with complaints of gradually increasing low back pain since one and a half years. The pain increased on changing position and relieved with rest. There was associated bilateral lower limb radiculopathy which was more on right side as compared to left. Manual muscle testing of upper and lower limbs did not show any reduction in the grade of power but right lower limb straight leg raising was restricted to 50 degrees. Radical involvement of L4, L5, and S1 nerve root was seen. However, there was no motor weakness present. The patient had radicular pain to right lower limb in posterior gluteal region, lateral and anterior shin. The sensations were intact in all four limbs and reflexes were of two plus grade with a flexor Babinski and negative Hoffman's test. He had associated fever and weight loss of seven kilograms in one year. There were associated voice changes and dry, scaly, erythematous skin, the biopsy of which was previously reported to be inconclusive of any infection. He had lumbar kyphosis and elevated ESR (Erythrocyte Sedimentation Rate) of 94 mm per hour. The patient had been taking anti-Koch's therapy since 1 year with little relief in pain.\nThe patient had a series of MRI (Magnetic Resonance Imaging) images starting with the first one taken 14 months ago (). It showed spondylodiscitis at lumbar 4 and lumbar 5 region and patient was started on anti-Koch's therapy. The second MRI taken after 4 months of anti-Koch's therapy did not show any improvement in the disc lesion or symptoms. The lesion rather progressed in the second MRI (). The third MRI taken 9 months after anti-Koch's therapy treatment did not even show any improvement (). The fourth MRI was taken after the patient completed 1 year of anti-Koch's therapy (). It showed further destruction of lumbar 4-lumbar 5 disc areas and bodies. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old African gentleman presented with left nasal obstruction and epistaxis for 2 years. Examination revealed a nasopharyngeal mass which upon biopsy revealed an undifferentiated nasopharyngeal carcinoma stage III. He had radiotherapy but in view of persistent symptoms and poor response to radiotherapy, endoscopic tumour excision was planned. Prior to that, he underwent embolotherapy of the maxillary branch of the left ECA under sedation and local anaesthesia. The indication for embolization was intractable epistaxis and to reduce intraoperative bleeding during tumour excision. Intermittent Embozene® Microspheres 250 μm injection under fluoroscopy guidance was done before deployment of a 2 mm × 5 mm coil. He was not given heparin or anticoagulant during or after the procedure.\nApproximately 2 h after the procedure, the patient complained of sudden painless profound visual loss in the left eye (LE). Visual acuity in the LE was no light perception with a dense afferent pupillary defect. Funduscopy examination showed a pale retina without cherry red spot; and generalized arterial attenuation (Fig. ). The other eye was completely normal. He did not have neurological deficit.\nA diagnosis of left central retinal artery occlusion was made but the absence of a cherry red spot further suggests the absence of choroidal circulation indicating a possible occlusion of the ophthalmic artery as well. Ocular massage and immediate lowering of intraocular pressure with intravenous acetazolamide 500 mg stat and topical antiglaucomas failed to restore the retinal circulation, with visual acuity remaining no light perception after 24 h. We did not do AC paracentesis as the patient was drowsy from the sedation. MRI of the brain and orbit showed high signal intensity foci on diffusion weighted image (DWI) involving the left caudate nucleus and basal ganglia (Fig. ), suggestive of small infarctions. The patent however did not show any clinically apparent neuro-deficits from these i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum (). In addition, two transition points were identified in the right lower quadrant, with one transition point at the distal ileum just proximal to the cecum and a second transition point in the proximal ileum. The two transition points were in close proximity to each other, indicative of closed loop obstruction. Decreased wall enhancement of the dilated small bowel loops was concerning for ischemia. Mucosal hyperenhancement of the ileum at the proximal transition point was felt to relate to ischemia or decompressed state (). Given the patient's symptoms and findings of closed loop obstruction on CT, the patient was taken to operating room. In the operating room, an internal hernia with closed loop obstruction was confirmed and resulted from herniation of small bowel through an adhesion of a transverse colon epiploic appendage to the ascending colon mesentery. The herniated small bowel was nonviable and a total of 60 cm of small bowel was resected (). Retrospectively, kinking of the ascending and transverse colon could be seen on the initial abdominal CT and was felt to correspond with the site of adhesion ().\nAfter resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.\nThe patient ha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n22 years old male presented with acute pain and tenderness with deformity of right elbow joint with inability to move the elbow joint after he fell down due to episode of seizure, there was no neurovascular deficit. He was a known case of epilepsy on medical management. He had an history of injury to same elbow five years back following which immobilisation in a plaster cast was done for four weeks but any documentation regarding the injury was not available with the patient. Radiological examination (Fig.) confirmed anterior dislocation of elbow joint with a ununited medial epicondyle fracture.\nManagement One attempt of closed reduction was done in emergency but reduction could not be achieved. Another attempt of closed reduction was done in operating room under general anaesthesia and muscle relaxants was successful and elbow was stable during complete range of motion and no restrictions of motion was present. Reduction technique included distal traction on the wrist and backward pressure on the proximal forearm, a coupling was felt as the joint was reduced. care was taken not to hyperextend the elbow as it may lead to traction and potential injury to anterior neurovascular structures. A smooth K wire was used to transfix the ulno humeral joint (Fig.) along with application of long forearm slab as the patient was having epilepsy and another similar episode may happen. No attempt to fix the medial epicondyle was done in view of soft tissue stripping may compromise joint stability, also under fluoroscopic examination medial epicondyle appeared to be stable suggestive of fibrous union. K wire was removed after 2 week time and active and active assisted elbow mobilisation exercises were started. Patient regained complete range of elbow motion after 15 days of physiotherapy and was pain free. He again had episode of seizure after 2 months of injury but his elbow was not affected this time."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nHerein, we report a case of a 71-year-old female patient hospitalized for anemia, motor incoordination, gait disturbance, weakness, and decline of her functional state. She was asymptomatic eight months prior to the day she was hospitalized, when she had asthenia, adynamia, hyporexia, symptoms of dizziness, and vertigo. Six months prior to admission, the symptoms increased, with onset of loss of balance, and postural instability. The patient also developed deterioration for walking, with repeated falls, which led her to stop walking for fear of falling, and limited her physical daily living activities to simply transferring from the chair to the bed. Likewise, it was noted that upon flexing her neck, she reported feeling an electrical discharge irradiating from her back to her legs. Two months before hospital admission, she noted lesions on the tongue, which produced a burning sensation and pain when swallowing foods - leading her to decreased intake of food and a loss of 5 kg coupled with increased feeling of weakness in her general state. She consulted with her local hospital, where she was diagnosed with paraparesis and anemia to continue studies.\nAs personal antecedents, she revealed hypertension managed with captopril 50 mg every 12 h. She did not report alcohol consumption, vegetarian nutritional habits, or other personal or family antecedents of importance.\nUpon physical exam for admission, she was in poor general state, pale, and marked loss of muscle mass. Blood pressure was 130/80 mm/Hg, without orthostasis, respiratory rate 17 per min and heart rate 85 per min. Her weight before developing the diseasewas 70 kg; her current weight is 60 kg, height 1.65 m. The oral cavity showed smooth, shiny, reddish depapillated tongue with ulceration at lateral level ).\nNeurological exam revealed that she was alert and oriented in all three spheres, no cranial nerve involvement, or abnormal movements. She had muscle weakness grade 3/5"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old female patient presented with progressive dysarthria, dysphagia, nasal regurgitation and hyper nasal speech for 5 months duration. She had 4 episodes of partial seizures involving the right upper and the lower limb for the past 5 months and was not on any medications. There was weakness of the left upper limb for the past 15 days duration but there was no headache, vomiting or blurring of vision. She had emotional instability in the form of inappropriate crying. Neurological examination showed exaggerated jaw jerks and gag reflex with spastic dysarthria. She had both proximal and distal weakness in the left upper limb with power of 3/5. All the deep tendon reflexes were brisk with plantar response mute bilaterally and cortical sensory loss in the left upper limb. There was no atrophy or fasciculation of the affected muscles. The fundus and other system examination were normal.\nLaboratory examination revealed positive neurocysticercosis serology. The peripheral smear was normal. The renal and liver function tests were normal. The MRI brain showed multiple small cysts with scolex in both the cerebral hemispheres and a giant intraparenchymal cyst measuring 5 × 4.3 cms in the right cerebral hemisphere [Figure and ].\nOur patient presented with pseudobulbar palsy, partial seizures and weakness of the left upper limb. Her NCC serology was positive and diagnosis confirmed by MRI, which showed multiple cysts with scolex (in vesicular stage). She received the treatment with albendazole at 15 mg/kg/day along with steroids (for two weeks). She also received phenytoin for seizures. The patient remained seizure free and there were no significant events during her hospital stay. On follow-up six weeks after the completion of albendazole therapy she reported no recurrence of seizures and her right upper limb weakness recovered partially with power of 4/5. There was also improvement in her speech, emotional instability and was able to take food without nasal regurgitat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old G4P3 Caucasian woman was followed up antenatally because of a stillbirth in her previous pregnancy. She had had mild pre-eclampsia in her first pregnancy and a Caesarean section was carried out after unsuccessful induction of labor. Her second pregnancy and delivery were uneventful. The reason for the stillbirth in her third pregnancy was found to be an umbilical cord knot.\nIn the pregnancy reported here, our patient had polymorphic eruption of pregnancy (PEP) from 26 weeks' gestation and had three separate courses of oral steroids. Anti-D-antibodies were also found to be increased but in quantitative analyses their concentration, however, remained low. She was hospitalized once for a short period in late pregnancy because of an abnormal fetal heart rate recording.\nAt 36 weeks' gestation, a hypoechoic, 3.6 × 4.2 cm rounded mass was noted within the placenta on ultrasound examination (Figure ). An ultrasound scan with umbilical artery Doppler measurement after 28 weeks' gestation was normal and it is likely that the leiomyoma had gone unnoticed probably because no special attention had been paid to the placenta on that occasion. Another explanation could be that the leiomyoma grew very rapidly in the third trimester of pregnancy and it was too small to draw appropriate attention in earlier scans.\nShe had induction of labor due to worsening of PEP at 38 weeks' gestation. A viable male infant weighing 3330 g was delivered with Apgar scores of 9 at one minute and 9 at five minutes. The placenta was removed without difficulty.\nA round-shaped nodule was noted on the maternal surface of the otherwise normal placenta. The size of the nodule was 4 × 4 × 3 cm. It had a pale cut surface without hemorrhage, necrosis or calcification (Figure ).\nHistologically, the nodule was composed of bundles of smooth muscle cells. Nuclei were round or oval shaped and there were no atypical features or mitotic activity (Figure ). No attached myometrium"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a premature Bahraini girl born at 29 weeks of gestation by spontaneous vaginal delivery, to a 39-year-old gravida 6 para 5 mother. She was born “flat” with an APGAR score of 4 and 9 at 1 and 5 minutes respectively and a birth weight of 910 g. Ventilatory support was required during her first 6 days of life, with a dose of surfactant. She had an uneventful Neonatal Intensive care stay, tolerating breast milk and was gaining weight at a steady pace. On her 47th day of life she developed sepsis and required repeated ventilator support for 3 days. At day 51 she weighed 1400 g, but developed abdominal distension and feed intolerance. She was referred to the pediatric surgeon on day 54 when pneumoperitoneum was detected by a shoot-through lateral plain abdominal film (Fig. ). Our examination showed her abdomen to be distended but soft with mild diffuse tenderness and no signs of peritonitis. There was no abdominal wall erythema or visible bowel loops. We did not find any hernias or abdominal masses. Her C-reactive protein (CRP) was 37 mg/L which is 12 times higher than the normal range. In view of pneumoperitoneum, she was taken for exploratory laparotomy. A classic right transverse upper abdominal incision was used to open her abdomen as the diagnosis was NEC. Her entire small and large bowel was healthy and normal in appearance (Fig. ). Her appendix measured approximately 2 cm in length and was acutely inflamed with a perforation at the tip. Except for the site of perforation, there was no other evidence of gangrene (Fig. ). The findings were consistent with a perforated appendix with no evidence of peritonitis or NEC. An appendectomy was performed. She had a smooth postoperative recovery where she was started on breast milk on the second postoperative day and her CRP was normal on the eighth postoperative day. Histology demonstrated mucosal ulceration of her appendiceal wall, marked acute transmural inflammation, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man, with a history of type 2 diabetes mellitus, underwent a colonoscopy with standard bowel preparation following a positive faecal occult blood test. He presented to the emergency department 2 days later with increasingly severe right upper quadrant abdominal pain. On questioning, he stated that the abdominal pain had started 3 h following his colonoscopy but he failed to present to hospital earlier as he lived on a rural property more than 2 h away from the nearest medical assistance.\nOn presentation to the emergency department, the patient was tachycardic and febrile and his serology showed a neutrophilia, elevated CRP and bilirubin with normal hepatic transaminases. On examination, he was focally tender with voluntary guarding in the right upper quadrant. A CT abdomen was performed which identified a distended gallbladder, with adjacent gas locules and fat stranding around the hepatic flexure. The differentials included a contained microperforation at the hepatic flexure or emphysematous cholecystitis. The patient was haemodynamically stable and therefore a period of non-operative treatment was pursued. The patient was commenced on IV ampicillin, metronidazole and gentamicin, strict fluid balance, nil by mouth with regular clinical reviews. On Day 3, the patient had shown minimal clinical improvement and a progress CT was obtained which revealed extensive gas within the gallbladder wall and adjacent-free fluid consistent with emphysematous cholecystitis ( and ).\nThe patient proceeded to theatre—at laparoscopy, the omentum was wrapped and densely adherent over a firm, thickened and palpable gallbladder. It was unsafe to proceed laparoscopically and the decision was made to convert to a laparotomy. A Kocher’s incision was performed, which revealed a necrotic, gangrenous gallbladder with surrounding seropurulent fluid in the right upper quadrant (). Due to necrosis and oedema of the surrounding anatomy, the cystic duct could not be confidently identi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51 year old female was admitted to our hospital with complaints of dyspnea on exertion and chest pain radiating towards the back and right arm for 3 months. She was a known case of hypertension and osteoarthritis of both knees, and had a positive family history for ischemic heart disease. On examination, the first and second heart sounds were normal and a III/VI systolic murmur was heard at the apex with radiation to the left axilla.\nUpon investigating, a transthoracic echocardiogram (TTE) showed thickened rolled up and prolapsed anterior mitral leaflet with severe mitral regurgitation (MR). A Trans-Esophageal Echocardiography (TEE) revealed thickened anterior mitral valve leaflet with rolled up margins, forming an aneurysm, with severe mitral regurgitation but no rupture of sub-valvular apparatus (Figs. and ). The posterior leaflet was also thickened with rolled up tips with mild prolapse of P1/P3. Mitral valve annulus measured about 42 mm. A diagnosis of mitral valve aneurysm along with severe MR was made, with prolapse of both leaflets and a grade II left ventricular diastolic dysfunction.\nSubsequently, an elective surgery was scheduled for mitral valve repair +/− replacement. Median sternotomy approach was taken. Cardiac arrest was achieved with antegrade cardioplegia, under cardiopulmonary bypass and the usual state of moderate hypothermia was maintained. Mitral valve was approached through the left atrium and the findings of anterior mitral leaflet aneurysm were confirmed. The severely thickened valve was grossly evaluated again and assessed for repair but it was not possible due to severely distorted leaflets, hence most of the anterior leaflet and part of the posterior leaflet had to be excised (Fig. ), and replaced with a Hancock II 29 mm valve. On histopathological examination, the valve tissue revealed nonspecific degenerative changes microscopically, with no significant inflammation, atypia or malignancy. Post-operative course of the patient was uneven"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 88-year-old Causasian woman presented with a large mass at the left prescapular region that had progressed in size over several months. Two years prior, she had undergone surgical excision of a SCC at the same site but resection margins were inadequate. She refused further treatment, was lost to follow-up and has been on homeopathy since. She is otherwise healthy with no significant comorbidities and does not smoke tobacco or drink. In fact, she had no attending physician and suffered from no pathology. She was rather resistant to medical treatment and had consulted very few doctors during her lifetime. Thus, she did not take any treatment except homeopathy to keep her in good general shape. She had no other medical history other than the surgical cure of a bladder prolapse and a right native hip luxation which was reduced in an operating room a few months before our first consultation. Socially, she is a retiree from laboratory work, who has been widowed for 5 years, and lives alone with three adult children nearby. She had a normal neurological examination at the consultation. On physical examination, she appeared cachectic and had received food supplements during hospitalization and there were numerous dermatological lesions suspected of being skin tumors. She had a heart rate of 78 beats per minute; her blood pressure was 125 mmHg (systolic) and 75 mmHg (diastolic). Her temperature was normal (37.6 °C). No medication was prescribed prior to surgery. However, on this physical examination, there was a notable fungating mass (measuring 10 cm in its major axis) involving the deeper tissues with contact bleeding (Fig. ). SCC was confirmed on biopsy. Oncological work-up included ultrasonographic evaluation of draining lymph nodes in the axillae and groin bilaterally, and a staging thoracoabdominal computed tomography (CT) scan (Fig. ); these were negative. Final staging of the SCC was T3N0M0 according to the 8th edition of the American Joint Committee on Cancer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA male patient aged 42 years reported to the department of maxillofacial surgery with the chief complaint of painless huge growth over left eye and loss of vision. History revealed that the patient was apparently alright 2 years back, when he first noticed a small pea nut size ulcerative growth over left lower eyelid near medial canthus. The growth was painless and persistent in growth. It was not associated with any kind of pain or fever. Initially eye site was normal but as the growth increased his vision started to diminish from left eye due to the increase in the size of growth, approximately 1 year before patient completely loses his vision from left eye. Only due to his extremely poor economic conditions he could not seek any sort of medical treatment.\nOn clinical examination the growth extended superoinferiorly from supraorbital ridge to ipsilateral alae of nose and mesiodistally from right inner canthus of eye to left side of maxillary buttress crossing midline (). Personal history was negative for any detrimental habits. On palpation superficial cervical nodes were not palpable. The growth was ulcerative, exophytic, and fungating and exudates were present. It was approximately 6 × 5 cms in size. The vision from right eye was normal and ocular movements in all directions were intact. All other parameters were within normal range. HR-CT scan was advised. The axial and coronal sections showed large homogenous mass covering the whole left orbit involving the globe but no erosive damage was seen in any of the bony structures (). Correlating the clinical history, examination, and radiological findings a provisional diagnosis of carcinoma of left lower eyelid was suggested. Incisional biopsy was performed and histopathological report revealed dermal invasion by abnormal cells from the epidermis, pleomorphism of the tumour cells with presence of keratinization within the cells which give the cells abundant pink cytoplasm, and intraepithelial keratin in the shape of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20 year-old Caucasian male presented to our department with incomplete left abducens nerve palsy; neuroradiological examination documented three intracranial space occupying lesions, respectively in the left cavernous sinus, on the right frontal convexity and on the superior aspect of the right petrous pyramid (Figure ).\nHe presented with a two year history of diplopia, of subacute onset, due to a left sixth cranial nerve palsy. Neurological examination was otherwise normal at the time; he denied any pain and had no fever. Head CT scan documented a small space-occupying lesion in the left cavernous sinus, with well-defined margins and minimal contrast enhancement (Figure A). Brain MRI confirmed the lesion in the posterior compartment of the left cavernous sinus: its signal behaviour excluded both fatty and hemorrhagic content of the tumour, excluding the hypothesis of paramagnetic effect related to hemosiderin and blood degradation products (Figure ). Due to the high complication rate associate with surgery inside the cavernous sinus, specifically with respect to a very high risk of permanent diplopia, his treating doctors chose to manage him conservatively with low dose corticosteroids and surveillance imaging. His diplopia resolved and a new MRI, three months after the previous, documented a minimal volume reduction of the left cavernous sinus mass lesion. Unfortunately the patient experienced bilateral femoral head necrosis secondary to corticosteroid use that resulted in discontinuation of dexamethasone. Three months later a new brain MRI documented minimal growth of the lesion, which was confirmed in subsequent examinations and the patient remained asymptomatic. One year and a half after the first neuroradiological examination, a repeat brain MRI documented a contralateral extraaxial lesion, at the level of the right frontal convexity, with the same radiological features, characterized by hyper-intensity on un-enhanced T1-weighted images (Figure A); a smaller"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase: a 63-year-old male was presented with pain in the left proximal thigh. A tumor was suspected by X-ray and magnetic resonance imaging (MRI).\nImaging findings: X-ray showed slight uptake in the left acetabulum ().\nComputed tomography showed bone destruction images mainly in the left acetabulum extending to femoral head ().\nMRI revealed a multilocular lesion from left acetabulum to pubis (). There was a slight accumulation of joint fluid. A lesion having similar abnormal signal was detected in the femoral head. The tumorous cords were well circumscribed from the surroundings, and there were findings suggestive of the existence of ligament component in the center.\nClinical course: an incision biopsy was performed and a diagnosis of chondrogenic sarcoma, suspect of chondrogenic osteosarcoma, was established. Tumor cells were fusiform or round shaped with atypical nuclei, often binucleated and scattered mitotic figures, suggesting high-grade sarcoma (). After preoperative chemotherapy was started, a deterioration of renal function was observed, and therefore, the chemotherapy (cisplatin + doxorubicin) was stopped after one course. The surgery consisted of wide excision and femoral head replacement for tumor ().\nPathology: gross cut surface of the resected specimen revealed that the tumor in the acetabulum progressed through the round ligament to the femoral head side. The articular cartilage was not destructed by the tumor, neither on the acetabular side nor on the femoral head side. There was no tumor extending into the joint cavity (). Final diagnosis was chondroblastic osteosarcoma with slight osteoid formation and little therapeutic effect (). Histological findings were similar to the preoperative biopsied specimen. Microscopic examination confirmed the unique extension of tumor cells on the gross findings. The tumor invaded along to the ligament from the acetabular site to the femoral head (). The pathological assessment of preoperative chemotherapy was grade 1"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old Caucasian man with stage IV squamous cell carcinoma of the tonsil presented for evaluation ulcerated nodules on his neck and multiple erythematous papules and plaques on his proximal chest. The patient had no history of alcohol or tobacco use and was diagnosed with invasive squamous cell carcinoma of the right tonsil in September 2012. He was treated with three cycles of cisplatin along with radiation therapy to his neck and upper chest over two months with good response.\nIn 2014, recurrence of squamous cell carcinoma was discovered in his cervical lymph nodes. He was treated with bilateral selective neck dissection. In 2015, he developed severe dysphagia, and esophagogastroduodenoscopy with dilation was performed. Tracheostomy tube was placed due to airway compromise.\nHe underwent a second esophagogastroduodenoscopy with dilation three months later in July 2015 for continued dysphagia; during the procedure, an abnormal area on the posterior pharyngeal wall was noted. Subsequent direct laryngoscopy with biopsy revealed squamous cell carcinoma in-situ. However, the gross appearance of the lesion was suspicious for invasive disease; positron emission tomography–computed tomography (PET-CT) was consistent with local progression of his carcinoma.\nIn November 2015, he was treated with two cycles of carboplatin and paclitaxel chemotherapy. He was then transitioned to nivolumab; he received 16 cycles from December 2015 to July 2016. In August 2016, he was restarted on carboplatin and paclitaxel. After three cycles, the patient decided to discontinue chemotherapy in November 2016.\nIn January 2017, the patient presented to his otolaryngologist for routine tracheostomy tube change. He described a two-month history of a neck rash that was initially painful, had spread to his chest, and was vesicular in appearance. The otolaryngologist noted not only a malodorous discharge near the tracheostomy site, but also skin lesions that were suspicious for varicella zoster"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old man presented to the Department of Orthopedic Oncology of the First Affiliated Hospital of Nanchang University (Nanchang, China) with the chief complaint of a painless mass in the right lower limb that developed over a period of 16 years. The patient appeared projections without apparent inducement at the medial cutaneous right leg which was about 2 × 2 cm in size, fixed block, soft, clear boundary, all directions and passive activities were unlimited at the beginning. Physical examination did not reveal any abnormalities, and the results of routine laboratory tests, such as erythrocyte sedimentation rate, were within the normal range. Three years after the mass was first recognized, a biopsy conducted at the Jian City People’s Hospital, Jiangxi, China showed signs of NF. However, the patient did not report any obvious discomfort, and therefore, the physicians did not recommend further examination but only regular follow-up instead. By early 2012, the patient started to limp. The symptom relieved after walking for a long period; however, the patient subsequently experienced numbness over the skin of the right lower extremity. On July 9, 2013, the patient underwent debridement at a local hospital, wherein the pathology results showed inflammatory cell infiltrations along with ulcers. The treatment did not illicit a favorable response and the tumors were not completely removed. Multiple tumors extending from the right leg to the popliteal fossa, buttocks, and groin were observed, with the largest tumor measuring approximately 10 × 12 cm; knee function was acceptable and no localized tenderness was detected. On April 30, 2014, the patient underwent multiple suction lumpectomies. Postoperative pathological findings indicated multiple schwannomas. However, the patient was hospitalized again owing to a right thigh and groin mass that enlarged; the patient also reported discomfort and weakness in the right calf, and underwent multisite lumpectomy for the righ"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old woman reported to the outpatient department of our tertiary care hospital with lower abdominal pain, vaginal spotting, and severe nausea lasting 10 days. At the time of presentation, she was primigravid at 18 weeks and six days of gestation according to her last menstrual period. The pregnancy was a planned conception occurring within three months of marriage. The pregnancy was confirmed with a positive urine pregnancy test. Further questioning about menstrual history revealed cycles of four to five days every 28 to 30 days. Past medical, surgical or family history was unremarkable. On physical examination, she was alert and pale with a blood pressure of 150/90 mmHg and a pulse of 80 beats/minute. Her abdomen was soft, non-tender with a 32-week fundal height. A speculum examination revealed no active bleeding or discharge; the os was closed. Apart from the elicited anemic signs, the remainder of the physical examination findings were within normal limits. An ultrasound examination revealed a single live fetus of 18 weeks and two days in duration (Figures -). We also noted a partial mole indicated by mass resembling a bunch of grapes and measuring 19 cm by 8 cm. The molar vascularity was insignificant on the Doppler evaluation. We ordered additional investigations through our hospital’s designated laboratory.\nAt 20 weeks of gestation, a repeat ultrasound revealed a single live fetus of 20 weeks duration with no gross fetal anomaly. A large mass with multiple short cysts was noted in the fundal region at the site of the placenta. We also noted evidence of a partial mole in the anterior fundal region of the uterus measuring 19.7 cm by 10.9 cm, bulging into the amniotic cavity and compressing the fetus. Repeat serial measurement of β-hCG at this point of pregnancy was 561,771 mIU/mL. At 20 weeks and two days, she reported concerns of a passage of grape-like vesicles, and spontaneous abortion followed."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 12-year-old boy was hospitalized with complaints of a headache and high fever accompanied by psychosis, delirium, and indistinct consciousness. He was diagnosed with limbic encephalitis, which is an autoimmune disorder characterized by inflammation of the limbic area in the brain. His symptoms became exacerbated, and he required intensive therapies including high-dose steroid and catecholamine administration.\nDespite the continuous therapeutic support mentioned above, he abruptly developed hypotension following diarrhea, fever, and abdominal distension on day 41 after admission. Metabolic acidosis (pH 7.34, base excess − 7.0 mmol/L) was confirmed by blood gas analysis, and highly elevated CPK 11800 U/L, AST 461 U/L, ALT 201 U/L, and LDH 1034 U/L values were revealed by a blood chemistry profile. An emergency CT scan revealed pneumatosis intestinalis localized in the ascending colon and rectum coexisting with portal venous gas (Fig. ). While the root of the SMA and the inferior mesenteric arterial (IMA) flow was maintained, the peripheral blood flow was attenuated adjacent to the non-contrast-enhanced ascending colon and rectum.\nAlthough intraabdominal free air was not detected in the CT scan, the massive ascites and progressing peritoneal signs with muscular guarding required an emergency laparotomy for suspected mesenteric ischemia and bowel perforation. Intraoperatively, skip ischemic lesions were observed in the ascending colon close to the hepatic flexure and the rectum without bowel perforation. Although SMA and superior rectal arterial pulsations were present, the marginal perfusion near the two lesions could not be confirmed. The patient was diagnosed with NOMI based on these operative findings and the rapid progression of the symptoms, which are unlike other vascular disorders or necrotizing enterocolitis. The remaining colon, from the transverse to the sigmoid colon, appeared intact. The color of the unaffected intestinal wall was restored, which suggeste"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old female was admitted to the emergency unit of our hospital suffering from acute dyspnoea, multiple episodes of vomiting, productive cough, and fever since 3 days. The patient reported a previous medical history of right mastectomy due to breast cancer followed by chemoradiotherapy and laparoscopic cholecystectomy for cholelithiasis ten months earlier. In the beginning of the operation after injection of anesthesia and endotracheal intubation, the patient developed pneumothorax which led to postponing the cholecystectomy. The pneumothorax was treated by inserting a thoracic drainage tube. After removing the thoracic drainage tube, chest X-ray and CT scan of the thorax were performed, but there was no evidence of diaphragm defect or herniation. Α laparoscopic cholecystectomy was performed four months later under general anesthesia with no complications. On admission to our department, the patient was febrile, pale, had considerable usage of accessory respiratory muscles, and had abdominal distention. On physical examination, the right lung presented decreased sounds during inspiration, while the abdomen was distended with diminished bowel sounds and peritonism. The blood exams were within normal values, while the arterial blood analysis demonstrated increased lactic acid levels and compromised pO2 values. Chest X-ray revealed that the right lung was totally suppressed by the intestine and suggested that due to intestinal transposition to the thoracic cavity, a functional right pneumonectomy had occurred (). CT scan of the thorax and abdomen detected a right diaphragm defect and herniation of the small intestine, which was also ischaemic due to venous circulation occlusion (). Urgent exploratory laparotomy was performed, and it revealed a diaphragm defect of 10 × 2 cm extending from the anterior side of the right diaphragm to the posterolateral side. Almost all the small intestine and part of the transverse colon were extending to the right thoracic cavity"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old Caucasian female, who had originally undergone an uneventful laparoscopic adjustable gastric band 4 years ago, presented to the bariatric surgery clinic with inability to tolerate solids. A work-up revealed that the laparoscopic band remained in good position but the patient had oesophagitis and gastritis, causing swelling of the mucosa at the band site. The fluid was removed from the reservoir, and the patient was treated conservatively with anti-reflux medication and a full liquid diet. After 2 weeks of treatment the patient’s symptoms improved. After careful consideration, she wished to undergo revisional surgery converting the laparoscopic adjustable gastric band to a laparoscopic vertical sleeve gastrectomy. The patient moved through the appropriate multidisciplinary team approach and was found to be an appropriate candidate for surgery. She underwent laparoscopic removal of the adjustable gastric band and conversion to a laparoscopic vertical sleeve gastrectomy without complications. Her post-operative course was uncomplicated and she was discharged on post-operative day 3.\nOn post-operative day 12, the patient was readmitted to an outside tertiary care hospital for lightheadedness and shortness of breath and was found to have leukocytosis, with white blood cell count of 18,000 cells μl–1. The work-up included a CT scan with intravenous contrast of the chest, abdomen and pelvis, and the patient was diagnosed with a pulmonary embolism. The patient was immediately transferred to our centre for definitive care. When the patient arrived at our centre, the CT films from the outside hospital were reviewed by our radiologists and there was concern that there was air and a faint suggestion of oral contrast outside of the suture line (). Given this finding, an UGI evaluation was ordered. During the early phase, no leak was observed, owing, in part, to the slow passage of 30 ml oral non-ionic contrast (). Some residual contrast from the outside hospital CT"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 54-year-old female with a past medical history of hypothyroidism and very severe obesity (BMI 48 kg/m2). She underwent laparoscopic gastric sleeve surgery in the year 2012. Results were non-satisfactory in terms of weight loss with a difference of 6 kg/m2 in BMI post-procedure. So after six years, she underwent a laparoscopic biliopancreatic diversion with a duodenal switch. She had an uneventful postoperative recovery period. An upper gastrointestinal (GI) study contrast post-procedure did not reveal any evidence of obstruction or leak. The patient was discharged home two days after the procedure. A few days later, she started experiencing three episodes of nausea with brown-colored vomitus. She was found to be septic, with a heart rate of 110 beats per minute and temperature of 100.2oF. Her white blood cells count was 12/mm3.The source of infection was presumed to be intraabdominal considering her symptoms. Computed tomography (CT) of the abdomen and pelvis showed mildly dilated proximal small bowel loops. The patient was started on empiric antibiotic therapy with ceftriaxone 1 gm intravenous (IV) daily and metronidazole 500 mg IV every eight hours. Symptoms did not improve, so she was taken back to the operating room for diagnostic laparoscopy. Partial small bowel obstruction was noted along with ischemia of a segment of the ileum that was part of the duodenoileostomy due to mesenteric dissection. She underwent an open revision of the small bowel anastomosis with resection and anastomosis for the obstruction revision of the duodenoileostomy. Her hospital stay post-surgery remained uneventful. Diet was advanced gradually throughout the hospital course and a week later, the patient was discharged home with outpatient follow-up. Three weeks after that procedure, she noticed a productive cough with thick, yellow, foul-smelling phlegm and shortness of breath. She saw her primary care physician. A chest X-ray performed showed a right lung infiltrate wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male patient presented with symptoms of pain and swelling localized on the medial aspect of his right ankle joint, specifically at the medial malleolus. The patient noted a recent history of a twisting injury of his right ankle 6-months before presentation at our specialty orthopedic clinic. The injury occurred while playing football. Initially, he was treated by his general practitioner, who assumed it to be a severe sprain injury and had placed him on a course of ice compress and anti-inflammatory medication followed by a below knee plaster cast for a period of 3 weeks. Following this treatment protocol, the patient was able to walk but reported on-going pain while walking once the plaster cast was removed. No radiographic imaging was done at the time and was therefore not available for review and comparison.\nOn further examination, swelling was observed over the distal aspect of the medial malleolus, along with tenderness over deltoid ligament of the right ankle. There was no bone related tenderness at the distal tibia. Ankle joint movement was also observed to be normal. We proceeded with a thorough radiograph examination including standard X-rays and 3-dimensional computed tomography (CT) scanning of the right ankle, which revealed the presence of a small bone fragment located anterior and distal to the medial malleolus (, ). This fragment was not free floating and rather appeared to be attached to the distal tibia. Furthermore, it was a uni-lateral presentation as the patient’s left ankle anatomy did not reveal the presence of a similar bone fragment and was rather normal in appearance (). Based on our findings as well as the findings of previously published reports on this topic, a benefit of doubt was provided, and it was assumed to be a case of acute trauma, leading to a small fracture of the anterior aspect of the distal tibia.\nAt first consultation, the patient was explained of his diagnosis and offered a conservative treatment protocol tha"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was an 11-year-old Japanese boy (height 141 cm, weight 36.5 kg) with acute lymphocytic leukemia. Since the onset of acute lymphocytic leukemia, he had received early-stage intensive chemotherapy, remission therapy, and maintenance therapy; however, because he had a positive test result for minor breakpoint cluster region, umbilical cord blood transplantation was performed. After transplantation, he complained of abdominal and articular pain; his abdominal pain was accompanied by frequent diarrhea. These were considered to represent gastrointestinal symptoms of graft-versus-host disease (GVHD); thus, opioid therapy was initiated. For long-term opioid therapy, few opioid medications provide information on the label regarding the safety and effectiveness of the drug in pediatric patients []. We selected fentanyl because chemotherapy for leukemia predisposes the patient to renal dysfunction, and it is considered effective because it has high selectivity for mu 1 receptors in the treatment of mucosal pain [, ]. However, the dose of fentanyl was gradually increased for pain management, resulting in dose as high as 2300 μg/day, which required intervention from the palliative care team.\nAt the time of intervention, the patient was isolated in a sterilized room after transplantation. In addition to the major complaint of pain in the lower left abdomen, upon palpation, the patient complained of pressure pain throughout the abdomen; he also complained of joint pain in the legs when the abdominal pain intensified. Computed tomography revealed changes showing pancreatitis and mild intestinal edema, which was considered to be a sign of GVHD (Fig. ).\nGiven the intense acute pain caused by GVHD, the fentanyl dose was increased again to 2700 μg/day; however, the frequency of the rescue dose for pain (equivalent to 1-h dose of continuous infusion) did not decrease below 15 times per day, and continuously increasing the dose did not reduce the frequency of the rescue dose."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male with a known VSD, who had not experienced any previous VSD-related complications, underwent a dental crown implantation without antibiotic prophylaxis in September 2016. Three months later he experienced fevers, sweats, and a dry cough, which spontaneously resolved after several weeks without antibiotic treatment. His symptoms recurred in June 2017 and at this time were associated with raised inflammatory markers. Further investigation, including a computed tomography (CT) chest, identified multiple peripheral lung lesions that were initially presumed to be malignant. Once again, his symptoms spontaneously resolved without any antibiotics. A follow-up CT chest in August 2017 identified resolution of the peripheral lung lesions, challenging the initial presumed diagnosis of malignancy.\nA further CT chest was organized in November 2017, and on this occasion there was recurrence of lung lesions in new areas, suggestive of septic emboli with internal cavitation (Fig. A, B). At this time that patient complained of sweats and lethargy, and was consequentially hospitalized for further investigation of his relapsing remitting lung lesions.\nOn admission, four blood cultures all identified Streptococcus mutans. A transthoracic and transoesophageal echocardiogram was completed, which identified a perimembranous VSD but no endocardial vegetation (Fig. C). A CT pulmonary angiogram was performed to exclude a pulmonary embolus and to identify an appropriate lung lesion to biopsy.\nA thoracoscopic lung biopsy was completed, which isolated S. mutans from the necrotizing lung abscesses. Furthermore, the patient complained of lower back pain, which was investigated with spinal magnetic resonance imaging and identified early L3-4 osteomyelitis without a complicating epidural abscess. As the patient was not haemodynamically compromised during admission, there was no need for urgent surgical repair of the VSD. The decision was made to treat the VSD-related IE medically,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is the case of a 48-year-old G2P2002 who originally presented to our office in March 2016 with vaginal discharge, dysuria, and dyspareunia. She had previously been evaluated by her primary care physician (PCP) where a small cyst on the anterior vaginal wall was drained. She had received antibiotic treatment without relief of her symptoms. Her past medical history was significant for multiple sclerosis, Crohn's disease, and anxiety/depression. Her surgical history was significant for cesarean section × 2, bilateral tubal ligation, polypropylene midurethral sling procedure, and cholecystectomy. On physical examination, she was noted to have a small anterior vaginal wall fold near the urethra. MRI showed a cystic mass posterolateral to the urethra measuring 2.1 × 1.7 × 2.3 cm likely representing a urethral diverticulum. The mass had signs of infection/inflammation (Figures and ). Of note, the patient also had a long history of abnormal uterine bleeding and was found to have fibroids on MRI. She underwent hysterectomy with concurrent repair of the urethral diverticulum.\nIn June 2016, she underwent total abdominal hysterectomy, bilateral salpingectomy, and adhesiolysis. After the hysterectomy was complete, excision of her previous midurethral sling was also performed due to the patient's chronic groin pain and recurrent UTIs. Approximately 2 cm of the polypropylene mesh was freed from the periurethral space and partially excised to the inferior pubic rami bilaterally. At the time of excision, no diverticulum was able to be identified and only an area of inflammation was visualized. A 20 gauge spinal needle was passed through that area in an attempt to aspirate fluid, but no fluid was able to be retrieved. Cystoscopy was also performed and no ostia or communication suggestive of a diverticulum was visualized. Postoperatively, patient had no complications. Although the diverticulum was not able to be isolated and repaired, the patient initially had improvement of her"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old girl presented with a port wine patch on the left side of face mainly over the lateral side of nose and nasolabial fold and malar area which was present since birth and was gradually increasing in size as the child grew. In the last 3 months period, she complained of appearance of a globular swelling on left lateral side of nose which rapidly increased in size resulting in bulky appearance of upper part of nose and slight deviation of nose to right side. Simultaneously two warty growths appeared on left ala and cheek which gradually increased in size []. There was no history of trauma to the area. There were no complain of pain or tenderness, or respiratory difficulty. Examination revealed a globular swelling of size 7 cm × 5 cm, with smooth surface, bony hard consistency, nonpulsatile, noncompressible, no palpable thrill or audible bruit, no fluctuation, not increasing in size with coughing, without local rise of temperature, with an area of port wine stain on the left side of nose and nasolabial fold area overlying the swelling.\nCT scan showed an avidly enhancing soft tissue density lesion with bone density within it with “sun burst appearance” from left nasal bone [].\nThe lesion was approached through an incision along the nasolabial fold slightly extending over the dorsum of nose. A well circumscribed bony growth was found within the left nasal bone. The swelling was gently dissected of the nasal bone which had a vascular stalk attached to the nasal mucosa which was ligated. Then the lesion could be completely enucleated and had a honeycomb appearance []. Rest of the nearby bony growths was chisselled out and hemostasis achieved with electrocautery. Wound was closed with subcuticular suturing and pressure dressing applied.\nHistopathology revealed large vascular spaces with endothelial lining giving the impression of venous channels, with scattered osteocytes surrounding the spaces []. The postoperative course was uneventful, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 59-year-old male with a postoperative union of a left tibial plateau fracture who, after open reduction and internal fixation, underwent surgery for implant removal at a local hospital (Fig. ). The first day after surgery, at approximately 9 a.m., he complained of severe pain in the wound region and developed a fever in which the highest temperature reached was 39 °C. Upon examination, the patient was conscious without chills and other discomfort, and the incision was severely swollen and filled with hemorrhagic content. Analgesic therapy was given, but the patient did not feel pain relief. Early on the second morning, the patient started to become irritable and apathetic and the incision was inflamed. The following afternoon, at approximately 3 p.m., the patient felt increasing pain out of proportion to the physical findings accompanied by progressive swelling, numbness, and weakness of the limb. The skin around the wound was darkened, and tension blisters were visible (Fig. ). The patient was delirious on the third morning after surgery, the systemic skin turned yellow, and there was a large amount of dark red, bloody discharge drainage from the incision with bubbles of gas, and a foul, sweetish, unpleasant odor was smelled in the incision. A physical examination revealed subcutaneous crepitus extending along the length of the limb, roentgenograms revealed the accumulation of gas in soft tissue (Fig. ), the lower limb skin temperature decreased, the dorsal artery of the foot could not be touched, and the patient had no response to pain in the lower extremities. Anaerobic infection gas gangrene was highly suspected, and the patient was transferred to our hospital at approximately 7 p.m.\nLeft lower extremity incision decompression was carried out immediately. Upon incision, the musculature was found to be extensively necrotic and crepitant, the appearance of the affected muscles was purplish red and brown with a characteristic foul odor,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female patient with no notable medical and family history was referred to our department after the discovery of a radiolucent image which spans the entire left mandibular ramus. She first consulted her dentist after the sensation of discomfort and slight pain in the left retromolar region. The extraoral examination was without particularities (no facial asymmetry) (). The intraoral examination revealed insufficient hygiene, absence of swelling and deep decay in tooth 36 ().\nThe panoramic radiograph showed a well-defined, corticated radiolucent lesion extended over the ramus in relation to the impacted wisdom tooth 38 (). The computed tomography (CT) scan revealed that this unilocular osteolytic lesion was with tissue matrix, very slightly enhanced by the contrast agent and contained sparse millimetric calcifications. It was not very blowing, eroding the internal surface of the internal cortical without cortical rupture. This lesion measured 34 mm in the coronal plane and 10 × 25 mm in the axial plane (). Based on the clinical and radiological features, we made a diagnosis of a calcifying epithelial odontogenic tumour (Pindborg tumour) or ameloblastoma.\nThe patient was treated under general anaesthesia. After detachment of a full thickness flap, bone milling and resection of the coronoid process to facilitate direct access to the lesion, we performed the total enucleation, curettage and extraction of the impacted wisdom tooth. The immediate postoperative follow-up was straightforward without complications. The lesional tissue was submitted to the pathology department for histopathological evaluation. Macroscopically, the tumour consisted in a whitish-yellow mass of soft consistency related to the impacted tooth (). Microscopically, the lesion was essentially made of a tissue of fibrous appearance with cells having an abundant pale cytoplasm, with rounded or ovoid nucleus and fine chromatin. The cell density was moderate with the presence of a few hyalin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old man was referred to vascular medicine clinic because of pain in the left calf while running, which had been occurring for the past 4 years.\nThis patient practiced almost daily physical activity that involved both combative and running (over 8 h per week), and he competed at a regional level (with a personal best of running of 36min12s/10000 m). In 2012, the patient had reported left calf pain when running, forcing him to stop. He described a calf swelling sensation that gradually increased with the intensity of running. While in the past he could easily run 15–20 km, the patient reported at that date that he could not run more than 2 km before having to stop. After stopping, the pain was deep and persisted for several minutes; it was also associated with swelling of the calf. This pain had led him to change his occupation to a less physically demanding job (military officer in the past, and now security officer). The consequences were a weight gain of 8 kg, and a cessation of all physical activity (running, fight sports). The patient also reported a loss of self-esteem.\nOver a period of 4 years, the patient was seen by two general physicians, a rheumatologist, a neurologist, a sports physician and a vascular physician. Many explorations were carried out (spinal and pelvic x-ray, pelvic and lumbar spine scan, venous duplex scan, arterial duplex scan, and electromyography), all of which revealed no sign of dysfunction. The sports physician raised the possibility of diagnosis of a compartment syndrome, but the patient refused to submit to investigation of intramuscular pressure taken at rest and in immediately post exercise. Different therapies were proposed, including anti-inflammatory drugs, paracetamol and compression stockings (Class 2).\nThe patient interview revealed that a proximal deep vein thrombosis DVT (thrombosis in the iliac, femoral and popliteal veins) of the left lower limb had been diagnosed in 2012 and treated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old male patient presented with a history of trauma and subsequent avulsion of tooth number 11 and crown fracture at the neck of tooth number 21, previously extracted two weeks prior, at another dental facility. The patient requested an immediate fixed solution to the lost anterior teeth from our department. Clinical and radiological evaluation revealed adequate apico-occlusal alveolar bone, but extensive loss of the labial plate [Figure and ]. The soft tissue dimensions were, however, adequate for functional and aesthetic acceptability. It was decided to perform a single stage immediate loading implant placement with simultaneous augmentation of the lost facial plate using calcium phosphate bone substitute and collagen barrier.\nAfter induction of local anaesthesia, full thickness flap was reflected in relation to number 11 and number 21. The sockets were debrided with curettes and two single piece implants (3.7 × 13 mm) were placed into the sockets. After checking for primary stability, which was achieved by wrenching the implant into the bone beyond the apex of the socket, calcium phosphate cement was mixed in sterile saline and injected into the spaces between the implant and the socket walls. Collagen membrane was trimmed to the appropriate size and shaped to cover the graft material. The flap was approximated and sutured with interrupted 3-0 Mersilk [Figure –]. The patient was instructed to discontinue tooth brushing and avoid trauma or pressure at the surgical site. A 0.2% chlorhexidine mouth rinse was prescribed two/three times daily for two-three weeks following surgery, and antibiotics and anti-inflammatory drugs were prescribed for five days. The sutures were removed after 10 days and the patient received temporary acrylic crowns on the same day. The patient was recalled for prophylaxis after two and four weeks and every three months. The clinical and radiographic appearances at six months and after one year show good aesthetic result and accepta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old boy presented to the Pediatric Clinic, Araraquara Dental School, Univ Estadual Paulista-UNESP with the main complaint of misaligned teeth. An intraoral examination revealed the absence of the left permanent upper lateral incisor (). The patient was submitted to panoramic radiograph that confirmed the hypothesis of the presence of the supernumerary tooth located near of the maxillary left central incisor (). Periapical radiograph was taken to confirm the location of the supernumerary tooth. After mother’s speech, it was verified that the patient presented healthy with positive dental and medical behavior prior and during the routine appointments. The need of the surgical procedure also the remotion of the tooth was explained to both the patient and mother.\nImmediately after the surgical procedure, the region of the extracted supernumerary tooth received an irradiation of the GaAlAs diode low-level laser (Thera Lase, DMC, São Carlos, SP, Brazil) in the invisible wavelength (830 nm) in two different points aiming to increase bone formation. Each point was illuminated for 17 seconds and was delivered 3.4 J of energy with the fluence of 60 J/cm, and the mean output was adjusted to 100 mW (0.1 W). The region that received the sutures was also irradiated into four different points. To these applications, the laser device was adjusted in the red visible light wavelength and the parameters utilized were similar to the anterior case described above, since the reason for the irradiation was increase the quality repair of the soft tissue. This protocol was applied after 24 and 48 hours after the surgical procedure.\nThe pain recorded in the VAS of the patient showed that apart from the period of 12 hours in which the patient marked a number between 2 and 3 thus demonstrating an annoying sensation. The other periods evaluated it was demonstrated a mild to none pain sensation (between 1 and 0). Furthermore"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old female patient presented to us with progressive deformity of her lower limbs towards the right side. It had started at two years of age and had continued until 14 years. She had then undergone corrective surgery for windswept deformity, following which there had been no further progression. At 16 years of age, she had sustained bilateral hip fractures after trivial trauma. She had consulted an orthopedic surgeon for her fractures and had been advised surgery. However, the family had not complied with the advice, and the patient had restricted her treatment to the intake of calcium and vitamin D supplements. Subsequently, for the past seven years until her current presentation, she had been bed-bound. Gradually, she had developed contracture deformity of bilateral lower limbs.\nThe patient also had diffuse musculoskeletal pain that was moderate to severe in intensity. In the past six months, her pain had worsened. Also, in the past two years, she had developed gradually worsening low backache and stiffness. She had also developed stiffness around bilateral hip joints, elbows, and shoulders.\nShe had a history suggestive of proximal and truncal muscle weakness. She could not get up from her bed without support. Neurological examination revealed a power of 3/5 in the proximal muscles of both lower limbs and the truncal muscles. There was also a history of dental abscesses that had started at the age of five years. When she presented to us, she was edentulous.\nShe had received multiple intermittent courses of calcium, vitamin D, and calcitriol supplements without phosphate. She was the shortest among all her peers. Her exact height and weight could not be measured as she was bed-bound and had contracture deformity of lower limbs.\nHer brother, who was 18 years old, also had a similar history of windswept deformity of lower limbs, along with proximal myopathy and dental abscesses. His complaints had also started at an early age of four years. The windswept def"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old diabetic hypertensive woman presented to the emergency department with acute retrosternal chest pain. Physical examination showed a heart rate of 110b.p.m., a blood pressure of 90/60 mmHg, and was otherwise unremarkable. Electrocardiography displayed non-specific ST-T wave changes, and cardiac troponin T was positive (2 ng/L). Upon admission, the haemodynamics of the patient continued to deteriorate, with a falling blood pressure of 75/50 mmHg and signs of poor peripheral perfusion. With a working diagnosis of non-ST-elevation myocardial infarction, emergency echocardiography was performed showing preserved left ventricular function and no pericardial effusion. The right ventricle could not be visualized due to acoustic window limitations. The suprasternal window (Figure ) was used to view the aortic arch, considering aortic dissection in the differential diagnosis. Unexpectedly, however, a mobile thrombus inside the right pulmonary artery was seen, establishing the diagnosis of pulmonary embolism. The patient received thrombolytic therapy, accelerated streptokinase regimen,with significant improvement in the haemodynamic status. Follow-up echocardiography revealed resolution of the thrombus. Further workup for hypercoagulable states is recommended.\nPulmonary embolism is sometimes a challenging diagnosis, with fatalities attributed to missed diagnosis rather than failure of therapy. Transthoracic echocardiography signs depend on the indirect detection of acute right ventricle pressure overload. Direct visualization of right-sided thrombi is possible in only <4% of cases.\nHigh-risk pulmonary embolism in this case was diagnosed by direct thrombus visualization in an unusual echocardiographic view in a patient with limited acoustic windows and when computed tomography pulmonary angiography was not immediately available.\nAlthough the detection of thrombi with echocardiography is uncommon in pulmonary embolism, their recognition can have significant impact"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old female presented to our department with progressive blurring of vision in the left eye. She had been diagnosed with chronic inflammatory bowel disease 3 years earlier and was in remission on azathioprine and mesalazine. The patient underwent best-corrected visual acuity testing, full ophthalmic slit-lamp examination of the anterior and posterior segments, spectral-domain optical coherence tomography (SD-OCT), and fluorescein angiography at baseline. A complete serologic search was performed to detect an infectious cause, and active toxoplasma retinochoroiditis was diagnosed. A classic treatment regimen of pyrimethamine and sulfadiazine plus steroids was started.\nDuring the ensuing observation period, the patient was evaluated every 2 months and underwent the same examinations performed at baseline except for fluorescein angiography. When the clinical course suddenly evolved toward a significant vitreoretinal traction due to retraction of the retinal scar, pars plana vitrectomy was considered. After written informed consent was obtained from the patient’s parents, a three-port pars plana vitrectomy was performed with a 23-gauge transconjunctival approach. The posterior hyaloid was removed intraoperatively using forceps and no attempt was made to remove the inner limiting membrane.\nOn presentation, visual acuity was 20/20 in the right eye and 1/20 in the left eye, with a mild relative afferent pupillary defect in the second one. No other neurologic signs or symptoms were detected. Anterior segment examination in both eyes was unremarkable and intraocular pressure was 16 mmHg. On biomicroscopic examination, the vitreous of the right eye was clear whereas the left eye exhibited mild inflammation. Fundus examination of the left eye showed a whitish yellow inflammatory lesion temporal to the macula surrounded by retinal edema with foveal involvement (). The lesion was apparently located under the retinal pigment epithelium and there was mild dilation of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old male sustained high-voltage electrical injury to his left forearm due to contact with a live wire hanging from a generator van. He also sustained a laceration over the site of contact of the wire while untangling the wire. He gave no history of head injury or fall. No entry or exit wound was found. On exploration of the forearm laceration, soft tissue structures were normal. A distal third minimally displaced radius fracture was noted and fixed by percutaneous nailing. No other proximal fractures were found. The patient complained of loss of shoulder abduction, elbow flexion and extension and inability to extend his wrist and use his fingers, suggestive of a brachial plexopathy. Conservative management with rest to the affected shoulder and arm was instituted and patient followed up at 1 month. No corticosteroids were given. Physiotherapy was initiated and an electromyography was done which was suggestive of axonal degeneration involving median, axillary, musculocutaneous and radial nerves. Serial electromyography was performed at 8 weeks which reported no axonal regeneration. However, the patient had started regaining partial shoulder abduction, ulnar deviation of wrist and finger flexion at approximately 4 months after injury. He was posted for brachial plexus exploration at 6 months as his elbow flexion did not recover. On exploration, there was extensive damage with multiple thickened lobulations to long sections of median, musculocutaneous and radial nerves extending from their origins at the cords up to mid arm []. Rest of the plexus exploration was unremarkable []. No perineural fibrosis was noted. The surrounding tissue was surprisingly well preserved. Histopathology of the affected nerve segments showed fibrous tissue.\nLong Sural nerve cable grafts were harvested. A single 13 cm long nerve graft was placed between anterior division of C7 root and radial nerve at the cranial end of sternal head of pectoralis major []. Lateral cord to musculocut"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old female came with complaints of on and off right lower quadrant abdominal pain for 1-year. The patient also had urinary complaints such as intermittency, burning, and frequency. She denied any episodes of fever, chills, gross hematuria, or dysuria. Her past medical and surgical history were insignificant. The per abdominal examination was normal, but on bimanual pelvic examination a mass on the right side near the bladder neck area was palpable.\nUltrasonography (USG) suggested a well-circumscribed polypoidal soft tissue lesion projecting in urinary bladder lumen and attached to the posterior wall and base of the bladder with no internal vascularity []. Intravenous pyelography demonstrated a large filling defect in the bladder and normal functioning kidneys []. To know the detailed anatomy, magnetic resonance imaging (MRI) was done, which showed a large, well-defined rounded, soft tissue lesion of size 67.6 mm ×51 mm at posteroinferior aspect of urinary bladder, close to anterior surface of the cervix and vagina. The mass was isointense to the skeletal muscles on T1 and T2 images. It also showed small focal irregular cystic areas of necrosis []. The finding was suggestive of a benign lesion, probably leiomyoma. The urine cytology smear showed large numbers of squamous cells; few degenerated cells and bacteria, but atypical cells were not seen.\nOn cystoscopy, a large smooth sessile growth arising from the right posterolateral wall was noted []. The right ureteric orifice was not visualized. Transurethral resection (TUR) of the lesion was performed, and resected specimens were sent for histopathological examination. At the completion of the resection, the previously palpable pelvic mass could no longer be appreciated by bimanual examination.\nOn postoperative day 1, the patient's urine was clear, the Foley catheter was removed, and the patient was discharged on oral antibiotics. The histopathological examination showed spindle cells in sheets and fascicles"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year old male with chronic rhinosinusitis was admitted for an elective Functional endoscopic sinus surgery (FESS) procedure under general anesthesia. During the operation, the surgeon applied several tampons soaked in 1:1000 dilution epinephrine to the nasal mucosa. Ninety minutes into the surgery, unexpectedly, blood pressure rose to 210/130 mmHg followed by pulseless electrical activity. CPR was initiated, with the administration of 2 mg of IV epinephrine in consecutive doses, leading to the return of spontaneous circulation. ECG showed sinus tachycardia and a prolonged QTc interval of 486 ms, Inverted T waves in leads I and aVL, and no signs of acute ischemic changes (Fig. ). A chest x-ray demonstrated pulmonary edema and a borderline enlarged cardiac silhouette (Fig. ).\nThe patient was placed on mechanical ventilation. Transthoracic echocardiogram showed a dilated left ventricle with an increased end-diastolic dimension (124% of normal value) with a mild reduction in LV mass, a severe reduction in systolic function, apical akinesis, and hyperdynamic base. The estimated systolic left ventricular ejection fraction was 30% (Fig. ). Cardiac troponin and CPK were elevated. NT or NT pro-BNP were not taken. A head CT was performed and demonstrated mild global cerebral edema, with multiple maxillary sinus fractures (Fig. ).\nMedical information gathered from family members indicated no family history of heart diseases. The patient did not smoke, use illegal drugs nor consumed alcohol on daily basis. The patient was diagnosed with dilated cardiomyopathy and admitted to the intensive cardiac care unit. Upon arrival, upload titration of ACE inhibitors, β-blockers, and diuretics initiated. The following ECG strips indicate normal sinus rhythm, QTc interval of 420 ms, and normal T wave in lateral leads. We decided not to perform a diagnostic coronary catheterization since the patient's risk profile for ischemic cardiomyopathy was low. Objectively, there were no ischemic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, C. C., was a 91-year-old female, suffering from chronic heart failure and osteoarthrosis with subsequent functional impairment. She was a retired teacher and lived alone without any external caregiving support. She came to our department presenting painful skin ulcers of the lower extremities with inflammatory signs and alarming initial gangrene. They arose from accidental wounds 6 months before and increased in size despite wound care performed by the patient herself (washing, disinfection, dressing with topical silver sulfadiazine, etc.). No history of diabetes was reported.\nAt admission, she presented in poor general condition and was malnourished, while cognitive functions were intact. A skin examination was performed at the time of admission and showed extensive right leg ulcers. These lesions had a necrotic appearance, without granulation tissue, and were covered by purulent exudates ().\nBlood sample showed increased levels of CRP and ESR. Main clinical data are shown in . A Doppler ultrasound of the lower limbs showed distally an initial decrease of arterial signal with normal venous axis. The ankle brachial index was 0.9, so that arterial insufficiency was not causing or contributing to the nonhealing wound [].\nConsultation from the vascular surgery department proposed a demolitive surgical approach that was refused. Given the lack of response, risk of amputation, and general deterioration in the patient, EBS stimulation was proposed and started on a compassionate use basis, with informed consent, 2 days after her hospitalization. She parallel underwent standard medication with washing, enzymatic debridement, dressing, and parenteral antibiotics (amoxicillin/clavulanic acid 3 grams daily).\nAfter 7 days of therapy, the wide ulcers of the lower limb started to present some granulation tissue with irregular edges and discrete fibrinous exudate (). Following a two-week EBS treatment period, all wide ulcers of the lower limb had improved with remarka"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man presented with a 3-month history of increasing pain in his left groin, and numbness and radiating pain in the anterior and medial thigh without any injury. He reported that he was in constant pain and that his pain continued during sleeping hours. The pain and numbness were markedly increased when he was in a sitting position. Although he had opportunities to sit in his job as a factory manager, he was unable to do so due to the increased pain and numbness that he experienced while sitting. At the medical examination, he was unable to sit on the chair in the consultation room. A physical examination revealed tenderness in the femoral triangle and radiating pain and numbness. There was no palpable mass or muscle atrophy. The patient was observed to limp from the time of start of walking. His range of motion was observed to be restricted to 100 of flexion, 10 of extension, and 10 of internal rotation due to an increase in the radiating thigh pain and numbness. Plain radiographs showed no osteoarthritic changes (, ). Computed tomography showed a bump and bone cyst in the anterolateral aspect of the femoral neck (, ). The presence of cam type femoroacetabular impingement was indicated. Magnetic resonance imaging (MRI) showed a cyst situated at the medial side of iliopsoas muscle and tendon. Its dimensions were 56 mm in the coronal view and 22×24 mm in the axial view. The mass, which was compressing the neurovascular bundle, was continuous with the hip joint (, , ). Based on these findings, a ganglion cyst arising from the hip joint and femoral nerve palsy associated with the ganglion were diagnosed. Initially, the patient was treated conservatively for 2 months with a nonsteroidal anti-inflammatory drug. However, his pain and numbness worsened, leading us to perform surgery. Hip arthroscopy was performed under general anesthesia in thesupine position with traction. Three portals (anterior: A-portal, mid-anterior: MA"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 31-year-old primigravida woman with a history of pulmonary embolism and multiple deep venous thrombosis during the index pregnancy was admitted to the obstetric department with pre-eclampsia with severe hypertension of 160/100 mm Hg at 26 weeks of pregnancy. She had been taking vitamin K antagonists, which were switched to low-molecular-weight heparin, and she was treated with magnesium sulfate and intravenous antihypertensive drugs. A primary caesarean section under general anaesthesia was performed at 30 weeks of pregnancy due to fetal distress, delivering a growth-restricted, premature girl of 920 g. Postsurgery the mother developed severe postpartum haemorrhage with a total of 5000 mL blood loss, and treatment was complicated by her anticoagulation therapy. She received blood transfusions and was discharged from the hospital with a haemoglobin level of 77.3 g/L. Three days later she was readmitted with complaints of fatigue, severe dyspnoea and fever. She had pleural effusion and thrombocytopaenia. She was later transferred to the cardiac intensive care unit (ICU) due to deterioration of her condition, and echocardiographic examination revealed severe left ventricular dysfunction with mild dilatation of the ventricles. ECG showed a sinus tachycardia with low voltages in the extremity leads and a QS pattern in V1–V3 (). Coronary angiography showed normal coronary arteries and she was diagnosed with PPCM. She soon went into cardiogenic shock with high lactate levels, and when high dosages of inotropes could not stabilise her extracorporeal membrane oxygenation (ECMO) was started. Heart failure medication was started, which stabilised her condition, and after 15 days the ECMO could be removed. ECMO was complicated by cannula-related severe ischaemia of her right foot, which had to be amputated. She was transferred to a rehabilitation clinic after hospital discharge.\nBecause of the combination of multiple venous emboli, pre-eclampsia with proteinuria, pleural e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn this report, we present a case of a 57-year-old female patient with a 10 × 15 cm2 mesenteric cyst of the sigmoid colon that was excised laparoscopically and histopathology reported a cystadenoma. A 57-year-old female attended rapid access clinic complaining of left iliac fossa pain and swelling for ten months. She was reviewed by the Obsteric and Gynaecology team and an ultrasound scan of the pelvis was arranged which found a 116 × 94 × 76 mm3 cystic lesion probably from the left ovary. Following further investigations, (which were all normal) the patient was listed and consented for laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oopherectomy and peritoneal washing. During the operation the Gynaecologist found a large 10 × 15 cm2 cyst attached to the mesentery of the sigmoid colon free from the ovaries. The operation was suspended and the on call general surgical team were called into theatre. A diagnostic laparoscopy was performed; all other organs were normal, however, due to the size it was difficult to assess the anatomy of the cyst and which other organs were involved, the only thing that was certain was this was not an ovarian cyst, therefore proceeding to operate would be risky. The on call consultant general surgeon did not see this as an emergency and suggested that the operation should be aborted and further investigations were required before proceeding with an operation on the cystic mass. An outpatient CT abdomen and pelvis scan plus a flexible sigmoidoscopy was arranged with an outpatient follow up appointment with the general surgeons. The flexible sigmoidoscopy came back as normal and the abdomino-pelvic CT scan revealed an 11 × 10 × 8 cm3 likely benign cyst but could not determine its origin (Figs and ).\nDue to the persisting discomfort the patient was booked and consented for an elective laparoscopic removal of cyst with possibility of converting it to an open procedure due to the size of the mass. The operation was approached la"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 70-year-old male patient was admitted to the Department of Neurology with isolated left upper extremity weakness and clumsiness. He had wrist drop and was unable to grip with the fingers. He complained of no sensory loss or numbness. His past medical history included long-term oral anticoagulation due to recurrent lower extremity deep vein thrombosis, glaucoma, and a non-significant aortic valve stenosis, with vascular risk factors including a 5-year history of treated hypertension, hypercholesterolemia, and a history of non-significant stenosis of the left anterior descendent coronary artery. On admission, no abnormality could be detected by physical examination, apart from the neurological signs, which included a wrist drop on the left side with decreased grip strength (Fig. ). Pronation and wrist dorsiflection were lost, as well as the ability to form a ring with the thumb and the index. The reflexes of the left upper extremity were slightly brisk, with not pathological reflexes present and no sensory deficits. Laboratory parameters were without abnormal findings except for a slightly elevated fasting blood glucose level. Cranial CT revealed contrast-enhancing, irregularly shaped lesions with diameters of 7, 10, and 9 mm (in the temporal, parietal, and frontal lobes, respectively), surrounded by perifocal edema. Carotid duplex ultrasonography did not demonstrate signs of focal atherosclerotic plaques, circulatory disturbance or stenosis on either side. In accordance with the findings of the CT scan, the cranial MRI confirmed the tumor in the right precentral gyrus, corresponding to the ‘hand knob’, accompanied by further similar lesions posteriorly in the parietal and the temporal lobes, and in the left frontal lobe (Fig. ). Electromyography and nerve conduction studies did not support a peripheral origin underlying the paresis. The neuropsychological examination revealed a deficit in the Luria three-step test as a single alteration, which performance could,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old female on a ventilator was transferred to our ICU from another hospital due to biliary sepsis. Previously, the patient had been treated for about 1 week with combined antibiotics and another supportive treatment. The patient looked severely ill and jaundiced. The patient also has comorbidities such as heart problems, hypothyroidism, and diabetes mellitus. The total and direct bilirubin levels were high (10.94 and 9.67 mg/dL), with a very high CRP level (269.48 mg/L). The abdominal ultrasound (US) and MRI evaluation from the previous hospital showed a large cyst 14.7 × 6.2 cm in size suspected from the left liver lobe which caused gastric compression, and there was also evidence of bile duct obstruction with a large stone in the distal common bile duct (CBD) area (Fig. ).\nThe main treatment given during admission was as follows: a combination of the antibiotics piperacillin-tazobactam with amikacin, levothyroxine, insulin therapy, and other supportive treatments. Then an abdominal MRI was blindly reviewed by our senior radiologist, and it was concluded that there was a large cyst possibly arising from the pancreas (possible pancreatic pseudocyst [PPC]). After discussion with the family, it was decided to do biliary drainage. The bedside biliary drainage procedure was performed in the ICU without any fluoroscopy guidance, only transabdominal US guidance. After the dilated bile duct was seen on the US image, an 18-G Chiba needle was used to puncture the dilated bile duct, followed by bile fluid aspiration and guide wire insertion. The distance between the tip of the needle inside the bile duct and the area of the US probe was measured for length guidance marked on the PTBD pigtail catheter (DIALL abdominal drainage catheter, China). Then, slowly, the needle was pulled out with maintenance of the guide wire inside the bile duct. The final step was PTBD pigtail catheter insertion into the bile duct, after which,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old man with a history of 3 years of excessive alcohol intake was admitted to the emergency department for 48 h of abdominal pain, mainly in the left hypochondrium associated with fever and vomiting. He had a history of 1 year of intermittent abdominal pain that intensified over the last month, which led him to stop alcohol consumption. He was hemodynamically stable upon admission. Laboratory test showed C-reactive protein 176 mg/dl, white cell count 16.7 × 109/L, platelet count 617 × 109/L and serum amylase level 109 U/L. The computed tomography (CT) showed a cystic lesion in the pancreatic tail of 5.7 × 9 cm in size and significant splenomegaly with hypodense areas consistent with a pseudocyst with splenic extension and rupture ().\nDue to patient stability, conservative management was decided. This included analgesics, antibiotics and nutritional optimization. During the first 48 h, the patient was stable, with little pain and without fever. On the fourth day of hospitalization, he developed tachycardia and severe pain. The abdominal examination showed signs of peritoneal irritation and laboratory tests with a white cell count of 41 × 109/L. Ultrasound assessment showed diffuse abdominal free fluid. An emergency laparotomy was performed, finding 1.5 L of dark serohematic and purulent fluid in the peritoneal cavity. The amylase level of this fluid was 3000 U/L. A large pancreatic tail pseudocyst was identified in addition to abundant clots in the left subphrenic space because of a ruptured spleen (). Due to extensive peripancreatic inflammation, dissection was difficult. Splenectomy was performed, extracting the shattered splenic parenchyma (). The amylase level of pancreatic cystic fluid was 13 000 U/L, confirming the diagnosis of a pseudocyst. We performed a double layer hand-sewn gastrocystic anastomosis with silk 2.0. One drain was located close to the anastomosis and two in the splenic bed. The patient had a satisfactory recovery, with drains"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old gravida 2, para 2 woman admitted to our hospital with complaints of headache, nausea, vomiting, and right-sided blurred vision. She did not report any previous medical history or malignancy. Her neurologic examination revealed a right optic disc edema suggesting a posterior orbital mass. Her cranial computerized tomography (CT) scan showed multiple lesions that are a 6 mm mass on the right parietal lobe, a 16 mm mass on the left occipital, and another 7 mm mass on the left temporal lobe (Figures and ). All the lesions were hyperintense and surrounded by edema which suggests a metastatic cancer. Her cranial magnetic resonance imaging (MRI) also confirmed similar findings suggestive of a metastatic cancer to the brain.\nFor identification of the primary malignancy, she initially underwent thoracic and abdominopelvic CT. Upper abdominal CT scan revealed indistinctly bordered and heterogeneously contrast accumulating multiple lesions less than 15 mm in the liver. There was a pelvic tumor of 62 × 53 mm sized and solid cystic in nature located in the right adnexa. The pelvic mass was round shaped and thin capsulated that contains irregular septations and a solid component of 38 × 24 mm on MRI scan (). The right pelvic lymph nodes were slightly enlarged. No ascites were detected in the pelvic cavity. The endoscopic evaluation of the upper and the lower gastrointestinal tract and the ultrasonographic evaluation of the breast was found to be normal. The Pap test was reported to be negative for malignancy. Her serum tumor marker levels (CA 125, CA 15-3, CA 19-9, CEA, and AFP) were within normal limits.\nThe patient underwent a diagnostic laparoscopy for further evaluation of the adnexal mass. Biopsy of the adnexal mass and the liver was obtained and the pathologic examination revealed an ovarian mucinous cystadenocarcinoma with metastatic lesions of liver. The patient then was subjected to a laparotomy for a surgical staging procedure including total abdominal hys"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old male, ex-smoker, with a history of type 1 diabetes, was referred by his general practitioner (GP) to the ear, nose and throat (ENT) department with odynophagia, dysphonia, dysphagia and anterior neck swelling. The symptoms began while he was eating a cracker and, upon swallowing, he felt a painful crack in the right side of his neck. By the following day, the patient had developed hoarseness and pain on swallowing. He attended his GP five days later after developing neck swelling. At this point, it was thought the symptoms may represent an infection or a possible underlying malignancy; the patient was prescribed a course of oral antibiotics and referred urgently to the head & neck clinic. At subsequent review in clinic, the patient reported ongoing odynophagia, dysphonia and dysphagia. Examination noted some fullness of the anterior neck. Flexible nasendoscopy (FNE) showed pooling of saliva and swelling of the right supraglottis. The patient was otherwise systemically well and managing to maintain adequate oral intake despite his symptoms. An expedited outpatient CT scan of the neck was requested to investigate for possible laryngeal malignancy. While awaiting this investigation, the patient re-presented to his GP with rapidly progressing symptoms and was referred to the ENT on-call team for same-day review. The patient had worsening dysphagia, now only managing sips of water. The anterior neck swelling had increased significantly in size and was now indurated with a central area of fluctuance. He underwent urgent inpatient contrast-enhanced CT scan of the neck (Figures , ).\nThis demonstrated a vertical fracture of the thyroid cartilage to the right of the midline, with depression of the right thyroid lamina posteriorly causing mass effect on the trachea. There was also a large multiloculated collection in the midline just anterior to the thyroid cartilage. This extended superiorly up to the hyoid bone and inferiorly over the thyroid gland."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old Chinese man who had been experiencing chest pain for 10 years presented at our institution. He was moderately active, doing odd jobs around the house, and accelerating angina over the past 2 years. The patient had been taking aspirin, nifedipine for high blood pressure and metformin for diabetes mellitus type 2 for almost 10 years. He smoked one pack of cigarettes per day for about 40 years before quitting the previous year. His past history was remarkable for chronic obstructive pulmonary disease.\nAt the time of admission, the physical examination showed heart rate (HR), 67 beats/min (bpm); blood pressure (BP), 156/89 mmHg; and blood glucose, 6.85 mmol/L. An electrocardiogram (ECG) showed a sinus rhythm with ST depression and T-wave inversion when chest pain occurred. A complete blood count and a basal metabolic profile were examined; the evaluation of kidney function, blood acid, base balance, and blood sugar levels showed that there were all within a normal range. The treadmill exercise test was positive, and showed ST depression on the ECG when chest pain or shortness of breath occurred. The patient’s response to clopidogrel therapy was determined by testing for CYP450 genetic polymorphism, which showed non-resistance to such therapy. Testing for CYP450 genetic polymorphism was to predict response to clopidogrel\n[].\nThe patient was prepared for coronary angiography (and stent placement if necessary). Before the procedure, the patient’s spontaneous baroreflex sensitivity (BRS), heart rate variability (HRV), and blood pressure variability (BPV) were measured (Table \n). Six hours before the patient underwent coronary angiography, he was given 300 mg aspirin and 300 mg clopidogrel. An initial dose of heparin (100U/kg) was intravenously given before the procedure; an additional dose of heparin at 500U would be given if the procedure lasted 1 hour. The activated clotting time was maintained at 325 s.\nThe coronary angiogram was done through the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old Caucasian female with no psychiatric history presented to the emergency department with her family for a one-week history of unstable mood and psychosis following her third epidural steroid injection for low-back pain due to falls history. The chief complaint included altered mental status, agitation, and hallucinations. Table shows the admission lab values that were significant.\nThe patient was treated for hyponatremia given low serum sodium and transferred to neurology for further workup. Magnetic resonance imaging (MRI) of the head and lumbar puncture were unremarkable. However, the initial electroencephalogram (EEG) was consistent with a partial seizure disorder and focal clinical status epilepticus in the right temporoparietal region. The patient was treated with phenytoin 300 mg daily. The patient also received quetiapine and later olanzapine for psychosis. No seizure events were captured on EEG study one week later. Table lists the results of the initial and final EEG. The patient was also briefly treated with intravenous methylprednisolone for suspected autoimmune encephalitis without noted benefit. Despite treatment with antiepileptic medication, methylprednisolone, and sodium correction, the patient continued to exhibit symptoms of mania and psychosis and was transferred to the geriatric psychiatric inpatient unit 12 days after the initial presentation.\nUpon psychiatric admission, the patient continued to identify her husband and daughter as demons. Her mental status exam was significant for disheveled appearance, uncooperative behavior, loud and disorganized speech with loose associations, grandiose, hyper-religious, and paranoid thought content. The patient was placed on one-to-one observation with assault precautions. Risperidone was initiated to target psychosis and mood and titrated to 1 mg twice daily; intramuscular (IM) haloperidol and lorazepam were also utilized during an event of acute agitation and assault on a healthcare staff mem"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old man with a history of hypertension was referred to our Department of Hepatobiliary Pancreatic Surgery with a persisting subxiphoid pain of 12 h duration. There was no positive sign, except for tenderness in the epigastric region. The results of the laboratory tests, including determination of blood glucose levels, were almost within the normal range. Computed tomography of the upper abdomen revealed an atrophic pancreas with a dilated pancreatic duct containing a single stone located at the pancreatic neck; no mass in the pancreatic gland head or biliary dilatation was detected (Figure ). The size of the stone was approximately 1.0 cm × 0.6 cm. Based on the clinical signs and test result, a diagnosis of pancreatic duct stone with CP was established.\nGiven the presence of only one stone in the pancreatic main duct, we elected to perform laparoscopic pancreatic duct incision and stone removal, followed by T-type tube drainage, under general anesthesia after obtaining informed consent from the patient.\nDuring the operation, the patient received prophylactic antibiotics intravenously, and intermittent pneumatic compression therapy and graduated compression stockings were applied to the lower limbs. After catheterization of patient, he was installed in a flat Lloyd-Davies position. The patient was tilted in a 30-degrees reverse Trendelenberg position during the operation by the use of two 5-mm ports, two 10-mm ports, and one 12 mm port (Figure ).\nBy an ultrasonically activated scalpel, the lesser sac was opened via the gastrocolic omentum. Then, mobilization of the gastric antrum was performed, followed by upward retraction of the stomach to expose the front surface of the pancreatic head to the gland body. The duct of the pancreas was located by ultrasound laparoscopy and opened (Figure ). An initial opening was made above the gland neck by the joint use of an electrocoagulation and an ultrasonically activated scalpel, which was then prolonged further"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man with a medical history of hypertension, atrial fibrillation, type 2 diabetes mellitus, and mild chronic renal impairment with a single functional kidney was referred to our hospital because of a Crawford type 3 thoracoabdominal aneurysm with a diameter of 6.4 cm. There was a preexisting occlusion of the left renal artery. Baseline serum creatinine was 1.81 mg/dL. The estimated glomerular filtration rate (eGFR) using the modified diet and renal disease study equation (MDRD) was 37 mL/min/1.73 m2.\nEndovascular repair was performed with an aortic branch graft including side branches for the celiac trunk, superior mesenteric artery (SMA), and the right renal artery. Covered stents were placed through the side branches in the target vessels and these were relined with nitinol self-expanding stents. The procedure was complicated by diplopia caused by occipital infarction, despite intraoperative heparinisation and immediate postoperative readministration of anticoagulant therapy (coumarin and clopidogrel). Postoperative serum creatinine remained unchanged. Three weeks after surgery, clopidogrel was discontinued because of side effects. Follow-up CT-angiography 6 weeks after discharge showed adequate position of the aortic branch graft (), patency of the visceral side branches, and target vessels without kinking of the (covered) stents. However, a mass in the left mamma was found. Additional diagnostic tests showed an invasive ductal carcinoma. Subsequently the patient was planned for mastectomy with sentinel node procedure. Anticoagulant therapy was discontinued 3 days before surgery. Upon admission for the planned surgery, the patient reported anuria for approximately 12 hours and right flank pain that had started early that morning. Blood test showed an increase in serum creatinine to 5.37 mg/dL. Ultrasound investigation showed an occlusion of the stents in the right renal artery side branch and minimal venous flow suggesting acute ischemic kidney injur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old white male presented with recurrent severe dizziness, chest tightness, shortness of breath, left upper back pain, night sweats, and chills of three weeks duration. His past medical history consisted of a 20 pack/year history of smoking and squamous cell carcinoma of the tongue, status-post excision with subsequent radiation and chemotherapy a year and a half prior to his presentation. He also had recurrent disease with biopsy-proven metastatic disease in the cervical lymph nodes nine months after the initial diagnosis and multiple lung nodules on CT and PET scans six months thereafter. He was continued on immunotherapy with nivolumab with subsequent cycles planned.\nHe was admitted for workup of the near syncope. A CT of the chest on admission revealed a filling defect in the left brachiocephalic vein extending into the right atrium and a filling defect in the right ventricle believed to be a thrombus. Heparin anticoagulation was initiated for possible thrombus in transit and a suspected pulmonary embolus (PE). Ten hours later, the patient developed severe diaphoresis, associated with inspiratory chest pain and shortness of breath. An electrocardiogram (ECG) revealed diffuse ST elevation, and a stat TTE revealed a large pericardial effusion with tamponade physiology. Emergent pericardiocentesis was performed and 1,600 cc bloody pericardial fluid was drained; the pericardial drain was left in for 24 hours with no significant additional drainage. Cytology of the pericardial fluid was negative. The patient’s shortness of breath persisted at rest and was associated with a low-grade fever (100.2° F). He experienced repeated episodes of hypotension and tachycardia, requiring intermittent fluid resuscitation and pressor support.\nA follow-up TTE (Figure ) and TEE (Figure ) revealed a growing right-sided mobile mass in the right atrium, right ventricle, and pulmonary artery (PA), which was believed to be a large thrombus.\nIn view of cardiac tamponade with a rapi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA seven and half year-old boy visited the outpatient clinic of Pediatric Dentistry Department, Faculty of Dentistry, Cairo University in June 2015 with a chief complaint of pain on the lower right molar area. The patient’s mother stated that the pain was at times throbbing in nature, and child is not able to chew on this side.\nClinical examination showed a badly decayed, lower second primary molar with related localized intraoral abscess, where the lower first primary molar was intact. The patient had poor oral hygiene; he had not received any professional dental care, and was very apprehensive.\nRadiographic examination revealed root resorption and bone rarefaction related to lower second primary molar. The interesting finding was a considerable amount of root resorption of the distal root of the adjacent lower first primary molar (\n).\nThe case was managed by performing pulpectomy\n to the lower second primary molar, with root canals filled with calcium hydroxide paste with iodoform (Metapex, Meta Biomed, Republic of Korea). The tooth was then restored with high viscosity glass ionomer (GC Fuji IX GP capsule, GC corporation, Tokyo, Japan) (\n). The lower first primary molar was not touched and instead monitored. No antibiotics or analgesics was prescribed.\nUnfortunately, the patient’s mother did not want follow-up appointments in person, however, she was contacted on the phone, after 2 weeks, 3 months and 6 months, and she said everything was fine and there was no swelling or pain.\nAt about 8 months from the treatment appointment, the patient’s mother visited the outpatient clinic with the patient for other reasons, and decided to pass by the Pediatric Dentistry Department for patient follow-up. Clinical examination showed no signs or symptoms, occlusal restoration was intact, and radiographic examination revealed arrested root resorption, on both molars, and an increase in the density of bone although this was not at a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33 years old female noted abnormal sensations in her left upper limb of two months duration. She was evaluated by neurologists and was believed to have psychiatric illness. She was then referred to a psychiatrist and was treated for somatoform disorder for two years when she complained of worsening of sensory disturbances in the form of sensory loss in a “cape-like” distribution along with painless ulcers in the left hand. At this time, the imaging of the cervical spine was done and she was found to have chiari I malformation and syringomyelia. She was later referred to neurosurgery for further management. On admission to neurosurgery department, she had normal optic fundi, sensory impairment from C4 to T8 on the left side with small, trophic ulcers in the left hand. Her left hand grip was weak. MRI examination revealed panventricular hydrocephalus with chiari I malformation along with syringomyelia extending from C1 to lower thoracic region. There was evidence of communication of fourth ventricle with the syrinx [Figure and ]. The patient underwent a right ventriculoperitoneal shunt. Following shunt insertion, there was no change in the patient's neurological status. CT scan showed decompression of the supratentorial ventricles with persistent dilatation of the fourth ventricle [] and hence, the patient underwent foramen magnum decompression and intradural exploration. An upper cervical laminectomy was also done for a possible syringopleural shunt, if necessary. During intradural exploration, an arachnoid veil was found to be covering the foramen of Magendie. The arachnoid veil was opened which revealed a gush of CSF. Following this the cervical cord size was found to decrease intraopertively and hence the planned syringopleural shunt was not done. Following foramen magnum decompression, the patient's neurological status improved with significant improvement in sensations and healing of trophic ulcers. Two months after surgery, she went back to work as a school t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old female presented to our hospital with fever, dry cough, shortness of breath, and poor appetite for three days. She was treated for pneumonia two weeks prior to hospitalization by her primary doctor and had completed a 10-day course of an oral antibiotic. There was no previously reported history of Clostridium difficile infection. She had moved to the United States two years prior. She was ambulatory and functional at baseline.\nAt the time of presentation, her blood pressure was 89/48 mmHg, pulse rate was 101 beats per minute, respiratory rate was 40 breaths per minute and temperature was 101 ° Fahrenheit. On examination, she was found to be obtunded and not moving any extremities. Her abdomen was soft and distended with reduced bowel sounds. Her peripheral pulses were palpable and her pupils were reactive bilaterally. Her trachea was cannulated for acute respiratory failure. Despite intravenous fluid challenge, she remained hypotensive and was started on norepinephrine for suspected septic shock and admitted to the intensive care unit. She was started on intravenous vancomycin, piperacillin-tazobactam, and azithromycin. Her initial laboratory findings have been mentioned in Table .\nX-ray imaging of the chest showed diffuse bilateral pulmonary infiltrates. Computed tomography (CT) imaging of her brain showed no acute large vessel distribution infarction, hemorrhage, mass, or mass effect. Venous Doppler ultrasound of her lower extremities showed bilateral deep venous thrombosis and therapeutic subcutaneous enoxaparin was started. She had multiple episodes of watery diarrhea since arrival in the ICU and she was started on oral vancomycin. The stool was sent for analysis and was found to be positive for the glutamate dehydrogenase (GDH) antigen and Clostridium difficile toxin B. She was noticed to have cold mottled skin and decreased peripheral pulses, first in the right upper extremity followed by the right lower extremity. This has been presented in Fig"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old woman presented with dyspnea on exertion. Chest radiography showed an enlarged mediastinal silhouette. Preoperative computed tomography (CT) and echocardiography revealed a giant cyst (12 × 10 cm in diameter) occupying a large area around the left atrium and ventricle, and it was present behind the pulmonary artery. Based on the preoperative CT findings, a pericardial or an epicardial cyst was suspected. Additionally, attachment of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was suspected (Fig. ). Compression of the left atrium and ventricle was considered to be the cause of her symptoms. Her hemodynamic condition was stable. Percutaneous cystocentesis was performed, and 800 ml of serous liquid was aspirated. However, 1 week after cystocentesis, the cyst recurred, and its size was the same as that before the procedure. Therefore, resection was planned.\nIf the cyst was an epicardial cyst, tight adhesion of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was considered possible. However, we believed that the cyst was more likely a pericardial cyst because a pericardial cyst is more common than an epicardial cyst. Therefore, resection involving video-assisted thoracoscopic surgery (VATS) was planned initially. However, the pericardium was intact and an epicardial cyst was diagnosed intraoperatively. As preoperative CT showed compression of the left atrium, ventricle, pulmonary artery, and pulmonary vein, adhesion was suspected. Additionally, the possibility of cardiopulmonary bypass (CPB) was considered. Therefore, open surgery through median sternotomy was performed. The cyst was found to be attached to the visceral pericardium involving the left atrium and pulmonary artery. Contrary to our expectation, the left ventricle was not involved. Additionally, coronary vessels were not involved. The cyst was most tightly attached to the main pulmonary artery. Thus, it was thought to have or"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old female with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia underwent surgical consultation in October 2015 for an incidentally found right foot mass subsequent to an elective gynecologic procedure. The patient first noticed a small lesion on the dorsum of her right foot approximately 12 years ago. She never sought medical attention for this slowly growing and asymptomatic lesion. However, this lesion had been growing more rapidly and had become foul smelling over the past 3 weeks. She denied any pain, paresthesias, weight loss, or recent trauma to the foot. She also denied any history of smoking or significant sun exposure. Her only surgical history included a recent total abdominal hysterectomy and left salpingo-ophorectomy. On physical examination, she was a well-nourished Caucasian female who was found to have a large exophytic, fungating 8.0 × 8.0 × 0.6 cm malodorous mass on the dorsum of her right foot (Figure ). This mass was insensate to light touch with no surrounding erythema. She had palpable dorsalis pedis and posterior tibial pulses with full range of motion of that foot. The left lower extremity was benign in examination, with no masses or lesions. A thorough dermatologic examination did not reveal any other concerning lesions. A punch biopsy of this mass was consistent with BCC. Subsequent magnetic resonance imaging (MRI) showed a large soft tissue irregularity surrounding the second to fifth extensor tendons (Figure ). Given these findings, the patient underwent a wide local excision of this BCC with full-thickness skin graft for coverage.\nThe lesion was excised in its entirety with a 5-mm circumferential margin beyond the extent of visible tumor. This incision was carried down directly to the fascia overlying the extensor digitorum longus tendons. Intraoperative pathologic evaluation noted a negative deep margin; therefore, resection of extensor tendons was not required. The specimen was sent to pathology"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year-old man was incidentally diagnosed with a left CIAA by abdominal ultrasonography, with computed tomography (CT) demonstrating a left CIAA measuring 4.5 cm in diameter (). The patient was referred to our hospital for surgical treatment. He had a medical history of liver cirrhosis and traumatic abdominal injury. Thus, he underwent EVAR using a GORE EXCLUDER AAA Endoprosthesis to embolize the left internal iliac artery. The postoperative course was uneventful, and postoperative CT showed no endoleak (). Follow-up CT scans at 6-month, 1-year and 2-year intervals post-EVAR revealed a reduction in the size of the aneurysmal sac. However, the 3-year interval CT demonstrated an increase in the sac size (). Contrast-enhanced CT and angiography revealed no endoleak but showed a dilatation of the CIAA. Therefore, the patient underwent open aortic repair of the CIAA.\nThe infrarenal aorta up to the right common iliac artery and the left external iliac artery were exposed via a retroperitoneal approach. Proximal control was achieved by clamping midway between the renal arteries and the aortic bifurcation, and distal control was achieved by inserting an occlusion balloon into the right common iliac artery and clamping the left external iliac artery. The sac of the CIAA was opened, and many thrombi were noted around the stent graft. No backbleeding of the lumbar arteries or junctional bleeding of the stent was detected, and the entire endograft was removed easily. Abdominal aortic replacement with a Y-shaped vascular prosthesis (J Graft SHIELD NEO, bifurcated vascular prosthesis) was performed (). Proximal and distal anastomoses were performed at the level of midway between the renal arteries and the aortic bifurcation where the endograft was fixed, and at the level of the right common and left external iliac arteries, respectively.\nThe patient recovered uneventfully, however, 1 year after open conversion, CT revealed a significant increase in the size of the unreplaced i"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77 year old male was treated at a chiropractic clinic for low back pain resulting from lumbar facet arthrosis and lateral canal stenosis. On a subsequent visit he reported right wrist pain which began while lifting a heavy box. On examination, redness and swelling was noted on the dorsal aspect of his right wrist. Range of motion was full with pain at end range of flexion and extension. His health history included two hip replacements, two previous episodes of gout in both first metatarsophalangeal joints (2 and 5 years prior), and hypertension. Medications for hypertension included perindopril (4 mg), hydrochlorothiazide (25 mg), and Norvasc (10 mg). In addition, he was prescribed 80 mg of aspirin/day and took a daily multivitamin. One week prior, the patient's general practitioner had increased his Norvasc dosage and also prescribed Tylenol 3 to be taken as needed for his back pain.\nTwo days later the swelling had increased in the dorsal aspect of his right wrist and hand. Wrist flexion was limited by 80% with severe pain. Pain was present on palpation of the scaphoid bone. Due to the suspicion of fracture, the patient was referred to his general practitioner for radiographs. The radiologist who read the films described tiny cysts at the distal radius and concluded that these were most likely due to old trauma. Mild osteoarthritic changes were noted at the carpal-metacarpal joint at the base of the thumb. The report stated that the radiographs were otherwise normal.\nThe patient's symptoms worsened with increased pain and swelling over the next few days. Due to the worsening symptoms, repeat radiographs were performed five days later and were read by a radiologist. The radiographs revealed well-marginated juxta-articular bony erosions at the radial styloid process and the dorsal rim of the distal radius with soft tissue swelling. These findings were deemed to be consistent with gouty arthritis. (See figure ).\nThe patient was referred"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35 years old (height, 159 cm; weight, 85 kg; gravida 3, para 1) pregnant woman with SAS presented to our hospital and was scheduled to undergo elective CS under epidural anesthesia at 36 weeks of gestation. An echocardiographic examination at 34 weeks of gestation revealed that the diameter of the beginning portion of the aorta (under the aortic valve) was narrowed by about 17 mm. The diameter of the ascending aorta was normal, the average pressure gradient was 40 mmHg, and the ejection fraction was 67%.\nIn the operation room, her baseline vital signs were as follows: heart rate (HR), 82 bpm with normal sinus rhythm; noninvasive blood pressure (BP), 130/76 mmHg; and oxygen saturation (SpO2), 96%. Supplemental oxygen was administrated by a face mask at the rate of 3 L/min. Traditional epidural puncture was performed at the L1–2 and L3–4 interspaces in the left lateral position, and a catheter was inserted to a depth of 4 cm into the epidural space at the cranial and caudal ends of the surgical field. The patient was then placed supine in a left-tilt position; 3 mL of 2% lidocaine was injected as a test dose, and another 7 mL was injected 5 min later through the cranial catheter. Additionally, 3 mL of 1.5% lidocaine was injected through the caudal catheter. At 20 min after the lidocaine injection, the sensory block had reached T6. The patient had no discomfort, and her hemodynamic parameters were stable. The operating bed was adjusted from the left-tilt to horizontal position, and the operation was allowed. Two minutes later, the patient reported chest distress and difficulty breathing (HR, 110 bpm; BP, 80/69 mmHg; SpO2, 96%), and 3 mg of intravenous ephedrine was promptly administered. The patient immediately lost consciousness with no response (HR and BP were depressed to 40 bpm and 53/15 mmHg, respectively). The lowest BP at"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old G3P0111 with a past medical history significant for seizure disorder and morbid obesity (Body Mass Index 33 kg/m2) presented with a chief complaint of progressively worsening abdominopelvic pain, nausea, and vomiting for one day. Two weeks prior she presented to an outside facility for right-sided abdominopelvic pain and dyspareunia at which time her intrauterine device was found to be malpositioned with the IUD was low lying and predominantly in the cervix but otherwise there was no evidence of pelvic pathology on transvaginal ultrasound imaging. She subsequently had the intrauterine device removed by an outside gynecologist prior to her presentation to our facility. On presentation to the emergency room, she was found to be tachycardic but normotensive and afebrile. Her laboratory values were significant for white blood cell count of 18.4-cells/mm3 and a glucose level of 443 mg/dL. Computed tomography (CT) scan of the abdomen and pelvis demonstrated a right-sided tubo-ovarian abscess that was 8 cm in diameter with foci of internal air and extensive surrounding inflammatory changes ().\nThe patient had not received primary care for a prolonged period of time. She was subsequently found to be in diabetic ketoacidosis with newly diagnosed type 2 diabetes mellitus and a hemoglobin A1c level of 14% requiring aggressive intravenous fluid hydration and insulin. She also had a low grade temperature so one set of blood cultures were obtained and she was initiated on empiric antibiotics with intravenous gentamicin and clindamycin pending complete work-up. Interventional radiology (IR) was consulted for possible drainage of the tubo-ovarian abscess but the location of the abscess was not amenable for a safe percutaneous approach secondary to bowel loops and major arteries being in close proximity to the abscess. While she initially had mild improvement of her abdominal pain with downtrending fever curve and leukocytosis, her clinical course was complicated by ol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old woman with renal insufficiency (GFR 16 mL/minute/1.73 m2) and known kidney stones, who had deferred definitive stone management for nearly 5 years, presented to our clinic in June of 2015 with left flank pain. A CT scan of the abdomen demonstrated bilateral staghorn calculi, severe bilateral hydronephrosis, and minimal right renal parenchyma with thinned left sided parenchyma. Compared to prior CT in 2013, there was an additional finding of a new hyperdensity within the left lower pole suggestive of hemorrhagic or proteinaceous debris (). She complained of increased fatigue and pain, however, denied weight loss or hematuria. She was desirous of definitive left stone removal for renal preservation and pain control and was counseled toward a staged PCNL.\nAfter gaining percutaneous access and removing a moderate volume of stone, we noted abnormal shaggy appearing urothelium of the collecting system, which was biopsied. The intraoperative course was complicated by moderate blood loss hypotension. The patient required postoperative blood transfusions and inotropic support and, ultimately, required interventional radiology guided angiogram and selective renal artery embolization to cease blood loss. Renal function declined as a result of the embolization, intravenous contrast nephropathy, and acute blood loss anemia and the patient ultimately required hemodialysis. After stabilization, she was discharged on postoperative day 13.\nHistologic assessment of the inflammatory tissue revealed papillary proliferation with squamous metaplasia and moderate atypia, interpreted as reactive urothelium given long-standing stone history. At 1-month follow-up, physical examination revealed a tender cutaneous bulge on her left flank, at the site of her previous nephrostomy, concerned for hematoma or abscess. A CT of the abdomen favored hematoma extending to the skin () and also noted nonspecific para-aortic lymph node enlargement. Shortly after, the collection was noted to e"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old Asian woman returned for a frozen embryo transfer (FET) cycle three years following an uncomplicated pregnancy and birth that resulted from a previous successful attempt at ovulation induction with gonadotropins and IVF. She had been placed on an antagonist protocol and her stimulation was unremarkable. Her medical history was significant for hyperlipidemia and oligoovulation secondary to PCOS, which was diagnosed at the time of her initial presentation. At that time, she had irregular menses occurring every 1–4 months and evidence of bilateral polycystic ovaries on ultrasound. Her androgen levels were normal and she did not exhibit any evidence of clinical hyperandrogenism. Prior to returning for FET, her menses remained irregular; however she denied the use of any hormonal agents. There was no personal or familial history of endometriosis or gynecologic malignancies. Pelvic ultrasounds (PUs) performed at her initial infertility consult as well as during treatment and in the early stages of pregnancy revealed polycystic-appearing ovaries, but were otherwise normal.\nPrior to the commencement of a FET cycle, the patient had a baseline PU, which revealed a complex ovarian cyst with layered low level echoes measuring 5.1 × 3.8 cm (). One area at the base of the cyst had a papillary growth (), while color Doppler revealed venous flow within the growth suggesting malignancy. Tumor markers including CA125 (21 U/mL) were within normal range. A repeat PU and a subsequent CT scan confirmed the previous ultrasound findings.\nAt exploratory laparotomy by gynecological oncologist, an enlarged fluctuant and cystic left ovary adherent to the rectosigmoid was found. The pelvis was otherwise normal. After obtaining peritoneal washings, the patient underwent a left salpingo-oophorectomy and omental biopsy but the cyst inadvertently ruptured during the procedure. Gross examination showed a 5 cm cyst with a 2.5 cm papillary lesion arising from the cyst wall. Final patholo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is an elderly woman, 82 years old this year. She went to the hospital for abdominal pain in May 2000. Color Doppler ultrasound showed moderate ascites and right ovarian accessory mass. Abdominal aspiration was taken as bloody osmotic fluid, and pathological smears found adenocarcinoma cells. She was then given preoperative neoadjuvant chemotherapy: intraperitoneal perfusion (cisplatin 120 mg) and systemic chemotherapy (cyclophosphamide 700 mg, pirarubicin 60 mg), every 3 weeks for 3 cycles.\nOn July 11, 2001, the patient underwent total uterine attachment, omentum, pelvic lymphadenectomy, and pelvic floor tumor reduction under general anesthesia. The postoperative examination was ovarian cancer. Adjuvant chemotherapy was performed after surgery: intraperitoneal perfusion (cisplatin 120 mg) and systemic chemotherapy (cyclophosphamide 700 mg, pirarubicin 60 mg), every 3 weeks for 3 cycles.\nThe patient was taken to the hospital because of the left breast mass on November 20, 2018. Physical examination showed that there was a hard mass in the left breast, which was not movable and painless, with a diameter of about 2 × 2 cm. The right breast and bilateral axillary fossa were normal. Molybdenum target showed a mass lesion in the lower quadrant of the left breast, which may be malignant. Doppler color Doppler showed that the low-echo nodules were found at 5 o’clock in the left breast. The shape was irregular, the edges were irregular, the right breast was not abnormal, and the bilateral lymph nodes were negative. Computed Tomography (CT) showed a small amount of effusion in the bilateral thoracic cavity; bilateral lungs were scattered in the nodules, with a maximum of 0. 7 × 0. 5 cm in the lateral segment of the right middle lobe.\nOn November 21, 2018, she underwent general anesthesia for left breast cancer breast-conserving surgery and sentinel lymph node biopsy (SLNB). The pathological results were malignant, and no tumor metastasis was observed in peripheral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man with SB developed ESKD due to reflux nephropathy and enrolled in a maintenance HD programme. After 1 year, he developed recurrent syncopal events with each HD treatment. Syncope would predictably occur 1–2 h into HD. He suffered light-headedness prior to each event and an occipital headache subsequently. He returned to normal each time over a variable period from 10 to 30 min after termination of HD. He was completely asymptomatic in the time between each HD session.\nHe had a ventriculo-atrial shunt due to hydrocephalus. This shunt was assessed by the neurosurgical service and found it to be functioning entirely normally. He had the cerebrospinal fluid (CSF) removed from the shunt reservoir pre-HD to increase pressure accommodation. Cardiac telemetry during the syncopal episodes demonstrated that sinus tachycardia and echocardiography were normal. Video-electroencephalography (EEG) during syncope showed a pattern consistent with the sleeping state, but no seizure activity or signs of encephalopathy.\nReducing the size of the dialysis filter, the blood flow rate and the duration of dialysis treatment in an attempt to reduce osmotic shifts were unsuccessful, however, this did reduce the severity of events and the recovery time, suggesting some benefit.\nMagnetic resonance imaging (MRI) of the brain revealed CM II with severe herniation of the cerebellar tonsils through the foramen magnum, as shown in .\nWe theorize that the severity of compression of the reticular activating system was such that very minor increases in cerebral volume were enough to cause syncope and could not be compensated for by the functioning ventriculo-atrial shunt. The EEG pattern consistent with the sleeping state adds further to the evidence of compression on the reticular activating system by the herniating cerebellar tonsils.\nIn an attempt to reduce intra-cerebral pressure, we gave a trial of 50 g of mannitol immediately before dialysis and an additional dose at the midpoint"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old woman presented with a slowly growing asymptomatic mass over the scalp in the right parieto-occipital region. Clinical history revealed that there was no trauma or fracture in the past. There was no history of headache or convulsion. The patient did not have weight loss or loss of appetite. Her menstrual cycles were normal. The mass had been progressively increasing in size over the last 4 years. On examination, the swelling measured approximately 2 cm × 2 cm, was firm, slightly fixed, nontender, and covered by normal skin []. It was non-fluctuant. There was no discharge or punctum associated with the swelling. There was no evidence of cervical lymphadenopathy on palpation. Further systemic and bilateral breasts examination revealed no abnormality in any of the systems.\nX-ray of the skull showed bony calvaria with no evidence of any bony abnormality or fracture. Laboratory investigations revealed normal hematological parameters such as complete blood counts and peripheral smear examination. Biochemical tests such as thyroid, kidney, and liver function tests, as well as lipid profile of the patient were normal.\nFNAC was performed and blood mixed cellular aspirate was obtained. Papanicolaou and Giemsa stains were applied. Smears prepared showed high cellularity comprising of clusters, sheets, whorls, and singly scattered epithelial cells. These cells showed mild pleomorphism and were round to oval with eccentric nuclei, fine granular chromatin, and moderate amount of cytoplasm [Figure ]. Few of the cells showed intranuclear inclusions []. Many tight whorls of such cells were also noted [, inset]. No necrosis or any mitotic figures were seen, and the background showed blood. Finally, an impression of cutaneous meningioma was made based on the cytomorphological features. The patient was advised radiological investigations and neurosurgical intervention.\nCECT brain showed evidence of soft tissue enhancing swelling over the right parieto-occipital region []."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old man presented with high-grade muscle-invasive bladder cancer and underwent robot-assisted laparoscopic radical cystoprostatectomy with urethrectomy, extended pelvic lymph node dissection, and intracorporeal urinary diversion. One week after surgery, clear fluid started leaking from the external urethral orifice. The leakage output was 300 mL per day. CT revealed a medium amount of ascites. Biochemical examination of the ascitic fluid was suggestive of lymphorrhea. A low-fat diet was started, but the leakage output did not decrease. Two months after surgery, intranodal lymphangiography was performed to detect the site of leakage and reduce the amount of lymphatic leakage. Under local anesthesia, bilateral inguinal lymph nodes were punctured with a 23-gauge cathelin needle under ultrasound guidance (). Lipiodol was injected slowly under fluoroscopy, showing a network of lymphatic vessels in the pelvis. Lymphatic leakage from the left pelvic wall into the peritoneal cavity was detected (). Although the therapeutic effect of lipiodol lymphangiography was expected, the amount of lymphatic leakage did not change after lymphangiography. Thus, laparoscopic surgical repair of lymphorrhea was performed two weeks later. During the repair, a dent was found on the left wall of the pelvis just above the external iliac artery, from which the serous fluid slowly leaked into the peritoneal cavity. Although the dent was suspected to be the lymphatic leakage point, the laparoscopic findings alone were not conclusive. We decided to perform intraoperative lymphangiography to confirm that the dent was the leakage point and to exclude other sites of leakage. A left inguinal lymph node was punctured under ultrasound guidance and lipiodol was slowly injected, showing leakage from the left wall of the pelvis. Then, indigo carmine diluted 10-fold with normal saline was slowly injected. In total, 1 mL of lipiodol and 1 mL of diluted indigo carmine were used. Three minutes after a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 79-year-old woman presented with post-menopausal bleeding and pain in lower abdomen for 2 months. The obstetric history of the patient was P2L2 and the patient had attained menopause 30 years back. The age of menarche was 14 years. On examination, a firm mass was palpable in lower abdomen extending upto umbilicus. On vaginal examination, uterus size could not be made out and a large abdomino pelvic mass was palpable. Abdominal ultrasonography revealed a normal-sized uterus with endometrial thickness of 7 mm and a 20 × 10 cm solid mass in pelvis and lower abdomen. Left ovary was not seen separately and there was minimal ascites. Patient underwent endometrial aspiration and it was reported as endometrioid adenocarcinoma (Grade 1). Patient underwent staging laparotomy which revealed a 20 × 10 cm solid left ovarian tumor. The right ovary was normal and there was minimal ascites which was sent for cytology. On exploration, intestines, liver and biliary tract, pancreas, omentum, and fallopian tubes were without lesions and the uterus was of normal size. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, infra-colic omentectomy, and pelvic lymphadenectomy and the specimen was submitted for histopathological examination.\nLeft ovary measured 21 × 14 × 10 cm and the cut section was homogenously fleshy with areas showing yellowish discoloration. Cut section of the uterus revealed a 4 × 3 cm exophytic fundal growth in the endometrial cavity infiltrating less than one-third of the myometrium. The right ovary, omentum, and bilateral fallopian tubes were grossly normal. On microscopic examination, left ovary showed features of a stromal tumor with minor sex cord elements []. The tumor comprised mainly of fibroma-thecoma component (more than 90%) with few aggregates of granulosa cells []. These granulosa cell aggregates were immunoreactive for inhibin [] and calretinin [].\nMultiple sections from the endometrial growth showed features of a wel"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old man with no medical history presented to our hospital with a 2-week history of the left low back pain. He reported a unilateral lower lumbar and buttock pain below the L5 spinous process that increased while sitting, particularly on a chair without a back rest. His physical examination revealed normal neurological findings, and tenderness on posterior iliac spine was reported. Moreover, provocation tests (Patrick’s test, Gaenslen’s test, and the SIJ shear test) indicated positive results on the left side. There were no specific findings in plain radiography of the lumbar spine and pelvis or magnetic resonance imaging (MRI) of the lumbar spine. In addition, blood chemistry test findings were normal. From the physical examination, SIJ pain was strongly suspected. However, the SIJ block under fluoroscopic guidance was ineffective. We prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and observed the patient through follow-up. We performed MRI of the pelvis 2 weeks later. MRI of the left SIJ revealed low signal intensity on T-1 weighted images and high signal intensity on T-2 weighted images. It revealed a diffuse bone marrow edema in the left SIJ (). Computed tomography scan of the pelvis was then performed for differential diagnoses of the lesion, however, neither tumors lesions nor fractures were detected. The treatment course was local rest and continued NSAIDs administration, and the pain resolved within 3 months. However, 2 months later, he was referred to our hospital again with right low back pain. The physical findings and examination were similar to the initial consultation. MRI revealed a diffuse bone marrow edema at the right SIJ; the left SIJ bone marrow edema had disappeared (). The patient was administered the same treatment course of local rest and NSAIDs. After 5 months, his symptom disappeared, and the MRI revealed a disappearing bone marrow edema with normal findings (). During the 2 years of follow-up, there has been no recurrenc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 93-year-old woman who came to the ED with two days of syncopal episodes, altered mental status, and chest pain. The patient had a past medical history of hypertension, renal cell carcinoma requiring left nephrectomy, thyroid cancer requiring thyroidectomy, and subsequent hypothyroidism. The patient was evaluated by the Internal Medicine team and was found to be very weak and confused with a heart rate (beats per minute) ranging from the 120s to 130s. She also had episodes of sinus arrest and elevated troponins. She was admitted to the medical intensive care unit (ICU) with symptomatic sinus node dysfunction and tachycardia-bradycardia syndrome.\nUpon admission, an ultrasound-guided right internal jugular catheter was placed without any reported complications or difficulties. Cardiology was consulted and the patient was started on an isoproterenol drip with plans for pacemaker placement. During the procedure, the central line was noted to be pulsatile and crossing the midline. Immediately after pacemaker placement, the Vascular Surgery team was consulted for evaluation and management of iatrogenic intra-arterial central catheter placement.\nUpon vascular evaluation, a chest X-ray (CXR) was reviewed (Figure ); and the central line was noted to have an unusual track with the tip projecting medially. To confirm the diagnosis of intra-arterial catheter placement, blood gases were obtained; and the line was evaluated for waveform and blood pressure. These studies showed clear arterial parameters confirming the presumed diagnosis. Ultrasound evaluation was inconclusive due to patient habitus. After discussing the risks and benefits of removing the line at the bedside versus in the operating room (OR), the patient was immediately taken to the OR.\nThe patient was placed under general anesthesia and intubated. The patient's position was similar to that used for a carotid endarterectomy with the head slightly extended and turned towards the left. The ca"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66 year-old Japanese male underwent upper gastrointestinal endoscopy by his practitioner for complaints of dysphagia, which revealed an esophageal submucosal tumor. He was referred to the National Hospital Organization Mito Medical Center in 2006 for treatment. He did not complain of fever, weight loss, or night sweating. On admission, physical examination revealed no remarkable features; the liver, spleen, and superficial nodes were not palpable. His laboratory data showed no abnormalities except a 10-year history of abnormal glucose tolerance treated by his primary physician. No elevated tumor markers or autoimmune antibodies were observed. A barium esophagogram, CT, and upper GI endoscope showed an esophageal submucosal polypoid lesion at the cervical esophagus (). Its location close to the esophageal orifice and large size (4 × 2 cm) made an endoscopic resection technically difficult, and the patient was enrolled in the Department of Surgery. As the tumor was endoscopically diagnosed as benign leiomyoma or lipoma, we decided to perform a tumor resection because of the patient's complaints of dysphagia and because the cervical esophagus is relatively approachable compared with the thoracic esophagus, even without pathological diagnosis. The tumor was removed through a cervical esophagotomy under a cervical collar incision.\nThe tumor macroscopically showed a submucosal polypoid appearance (). Resected tissue was fixed in 20% formalin, embedded in paraffin, and routinely stained with hematoxylin and eosin, followed by immunohistochemical analyses with monoclonal antibodies, as summarized in (supplement). The tumor was composed of multiple, vague nodules (,) that contained abortive CD10+Ki67+ germinal centers surrounded by a regular proliferation of CD3-CD20+CD79a+bcl2+ small lymphoid cells without immunoblastic large cells (). These areas corresponded to the mantle zone, with no definite formation of the marginal zone observed. No lymphoepithelial lesions (intrae"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female of north Indian origin, reported to the OPD of GMC, Patiala, on 2 April 2013 with the complaint of postmenopausal bleeding since six months. Bleeding was off and on and irregular in nature. She also had lower abdominal pain, which was mild in intensity, non-radiating and having no variability with change of posture or respiration. There was also a history of weight loss and decreased appetite over the last two months. There were no associated bowel or bladder complaints. There was no history of any long-term illness or any chronic disease or any prior hospitalization.\nPatient was moderately built. Vitals were stable with blood pressure 136/88mm Hg, pulse rate 76/min and respiratory rate 18/min; no pallor was present.\nOn per abdominal examination, a soft to firm midline mass was palpable, which was about 20 weeks as compared to a pregnant uterus and had smooth surface. The mass was mobile from side to side, with no tenderness or any changes in the overlying skin.\nOn per vaginal examination, the cervix was directed backward, uterus was anteverted, around 20 weeks size and mobile, B/L fornices were clear, and no tenderness was observed.\nPatient had already undergone an endometrial biopsy and cervical biopsy on 8 March 2013 at a private nursing home, which showed malignant mesenchymal lesion and features suggestive of chronic cervicitis. On computed tomography dated 22 March 2013, there was a large, well-defined heterogeneous enhancing mass of approximately 14 × 12 cm size seen arising from uterus with thinned out peripheral rim of normal myometrial tissue with possible infiltration into myometrial wall anteriorly with few nodular calcifications seen in the peripheral and central regions. Both the ovaries were normal looking. The pelvic fat planes were well maintained and appeared normal. Muscular and bony walls had normal outline. There was no lymphadenopathy.\nProbable diagnosis of endometrial growth was made and the patient was advised surgery. Al"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female patient with hemoglobin-SS sickle cell disease, osteonecrosis of the right hip with chronic right hip pain, and asthma presented complaining of pain in both thighs for 5 days. The pain began after ice-skating but she denied any direct trauma to her limbs. On presentation, she was febrile and tachycardic, with leukocyte count of 25.3 × 109/L and hemoglobin of 7.0 g/dL. There was no tenderness to palpation of the hips bilaterally and no tenderness to palpation of the joints, but an ill-defined swelling to the right anterior thigh was noted which the patient reported was chronic.\nAn initial diagnosis of sickle cell vasoocclusive painful crisis with systemic inflammatory response syndrome was made, and sepsis work-up was done. She was started on analgesics and intravenous fluids and also received a simple blood transfusion. On hospital day (HD) 2, she was noted to have persistent fever and leukocytosis and so was started on intravenous Levofloxacin empirically. At that time, her left thigh pain appeared to be worsening, with a new area of swelling and warmth but no tenderness. X-rays of the left hip and left thigh were done, which showed heterogeneous appearance of the proximal left femoral shaft, which was thought to be likely secondary to sickle cell osteodystrophy, infarct, or infection.\nThe patient's blood cultures obtained on admission had shown no growth and her urine culture was negative. Her chest X-ray showed no evidence of pneumonia. However, clinically, she did not appear to be improving, with persistent pyrexia and leukocytosis. Her C-reactive protein levels were elevated at 7.8 mg/dL, for which her dose of Levofloxacin was increased and Vancomycin was added. Due to increasing suspicion for osteomyelitis, an MRI of the left lower extremity was done. It demonstrated 2 areas of loculated fluid collection: the first was in the proximal left thigh anteriorly, in the quadriceps"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 68-year-old male underwent pelvic exenteration, right lower quadrant ileal conduit creation, and left lower quadrant colostomy for the treatment of rectal carcinoma. Four years after these surgical procedures, the patient presented with vague lower abdominal and perineal pain and decreased ileal conduit output for four days. In addition, he related that he was experiencing persistent drainage of cloudy, yellow fluid from the perineum for four weeks.\nOn physical examination, the patient was found to have a wet perineum with a visible draining sinus in the ventral aspect of the anal scar.\nRenal ultrasound was performed and revealed normal kidneys with no evidence of hydronephrosis. A nuclear medicine bone scan was negative for metastatic disease, but it was evident that the ileal conduit was leaking urine into the deep pelvis (). A retrograde ileal conduit examination, with water soluble contrast, revealed contrast flowed promptly from an open end of the conduit intoa pelvic fluid collection. Neither ureter could be visualized as the contrast preferentially flowed into the pelvis (). The findings were considered to be consistent with a proximal ileal conduit dehiscence and extravasation of contrast into a pelvic cavity.\nUrology consulted interventional radiology to discuss placement of bilateral nephrostomy catheters, followed by antegrade ureteric stents, in an attempt to divert urine away from the conduit dehiscence.\nIn the absence of hydronephrosis, nephrostomy insertion was deemed to be too technically difficult and would require multiple needle punctures of the kidneys while attempting to gain access to the collecting system. In addition, the collapsed collecting systems would present a very confined space in which to attempt to maneuver needles, guide wires, and catheters. Because of the probability of procedure technical failure, and heightened concerns about procedural complications, another treatment option was felt to be necessary. It was decided that a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old male was taken to a general hospital after the car he was travelling in collided with a tree at fifty miles per hour. CT demonstrated free fluid in the pelvis, likely from a mesenteric bleed, but no free air and no solid organ damage (). He was transferred to a major trauma centre where he was managed conservatively and discharged the next day.\nFive days later he represented to a third hospital with severe abdominal pain. A repeat CT showed an increase in the volume of pelvic free fluid and he was immediately taken to theatre for exploratory laparotomy. This revealed a mid-small bowel point of obstruction caused by adhesion to a mesenteric haematoma. Extensive adhesions were evident (the patient had an appendicectomy age nine), but there was no prior history of symptoms of obstruction. Proximal adhesiolysis was performed to allow mobilisation of bowel but this was limited by extensive peritoneal contamination and patient stability; distal and pelvic adhesions therefore remained.\nAlthough there was no full thickness or serosal injuries to the small bowel, it was completely detached from the mesentery and showed signs of ischaemia. A 20 cm section of small bowel was resected, with a side-by-side anastomosis fashioned. Histology from the resected section of small bowel showed only inflammatory and fibrotic changes compatible with trauma.\nAfter four days in ITU, a repeat CT scan was performed as NG aspirate volumes and inflammatory markers remained high. This showed a small left iliac fossa collection with no clear features of perforation. There was small bowel dilatation with a change of calibre in the region of the anastomosis, raising the possibility of obstruction (Figures and ). This most likely represented a paralytic ileus and it resolved without further intervention. The patient was discharged twelve days after surgery.\nHowever, he represented later that day with a leaking abdominal surgical wound. The fluid had the appearance of undigested food, r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old man underwent a computed tomographic (CT) scan to determine the status of cervical lymph node involvement and discrete swelling of the right parotid gland. One year before, the patient had undergone partial resection of soft palate for mucoepidermoid carcinoma. Neck lymph node involvement was negative, but 32 x 24 mm well-circumscribed mass was incidentally detected in the deep lobe of the right parotid gland []. MRI of oropharyngeal and neck region was performed. The MR images showed a well-circumscribed mass in the deep lobe of the right parotid gland with extension to para pharyngeal space [].\nThe mass showed low-signal intensity to parotid gland parenchyma on T1- and T2-weighted images and homogeneous enhancement after intravenous gadolinium-based contrast medium administration. On the basis of these findings, the lesion was diagnosed as a deep lobe parotid tumour. FNAC with screening performance was applied immediately prior to operative treatment. A parotidectomy was performed with mandibular osteotomy, selectively excising a portion of a deep lobe of the right parotid gland []. Postoperatively, an operative specimen with the tumour was examined macroscopically and histologically. Tumour was 32 x 24 mm in size, was resilient, soft, and surrounded by a capsule. It did not adhere to the surrounding tissues. The surface of the tumour was soft, homogeneous, and yellowish brown []. Microscopic examination showed large cells separated by exceedingly obscure stroma []. The cytoplasm was bright eosinophilic with eosinophilic granules. The cells contained relatively small, round, vesicular nuclei with no or more nucleoli. Mitotic figures were absent. There was a scattering of ducts, suggesting remnants of a duct system. The final histological diagnosis was an oncocytoma. No capsule is discernible in microscopic features. PTAH stain was done to confirm that the eosinophilic granules were mitochondria.\nPostoperative period was uneventful. The patient was tr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old man was being referred to our hospital due to hemoptysis. He experienced hemoptysis 16 months ago. The non-contrast outside chest computed tomography (CT) missed the anomaly thereafter. Otherwise, his past medical history and family history were not remarkable. Physical and laboratory findings were within normal limits. A chest radiograph demonstrated no active lung lesions. Chest CT with contrast enhancement showed a ground-glass attenuation and consolidation in the right lower lobe posterior basal segment and a large anomalous artery from the distal descending thoracic aorta supplying basal segment of right lower lobe (). The diameter of the feeding artery was about 10 mm. Bronchoscopy revealed that the major bronchial branches were normal and at the right 2nd carina there were bleeding evidences and woozing on saline washing (). Angiography showed about 10 mm diameter feeding artery to basal segment of right lower lobe, enlarged arteriovenous vessels and draining vein. On diagnosis of anomalous systemic arterial supply to the basal segments of right lower lobe from descending aorta without sequestration, the therapeutic embolization was performed with Amplatzer Vascular Plug (two 12 mm; AGA Medical, Golden Valley, MN, USA) ().\nAfter the embolization, the patient suffered from fever. At 2 days after embolization, chest X-ray revealed hazy and nodular opacities at right lower lobe (RLL). With a suspected diagnosis of post-embolization syndrome with pneumonia, the patient was prescribed to empirical antibiotics. Although the fever subsided 5 days later, his chest X-ray showed pleural effusion in the right lung (). A diagnostic thoracentesis revealed amber colored fluids, which was found to be neutrophil-predominant exudates. At 14 days after the antibiotics application, he was discharged when symptoms and conditions had improved, but pleural effusion sustained. Twenty-two days later, his chest CT revealed vascular plugs, anomalous systemic artery from"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe present case report is about a 34-year-old gentleman who presented with a painful swelling behind the angle of left mandible of 5 months duration. He also complained of change in character of voice, dysphagia and weakness of left upper limb for 3 months prior to admission.\nOn neurologic examination, he had IX, X and XI cranial nerve palsy on the left side. There was a 3.5 cm × 3.0 cm bony hard swelling underneath the angle of left mandible leading to obliteration of post auricular groove. It was extremely tender. On examination of the oral cavity, the swelling was bulging into the tonsillar fossa and compressing the palatal arches.\nSince, the mass was palpable externally, fine-needle aspiration was attempted pre-operatively (twice) and on both occasions, but it was found to be inconclusive.\nThe axial and reformatted sagittal computed tomography showed a large expansile and destructive bony lesion involving the foramen magnum on the left side from lower clivus up to the axis. There were calcifications seen within the tumor. Thin sclerotic rim was visible around most of the periphery of the lesion [Figure –]. The lesion had involved the lateral masses and part of anterior and posterior elements of upper 2 cervical vertebrae.\nMagnetic resonance imaging showed a heterogenous mass (size approximately 5.3 cm × 6.2 cm × 5.5 cm) with strong post contrast enhancement. The lesion was displacing left internal carotid artery peripherally causing mild compression and had involved the left vertebral artery, the oblique part of V3 segment [Figure –].\nWith pre-operative impression of a high grade bony lesion, the patient was planned for surgical decompression of the mass through left sided far lateral approach. At surgery, near total excision of the tumor was achieved, deliberately leaving a thin rim of tumor tissue attached to posterior pharyngeal wall to prevent opening the oral cavity [Figure and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 58-year-old woman presented with dyspnea on exertion of 2 months’ duration and 2 episodes of syncope on January 20, 2020. Transthoracic echocardiography showed a well-defined heterogeneous, large, round mobile mass with attachments to the atrial side of the anterior mitral valve leaflet (26 × 20 mm), suggestive of an atypical myxoma (Fig. ). In addition, the patient had a left ventricular ejection fraction (LVEF) of 55%, severe mitral stenosis, severe mitral regurgitation, mild-to-moderate tricuspid regurgitation, and a pulmonary arterial systolic pressure (PASP) of 42 mm Hg. Coronary angiography revealed normal epicardial coronary arteries. Brain computed tomography (CT) and neurologic evaluations were unremarkable.\nThe patient was scheduled for surgical mass excision. On January 24, the LA mass (20 × 25 mm) was removed completely, and the mitral valve was replaced with a St Jude Medical prosthetic valve given the destruction of the anterior mitral valve leaflet and chordal involvement. The histopathological examination illustrated diffuse fibrosis in the mitral valve, as well as cellular pleomorphism and high mitotic activity in the removed cardiac tumor. The evaluation of the surgical margin was rendered impossible by the fragmentation of the specimen. Postoperative echocardiography revealed that the prosthetic valve had good leaflet motion with an acceptable gradient. An LVEF of 45%, mild tricuspid regurgitation, and a PASP of 28 mm Hg were also reported. No residual mass was detected. The patient was discharged thereafter on February 3.\nSeventy-nine days later, on April 22, 2020, the patient was readmitted with a 1-week history of dyspnea, palpitation, fever (body temperature = 38 °C), and a sore throat. The time in therapeutic range assessment revealed that the international normalized ratio was acceptable during the mentioned period. In the emergency department, transthoracic echocardiography demonstrated the fixation of the prosthetic mitral valve in 1 lea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was an 11-year-old boy with no family history of optic neuropathy or dystonia. He presented with focal dystonia in the right upper limb at 3 years of age, and his disease progressed over 4 years to dystonia in both the upper and the lower limbs on his dominant right side. At 5 years of age, he was able to walk slowly without holding a handrail. However, at 7 years of age, he had severe dysarthria and was unable to walk without support owing to dystonia and spasticity. He had neither mental retardation (verbal IQ, 129; performance IQ, 97; full-scale IQ, 115 by the Weschler Intelligence Scale for Children) nor short stature. Ophthalmologic examination showed no remarkable findings indicative of optic neuropathy. Magnetic resonance imaging findings at 3 years of age showed high signal intensity lesions in bilateral putamina on fluid-attenuated inversion recovery images () and diffusion-weighted images (). With time, the high signal intensity lesions on diffusion-weighted images migrated from the putamina to the caudate nuclei (). The MRI findings obtained at 6 years of age showed that the high signal intensity lesions had spread to the bilateral caudate nuclei and the midbrain on fluid-attenuated inversion recovery images () and diffusion-weighted images (). On laboratory examination at 7 years of age, blood cell counts were normal, and the concentrations of lactate and pyruvate were not elevated in serum and cerebrospinal fluid. The serum concentrations of copper and ceruloplasmin were normal. In the serum Amino acid analysis, organic acid level in urine, and levels of lysosomal enzyme in white blood cells were found to be normal. Sequence analysis of the white blood cell mitochondrial DNA from this patient showed the presence of a homoplasmic G>A transition mutation at nucleotide position 14 459 in the reduced nicotinamide adenine dinucleotide dehydrogenase subunit 6 gene ().\nThe patient had been treated with coenzyme Q10 (2 mg/kg/d), l-carnitine (90 mg/k"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old female presented to the Department of Plastic Surgery in surgical super specialty block. History revealed repeated administration of intramuscular injections at bilateral gluteal regions. Clinical examination showed hard mass in bilateral gluteal area. Ultrasound scan of the gluteal areas showed hard lesions with pockets of necrosis within. Biopsy revealed calcified tissue. Patient was further evaluated by dermatologists for connective tissue disorders and muscular dystrophies. Laboratory investigations for rheumatoid arthritis, systemic lupus erythematousus (SLE) were done. Patient's clinical examination, blood investigations for connective tissue disorders and muscular dystrophies were negative.\nThe lady was posted for bilateral gluteal mass excision and flap cover procedure under anesthesia. Patient's preanesthesia check-up was done a day prior to surgery. Lady gave a history of getting intramuscular injections for fever and body ache from adolescence. Lady weighed 40 kilos and height of 150 cm. General physical examination showed thickened skin and small discrete bony masses beneath the skin in areas like face, elbows, knees and surgical site. Airway examination-mouth opening vertically allowed three fingers. Angles of the mouth were inelastic and allowed three fingers with difficulty. Jaw and neck were normal with a normal range of neck movements. Systemic examination was normal. There was restriction in the movement of the hip joint due to hard mass over gluteals. Fungal infection was present on the back till lumbar region. Anesthesia technique planned was general anesthesia with the endotracheal tube as position needed for surgery was the prone position.\nNil per oral guidelines were advised, and a written informed consent was taken from the patient Tablet Ranitidine 150 mg and Tablet Alpralozam 0.5 mg was advised for the night. On the day of surgery intravenous line was secured in preoperative holdup area and intravenous premedication of inject"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nEleven years ago, when our patient was a 33-year-old unmarried nulligravida, she developed CCC of the ovary for the first time. At that time, her menstrual cycle was regular and 30 days long, with dysmenorrhea, manifesting as lower abdominal and lumbar pain, persisting for 5–7 days. There was no family or medical history of note. She had visited a local clinic with the chief complaint of lumbar pain, where a right ovarian tumor 8 cm in size that included solid internal components, was identified, and she was referred to the University of Tsukuba Hospital. Transvaginal ultrasound had revealed a right adnexal mass with solid components, 68 mm × 53 mm in size, and an intramural uterine fibroid 23 mm × 27 mm, with no hypertrophy of the endometrium, which measured 2.1 mm. Blood counts and blood biochemistry test results revealed no abnormalities. Her serum CA19-9 level was 45.9 U/ml, CA125 was 22 U/ml, and CEA level was 1.3 ng/ml. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed an 80-mm unilocular cystic mass in the right ovary with a papillary protrusion of longest diameter 45 mm. The left ovary was not enlarged, and there was no obvious peritoneal dissemination or enlarged lymph nodes. Surgery, comprising right adnexectomy, left ovarian biopsy, partial omentectomy and uterine fibroid removal, was performed. The right ovary was enlarged to 8 cm in size, and it was removed without intraoperative rupture and with its capsule intact. The left ovary was not enlarged, but was seen to have a small endometrial cyst, which was resected. The absence of peritoneal dissemination and enlarged lymph nodes was confirmed during surgery. The pathological diagnosis was CCC localized to the right ovary and endometriosis was observed in the left ovary, with ascites cytology Class III. The cytology was composed of clusters that include atypical cells having somewhat nuclear enlargement, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 17-year-old female patient was presented to our institute on April 2016 complaining of occasional back pain and spinal deformity. On examination, the patient had no limitation of physical activity, occasional pain, no neurological deficits with mild thoracic scoliosis. Reassurance of the patient and her family was done with conservative treatment. Six months later, the patient presented back with worse pain, numbness of both lower limbs, progressive deformity, and shortness of breath. MRI was ordered for her, and revealed a giant extra pulmonary mass shifting the mediastinum to the opposite side, extending opposite T6 to the lower border of T10 with intra spinal extension through the left neural foramina compressing the spinal cord. Full-length spinal PA and lateral X-rays showed left thoracic scoliotic curve extending from T5 to T9 with apex at T7 and measuring about 50° with Cobb method with thoracic kyphosis of 65° (–).\nPercutaneous US-guided needle biopsy was done, and the histopathological report confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass through posterior approach was planned for the patient after a multidisciplinary team approval in our institute comprising spine surgeon, anesthesiologist, and cardiothoracic surgeon.\nThe patient was operated under general anesthesia in prone position over a radiolucent table. Standard posterior approach to the thoracic spine was done exposing the posterior elements subperiosteally. Then pedicle screws were inserted using the free hand technique from T3 to T11 and their position was checked by intra operative radiograph. A rod was connected to the screws on the right side and then wide microscopic decompression of the spinal canal was done exposing the mass and the spinal cord. Careful dissection of the mass from the spinal cord was done and the nerve root connecting the mass to the cord was identified and liga"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nHistory\nA 27-year-old Caucasian male presented to the emergency department with an open right tibia and fibula shaft fractures following a high-speed motorcycle crash. The patient was helmeted at the time of the crash and there was no reported loss of consciousness. He reported isolated right lower extremity pain without neurologic complaints.\nExam and diagnostics\nThis was an isolated injury with no clinical or radiographic evidence of intracranial, -thoracic, -abdominal, or -pelvic injury. A FAST exam (Focused Assessment with Sonography in Trauma) was performed prior to our orthopaedic exam, which demonstrated no signs of hemorrhage.\nInspection of the right lower extremity revealed two large wounds to the anterolateral and anteromedial tibial diaphysis. The anterolateral and anteromedial wounds measured approximately 20 cm and 12 cm in length, respectively. Both wounds exhibited gross contamination with road debris as well as exposed muscle and fracture fragments (Figure ). There was no clinical evidence of compartment syndrome. There were no sensory or motor deficits involving the superficial peroneal, deep peroneal, or tibial nerves. A strong dorsalis pedis pulse was palpable, however the posterior tibial pulse was unidentifiable on palpation or Doppler ultrasound. A computed tomography (CT) angiogram was obtained which demonstrated vascular stenosis of the posterior tibial artery at the level of the fracture. All hematologic and metabolic labs were within normal ranges.\nTime from the emergency department to the initial operative encounter\nDual antibiotic prophylaxis, consisting of cefazolin and gentamycin, was administered promptly upon arrival to the emergency department. Antibiotic administration was estimated to be within three hours from the time of injury. A brief bedside irrigation with 3 L of sterile saline was performed and the wounds were dressed with moist gauze. The patient was then provisionally stabilized with a moldable long leg fiberglass splint a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 35-year-old African American male presented with a one-month history of worsening lower back and bilateral lower extremity pain, intermittent night sweats, and 32 kg unintentional weight loss over the course of a year. He did not have saddle anesthesia or urinary or fecal incontinence. He was initially seen in a primary care clinic and was diagnosed with sciatica. As symptoms continued to worsen, he underwent a computed tomography (CT) scan of the lumbar scan as an outpatient that was concerning osseous spinal metastasis. He was started on prednisone 10 mg daily and was referred to the oncology clinic at our center. Prednisone gave him minimal symptomatic relief. While waiting to be seen in the oncology clinic, the patient had an episode of leg weakness with near-fall prompting him to present to the emergency department of our hospital and was admitted for further evaluation. His vital signs were stable. He had no palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Neurological exam was normal with intact strength and sensation in both lower extremities.\nHis complete blood count and serum electrolytes were normal including a normal serum calcium level at 8.1 mg/dL. He tested negative for human immunodeficiency virus 1 and 2 antibodies. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine showed several enhancing lesions in T11, T12, L3, L4 vertebral bodies, right sacrum, and ilium that were concerning metastatic disease. There was effacement of the right lateral recess and right neural foramen at the L3-L4 and effacement of the left lateral recess and left neural foramen at the L4-L5 due to tumor retropulsion (Figures –). In addition, a small epidural tumor was noted at the T5 vertebral level without significant spinal canal stenosis or cord compression. Imaging was also concerning osseous metastasis involving the sternum and multiple ribs. Incidentally, narrowing of the neural foramen at"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 1-month-old male child was brought with a translucent swelling at the back since birth. On magnetic resonance imaging (MRI), there was evidence of a sacral spinal dysraphism with cerebrospinal fluid outpouching suggestive of a sacral myelomeningocele with tethering noted at the lower end of the cord (). The child underwent repair of the sacral myelomeningocele with sac excision and detethering of cord at the age of 1 month. Closure of the defect was done with advancement flaps using multiple Z plasty technique. Postoperatively, child developed pyogenic meningitis and urinary tract infection which was treated with intravenous antibiotics. The child recovered completely and had normal developmental milestones and could walk normally and was on regular follow-up for 1 year.\nThe child now presented at the age of 4 years with complaints of fever since 7 days, weakness of both lower limbs with difficulty in walking and urinary disturbance for 4 days. On examination, tone was decreased in both lower limbs with decreased deep tendon reflexes. On evaluation for fever, the child was diagnosed to have urinary tract infection and was started with appropriate antibiotics. On ultrasonogram, child had a significant postvoid residual urine volume of 73 mL. On further evaluation with an MRI, bulbous dilatation of the lower end of spinal cord was present with 3 well defined peripherally enhancing septated cystic lesions at L3–5 levels. Lower end of the cord could not be identified separately from the upper 2 cystic lesions, which thus appeared to be intramedullary. The intramedullary component showed greater peripheral enhancement indicating a thicker capsule with greater adhesions as per the senior author. There was a syrinx from D6–9 levels (). In view of fever and short duration of symptoms, we considered the possibilities of an abscess or an infected dermoid/epidermoid cyst.\nThe patient underwent L3–5 suspension laminoplasty and excision of intradural lesion. The cystic lesions"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 57-year-old Caucasian postmenopausal female who presented with dyspnea, shortness of breath, and fatigue. Echocardiography was performed that showed a mass in the left atrium which was presumably a myxoma or a thrombus. The patient was then transferred to a more specialized hospital in the capital city. After transportation, the patient was admitted to the hospital with the same symptoms of shortness of breath and fatigue. Echocardiography confirmed the presence of a mass in the left atrium (). ECG did not reveal any abnormalities. The patient's condition started to deteriorate. Hemoptysis and nasal bleeding were present. The patient's extremities were cold with a capillary refill of >3 sec, and the jugular veins were distended. The patient was sitting in bed because of shortness of breath. A diagnosis of bilateral pneumonia was made. Vital signs at that moment were heart rate, 125 beats per minute without any signs of arrhythmia; blood pressure, 120/80 mmHg; respiratory rate, 32–28 BMP; and SPO2, 93–94% on an O2 cannula of 15 L/min; and bilateral crackles were noted on chest auscultation. The patient's condition started to deteriorate quickly, and it was decided to intubate the patient and start mechanical ventilation because of progressive and rapid respiratory distress that involved extra muscle groups for respiration. Vital signs before intubation and mechanical ventilation were respiratory rate 44 BMP and SPO2, 86–87%. Before intubation echocardiography was performed again, it showed a mass causing blood flow obstruction at the level of the mitral valve, which resulted in blood stasis in the pulmonary system and led to pulmonary edema (mean pressure gradient across the mitral valve, 27 mmHg). It was decided to operate immediately and remove the tumor as fast as possible because cardiogenic shock had developed. Additionally, the patient had a previous mitral valve replacement because of mitral regurgitation and a mechanical valve and tricuspid v"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.\nPatient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman with a significant medical history of end-stage renal disease, chronic hypertension, and type two diabetes mellitus presented to the emergency department two hours after experiencing chills and hypotension during her weekly scheduled hemodialysis. She initiated hemodialysis two weeks ago after having a permcath placed. The patient had a grade two sacral decubitus ulcer recently diagnosed and treated with clindamycin six days prior to admission. She reports one week of chills, constipation, and non-productive cough and denies any other symptoms such as shortness of breath, dysuria, chest pain, subjective fevers, nausea, vomiting, abdominal pain, or dysphagia. Blood cultures were drawn after dialysis and she was admitted the next day because of concern for sepsis from the permcath and or the decubitus ulcer, although the ulcer was clean, dry, and intact.\nAfter blood cultures were drawn the patient was empirically begun on intravenous (IV) vancomycin and cefepime. The vancomycin was dosed after dialysis based on blood levels. The cefepime was renally dosed at cefepime 1 gram IV loading dose and 500 mg IV daily. On dialysis days it was given post-dialysis. The next day the blood cultures from the outpatient dialysis unit grew pseudomonas and streptococcal species. The vancomycin was discontinued and the permcath was removed, and tip cultured. The permcath was not replaced and so the patient did not receive hemodialysis until blood cultures were negative, five days later. The patient’s hemodynamic state improved, and the white blood cell count returned towards normal over the next few days, however on day four a new 2/6 left upper sternal border murmur was noted. There was concern for bacterial endocarditis, so a transthoracic echocardiogram was done and no vegetations or significant valvular abnormalities were detected. The patient continued to clinically improve otherwise, remaining afebrile with no leukocytosis. On the sixth hospital day, she was n"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old man sustained a tibial shaft spiral fracture (AO/OTA classification 42-A2) with a fibular fracture (). He had no previous medical history. The fracture was treated initially at another hospital with a reamed statically locked intramedullary nail (). He noted increased external rotation of the affected leg immediately after the surgery. The tibial fracture united after a year (), but he still complained of the asymmetry of his legs, difficulty walking and running, and inability to ride a bicycle. Computed tomography (CT) of both tibias showed 24° of increased external rotation of the affected leg (Figures , ). Because it was a symptomatic rotational deformity, we decided to perform corrective osteotomy in a minimally invasive fashion.\nThe surgical procedure consisted of, first, a 1 cm skin incision at the original fracture site. Multiple efforts were then made to drill around the nail in a radial manner (leaving the nail in place) while using a 3.0 mm Kirschner wire to prepare a percutaneous osteotomy line. Osteotomy for the affected tibia was performed percutaneously using an osteotome on the prepared osteotomy line while retaining the intramedullary nail (). Fibular osteotomy was also done at the same level. Next, two 3.0 mm Kirschner wires, which created a 24° rotational angle in the axial plane between the bone fragments, were inserted as guides for correction (). The distal locking screws were then removed. After matching the two Kirschner wires in a straight line, correct rotation was confirmed (). We assessed the rotational correction intraoperatively to evaluate both sides of the thigh-foot angle [, ]. Finally, the distal three locking screws were inserted into holes different from the original hole (). At 1 year postoperatively, the patient obtained bony union and has returned to his preinjury activities with no symptoms. The implant was removed 1 year postoperatively on the patient's demand. The appropriate correction of the rotational deformi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old man, who complained of upper abdominal pain, was found to have EGJ tumor by endoscopy (Fig. ). He was diagnosed as having Siewert type II adenocarcinoma (E=G, cT1b, cN0, cM0, cStage I) []. We planned to perform lower esophagectomy and proximal gastrectomy with double tract reconstruction.\nIn the computed tomography (CT) scan before surgery, a 10-mm aneurysm in the middle third of the splenic artery was found (Fig. ). Due to the anatomical location of the aneurysm, endovascular treatment was not considered due to recanalization and coil migration. The size of the aneurysm was not a high risk of rupture [], but we concerned about the possibility of SAA rupture due to postoperative pancreatic fistula (PF) associated with suprapancreatic lymph node dissection such as station 11p and 11d. We thought that spleen blood flow could be preserved even after SAA resection by preoperative CT scan and unnecessary invasive procedures could be avoided by simultaneous surgery. However, during simultaneous proximal gastrectomy and SAA resections, it was not clear whether there was sufficient blood supply to the spleen. Thus, we performed the surgery with a minimally invasive abdominal and left thoracic approach (MALTA) while continuously examining for the presence of blood supply to the spleen using fluorescence imaging.\nThe patient was placed under general anesthesia and was positioned in reverse Trendelenburg with the left side of the upper body lifted and the legs spread. Laparo- and thoracoscopic proximal gastrectomy and lower esophagectomy with D1+ lymph node dissection and double tract reconstruction were performed. First, we resected the SAA. Next, laparoscopic proximal gastrectomy was performed using five ports. Four ports were inserted into the thoracic cavity through the 9th, 10th (× 2), and 11th intercostal spaces, with the patient in the same body position. Lower thoracoscopic esophagectomy and lymph node dissection of the lower mediastinum was performed und"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 2. A 50-year-old non-insulin-treated woman with diabetes sustained a right distal radius fracture after a slip on ice. She was casted for six weeks and developed right hand and wrist pain by the end of the six weeks. X-rays revealed that the fracture healed well. She was assessed one year after injury and reported diffuse hand and wrist pain. She was unable to make a complete fist on the right, and there was loss of joint extension. In particular, the 5th digit was contracted at the interphalangeal joints; the hand was not uniformly swollen. The digits were all flexed at rest. Due to the late presentation and maturity of the contractures, she was sent for hand therapy, an extension splint, and a bone scan. Four days after this visit, she was involved in an accident and sustained a left wrist fracture of the distal radius and ulna. She required open reduction internal fixation and underwent a bone scan several weeks after the second fracture. The right side, the older fracture, showed no significant periarticular uptake. In contrast, on the newly fractured left hand, there was diffuse hyperemia in the left wrist, distal forearm, and fingers, as well as uptake at the left sided ribs in the 5th, 6th, 7th, and 10th ribs, consistent with fractures. On the newly fractured left arm, she had developed swelling in the digits and capsular restrictions. The 5th digit was difficult to extend. There was an obvious deformity in the left wrist. She experienced pain with MCP compression. While the right hand had continued to settle, the left hand was acutely swollen and a diagnosis of CRPS was made. She was treated with the titrating dose of prednisone with instructions to monitor her blood sugars. The inflammation rapidly improved; however, her blood sugars proved difficult to control and her weaning was escalated. She gained improvement in the left hand and wrist, with the return of normal range of motion, skin"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28 year old male patient presented initially in December 2013 with clinical features of acute osteomyelitis of right tibia. His haemogram was normal and the blood culture was negative for bacterial study. The erythrocyte sedimentation rate was 22 mm/h and C-reactive protein of 34 mg/dl. Polymerase chain reaction and culture for Mycobacterium tuberculosis were negative. There was no regional or generalized lymphadenopathy. X-ray of the right leg showed an osteolytic lesion of the right tibia within distinct margins, cortical breach, and moth-eaten appearance. Magnetic resonance imaging (MRI) scan done prior to the biopsy was reported as osteomyelitis of tibia. Biopsy report came as inflammatory granulation tissue densely infiltrated by lymphocytes and histiocytes consistent with nonspecific chronic osteomyelitis. Tissue cultures were negative for bacterial or fungal elements. Tumor markers or special strains were not done. The patient was treated with antibiotics and anti-inflammatory drugs. He was then discharged from the hospital once his pain subsided and was kept under close followup.\nHe remained asymptomatic except a diffuse swelling over the anteromedial part of the right tibial shaft. After 6 months, he presented again with complaints of pain and rapidly increasing swelling on his right leg, which increased to a size of 10 cm []. There was no regional lymphadenopathy. X-ray showed a permeative lesion with significant periosteal reaction over the mid-diaphysis of the tibia. We suspected some type of aggressive bone tumors in view of the rapidly increasing swelling and the permeative lesions in the X-ray. Hence, his chest X-ray, computed tomography of chest, and ultrasound abdomen were taken which were negative for any lesion. This prompted us to take a repeat MRI contrast study, which showed (coronal image) altered signal intensity and irregular patchy enhancement lesion involving the marrow of the diaphysis of the tibia. There is enhancing soft tissue compon"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year old male patient reported to clinic with a chief complaint of swollen gums of 5 year duration and wanted to replace his missing teeth. Patient noticed swollen gums prior to his 4 years of edentulous state and the condition persisted to present. He was a known hypertensive and was on medication for the same since 7 years (10 mg Nifedipine/day).On intraoral examination- pink, firm, irregular, nodular, non- tender enlargements were found on labial aspects of maxillary and mandibular residual alveolar ridges. The enlargements were asymptomatic in nature with no history of bleeding. Both arches were completely edentulous (Fig. ). Panoramic radiograph showed no osseous deformities of maxilla and mandibular ridges (Fig. ). Patient’s complete blood count, bleeding time, clotting time and platelet count were with in normal limits. An incisional biopsy was obtained from anterior right side of the maxilla. Histological report revealed hyperplastic and acantholytic stratified squamous epithelium with elongated rete ridges extending into connective tissue which was fibro collagenous and showed focal areas of fibrosis. Infiltration of chronic inflammatory cells and congested blood vessels were seen which suggested of gingival hyperplasia (Fig. ). As patient wanted complete dentures, we planned to surgically excise entire overgrowth. Considering medical status of the patient, drug was not altered because, dose taken by the patient was low (10 mg/day). Local anesthesia devoid of vasoconstrictor was used to remove fibrous tissue from alveolar ridge with help of 15 no. B.P blade (Fig. ). To avoid any discomfort during the early phase of wound healing, a surgical splint was placed on both ridges after thoroughly covering the operated site with periodontal dressing (Coe Pack). The patient was recalled and followed at a period of 1 week, 3 months, 6 months and 1 Year intervals (Figs. , , and ). No recurrence of growth was observed during any of the recall visits. After 3 month"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old male with no chronic disease admitted for laparoscopic exploration for intermittent abdominal pain after an open appendectomy that was performed 11 months ago. On previous admission, he was operated for clinical and radiological diagnosis of acute appendicitis. Initial CT scan showed distended appendix measuring 8-9 mm in diameter, showing abnormally thickened enhancing the wall, with surrounding fat stranding, free fluid, and adjacent pocket of pus collection measuring 2 × 4 cm. Open appendectomy was performed with findings of the gangrenous appendix, where the base was healthy and appropriately secured with Vicryl suture. He was discharged in good condition two days postsurgery. Pathology of the specimen showed 4.5 cm long appendix and 0.7 cm in diameter with a diagnosis of acute appendicitis and periappendicitis. After almost a year, he was seen in the clinic as he complained of recurrent abdominal pain for one month and a slight decrease in appetite. His ultrasound abdomen showed a complex heterogeneous collection with internal echoes in the right iliac fossa measuring 5.5 × 2.7 × 6.4 cm, corresponding to a volume of 50 ml. His CT abdomen showed a well-defined mass-like lesion about 5 × 5 cm in diameter of fluid density (22 HU) suggesting thick fluid in the right iliac fossa; the stump of the removed appendix is well demonstrated and about 4 cm in length and closely related to the lower part of this collection (). The patient underwent laparoscopic exploration with excision of the subserosal appendicular stump of about 5 cm and cyst extending from the tip and distal part of the appendix to the pelvis, easily separable from the pelvis, containing gelatinous yellowish material (Figures –). The terminal ileum and right-sided colon were normal, and no peritoneal deposits were observed. Because of these findings, we resorted only to stump excision.\nCytology of the gelatinous fluid was negative for malignant cells. At the same time, the histopathology of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old 105.5 kg male with a previous history of ALS for 7 years, history of respiratory insufficiency with a tracheostomy, and PEG for over two years, was admitted from a nursing home after a cardiac arrest. The return of spontaneous circulation (ROSC) was 12 minutes, and the patient was treated for aspiration pneumonia and urinary tract infection. In the past, he has had three previous cardiac arrests associated with respiratory insufficiency. Cardiac echocardiogram revealed a normal left and right ventricular function. Serum albumin was 3.1 g/dl. The patient has had quadriplegia felt secondary to his ALS and multiple cardiac arrests and has always stabilized and been treated for various infections. Neurologically, the patient still had a pupillary reflex on the left with spontaneous eye movement and he had partial mouth opening and closing. The patient does not visibly respond to pain. No gag or corneal reflexes were noted by the ICU team or neurology.\nOver the last several years, the family was approached by the health care team on multiple occasions regarding consideration of Do Not Resuscitate (DNR). The family was told that the overall situation was hopeless due to his underlying primary disease. Despite this, the family always had hope that an ALS cure would be found and always wanted everything done.\nInitially, a 24 hr urine creatinine was collected (patient with indwelling foley catheter) and was 172 mg. This was repeated since the value was very low but still came back 199 mg of urinary creatinine in 24 hr. The coefficient of variation was 10%, and the average was 186 mg of urinary creatinine excreted in 24 hr (see for data summary). In addition, the patient's height was 185 cm.\nThe patient was treated successfully over several weeks in the ICU and was eventually transferred back to his nursing facility. Within one month after discharge, the patient died at another facility."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn September 2014, an 18-year-old, non-smoking male was diagnosed with an open fracture of the right tibia, Gustilo’s classification grade IIIB [] following a traffic accident. The patient weighed 65 kg. Emergency debridement was performed at the local hospital following injury (Fig. a and b). The fracture and wound had not healed 3 months after injury. Copious pus was drained and the patient was transferred The Second People’s Hospital of Yunnan for further treatment.\nThe patient was admitted to The Second People’s Hospital of Yunnan 97 days after the injury. A physical examination of the patient’s right calf revealed a soft tissue defect and exposed tibia. A 4 × 10 cm incision was observed on the anterior medial side of the upper calf and a 3 × 12 cm-sized wound was seen on the anterior medial side of the lower leg. Significant foot drop was observed. The patient experienced hypoesthesia on the lateral side of right calf and the dorsal surface of the foot; however, normal sensation was felt on the plantar surface of the foot and the dorsalis pedis artery appeared normal. The range of motion of the knee was 0–80°, and ankle extension and flexion were 10 and 20°, respectively. Level III myodynamia was observed in the pretibial muscle and the triceps surae (Fig. ).\nFollowing discussion with the patient, a limb salvage protocol was adopted in favor of amputation. The treatment plan consisted of two stages. The first step was to treat the infection by performing repeated debridement, replacing the external fixation, vacuum sealing drainage (VSD) and local and systemic application of antibiotics. In the second stage, the bone transport technique was used to repair the bone defect, and rehabilitation exercise was performed to restore the function of the affected limb as much as possible. The patient was informed about the treatment plan and the associated risks. A series of examinations were performed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old woman with a history of chronic migraine presented to the emergency department for a sudden thunderclap headache after swimming. She regularly used nonsteroidal anti-inflammatory medication and ergotamine associated with caffeine for chronic headache. At admission she described diffuse, explosive, and unusual headache with spontaneous resolution in 8 h. On initial examination, general and neurological clinical examination was normal. Arterial blood pressure was normal. The initial cerebral computed tomography (CT) scan without contrast was normal. The cerebrospinal fluid sampling obtained by lumbar puncture revealed presence of oxyhemoglobin with 290 red blood cells/mm3. The diagnosis of SAH was retained and a cerebral angiography scheduled for the next day. On day 1, she presented severe unusual headache with arterial hypertension followed by aphasia and a right hemiplegia. Shortly afterward, her consciousness worsened requiring intubation and intravenous sedation. A cerebral CT scan was immediately performed and revealed a left rolandic ICH (Fig. ). Cerebral angiography was performed showing a diffuse segmental narrowing of cerebral arteries without aneurism or arteriovenous malformation (Fig. ). The diagnosis of RCVS with hemorrhagic complication was retained and intravenous nimodipine was introduced. The ICH was removed by a neurosurgeon and an ICP monitoring probe was inserted in the left frontal lobe. Initial ICP reading was 15 mm Hg. Intravenous sedation was continued in the intensive care unit. However, norepinephrine was required to keep cerebral perfusion pressure (CPP) over 60 mm Hg. Immediate postoperative transcranial Doppler (TCD) was normal. A control cerebral CT scan was performed the next day showing a residual intracranial hematoma and perilesional edema. Forty-eight hours later, ICP increased to above 30 mm Hg despite optimization of medical treatment (head elevation, increased sedation, and osmotherapy). TCD readings for the right m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old Sri Lankan woman was referred from the orthopedics unit to the endocrinology unit, National Hospital of Sri Lanka, for further evaluation of recurrent femur fractures. She first experienced a right sided subtrochanteric fracture following a low trauma injury at the age of 20 years (), for which she underwent internal fixation. Thereafter, she experienced a left intertrochanteric femur fracture at the age of 22 years, 2 months prior to the current presentation.\nShe had an interesting past medical history. She was diagnosed to have a left side nephroblastoma at the age of 8 years, for which she underwent left side radical nephrectomy followed by chemotherapy. Thereafter, at the age of 14 years, she developed a right sided facial swelling and was found to have a maxillary tumor which was described during the surgery as a well-circumscribed mass lesion in the left maxilla, eroding the anterior wall of maxilla and lateral nasal wall. She underwent partial maxillectomy for this, and histology revealed features suggestive of fibrous dysplasia.\nShe did not have a history of chronic steroid use, hypogonadism, hyperthyroidism, rheumatoid arthritis, and exposure to cigarette smoking to suggest secondary causes for osteoporosis. She had neither any features of malabsorption nor inadequate exposure to sunlight to suggest a vitamin D deficiency causing these fractures. The histology of bone biopsies was negative for metastatic deposits.\nShe did not have a family history of hyperparathyroidism, renal, or uterine tumors. There was no past history or family history suggestive of MEN 1. Her general and systemic examinations were normal apart from the healing fracture sites.\nHer investigation findings are summarized in .\nHer investigations revealed high total calcium and urinary calcium excretion, with low serum phosphate level. She was found to have a vitamin D deficiency, which was corrected by vitamin D replacement. As high calcium and low phosphate were suggestive of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).\nThe patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.\nWe performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase 3: a 43-year-old female patient, 55 kg, was admitted 1 month after pancreaticoduodenectomy with 1 day of fever. She was admitted with a diagnosis of intra-abdominal infection and type 2 diabetes mellitus. Due to recurrent vomiting, the physician arranged for her to have a jejunal nutrition tube placed under gastroscopy. On August 3, 2020, the patient underwent gastroscopy under local anesthesia. After confirming the absence of gastric contents, the procedure was subsequently started with 12 mL of intravenous propofol at 16:10, with additional 2 mL of propofol intermittently during the operation. At 16:35, the patient's SpO2 suddenly dropped to 76%, and the patient was immediately ventilated with a face mask under pressure, followed by a gradual increase in the patient's oxygen saturation to 89%. During this process the patient's blood pressure fluctuated between 180 to 210/100 to 122 mmHg. At 16:45, the patient's blood pressure suddenly dropped to 64/32 mmHg and heart rate dropped to 30 to 40 bpm. The anesthesiologist instructed the surgeon to immediately withdraw the gastroscope while giving the patient intravenous epinephrine 1 mg and performing tracheal intubation, then the patient was under mechanical ventilation, at that time oxygen saturation rose to 95%, blood pressure rose to 105/58mmHg, ECG showed a heart rate of 62 bpm and ETCO2 showed 25mmHg. At 17:00 the patient's heart rate dropped to 30 to 40 bpm again and blood pressure and SpO2 could not be measured. The anesthesiologist immediately organized to give the patient resuscitation measures such as chest compressions, intermittent intravenous epinephrine, and ice caps. Then the patient's systolic blood pressure fluctuated from 58 to 85 mmHg, heart rate from 30 to 50 bpm, oxygen saturation from 75% to 90%, and ETCO2 from 8 to 12 mmHg. At 17:17, the anesthesiologist performed a TEE, which showed a significant enlargement of the right heart and a large volume of gas"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man was brought to the emergency department with a chief complaint of periumbilical abdominal pain. He suffered from abdominal pain for two weeks but it was significantly increased in the three days prior to admission. The pain radiated to the back and no accompanying signs or symptoms were present. It was described as a constant pain without any alleviating or exacerbating factors. The patient was a heavy smoker without any history of previous surgery or drug use.\nThe patient showed stable vital signs and a nuisance general appearance. No objective signs of weight loss or cachexia were observed. The physical exam was normal in the head and neck, chest, and extremities. In the abdomen a pulsatile mass was palpated in the periumbilical region. Routine laboratory tests revealed mild normocytic normochromic anemia, normal ESR and CRP, and liver function and diagnostic tests within normal limits.\nDue to the pulsatile nature of the mass a CT angiography of the abdomen was ordered to look for vascular pathology. The tomography revealed a 5-by-4 cm pseudoaneurysm with hematoma formation in the infrarenal aorta alongside diffuse dilation of the infrarenal inferior vena cava with extension into both common iliac veins (), and the patient was prepped for surgical repair.\nDuring surgery a pulsatile mass 20 by 20 cm in diameter with surrounding hematoma was observed in left zones 1 and 2. Upon further investigation a huge retroperitoneal mass 11 by 8 by 6 cm in diameter with apparent local invasion to the aorta and the inferior vena cava was found. En bloc resection was attempted along with involved vascular segments. The abdominal aorta was reconstructed using 16 mm-by-8 mm Dacron bifurcated graft, while the IVC was ligated below the renal veins but perhaps because of chronic process of disease no lower extremity edema happened and the patient was discharged after a week.\nPathologic evaluation of the specimen showed an undifferentiated pleomorphic sarcoma (a.k.a."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old man applied to the outpatient clinics with the complaints of abdominal pain and weight loss for two months. Abdominal pain had worsened for the last two days. He also complained of diarrhea for the last week. His past history revealed restless leg syndrome. He had undergone an operation for sinusitis four months before the admittance day. Physical examination revealed a mass and tenderness in the right lower quadrant with local signs of peritonitis. White blood cell count was 11,330/mm3; haemoglobin level was 11 gr/dL with normal platelet count. Liver and kidney function tests were in normal limits except an increased blood glucose level (146 gr/dL) but the patient denied a history of diabetes. Computerized tomography (CT) scans of the abdomen demonstrated a 90 × 83 × 95 mm mass with gas containing abscess involving cecum and distal ileum with luminal narrowing and marked inflammatory changes in the contiguous tissues. Multiple lymph nodes measuring up to 19 × 11 mm were seen in the pericecal region (). On the same day, the patient was referred to the general surgery department with suspicion of perforated colonic carcinoma. Colonoscopy was not performed. Broad spectrum antibiotics were given and the patient underwent laparotomy and right hemicolectomy with segmental ileal resection and partial omentectomy. The intraoperative findings were compatible with perforated cecal neoplasm that invaded the parietal peritoneum. The postoperative period was uneventful and the patient was discharged on postoperative day 9.\nThe mass was 11 × 8 × 3 cm in macroscopic evaluation. Pathology revealed pseudotumor formation with necrosis of cecum and ileocecal valve () involving multifocal colonies of Actinomyces with periodic acid-Schiff and Grocott's dye (). There were multifocal Entamoeba trophozoites on the surface of the necrotic tissue (). Transmural and mesenteric fibrosis with lymphocytic infiltrate was seen. Similar inflammatory granulomatous process was present"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA six-year-old boy was referred with a painful swelling in the left thigh and difficulty in walking since four months. On examination, a firm swelling approximately five centimeter in size was noted on the posterior mid thigh. The swelling was diffuse, tender, and deep to the muscles. The overlying skin was normal. The child was febrile and total counts were elevated. Sonography reported the possibility of abscess deep to the thigh muscle. He symptomatically responded to antibiotics, analgesics, and rest. Magnetic resonance imaging (MRI) and computer tomography (CT) angiography reported the possibility of an infected hematoma or hemorrhage in non-involuting hemangioma with close proximity to the sciatic nerve [Figure and ]. The child was advised surgical excision for diagnostic confirmation with an explained risk of nerve damage. However, the parents did not give consent, so it was deferred.\nOn follow-up, the child developed weakness in the limb. The swelling was now more localized, firm, and non-tender. Fine needle aspiration was done, which revealed small round cells with mitotic figures. He was advised surgical excision. Operative findings revealed a variegated consistency mass in the substance of sciatic nerve []. The mass originated from the sciatic nerve with no gross involvement of the surrounding tissue []. The parents were counseled and informed consent was taken for nerve excision. The tumor was excised completely with one centimeter of the intact nerve at the upper and lower pole. In view of an established peroneal neuropathy for distal limb, a size-matching, peroneal nerve was harvested as a donor nerve for autologous nerve grafting. A 7.5-cm-long segment of the peroneal nerve was grafted with 7-0 polypropylene epineural sutures, avoiding any twist or torsion or tension at the anastomotic sites [].\nHistopathology and immunohistochemistry studies were suggestive of Ewing's Sarcoma in the substance of the sciatic nerve. Nerve endings were tumor free []. Wo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old female was admitted to our hospital complaining of an intermittent headache for 5 years, menopause for more than 2 months, and blurred vision and lactation for more than 1 month. Five years prior, the patient began suffering from intermittent and gradually deteriorating occipital and frontal headaches. One month prior to admission, she had impaired vision and an absent right temporal view and simultaneous bilateral galactorrhea, without purulent or bloody secretions. Since the onset of symptoms, the patient experienced no nausea or vomiting, sleepiness, chills, hair loss, or fatigue. Computed tomography (CT) showed an irregular cystic solid mass in the suprasellar area. The size of the mass was 1.4*1 cm and could be markedly enhanced. The CT value of the solid part of the lesion on plain CT was 40 Hounsfield units (HU); in the enhancement, the value was 74 HU, and the cystic part showed no enhancement. The boundary of the lesion was less clear, the density was not uniform, and no obvious calcification was observed. The cavernous sinus was involved. There were no abnormalities in the ventricular system, sulcus, brain split and pool. Moreover, there was no shift in the midline structure, and no abnormalities were found in the skull structure. The sinuses exhibited no obvious abnormalities. Magnetic resonance imaging (MRI) of the brain and pituitary showed an irregular cystic solid mass in the suprasellar area, involving in the pituitary stalk, and the boundary between the lesion and pituitary was unclear. In addition, the mass pressed on the optic chiasm, and the solid part of the lesion was significantly enhanced, while the cystic part showed no enhancement. There was no abnormal signal in the brain or paranasal sinuses nor signs of calcification (Figure ). Auxiliary examinations revealed that the patient's urine volume and specific gravity were within the normal range (urine volume: 1,800 mL/day; urine specific gravity: 1.015). A pituitary function eva"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old Japanese man consulted our hospital due to an abdominal mass that had persisted for 1 month. He also had a history of appetite and weight loss. He had a past history of a duodenal ulcer and resection of the left adrenal gland due to primary aldosteronism. He had hypertension and paroxysmal atrial fibrillation, as well as rheumatoid arthritis. Computed tomography (CT) revealed a 180-mm tumor in the posterior region of the gastric body (Fig. A and B). The tumor consisted of solid and cystic parts. The primary tumor site was unclear on imaging. There was no significant lesion observed in the mucosa of the upper and lower digestive tracts on endoscopic examination.\nResection of the tumor was carried out. Intraoperatively, the tumor was not in contact with the gastrointestinal tract, but was present in the transverse mesentery immediately anterior to the pancreas, and it seemed to invade the body of the pancreas. The tumor was also in contact with the omentum and peritoneum just anterior to the pancreas. Therefore, the tumor was resected, along with the pancreatic body and tail and the spleen (Fig. A and B). The size of the resected tumor was 210 × 200 × 200 mm. There was a large cyst in the tumor (Fig. C). The tumor was found to be very close to the pancreas (Fig. A). Although the tumor did not invade the pancreas, it was impossible to detach the tumor from the pancreas surgically. Microscopically, the solid component and cyst wall of the tumor showed similar histological features, being mainly composed of mesenchymal spindle cells with plump cigar-shaped nuclei (Fig. B and C). Immunohistochemically, the tumor cells were positive for cluster of differentiation (CD)117 (c-Kit) and CD34, and negative for alpha-smooth muscle actin and S100, suggesting that the tumor was an EGIST (Fig. D and E). The number of mitotic cells in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old female patient from Southeast Ethiopia, presented to Goba referral hospital with complaints of right flank pain and swelling on the right lumbar region. The pain was a dull ache and not associated with urinary complaints like dysuria, frequency, urgency or hematuria. She had no cough and chest pain.\nThe patient reported that she had been visiting more than three hospitals with complaints of right flank pain for the last eight years and had been taking an ultrasound, magnetic resonance imaging, renal function test, and urine analysis. However, the patient reported that the results of these investigations were normal, and she was only treated with different types of anti-pain medications. Four years later, the patient noticed that swelling on the right lumbar region, and the swelling had increased gradually and was associated with pain. She had no history of flank trauma, surgery, chronic constipation, and other abdominal infections. In addition, the patient had no history of chronic cough, difficulty of urination, and history of diabetes mellitus.\nOn admission, the patient was clinically active and had normal vital signs. On abdominal examination, there was round protruding swelling immediately beneath the 12th rib of the right upper flank region (). The swelling was palpable and bowel sound was heard in the region. The swelling was easily reducible and protruded when the patient was coughing or straining. The opposite side lumbar region was normal, and chest examination was clear and normal. The hematological and urine analysis laboratory findings were normal. The ultrasound picture revealed the bowel contents within the hernial sac. Otherwise, all visceral organs were normal.\nWith the diagnosis of primary acquired superior lumbar hernia, the patient underwent open surgery. The open approach was designed due to the absence of laparoscopy services in the hospital. The defect was reduced back and repaired using a retro-muscular or sublay prolene mesh (15"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case report will focus on a 39-year-old male with a smoking history of one pack per day and regular alcohol intake of beer for over 20 years. He has had ongoing respiratory and abdominal symptoms which had been attributed to his smoking and drinking history. Starting in his early twenties, he began to have multiple episodes of mild upper respiratory tract infections and bronchitis on a yearly basis. He also experienced mild abdominal discomfort and nausea which would come and go sporadically. High-resolution computed tomography of the chest confirmed emphysematous changes of the lung as shown in Figures - below.\nHis liver enzymes had been slowly trending up throughout the years. Over the span of a few months, his aspartate transaminase (AST) level increased from 52 units per liter (U/L) to 58 U/L. His alanine transaminase (ALT) level increased from 81 U/L to 86 U/L. The upper limit of normal for both AST and ALT levels fall in the low 40s U/L. Other markers of liver damage, including serum prothrombin concentrations and serum albumin, were not affected.\nHis primary care physician instructed him to quit smoking and drinking, eat healthily, and exercise regularly. He was successful in making these lifestyle changes, but over the next few years, his liver enzymes remained elevated and his lungs continued to show persistent emphysema. There was little to no improvement in his overall symptoms. Due to these abnormal findings, he was tested for alpha-1 antitrypsin deficiency (AATD) and was found to be homozygous for the Z allele (PI*ZZ). His alpha-1 antitrypsin (AAT) level was 18, which is well below the protective threshold of 57. Once the diagnosis was confirmed, the patient was immediately started on weekly Prolastin infusions. Since his diagnosis, our patient has completed eight infusions of Prolastin and will continue to receive weekly infusions for as long as he is able to tolerate them in order"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year old male patient with early gastric cancer was transferred from Aruba to our institution. He had a 3-year history of black stools and anemia. His past medical history included multiple comorbidities: diabetes, chronic renal failure, alcoholic cirrhosis Child A, complete heart blockade and thrombocytopenia of unknown etiology. An upper endoscopy and biopsy revealed a well-differentiated intestinal type adenocarcinoma in the antrum. Endoscopic ultrasonography showed a hypoechoic, 3.2 cm neoplasm, without muscularis externa infiltration and reactive ganglia (). Endoscopic mucosal resection was chosen due to tumor size, stage and comorbidities of the patient. The tumor was fully resected without complications. At the end of the procedure the anesthesiologist had difficulty with ventilation and abdominal distention was observed (). He had a 128/91 mmHg blood pressure and 70 bpm heart rate. An endoscopic revision was done before finishing the procedure, without identification of any macroscopic perforation. A nasogastric tube was placed and therapeutic strategies to improve abdominal-wall compliance were instituted (changes in ventilation parameters, nasogastric suction, change to a supine position and removal of any strap over the abdomen). A plain abdominal radiography in the operating room showed a massive pneumoperitoneum (). Decision of a nonsurgical management was conducted and the patient was taken to the intensive care unit (ICU) for monitoring. The IAP measured by a trans-bladder catheter was 33 mmHg. Six hours after ending the procedure the patient developed dyspnea and anuria. The diagnosis of an abdominal compartment syndrome was established. Given the worsening status, interventional radiology evaluated the patient. A CT scan confirmed the massive pneumoperitoneum without intraperitoneal extravasation of contrast (a & b). A percutaneous decompression guided by CT scan was performed with a pigtail catheter G14 (c & d). Air was immediately released un"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nHerein we presented the case of a 48-year-old male who presented to our emergency service due to ocular pain and blurred vision in his right eye. While cleaning an oven with a metallic brush, the patient felt a foreign body sensation in the right eye. Best-corrected visual acuity of his right eye was 0.9.\nSlit lamp examination of the anterior pole of the right eye revealed conjunctival congestion, watery discharge. Around 12 o’clock, a metallic foreign body was detected near the corneoscleral limbus, which perforated the cornea, the iris, the anterior capsule of the lens and the lens (). We could not perform the full examination of the posterior pole, so we could not establish the trajectory of the intraocular foreign body. Ocular B-scan was not performed because of the penetrating corneal wound. X-ray of the orbit did not offer enough details and computed tomography could not be performed at that time in our service.\nAfter performing an anti-tetanic prophylaxis, we decided to extract the intraocular foreign body by using a forceps. Since it had a helicoidal shape, we had to perform several circular movements (). We were surprised to find out that the wire that perforated the eye was almost 20 mm long (). We injected an antibiotic in the anterior chamber and placed a contact lens to protect the cornea and facilitate the healing of the point-like corneal wound\nOn the first day postoperatively, the slit lamp examination revealed a stable anterior chamber and a totally opacified lens with anterior capsule rupture. B-scan ultrasound showed no sign of vitreous haemorrhage and an attached retina. Visual acuity of the right eye was hand motion determined because of the traumatic cataract. We decided to extract the opacified lens. Due to the age of the patient, the lens was very soft so we performed its extraction with a blunt cannula under viscoelastic protection, with good results (). We noticed a posterior capsule break because the foreign body passed through the lens"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 56-year-old female with history of syncope due to third degree atrioventricular heart block presenting initially with onset of stroke symptoms six days after pacemaker placement and two days after hospital discharge. At 5 PM she developed abrupt onset of left facial droop along with left upper and lower extremity weakness. The patient was initially treated at an outlying hospital and received alteplase at 6:35 PM for treatment of acute ischemic stroke.\nA chest radiograph performed at the outlying hospital prior to alteplase administration demonstrated an enlarged cardiac silhouette when compared to prior radiographs showing only borderline cardiomegaly. Upon administration, the patient reported mild chest pain and was given nitroglycerine and morphine. Her chest pain resolved and she was transferred to our comprehensive stroke center for admission. The patient presented to our emergency department at 10:10 PM with a heart rate of 122 beats per minute (bpm) and a blood pressure of 109/41 millimeters of mercury (mmHg).\nAt 11:20 PM the patient went for a computed tomography angiogram (CTA) after an initial assessment by the emergency physician in consultation with the stroke-team attending physician. After CTA at 10:28 PM, she was documented to have a blood pressure of 49/25 mmHg and heart rate of 109 bpm. She was returned to the resuscitation bay for re-evaluation. Cardiac tamponade was suspected due to the extreme hypotension in the setting of thrombolytic administration after recent pacemaker placement.\nOn reassessment, the patient had become confused with a Glasgow Coma Scale of 14. The emergency physician performed a POCUS, which demonstrated a pericardial effusion with features of cardiac tamponade including diastolic collapse of the right ventricle (). At that point the diagnosis of cardiac tamponade was made. The patient was alert and responsive, so an intravenous bolus of normal saline was given while a stat surgical consult was obtain"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old male patient was admitted to the Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China in November 2016, 1 month after a previous head trauma that caused a loss of consciousness and was treated with decompressive craniectomy, which was initially followed by a good recovery. The earlier head trauma was caused by a fall injury and the patient had become unconsciousness immediately. He was sent to the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine with the right pupil dilated and fixed. An immediate craniocerebral computed tomography (CT) scan found an epidural haematoma in the right temporal area and a severe right-to-left midline shift. A right fronto-temporo-parietal craniotomy was performed and the haematoma was evacuated. The bone flap was not replaced in case of delayed cerebral oedema. The patient recovered his consciousness after the operation and had a favourable prognosis during the subsequent 3 weeks of uneventful clinical recovery, although paralysis in the left upper limb was evident. However, his conscious state deteriorated again in postoperative week 4 and he had a cranial defect bulge. The following CT scan found a contralateral subdural effusion with the midline shifted more than 1 cm to the right side. He underwent a burr-hole drainage operation to evacuate the subdural effusion while his attending physicians implanted an Ommaya reservoir in case of the recurrence of the effusion. His condition recovered after the operation but deteriorated again after the drainage was removed. His condition only improved during short periods after each percutaneous fluid aspiration of the Ommaya reservoir. He was transferred to the Department of Emergency and Trauma Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China 1 week after the second surgery with the hope of him achieving a full recovery"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old male patient presented with worsening symptoms of chest discomfort and exertional dyspnea {New York Heart Association (NYHA) III} for 2 months. He had past medical history of hypertension and dyslipidemia. Four years ago, the patient had been treated with percutaneous coronary intervention with implantation of stents at the left main artery and the distal left circumflex artery. At that time he also underwent percutaneous transluminal angioplasty with implantation of self-expandable nitinol stents at the bilateral iliac arteries. On admission, transthoracic and transesophageal echocardiography showed severe AS and mild aortic regurgitation (AR) due to degenerative change with calcification (). The aortic valve area was 0.44 cm2. The peak and mean pressure gradients across the aortic valve were estimated to be 97 and 59 mm Hg, respectively, while the diameter of the aortic annulus by echocardiography was 25 mm. The left ventricle (LV) showed a dilated enddiastolic dimension (64 mm) with LV hypertrophy. The LV systolic function was globally reduced with an LV ejection fraction (EF) of 39%. Based on the coronary angiography, the stent at the left main artery was patent. However, the stent implanted at the distal left circumflex artery showed in-stent restenosis, which was subsequently treated with a 3×30 mm paclitaxel-eluting balloon (SeQuent® Please, B. Braun Melsungen AG, Berlin, Germany). The previously inserted stents at the right and left iliac arteries were patent, however computed tomography (CT) angiography revealed that the minimal lumen diameter of the stented right iliac artery was 5.5 mm and that of the left iliac artery was 4.5 mm. Both common femoral arteries also showed significant stenosis with a minimum lumen diameter of 4.0 mm (). The diameter of the left subclavian artery was measured to be 7 mm on CT angiography. The calculated EuroSCORE was 44.08%.\nIn this patient we decided to perform TAVI by transsubclavian approach. The procedure"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Saudi man with diabetes mellitus was admitted to the Neurology Department with an unremitting headache lasting 5 days, episodic confusion, and visual disturbances. According to his family, the headache started gradually over the left side of his head and then became holocephalic and moderate to severe in intensity. The patient reported feelings of nausea and 2 episodes of vomiting. Moreover, his family stated the patient was often seen “bumping” into surrounding objects while ambulating. The patient reported experiencing some visual disturbance during this period. The patient's family felt he appeared confused at times and was not responding to his surroundings. He had no clear history of seizure, according to the family, and his past medical history was unremarkable apart from diabetes. He had sustained a minor head trauma 3 years prior with no concussion; however, his scan was reported to have shown “scattered areas of bleeding” in his brain. He otherwise maintained a healthy life and never required a hospital visit for any medical issues. His family reported the patient had normal cognitive function, especially as someone who ran his own business.\nThe patient was lethargic upon arrival to the accident and emergency department. Given the apparent risk of airway obstruction, the emergency physician intubated the patient. On general examination, we found no facial phakomas. While the patient was sedated, we found tonic eye deviation with nystagmoid-like eye movement and subtle myoclonic jerks of the distal limb suggestive of subclinical seizures. He was given an intravenous (IV) loading dose of phenytoin in addition to a midazolam infusion. Despite this, he sustained several clinical seizures in the subsequent days. Therefore, he required further titration of midazolam infusion (up to 14 mg/hr) and IV levetiracetam was added to optimize the antiepileptic coverage. His electroencephalogram was obtained postictal. His brain MRI was obtained 1 day followi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old woman presented as a transfer from an outside facility with painless, obstructive jaundice. She observed yellowing of her skin, poor appetite, and fatigue for two days, as well as dark brown urine. She was otherwise healthy and independent at home. She did not smoke and had no family history of malignancy.\nDiagnostic workup at the outside facility was notable for elevated total bilirubin to 14.4 mg/dL, alkaline phosphatase to 1,004 U/L, and white blood cell count was elevated at 23.6 × 103/μL. Magnetic resonance cholangiopancreatography (MRCP) had shown intra- and extrahepatic biliary dilation with evidence of a stricture in the distal common bile duct (CBD) suggestive of a pancreatic head mass. It also revealed the presence of a large, type III hiatal hernia, which had been previously asymptomatic other than mild reflux disease.\nGiven the concern for cholangitis, the patient was taken for an endoscopic ultrasound with subsequent ERCP to further evaluate her pathology and relieve her biliary obstruction. Endoscopy confirmed the presence of a large, type III hiatal hernia, which made advancing the endoscope into the duodenum difficult. The endoscopists were still able to proceed with ultrasound and were successful in identifying and obtaining biopsies of a mass in the pancreatic head. However, ERCP was aborted as the scope could not be advanced past the second portion of the duodenum. As the scope was being removed from the stomach, a small, linear tear was noted in the stomach mucosa along the greater curvature of the fundus, though the endoscopist believed it to be a partial-thickness tear. This was closed with serially placed 5 mm endoscopic clips, and complete approximation of the mucosa was seen.\nThe patient was subsequently placed on IV antibiotics and closely observed. Unfortunately, she progressed to develop signs of mediastinitis, peritonitis, and sepsis. A subsequent computed tomography (CT) scan showed a persistent hernia with intra-abdomina"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA fit 45-year-old man, with a background of Brugada Syndrome had an ICD inserted 10 years previously for secondary prevention. He was initially admitted for lead replacement and ICD box change. This procedure was attempted, however failed due to an occlusion of the brachiocephalic vein. Therefore, a laser-assisted lead extraction was undertaken. Immediately following the procedure, the patient showed sign of tamponade and a pericardiocentesis was carried out. This was unsuccessful and the patient became hemodynamically unstable. He was transferred immediately to the operating theatre, intubated, ventilated and proceeded for emergency sternotomy. On arrival to theatre, the patient developed pulseless electrical activity and external chest compressions were delivered for 30–60 s.\nFollowing sternotomy, the pericardium was opened and copious amounts of blood and clots were removed with prompt restoration of spontaneous circulation.\nA bleeding point was identified on the right ventricular acute margin, which was repaired using a single 3/0 pledgeted Prolene suture. A large volume of blood was also noted in the right pleura, with extensive infiltration of the extra-pericardial portion of the superior vena cava. Careful dissection revealed a 5–7 cm linear tear extending from the right subclavian vein to the pericardial reflection of the Superior Vena Cava (SVC; ). In order to repair this, the patient was connected to cardiopulmonary bypass and cooled to 25° without circulatory arrest. A patch of bovine pericardium was used to reconstruct the SVC and the right subclavian vein (). The patient was rewarmed and hemostasis secured.\nHowever, the patient remained hemodynamically unstable and the hemoglobin was noted to be low. The abdomen was very distended and an ultrasound demonstrated free abdominal fluid. The possibility of having a CT scan was dismissed due to the unstable condition of the patient. He proceeded for an emergency laparotomy with 4 L of blood drained from the a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18 year-old male patient presented with the chief complaint of pain and discolored upper front tooth. He had incurred trauma to the teeth due to a fall from a two-wheeler motor vehicle more than 10-years ago and underwent endodontic treatment followed by crown immediately after the trauma for the maxillary right central incisor. Patient was symptomless for sometime but in due course developed periodic swelling and now since 6 months had noticed intermittent pus discharge. On consulting another dentist, endodontic treatment for the right lateral incisor was started but as the pain was progressively increasing, so the patient was referred by the dentist to the college. The patient's medical history was noncontributory and vital signs were within normal limit.\nIntraoral examination revealed the presence of porcelain fused to metal crown in right maxillary central incisor associated with a sinus tract in the periapical region. Tracing of the sinus tract with gutta percha confirmed the involvement of the central incisor. The tooth was tender on percussion and palpation. The periodontal status was normal (probing depth <3 mm) with no mobility ruling out any periodontal pathology. The lateral incisor showed incompletely done root canal treatment. Radiographic examination of the central incisor revealed poorly obturated root canal with incomplete root formation. The root end had thin dentinal walls with apical flaring and periapical rarefaction of 2-3 mm []. The lateral incisor had intact periodontal ligament space and showed complete root formation. Electric and cold tooth vitality testing were performed for all the maxillary anterior teeth except the maxillary right central incisor. The right lateral incisors gave a negative response and all the other teeth gave a positive response. According to the clinical and radiographic findings, there were two treatment options available for the central incisor, either a surgical removal of the periapical lesion followed by retro"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman with no past medical history was admitted to hospital after slipping on the ice. The patient did not lose consciousness, but she immediately noted drooping of her right eyelid and double vision when she elevated the lid. There was a 3 cm laceration wound on the chin and some abrasions over the neck and the central region of her face ().\nThe right pupil was fixed and dilated, and there was complete right ptosis. The patient could not elevate, depress, or adduct the right eye, but the eye intorted on attempted downgaze (). The right pupil measured 5 mm in diameter and was sluggish reactive to light. Ophthalmologic tests of vision and intraocular pressure were within normal ranges in both eyes. Further physical and neurological examinations were normal. Skull X-rays and orbital computed tomography (CT) scans immediately after the accident failed to show fractures. MRI and MR angiography of the brain did not reveal any pathology on admission (). Contrast-enhanced spoiled gradient-recalled (SPGR) MR sequences with multiplanar reconstruction (MPR) was subsequently performed to produce high-resolution images of the cisternal portions of the cranial nerves. The 3D MR studies indicated a slightly rough-shaped ON near the the posterior petroclinoid ligament (PCL), but no nerve enhancement (). The patient's history, along with the ophthalmologic symptoms and the radiologic findings strongly suggested the diagnosis of an isolated lesion in the course of the ON without further damage in the right oculomotor nucleus.\nShe was then treated with oral prednisone in a tapering dose over several weeks. MPR of contrast-enhanced 3D MRI taken 2 weeks after the event clearly demonstrated strong enhancement and enlargement over the whole length of the right ON (). At the time of follow-up two months after trauma, her ptosis slightly improved. Three months later, ptosis was completely resolved, and there was some restoration of ocular motion in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-day-old, 5.3 kg, male patient presented for general anesthesia for undergoing craniotomy and vertical parasagittal right hemispherotomy. He was normally delivered at 39 weeks of gestation with a birth weight of 3,180 g without any complications or abnormal findings. One week after birth, his seizures started with repetitive clustered tonic spasms for 30 min, at a frequency of 10 clusters a day. He was admitted at an outside hospital, and vigabatrin 250 mg and phenobarbital 20 mg were administered. Yet his seizures were refractory to anticonvulsants, so he was transferred to our hospital at the age of 30 days.\nThere were no abnormal physical findings and laboratory investigations. The electrocardiogram and chest X-ray were also normal. After admission, he had generalized tonic seizure with right-ward eyeball deviation, blinking and nystagmus at a frequency of 1-3 a day. Flexor spasms in clusters were also observed for 10 minutes, at a frequency of 7 clusters a day. His magnetic resonance imaging (MRI) showed cortical dysplasia at the right temporal and parietal lobes (). On the positron emission tomography (PET) study, abnormal high uptake for that age was discovered at the right cerebral hemisphere. His video EEG for 2 days demonstrated excessively asynchronous and discontinuous rhythms, the so called suppression-burst patterns, and this was consistent with OS during both the awake and asleep states (). He was diagnosed with OS and right hemispherotomy was planned for treatment.\nHe was transported to the operating room and the immediate vital signs revealed a blood pressure, pulse rate and oxygen saturation of 83/42 mmHg, 152 beats/min and 100%, respectively. Before induction, 0.02 mg of glycopyrrolate was injected intravenously. The patient was preoxygenated and general anesthesia was induced with thiopental sodium 25 mg and atracurium 3 mg. Mask ventilation was begun with 100% oxygen and there was no difficulty in ventilation. After confirming full relaxation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48 year-old woman was scheduled for an urgent diagnostic flexible bronschoscopy, mediastinal washout as well as video-assisted thoracoscopic surgery. She was cared for in the intensive care unit having received a dual liver and lung transplant twelve days prior to the request for the thoracic procedure. The initial dual organ transplant (day 0) was complicated by intra-thoracic placement of the veno-venous bypass cannula. This was detected at the time and managed by resiting the cannula surgically into the axillary vein. The immediate post-transplantation course consisted of an initial uneventful recovery, monitoring and supportive management in intensive care unit. There was evidence of near complete resolution of the right-sided haemothorax with radiological confirmation on computed tomographic (CT) chest scan. Patient was afebrile with clinically stable markers of respiratory and haemodynamic function. She was extubated on day 9 post dual organ transplantation. The PICC line was inserted through the left basilica vein for total parenteral nutrition post extubation also on day 9. Both PICC lumens were found to flush and aspirate blood when tested clinically. Subclavian vein PICC tip placement was confirmed with a chest X-ray and total parenteral nutrition was commenced (). Patient developed mild voice changes and shortness of breath 36 hours later. The PICC line was checked. No blood could be aspirated. The PICC line was deemed likely blocked and remained in situ. This decision was made due to the high confidence in the initial appropriate placement of the line. Two days following the PICC line insertion, there were further changes with alteration in the quality of voice and difficulty verbalising. Patient developed difficulties with swallowing. Clinically, there was attendant deterioration in the respiratory function with chest pain, tachypnoea and hypoxemia. Patient oxygen saturation was low in the range of 91–93% despite oxygen therapy via hudson mask. Increa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old man was transferred to the emergency department by ambulance with an injury to the left ankle, after been involved in a road traffic accident (fall from own motorbike). He had sustained a minor injury to the head with an extensive blunt laceration of the soft tissues of the scalp (Glasgow Coma Scale, 15/15), a rib fracture accompanied by pneumothorax, as well as bruises and abrasions of the lower extremities. His primary complaint was severe pain and deformity of his left ankle. On physical examination, the ankle joint was noted to be deformed, swollen, and tender without lacerations. The skin temperature was normal, the sensory function could not be estimated because of pain, and there was motor loss. As the peripheral pulse was not palpable, the initial vascular status was assessed by applying the capillary nail refill test (observed). There is an obvious clinical deformity, and the ankle is revealed in a medial position with the talus head raised under the skin (). Radiographic evaluation of the ankle revealed an anteromedial dislocation of the talus, without any accompanying fracture (). Due to the absence of other fractures or neurovascular trauma, a closed reduction was attempted under general anesthesia with image intensifier fluoroscopy. Utilizing a technique previously described [], the talus was not able to be reduced to its anatomical position, neither was any sign of a “click” perceptible. A second attempt was also unsuccessful, and thus, a decision was made to perform an open reduction. Probably, the anteromedial dislocation of the talus, without malleolus fracture, was responsible for the unsuccessful closed reduction. The joint was explored through a dorsomedial incision (). The anatomical elements were identified, and the deltoid ligament and the tibiotalar syndesmosis were found to be intact. The displaced talus was easily reduced into the joint using gentle traction of the foot. The ankle and subtalar joints were"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 29-year-old Chinese woman was referred to the outpatient department of our hospital on 1 September 2016 with a 4-month history of catamenial hemoptysis. The patient also had a history of a laparoscopic operation for treatment of an ectopic pregnancy and a 6-year history of secondary infertility.\nIn May 2016, the patient developed her first episode of catamenial hemoptysis with no prodrome. During the following 4 months, the hemoptysis became associated with her menstrual cycle. The patient reported that she began coughing blood on the first or second day of her menses and produced about 150 mL of hemoptysis during her menstrual cycle. She had no thoracic pain, respiratory embarrassment, cough, fever, night sweats, or weight loss. On 1 September 2016, chest computed tomography (CT) revealed exudation shadows in the right lower pulmonary lobe () and small fiber lesions in the right middle lobe and left lung (), which were suggestive of pneumonia and endometriosis. The patient’s clinical symptom returned when menstruation began, but she did not receive treatment. The patient agreed to undergo an examination on 27 September 2016 to obtain a definitive diagnosis. Chest CT revealed patchy infiltration in the right lower pulmonary lobe () and small fiber lesions in right middle lobe () and left upper lobe (); the clinical diagnosis was pulmonary endometriosis. Thoracoscopic wedge resection of the right lower pulmonary lobe was performed on 30 September 2016. We observed slight pleural adhesion under thoracoscopy; local stasis of blood in the lower lobe of the right lung, which was soft and had a smooth surface; no blood stasis in the right middle and lower lobes, chest wall, and pericardium; and no hydrothorax in the right thoracic cavity. The pathologic examination revealed chronic inflammation with hemorrhage and hemosiderin deposition in the lung tissue. Immunohistochemistry examination revealed estrogen receptor negativity, progesterone receptor negativity, CD positi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 81-year-old male patient was referred to our department with dysphonia. There was no history of smoking. A status past multiple myeloma was known in his medical history that was in complete remission at the time of presentation. The patient denied dyspnea, dysphagia, pharyngalgia, and fever. Laryngoscopy revealed a diminished mobility of the right vocal cord and a thickening of the right vestibular fold so that a microlaryngoscopy with tissue sampling was performed. The histological examination of specimens obtained from this region revealed fibrosis. Computed tomography (CT) scans of the neck and the thorax were without any pathologic findings. The patient was discharged to outpatient care.\nThree months later, the patient was admitted with progressive dyspnea along with inspiratory stridor. The clinical examination revealed now a complete paralysis of the right vocal cord and a remaining glottic cleft of only 1 mm due to a supraglottic protrusion of the right vestibular fold. The CT scan () showed now a tumor of the right vocal cord extending to the right piriform sinus.\nAfter tumor debulking in order to expand and secure the airway, the excised material that consisted of several red brown elastic tissue fragments measuring together 24 × 12 × 10 mm was sent for pathological examination. Histologically, one could see tight lymphoid infiltrates. The cells had large nuclei and were irregularly shaped, and the proliferation was strongly enhanced in the staining for Ki67 (50%). The immunohistochemical analyses showed a negative result for CD20 and CD3, and a positive staining for CD138. BCL2 and CD10 were coexpressed (). The clonal light chain restriction for lambda chains substantiated the diagnosis of a multiple myeloma. These results were consistent with laryngeal involvement from the patient's previously diagnosed multiple myeloma.\nThe patient was referred to the Department of Hematology and a systemic therapy with the proteasome inhibitor Bortezomib was discusse"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old male patient came to the orthopedic and rehabilitation clinics at our hospital with right equinovarus and gait disturbance. He had a history of hypoxic brain damage caused by the umbilical cord wrapping around fetal neck at birth, and was diagnosed with CP at the age of 1 year. He was experiencing severe dystonia in his neck and bilateral upper extremities; the Burke-Fahn-Marsden dystonia rating scale (DRS) showed 55 points on the dystonia movement scale, and 10 points on the disability scale.\nOn manual muscle test, the left extremities were within the normal limit, but the right upper and lower extremities only showed grade 3 (Fair). He showed right hip joint flexion contracture and right ankle plantar flexion contracture on the range of motion test. In terms of spasticity, his right upper and lower extremities scored grade 2 on the modified Ashworth scale (MAS). He had 78 points on the modified Barthel index (MBI), and 105 points on the functional independence measure (FIM). He showed asymmetry in the lower extremities and equinovarus in the right ankle on a plain X-ray, and 60 degrees right femoral anteversion, 15.3 degrees left femoral ante version, 38.9 degrees right tibial torsion and 37.1 degrees left tibial torsion on CT.\nIn gait analysis, he showed no dissociated movement between the pelvis and lower limbs, so we were able to see the bump sign, and the right pelvis were positioned superiorly to the left pelvis in the coronal plane during the whole gait cycle. Internal rotation of the right pelvis and external rotation of the left pelvis were observed in the transverse plane, and both hip joints showed internal rotation in the sagittal plane. Due to tightness in the hamstring muscle, both knee flexion posture and right ankle planter flexion posture were displayed during the whole gait cycle ().\nTo differentiate from hereditary torsion dystonia, when fragment analysis was performed on the DYT1 gene"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase One: A 35-year-old woman presented at six weeks of gestation, dated according to her last menstrual cycle, with painless vaginal bleeding. The patient had regular menses and a history of cesarean delivery 3 years prior with no other significant medical history, or history of sexually transmitted infections.\nThe patient’s transvaginal ultrasound was notable for a uterus anteflexed with a gestational sac of 12 mm and embryo of 4 mm with positive cardiac activity located on the anterior aspect of the lower uterine segment. The anterior aspect of the myometrium measured 5.2 mm and the lower uterine segment measured 1.5 mm. We could demonstrate color Doppler signal uptake in the area that contacts the posterior lip of the cervix and the preserved bladder. The patient’s serum quantitative beta human chorionic gonadotropin (β-hCG) was 3600 UI/L. At presentation, her vitals were within normal limits and stable.\nThese ultrasound findings raised the suspicion of cesarean scar ectopic pregnancy. Following appropriate counseling, the patient confirmed her desire for future fertility and, understanding the risks and benefits, she agreed to medical treatment. An initial dose of intramuscular methotrexate at one milligram per kilogram (mg/kg) was administered. At one week follow-up, she received a three multi-dose regimen over a period of five days. Three doses of folinic acid were added to the treatment. After a systemic treatment of multiple doses for one week, the patient was asymptomatic and the betahCG serum level was 5809 UI/L. An aspiration curettage was thus performed in the ultrasound operating room, affording possible transvaginal access by imprinting the sac at the cervical level. During the curettage, access to the gestational sac area was achieved by obtaining decidual material. The pathological report showed decidual remains. On follow-up the next day, the patient’s serum quantitative beta-hCG was 1371 UI/L. The following week, a transvaginal ultrasound confirme"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old woman, gravida 1, para 0, was diagnosed with invasive squamous cell carcinoma of the cervix following conization. Pathological findings showed carcinoma consistent with FIGO stage IA1 with lymphovascular invasion. She was referred to Keio University Hospital. The patient and her husband were informed of the treatment options, including AmRT and pelvic lymphadenectomy. The patient was told that the outcome of this procedure could not be guaranteed because an insufficient number of these procedures have been performed worldwide to yield reliable conclusions. The patient wished to preserve fertility, and she and her husband signed a written consent form agreeing to this treatment. Pathological findings after AmRT and pelvic lymphadenectomy showed no residual tumor and no lymph node metastasis. There was no finding of an ovarian tumor before surgery. A left ovarian cyst of 4 cm was identified during postoperative follow-up.\nAt 3 years and 6 months after surgery, the patient underwent IUI and then had fever and pain in her left lower abdomen 10 days later. At her first visit, her temperature was mildly elevated to 37.5°C. The patient's pregnancy was denied because a qualitative urine human chorionic gonadotropin (hCG) test was negative. A tumor with tenderness was palpated in the left adnexal area. A cystic tumor of 64x 41 mm was found by transvaginal ultrasonography (). Blood tests showed increases in white blood cell (WBC) count to 11900/μL and C-reactive protein (CRP) to 22.80 mg/dL. The patient was diagnosed with PID with ovarian cyst infection and hospitalized for treatment. Conservative treatment with antibiotics was initially used, but her symptoms did not improve. On hospital day 8, blood tests showed a further increase in WBC count to 23900/μL and CRP to 28.17 mg/dL, and pelvic CT showed that the ovarian cyst had grown to 10 cm in size ().\nWe decided to perform laparoscopic left ovarian cystectomy on day 8."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 33-year-old primigravid African woman who had been pregnant for 40 weeks and three days dated from the first day of her last normal menstrual period presented to our unit with a three-day history of continuous pain around the umbilical area. She did not have any other complaints.\nA review of her antenatal records revealed that she had sought medical attention at her local clinic for lower abdominal pain at eight weeks and four days and once again at 14 weeks and two days of gestation. Both episodes of lower abdominal pain were managed conservatively.\nThroughout the pregnancy the patient continued to experience on and off abdominal pain which became better as the pregnancy progressed.\nShe denied any per vaginal bleeding during her pregnancy.\nOf note, the patient said that her mother had developed hypertension when she was pregnant.\nThe results of her serologic tests for human immunodeficiency virus as well as rapid plasma reagin were negative at the antenatal clinic. Her hemoglobin concentration at 22 weeks of pregnancy was 10.7g/dL. Methyldopa and nifedipine were commenced for pregnancy-induced hypertension from 22 weeks of gestation. During antenatal care visits at 26 weeks and three days, 30 weeks and three days, 34 weeks and four days, and 37 weeks and three days she was normotensive. At 38 weeks and four days her blood pressure was 150/100mmHg.\nThe patient had an ultrasound scan done at 33 weeks and three days at a local clinic which showed a single viable breech intrauterine pregnancy with a left lateral upper segment placenta, slightly reduced liquor volume and some small free fluid in the hepatorenal area. The estimated gestational age by scan was 34 weeks and two days. From the time of this ultrasound scan, the presentation by clinical examination which had previously been documented as cephalic was then documented as breech.\nBesides the on and off abdominal pain, her pregnancy had been uneventful until she developed periumbilical pain prompting her to pre"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 13-year-old female patient, known with severe visual field loss, who referred for another opinion regarding the ophthalmological diagnosis.\nAnamnesis at presentation revealed that at the age of 9 years and 3 months, on a routine ophthalmological examination, papillary calcification and retinal hemorrhage were discovered in the left eye. At that moment, the suspicion of intracranial calcifications was raised. The patient underwent clinical neurological examination, EEG, and cerebral MRI, all of them revealing a normal aspect. The patient was also recommended fluorescein angiography, which showed papillary autofluorescence. The diagnosis established then was papillary drusen in both eyes, buried in the right eye and mixed in the left eye and the patient was recommended to keep it under observation, together with a periodical examination of the visual field.\nThe patient had had multiple examinations of the visual field over the time.\nThe first visual field examination of the right eye showed an arcuate nasal defect, in the superior nasal quadrant, sketching an aspect of nasal step, structure of the sensitivity defect that in 3 years time evolved into a quadranopsia.\nIn the left eye, the first visual field examination showed inferior nasal quadranopsia, extended superiorly with a nasal arcuate defect respecting 20° centrally, which after three years evolved into a paracentral diffuse defect with an island of central vision of 5°.\nHowever, over the time, the examination of the visual field was made with different types of machines, and no correlation of the modifications could be made objectively.\nThe patient received several different diagnoses from several different ophthalmologists, among which optic nerve drusen; papillary oedema and hamartoma have to be mentioned.\nAt presentation, the patient’s visual acuity was 20/ 20 with correction for the RE and 20/ 20 without correction for the LE, with a refraction ROD: -1 DSf<> -0.75 DCyl, 179* and RO"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient, a 67-year-old Caucasian man, presented in the morning to the emergency department complaining of a sudden onset of excruciating right-sided arm and neck pain radiating to his head, followed by two episodes of vomiting. Both arms had reduced power from the shoulder distally. He complained of weakness in his legs, but denied any recent trauma, falls or loss of consciousness. On initial examination, shoulder abduction and adduction were absent, and flexion and extension of the elbow joint 2/5 on the Medical Research Council (MRC) power scale. Power in the lower limbs was normal. All modalities of sensation were intact bilaterally in the upper and lower limbs. No cranial nerve abnormalities were detected.\nThe patient had recently been diagnosed with hypertension and type 2 diabetes. His blood results on admission showed no abnormalities apart from a high glucose level consistent with untreated diabetes. A computed tomography angiogram showed no signs of thrombosis or dissection of the aorta. A spinal MRI scan showed a high-intensity lesion in the anterior two-thirds of the gray matter extending from C3 to C5 (Figures and ). He was diagnosed with anterior spinal artery ischemia secondary to dissection of a distal vertebral artery. He was started on 300 mg aspirin, and his case was reviewed by both a physiotherapist and a diabetic specialist nurse while he was an in-patient. Within three days of presentation, power in both of his arms had improved (MRC score 4/5), except for abduction of his right shoulder, which he could not lift above the horizontal position.\nSpinal cord infarction and ischemia are rare and often difficult to diagnose, but they represent important differential diagnoses of acute spinal symptoms. This case presentation describes an interesting presentation of ASCIS which differs from the classically described symptoms, insofar as the patient had no clinically detectable sensory deficit. This disorder is also associated with significant morbi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA five-year-old typically developing female was referred by her primary care provider for evaluation of a rash reported to be sensitive to sunlight and had been reoccurring for the last 4 years. Cutaneous exam revealed fine scale on her trunk and extremities as well as small pink flat papules on lower left leg. She was diagnosed with ichthyosis vulgaris and provided with a treatment plan. She was subsequently referred to gastroenterology for decreased appetite. Two weeks later the child presented to the Emergency Department for right knee pain. Her mother reported her daughter had experienced bilateral lower extremity pain and had been limping. During the evaluation she was able to walk for the physician without reporting pain and no tenderness was reported with palpation. The mother reported her daughter was bitten by a tick about 1 year ago and that no workup or treatment was conducted. Radiographic scans of the right knee and leg showed no abnormalities. Laboratory testing for Lyme disease was conducted and found to be negative. She was discharged with the diagnosis of tenosynovitis. The child presented again to the Emergency Department the following week for left knee and ankle pain. She reported pain in her left calcaneus when asked to bear weight. Migratory arthralgia was noted and further laboratory testing, including a vitamin C level, was ordered. Her vitamin C level was found to be < 5 umol/L (reference range: 23 to 114 umol/L). Her prealbumin level was also low, 14 mg/dl (reference range: 17–36 mg/dl) as was both her ferritin 3.9 ng/ml (reference range: 6.2–137.0 ng/ml) and her iron saturation 15% (reference range: 20–55%). Both vitamin A and vitamin D were found to be within the normal reference range. With the diagnosis of the vitamin C deficiency, the child was started on ascorbic acid and referred to the feeding program.\nThe participant was the youngest of six"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA fifty-nine year old male presented with a 4 × 2 cm lump in the right neck at level II. He had noticed the swelling for less than one week but reported a three year history of sore throat, fatigue, reduced exercise tolerance and shortness of breath. He had never smoked and consumed 18 international units of alcohol per week. There was no other lymphadenopathy and no intra-oral abnormality. Fine needle aspiration cytology was inconclusive and the patient underwent a diagnostic lymph node excision for histological evaluation, which showed metastatic squamous cell carcinoma. Computed tomography (CT) and 15fluoro-deoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) were undertaken to identify the primary site and revealed a 2 cm mass involving the right tonsil with a right sided level II lymph node mass extending into the deep lobe of the right parotid gland. He was treated with radical chemoradiation comprising image-guided intensity modulated radiotherapy (IMRT) delivering 65Gy in 30 fractions to the oropharynx and right neck level II with 54Gy in 30 fractions to right neck levels III to V and left neck levels II to V. Concomitant cisplatin 100 mg/m2 was given on days 1 and 29 of radiotherapy. A FDG-PET/CT scan performed at 3 months post-treatment confirmed a complete metabolic response. The patient remains disease free after 15 months.\nHistological evaluation of the excised lymph showed complete effacement by carcinoma comprising two clearly demarcated and morphologically distinct subpopulations of cells. In most areas, the two subpopulations were separated by fibrous tissue bands. Where the two phenotypes were not separated by fibrous tissue, there was abrupt delineation of the subpopulations without any intermediate transition. One component was composed of broad interconnecting strands of tumour cells with obvious squamous maturation but with minimal keratinisation typical of conventional HPV-associated OpSCC, designated the ‘differentiated’"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old Chinese man sustained severe knife trauma and was referred to a local hospital. An exploratory laparotomy showed traumatic rupture of his left external iliac vein with massive intraperitoneal bleeding, but his iliac artery was intact. To rescue him, the proximal and distal parts of his injured external iliac vein were ligated (there was no vascular surgeon in the local hospital); however, his left leg quickly became severely swollen, cyanotic and pulseless. Two hours after the first operation, he was transferred to the emergency department of our university hospital with endotracheal tube intubation. On physical examination, he was tachycardic (142 beats per minute), hypotensive (86/50mmHg). His left lower extremity was markedly edematous, cyanotic, mottled (Figure \na) and had no palpable pulse, but his right lower extremity was normal. He was diagnosed with posttraumatic PCD. Considering the high risk of pulmonary embolism during the next surgical procedure, an OptEase® retrievable vena cava filter (Cordis Corp., New Brunswick, NJ, USA) was placed in his inferior vena cava via his right femoral vein under digital subtraction angiography (Figure \n). His abdomen was immediately reopened while his left leg was also prepared for treatment.During the second emergent laparotomy, there was less blood in his pelvic cavity. No active bleeding was identified. His left iliac vein and artery were exposed and his entire iliac artery appeared normal and without rupture. His external iliac vein was ligated but not transected, connected only by the posterior wall, and the caudal part of his iliac vein was significantly dilated. By replacing the vascular clamp in the proximal and distal parts of the rupture, the ligations on both sides of the venous rupture were resolved. A wedge-shaped rupture was revealed, approximately 4cm in length, on the anterolateral side of his left external iliac vein. The edges of the venous rupture were smooth as a result of the kn"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old woman presented to our department with signs and symptoms of multinodular goiter (MNG). Bulky hypertrophy of the thyroid gland at the anterior neck was determined by inspection. Larger nodules with regular margins were palpated in both lobes by physical examination. Serum thyroid-stimulating hormone and free thyroxine levels were normal by biochemical analysis. Thyroid ultrasound revealed multiple nodules in both lobes. Bigger nodules were a 50 x 36 x 40 mm hypoechoic solid nodule in the right lobe and a 33 x 25 x 37 mm isoechoic solid nodule in the left lobe. Fine needle aspiration from dominant nodules revealed benign cytology. The diagnosis was MNG. Total thyroidectomy under the guidance of IONM was planned as the surgical treatment. Informed consent was obtained from the patient.\nThe right thyroid lobe was partially mobilized after ligation of the middle thyroid vein. The carotid sheath was incised, and the right vagus nerve (VN) was located behind the carotid artery and the jugular vein. Direct stimulation of the VN with the stimulator probe at a standard distal point did not create a sound signal. The absence of a distal V1 (d-V1) signal revealed the early proximal separation of the inferior laryngeal nerve and eventual presence of the non-RLN. The carotid sheath incision was extended toward the cephalic direction. The right VN was proximally followed under the guidance of IONM with serial electrophysiological stimulation to identify the separation point of the inferior laryngeal nerve. A positive signal from a proximal point of stimulation (p-V1 = 648 µV) helped us to locate the separation point of the right inferior laryngeal nerve. Stimulation of the inferior nerve when first identified at the separation point posterior to the carotid artery created a positive sound signal and wave amplitude (R1 = 661 µV). Both lower and upper poles of the right lobe were carefully dissected, and the lobe was mobilized medially. The right non-RLN arising"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old male, working as a shopkeeper, presented to our emergency department with complaints of pain and loss of movement in bilateral shoulder, following fall from the standing height. This incident was associated with an epileptic episode while he was doing routine work in his shop. On detailed history, we discovered that he was a diagnosed case of generalized tonic clonic seizure for 9 years with the past episode 3 years back and was off medication for 2 years. There was no history of diabetes, hypertension, alcohol, and smoking. A history of oral tobacco intake for the past 20 years was present. He had suffered 4 episodes of right shoulder dislocation, the most recent episode being 2 months ago.\nOn examination, diffuse tenderness and swelling were present over bilateral shoulder with bony crepitus. No distal neurovascular deficit was noted. No other injuries were noted during the examination. Immobilization and analgesics were given in an emergency. Plain radiographs followed by computed tomography scans revealed bilateral Neer [] IV part fracture with anterior shoulder dislocation (Figs. , ). The patient was prepared for operative intervention and necessary investigations were done. Both the shoulders were operated in a single sitting. The same deltopectoral approach was used bilaterally and open reduction with Proximal Humerus Interlocking Osteosynthesis (PHILOS) plating was done (). The right side was operated first for no particular reason, taking approximately 3 h followed by the left side in the next 2 h. Re-draping was done and a shot of an intravenous antibiotic was given before starting the left side. Intraoperatively, a bony Bankart lesion in the right shoulder was noticed which led to persistent instability even after fixation of the proximal humerus. Henceforth, a Latarjet procedure was done for the same.\nPostoperatively, the right shoulder was immobilized for 2 weeks. Pendular exercises were started on the 1st post-operative day on the left si"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old woman was admitted to our hospital in March 2018 with a lump in her left breast. On a physical examination in the outpatient service, we found a lesion that was approximately 8 × 7 cm in size in the upper outer quadrant of the left breast with occasional bloody nipple discharge. Some abnormally enlarged lymph nodes were observed in the left axilla ().\nA biopsy specimen of the left nodule showed invasive ductal carcinoma and scirrhous type cancer of the breast (cT3NxM0). Estrogen and progesterone receptors were positive, but human epidermal growth factor receptor 2 (HER2) was negative in immunohistochemical staining. The Ki-67 labeling index was 60%. At the same time, ultrasound imaging showed a 20 × 22 ×27-mm hypoechoic nodule of Thyroid Imaging Reporting and Data System category 4 in the left thyroid. Fine needle aspiration biopsy of a thyroid nodule showed papillary thyroid carcinoma (cT2NxM0, stage I) ().\nDuring routine examinations, transvaginal ultrasound showed a hypoechoic area in the muscle layer of her uterus (). She was diagnosed with uterine fibroids. Her history of disease included adenomyosis and dysfunctional uterine bleeding. She had continuous androgen, estrogen, and progesterone treatment for her gynecological diseases for longer than 5 years. She did not have any family history of papillary thyroid or breast cancer. The patient did not receive external beam radiation to the neck region. She did not know whether she had thyroiditis because she had not been examined before admission. She was not diagnosed with thyroiditis during preoperative laboratory tests in this hospitalization. She underwent endometrial scraping surgery 30 years previously because of uterine functional bleeding and adenomyosis.\nThe patient was diagnosed with breast cancer and thyroid cancer. Her breast cancer was in the advanced stage and luminal B type. She was treated with neoadjuvant chemotherapy of epirubicin 100 mg/m2 and cyclophosphamide 600 mg/m2, followed b"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45 year old single woman with a non regressing congenital vascular malformation of the right arm and upper chest, presented with a 3 day history of high fever, chills, dysuria, hematuria and right loin discomfort. Her urine output was normal and she had no spontaneous bleeding manifestations or features of uremia. A marked drop in her platelet counts compared to recent baseline levels had been detected by her primary care physician following the onset of symptoms.\nHer past medical history was significant for persistent low baseline platelet counts in the region of 100,000/mm3 with episodic reduction to values as low as 30,000/mm3 following infections. She had been extensively and repeatedly investigated from the time the low baselines platelet counts were detected at the age of 28, however no definite cause was identified. On direct questioning she denied spontaneous mucocutaneous bleeding in the past. However her past medical history was significant for an abandoned plastic surgical procedure after developing a haematoma surrounding the preoperative intravenous cannulation site with a corresponding platelet count of 47,000/mm3. She had also been managed conservatively for uterine adenomyosis with depot provera from the age of 45 due to concerns of high risk of perioperative bleeding.\nDetailed evaluation was negative for symptoms attributable to anemia, connective tissue disease and liver disease. History of medications was negative for agents associated with thrombocytopenia.\nExamination revealed an ill looking lady with a temperature of 100.4 degrees Fahrenheit. She had a giant hemagioma involving the entire right arm, right lateral aspect of the neck and both the anterior and posterior aspect of the chest extending up to the 4th intercostal space (Figure \n). The hemangioma had small areas which were ulcerated and inflamed as well as healed scars. A soft bruit was appreciated on auscultation over the hemangioma. She had no petichiae or ecchymoses and her conjunc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old primiparous woman was seen at our hospital for preterm contractions for seven days with reduced fetal movements at 27 weeks and 4 days of gestation. A threatened premature labor was diagnosed. Ultrasound showed a female fetus with normal development and amniotic fluid volume. Small bowel appeared mildly dilated (14 mm) with thickened and hyperechogenic intestinal wall. There was a typical whirlpool configuration of the bowel (). First and second trimester ultrasounds were unremarkable. Screening for infectious diseases was negative. A molecular genetic testing of CFTR was realized in the parents who were tested for the 32 main mutations of CFTR during a genetic counseling. This testing was negative in both of the parents. So, the fetus was not screened for cystic fibrosis. The patient received atosiban for tocolysis and steroids for fetal lung maturation. Ultrasound follow-up one week later and every two weeks showed absence of significant modification in small bowel dilatation and normal fetal development and amniotic fluid volume up to 33 weeks and 1 day of gestation when a peritoneal calcification appeared leading to the suspicion of meconium peritonitis. Fetal biometry measures including the abdominal circumference and amniotic fluid volume were normal throughout the follow-up in antepartum period. Ultrasound follow-up at 36 weeks and 4 days of gestation revealed a significant aggravation of intestinal dilatation (30 mm) appearing more extensively with persistent intestinal peristalsis, and some parietal calcifications appeared with a meconium pseudocyst but there were no ascites (). Fetal vitality was good with a satisfying Manning's score; there were neither ascites nor significant increasing in abdominal circumference nor abnormality in fetal heart rate and the amniotic fluid volume was normal. So, the patient was hospitalized for close monitoring of fetal heart rate. After consultation with members of pediatric surgery team, induction of labor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-year-old male presented to urology clinic with the chief complaint of persistent feelings of impending orgasm. He reported a sensation similar, but not identical, to sexual arousal that did not occur in the setting of sexual thoughts or desire. During these episodes his penis would be extremely sensitive. With manual stimulation he would achieve orgasm, which alleviated the arousal for only a short time after which the symptoms would return. This had become quite bothersome to him.\nThe onset of symptoms was sudden. This was associated with a change of bowel habits with a sensation of fecal urgency and inability to have a bowel movement without straining. He also complained of an ache in the area of his coccyx. The need to strain resolved with fiber supplementation and did not return, but the fecal urgency persisted. His arousal symptoms persisted as well. He denied any urinary frequency, hesitancy, or urgency. The patient reported normal erections and ejaculation.\nHis past medical history was significant intermittent neck pain and chronic back pain from a herniated disk at L5-S1, for male pattern baldness, for which he was taking Propecia, and Peyronie's Disease for which he had seen an urologist in the past, but had declined treatment because he was not sexually active. Past surgical history was significant for appendectomy.\nGenitourinary exam revealed a circumcised phallus with a 1.5 cm plaque on the dorsum of the penis at the base, otherwise the penile and perineal exam were normal. There was a grade 3 varicocele on the left. No inguinal hernias were present. Digital rectal exam revealed good sphincter tone and a small, smooth, nontender prostate.\nThe patient was referred to an orthopedic spine surgeon and MRI of the brain and cervical, thoracic, and lumbosacral spinal cord was obtained. The MRI showed the previously diagnosed L5-S1 herniation which was stable and a synovial cyst"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year old male patient presented to the Emergency Department of our hospital complaining of malaise, fatigue, night sweats and fever during the last month. The patient had been tested positive for HIV 7 years ago and had been followed on a regular basis in our Infectious Diseases Unit, until two years ago, when he had insistently denied initiation of HAART and was lost to follow up.\nOn admission, the patient was in a good clinical condition. Clinical examination was remarkable for a mild splenomegaly and a small focus of Kaposi sarcoma in the ankle. Apart from moderate normocytic anemia and elevated ESR, other blood tests and biochemistry panel were normal (). His CD4 cell count was 17 cells/uL and HIV viral load 105,000 copies/mL.\nBlood cultures for common bacteria and mycobacteria were negative. Serum Cryptococcus neoformans antigen and Wright reaction were negative. PCR amplification for CMV genome was undetectable, while for EBV genome 3.4×103 copies/mL were detected. Bone marrow aspiration and biopsy were performed and cultures were drawn. PCR amplification for Leishmania infantum was positive in the bone marrow and the serum. However, Giemsa stain of the bone marrow was negative for the parasite and antibodies against K39 antigen in the serum were also negative. In view of the above findings, HAART with abacavir, lamivudine and dolutegravir was initiated in the 6th hospital day (day 0 from that point) and the patient was subsequently treated with liposomal amphotericin, while continuing the diagnostic workup.\nWhole body CT scan performed early in the course of the fever had revealed mild lymphadenopathy in the mesenteric region, as well as mild splenomegaly. A PET-18-FDG scan had then been performed, which had raised suspicion of lymphoma in the above lymph nodes. In the meantime, there was a transient amelioration of the patient’s fever spikes and transfusion needs and laparoscopic biopsy of the lymph nodes was postponed.\nOn day"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old female was admitted to our hospital complaining of numbness in the left limb for one week. Past medical history was notable for the diagnosis of NMO and intracranial hemorrhage. The patient was diagnosed with NMO ten years ago due to repeated episodes of blurred vision and numbness and weakness in the limbs. Brain and spinal magnetic resonance imaging (MRI) at that time indicated lesions in the brain white matter as well as spinal cord involving cervical and thoracic regions. AQP4 antibody test was not performed. Considering the potential diagnosis of demyelinating disease, steroid pulse therapy was initiated and the patient improved after the treatment. After discharge, corticosteroid was gradually tapered and the patient was maintained at a low-dose corticosteroid and azathioprine in the long term. The patient was also diagnosed with left basal ganglia hemorrhage three years ago, presenting as right-sided hemiplegia and confusion. Brain angiography was not performed at that time, and the patient recovered after symptomatic treatment. Family members exhibited no sign of the case pathology. Upon examination, the patient appeared lethargic and sluggish, with normal vital signs. Visual acuity was impaired in the right eye with a score of 20/200 on testing. Pupils were 3 mm bilaterally, round and reactive. Regarding motor function, muscle strength was decreased in the left extremities (Medical Research Council strength score, grade 3). Hypoesthesia of the left side was also observed. Babinski sign was present bilaterally. Further investigations revealed a positive AQP4 antibody in the serum, with an elevated titer of 1:32. An initial diagnosis of NMOSD was made considering her medical history and radiological findings. Other tests including complete blood count, basic metabolic panel, serum glucose, and anti-nuclear antibodies were all normal. Brain MRI after admission indicated lesions with restricted diffusion in the right thalamus and hemosiderin depos"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man was admitted to our Department on May 2013 as emergency case because of gastrointestinal bleeding and anaemia. The patient's medical history was significant for hypertension, noninsulin-dependent diabetes mellitus and iron-deficiency anaemia.\nAnamnesis is also characterized by a diagnosis of skin melanoma in the abdominal region on April 2011; however, the patient gave us such information only at the end of our surgical treatment. At that time a diagnostic excisional biopsy of the lesion was performed and the histological report confirmed: “III Clark level, Breslow thickness 0.55 mm malignant melanoma with the prevalence of superficial diffusion and without regression or vascular infiltration”. Consequently a wide skin removal was performed, because a melanoma was found on the skin near to the previous excision. However the patient did not have sentinel lymph node biopsy procedure or any follow-up control because he did not accept them.\nAt the beginning of 2013 the patient had several episodes of melena and, with the aim to discover the source of bleeding, we performed a colonoscopy with biopsy (the histological diagnosis was hyperplasic adenomatosus polyp) and a gastroscopy which solely showed an antral gastritis and an inflammatory stomach polyp. Moreover the patient underwent abdominal US and MRI and a total body CT scan that showed right axillary lymphadenopaty, a nodular lesion in the medial lobe of the right lung and a big mass (7 cm of diameter) in the IV–VIII segment of the liver of which an US-guided biopsy was carried out. In addition we founded an increase in the tumour markers (TPA, NSE, S100B). For a more accurate diagnosis, the patient underwent capsule endoscopy which showed a subtotal stenosing vegetating ulcerating neoplasm of the upper jejunum (just below the Treitz's ligament); because of this, it was impossible to end the examination.\nWhile we were waiting for the histological response of the hepatic biopsy, the patient had a se"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe propositus is a 3-year-old right-hand dominant girl who presented to a multidisciplinary neurodevelopment clinic with a question of developmental delay and hypotonia. Early spotting in the third week complicated the pregnancy however, no subsequent difficulties occurred. She was born at 41 weeks of gestation by vaginal vertex delivery. Apgar scores were 8 at 1 min and 9 at 5 min. The birth weight was 3935 grams. She had a stable neonatal course and was breastfed for the first 7 months of life. She presented with early emesis but with no history of reflux or aspiration. She did have a history of chronic respiratory congestion since early infancy and was subsequently diagnosed with asthma; which was treated with Flovent and Ventolin. She had a history of recurrent middle-ear infections requiring myringotomy tubes. Serial neuro-opthalmologic assessments were performed for mild intermittent exotropia, which had been improving. An MRI of her brain at 1 year of age showed normal brain structures with no evidence of agenesis of the corpus callosum.\nEarly in her second year of life, her parents were concerned when her walking milestone was delayed. She walked at the age of 23 months, but continued to have difficulties with balance and coordination and was quite a cautious child. Her first words were around the age of 8 months. Slow progress was made and by her assessment at 31 months of age she had approximately 30 single words and was not combining words into phrases. She had difficulties with pronunciation and remained unintelligible to unfamiliar people. In her fine motor skills, she was found to be severely delayed in both manipulation and skills required for self-care. She was not toilet trained. A decrease in pain sensation was also reported. She was very social, had a happy temperament and enjoyed a variety of play activities although at a younger developmental level than her chronological age. There was no regression and no signs of autism."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old Caucasian woman, gravida 4, para 1, was referred to our high-risk obstetric unit at 24 weeks' gestation for fetal ascites detected during a routine ultrasound examination. Her personal and family history did not reveal any pathology of note. Her first pregnancy ended with an intra-uterine death at 23 weeks' gestation caused by chorioamnionitis. In the second pregnancy, a live baby girl was delivered at 40 weeks' gestation. Four years later our patient had a spontaneous miscarriage. Our patient denied any fever, rash, cold symptoms, or joint pain before and during pregnancy. She did not refer to any vaginal bleeding. Laboratory tests for Toxoplasma and rubeola showed negative immunoglobulin M (IgM). An ultrasound examination performed during the consultation confirmed the presence of abdominal ascites (Figure ). A borderline monolateral dilation of the cerebral ventricle was also seen. Biometry of the fetal limbs was below the mean in relation to gestational age, while cephalic measurements were normal. No other fetal anomalies were observed. Amniotic fluid was present in adequate quantity, but fetal movements were poor. For these reasons, the woman was admitted to our institution for close pregnancy monitoring. During hospitalization, her blood pressure and heart frequency were measured several times during the day, while cardiotocography was performed twice a day. Maternal blood pressure was normal, and there was no proteinuria. Investigation about the etiology of the fetal ascites were carried out, and a fetal paracentesis was also performed. Both parents had normal mean corpuscular erythrocyte volume with no sign of microcythemia and they both had positive blood group Rh without any pathologic antibodies. A routine blood laboratory assessment did not show any kind of abnormalities. Viral serology markers (cytomegalovirus IgG and IgM, parvovirus IgG and IgM) were negative in the maternal blood, and no viral genome was isolated in her amniotic fluid o"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 15-day-old dizygotic twin girl born via uncomplicated vaginal delivery. She was referred to our institution as a result of findings of ventriculomegaly noted on prenatal screening ultrasonography. The cause of the hydrocephalus was unknown at that time. On examination, the patient had a soft but full anterior fontanelle, along with dilated scalp veins. The head circumference was greater than the 97th percentile for gestational age. No focal neurologic deficits were appreciated on examination. Postnatal cranial ultrasonography revealed progressive hydrocephalus as well as a midline echogenic mass in the posterior fossa with mass effect on the cerebellum. Magnetic resonance imaging (MRI) was obtained, which revealed a very large dural-based extraaxial mass along the dorsal aspect of the posterior fossa []. The mass was well-circumscribed and heterogeneous, but mostly T1 isointense and T2 hypointense with flow voids and evidence of previous hemorrhage within it. Avid contrast enhancement was seen. There was marked mass effect on the cerebellum, fourth ventricle, and brainstem with resultant obstructive hydrocephalus and evidence of transependymal flow. The differential diagnoses of an intracranial vascular lesion in this 15-day-old infant included hemangioma, hemangioblastoma, vascular malformation, and other neonatal tumor types, such as soft-tissue sarcoma.[] In addition, meningioma could not initially be definitively excluded because of the dural attachment.\nOwing to the compressive nature of the lesion and the progressive hydrocephalus, the infant was taken to the operating room for resection of the posterior fossa lesion. Prior to the resection, an external ventricular drain (EVD) was placed in the occipital horn of the right lateral ventricle with care to avoid the egress of cerebral spinal fluid until the tumor was resected. A suboccipital craniectomy and C1 laminectomy were performed. The lesion appeared extremely vascular and clearly emanated"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old man presented to our emergency department due to acute onset chest pain. He originally presented three days earlier with similar symptoms but was released from the emergency department when the cardiovascular workup was negative. His current chest pains were localized to the midsubsternal area. Morphine and nitrate treatment were not effective in relieving his pain.\nThe patient has a history of seizure disorder, high blood pressure, reflux disease, gastritis, hiatal hernia, osteoporosis, and osteoarthritis. He had encephalitis at approximately 18 months of age and a subsequent head injury. At 3 years old, the patient had a large benign brain tumor which was removed. These early incidents resulted in developmental and physical disabilities.\nOn admission his troponin I level was minimally elevated, and D-dimer was elevated. The patient was anemic and an upper endoscopy was scheduled to rule out a gastrointestinal bleed.\nThe endoscopy findings showed evidence of Grade IV esophagitis. The ulcerations extended in the esophagus from 25 cm to 32 cm. A 15 mm linear ulcer was also seen on a hiatal hernia (). The stomach and duodenum appeared normal.\nThe biopsy results of the esophagus showed esophageal squamous mucosa with marked acute and chronic inflammation, granulation tissue, and overlying necroinflammatory exudate. In addition, there were abundant sheets of plasma cells, seen in all biopsy fragments (). The atypical plasma cells demonstrated abundant cytoplasm with eccentrically placed nuclei, some with prominent nucleoli ().\nImmunohistochemical analysis revealed that the plasma cells expressed CD138 and MUM1 and were IgG kappa restricted ().\nA whole body PET/CT scan was subsequently performed. The findings showed a focal area of increased metabolic activity in the midesophagus which may correspond to the biopsy site. An enlarged and abnormally metabolically active lymph node was identified in the left paratracheal position measuring 1.3 cm. There was als"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old otherwise healthy woman presented with three to four months of mechanical right groin pain radiating to the right buttock. She had a history of a benign soft-tissue mass in the right thigh that had been biopsied 10 years earlier, and the patient was told it was a myxoma. No other workup was done at the time, and no other lesions were clinically detectable. She had been very active and played tennis regularly. She was assessed with a hip ultrasound for her right groin pain and was prescribed physiotherapy. During physiotherapy, she felt a snap in her right groin and was no longer able to ambulate without a walker. Initial radiographs demonstrated a lucent intramedullary lesion within the subtrochanteric region—further characterized by a focally aggressive appearance with cortical destruction and lytic expansion of the lesser trochanter (Figures and ). A ground-glass appearance, typical of fibrous dysplasia, was also noted in the mid-femoral shaft ().\nFurther workup included a Computed Tomography (CT) scan of the chest, abdomen, and pelvis which showed multiple hepatic and renal cysts but no evidence of a primary carcinoma or lung metastases. Bloodwork including serum protein electrophoresis was normal. A Total Body Bone Scan (TBBS) revealed increased uptake in the right proximal femur and two areas of relatively mild uptake in the mid femur. Fat-suppressed T2 Magnetic Resonance Imaging (MRI) displayed an intermediate to high signal lesion within the medullary cavity of the proximal and mid right femoral shaft (). In line with the initial radiographs in which two benign sites of fibrous dysplasia were noted, in the third proximal lesion, there was cortical destruction with an extraosseous soft-tissue mass in the region of the lesser trochanter. Additionally, in keeping with the known myxoma, a soft-tissue T2 hyperintense mass within the medial distal thigh was also present (). On further review of the MRI images, five other myxomas were seen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41 years old South Asian female of Indian descent, a homemaker by occupation, presented to the Otorhinolaryngology outpatient department with bilateral hearing loss for one month. The hearing loss was sudden and occurred within two days. The hearing loss was preceded by an episode of upper respiratory tract infection. There was no history of diabetes mellitus, hypertension or tuberculosis. She was taking hormone supplementation for hypothyroidism. There was no relevant family history. On examination of the ear, the tympanic membrane was retracted bilaterally. An audiogram revealed moderate to profound sloping mixed hearing loss on the right and moderate to severe sloping mixed hearing loss on the left with bilateral “B” type tympanogram ).\nHer routine blood investigations were unremarkable except for an erythrocyte sedimentation rate of 42 mm. Ultra-sonogram of the neck showed bulky thyroid gland with nodules in the right lobe. She was treated with systemic steroids (Prednisolone 1mg/kg body weight) for 10 days, which was tapered over 16 days. At the time of discharge, her hearing had dramatically improved ().\nTwo weeks later, she again presented with decreased hearing in both ears. An audiogram revealed mild to moderately severe mixed hearing loss with bilateral “C” type of tympanogram. On myringotomy, thin serous fluid was present in both middle ears and grommets were inserted bilaterally. Diagnostic nasal endoscopy and blind biopsy of the fossa of Rosenmuller on both sides was also done. Histopathology was reported as normal with no evidence of malignancy.\nAfter 10 days she presented with facial weakness on the right side and difficulties in speech and swallowing in addition to hearing loss, tinnitus and vertigo. Vertigo was mild, rotatory and brought about by sudden changes in posture. It was not associated with vomiting or sweating. Tinnitus was bilateral, continuous and resembled a whistling tone. Audiology revealed moderate to severe mixed hearing loss on t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34 year old female patient reported to Department of Oral Medicine and Radiology, with a chief complaint of swelling of the lower jaw since six years. She stated that a small swelling on the left side of jaw was noticed six years ago, measuring about 1cm in diameter, which gradually increased to the present size, involving both sides of the face. There were no subjective symptoms, except for difficulty in chewing food.\nGross facial asymmetry was noticed due to a swelling involving the middle and lower one third region of the face []. Bilaterally fullness of the cheeks and lower lip with obliteration of the mentolabial sulcus and nasolabial fold was noticed. A well demarcated swelling was noticed over the left cheek region and a diffuse swelling over the right side, which extended from the left ramus of the mandible to the right body of the mandible with obliteration of inferior border of the mandible. Swelling on the left side was roughly ovoid in shape, measuring about 8 × 6 × 5 cm[]. Skin over the swelling was stretched. On palpation the swelling is hard in consistency, lobulated and nontender; with no accompanying cervical lymphadenopathy.\nOn intraoral examination [], a diffuse swelling was seen extending from the left to right retromolar region. Bilaterally, vestibular obliteration was noticed due to buccal labial and lingual cortical plate expansion with normal appearing mucosa. Swelling was hard, lobulated and nontender. Correlating the history and clinical findings, a provisional diagnosis of benign fibro-osseous lesion of mandible was given and differential diagnosis of fibrous dysplasia, ossifying/cementifying fibroma and central giant cell granuloma (non- aggressive lesion) was given. Patient was further subjected to hematological, radiological and histopathological investigations. Routine hematological examination, serum protein, calcium, phosphorus and alkaline phophatase levels were estimated and the values obtained were within the normal range.\nPanor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn 2008, a 13-year-old boy was referred to Department of Oral Pathology, Government Dental College and Hospital, Aurangabad, Maharashtra, with a complain of progressive deformity of left side of face since 5 to 6 years. During the physical examination, it was noted that this patient presented a facial asymmetry with marked hypoplasia of the left side of the face, deviation of lips and nose toward left side, and enophthalmy in left eye region [Figures and ]. A big linear dark scar (coup de sabre) was present in the left side of mandibular mentum region passing upward to involve lips and left ala of nose producing obvious depression []. The notching of the upper and lower lip leads to exposure of anterior teeth on left side. Alopecia was noticed in the region of left eyebrow toward medial side []. Patches of hyperpigmentation were seen on the skin of affected area. In addition, ear on left side was slightly smaller than that of right side.\nIntraorally, the most relevant alteration was the unilateral atrophy of tongue papillae of left side []. There was over-retained maxillary left deciduous canine with palatally erupted permanent canine leading to crowded left maxillary arch. The occlusion was disturbed with midline shifted to the left side. Also, there was hypoplasia of maxillary anterior teeth [].\nRadiographically, an abnormal root development was seen with maxillary left premolars. The over-retained root pieces of deciduous mandibular second molar of left side were seen on mesial and distal side of roots of second premolar. The overall eruption pattern of teeth on left side was retarded as compared to that of right side. The mandible showed decreased vertical height of ramus along with loss of gonial angle prominence on the affected side [].\nThe patient presented with good general health condition without any history of obvious past illness that would explain the cause of facial asymmetry.\nWith these clinical and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman fell over a barrier curb while walking and bruised her right shoulder. A local clinic examined the patient and diagnosed her with anterior dislocation of the shoulder with a glenoid rim fracture (). The right shoulder had been immobilized with a sling for a month after immediate reduction (). However, the active range of motion for the shoulder remained limited. An MRI scan two months after injury revealed rupturing of the supraspinatus tendon. The patient was referred to our hospital for further management. Clinical examination found stiffness in the right shoulder with muscular weakness. Respective ranges for active and passive right shoulder flexion were 30 degrees and 120 degrees. There was sensory disturbance over the lateral aspect of the shoulder. Radiographs and CT scanning revealed a large anteroinferior glenoid rim fracture, a type IA fracture under the Ideberg classification [, ]. The articular surface was displaced by 2.5 mm, and the width of the bony fragment was 30% of the glenoid length. Upon initial presentation at our hospital, the fracture had already achieved partial union (); therefore, we treated the glenoid rim fracture conservatively. An MRI scan showed a large tear approximately 3 cm long in the supraspinatus tendon, with atrophy and fatty degeneration of the supraspinatus muscle (). Electromyography and nerve conduction studies showed an incomplete lesion of the axillary nerve; therefore, we diagnosed axillary nerve palsy in addition to glenoid rim fracture and rotator cuff tear. The axillary nerve palsy was incomplete and recovering. Following improvement in manual muscle testing (MMT) of the deltoid from grade 4/5 to 5/5 and the disappearance of the sensory disturbance three months after injury, we performed an arthroscopic rotator cuff repair using a suture bridge technique (). Shoulder function recovered satisfactorily with approximately full ranges of motion one year after surgery. Constant score recovered from 38 po"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAfter falling off a mountain bike down an incline into some brush, a 49-year-old male mountain biker presented to an outside ED with normal vitals, severe vertigo, nausea, intractable vomiting, profound hearing loss, and tinnitus. A CT was performed, which showed opacification of the ear canal, but did not comment on any abnormalities of the inner ear. The patient was transferred to our facility for further management. On examination, there was a spontaneous right-beating nystagmus and the facial nerve was intact. A tree twig was embedded in the left external auditory canal, obscuring visualization of the tympanic membrane.\nTemporal bone CT demonstrated a linear foreign body projecting from the external auditory canal to the oval window, and an additional, separate small foreign body projecting into the vestibule. Presence of extensive intralabyrinthine air was detected radiographically (). On axial view, air bubbles were seen in the vestibule, posterior semicircular canal, and the scala vestibuli compartment of the cochlear basal turn, as well as in the lateral and superior semicircular canals (). Preoperative audiogram conducted at bedside revealed normal hearing on the right side and moderate-to-severe mixed hearing loss on the left.\nThe patient was diagnosed with a traumatic PLF with extensive pneumolabyrinth due to penetrating temporal bone injury and was taken urgently to the operating room less than one day after his inciting injury. A three- centimeter tree twig was lodged in the ear canal and found to be penetrating the tympanic membrane. Postauricular approach included mastoidectomy and intraoperative assessment of the middle ear ossicles and extent of injury. The long process of the incus was dislocated but still attached to the malleus, the stapes was deeply embedded into the vestibule, and the oval window was completely open but covered by blood clot. All penetrating foreign bodies were extracted. Temporalis fascia was used to seal the oval window and a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn otherwise healthy 33-year-old woman, gravida 3, para 2, from a Sephardic Jewish origin, was initially referred to our institution at 30.6 weeks of gestation due to a large neck mass found on prenatal ultrasonography (US). Her previous two pregnancies were uncomplicated. The fetal sonogram showed a 10 by 8 cm mass on the right side of the neck, which was not present in detailed scans taken at 14 and 22 weeks. The mass was composed of a cystic portion and a solid portion containing blood vessels and was growing rapidly in subsequent ultrasound studies. A significant polyhydramnios with amniotic fluid index (AFI) of 50 suggested an upper gastrointestinal obstruction and a highly possible airway obstruction as well. Findings were confirmed by fetal magnetic resonance imaging (MRI). In anticipation of the difficulty in establishing a secured airway at birth and the potential complicated resection of the giant tumor after birth, the mother was referred to our hospital for consultation.\nThe parents were in consultation with the maternal fetal team, neonatologist, anesthesiologist, pediatric surgeon, and otolaryngologist. The parents were presented with a guarded prognosis but insisted that the pregnancy continue with maximal efforts during delivery and during the neonatal period.\nTherefore, a planned EXIT procedure, which provides the best chance to establish a patent airway, was offered to our patient, presenting the risks []. Specifically, we informed the parents about the risks for the mother, including significant hemorrhage from the uterus due to the uterine relaxation necessary to avoid placental separation, with a possible uterine resection in the case of a life-threatening hemorrhage.\nKnowing the risk of an unplanned preterm delivery due to polyhydramnios and uterine contractions, we scheduled our patient for a planned cesarean delivery at 34 weeks organizing and preparing a multidisciplinary team ready to perform the EXIT procedure.\nA multidisciplinary team inc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old woman was referred to our center for urgent coronary angiography due to failed thrombolysis and ongoing chest pain. She had been previously admitted to a hospital in another city far away from our center due to acute inferoposterior myocardial infarction (MI). She had no known atherosclerotic risk factors, but laboratory examination revealed dyslipidemia with high serum triglyceride (230 mg/dl) and low high-density lipoprotein cholesterol (36 mg/dl). On admission, hemodynamics was stable and chest pain had subsided. On electrocardiography, there were low-voltage limb leads with small q waves in the inferior leads and a pattern of incomplete right bundle branch blockage with an R/S ratio greater than 1 in lead V3 in the precordial leads, altogether indicating a recent inferoposterior MI. Echocardiography revealed inferoposterior wall akinesis with a left ventricular ejection fraction of 40%.\nThe patient subsequently underwent coronary angiography. The left circumflex artery (LCx) was cut off after the first obtuse marginal. The LAD had severe long stenosis (up to 90%) at midportion. An anomalous vessel was seen originating from the midportion of the LAD (shortly after the second septal perforator within the diseased segment), which followed the course of the RCA (). In this case, the anomalous RCA traveled along the free wall of the right ventricle into the atrioventricular groove and gave rise to a posterior descending artery (). Interestingly, there was also a separate small artery originating from the right coronary sinus that was most probably a right atrial branch (). Aortic root injection confirmed the absence of the RCA stump or any other vessel except for the small right atrial branch in the coronary sinuses as well as the ascending aorta ().\nA decision was made to predilate the LCx lesion using a 1.5 × 15 mm balloon in order to visualize the distal bed. There were 2 more large obtuse marginal branches at distal (). Stenting was not performed du"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old Caucasian female with no past medical or surgical history. She presented to the orthopedic oncology clinic three months after a sudden onset of a traumatic left ankle swelling. An outside provider placed her in a CAM walking boot for a presumed ankle sprain; her swelling eventually subsided. After removing the boot and returning to unrestricted activity, the swelling returned. An MRI was done, which showed a large distal fibular mass with characteristics consistent for Ewing Sarcoma (). She underwent a CT guided biopsy on the same day of the initial consultation, which demonstrated a small round blue cell lesion that was CD99 positive, FLI 1 positive, and FISH positive for EWSR 1, confirming the diagnosis of Ewing Sarcoma (). The Hematology/Oncology service promptly saw her, and staging studies were negative for distant metastasis (). Pre-chemotherapy echocardiogram demonstrated an ejection fraction of 62 %. She was started on a neoadjuvant regimen of vincristine, doxorubicin, and cyclophosphamide. She also underwent a pre-operative radiation therapy regimen at a total dose of 4500 cGy broken up into 25 fractions. After completing her neoadjuvant chemotherapy and radiation treatment, a repeat MRI scan showed a significant decrease in the distal fibular lesion and soft tissue component (). She continued to be followed with surveillance MRI scans for local recurrence until a decision was made between the patient, family, and treating specialties to proceed with surgical treatment.\nJust over one year from the initial presentation, she underwent en bloc resection of the distal left fibula, neurolysis of branches of both the superficial peroneal and deep peroneal nerves, local flaps, and reconstruction of the lateral ankle ligaments using the peroneus brevis (). She was immobilized in the immediate postoperative period with a three-sided short leg splint and was instructed to be non-weight bearing.\nShe did very well ten months postoperative without evidence"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old female patient presented to our department with complaint of pain and mild swelling on the right side of the face since the last 2 months. She gave a history that pain is aggravated while opening the mouth, chewing and on application of pressure on that area and was not relieved by NSAIDs. Her past medical history revealed history of typhoid fever 3 months back for which she had taken complete course of treatment.\nOn extraoral examination, maximal mouth opening was reduced to around 28 mm and a diffuse swelling around 1 × 1 cms in diameter was also observed in the right temporalis muscle which was soft to firm in consistency and was tender on palpation (). Examination of the TMJ and other muscles of mastication revealed normal findings. On intraoral examination edentulous spaces were present involving the right and left mandibular posterior teeth.\nOn the basis of the history and examination findings, a clinical provisional diagnosis of myofascial pain was made and the patient was put on the treatment of muscle relaxants Tab Myospaz forte two times a day and topical application of voveran emuigel along with hot fomentation, soft diet, and bilateral chewing. The patient reported to us after 3 days but she did not have relief whatsoever. Reevaluation of the case was done and she was advised of blood investigations along with ultrasonogram (USG) and MRI involving the right side of the face. The findings of the blood investigations were normal. USG showed the presence of a well-defined anechoic lesion around 1.2 × 1 × 0.9 cms involving the right temporalis muscle with its long axis parallel to its fibres and 14 × 12 mm echogenic nidus was also seen within it (). MRI revealed the presence of a rounded iso to mildly hyperintense lesion in the right temporalis muscle with an identifiable hypointense nidus on T1 and T2 and Fiesta-C images (). The lesion also"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report the case of a 7-year-old girl with metastatic medulloblastoma (T3b M1 according to the Chang staging system) diagnosed as a result of an epileptic seizure after 3 months of headache. Brain MRI in July 2000 revealed a mass in the posterior fossa, in the midline cerebellum next to the fourth ventricle and vermis, causing hydrocephalus and an initial herniation of the cerebellar tonsils. At the end of July, she underwent a macroscopically complete resection of a 3 × 3 cm nodule filling the fourth ventricle and attached to its lateral recesses. The final histologic diagnosis was classic medulloblastoma.\nA postoperative cerebral and spinal MRI in August 2000 revealed an ambiguous neoplastic residue close to the surgical cavity, jutting out into the fourth ventricle, and malignant neoplastic cells were found in the cerebrospinal fluid.\nFrom August 2000 to March 2001, the girl was treated according to our institutional protocol for metastatic medulloblastoma/PNET in children over 3 years of age, which included sequential high-dose chemotherapy, radiotherapy, and myeloblative-dose chemotherapy with autologous hemopoietic stem cell rescue []. The protocol was partially modified omitting two scheduled vincristine administrations due to intestinal toxicity after the first course.\nHyperfractionated accelerated radiotherapy was administered from November to December 2000, scheduled in two daily 1.3 Gy fractions 6 hours apart, 5 days a week for a total dose of 31.2 Gy to the craniospinal axis plus a boost to the posterior fossa using a 1.5 Gy fractionation twice a day to give a total dose of 59.7 Gy.\nDiagnostic lumbar puncture before radiotherapy still documented malignant neoplastic cells, while lumbar puncture and MRI after radiotherapy and between the two myeloablative courses were both negative, with the latter showing only surgical sequelae.\nIn June 2001, our patient started the follow-up program with routine MRI and outpatient visits. In September 2001, MRI showed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 14-year-old female patient had come to the Department of Orthodontics, with the chief complaint of forwardly placed upper front teeth. Her medical history was found to be noncontributory.\nOn extraoral examination, facial asymmetry was evident for which patient was unaware. There was no history of trauma. The patient did not have any difficulty in opening of mouth. Inspection showed elongation of left side lower half of face as compared to the right side. The left side of the face appeared flattened as the prominence of the chin appeared shifted to the right side [].\nOn intraoral examination, her molar relationship was found to be Angles Class II on right side and end on the relationship on the left side. The lower midline was shifted 3 mm to the right side with respect to maxillary midline [].\nRadiographic investigations were also carried out. Panoramic view of girl revealed symmetrical condylar enlargement of the left side in comparison to the right side and condylar neck along with the elongation of the left side of ramus [].\nPA cephalogram of the girl showed a shift of dental midlines due to the asymmetry of the mandible [].\nHer mother who was 44 years old had accompanied her and asymmetry in her face was also noticed. She was unaware of it and gave consent to be examined. On examination, she did not have any difficulty in opening her mouth. The chin was deviated to the right side as left side of her face was elongated. The left side of face appeared flattened [].\nIntraorally, her oral mucosa was normal with permanent dentition and a total of 24 teeth. Her oral hygiene was poor and no previous history of trauma. Medical and family history was noncontributory. There were root stumps and carious teeth present. Maxillary right first molar had already been extracted. Clinically, she showed a lower midline shift to the right side, chin deviation and misalignment [].\nPA cephalogram"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old man without any symptoms was referred to Hino Municipal Hospital, because of a faint infiltrative shadow observed in the left lower lung field on routine chest radiography (). The patient did not complain of chest wall swelling; however, the physical examination revealed a subcutaneous soft tumor on the left anterolateral chest wall without tenderness or a skin surface abnormality. The transcutaneous oxygen saturation of peripheral artery was 94% under the room air inhalation at the diagnosis. He had never smoked previously and was taking medication for hypertension and asymptomatic cerebral infarction. Contrast medium-enhanced chest computed tomography (CT) revealed an enhancing tumor (58 × 33 mm in size) on the left anterolateral chest wall with destructive changes in the 6th rib bone (), corresponding to the abnormal shadow on the chest radiograph. In addition, a massive filling defect of the right proximal pulmonary artery was detected with pulmonary nodules in the right lung (Figures and ). Importantly, the “mass” in the pulmonary artery was, unlike in CPTE, weakly enhanced with contrast medium. Pulmonary nodules existed only on the ipsilateral side of the pulmonary artery mass and formed a mold-like shape in the peripheral pulmonary arteries. Further examination did not identify another site of suggestive malignancy, except for prostate cancer using body CT and head magnetic response imaging (MRI). A laboratory test did not show any significant abnormalities, including those of D-dimer and tumor markers. These findings implied a possible diagnosis of primary sarcoma of the pulmonary artery with metastases to the lungs and chest wall.\nThe patient was referred to Keio University Hospital for further examinations. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a positive uptake of FDG to the pulmonary artery tumor (standardized uptake value, SUVmax 5.32), the chest wall tumor (SUVmax 9.56), and lung nodules (highest SUVmax 3.50)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old male with no history of trauma or prior neurological disease presented with 3 days of intermittent dizziness and vomiting. On the second day, the patient was examined by a head computed tomography (CT) scan, and no abnormal changes were found. Five days later, the patient had a sudden onset of weakness in his right limbs, followed by an episode of focal seizure without impaired awareness. The patient had symptomatic deep venous thrombosis (DVT) in the left lower limb 4 years ago, which was treated with warfarin for 3 months. No secondary prophylaxis was subsequently applied, and as a result he experienced multiple recurrences of lower limb DVT. The patient also had a 5-year history of hypertension without antihypertensive therapy. He also had a 2-year history of Raynaud’s phenomenon in his hands, as well as a 30-year history of smoking (10 cigarettes per day) and alcohol intake (50 g per day). The patient’s parents had died of ICH. Additionally, the patient’s three sisters were diagnosed with hypertension, and one brother had a history of occlusion of the distal artery in the right leg at the age of 55 years. The patient’s son had their first symptomatic lower limb DVT at the age of 25 years, for which he underwent inferior vena caval filter placement.\nUpon examination after admission, the patient had a blood pressure of 164/92 mmHg. Skin color, temperature, and peripheral pulses were normal. No varicose veins or swelling of the limbs were found, and the lung and heart examinations were normal. The patient was fully alert and oriented, with no signs of cognitive impairment, thus neurocognitive tests were not performed. Results of the cranial nerve and sensory examinations were normal. Motor examination revealed spastic tone and moderate pyramidal weakness in the right arm and leg (4/5), with a total NIHSS score of 2. Repeated head CT plain scans (Fig. a) and brain magnetic resonance imaging (MRI)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old Greek male patient underwent a radical nephrectomy for a stage 2, grade 3, renal cell carcinoma in September 2001. Five years later, he presented with left hip pain and he was eventually diagnosed with biopsy proven relapsed disease. Imaging with CT scans and bone scan revealed a prominent bulky metastatic lesion extending from the acetabulum of the left iliac bone into the iliosacral joint, a metastatic lesion of the second left rib, as well as several metastatic pulmonary nodules (,). He was started on anti-angiogenetic TKI agent sorafenib and biphosphonates.\nAfter a year of treatment, in October 2007, a necrotic ulceration appeared on the left flank area, proven by CT to be an extension of the increasing metastatic left iliac focus, which measured 8 cm in maximum diameter, associated with increasing pain. The lesion was considered too large to be controlled with irradiation. The patient underwent an arterial embolization of the metastasis using a femoral artery approach (). One week later, the same mass was treated by radiofrequency ablation (RFA) (). The procedure was well tolerated overall and led to significant pain reduction (). However, the ulceration rapidly enlarged and evolved into a crater-like deficit of the skin and subcutaneous tissue 5 cm deep and of 5 cm diameter (). It was decided to be managed conservatively with frequent local wound care. Antiangiogenic treatment was suspended for a period of a month to allow for wound healing. However, during this time the pain recurred and a follow up CT showed evidence of extension of the large lesion medially towards the spinal canal; the bulk of the lesion was necrotic and a large tissue deficit was documented. The patient received external beam irradiation with symptomatic control (4750 cGy in 19 sessions) followed by initiation of sunitinib and biphosphonates. The patient continued improving, regained ambulation, and his disease elsewhere remained stable for over 16 months. His necrotic ulcer"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old premenopausal woman with Gravida 3 and Para 3 came to gynecology outpatient unit with complaints of irregular vaginal bleeding and lower abdomen pain since 6 months. There was no significant medical history. On clinical examination, vital signs were normal, and abdomen was soft with no palpable mass. Abdominal and pelvic ultrasonography (USG) was performed and revealed heterogeneous echogenic mass each in uterine corpus (3.5 cm × 2.5 cm × 2.5 cm) and cervix (1.2 cm × 0.8 cm). A diagnosis of leiomyoma in uterine corpus and cervix with degenerative change was made. Surgical specimen of hysterectomy was received for histopathological examination. Specimen showed a well-circumscribed gray-white to yellow tumor mass (3 cm × 2.5 cm) at upper pole of uterine corpus and yellow tumor mass (1 cm × 1 cm) in cervix [].\nHistopathology examination of the tumor from uterine corpus showed a tumor composed of lobules of mature adipocytes separated by fibrous septae. At places, thin bundles of smooth muscle cells were seen. Small sized normal blood vessels were seen in . There was no nuclear atypia or increased mitotic figures. A diagnosis of lipoleiomyoma was made. Histopathology of tumor from cervix showed a tumor tissue composed of lobules of mature adipocytes, thick fibrous septae [], and few entrapped mucosal glands []. A diagnosis of pure lipoma was made.\nImmunohistochemical (IHC) stains such as smooth muscle actin (SMA) and vimentin were done in sections of both the tumors to confirm the nature of cells. Smooth muscle cells, endothelial cells from the tumor of uterine corpus showed immunoreactivity with SMA and adipocytes were negative [] Vimentin staining showed immunoreactivity with smooth muscle, endothelial cells and mature adipocytes, fibrous septae were negative [].\nIn sections of cervical lipoma, only endothelial cells of blood vessels showed immunoreactivity with SMA, and fibrous septae and mature adipocytes were negative []. Mature adipocytes"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old man was referred for surgical assessment after the findings of an abdominal wall and left atrial (LA) mass. He had mild obstructive lung disease and a 30-pack-year smoking history. He sought medical attention after experiencing abdominal discomfort and had noted a 30 lb weight loss over the last few months, apparently related to dieting. There were no other constitutional symptoms. His symptoms persisted despite a course of antibiotics, for presumed diverticulitis. Physical examination was unremarkable. Laboratory investigations revealed a hemoglobin of 131 g/L (normal: 140–180), with all other values within normal limits. Emergency computed tomographic (CT) scan revealed a 5 × 4 cm heterogenous mass in the left anterior abdominal wall and an intracardiac mass. CT head, chest, and abdomen did not show any other masses.\nTwo biopsies of the abdominal wall mass were examined, and most of the tissue was necrotic. The conclusion was that a definitive diagnosis was not possible (in spite of the immunohistochemistry) and that the definitive diagnosis was best accomplished following cardiac and abdominal mass resection.\nTransesophageal echocardiogram (TEE) revealed a 4.4 × 3.5 cm mass attached to the posterolateral wall of the left atrium, above the mitral annulus. Mean and peak gradients across the mitral inflow were 4 and 12 mmHg, respectively (). Cardiac CT and MRI corroborated the TEE findings ().\nCoronary angiography showed a 90% right coronary artery (RCA) lesion. The patient underwent extensive resection of the LA mass and repair of the left atrium, left ventricle, left ventricular outflow tract, as well as mitral valve replacement and saphenous vein graft to RCA. The postoperative course was complicated by acute renal failure requiring dialysis and reintubation for volume overload. Ten days postoperatively, he became acutely hypotensive, developed multiorgan failure, and succumbed to his illness.\nMacroscopic examination of the cardiac specimen revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old male patient was admitted to our hospital's gastroenterology department. The patient had no specific medical history, except for dyslipidemia, and complained of rectal tenesmus, lasting for 1 month, and anal pain, which had progressively worsened for 10 days. At the time of arrival, stool occult blood test was negative and no relevant findings in other laboratory results were identified. An 8-mm polyp in the ascending colon was detected during colonoscopy, and hyperemic mucosal swelling with nodularity was noted at 4–17 cm from the anal verge (Fig. ). Biopsies performed for each lesion indicated adenoma and chronic colitis, respectively. Diffuse swelling throughout the rectum was seen on CT, and engorgement of the superior rectal veins with early draining was also observed (Fig. ). AVM-related venous hypertension was suspected as the cause of symptoms, and angiography was requested. On angiography performed 3 days later, rectal AVM was identified at the inferior mesenteric artery just before the beginning of the superior rectal arteries and was drained via fine feeders into the inferior mesenteric vein with a large venous aneurysm (Fig. ). Venous regurgitation by venous hypertension was also clearly observed through the retrograde flow of the superior rectal veins (Fig. ). After an in-depth discussion with the patient about the options for surgery or other endovascular embolization, transarterial sclerotherapy using ethanol was decided. After selection to the far distal feeding artery using a microcatheter, sclerotherapy was performed several times using a total of 5 mL of 80% ethanol (Fig. ), while shunt was gradually reduced in serial follow-up angiography. To prevent venous thrombosis, 2,000 units of heparin were intravenously administered during the procedure. The early arteriovenous shunt was completely lost in completion angiography, and a little spasm was observed in the distal branch of the superior rectal arteries (Fig. ). The spasm improved a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56 year old previously healthy Caucasian woman and non-smoker, presented to the outpatient chest department with symptoms of episodic bouts of dry cough associated with an occasional wheeze for 12 months and upper thoracic back pain for 3 months. She had no history of chest trauma. On examination, she was not breathless or wheezy and she had a normal temperature. The chest radiograph revealed an area of gas-filled tissue in the upper right mediastinum (fig. ) and a Computer Tomography (CT) scan confirmed a loculated air-filled collection predominantly anterior to the trachea and extending below the carina with no evidence of fluid within the locules. There was no air tracking into the neck or the abdomen. (fig. ). The patient had no recollection of having the cyst diagnosed in the past. The patient was stable and a wait and watch approach was taken, and the patient was to be reviewed in 3 months.\nShe was readmitted 2 months later with severe chest pain. On examination she was breathless with an expiratory wheeze and was febrile (37.5°C). The patient was not in shock. A repeat chest radiograph (fig ) and CT scan (figs. and ) demonstrated a 9 × 5 cm loculated mass containing fluid and gas, encasing the lower trachea and the main proximal bronchi and extending from the innominate vein to the left atrium consistent with a mediastinal abscess. Bilateral pleural effusions were also present. The lungs were normal. The patient was treated with broad spectrum antibiotics and then had an open thoracotomy three days later with complete resection of the mass. The air-fluid level seen on the CT scans would suggest a tracheobronchial communication but no such communication was found during the operation. Histopathological examination of the mass revealed a collapsed thick walled cyst about 55 mm in diameter. The cyst wall consisted of fibrous and granulation tissue with heavy, chronic active inflammation. There were fragmented seromucinous glands on the inner surface of the cys"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female with significant past medical history of recurrent pancreatitis presented to the emergency department with abdominal pain that was radiating to the back, to the left inferior angle of the scapula. She described it as sharp, stabbing pain of 8/10 on severity scale. She mentioned that she has experienced this type of pain before, but it has been three years since her last episode. She was unable to consume solid foods without “debilitating” nausea, but denied vomiting. The patient mentioned that her first episode of pancreatitis was at the age of seven when she underwent surgery for pancreatic cyst drainage. Family history was also unremarkable. She has an 11 pack year smoking history but denied alcohol intake. Her vitals were as follow: blood pressure of 132/80 mmHg, heart rate of 81 bpm, 94% oxygen saturation, and a temperature of 98.6 F. Patient weighed 247 lbs with a BMI of 36.49. Abdominal examination revealed a large scar in the center of the abdomen with bowel sounds present in all quadrants. Her abdomen was soft, and non-distended but presented with guarding and tenderness, which was especially tender in the left and right upper quadrants radiating to the umbilicus. She had a negative Murphy sign. Her labs were consistent with elevated lipase and amylase. Computed tomography examination conducted in 2010 and 2017 showed evidence of pancreatitis. In the CT study performed in 2017, there was a 10-mm calcification discovered in the head of the pancreas that was not seen in the 2010 study. We suggested magnetic resonance cholangiopancreatography (MRCP) radiological analysis for the patient which displayed a dilated pancreatic head with a maximal diameter of 6-mm. The MRCP findings demonstrated a small amount of fluid between the pancreatic head and proximal descending duodenum, as well as the posterior border of the liver and diaphragm consistent with pancreatitis. The MRCP also showed evidence of a small remnant"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old man, with extensive cardiac history and an AICD located within the radiotherapeutic field, was successfully treated for stage IIIB NSCLC with definitive dose of thoracic chemoradiation. With a history of type II diabetes mellitus and transient ischemic attacks, the patient was initially evaluated at our institution for cardiac disease. He was found to have triple vessel coronary artery disease and congestive heart failure requiring coronary artery bypass grafting (CABG) and placement of a prophylactic AICD (St. Jude Medical Fortify Assura VR 1257-40Q ICD). During preoperative assessment for CABG, an incidental left apical lung mass appeared on chest radiograph. The decision was made to follow the mass without intervention at that time.\nTwo months after surgery, he returned to the hospital for a fall during a hypoglycemic episode, at which point a chest radiograph revealed a persistent 3.0 by 2.2 cm mass in the left upper lobe as well as left hilar and supraclavicular lymphadenopathy, this time prompting evaluation for malignancy. Biopsy and staging studies confirmed T1bN3M0, stage IIIB poorly differentiated adenocarcinoma of the lung. Due to the complexities involved in radiation therapy (RT) to patients with AICDs, the final treatment plan included interdisciplinary input from radiation oncology, medical oncology, and cardiology.\nThe radiation oncology team hesitated to deliver RT to the patient with an AICD located within the field of radiation due to the risk of AICD malfunction. Multiple discussions were held with cardiology, St. Jude Medical, and with the physicians and radiation oncology physics teams about the patient. However, repositioning of the AICD was not possible in this patient's case. Fortunately, our patient was not AICD-dependent, as he had the device prophylactically implanted after CABG and had since experienced a single remote episode of ventricular tachycardia []. After thorough consultation and discussion among the physicians and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old man visited a private ophthalmic clinic because of diplopia that was aggravated during his upward gazing. No significant abnormalities were found upon ophthalmologic examination except for a mild conjugation problem occurring during his upward gazing. He was referred to the department of neurosurgery of our institute and he underwent a brain CT. The brain CT showed acute hemorrhage in the third ventricle and there were also spots of calcification (). This hemorrhage showed mixed signals that indicated different ages of the pathology, but there was no hemosiderin rim on the T1- and T2-weighted MR (). The clinical differential diagnosis was primarily split between intratumoral hemorrhages originating from a pineal germ cell tumor, specifically choriocarcinoma vs. hemorrhage from a pineal cyst. The presence of a cavernous malformation was considered to be a less likely diagnostic possibility. We were easily able to rule out the possibility of vascular malformations because MR angiography revealed no such abnormalities (). Two weeks later, he experienced an improvement in the diplopia, but the headache that he had been experiencing became progressively more severe. Brain CTs, performed weekly after the first attack of symptoms, revealed a resolving hemorrhage and the progressively enlarging ventricles (). We performed VP shunting using the HAKIM programmable valve without the prechamber Shunt System, and it was adjusted to an opening pressure of 120 mm CSF. Two days after the shunting, he complained of a sudden aggravation of his diplopia. The follow-up brain CT revealed rebleeding from the previous lesion (). The patient underwent an emergency operation consisting of an occipital-transtentorial approach to the pineal region, and this resulted in the complete excision of a discovered tumor and the removal of the hematoma. The lesion mass was composed of acute and subacute hematomas and it was well encapsulated. These surgical findings corresponded to a cav"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old healthy Caucasian woman presented with a metal ceramic restoration on the left maxillary central incisor, that did not satisfy her esthetic demands anymore. In addition, the patient was feeling a dull pain in the area. The patient did not smoke and was healthy. The radiographic examination showed an oversized cast post and core, which occupied three quarters of the root's length (). The clinical examination revealed that the metal ceramic restoration was fractured at the buccal marginal area, it had a surface texture that did not match that of the adjacent natural teeth, it was rather opaque, and its margins were placed on the underlying cast post and core instead of on sound tooth structure (). Soft tissue inflammation was evident around the crown's marginal area. An 8 mm pocket depth was found at the distal area of the tooth. The examination also demonstrated a discrepancy of the soft tissue contours between the two central incisors, sufficient width of keratinized tissue in the maxillary anterior area and a scalloped thin periodontium [–].\nTreatment options were presented to the patient after assessment of all clinical and radiographic data. The patient wished to restore the failing tooth with an implant-supported restoration.\nPrior to implant surgery, preliminary impressions were obtained by using irreversible hydrocolloid impression material. Diagnostic casts for both the maxillary and mandibular arches were fabricated with type III dental stone and they were mounted in maximal intercuspal position on a semiadjustable articulator. A diagnostic waxing was made and the maxillary cast was duplicated. A surgical stent was then fabricated with clear autopolymerizing polymethyl-methacrylate resin. The tooth's cingulum area was marked and an access channel was opened with a 261E-023 laboratory carbide bur (Brasseler, USA). A provisional restoration was also fabricated by using autopolymerizing acrylic resin (GC Unifast III, GC Tokyo, Japan). Two acrylic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old male patient suffering from severe back and both legs radiating pain was transferred to our hospital. The magnetic resonance imaging (MRI) taken at the previous hospital showed an epidural mass at L1-2. Besides, there was a spinal stenosis at L4-5 and a spondylolytic spondylolisthesis at L5 (). The patient had suffered from neurogenic claudication for the last 10 years and had received epidural steroid injections from time to time. Eleven days before his transfer he was troubled due to multiple tryouts of an epidural injection. Severe back pain and both legs radiating pain were developed after that night. MRI was done the next day and SEH compressing the cauda equina was found at L1-2. The conservative treatment failed to ameliorate the symptoms. Thus, he was transferred to our hospital. On neurological examination, there was a diffuse sensory decrease in the left lower extremity, the motor power was intact. On laboratory findings, platelet count, bleeding time, clotting time, and prothrombin time were within normal limits. Activated partial thromboplastin time was slightly extended with 36.4 seconds (). As the patient had neither a past history of abnormal bleeding nor any medication of anti-platelet agents and there was nothing specific in his laboratory findings, we couldn't consider any bleeding disorder. His SEH was suspected to be related to the unsuccessful epidural injections. Carelessly, we did not give attention to the fact that the location of the hematoma was different from the site of epidural injections. We performed the hematoma evacuation and the surgery for L4-5-S1 simultaneously. All surgical procedures were uneventful. The symptoms had improved after the operation. However, the pain in the right leg re-developed after 6 hours. So, the MRI was retaken. During the MRI, his blood pressure dropped to 90/60 mm Hg and a complete paraplegia developed. The MRI showed large hematomas at L1-2 and L4-S1 comp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old male was referred to GI clinic by his primary care physician for evaluation of anemia, weight loss, and positive stool occult blood. On obtaining a detailed history he admitted to having early satiety for the past three months and nonbilious vomiting and colicky epigastric abdominal pain for the past three weeks. His physical examination was pertinent for pallor and his abdomen was soft and nontender with no apparent swelling or hepatosplenomegaly. An esophagogastroduodenoscopy () was performed which showed a large mass in the gastric antrum obstructing the gastric outlet with a nonbleeding but friable ulcer on top []. Biopsies were sent due to the concern for Gastrointestinal Stromal Tumor (GIST), gastric lymphoma, or adenocarcinoma stomach. A Computerized Tomography (CT) abdomen was ordered to further look into the etiology of the mass and determine the size and presence of lesions elsewhere. The CT abdomen [] revealed a homogeneous submucosal mass of 5 cm x 2.5 cm size. The lesion was in the gastric antrum, homogeneous, and well contained within the gastric wall. There were no lymphadenopathy or remote lesions in the abdomen. This together with endoscopic features of the mass was suggestive of benign gastric lipoma. Surgical referral was done for possible surgical removal; however, it was advised to try to endoscopically resect or at least debulk the mass for palliation of his symptoms before attempting a surgical removal because of patient's debility and comorbidities.\nAfter the failure of initial attempts to do a complete resection, partial piecemeal resection was made with the aim of debulking the lesion to relieve symptomatic gastric outlet obstruction. To limit bleeding, endoloops were deployed at the base of the lesion prior to the start of resection. Because of the location and size of the lesion, only 2 cm by 2 cm of the mass was resected. At the end of the procedure, one of the endoloops remained deployed tightly at the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66 year-old male presented to the emergency department (ED) with a one-week history of progressive pruritic erythematous rash, dry cough and two days of episodic high fevers. He had suffered a fall 12 weeks prior that had resulted in a pelvic fracture requiring an open-reduction internal fixation, which subsequently became infected with methicillin-resistant Staphylococcus aureus (MRSA) and treatment with intravenous vancomycin was initiated. After four weeks of vancomycin therapy he developed a rash. This was initially thought to be due to a red-man syndrome variant. Infusion rates were slowed, and premedication with diphenhydramine was initiated, but the rash worsened, with the subsequent development of episodic daily fevers, documented to be as high as 40°C.\nHis past medical history was significant for heterozygous hemochromatosis, a remote splenectomy secondary to traumatic rupture, and non-anaphylactic adverse reactions to penicillin and sulfa antibiotics. He had no history of reactive airway disease and had no travel history, living in an Ontario city.\nIn the ED he was hemodynamically stable with a normal mental status. He had a severe erythematous macular rash involving his face and trunk (see Figure ), and some facial edema. He had no mucous membrane involvement. He had palpable bilateral cervical and left axillary lymphadenopathy. Cardiorespiratory examination was normal, and his abdominal exam revealed central obesity and a scar from his remote splenectomy. Initial laboratory investigations are shown in Table . A computed tomography (CT) scan of his pelvis showed no abscess formation. A skin biopsy of the initial rash showed a mild perivascular lymphocytic infiltrate, consistent with a drug reaction.\nOur initial working diagnosis was Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) secondary to vancomycin, which was immediately discontinued. Initially, his liver enzymes and eosinophilia appeared to improve spontaneously, thus management was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old married male patient presented to our outpatient clinic with complaint of severe dysuria, weak stream and suprapubic pain that had lasted for 1 week accompanied by complete urinary retention and a month history of incontinence. Due to incontinence, he began self-treatment by instilling superglue into his urethra for 2 weeks. The patient had no urination problem during the early days of insertion. After 4 days, he complained about oliguria and dysuria which emerged simultaneously. By the time of referral to our center (2 weeks later), he was suffering from urinary retention. There was no history of psychiatric disorders. On perineal examination, his penis had erected form. A FB was palpable within the penile urethra and brittle fragments of superglue were seen on the meatus. An abdominal ultrasound revealed bilateral mild hydronephrosis, with normal cortical thickness, and without any sign of stone in the bladder. Laboratory examinations were normal. The patient was taken to the operating room urgently. He underwent a cystoscopy however, it failed due to obstruction.\nSo the glance was incised in 2 cm length at 6 o'clock position ().\nThe urethra was then washed with 3 liters of normal saline for approximately 15 minutes. During that period we managed to make the solution permeate across the solid material by performing certain maneuvers thereby shedding the adherent layer off the urethral wall. Eventually, a 10 cm rod-shaped solid block of dried superglue () came out with the aid of forceps and was removed successfully. The incision was sutured with nylon. After surgery, urination was normal in caliber and direction and the patient was satisfied with urinary drainage. The urine analysis was normal and we did not have requirement for cystoscopy. A 16F Foley catheter was left in place for 10 days. Amikacin 500 mg BD and cefazolin 1gr QID were administrated and he was discharged on the 5th postoperative day without any complication. By"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 26-year-old young woman was admitted to the West China Hospital, Sichuan University, China, complaining of spontaneous nipple discharge in her left breast for one month. Her past history showed that she had accepted a lumpectomy on her left breast because of a palpable breast mass. The postoperative pathological report showed a complex fibroadenoma, with stromal cells proliferation, local lobulated structures were observed. She denied any family history of breast cancer or ovarian cancer.\nOn physical examination, a firm mass with a clear margin was palpated in lower inner quadrant near the nipple of the left breast, which measured approximately 2.5 cm in diameter. Single duct non-bloody discharge from the left nipple was evident after squeeze. There was no nipple retraction and skin dimpling evident.\nAn ultrasonography detected mammary duct ectasia and a solid-cystic mass measured 28 × 20 × 20 mm near nipple-areola complex (NAC) of the left breast (Fig. ). Left breast galactography showed mammary duct actasia and multiple irregular filling defects in the dilated duct (Fig. ).\nThe mass and the related mammary duct were excised through a circumareolar incision. Two intraductal neoplastic lesions measured 20 × 20 × 20 mm and 28 × 20 × 20 mm respectively were found in the dilated duct system. The cytology of the nipple discharge showed no tumor cells. The histological examination showed a biphasic tumor, with mesenchymal and epithelial components (Fig. A). The mesenchymal cells highlighted moderate stromal hypercellularity (Fig. B), marked nuclear atypia and occasional mitoses (Fig. C). Ki67 immunohistochemistry to assess the index of proliferation showed 20% to 30% positive (Fig. D). The histologic diagnosis was a borderline PT. The margin of resected tissue showed to be free of tumors.\nAfter operation, the patient is undergoing surveillance through ultrasonography and physical examination every 3 months. Till now, she has been followed up for 12 months,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA man aged 72 years underwent elective surgery, a surgical revascularization of the myocardium, for a previously verified triple vessel coronary artery disease (CAD) with LAD 100%, CX 90%, RCA 90%. In the previous history of the disease he had diabetes mellitus type 2, arterial hypertension, myocardial infarction, hyperlipidemia and a positive family history of cardiovascular diseases.\nThe operation and early postoperative recovery went without any complications, and the patient was discharged on home care by protocol. On the first postoperative visit, 15 days after surgery, echocardiography showed a neat finding and upon recommendation, the patient continued with the previous treatment recommended for discharge. A month after the first visit or two months after the surgery, the patient was sent from a local hospital to our Heart Center with verified pericardial effusion and with the susceptible signs of right ventricular compression. At this point the patient had symptoms like fatigue and mild chest pain, more on his left side. On physical examination there were slightly pointed veins on the neck. He was afebrile and with neat diuresis. Heart tones were quieter, without murmurs and the action of the heart was rhythmic. Auscultatory findings on the lungs were without pathological murmurs. Measured blood pressure was 90/60 mmHg and the pulse was 96/min. Laboratory blood tests were in reference values range (white blood count - WBC, CRP). In addition to other discharge therapy, he had all that time acetylsalicylic acid 100 mg and clopidogrel 75 mg, without anticoagulation therapy.\nThe patient was kept for the observation. On the admission, a X-ray P/A of the chest was performed, that showed a regular size of the heart (). Transthoracic echocardiography (TTE) showed free fluid by the lateral and posterior wall of the right ventricle and possible compression of it, but there was no visible fluid in some views e.g. long axis view (). Due to a difficult visualization, it"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 54-year-old female with a past medical history of hypothyroidism and very severe obesity (BMI 48 kg/m2). She underwent laparoscopic gastric sleeve surgery in the year 2012. Results were non-satisfactory in terms of weight loss with a difference of 6 kg/m2 in BMI post-procedure. So after six years, she underwent a laparoscopic biliopancreatic diversion with a duodenal switch. She had an uneventful postoperative recovery period. An upper gastrointestinal (GI) study contrast post-procedure did not reveal any evidence of obstruction or leak. The patient was discharged home two days after the procedure. A few days later, she started experiencing three episodes of nausea with brown-colored vomitus. She was found to be septic, with a heart rate of 110 beats per minute and temperature of 100.2oF. Her white blood cells count was 12/mm3.The source of infection was presumed to be intraabdominal considering her symptoms. Computed tomography (CT) of the abdomen and pelvis showed mildly dilated proximal small bowel loops. The patient was started on empiric antibiotic therapy with ceftriaxone 1 gm intravenous (IV) daily and metronidazole 500 mg IV every eight hours. Symptoms did not improve, so she was taken back to the operating room for diagnostic laparoscopy. Partial small bowel obstruction was noted along with ischemia of a segment of the ileum that was part of the duodenoileostomy due to mesenteric dissection. She underwent an open revision of the small bowel anastomosis with resection and anastomosis for the obstruction revision of the duodenoileostomy. Her hospital stay post-surgery remained uneventful. Diet was advanced gradually throughout the hospital course and a week later, the patient was discharged home with outpatient follow-up. Three weeks after that procedure, she noticed a productive cough with thick, yellow, foul-smelling phlegm and shortness of breath. She saw her primary care physician. A chest X-ray performed showed a right lung infiltrate wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old male, driver by occupation, presented with complaints of neck pain on and off for the past six months. He also gave history of pain radiating to the right upper limb, which aggravated on bending the neck forward. Occasional episodes of numbness over the thumb and adjacent areas were present.\nOn clinical examination of neck, the patient was found to have no obvious external deformity. Minimal spinal tenderness was present over the C5 and C6 regions. Paraesthesia was present over the area of distribution of C6 nerve root, but there was no distal neurological deficit. The cervical X-ray showed obliteration of the normal cervical lordosis with no obvious vertebral lesion. The MRI of cervical spine [] confirmed the presence of diffuse annular bulge with right posterior paracentral and foraminal disc protrusion seen at C5-C6 disc with impression on the dural sac and exiting nerve root on the right side with stenosis of right exiting neural foramina. There was no evidence of cord edema. All the routine haematological investigations were found to be within normal limits. Therefore final diagnosis of C5-C6 prolapse bulge with C6 radiculopathy was made. The patient had been on conservative management for the past six months with no satisfactory improvement in symptoms. Therefore the patient was planned for anterior discectomy and bone grafting and stabilization with cervical locking plate.\nOn the day of surgery under general anesthesia and through right lateral approach to the cervical spine, skin and the platysma were incised in the line of incision. While trying to retract the pretracheal fascia medially we noticed a bulging structure [] protruding out, that felt soft like muscle but was compressible.\nStopping there we then retrospectively studied the pre-operative MRI film [] of the cervical spine, which showed the right internal jugular vein to be enormously dilated in comparison to the left. This preoperative finding had been missed by the radiologist too"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAbdominal computed tomography for regular monitoring of uterine fibrosis in a 49-year-old woman found a hypodense lesion 7 cm in diameter with a clear boundary near the gallbladder (Fig. a, b). No obvious change in size and internal density of uterine fibrosis had been observed during these 5 years (Fig. b). She had no previous history of alcohol or drug abuse. Ultrasound revealed a well-defined, non-calcified tumor between the gallbladder and liver (Fig. ). Magnetic resonance imaging demonstrated a hypointense tumor that compressed the gallbladder and liver on precontrast T1 mapping (Fig. a). T2-weighted images revealed hyperintense tumor with delayed enhancement on arterial phase and portal venous phase (Fig. b) followed by a delayed washout on the hepatocyte phase. Clinical evaluation and laboratory results were nonspecific, and serum tumor markers including carcinoembryonic antigen, cancer antigen (CA) 19-9, alpha-fetoprotein (AFP) and squamous cell carcinoma antigen were within their normal ranges. The findings were consistent with a gastrointestinal stromal tumor (GIST) or another benign tumor originating from the liver or gallbladder. Accordingly, we planned firstly laparoscopic partial hepatectomy concomitant with gallbladder resection. Lymphadenectomy among the hepatoduodenal ligament were also planned under the situations where malignant tumor was suspected intraoperatively. Under the laparoscopic view, a soft tumor had expansively progressed behind the gallbladder, with dorsal compression of the liver (Fig. ). The tumor was easily separated from Laennec’s capsule of the liver at the gallbladder neck and body without adhesion, which indicates the tumor is benign. Therefore, operative policy changed to tumor enucleation with cholecystectomy. Frozen sections including the surgical margin of the cystic duct were negative for tumor cells. As the tumor was moderately attached to the liver at the fundus of the gallbladder, the liver parenchyma was partially rese"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old male smoker presented with a mass in the right upper lobe associated with mediastinal lymph node enlargement. The radiological profile was consistent with primary lung cancer; however, during endoscopic aspiration biopsy of the subcarinal lymph node, uncertainty arose as to whether it was a granulatomous lesion. Therefore, we opted for performing a transthoracic biopsy, as well as a mediastinal lymph node biopsy by mediastinoscopy, and, depending on the results of the intraoperative analysis, we would also insert an indwelling central catheter for chemotherapy. The patient was brought to the HOR, and the procedures were performed sequentially. Elective endotracheal intubation, large-bore peripheral venous access, and an indwelling urinary catheter were used. The patient was initially placed in the right lateral decubitus position for performance of a percutaneous Tru-Cut needle biopsy, with the gantry (Artis Zeego; Siemens, Munich, Germany) set to tomographic mode, by the interventional radiology team. Pathological examination of the biopsy specimen revealed that it was a carcinoma. The patient was then placed in the supine position to undergo mediastinoscopy with biopsy of the lesion, with the gantry set to fluoroscopic mode. Examination of a frozen section biopsy specimen confirmed an epidermoid carcinoma in the infracarinal lymph node. In view of the diagnosis of (stage N2) lung cancer, we proceeded to insert a catheter for chemotherapy, again with the gantry set to fluoroscopic mode.\nThe use of an HOR in the case described here allowed all procedures to be performed sequentially, in the same setting, without need for transportation. In addition, we would have the flexibility of adding pulmonary lobectomy if the pulmonary mass was positive for cancer and did not extend into the mediastinum. We were planning to use the gantry set to tomographic mode during mediastinoscopy in order to assist the intraoperative localization of the mediastinal lesion. H"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis 31-year-old P0323 was 12 weeks into her sixth pregnancy at the time of initial referral to the Maternal Fetal Medicine Unit at the Gold Coast University Hospital, for planning of antenatal management, given her past obstetric history. Each of her previous three confinements resulted from preterm premature rupture of membranes and ensuing preterm labour between 27 and 28 weeks of gestation. She had to be delivered by Caesarean section in her last two confinements (fetal distress and elective repeat, resp.). She had retained placenta following her last Caesarean section, for which two separate hysteroscopy-guided curettage procedures had to be performed, placental histology confirming placenta accreta.\nAt the initial ultrasound assessment using the Voluson E8 (GE Healthcare) [], the fetus appeared morphologically normal. A transvaginal ultrasound with a RIC5-9-D transducer demonstrated a shortened cervix, 23 mm in closed length. A complete posterior placenta previa was recognized. The posterior decidual interface was not clearly visualized and turbulent blood flow was visualized at the interface, further raising suspicion about abnormal invasiveness of the placenta. An elastogram was performed at the same time []. Subjective interpretation of the elastogram was that this was a case of morbidly adherent placentation (MAP) in the posterior uterine wall, not to the extent of percreta. This was based on lack of a distinct zone of elasticity interspersed between the placental zone and the myometrial zone, which measured 2 mm in thickness. The uterine serosa appeared intact along its entire length on elastogram (Figures and ). An urgent MRI was arranged soon after this first visit, which confirmed MAP based on regional discontinuity of the uteroplacental interface ().\nDespite being on vaginal progesterone supplementation, the cervix continued to efface and two weeks from the initial assessment, the patient presented with heavy vaginal bleeding. On ultrasound assessment"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old female sustained an injury, while pillion riding a bike, and she was hit and run over by a tractor over both lower limbs and was brought to the trauma center 5 hours after the injury. The patient was normotensive with a blood pressure of 110/80 mmHg and a pulse of 90/minute in the emergency department. The right thigh and knee were swollen and tender with absent anterior tibial artery (ATA) and posterior tibial artery (PTA) without any knee instability ( and ). Capillary refill time and pinprick were delayed. The limb was cold, associated with diminished toe and ankle movements, and diminished sensation over the foot. The left lower limb was shorter with crepitus and abnormal movement in the left thigh and intact distal pulses. Radiographs were performed, which showed left femoral shaft fracture and no bony injury on the right lower limb. Radiographs also showed abnormal soft tissue shadow in the medial aspect of the right distal thigh (). Doppler showed absent ATA and PTA on the right side following which computed tomography (CT) angiogram was performed, which showed non-opacification of right distal superficial femoral artery (SFA) (length of 6 cm) () with popliteal artery reformation, non-opacification of ATA and opacification of PTA and peroneal artery.\nThe patient was taken up for surgery, and the SFA was explored, which was found to be transected with a 7 cm contused segment of the vessel around 10 cm proximal to the knee joint. The contused segment was resected, fogartisation of distal and proximal ends was done, and reconstruction with reversed saphenous vein interposition graft was undertaken using 5-0 prolene. Medial and lateral fasciotomy for right leg was conducted and external fixator was applied for left femur fracture.\nPostoperatively, heparin and low-dose aspirin were given. The limb was warm with normal capillary refill, and Doppler showed biphasic flow in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old man presented with a gradually increasing mass located in the soft tissue of the oral cavity. The lesion was biopsied, and the pathology report showed increased infiltration of the buccal mucosa with monoclonal plasma cells. Immunochemistry demonstrated positivity for CD138, CIgA, and negativity for CD56, Cyclin D1 and CD20. Therefore, the diagnosis of soft tissue plasmacytoma was confirmed, for which he received localized radiotherapy with a total dose of 40 Gy, due to the absence of systemic disease as the bone marrow biopsy revealed the absence of neoplastic infiltration and serum and urine immunofixation were all negative.\nAfter five years, the patient noticed a painless swelling in his right testis. An ultrasound of the scrotum was performed that showed a hypoechoic mass in the right testicle with increased vascularization, and a normal-appearing left testis (Figure ). The patient subsequently underwent a right radical orchiectomy and the histopathology report showed testicular infiltration by a plasma cell neoplasm with identical immunophenotype (CD138+, CIgA+, CD56-, CD20-, Cyclin D1-) to the primary site in the oral cavity. Subsequently, the patient underwent a bone marrow biopsy that showed the absence of monoclonal plasma cell infiltration, and a PET/CT scan that was negative for reactive lesions suspicious of malignancy. In addition, serum and urine protein electrophoresis, as well as serum-free light chain assay were all within normal range, thus, excluding the presence of systemic disease, while complete blood count and full biochemical profile were normal.\nHowever, after one year, the patient presented again with painless swelling of his left testis that was attributed to disease relapse based on the imaging findings (Figure ). He refused to undergo left orchiectomy, thus he proceeded with systemic treatment based on lenalidomide, bortezomib and dexamethasone. Following 4 cycles of treatment, the patient underwent high dose melphalan with"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA four-month-old Saudi Arabian male baby was presented to our neurosurgical clinics with a progressive increase in head size for four weeks. He was the first child for an unrelated couple and the outcome of an uneventful pregnancy. An antenatal ultrasound at week 34 of gestation reported mild ventriculomegaly. Nevertheless, he was delivered at full term with spontaneous vaginal delivery. At birth, his head circumference was in the 90th percentile, without clinical evidence of increased intracranial pressure, and his general examination was within normal limits. His mother brought him because of vomiting and her concern with the rate of increase in his head size over his second month of life.\nOn examination, our patient was alert and active with a normal physical examination, apart from ‘setting-sun’ eyes. His head circumference exceeded the 90th percentile and he had a full anterior fontanel measuring 2 × 3cm in diameter. A cranial magnetic resonance imaging (MRI) scan demonstrated obstructive hydrocephalus due to congenital aqueductal stenosis (Figure ). His routine laboratory tests, including a complete blood count, electrolytes, renal and coagulation profiles, were within normal limits. He underwent an uneventful endoscopic third ventriculostomy and was discharged home after 48 hours in good condition.\nA follow-up after four weeks revealed recurrence of vomiting and increasing head circumference with a full anterior fontanel. He was admitted and a repeat MRI scan revealed a patent third ventriculostomy with no significant changes in the size of the ventricles (Figure ). He had a medium pressure VPS (P.S. Medical, Medtronic, Minneapolis, USA,) inserted. The procedure was carried out in the routine fashion and a ventricular catheter was introduced through a right parieto-occipital burr hole. Adequate placement was confirmed by the drainage of clear cerebral spinal fluid (CSF) under pressure, with care taken to drain less than 5cm3 to send for a cell count, chemistr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male patient reported with the chief complaint of chronic, dull, localized, intermittent pain in the left mandibular first molar for the past 1 month. The pain aggravated on chewing hard food. There was no history of any radiation of pain. However, the patient gave an account of occasional enlargement of the left submandibular lymph node and mild fever. On examination, clinical probing depth of 8 mm on the buccal surface of the left mandibular first molar along with Grade 3 furcation defect was noted. The tooth had been root canal treated 3 years back and had been restored with a complete metal crow []. The patient was systemically healthy and did not report any oral abusive habits such as smoking, tobacco or betel nut chewing, or alcohol consumption. An intraoral periapical radiograph revealed incomplete obturation of the mesiobuccal root with a broken endodontic file in the root canal along with extrusion of the gutta-percha and furcal perforation []. The IOPA of the concerned tooth revealed the presence of a broken endodontic file and furcal perforation with extruded gutta percha.\nNonsurgical periodontal therapy with complete full-mouth scaling and root surface debridement was initiated. The crown and amalgam core was removed []. The access opening was enlarged and the gutta-percha that was extruding from the perforation was removed. The perforation was sealed internally using mineral trioxide aggregate [Figure –]. The broken H-file was retrieved from the root canal using an instrument removal system. The biomechanical preparation was then accomplished by a step-back technique using 2% sodium hypochlorite and 17% ethylenediaminetetraacetic acid. Obturation was completed, and core build was done with amalgam []. The radiograph at 4 months revealed a significant reduction in the periapical radiolucency at the apex of the tooth []. The gingiva showed no signs of inflammation or bleeding on probing. However, Grade 3 furcation with the horizontal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA healthy 20-year-old female came to our clinic with a complaint of progressive, continuous, and long-standing history of bilateral nasal obstruction that was worse on the left side. She was having frequent thick mucoid nasal secretions, left-sided facial pain, and intermittent hyposmia, also it was associated with moderate to severe allergic rhinitis symptoms; she had no visual disturbances. The patient had already tried intranasal corticosteroids with no satisfactory improvement.\nA nasal endoscopic exam revealed a deviated nasal septum to the right side, a mildly hypertrophied right inferior turbinate, and a large mass occupying the left nasal cavity. This mass had displaced the nasal septum to the contralateral side and compressed the left inferior turbinate. Using the freer and fraiser suction, the mass was found to be hard but with normal overlying mucosa (Figure ).\nIt originated from the skull base on the endoscope, with small nasal polyps noted beside it, but a further passage to the nasal cavity was not possible. The rest of the clinical exam, including her cranial nerves and orbital exam, was unremarkable.\nThe patient came to our clinic for a second opinion, as she was concerned about the results of her medical imaging, which included CT scans and magnetic resonance imaging (MRI) of the paranasal sinuses. These reports commented on a bony nasal lesion measuring 1.7 × 3.7 × 3.0 cm and arising from the left skull base. The lesion was obstructing all ipsilateral paranasal sinuses with complete opacification and displacing the nasal septum to the contralateral side. Fortunately, there was no intracranial or orbital extension. No comments were made regarding heterogeneous opacification. These findings were thought to be an aneurysmal bone cyst, mucocele, mucopyocele, or other sinonasal tumors.\nHowever, upon careful study of the imaging, AFS was considered due to the heterogeneous nature of the content, the bony expansion of the lesion in the CT scans,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 27-years-old female patient presenting with recurrent coughing and hemoptysis for more than 10 years first came to our hospital in January 2019. According to the medical history information provided, the patient was previously diagnosed as pneumonia and treated symptomatically in local clinical institution. The symptoms of patient were once relieved after the treatment, but recurred frequently. The patient has no family history of primary lung malignancy and genetic disease, 155 cm in height and 42 kg in weight with a lean body shape, symmetrical thorax without deformity. The trachea of the patient deviated to the right slightly, no obvious rhonchi and moist rale as well as wheezing rale were heard. The heart rhythm was regular, the auscultation area of heart sound apparently deviated to the right thorax, and no obvious abnormality was found in abdominal physical examination.\nA chest radiograph and computed tomography were performed for the patient showed a giant abnormal space-occupying lesion in the hilum of right lung. The tumor was closely related to the right pulmonary artery and bronchus (Fig. a, b). The right lung was atelectasis and some of the left lung as well as heart were obviously deviated to the right thoracic cavity. A Chest MRI showed a mass abnormal signal tumor in the region of right hilum about 10.0 × 4.5 cm in size. The T1WI was isointense, while T2WI and DWI were both hyperintense. A 3D reconstruction of the hilar structures have shown a complete anatomical disorganization of right pulmonary artery and vein (Fig. c). A neoplasm with smooth surface was observed in the right main bronchus by bronchoscopy examination. However, a biopsy was not performed concerning that existing hemoptysis might be aggravated (Fig. d). Pulmonary function showed a severe obstructive mixed ventilation dysfunction. The forced expiratory volume in 1 s (FEV1) was 1.36 L, accounting for 45% of the predicted value, Maximal voluntary ventilation (MV"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old healthy male with complaints of a gradually increasing growth of 9 months duration on right wrist presented to Dermatology OPD. The lesion became more prominent on movement of wrist. There was a history of similar growth in the father. No abnormality was detected on general physical examination. Local area examination revealed a 3 × 3 cm, soft to firm, hemispherical, non-tender, mobile lesion on the medial aspect of right wrist []. Clinically, a diagnosis of lipoma was made and confirmed by FNAC. The patient was not open to any surgical intervention and was given the option of injection lipolysis. After discussing the possible side effects like hyperpigmentation, skin loss, prolonged pain, swelling, or tenderness, late onset hives or itching and skin contour irregularities in detail, an informed written consent for three sessions at 6-8 weeks gap was taken.\nThe lesion was cleaned and draped. The area was divided into small grids (1.5 cm apart) []. Solution of phosphatidyl choline and deoxycholate (50 mg/ml) was filled in insulin syringes (4 injections of 16 units of formula). The pinch and pull technique was used. The lipoma was pulled away from the underlying structures and four units were injected in each of four grids (total of 16 units). Care was taken not to inject any material while withdrawing the needle to avoid any intradermal deposition of the drug. The injections were not perceived as painful by the patient. Immediately after the injections there was swelling, redness and burning sensation which persisted for around half an hour []. No external compression was used and gradually the swelling settled. In the next 48 h, the lesion shrunk to half of its original size and disappeared completely within next 3 weeks, after the first injection itself. The patient is under follow up for the last 9 months with no evidence of any recurrence []."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn elderly man in his seventies presented to the Urology department with two episodes of acute urinary retention. There were no rectal symptoms and rectal examination revealed an enlarged prostate. He underwent a laser transurethral resection of prostate during which a large palpable pelvic mass was noted. The subsequent urgent MR pelvis revealed a large tumour in the mesorectum arising from the anterior rectum 10 × 8.5 cm (Figs and ). A transrectal ultrasound and biopsy were performed; histology revealed a spindle cell tumour, with positive immunostains for CD117 and DOG1 with 5 mitoses per 50 high power fields. This was confirmed to be a locally advanced high-risk GIST.\nThe multidisciplinary team review advised neoadjuvant treatment with imatinib mesylate and further reassessment. Repeat MR pelvis and staging PET CT abdomen, thorax and pelvis were then performed. These showed a large extra-luminal tumour with downsizing in tumour bulk (6 × 5.7 × 5.4 cm) (Figs –) but in close approximation with the right seminal vesicle.\nFurther examination under anaesthesia, flexible sigmoidoscopy and cystoscopy were performed. The tumour was a large right-sided mass with no prostatic involvement. An elective Hartmann's procedure plus possible pelvic clearance was organized. Intraoperatively a large tumour in close proximity to the posterior bladder and seminal vesicles was found. Although there was no evidence of invasion, dissection of the plane between the GIST and posterior bladder was not possible, thus cystectomy and prostatectomy were performed with an ileal conduit and urostomy. The sigmoid colon and rectum were resected leaving an end colostomy as planned. In the postoperative period the patient developed signs of sepsis. A subsequent CT revealed an anastomotic leak at the ileo-ileal site. The patient returned to theatre, the anastomosis was taken down and a double barrel ileostomy sited. He initially went on to recover well. Operative histology revealed reduced mitotic a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe second case involved a 70-year-old Native American man presenting with upper back pain and numbness of his right foot for approximately 10 days. The symptoms had worsened, and he noticed some difficulty with walking. He did not have any past medical or surgical history. He was a former tobacco smoker and stopped smoking approximately 20 years ago, but it is unknown how many packs or cigarettes per day he smoked. He drank alcohol very rarely and not significantly. He did not have family history of any significance. He was never on medications until he was diagnosed as having HCC. He worked at a warehouse in the past. His job position was unknown. He has no known environmental or drug allergies. On admission, his BP was 166/119 mm Hg, HR was 97 beats per minute, and temperature was 36.7 °C. His physical examination had the following results: he was normocephalic, he had a non-traumatic skull, he had normal hearing, he had no nasal discharge, his chest wall movement was symmetric, his breath sounds were clear, he had no rales/wheezing, his HR was within the normal limit and had regular rhythm with no murmurs or thrills, his abdomen was soft with no distension, there was no palpable mass, there was no hepatomegaly or splenomegaly, a bilateral pedal pulse was present, there was no visible joint swelling, his skin was warm to the touch, he had normal color, and he had no rash/ulcers. A neurological examination had the following results: he was alert and awake; he was oriented to time, his name, and his location; his cranial nerves were grossly intact; he had no gait disturbance or motor deficits; his superficial reflexes were intact; a slight decrease in sensation over his right lower extremity was noted. Abnormal laboratory results were as follows: aspartate aminotransferase level of 104 U/L and alanine aminotransferase level of 90 U/L. CT of his chest"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nMrs SA was a 35-year-old housewife with three living children, who was referred from a peripheral hospital to the accident and emergency department of Abuja Clinics Ltd. on the 5th of July 2010 with a 6-h history of lower abdominal pain. The pain was of sudden onset, sharp and radiated to the anal region. It was aggravated by movement but relieved by lying still. There was associated weakness and dizziness, but there was no fainting sensation. There was no bleeding per vaginum and no constitutional or urinary symptoms. Her last menstrual period was about 5 weeks prior to presentation. She claimed to have had a regular 28-day cycle with 4 days menstrual flow. She had right ectopic pregnancy and salpingectomy in 1997 and a miscarriage in 1998. She had spontaneous vaginal deliveries in 1999, 2001 and 2005. She wore an IUCD in between the pregnancies for an average of 13 months. She had Cu T IUCD in June 2005, about 6 weeks after her last confinement. She experienced pain during the Cu T IUCD insertion, which prompted an ultrasound scan to be done the same day. The ultrasound scan suggested that the IUCD was in situ and normally placed. She was reassured and was given paracetamol tablets for 2 days and the pain stopped.\nExamination on presentation revealed a young woman in painful distress, pale, anicteric and not dehydrated. Her pulse rate was 88 bpm while her blood pressure was 120/80 mmHg. Her abdomen was generally tender, but the tenderness was more marked at the right iliac fossa. Vaginal speculum examination showed the tail of her IUCD protruding from the external cervical Os. There was cervical excitation, tenderness and a bulging pouch of Douglass on digital vaginal examination. Rectal examination revealed no abnormality. An impression of acute abdomen due to ectopic pregnancy or acute appendicitis was made. Her packed cell volume (PCV) was 34%, genotype AA and blood group A"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 22-year-old young female presented in outpatient department (OPD) for uncontrolled hypertension from past 3 years, she has a past history of subarachnoid hemorrhage in 2016 for which she underwent craniotomy with right middle cerebral artery aneurysm clipping. On clinical evaluation, she had a blood pressure (BP) of 180/110 mm Hg in both the upper limbs, with no palpable pulses in both the lower limbs, prominent suprasternal pulsations with a systolic murmur in the left side precordium and a soft bruit over the back on both the sides. Her routine blood investigations were within normal limits\nHaving a possibility of coarctation of aorta, she was subjected for detailed cardiac evaluation. Electrocardiogram (ECG) revealed normal sinus rhythm. 2-D echocardiogram (ECHO) had evidence of coarctation of the aorta (post ductal) with high gradients (94 mm Hg), normal left ventricular function. Chest X-ray showed signs of bilateral posterior rib notching in the inferior aspect and no evidence of aortic dilatation (). The patient was subjected for computed tomography (CT) aortography for localizing the site and extent of coarctation of aorta which revealed coarctation of aorta 22 mm caudal to the origin of the left subclavian artery, measuring 4 mm in length and about 2.3 mm in caliber. Bilateral extensive collaterals were seen in the scapular, paravertebral and posterior thoracic wall with hypertrophied right internal mammary artery (RIMA), left internal mammary artery (LIMA) and intercoastal arteries. B/L renal arteries were normal (). The diagnosis of coarctation of the aorta with secondary hypertension was made, and the patient was planned for coarctoplasty. The patient underwent successful coarctoplasty through right femoral artery approach using a Tyshak balloon measuring 15 × 30 mm (). The stent was not placed as the results were very good with gradients across the coarctation of aorta reducing from 95mm Hg to 10 mm Hg post balloon dilatation. The patient tolerated th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 86-year-old woman was admitted from an outside institution to our neurological intensive care unit with fluctuating consciousness after hitting her head during a fall. Four weeks before admission, she was in normal health for her age with a history of arterial hypertension. Because of atrial fibrillation, she was treated with rivaroxaban 20 mg once daily. Two weeks before hospitalization, she experienced pain in her lower abdomen accompanied by a feeling of illness and fatigue which she self-medicated with aspirin. She experienced nose bleeding but continued to take aspirin. She was then admitted to an external clinic after falling. During the first in-hospital night, she fell out of bed and struck her head. Thereafter, consciousness decreased and she was transferred to the neurocritical care unit of our institution. She presented with dysarthria and mild motor aphasia, but language comprehension was fully preserved. In addition, mild right-sided hemiparesis was noted. Most of the time, she was awake but intermittently somnolent. Body temperature was 37.6 °C. Routine laboratory tests revealed prolonged prothrombin time, increased international normalized ratio (INR), increased CRP, leukocytosis and corresponding signs of a urinary tract infection. She was treated with prothrombin complex concentrate and antibiotics.\nThe initial computed tomography (CT) on day 0 showed contusions in the left frontal and temporal lobes and tSAH. Figure a shows this first CT scan with subarachnoid blood in two sulci of the left frontal cortex. A contre-coup injury was found in the right posterior cranial fossa with an epidural hematoma and corresponding tSAH. In addition, a small intra-parenchymal hemorrhage was observed in the right basal ganglia. Arterial aneurysms or arteriovenous malformation were ruled out using CT angiography (CTA). Blood was also detected in the fourth ventricle, but signs of disturbed cerebrospinal fluid circulation were not seen. Accordingly, the patient di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63 year-old female with longstanding type-1 diabetes mellitus and hypertension developed chronic renal failure in 2002 and underwent a pre-emptive renal allograft transplant from her donor husband in 2004 without requiring prior dialysis. Both the donor and recipient were cytomegalovirus-negative. She received basiliximab 20 mg prior to her transplant surgery and another 20 mg on day 4 post-transplant. Following transplantation she was immunosuppressed with mycophenolate mofetil, prednisone and tacrolimus. She had longstanding stable kidney function following transplantation with a baseline GFR of 84 mL/min and a creatinine of 80 micromol/L. Her past medical history was remarkable for iatrogenic hypothyroidism following parathyroidectomy for primary hyperparathyroidism, and she had no prior history of malignancy.\nIn April 2015, after ten years of immunosupression, she developed an irregular hyperpigmented and evolving lesion on her left upper back which was resected in May 2015. The biopsy of the left scapular site revealed a superficial spreading invasive melanoma with a maximum Breslow thickness of 2.59 mm, Clark level of IV, with, mitoses of 5/mm2. No ulceration was identified, but tumor infiltrating lymphocytes and tumor regression were present. Peripheral margins were uninvolved, but deep margin was involved by a satellite nodule and microsatellitosis was also present. Wide-local excision and bilateral axillary lymph node biopsies were performed July 2015, as lymphoscintigraphy had identified drainage of each of the lesion to the contralateral axilla when injected with technetium 99 sulfur colloid. Three right axillary lymph nodes were removed and were negative for malignancy, but 1 left axillary lymph node was removed and pathology revealed an 8.5 mm × 7.5 mm melanoma deposit with extranodal extension. As a result, the patient required a wide local excision with a 2 cm margin and pathology demonstrated residual disease and microsatellites, with negative marg"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old Caucasian woman was admitted to our hospital presenting with a painful mass in her right groin, without fever, rectal bleeding or any other bowel symptoms. She had no history of malignant diseases. A physical examination showed an irreducible palpable mass in her right inguinal region protruding through the external inguinal ring. Routine blood examinations showed she had chronic anemic status with an hemoglobin value of 8.9g/dL. Tumor markers values of carcinoembryonic antigen and carbohydrate antigen 19.9 were 4ng/mL and 24U/mL, respectively. A computed tomography scan of her abdomen showed the presence of the cecum in her inguinal canal, with an irregular thickening of its wall suggesting a cecal neoplasm within the inguinal hernia involving the femoral vessels (Figure ).\nA colonoscopy was not completed due to the large involvement of the cecum into the hernia sac. Surgical exploration was made through a midline laparotomy that confirmed the herniation of the cecum into her right inguinal canal (Figure ), without the possibility of reduction in her abdominal cavity owing to the tumor infiltration into her abdominal wall and inguinal structures. Thus, a right inguinal incision was made, which revealed an aggressive cecal tumor infiltrating her inguinal wall, right round ligament and femoral artery. The mass was resected en bloc, with complete vascular control of her femoral vessels, and reduced into her abdomen.\nFinally, a right colectomy was performed with a manual ileocolic anastomosis and her inguinal wall was repaired by a direct suture without mesh. The operative field of the femoral region was also marked with surgical clips for further postoperative radiation therapy (Figure ). Histopathological examination of the specimen showed a poorly differentiated adenocarcinoma of the large bowel with lymphovascular and perineural invasion, microscopic involvement of the resection margins, and metastases of 8 out of 17 regional lymph nodes (pT4b pN2b M0"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a cardiac benign metastasizing leiomyoma incidentally found in a patient who presented to our hospital after a motor vehicle accident.\nA 36-year-old female patient presented to the emergency department of our hospital with right-sided blurry vision after being involved in a motor vehicle accident. The patient was a restrained back seat passenger and sustained a right eye trauma with no other injuries nor loss of consciousness. She was found to have traumatic uveitis. CT scan of the head and sinuses showed no evidence of fracture or acute pathology. A CXR was performed to rule out any rib fracture and found a 1.1 cm pulmonary nodule in the right midlung. A contrast CT scan confirmed the presence of 1.1 cm nodule within the anterior inferior aspect of the right upper lobe and found an additional 1 cm nodule within the posterior superior aspect of the right upper lobe. Both nodules were well circumscribed, compatible with benign nature. Unexpectedly, a large defect was noted within the contrast-enhanced right ventricle and was thought to be a large thrombus extending to the right ventricular outflow tract (). The patient was started on therapeutic anticoagulation overnight. A transthoracic echocardiogram (TTE) and a subsequent transesophageal echocardiogram (TEE) disclosed the presence of a large mobile mass in the right ventricle arising from the interventricular septum. Turbulent flow was demonstrated in the right ventricular outflow tract (Supplemental Material video ()). Cardiac magnetic resonance imaging showed an oblong soft tissue mass that measured 4.9 cm in length abutting the pulmonary valve. The mass occupied the entire RV outflow tract ().\nThe patient denied any symptoms including chest pain, dyspnea, syncope, or weight loss. Physical exam was significant for a systolic murmur. On further history taking, she reported that she underwent a hysterectomy 12 years earlier for “myomas” but denied any personal or family history of malignancy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old female with symptoms of hoarseness and Horner's syndrome presented with a left cervical mass that was diagnosed to be undifferentiated carcinoma based on the findings of aspiration cytology (Figure ). The patient's chest computed tomography (CT) findings showed a mass measuring 5.0 cm in size spreading from the left upper mediastinum to the left supraclavicular area, which pressed against both the trachea and esophagus and it seemed to involve the left common carotid artery (Figure ). Based on these findings, and cytology findings a clinical diagnosis of stage IIIB (T4N3M0) non-small cell lung cancer (NSCLC) originating from the apex of the left lung involving both the mediastinum and the supraclavicular lymph nodes was made []. The patient received concurrent chemo-radiotherapy (cisplatin 80 mg/m2 for days 8 and 36 + UFT 400 mg/m2, both on days 1–14 and on days 29–42 plus radiotherapy, 2 Gy/day on days 1–20 for a total of 40 Gy) []. After this treatment regimen, the tumor size decreased by 35.0%. Thereafter, the patient underwent a surgical resection though a median sternotomy with a combined resection of the left clavicle. During the operation, an encapsulated tumor was detected in the mediastinum. Although the tumor was easily ablated from the left common carotid artery, it involved both the left vagus and the sympathetic nerves. As a result, both nerves had to be sacrificed in order to achieve a complete resection of the tumor. Grossly, the tumor was in continuity of the vagus nerve was whitish in color and oval shaped measuring 5 × 3 cm in diameter (Figure ). Both cytological and histological examinations revealed 1) Continuity between the vagus nerve and tumor was seen, while the no continuity between the tumor and the sympathetic nerve was found. 2) The findings of aspiration cytology of the tumor diagnosing it to be undifferentiated carcinoma before the treatment included"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old female was admitted to our hospital due to a progressively enlarging mass over four years of her anterior chest wall. Since October 2008, she had experienced intermittent anterior chest pain with the pain intensifying in August 2012. Physical examination revealed a warm 10 × 8 × 6 cm mass fixed to the upper sternum, and tender to palpation. No pulsation was noted. Computed tomography revealed an osteolytic lesion with discrete calcification in the bone marrow of the sternum. The tumor extended across the destroyed cortex to the parietal and visceral soft aspects, involving some of the costal cartilage and most of the sternal body (Fig. ).\nDuring the surgery, the manubrium sterni, two-third of corpus sterni, both of the proximal clavicular heads as well as bilaterally the first three ribs and the costal arch with more than a 2.0 cm surgical margin were removed. Frozen section analysis of margins confirmed the complete resection. This resection left a defect measuring 18 × 15 cm2 on the anterior chest wall (Fig. ). According to the reconstructed images of the chest CT, an individual-specific stainless steel plate was made in the same shape as the thoracic bony structure of the patient, using for the reconstruction of the upper sternum, the costal arch and both sternoclavicular joints. The placement and fixation of the plate were straightforward without any difficulty. The securement of the plate was achieved with claw fixator and screws to the remaining ribs and clavicles (Fig. , ). The surgery was successful, and the reconstruction of the chest wall was satisfactory both in appearance and function (Fig. ). The postoperative course was uneventful, and with a body belt, the patient was discharged on the 14th postoperative day. The histological examination of the surgical specimen confirmed the diagnosis of chondromyxoid fibroma (Fig. ).\nHowever, nine months after the first surgery, the patient presented with aggravated chest pain and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 31 y/o Gravida 3 Para 2 who presented to our center at 19-week gestation. She had two prior uncomplicated full term vaginal deliveries and received Rh immunoglobulin during and after each of her previous pregnancies. She has no significant past medical or surgical history.\nDuring this pregnancy, her first trimester studies revealed an anti-D titer of 2048. The fetal status was noted to be RHD positive on amniocentesis.\nOn her initial evaluation at 19-week gestation at our center, the middle cerebral artery (MCA) Doppler revealed a peak systolic velocity (PSV) of 2.37 MoM. There was mild ascites and cardiomegaly.\nAfter counseling the patient underwent the first in a series of combined intravascular/intraperitoneal intrauterine transfusions (see ). The ascites and cardiomegaly resolved after the second transfusion.\nThe fourth transfusion was complicated by an episode of transient bradycardia with spontaneous recovery after removal of the procedure needle from the umbilical vein. On a preoperative ultrasound prior to her sixth procedure, thrombosis of one of the umbilical arteries was noted (see ). A review of earlier ultrasounds indicated two patent umbilical arteries although visualization of the cord was not specifically undertaken postoperatively after the fourth procedure or before and after the fifth procedure. Based on the reassuring status of the fetus, a decision was made to continue serial intrauterine transfusions. Antenatal testing was initiated with weekly biophysical profiles and daily kick counts.\nIn addition to fetal anemia, this pregnancy was complicated by diet controlled gestational diabetes and mild polyhydramnios with an AFI of 29. The estimated fetal weight at 35 weeks ultrasound was 3193gms (87th %ile). She underwent a cesarean section at 37 weeks, delivering a 3480-gram male fetus in vertex presentation with APGARS of 8 and 9 at 1 and 5 minutes, respectively. After delivery the umbilical cord was examined and a 3-vessel cord wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old woman received a diagnosis of cancer of the right breast 6 years prior. At that time, she underwent right mastectomy with placement of a tissue expander. This was followed by exchange to 650 cc silicone implant for right breast reconstruction and concurrent left breast reduction using inverted-T incision with inferior pole technique to achieve symmetry. Unfortunately, she developed ductal carcinoma in situ with microinvasion in her left breast 4 years later. After left-sided vertical mastectomy, her first tissue expander failed secondary to infection and was removed. After debridement and resolution of the symptoms, a second tissue expander was placed and later exchanged with a 650 cc implant. Within 2 weeks, there was again evidence of infection and the implant was removed. Now, 6 years after being diagnosed with breast cancer, she had a successful right breast reconstruction and a failed left breast reconstruction (a).\nAt this point, we had essentially exhausted implant-based reconstruction techniques and offered alternative autologous tissue options for further repair. She elected to pursue several rounds of fat grafting instead of a pedicled flap or free tissue transfer. Next, the left breast was fit with a Brava dome external tissue expander device (Brava, LLC, Miami, Fla). This was worn only in the preoperative period for 6 weeks, 8 hours per day, in an effort to best prepare the recipient site to receive and support large volume of fat grafts. Over a 2-year period, she received 5 rounds of AFT using the TLL system. Fat was harvested from various sites including abdomen, flanks, posterior hips, thighs, saddlebags, bra line, and lateral chest wall. After 4 AFT procedures, 250, 300, 250, and 270 mL were transferred to the left breast, respectively. In the fifth and final round of AFT, 180 mL of fat was grafted to her left breast and 120 mL to her right breast"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old Japanese man with no past psychiatric history, but with a past neurologic history of PKD, was referred by the neurologic department at our hospital to the Department of Psychiatry because of severe anxiety and hyperventilation. When the patient was 16 years old, he was clinically diagnosed as PKD by a neurologist based on characteristic symptoms including involuntary movement induced by voluntary movements and various examination findings, such as test using blood and cerebrospinal fluid, and several image findings. After that, he had been maintained on carbamazepine (CBZ) at 200 mg/day since 16 years of age without any attacks.\nIn February 2013, on a regular follow-up in the neurologic department, the neurologist changed CBZ to topiramate after the patient complained of long-term symptoms of drowsiness and wobbliness, which he thought might be the side effects of CBZ. Two days later, he visited the emergency department at our hospital with chest pain and hyperventilation. Although the neurologist suspended topiramate and resumed CBZ, his anxiety and hyperventilation did not improve as was expected. The following month, the patient was referred to our department, but he stated that he had no anxiety about PKD or any other psychosocial stressors. He presented as a gentle young man without any abnormal affect, but seemed somewhat nervous with an impassive facial appearance. We took time to have a good discussion about his history and symptoms. At last he confessed that, 10 years before this referral, he became aware of a feeling of breakdown in his overall physical functions to what he considered as about 70% of his earlier state. He had then avoided becoming familiar with people out of concern that his physical dysfunctions might be perceived in a negative light. It means that his anxiety symptoms had existed and persisted 10 years before a change of drug, CBZ to TPM, though we could not completely deny it affected these symptoms. Then we began treatmen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old male runner fell forward over an outstretched left leg during a race. He felt a popping sensation with his left hip in deep flexion and the left knee in forced extension and a sharp pain in the posterolateral aspect of the left distal thigh. He could not bear weight on the affected leg, which prevented him from walking and he was immediately transferred to our hospital. He had no history of other trauma, chronic disease, or use of corticosteroids. A clinical examination revealed swelling and tenderness at the posterolateral aspect of the left distal thigh. The ridge formed by the left biceps femoris tendon was distinctly deficient to both visual inspection and palpation. Active extension or flexion of the left knee was prevented by severe pain. Ligamentous instability of the knee was not evident and the left knee appeared normal on plain radiography images. T2-weighted magnetic resonance images of the left thigh revealed a loss of continuity of the distal biceps femoris tendon at the musculotendinous junction surrounded by a hematoma with high signal intensity (). Isolated rupture of the distal part of the left biceps femoris tendon was diagnosed and surgical exploration proceeded under lumbar spinal anaesthesia. A lateral incision over the belly of the biceps femoris revealed that the biceps femoris tendon had completely ruptured at the musculotendinous junction (). The tear was repaired using a modified Kessler method with strong nonabsorbable sutures.\nThe knee was postoperatively immobilized in a plaster cast at 30° of flexion. However, the patient described numbness and sensory loss over the anterior aspect of the left foot and dorsiflexion of the foot was weak on the day after surgery. Common peroneal nerve palsy at the fibular head due to compression by the plaster cast was diagnosed and the cast was removed to decompress the nerve. However, this did not result in any neurological improvement. Surgical assessment was applied 2 months after the co"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn June 2002, a 36-year-old woman presented to her primary health care doctor with a history of flushing, diarrhoea, night sweats, and a clinically detectable mass in her left medial supraclavicular fossa. Her past medical history consisted only of essential hypertension for which she did not require prescribed therapy. Her family history included a brother with a diagnosis of sarcoma and two other non-first-degree relatives with primary brain malignancies.\nFine needle aspiration confirmed the diagnosis of medullary thyroid cancer, and in July 2002, she underwent total thyroidectomy with left-sided modified radical neck dissection and central compartment clearance. At this point, concerns were raised regarding optimal cytoreduction as the appearances of the central compartment, level 4 and level 5 nodes, were that of extensive disease. In order to maximise local disease control, she received adjuvant radical radiotherapy delivering 60 Gy to the thyroid bed.\nTwo years after completion of treatment, in February 2004, follow-up repeat imaging reported a recurrent nodule at level 4 of her neck. Subsequent resection confirmed this to be recurrent medullary thyroid cancer with no evidence of distant spread at the time. She continued to be monitored at the oncology clinic and remained disease-free until four years later, in May 2008, when computer tomography (CT) imaging revealed new pulmonary parenchymal metastases. These were closely monitored for the next 2 years with repeat imaging and measurement of calcitonin levels. In May 2010, it was decided that the patient should embark on systemic anticancer treatment.\nShe was offered participation in a phase 2 clinical trial with the agent lenvatinib (E7080) and she commenced treatment with 24 mg once daily in May 2010. One week into therapy, it was noted that she was marginally hypertensive with a blood pressure of 140/100 mmHg. No proteinuria was identified at this point, but she was commenced on 5 mg of amlodipine to manage"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old man with a past medical history of hypertension, diabetes mellitus, coronary artery disease, and aortic insufficiency was admitted to our hospital with an unprovoked pulmonary embolus. As part of an occult malignancy work-up, a computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast was performed and revealed a right persistent sciatic artery aneurysm. Follow-up CT angiography confirmed the diagnosis of a right sided persistent sciatic artery aneurysm and also demonstrated a hypoplastic right superficial femoral artery (SFA). (). Maximal aneurysm dimensions were 40 mm × 35 mm in the right gluteal region (). The patient did not endorse any right lower extremity complaints. Physical exam was notable for a pulsatile right sided gluteal mass, bilateral palpable femoral pulses but no palpable pedal pulses.\nAfter a standard pre-operative evaluation, the patient elected to proceed with surgery to reduce the potential risk of aneurysm rupture, thrombosis or embolization (). From a percutaneous left femoral access, two 16 mm Amplatzer ™ vascular plugs (Abbott Medical, Plymouth, MN) were placed proximally and distally to exclude the PSA aneurysm. Next, standard exposure of the proximal superficial femoral and below knee popliteal arteries was performed. Ipsilateral saphenous vein was harvested and a non-reversed proximal superficial femoral to below knee popliteal artery bypass was performed to restore perfusion to the patients right lower extremity (). The proximal superficial femoral artery was chosen as inflow for the bypass due to limited saphenous vein conduit length. His surgery was performed by one of our fellowship trained vascular surgeons at a facility with an endovascular capable operating suite. After an uneventful three-day hospital stay, the patient was discharged in a stable condition. Aside from the immediate post-operative recovery, he has had no changes to his level of activity or lifestyle.\nA CT angiogram of the aorta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old female, with a history of left breast cancer and total mastectomy followed by neo-adjuvant radiation in 2009, presented to the Plastic and Reconstructive Surgery clinic in December 2014 to discuss options for breast reconstruction. Other significant past medical and surgical histories at the time of her initial presentation included a left posterolateral thoracotomy for complicated pneumococcal pneumonia, three cesarean sections, and 1 ppd tobacco use. Her disease status was closely monitored by her oncologic team and was deemed disease-free as evident in her then most up-to-date negative screening mammogram in 2013.\nUpon successful cessation of her tobacco use for a period of six months after the initial consultation, the patient was taken to the operating room in June 2015. With goals to recreate a full C-cup sized breast in a patient with a very thin body habitus (body mass index = 24), our team utilized a supercharged muscle-sparing fTRAM flap in order to safely utilize all four zones of the abdominal flap. Utilizing a two-team approach, the recipient site of the left chest was entered from her previous mastectomy incision, along with resection of the surrounding radiated fibrotic skin. A laterally based pectoralis flap was utilized to dissect up to the second rib, which was then partially resected to expose the left internal mammary artery and two veins. Simultaneously, the transversely oriented abdominal flap was elevated by the second surgeon, being particularly careful to preserve both the superior and inferior epigastric vessels on both hemi-abdominal flaps. Dissection proceeded in the prefascial plane above the anterior rectus sheath in a lateral to medial approach. After the favorable right-sided lateral row perforators were identified, the fascia was incised and the rectus muscle exposed, allowing us to trace the vessels down to the origin of the deep inferior epigastric artery and vein in the right lower quadrant. Care was taken to preserv"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old female with past medical history significant for type 2 diabetes mellitus, hypertension, and dyslipidemia and family history of breast cancer in her brother and maternal aunt presented to the emergency room for recurrent chest pain. She also reported fatigue for the past few months and was being evaluated for worsening anemia by her primary care physician. Her hemoglobin was 6 gm/dl with iron panel consistent with anemia of chronic disease. Her electrocardiogram (ECG) at arrival showed an “RSR pattern” in V1 and V2 leads but was otherwise normal. She underwent a stress myocardial perfusion imaging (MPI) which was negative for cardiac ischemia. A transthoracic echocardiogram revealed a 1.6 cm × 1.5 cm atrial mass attached to the anterior wall of the left atrium, which appeared to cross the mitral valve in ventricular diastole. The left atrial mass was further characterized by a transesophageal echocardiogram (TEE) as a solid, irregularly shaped, partly mobile mass attached to the atrial septum and extending to the anterior mitral valve leaflet (). The segment attached to the septum measured 2.6 cm × 1.43 cm, and the segment attached to the valve measured 1.4 cm × 2.22 cm. In addition, MRI of the heart with gadolinium was done preoperatively which confirmed the circumscribed hypodense mass with speckled appearance which originated at the atrial septum and extended along the anterior mitral valve leaflet (). The mitral valve flow was normal with no evidence of obstruction, stenosis, or regurgitation. The patient underwent a minimal incision valve surgery for resection of the mass which was presumed to be myxoma due to its location. Intraoperatively, on open examination of the left atrium, it was noted that the mass originated from the fossa ovalis region of the interatrial septum and infiltrated the atrial wall down onto the entire anterior leaflet of the mitral valve. A fibrotic density that surrounded the tumor was also noted. The mass along with a port"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 3-year-old girl presented with a palpable abdominal mass that was noted on her well-child examination. Her parents reported a gradually increasing abdominal distention for 1 year with no other symptoms. On physical examination, the child had a soft, grossly distended, and nontender abdomen, with a large firm palpable mass on the left side []. Hemoglobin, alpha-fetoprotein, and human chorionic gonadotropin beta subunit levels were normal. An abdominal ultrasound showed a heterogeneous soft-tissue mass with septal walls in the left lower quadrant. A computed tomography (CT) scan revealed a well-circumscribed, heterogeneous, and fatty mass with thin internal fibrous septations in the left lower quadrant measuring 13.5 cm × 10.5 cm × 17.5 cm. The mass appeared to be intraperitoneal and to be causing mass effect on the spleen, left kidney, small intestine, and pancreas. A magnetic resonance imaging (MRI) scan confirmed a multilobulated mass suggestive of a lipomatous tumor of retroperitoneal origin, and a laparotomy was planned for both diagnosis and therapy []. The preoperative diagnosis of this case was a retroperitoneal teratoma.\nSubsequently, an exploratory laparotomy with resection of the retroperitoneal mass was performed under general anesthesia. A well-encapsulated mass was loosely attached to the retroperitoneum. A thorough exploration of the abdomen was carried out without identifying other abnormalities. On the superior pole of the tumor, the left diaphragm was adherent and carefully dissected free from the mass. The tumor was easily dissected free from the retroperitoneal space without injury to adjacent structures. Grossly, the tumor weighed 1015 g and was well circumscribed, with a thin fibrous capsule. The specimen had a yellow lobulated fatty parenchyma separated by thin fibrous septa. Histologically, the lipomatous tumor consisted of mature adipocytes mixed with numerous lipoblasts in a focal background. No evidence of cellular atypi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old woman, teacher by occupation, presented with a painless progressive oval mass at the lateral canthus of the right eye since 1 year. The swelling to start with was of the size of a mole at the lateral canthus which increased to the present size of a pea and used to bleed intermittently on touch [].\nOn examination, a single nodular mass of size 18 mm × 11 mm which was pigmented, with well-defined margins was noted. The overlying skin was firmly adherent, irregular, and pinkish in color due to telangiectatic surface. The mass was firm in consistency on palpation with no signs of inflammation. The visual acuity, extraocular movements, and fundus examination were within normal limits. The systemic examination did not reveal any preauricular lymphadenopathy or nodular lesions elsewhere in the body. The patient did not have any abnormal facies or any abnormal pigmentation of the skin. Routine blood investigations, peripheral smear, and computed axial tomography of the orbit were within normal limits.\nSurgical excision of the lesion was planned. A 3 mm safety margin was marked around the mass; an incision was taken along the markings under local anesthesia. The lesion was then meticulously dissected out, and no adhesions to the surrounding tissues were found. The mass was then excised in toto along with the 3 mm skin frill. Reconstruction of the wound was done by direct closure in two layers with 6-O vicryl and 6-O prolene without tension [].\nMicroscopy of the mass revealed that the epidermis had thinned out and showed focal acanthosis. The subepithelial tissue showed a tumor mass composed of cells arranged radially around islands of loose connective tissue (mucoid) giving a lace-like pattern with intervening strands in between. The cells had nuclei showing mild anisonucleosis, at places lumina were surrounded by darker cells resembling glandular cell. Some foci showed peripheral palisading with some squamous differentiation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old man was admitted to the Department of General Surgery of the University of Catania with a persistent abdominal pain in the left hypochondrium associated with nausea, vomiting, and weight loss (5 kg in two months). Clinical examination revealed a palpable mass in the epigastrium and in the left hypochondrium, which was approximately 40 cm long. The abdominal mass appeared to be fixed to adjacent structures, with its limits poorly defined.\nAll routine blood test results and levels of tumor markers (CEA, CA 19–9, α-fetoprotein) were within the normal ranges. Ultrasonography and computed tomography of the abdomen showed a large mass of 40 × 25 cm, which extended from the posterior wall of the stomach to the spleen, enveloping the body and the tail of the pancreas (Figures and ). Moreover, the mass was in close proximity to the left colic flexure.\nAfter appropriate fluid resuscitation and positioning of a naso-gastric tube, the patient was urgently taken to the operating room for exploration. A bilateral subcostal approach was chosen. The giant mass occupied the central abdomen and displaced the stomach anteriorly. The tumor abutted surrounding structures closely, especially the left colic flexure, which was compressed. There was no evidence of liver or peritoneal metastasis. After division of the gastro-colic ligament, it became clear that the giant mass derived from the posterior wall of the stomach and encased the body and the tail of the pancreas without infiltrating the celiac trunk or the mesenteric vessels. An intraoperative biopsy of the mass revealed an uncertain ‘spindle cell tumor’.\nOnce the technical feasibility of the intervention had been established, the splenic vessels were ligated at the superior margin of the pancreas, and the patient was subjected to en-block resection of the mass by distal spleno-pancreatectomy and sleeve resection along the large curve of the stomach. The mass was solid, measured 37 × 24 × 13 cm, weighed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA ten-year-old female patient reported to the author’s clinic with a complaint of painful swelling on the left upper lip region. The patient had first noticed the swelling eight months back, which was initially asymptomatic and gradually increasing in size. The patient later developed pain in the region of swelling over the last two months. The pain was dull and continuous in nature. The patient had no known underlying medical conditions. Family history revealed no significant finding.\nExtra-oral examination revealed a marked asymmetry, with a swelling arising from the left side of the upper lip at the region of canine fossa. The overlying skin appeared normal. The swelling was hard in consistency, had a normal temperature, was tender on palpation and the overlying skin was pinchable. There was no paraesthesia or lymphadenopathy.\nOn intra-oral examination, the swelling appeared ovoid in shape, measuring approximately 1.5 cm x 1 cm. The overlying mucosa appeared normal with no secondary changes (Figure ). On palpation, the mass was hard in consistency and was not adherent to the underlying tissues. The patient elicited tenderness on palpation.\nCT images revealed a well-defined calcified mass of size 11 mm x 6.2 mm x 10 mm seen on the left subcutaneous plane of the upper lip and extending into the adjacent muscular plane. There was no evidence of communication with the maxilla. No adjacent inflammatory changes were seen (Figure ).\nThe management involved the surgical excision of the lesion in toto under local anesthetic solution containing 2% lidocaine HCl with vasoconstrictor (1:100,000 adrenaline). The lip was retracted and the lesion was fixed by pressing a finger against the base of the tumor. An incision was placed over the labial mucosa covering the lesion (Figure ). Once the muscle layer was reached, blunt dissection was performed to relieve the lesion from the muscle (Figure ). The lesion was completely excised (Figure ) and placed in 10% formalin solution and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old Caucasian female presented with a chief complaint of “twisting” right breast pain, associated with the development of yellow-green bruising on the breast. The patient waited approximately 7 to 8 months before obtaining a mammogram and ultrasound of the right breast, which revealed a right breast mass and right axillary adenopathy (Fig. ). A biopsy was significant for cancer within lymphatic vessels in the skin, and the breast tissue showed grade 2 invasive ductal carcinoma. The tumor was estrogen and progesterone receptor- negative (< 1% each) and HER2+ (3+ by immunohistochemistry). During the initial visit, the patient complained of a productive cough with scant sputum production and mid-back pain for 2 months. The patient suffered from fatigue, and experienced night sweats for the past year with no weight loss. The patient admitted to noticing a change in breast shape and size, but no nipple discharge. The initial physical examination was significant for morbidly obese body habitus. The left breast was large, free of masses, and non-tender. The right breast was significantly larger compared with the left, and tender with a rash. A palpable 2-cm axillary lymph node on the right was appreciated. A positron emission tomography (PET)/computed tomography (CT) scan revealed hypermetabolism within the anterior aspect of the right breast consistent with inflammatory carcinoma, right axillary and supraclavicular lymphadenopathy, and several skeletal metastatic lesions predominantly within the cervical and thoracic spine. The primary tumor, regional lymph node, and distant metastasis (TNM) staging was T4b, N1, M1.\nAs indicated for the treatment of metastatic inflammatory breast carcinoma in a premenopausal patient, treatment was initiated with doxorubicin and cyclophosphamide every 2 weeks for 4 cycles. After the first week of chemotherapy, monthly zoledronic acid was added to the treatment regimen due to the presence of bone metastases. Treatment was then fol"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 75 year old woman addressed to Allergology Department of our hospital in January 2014 for recurrent episodes of angioedema since the age of 66, with progressively increased severity and frequency. It was first considered to be induced by treatment with angiotensin-converting-enzyme inhibitors (ACEI) for mild hypertension, but she continued to have angioedema attacks for the next 6 years after discontinuation of ACE, with progressive aggravation during the last year. The previous multiple evaluations by many specialists in other hospitals did not succeed to give a clear diagnosis and treatment.\nThe patient had no relevant medical history and took no medication, except ACEI that was stopped some months after angioedema onset. No relation with possible allergic stimuli could be identified and she had no clinical manifestations between attacks. Angioedema was painful, not accompanied by urticaria or abdominal symptoms, located variably to neck, arms or buttocks, without facial involvement during 6 years. The attacks occurred at weeks or months intervals and usually lasted between 48 and 72 h, irrespective of corticosteroids and antihistamines treatment usually administered. The frequency of attacks had progressively increased from one at 2–3 months intervals to almost weekly during the last year before presentation. The last angioedema attack, determining emergency hospitalization in September 2014, was more severe and prolonged, accompanied for the first time by laryngeal edema and respiratory symptoms. The extended medical evaluation, including complete blood tests for inflammation, allergy, autoimmunity and cancer, were all negative (Table ). Full body CT scan and bone marrow examination were normal. No criteria for lymphoproliferative, mieloproliferative or autoimmune diseases could be found. Measurement of C1 inhibitor (C1INH) in plasma showed significantly decreased level at all measurements, with low activity ranging from 58 to 4% and consta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old man underwent right hepatectomy at previous hospital, due to trauma, in August 2012. At that time, a thoracotomy in the eighth intercostal space was performed for direct closure of the diaphragm. Pooling of right pleural effusion was treated with drainage up to postoperative day (POD) 9. The patient recovered and was discharged on POD 14. In November 2012, he presented with a right DH and strangulation of the ileus of the small intestine. He underwent laparotomy at the same previous hospital, found the defect which was separated from the previously sutured area of the diaphragm, and repaired it.\nIn May 2017, the patient presented to the local hospital with abdominal pain and vomiting and was diagnosed with an intestinal obstruction; an ileus tube was inserted and the patient was referred to our hospital for treatment. Upon admission, the physical examination was unremarkable, and laboratory findings, including complete blood count, erythrocyte sedimentation rate, and biochemical tests, were all within normal limits. Chest and abdominal radiographs revealed colon gas in the right intrathoracic space (Fig. a, b). On contrast imaging, the ileus tube in the transverse colon was observed to be incarcerated in the right intrathoracic space (Fig. c), a finding which was confirmed on computed tomography (CT) of the chest and abdomen (Fig. d). The patient was diagnosed with a DH and underwent laparoscopic hernia repair.\nThe surgical repair was performed with the patient in the left half-lateral decubitus position. Four laparoscopic ports were placed in the abdomen as follows: a 12-mm port at the umbilicus for the scope, two 12-mm ports at the right lateral lesion as working ports, and a 5-mm port at the middle of the upper abdomen used as an assistant. Under laparoscopic view, the transverse colon and small intestine anastomosis were found to be adherent to the right hemidiaphragm (Fig. a), and we proceeded with careful separation"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old man was treated for an esophageal carcinoma. The diagnosis of carcinoma was made when the patient developed a symptomatic, but subacute non-ST-segment elevation myocardial infarction (NSTEMI). Basic diagnostic showed an advanced anaemia with hemoglobin concentration of 5.9 g/dl. Further investigation could explain this by a distal adenocarcinoma of the esophagus (cT3 cN1 cM0 G2). Coronary angiography provided a medium grade stenosis both of the anterior descendant branch of left coronary artery and right coronary artery without any need for intervention. Echocardiographically an ejection fraction of 60% and a low grade diastolic dysfunction could be demonstrated. Given the moderate findings of diagnostics, the myocardial infarction was seen in connection with advanced anaemia. Hence, in interdisciplinary consensus, primary chemoradiotherapy with continuous infusion of 5-FU (1000 mg/qm per day, day 1 – 4) and cisplatinum (60 mg/qm, day 1) including cardiac monitoring was indicated. The therapeutic concept included irradiation of distal esophagus including locoregional lymphatic region with single doses of 1.8 Gy to a total dose of 66.6 Gy. Before the beginning of the therapy the patient's medication was adapted to the new diagnosis of coronary artery disease and myocardial infarction.\nDuring the first cycle of concurrent chemotherapy, after approximately 93 hours of 5-FU-infusion (total applicated dose about 6800 mg), the patient developed an angina pectoris, so that application had to be stopped. Symptoms completely disappeared within few minutes for four hours, then the patient again complained about retrosternal chest pain and ECG showed new tachycardia. The patient was transferred to intensive care unit for monitoring, and further diagnostics revealed new significant ST-segment elevations (Figure ), negative heart enzymes and intermittent atrial fibrillation. Consequently, the patient was treated with digitoxin, the dose of bisoprolol was increased"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old woman with morbid obesity, hypertension, hyperlipidemia, active smoking, and bipolar disorder was evaluated for paroxysmal atrial fibrillation as an outpatient. A transthoracic echocardiogram showed a right atrial mass close to the RA-IVC junction. A transesophageal echocardiogram confirmed the presence of a pedunculated right atrial mobile bilobular mass measuring 2.1 × 1.8 cm, not arising from the interatrial septum with extension into the inferior vena cava (Figures –). A secundum atrial septal defect was also identified. The patient was referred to cardiac surgery for resection of a presumed right atrial myxoma given the possibility of embolization. The intraoperative TEE suggested the presence of one bilobulated mass arising low in the right atrium.\nUsing aortic and bicaval cannulation, a right atriotomy was performed and a discrete 2 × 3 cm mass was removed from the IVC-RA junction near the Eustachian valve. The right atrium was closed and the patient weaned from bypass. The specimen did not appear to be a myxoma, so it was sent for frozen section and interpreted as being ectopic liver tissue. In the interim, a repeat TEE showed an additional discrete 2 × 2 cm mass in the IVC near the hepatic veins. Femoral venous cannulation was then performed to allow for visualization of the IVC below the pericardial reflection. Through the same right atriotomy and using additional suction directly in the IVC, the IVC mass was visualized and resected. Both specimens were interpreted as showing partially encapsulated liver parenchyma with mild steatosis, fibrosis, ductal proliferation, and periductal chronic inflammation, consistent with ectopic hepatic tissue ().\nDespite a brief period of cardiopulmonary bypass, the patient had persistent hypoxemic respiratory failure ascribed to her morbid obesity and underlying lung disease. She also developed extensive left lower extremity deep venous thrombosis from a presumed heparin-induced thrombocytopenia for which she"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 30-year-old Spanish Caucasian man; the third child from healthy and non-consanguineous parents. The first child was a healthy boy and the second child was also a boy who died after two days due to hyaline membrane disease and prematurity. Our patient was delivered by caesarean section after 39 gestational weeks because of macrosomy, with a weight of 4250 g and an Apgar score of three, thus, intensive reanimation was required. Within five hours of life he suffered apnea. He was also hypoglycemic and hypocalcemic, but responded well to treatment without suffering a recurrence. Clinical examination showed bilateral cryptorchidism. During her pregnancy our patient's mother was treated with diazepam towards the end of the pregnancy.\nWhen our patient was 19 months old, his weight and length were two standard deviations below normal. During further development, he showed psychomotor delay and a bilateral convergent strabismus; also he started walking when he was 22 months old. At the age of 10 years, his testes were surgically descended. And at the age of 13 years the strabismus was corrected. At school he had slight learning difficulties, with normal social behavior. He later left studying to become a painter.\nWhen he was 22 years old, he had no facial dysmorphism, he weighed 89 kg, his height was 165 cm and he had a corporal index mass of 32.7. He had hypogenitalism, with a short thick penis (6 cm), and testes of 8 and 10 cc. He has multiple hyperpigmented nevi all over his body, showing no sign of malignancy after biopsy (Figure ). He also had a left vesicoureteral reflux grade III, with normal renal function. His cardiac, audition and fundus of the eye examinations were normal, as was his blood biochemistry. His feet are short with a pes cavus and claw toes (Figure ). At this time, he was referred to a Genetic Laboratory and one sS"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man was referred to Seoul National University Dental Hospital for further evaluation and treatment of bilateral nodular lesions of the neck that had been present for several months. He had visited a local plastic surgery clinic with a chief complaint of a large lesion and pain in the right cervical area. Documentation from the clinic stated that he had only agreed to a drainage procedure and had refused surgery to remove the lesions. According to the patient, the pain and swelling had subsided as a result of the aspiration performed during his visit to the clinic. Additionally, while the patient had an operative history of cardiac septal defect repair performed when he was 10 months old, he gave no family history associated with skin lesions like those that he exhibited.\nPanoramic radiography showed abnormal dentition. First, the deciduous second molars were in a state of prolonged retention and submergence on both sides of the maxilla and the right side of the mandible. Second, multiple permanent teeth were missing, including the maxillary second premolars on both sides and 2 mandibular incisors on both sides and 1 mandibular molar on the right side. Finally, microdontia of 2 maxillary lateral incisors (peg lateral incisors) and 2 mandibular premolars was observed ().\nTo accurately evaluate the soft-tissue lesions, contrast-enhanced computed tomography (CECT) was performed. The images revealed multiple well-defined round to ovoid, smooth or scalloped, nodular lesions with diameters ranging from 2 to 20 mm in the subcutaneous layer on both sides of the cervical region. The internal structure showed fat attenuation on the level of −110 to −100 Hounsfield units (HU) and some lobulation. Additionally, the large lesion of the right upper neck, where the patient experienced the pain, displayed peripheral enhancement with mild swelling, suggesting that it was accompanied by inflammation. The epidermis of that lesion was elevated, and the adjacent platysma mu"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a nonsmoking 53-year-old male with a history of obesity (body mass index 32 kg/m2), type 2 diabetes mellitus, and hypertension who developed fevers, diarrhea, and cough. After 6 days of worsening symptoms, he presented to an outside hospital for rapidly worsening dyspnea and confusion. Upon arrival, he was found to have profound hypoxemia with an oxygen saturation of 33% by pulse oximetry. He was emergently intubated and admitted to the intensive care unit (ICU). Initial chest X-ray demonstrated mild bilateral pulmonary infiltrates (). He was started on broad-spectrum antibiotics including vancomycin, piperacillin-tazobactam, and doxycycline. While in the ICU, his condition continued to worsen and he remained profoundly hypoxemic despite escalating ventilator support. Within five hours of hospital admission, he was on maximal ventilator settings, in the prone position, chemically paralyzed, and on inhaled epoprostenol. Despite these interventions, the patient remained severely hypoxic with oxygen saturation of 70% and PaO2 of 48 mmHg. Our institution was contacted to evaluate for initiation of VV ECMO. The patient was transferred to our surgical ICU still in a prone position and paralyzed.\nOn arrival to our surgical ICU, approximately 9 hours after his initial hospital presentation, his oxygen saturations were found to be between 40 and 60%, and he was increasingly hypotensive requiring norepinephrine and vasopressin to maintain an adequate blood pressure. His arterial blood gas identified a respiratory acidosis with a pH of 7.29 and elevated pCO2 to 59 mmHg. His PaO2 : FiO2 ratio was 36, consistent with severe ARDS. Initial management in our ICU included increasing PEEP to 24 cm while continuing 100% FiO2. Epinephrine was added as a third vasopressor for worsening hypotension. Despite these interventions, the PaO2 remained low at 44 mmHg and his oxygen saturation remained <70%. A bedside echocardiogram was obtained and identified globally diminished"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old man was referred to the opthalmology clinic with a history of a mass in the left upper eyelid that had been present for four years. Visual acuity was 7/10 for the right eye and 6/10 for the left eye, anterior segment examination revealed grade 2 nuclear cataract for the right eye and grade 3 nuclear cataract for the left eye. Motility was bilateral normal with no diplopia. Levator functions were bilateral normal, except there was a minimal mechanical ptosis for the left eye. There was also a subcutaneous mass on the left forearm. Systemic check-up relevead no other illness or malignancy. On clinical examination, there was a subcutaneous, firm and round mass located on the central left upper eyelid, which was non-tender to palpation. It was inconspicuous on inspection. There was no eyelid movement restriction but a feeling of friction on the superior orbit during lid movement. Ultrasonography showed a homogeneous echogenic and well defined mass in the anterior orbit. No internal vascularity was seen. An excisional biopsy was taken through the crease of the upper eyelid under local anesthesia. The lesion was 9x7x7 mm in diameter and located 15 mm superior to the eyelid margine and located under the orbicularis muscle. During the removal operation, it was noted that the lesion was stuck to the tarsal border from its base. The mass was removed completely and its location was cauterized while preserving the underlying tarsal plate (Figure 1 ). Histologically, this nodular lesion, which was composed of mature adipose lobules with a patch of proliferating vascular components and well-circumscribed by fibrous connective tissue, was classified as angiolipoma (Figure 2 ). Postoperatively, visual acuity was 7/10 for the right eye and 6/10 for the left eye, with no change in the anterior segment examination. The patient did not have any motility restrictions and there was no recurrence during follow-up for the next 12"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 39-year-old female with a history of obesity and tobacco use presented to the emergency department with a 10-day history of increased swelling, redness, drainage, and pain of the right breast and upper abdomen. The patient reported associated fever, chills, nausea, and emesis. There was no history of trauma or previous surgery. She also stated she was reluctant to visit her primary care physician or any emergency department when her symptoms began due to anxiety related to COVID-19 viral exposure.\nOn clinical examination, the right breast was noted to have a 12 × 14 cm area of skin sloughing along the inferior inner aspect of the breast. A necrotic open wound was also seen within the lower outer quadrant with foul-smelling drainage surrounded by edema, erythema, and crepitus extending onto the right anterior abdominal wall (Figures and ) The patient was noted to be hypotensive with mild tachycardia.\nPertinent laboratory findings revealed a leukocytosis of 16.9 × 109/L with neutrophilia, thrombocytosis of 608 × 109/L, and mild hyponatremia of 133 meq/L. Mild anemia was present, but renal function and lactic acid were found to be within normal limits.\nA chest computer tomography (CT) ordered by the emergency room physician revealed the right breast wound with several locules of gas within the superficial subcutaneous tissues of the right lateral and posterior breast with minimally increased attenuation of the subcutaneous tissues. (Figures –) These findings were consistent with a necrotizing soft tissue infection, and general surgery was consulted. After surgical evaluation, a decision was made to proceed with emergent surgical intervention to provide source control. Prior to surgery, resuscitative intravenous fluids were administered in addition to vancomycin, clindamycin, and aztreonam, due to an unknown reported allergy to cephalexin.\nThe patient was taken to the operating room for an emergent wide excision and debridement of the infected tissue within the inferi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old boy presented to a retina specialist with symptoms of nyctalopia and decreased vision. He was referred by an optometrist after an evaluation that included an abnormal optical coherence tomography (OCT) scan. He was followed since the age of two by the optometrist and his examination was limited to refractive evaluation prior to this scan. His parents became concerned when he could not see objects directly in front of him and he frequently ran into household objects. They noted that he even ran into a tree while at a birthday party at the age of six, and has been followed by his primary care physician for multiple complaints. This history prompted further workup by the optometrist.\nThe patient had a relatively complex medical history, starting during gestation. During pregnancy, his mother had oligohydramnios and decreased fetal movements. At birth, the patient had joint laxity with associated hypotonicity. Shortly after an in-hospital birth, he required resuscitation due to a nasolacrimal cyst obstructing his airway, which was subsequently removed. Both physical and mental development were delayed, as he did not sit until eight months of age, the cruise until 14 months, and walk until 17 months. He had a history of growth hormone (GH) deficiency and delayed bone age, which, after discussion of the risks and benefits with the parents, were not treated with GH replacement. MRI of the brain at age two for GH deficiency revealed mild vermian hypoplasia among other non-specific findings. He had also had frequent illnesses, particularly ear infections with high fevers. He recently failed his hearing test at school but had not yet had a formal hearing evaluation.\nOn physical examination, visual acuity was 20/50 right eye (OD) and 20/40 left eye (OS) with an intraocular pressure (IOP) of 18 and 19, respectively. His refractive error was -2.25 OD and -2.50 OS. An informal illustr"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old heavy smoker, otherwise healthy male, presented with 3 weeks of gallstone pain. After a couple of admissions where the patient was treated with a non-selective COX inhibitor (Todolac 600 mg daily) for ∼2 weeks, he was scheduled to outpatient laparoscopic cholecystectomy.\nDissection of gallbladder was complicated by blood oozing from the liver. It was treated successfully, and haemostasis established. A drain was placed to monitor further bleeding episodes. The drain was removed on the second postoperative day as the output was negligible. Treatment for postoperative pain included 10 mg morphine tablet on need with a maximum dose of six times, Paracetamol tablet 1000 mg four times per day and Ibuprofen 400 mg three times per day.\nOn the evening of the second postoperative day, the patient complained of increasing diffuse pain. Vital signs were normal and stable. Blood tests were normal. He was observed overnight, and the following morning the situation worsened with rebound tenderness and rigid abdomen. The situation was rapidly deteriorating, thus an immediate surgical intervention was indicated without diagnostic imaging. An emergency diagnostic laparoscopy revealed a diffuse peritonitis due to perforation of a diverticulum in colon sigmoidium. The abdomen was irrigated, and two drains were placed in both the right and left sides according to the department's guidelines. The following day, a leakage around the drains was noted, and a brilliant blue was given. A blue-coloured output in the drains confirmed the suspicion of perforation. The patient's condition was deteriorating, necessitating a new diagnostic laparoscopy that showed massive intraperitoneal fibrin plagues and terminal ileum adherent to the pelvis most probably due to the inflammation of the re-perforated colon sigmoideum. Resection of the diverticulosis-bearing segment in colon sigmoidium ad modum Hartmann was performed, and the patient was treated with broad-spectrum antibiotics. The po"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present a case of a 58-year-old female patient with a large recurrent ventral hernia. Six years before, the patient had been operated on for the umbilical hernia, with the simple repair without a mesh. The patient was an active smoker who suffered from morbid obesity with a body mass index of 43 kg/m2 and COPD as comorbidities relevant for this case report.\nThe patient was introduced to the surgeon during hospitalization at the gastroenterology department where a diagnostic workup due to a clinical picture of chronic small bowel obstruction was conducted. While taking the anamnesis, the patient reported frequent abdominal cramps, swelling, and pain in the area of the hernia that had intensified in the last few weeks. The physical examination revealed a large irreducible ventral hernia in the lower abdomen that was quite painful on palpation, but soft and, at that time, without signs of incarceration or strangulation. Taking into account the clinical picture with threatening hernia incarceration, the surgeon did not opt for preoperative optimization of the patient in terms of smoking cessation and starting a weight loss program but made an indication for semielective surgery.\nOn operative procedure, greater omentum, part of the transverse colon, and a cluster of small bowel loops with signs of chronic obstruction were found as hernial content. After adhesiolysis hernial content was reduced into the abdominal cavity. Hernial defect measuring about 7 cm in diameter and about 15 cm in the vertical line with significant rectus diastase in the supraumbilical part of the abdomen was revealed. Using the Rives-Stoppa technique a wide retromuscular space was created. Lateral dissection boundaries of this space were perforating neurovascular bundles in the area of the lateral edges of the rectus muscle on both sides. The posterior fascia was easily closed using also a portion of the hernia sac to bridge the defect between the posterior rectus sheaths. A 30 × 25 cm polypropy"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old female patient came with a complaint of massive, painful, and swollen with mobile upper anterior teeth with detached mucoperiosteum from the palatal mucosa since 1 month []. The swelling started slowly and attained the present size. She was associated with fever since 2 days and also complains of discomfort and unable to eat since 1 week. Patient was from a low socioeconomic back ground, residing in a rural area. She had a history of mouth breathing with poor generalized periodontal status. The swelling was extending from infra-orbital region bilaterally to the entire upper lip. Skin over the swelling appeared stretched, erythematous and there was localized rise in temperature.\nIntraoral examination revealed poor oral hygiene with severe halitosis. Swelling may be seen involving the lips, anterior portion of hard palate. Palatal flap in the premaxillary region was necrotized, detached from the underlying bone. Computed tomography revealed that there was no involvement of maxillary sinus, nasal cavity which was suspicious for involvement. Maggots were seen between the palatal bone and flap. The case was posted for surgery under local anaesthesia after taking informed consent. Turpentine oil was placed in the wound area during which maggots were coming out [Figures , and ]. Around 25-27 maggots were removed. Based on the clinical findings and the presence of maggots the provisional diagnosis was made as myiasis. The larvae were preserved in 40% formaldehyde and sent for pathological investigation. On pathological examination the diagnosis of larvae of Musca domestica was confirmed.\nComplete treatment was executed with Taxim 1 g, Metranidazole 100-ml IV injections along with intramuscular injection of Voveran injections for 10 days faster and better recovery. Postoperative healing was uneventful in the wound area. A week later patient discharged and was asked to report back after a period of 6 months to evaluate the healing status and the healing was unev"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old man presented with cardiac arrest after choking on food at home. He had been suffering from dementia and right-sided weakness after a traumatic intracranial hemorrhage 7 years prior. He received immediate bystander CPR and was brought to our emergency department (ED). Asystole was documented at admission, and the resuscitation attempt was continued in the ED. After endotracheal intubation, a TEE transducer was inserted to find the cardiovascular cause of cardiac arrest. TEE revealed no cardiac contraction. No structural cardiac abnormality or pericardial effusion was noted. A focal separation of the intimal layer at the anterior wall of the descending thoracic aorta (DTA) was seen 10 cm from the distal portion of the aortic arch (). The DTA was compressed and deformed repetitively whenever the chest was compressed (). After 19 minutes of resuscitation, the patient regained spontaneous circulation and the TEE transducer was removed. His systolic blood pressure rose to 130 mmHg. Ten minutes after restoration of spontaneous circulation (ROSC), his systolic blood pressure dropped to 80 mmHg. Transthoracic echocardiography showed a newly developed pericardial effusion with diastolic collapse of the right ventricle, suggesting cardiac tamponade. Bloody pericardial fluid was drained during emergency pericardiocentesis. Follow-up TEE was performed to investigate the origin of pericardial effusion. TEE revealed an intimal flap, not seen on the first TEE, in the DTA (). The intimal flap was observed between the distal portion of the aortic arch and 11 cm down from the aortic isthmus ( and , ). Thoraco-abdominal angiography with a multi-detector computed tomography (CT) scanner (Brilliance 64; Philips Medical Systems, Cleveland, OH, USA) revealed aortic dissection of the DTA with no involvement of the ascending and abdominal aorta (). Bloody pericardial effusion was thought to be one of the complications from CPR because there was no evidence of dissection of the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe subject described in this case report is a 21-year-old male who suffered a concussion 356 days prior to the physical therapy evaluation. The injury occurred during a fall out of a moving golf cart onto his left shoulder/neck region. The subject reported loss of consciousness and post-traumatic amnesia following the injury. The subject was taken to a local emergency department and CT scan results appeared negative for cerebral bleeding but identified a left temporal bone fracture not requiring medical intervention. The subject received no education on symptomology or symptom duration, and no referral or follow-up was scheduled at the time of discharge. The subject reported a history of four previous concussions, three of which were sport-related, but otherwise had no co-morbidities or significant past medical history. Only minor residual symptoms from his previous concussions were reported that all gradually resolved. The subject had constant, persistent symptoms since the injury that impaired his abilities in school as well as his social life and had restricted athletic or recreational activities, reducing his overall quality of life. The subject visited his primary physician a few weeks prior to evaluation; his cervical spine was cleared via radiographs, and he was referred to a metropolitan outpatient physical therapy clinic.\nThe subject was given the Rivermead Post-Concussion Questionnaire (RPQ) to assess symptomology. The RPQ is a subjective, self-report measure that encompasses 16 items, each of which is scored from 0-4 in increasing severity, assessing separate cognitive, emotional, and somatic physical factors. The RPQ demonstrates high test-retest and inter-rater reliability for both total score and individual items via spearman rank correlation coefficients (r = 0.91, r = 0.87 respectively). The subject’s chief reported symptoms during the initial evaluation were neck pain and stiffness, bilateral radicular symptoms that were worse in the left shoulder"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year old, asymptomatic woman was admitted to our hospital by her family doctor after receiving a chest-x-ray during routine clinical examination. The x-ray showed a mediastinal mass overlapping the aortic arch region (Fig. ). For verification a computed tomography (CT) was performed and revealed incidentally a type B dissection, which was most likely chronic without information of the index date, originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm (Fig. ). The left renal artery, the coeliac trunc and the main part of the superior mesenteric artery branched from the false lumen without a sign of malperfusion of the organs. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Before intervention the patient got a blood pressure adjustment by ACE inhibitor. Betablocker was not necessary because of a resting pulse under 60 beats per minute. For neurological online monitoring, sensitive and motor evoked potentials were monitored. Spinal drainage was installed 1 day before the procedure. Surgical access was carried out through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space (Hemi-Clemshell). Simultaneously to the preparation of the aneurysm, partial cardiopulmonary bypass was installed in the left groin by cannulation of the femoral artery and vein under echocardiographic guidance. During selective ventilation of the right side, the left lung was mobilized by transsection of the Ligamentum pulmonale and preparation of the perianeurysmatic tissue and adhesions. After identification and preparation of the recurrent and phrenic nerve and the supraaortal branches, the descending aorta was clamped and a distal anastomosis performed with a straight graft (20 mm). The visceral arteries partially branched from the false and true lumen without a sign of malperfusion. Before the final distal anastomosis, we performed a fenestration of the d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nPatient B was a 74-year-old woman with a history of breast cancer that had been treated with curative intent 10 years earlier. She was referred with shortness of breath. A CT scan showed multiple lung nodules. In addition, a PET-CT scan showed 4 PET-positive lesions in the right lower lobe, as well as 2 nodules in the right middle lobe and an enlarged PET-positive lymph node in station 7, which were suspicious for metastatic breast cancer lesions. Mammography of the right breast showed no local recurrence of the tumor. EUS-FNA of station 7 was performed using a 19G needle. Directly after the procedure, the patient experienced pain and was admitted for observation. A chest X-ray showed subcutaneous emphysema on the left side of the neck. A non-contrast CT scan showed pneumatosis in the mediastinum, and pleural effusion and atelectasis on both sides (). The laboratory results demonstrated a CRP of 600 mg/L and a WBC count of 22×109/L. The patient was placed on a fasting regimen and intravenous antibiotics were started. The patient experienced clinical deterioration and was admitted to the intensive care unit (ICU) 2 days after the EUS-FNA. She was septic, with a blood pressure of 90/50 mm Hg, a regular heart rate of 110 beats/min, a temperature of 37.7°C, and a respiratory rate of 21 breaths/min. Upper gastrointestinal endoscopy revealed a laceration of the esophagus at 27 cm from the incisor teeth. Consequently an 8-cm colon stent was placed endoscopically. The next day, a chest tube was placed in the left pleural space, draining 400 mL of turbid fluid immediately. Then, u-VATS debridement of a right-sided thoracic empyema was performed and 2 chest tubes were placed in the posterior mediastinum. Postoperatively the patient returned to the ICU. On the following days, the drains kept producing excessive turbid fluid. On day 4 after surgery, upper gastrointestinal endoscopy was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old Chinese woman presented with a history of abdominal pain for 3 days. The patient developed paroxysmal abdominal pain in the past 3 days, accompanied by nausea, bloating and acid regurgitation. The pain was limited to the middle and upper abdomen, and anal exhaust and bowel movements were normal. The symptom did not become aggravated during the 3 days. She denied the symptoms of steatorrhea. The patient has had type 2 diabetes for more than 20 years and used a drug regimen to control the DM, but the patient complained that her fasting blood glucose was still poorly controlled. She had no other diseases. Her family medical history was unremarkable.\nNo positive signs were found in the physical examination. The results of the hematological examinations were normal. Only the blood sugar (11.7 mmol/L) and triglycerides (4.3 mmol/L) were abnormal in the blood biochemical examination, and no signs of infection were found. No abnormal results were observed from the electronic gastroscopy and electronic colonoscopy, which were performed 2 months ago. An enhanced abdominal CT scan revealed slightly increased gastrointestinal contents and no signs of acute abdominal (obstruction, perforation, etc.) or celiac vascular disease but found that the patient did not have the body and tail of the pancreas (Fig. a-b).\nSo the preoperative diagnosis is gastrointestinal dysfunction, agenesis of the dorsal pancreas, and pancreatic exocrine insufficiency were not excluded. Mosapride and trimebutine were used to improve gastrointestinal function, and 0.6 g pancreatin enteric-coated capsules were given to the patient before each meal continuously to supplement her pancreatic exocrine function. And Intermediate effect insulin were used to help control the fasting blood glucose.\nThe patient returned to the gastrointestinal surgery clinic 1 week later, complaining that although the symptoms were significantly relieved, but there was still mild postprandial bloating. Here fasting blo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old Mexican man presented with a three-month history of a skin rash and recurrent blisters. He was a resident at a skilled nursing facility and had multiple medical problems including ankylosing spondylitis, chronic pain syndrome, cognitive impairment, dysphagia with a feeding gastrostomy tube, epilepsy since childhood with occasional seizures, manic depressive disorder, and weakness. His long-term seizure medications included carbamazepine, phenobarbital, and phenytoin; citalopram had been added three years ago for the management of his psychiatric disorder.\nInitially, blisters appeared on both of his feet. Within a month, he developed a lesion on his arms and legs. His physicians initially suspected a scabies infestation and he was treated with permethrin 5% cream; however, his skin condition persisted. Subsequently, a skin infection was also considered and he received several courses of oral antibiotics without improvement.\nThree months after the onset of his cutaneous condition, he was brought to see a dermatologist for an evaluation. Cutaneous examination showed hemorrhagic blisters on both the dorsal and plantar surfaces of his feet and toes (Figure ). There were no mucosal lesions. Erythematous plaques were present on his arms and legs (Figure ); biopsies from a left thigh plaque and adjacent skin were performed for routine staining and direct immunofluorescence, respectively. Initial management included soaks to feet with aluminum acetate solution and application of triamcinolone 0.1% cream to the lesions on his body; both interventions were to be done three times daily.\nMicroscopic examination of the hematoxylin and eosin-stained specimen showed eosinophilic spongiosis (showing eosinophils being present in the widened spaces between the epidermal keratinocytes), marked edema in the papillary dermis, and abundant eosinophils with some lymphocytes present in the inflammatory infiltrate in the upper dermis. These changes were consistent with those of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 57-year-old female with medical history of diabetes and hypertension was transferred to our facility with complaints of high-grade fever for the past 3 days. There was no other significant associated history to explain the probable cause of fever except that she had a history of fall about 2 weeks ago. She had taken initial treatment at a primary health center and was ambulating well at home. On arrival at the emergency room, she was conscious and oriented, febrile, hypotensive, and with minimal respiratory distress. An initial diagnosis of sepsis due to the unknown source was considered and managed per protocol with fluid resuscitation, cultures, and imaging to identify the potential source and broad-spectrum antibiotics. Complete hemogram revealed leukocytosis with toxic neutrophil granulation. Renal, liver, and coagulation panels were within normal limits. Electrocardiogram revealed right axis deviation, S1Q3T3 pattern, and echocardiography did not suggest right heart strain. Lower limb venous Doppler and compression ultrasound did not show any evidence of lower limb deep venous thrombosis (DVT). Computer tomography (CT) pulmonary angiogram was performed which ruled out pulmonary embolism (PE), and she was initiated on unfractionated heparin for DVT prophylaxis.\nBlood cultures grew methicillin-sensitive Staphylococcus aureus (MSSA), and the antibiotic was appropriately de-escalated, and the patient was gradually improving. Rest of the cultures did not reveal any bacterial growth and screening for tropical infections was also negative. CT abdomen revealed a fracture of body of D8 vertebra. In view of MSSA bacteremia, transesophageal echocardiography was performed which did not show any features of infective endocarditis.\nSubsequently, during the course in hospital, she developed acute left lower limb swelling with pain and redness. Repeat venous Doppler of the left lower limb revealed acute DVT extending from the left internal iliac vein to popliteal vein. Repea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-month-old female was seen in our emergency department for evaluation of a congenital infection. During pregnancy, mother was routinely screened for human immunodeficiency virus (HIV) and syphilis in the first trimester and tests results were negative. Throughout the entire pregnancy, mother had regular prenatal care at scheduled visits. She presented to her obstetrician at 28 weeks gestation with generalized skin lesions on palms and soles, as well as a painless lesion in her genital area. At both the 28-week and 36-week prenatal visits, she was referred to dermatology, and mother was subsequently treated with topical hydrocortisone cream. No further workup was done. Two months after delivery, mother followed up with her primary care provider due to lack of resolution of skin lesions. At that time, a sexually transmitted infection was suspected and mother was tested for syphilis, and rapid plasma reagin (RPR) came back positive at 1:128. Infant was referred for further workup.\nOn presentation, physical exam of the infant was significant for desquamation of the skin on the bilateral soles of her feet, pinpoint pink dots on the soles of her feet bilaterally, and a erythematous skin lesion 1 × 1 cm on her right medial knee. Mother did report that infant was not moving her left leg. Infant did not exhibit any neurological deficits on physical exam. Significant laboratory findings included slight anemia, hemoglobin of 8.9 g/dL, and hematocrit of 26.5%. Further workup for congenital infection was done including lumbar puncture. All findings in the cerebrospinal fluid in this patient were within normal limits, including normal cell count, glucose, and protein. Venereal disease research laboratory (VDRL)tests was negative as well. Long-bone radiographs were also done, which were significant for osteochondritis and periostitis. This was seen in the medial metaphysis of the proximal left tibia and distal left femur (), the metaphysis of the medial right proximal tibia, an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old right-handed retired male teacher was referred to our clinic with an inability to flex the interphalangeal (IP) joint of his left thumb. One week previously, he was gardening. He had flexed his thumb around the stem of a firmly embedded weed, and as he pulled hard, he felt a sudden pop in his left thumb and found he could not flex his left thumb. Although he often played saxophone, he could not recall any specific episode of pain or discomfort within the left thumb. There was no evidence of any history of rheumatoid or other inflammatory arthritis and his rheumatoid serology was normal.\nUpon examination, no specific painful swelling in the left thumb was detected. However, the patient was unable to actively flex his thumb at the IP joint (Fig. ). He had full passive range of motion of IP joint.\nInitial plain left thumb radiographs revealed no bony abnormalities resulting in secondary tendon rupture. Magnetic resonance imaging (MRI) revealed complete FPL tendon rupture at the level of the distal one-third of the proximal phalanx and the proximal end of the ruptured tendon was retracted to the level of the metacarpophalangeal (MP) joint (Fig. ).\nWith the patient under general anesthesia, the FPL tendon was explored through a volar zig-zag incision. During the operation, the FPL tendon was found to be ruptured completely. Gross examination revealed a slightly yellowish denaturated tissue at the distal end of the ruptured tendon and the gap of the ruptured ends was interposed by a fibrous tissue (Fig. ). No bony prominence was observed throughout the excursion of the tendon. We excised the denaturated tissue from the distal end of the ruptured tendon and sent it for histological examination. FPL tendon was repaired primarily via modified Becker method (Fig. ). Histopathological examination revealed normal vasculature in the tendon tissue and degenerative changes associated with lipid deposits in"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was an 82-year-old male who was scheduled for a robotic left lower lobectomy for the resection of a biopsy-proven squamous cell lung carcinoma. He had a medical history of hypertension controlled with multiple medications; a 40-pack-year history of tobacco abuse, with a 20-year history of abstinence; and a prior history of melanoma of his left upper extremity, which was successfully resected.\nStandard American Society of Anesthesiology (ASA) monitors were placed and preoxygenation was performed; general anesthesia was induced with propofol, followed by the administration of muscle relaxant and the placement of a left-sided, double-lumen endotracheal tube. Additional venous access and arterial line placement occurred concurrently while the correct placement of the endotracheal tube was confirmed by bronchoscopy. The placement was then reconfirmed after the patient was situated in the right lateral decubitus position. The left lung was isolated and deflated, and the surgeon proceeded to place ports to facilitate the robotic resection as follows: the sixth intercostal space in the anterior axillary line, the third intercostal space in the anterior axillary line, and the ninth intercostal space in the posterior axillary line. The surgical procedure continued uneventfully from an anesthesia perspective with level 7 and 10 lymph node dissections, extensive lysis of adhesions and pericardial and pleural fat to facilitate visualization, and a left lower lobectomy. Surgical blood loss was estimated at less than 50 cc. Chest tubes were placed through the sixth and ninth intercostal port incisions. A bolus of 30 cc of 0.5% bupivacaine was administered via a catheter placed at the tenth intercostal space in the posterior axillary line for an elastomeric pump ball to infuse local anesthesia for post-operative pain management. Within 15 minutes of this, the patient began to experience hypotension, requiring incrementally increasing doses of vasopressors. Over the cour"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-years-old male with no comorbidities presented with nonlocalized anterior knee pain since 3 years. The pain was only on squatting and climbing up and down the stairs. He reported no pain on regular daily activities. The body mass index was 23.4. Clinical examination was unremarkable, except for a significant bump on the superior lateral aspect of the right knee. Before the presentation, he had been treated with anti-inflammatory, physiotherapy, and local steroid infiltration in the knee with failure to relieve his symptoms.\nOn the current presentation, plain radiographic study anteroposterior (AP, lateral and skyline views) revealed a bipartite patella fragment. MR imaging confirms the absence of any other significant pathology []. There is no bony edema on the fragment. Squat stress skyline view was done and demonstrated separation of fragment []. However, in the absence of direct tenderness on the superolateral aspect, equivocal radiological findings, and high suspicion, another test was performed.\nThe test performed to the best of my knowledge had not been reported earlier. The pull of the lateral structures causes a repetitive strain and relative motion on the synchondrosis and generates pain, forming the pathophysiological basis of this test. The pain arising from the synchondrosis was blocked using the 2% lidocaine infiltration. The test was performed using an image intensifier using three (26 gauge, 13 mm) Dispovan needles. The three needles were inserted in the synchondrosis using an image intensifier and checked in AP and skyline views. Inject 0.75 ml lidocaine 2% in all three needles []. After a latent period, the patient was allowed to do pain-generating activities, which in this case was squatting and stair climbing. The absence of pain in performing the activities was considered to be a positive confirmatory test.\nThe patient underwent the test as described with a positive result. The surgical diagnosis was achieved, and arthroscopic excision of th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a 72-year-old Caucasian male with a past medical history of hepatitis C-related cirrhosis (status post-liver transplantation 14 years prior), with recurrence of HCV genotype 1a, untreated, who was admitted three times over 3 months for recurrent episodes of small bowel obstruction. During the first two admissions, the patient presented with early satiety, abdominal pain, and inability to pass flatus or have bowel movements, which led to him being treated conservatively with nasogastric tube decompression and intravenous fluids with clinical improvement. The patient presented 4 days after discharge from his second hospital admission with similar abdominal pain complaints, decreased appetite, and increased abdominal distention. The patient denied nausea, vomiting and was able to pass flatus. However, he had no bowel movements for three days. His white blood cell count, electrolytes, and liver function tests were all within normal limits. CT of the abdomen and pelvis showed dilated loops of small bowel concerning ileus versus small bowel obstruction (). Due to the failure to improve symptoms after 9 days from conservative management, the patient was taken for exploratory laparotomy with lysis of adhesions and peritoneal biopsy.\nIntraoperatively, it was noted that there were chronic fibrinous inflammatory changes to both the bowel and the mesentery. There was a trabeculated rind covering all of the bowels. The thickened bulky adhesions covered the terminal ileum, with a few bands at both the terminal ileum and the cecum. All bowel proximal to the terminal ileum’s thickened rind area was dilated, and a small amount of the ileum, and the large bowel, were decompressed. Some of the bands and adhesions near the ileocecal junction were taken down. The surgeon stated they could not safely dissect the peritoneum from the small bowel; therefore, the procedure was terminated without significant lysis of adhesions ().\nInterestingly, the peritoneal biopsy results revealed"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman was hospitalized at a local hospital for pelvic mass found by physical examination in November 2017. Exploratory laparotomy was performed at that hospital immediately. Intraoperatively, a free mass at approximately 6 cm × 5 cm × 5 cm in size was observed at the bottom of the right pelvis and adjacent to the uterosacral ligament without any other abnormalities. Due to the examination of frozen sections showing germ cell tumor and consultation with relatives of this patient, pelvic mass resection, biopsy of bilateral ovaries and partial omentum resection were performed. Postoperative pathology reported yolk sac tumor of the pelvic mass, normal biopsy from ovaries and normal tissue of omentum. From December 2017 to June 2018, six courses of chemotherapy with BEP regimen were administrated for her. After five cycles of chemotherapy, serum tumor markers of the patient were all normal, but her alanine aminotransferase (ALT) was elevated nearly to 600 IU/L. She was treated with hepatoprotective therapy for 20 days before completing the sixth cycle chemotherapy. Unfortunately, the serum AFP increased again after sixth cycle of chemotherapy.\nDue to increase of serum AFP, the patient was admitted to our center in July 2018. Positron emission tomography–computed tomography (PET/CT) demonstrated a round-like mass at the right pelvis accompanied by increased [18F]-fluorodeoxyglucose (FDG) metabolism. CT scan also indicated a 2-cm mass at the right pelvis (\n). Considering relapse of the disease, the patient was hospitalized at our department for a second surgery. During the operation, a dumbbell-shaped, hard, and smooth mass at approximately 3 × 2 × 1.5 cm in size was found at the posterior lobe of right broad ligament and near the uterus. No abnormalities were observed at any other sites of the pelvic and abdominal cavity. After mass resection and right adnexectomy, frozen section was examined and demonstrated yolk sac tumor of broad ligament and normal right"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is an 18-year-old boy not known to have any medical illness previously, who was referred to the outpatient department from another hospital after 3 months history of seizures. Seizures started with blurring of vision and proceed to right sided head deviation and tonic posturing of the right upper limp which progress to generalized tonic-clonic seizures. The episodes are followed by loss of consciousness and postictal suboccipital and frontal tension headache. There was no history of fever, loss of weight, trauma, or any sensory/motor neurodificit. Family history was unremarkable, with negative past surgical history. All general and local physical examinations were done and all were within normal range. There were no physical findings or family history in favour of neurofibromatosis. Brain MRI with contrast was done and showed right parieto-occipital cortical and subcortical mass lesion measuring about 1.5 x 1.5 cm that has a low signal intensity on T1 and intermediate signal intensity on T2 and FLAIR with intense enhancement postgadolinium administration mainly peripherally with few small susceptibility artefact on T2 associated with significant vasogenic oedema and mass effect on the adjacent sulci ().\nThe radiological impression with the above description was most likely representing granulomatous infection (TB) or metastasis. Although a preoperative diagnosis could not be clearly established, the tumor was surgically removed through a right occipital craniotomy. The dura was incised and small area of discoloration was noted. Cortical dissection was done, with multiple pieces for frozen section, which was diagnosed later as suggestive of schwannoma, differential diagnosis meningioma. The tumor was encountered 2mm in subcortical area, which was firm, fibrous in content, yellowish in colour, and resembling meningioma. Postoperatively, the patient did not have any new neurological deficit, and he was discharged 1 day postoperatively in stable condition to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 24-year-old female patient presented to our clinic with complaints of blurred vision and pain in her left eye for 4 days. She reported that at another medical center, her intraocular pressure had been measured as 38 mmHg and she had been treated with intravenous mannitol, oral acetazolamide, and topical antiglaucomatous therapy for glaucoma. On ophthalmologic examination, her BCVA was 10/10 in the right eye and 5/10 in the left eye. Intraocular pressure was 12 mmHg in the right eye and 14 mmHg in the left eye. Examination findings were normal in the right eye. In the left eye, diffuse, medium-sized brownish-gray keratic precipitates (KP) were observed in the corneal endothelium () and 2+ cells were noted in the anterior chamber. Dilated fundus examination of the left eye revealed a small amount of vitreous cells and 1+ haze. There was pronounced hyperemia and swelling of the optic disc (). There was peripheral vascular sheathing associated with vasculitis and a focus of hemorrhagic necrotizing retinitis in the superotemporal periphery (), with multiple smaller foci located more peripherally (). The patient reported no systemic symptoms or history of systemic disease.\nThe patient was diagnosed with ARN based on clinical findings and treatment with prednisolone acetate drops hourly, cyclopentolate hydrochloride drops 3 times daily, and intravenous acyclovir 750 mg, 3 times daily was initiated for anterior segment inflammation. Fundus fluorescein angiography (FFA) examination was recommended to confirm clinical findings, but the patient did not consent to the procedure. On day 3 of treatment, the patient decided she did not want to remain hospitalized and undergo the 14-day intravenous acyclovir treatment plan, and her therapy was changed to oral acyclovir 2 g, 3 times daily. On examination performed that day, the patient’s corrected visual acuity was 5/10 in the left eye and fundus examination revealed no further progression of the retinal lesions. On day 4 of treat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old man with a past surgical history of C5–C7 anterior arthrodesis for cervical fracture 17 years ago was found on the floor after an unwitnessed ground-level fall, resulting in a head strike. He was taken to the local hospital in an Aspen collar with a GCS of 15 and no neurologic deficits. Routine ECG and laboratory evaluation was unremarkable except for elevated serum alcohol level. Full cervical spine computed tomography (CT) scan was performed which showed an Anderson and Montesano classification (20) type III left occipital condyle fracture (), a Levine and Edwards classification (21) type III (Jefferson) fracture with mild lateral subluxation of bilateral C1 masses (), and an asymmetric widening and slight anterior subluxation of the right AOJ (). A head CT was performed which showed no acute intracranial abnormalities.\nThe patient was immediately transferred to a level I trauma center for further management. In the emergency department, he reported severe midline neck pain, worse with movement, and unchanged paresthesia to bilateral upper extremities which he states is his baseline. Physical exam was unremarkable except for a right forehead hematoma with overlying abrasions and tenderness to palpation over the midline posterior neck. He exhibited full strength and unchanged baseline sensation to all extremities. He denied bowel or bladder incontinence and had strong rectal tone and intact perianal sensation. Through his clinical course, he became increasingly altered and agitated, refractory to medication. He was unable to maintain spinal precautions due to his agitation, and in an attempt to protect his cervical spine, he underwent endotracheal intubation.\nMRI of the cervical spine was performed and showed ligamentous injury at the craniocervical junction (CCJ) (Figures and ), asymmetric left odontoid-lateral mass widening, widening and subluxation of the right AOJ (), and edema of the paravertebral soft tissues around the fracture. CT and MRI esta"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 54-year-old man was referred to our electrophysiology laboratory because of dizziness and dyspnea. He was diagnosed with leiomyosarcoma of the right lower leg and received wide excision at another hospital 5 years ago. Later, he underwent several operations due to recurrent pulmonary lesions. Histological examination confirmed metastasis of leiomyosarcoma. Recently, the patient was in good physical condition for 2 years and no abnormal findings were detected on the surface electrocardiography (ECG) 2 years prior. However, the current ECG revealed complete AV block and idioventricular escaped rhythm of bifascicular block morphology suggesting infrahisian block (). Chest computed tomography revealed multiple pulmonary lesions and significant thickening of interventricular septum. The patient underwent cardiac magnetic resonance imaging, which revealed huge interventricular mass (67×35 mm) from base to apex with low signal intensity, similar to the myocardium on the T1-weighted image () and mild higher signal intensity, as compared with the myocardium on the T2-weighted image (). After enhancement with gadolinium, the tumor showed peripheral enhancement (). Trans-thoracic echocardiography revealed normal left ventricular ejection fraction (LVEF 60%) and no hemodynamic compromise. Dual chamber permanent pacemaker was implanted on the second day of admission and we placed a right ventricular (RV) lead toward free wall of RV apex that was confirmed by fluoroscopy and echocardiography because of tumor invasion in the septum of RV apex. There were no procedure-related complications, however, ventricular tachycardia (VT) developed 3 days later. Twelve-lead ECG showed wide QRS complex tachycardia, left bundle branch block pattern with left superior axis morphology and late transition, which is compatible with VT from RV apex (). Administered amiodarone and ß-blocker suppressed further events of VT and the patient was discharged uneventfully. He received pazopanib for pallia"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old Indian female patient presented with a complaint of slow-growing painless palatal swelling of 1-year duration. Clinical examination revealed an oval, non-tender, bony hard swelling on the left side of the hard palate, extending from the canine to second molar region []. A premolar was missing on either sides of the maxillary arch. The teeth associated with the swelling were firm. There was no functional disturbance with speech, swallowing, and breathing. The family and medical histories were non-contributory.\nA reformatted panoramic image [] from a cone beam computed tomography (CBCT) scan showed a large amorphous hyperdense mass in left maxillary molar region. The lesion appeared to be extending beyond the apices of the molars, with the superior extent of the lesion not clear on this view. However, the cross-sectional image at the level of maxillary first molar [] showed a well-defined, hyperdense mass originating from the palatal root that measured about 19 mm in greatest dimension. The density of the mass appeared to be similar to that of the dentino-cemental complex. The superior margin of the lesion seemed to have pushed the floor of the maxillary sinus superiorly. The tangential (parasagittal) section [] showed the lesion to extend from the distal of premolar to the second molar region, superimposing over the maxillary sinus. This view showed a slight variation in the density of the lesion (heterogeneous appearance). The axial section [] at the level apical to the furcation area of first molar showed the mass to be originating from the palatal roots and appeared to have breached the palatal cortex. All the above features were suggestive of a lesion originating from the root and made up of odontogenic tissues. Based on these radiographic images a differential diagnosis of cementoblastoma, cemento-ossifying fibroma, hypercementosis and focal sclerosing osteomyelitis was considered.\nSurgical enucleation of the lesion including removal of the involve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 72 year old male patient was referred to our clinic with the complaint of bilateral axillary masses and numbness in the right hand. In his medical history, he had hypertension for 4 years but no history of trauma. A physical examination showed the presence of palpable pulsatile masses in his both axillae (12 cm in size in the right axilla and 8 cm in size in the left axilla) (Fig. ). His neurological and systemic examinations were within normal limits. An upper-extremity ultrasound examination revealed an aneurysm in a 12-cm segment of the right axillary artery, reaching 67 × 45 mm in dimension. There was a 27-mm thick thrombus at the edge of the aneurysm lumen. Adjacent to the aneurysm, there was a 48 × 40 mm hyperechogenic mass not related to the aneurysm. There was also an aneurysm reaching 40 × 43 mm in dimension in a 9-cm segment of the left axillary artery, with a 17-mm thick thrombus. A Doppler ultrasonic examination revealed a thrombus surrounding the lumen and a turbulent, pulsatile flow in the center. The aneurysmal segment was continuous with the brachial artery. There was no blood flow in the region adjacent to the right axillary artery (Figs. and ). On CT angiography, giant fusiform aneurysms were detected, measuring 140 × 77 mm in the right axillary artery and 93 × 45 mm in the left axillary artery. There were thrombi in both aneurysms, allowing the flow in the lumen. There was also an extension to the brachial artery and contour irregularities at the distal end of the right-side aneurysm. These latter findings were proposed to be due to a spontaneously healed rupture. A physical examination of the eyes, bones, skin and joints revealed no signs of collagen tissue disease, nor was it detected through laboratory examinations. Because the patient was symptomatic and had a high risk of aneurysm rupture, endovascular closure was initially planned. However, appropriate size stents could not be found for aneurysms so large and tortuous. Besides, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 56-year-old healthy male presented to the emergency room with facial injuries following an accident while riding his motor scooter. He was wearing a helmet and did not suffer from a head injury or loss of consciousness. He was alert and oriented on presentation; on examination he had ecchymosis around his eyelids and a lacerated left eyebrow. His systemic and neurological examination was normal. His complete blood count and complete metabolic panel were within normal limits and toxicology screen was negative. He had a sinus bradycardia with a heart rate of 50–60 beats per minute with normal blood pressure. The electrocardiogram showed sinus bradycardia with normal PR interval. CT head, cervical, chest, and abdomen studies were normal. Maxillofacial CT showed undisplaced fracture of the left zygomatic arch with intact orbits. He had a left temporal artery laceration which was sutured and pain was controlled with opioids.\nDue to the patient's sustained bradycardia, he was admitted to a telemetry bed for continued observation. The following morning, he had a 16-second pause and became unresponsive but regained consciousness before resuscitation could be initiated (Figures and ). In view of this event, the patient was transferred to the cardiac intensive care unit and observed with transcutaneous pacer pads in place. Over the next 24 hours, he had 3 more episodes of asystole (Stokes-Adams) lasting 3–6 seconds. A transthoracic echocardiogram preformed to evaluate for evidence cardiac contusion was found to be normal. Cardiac biomarkers were obtained and were nonelevated.\nThe cause of his significant bradycardia and recurrent asystole was a diagnostic quandary. Our patient was not on any bradyarrhythmic medications, his urine toxicology was negative, and there was no history of any tick bite. Over the next 48 hours, his frequency and duration of asystole decreased and his bradycardia gradually resolved. His opioid medications for pain control were gradually decreased ov"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 16-year-old boy was admitted at age 8 years. He had mild hemiparesis on the right side that started at age 8 years (). His parents noticed this complaint when he was walking independently at age 18 months. He had a history of partial epilepsy with reduced consciousness that started at age 1 year and incompletely controlled by oral Na+ valproate treatment.\nHe had seizures usually twice a month, typically complex partial seizures or complex partial seizures evolving to generalized seizures localized to the right side. The patient was previously followed up with a diagnosis of perinatal hypoxic-ischemic sequelae at another center. His seizures were usually prolonged (>5 minutes) and sometimes lasted for about half an hour, which was compatible with status epilepticus.\nHe was born at home by spontaneous vaginal delivery with the help of a midwife without complication. Birth weight, head circumference, and height were unknown; therefore, the Apgar score could not be calculated. The mother had neither related significant medical history nor regular antenatal medical follow-up. Fetal movements during the antenatal period were normal.\nHis early motor development was normal, except having mild hemiparesis that was noticed at age 18 months. The patient's hand preference during the first 2 years is not known. The patient started walking without support at age 18 months. His social and language milestones were normal. At age 6 months, bilateral cataract was noticed. He was operated for cataract and glaucoma, and prophylactic glaucoma treatment was started.\nHis initial physical examination revealed a marfanoid appearance with disproportionately long arms and legs compared with the trunk. However, he had no signs of wrist (Walker) or thumb (Steinberg), or joint hypermobility or arachnodactyly, that are typical signs of Marfan syndrome. Cranial nerve examinations and eye movements in all directions were normal. He was using hypermetropic glasses. Ophthalmologic examination revea"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male patient referred to us with a history of progressing right nasal early obstruction that tended to become bilateral during the period of 1 year. The patient also had the complaint of bloodstained, on and off nasal discharge. Over time he developed dull pain in the right facial region. Initially the patient took indigenous treatment. During this course of management, he did not get significant relief from his symptoms. Hence he came to the tertiary care center Ear, Nose, and Throat (ENT) OPD at IGIMS, Patna, Bihar, India for further treatment after 9 months of the appearance of initial symptoms. At the tertiary care center, the ENT surgeon examined him and found a lobulated fleshy mass obliterating his right nasal cavity, with deviation of the septum toward the left side. Computed tomographic (CT) scan of the peripheral nervous system (PNS) was advised, which revealed a large, enhancing, destructive nasal mass involving both nasal cavities, 9 × 4.5 × 4.4 cm3 in size, with significant bone erosion involving the lamina papyracea and cribriform plate without significant intracranial extension. On the basis of this, a diagnosis of inverted papilloma was made and a biopsy was taken. The histopathological examination (HPE) report revealed poorly differentiated malignant tumor and the possibility of malignant melanoma; the case was referred to the oncology department for further management and treatment.\nThe eye examination revealed eye movement in all quadrants with normal pupillary reflex. The oral cavity examination was normal, including normal alveolar process and palate, and no loose teeth. The rest of the ENT examination including ear, pharynx, larynx, and neck was within normal limits (WNL); the chest and abdomen were normal.\nOn the basis of these findings, total maxillectomy on the right side was done and a specimen was sent for HPE. The final examination revealed the possibility of malignant melanomas, and immunohistochemistry (IHC) was advised. I"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old nulliparous woman presented with abnormal vaginal bleeding. Ultrasound detected the presence of an endometrial polyp, which was confirmed on hysteroscopy and removed using a resectoscope. The polyp was approximately 2 cm in length. Histological analysis revealed benign endometrial glands with moderately cellular stromatolites showing some degree of periglandular condensation and mild pleomorphism. No SO or MI was noted. The histological diagnosis of low-grade adenosarcoma was made. Subsequently, the patient was advised to undergo hysterectomy, BSO and lymphadenectomy, but she declined to preserve her fertility. She was referred for a second opinion and following extensive counselling, opted for conservative management.\nOver the following 10 years, she was monitored with pelvic ultrasound, hysteroscopy and endometrial biopsy every 6 months, and with annual pelvic magnetic resonance imaging. Follow-up was largely uneventful, with normal imaging and histology. Nine years post-operatively an abnormal appearing area on the posterior aspect of the lower uterine segment was identified on hysteroscopy and subsequently resected. Histology was benign with no features of recurrence.\nEleven years post-operatively, she underwent in vitro fertilization (IVF) and successfully conceived following the first cycle. Unfortunately, she suffered a second trimester miscarriage at 16 weeks’ gestation, with a history suggestive of cervical incompetence after admission with a dilated cervix and bulging membranes. The following year she conceived twins following another IVF cycle. She underwent an uncomplicated elective trans-vaginal cervical suture. She delivered male twins at 28 weeks’ gestation following pre-term labour, which was attributed to placental abruption. Both children are alive and well. She was offered hysterectomy after delivery, and at each subsequent follow-up appointment, but declined as she was uncertain as to whether or not her family was complete. Followi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe a case of a 74 year old male patient, affected by a myeloproliferative syndrome. At the age of 26 he underwent a surgical gastrectomy for a hemorrhage caused by a perforated ulcer. Later, in December 2006, an upper gastrointestinal endoscopy revealed a neoplasm at the level of the thoracic esophagus. Multiple tissue biopsies histologically showed a scarcely differentiated squamous cell carcinoma. Subsequently all the necessary staging exams, including a total body Computed Tomography (CT) were performed. The CT did not show any suspected lymph nodes nor other lesions. In March 2007 the patient underwent a total esophagectomy and an esophago-gastroplasty with colon interposition for replacement of the esophagus.\nThe final histological findings confirmed the diagnosis of infiltrating squamous cell carcinoma; (Figure ). The lesion extended into the sub mucosal layer, a grade G3 was diagnosed and the surgical margins were considered free of infiltration. Since the regional lymph nodes were not reported, the final staging was pT1 pNx. In addition, a sample was taken at a distance from the original tumor as an occasional finding in the esophageal muscular tunica. This showed a fused cellular intramural micro nodule with a maximum diameter of 0.2 cm, and with morphological characteristics suggesting a very low risk GIST (Figure ).\nThe immunohistochemistry of the fused cells showed an intense and diffuse positivity for CD117, CD34 and CD99 and negative results for S100, desmin and actin (Figure ). The proliferate index Ki 67 was less than 5% with 4 mitoses per 50 HPF.\nThe aspects of this lesion reminded palisading-vacuolated spindle cell GISTs. In fact it showed nuclear palisading, resembling peripheral schwannomas and the typical feature of prominent perinuclear vacuolization.\nIn May 2007, a total body CT scan showed the presence of necrotic-hemorrhagic foci, of probable ischemic nature, in the cortical and sub cortical brain regions. At the same time, the thor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOn March 2015, a 22-year-old right-handed male with a 2 month history of right sided weakness and numbness was diagnosed with a primary brainstem tumor on MRI. He was empirically treated with temozolomide, bevacizumab, and stereotactic radiosurgery (SRS). Six months later, while stable disease was noted on brain MRI, the patient was also treated with an additional hypo-fractionated course (~50Gy in 25 fractions over 2 months) of involved field radiation.\nPatient received empiric chemotherapy and radiation therapy for 21 months and follow-up brain MRI on December 2016 revealed a stable, necrotic left midbrain mass lesion measuring 2.5 × 2.1 × 1.8 cm with subacute hemorrhage in the inferior posterior margin [].\nNearly 2 years after the initial diagnosis, the patient presented to the clinic with progressively worsening gait instability and left greater than right weakness. Additional symptoms included transient confusion with malaise and dizziness. Brain MRI at this time revealed progression at medial and inferior margins along with interval mild ventriculomegaly consistent with obstructive hydrocephalus []. Decision was made to place the shunt and resect the tumor in a two-stage procedure during the same admission.\nThe patient underwent an uneventful right occipital ventriculoperitoneal shunt placement with utilization of volumetric image guidance and laparoscopic assistance.\nThe following day, left posterior temporal-occipital craniotomy was performed with an intention to obtain tissue for diagnosis and remove as much of the brainstem tumor as safely as possible. Volumetric image guidance, microscope, neuro-monitoring, and intraoperative MRI were utilized. The brainstem lesion was approached through the posterior temporal-occipital supratentorial plane with sectioning of the tentorium to widen the exposure. The inferior posterior temporal gyrus was partially resected, allowing mobilization and preservation of the vein of Labbe. The midbrain was entered through the la"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old woman with recurrent pneumonia, who had been repeatedly hospitalized every year since 1988, was admitted to our hospital. She was treated for pulmonary tuberculosis 9 years before admission to our hospital. She was a nonsmoker and did not have any other disease or a family history of any disease.\nChest radiography showed a calcified wall in the left lower lung field and multifocal nodular calcification in the adjacent lung parenchyma (). Computed tomography (CT) angiography () showed a multiseptated cystic mass in the left lower lobe, systemic arterial supply from the descending thoracic aorta, and venous drainage to the left inferior pulmonary vein. Therefore, she was diagnosed with intralobar pulmonary sequestration. A posterolateral thoracotomy with single-lung ventilation was performed through the fifth intercostal space, sparing the serratus anterior muscle. This procedure was performed under general anesthesia, with the patient lying in the right lateral position. A necrotic mass 10 cm in diameter was located in the left lower lobe with severe pleural adhesion, and 3 feeding arteries from the descending aorta were observed. After ligation and division of the feeding arteries, a standard left lower lobectomy was performed.\nThe resected mass measured 5×5×2 cm and showed multiseptated cystic spaces interposed by consolidated or fibrotic lung parenchyma and bronchus-like structures (). The mass was located at a distance of 2.5 cm from the bronchial resection margin. Microscopically, the mass consisted of congested alveoli, dilated bronchi and bronchioles, and accompanying thick walled vessels, consistent with pulmonary sequestration. A few atypical cells were identified in the cystic wall, spanning 0.5 cm. They were arranged in nests and cords without stromal reaction. The cells showed salt-and-pepper type nuclear features without prominent nucleoli. Small amounts of cytoplasm were eosinophilic with an indistinct boundary (). The nest and cord-like g"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 65-year-old white male presented to our clinic for a second opinion. Seven years earlier, he noticed a skin rash over the anterior part of his neck. He was initially evaluated by a dermatologist, who prescribed topical steroids leading to temporary improvement of the lesion. Unfortunately, the rash returned and was associated with the tightening of the skin over his neck.\nThree years later, despite the occasional use of topical steroids, the skin tightness started to spread down his body, affecting his chest, upper and lower extremities. The patient underwent multiple skin biopsies, and the histopathological report was consistent with lymphocytic infiltration, possibly EF. Peripheral eosinophilia was also present.\nBased on the biopsy report, the patient was referred to a rheumatologist who diagnosed his disease as EF and first prescribed Plaquenil, and then, due to a lack of improvement, switched to 15 mg of methotrexate (MTX) orally once a week, 1 mg of folic acid orally once a day, and prednisone orally as needed.\nDespite being compliant with his regimen, the skin over his body was getting progressively tighter, and was associated with a lack of energy and joint pain that affected his hands, elbows, knees, and feet. The skin around his neck became so indurated that swallowing solid food was difficult. He developed contraction of the upper and lower extremities associated with severe muscle weakness, requiring a wheelchair for daily activities.\nThree years prior to presentation in our clinic, he had developed a diffuse erythematous rash all over his body requiring hospitalization and was subsequently diagnosed with Stevens-Johnson syndrome and was treated with high doses of steroids.\nAt the time of our evaluation, the patient denied chest pain, skin rash, shortness of breath, Raynaud’s phenomenon, uveitis, episcleritis, mouth ulcers, or blood in his urine or stools. Physical examination showed a debilitated, frail male who appeared older than his age. Eyes,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old woman was referred to our clinic with a history of chronic abdominal pain and weight loss of 10 kilograms in the past six months. The patient was postmenopausal for 30 years and had a free medical history. Physical examination revealed no tenderness, but a hard and mobile mass palpable in the right iliac fossa. Further investigation by means of transvaginal ultrasound revealed a cystic formation, sized 83 × 65 × 64 mm in the right adnexal area. The mass was of mixed structure, comprising of solid and cystic areas. The wall was smooth and anechoic on ultrasound imaging. No papillary projections or septations were identified and there were no signs of blood flow during the color Doppler evaluation. The left ovary was illustrated measuring 25 × 13 × 11 mm, but the right ovary could not be visualized (Figures and ). A polyp of the endometrium was also recorded, with total endometrial thickness of 8 mm. No free fluid was seen in the Douglas pouch. However, it was inconclusive whether the mass originated from the right adnexa or it concerned a uterine necrotic leiomyoma that protruded towards the adnexa. Because of the indeterminate ultrasound findings, an abdominal CT scan was carried out which identified a cyst sized 100 × 80 mm with signs of peripheral calcification attributed to a lesion of the right ovary (Figures and ). As a routine investigation, when an ovarian tumor is suspected, our patient underwent colonoscopy, during which a benign polyp of the sigmoid colon was excised; also a submucosal round smooth cystic formation of one cm in diameter at the site of the appendix was identified. Tumor markers were within normal limits, with the exception of carcinoembryonic antigen (CEA: 54, 2 ng/mL).\nThe patient underwent laparotomy with the diagnosis of a pelvic mass, in which a cystic tumor originating from the appendix, sized 80 × 90 mm, was identified, whereas the uterus and ovaries were atrophic. The abdominal viscera were covered with surgical pad ga"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 37-year-old female presented to the Center for Temporomandibular Disorders and Orofacial Pain, with a chief complaint of limitation of mouth opening and pain on the left side of the face of 1-month duration. The onset was sudden. The patient described the pain in the area of the left cheek and in front of the ear, sometimes radiating to the neck. The patient reported that the pain was related to function, such as talking, chewing, and yawning. The patient also reported a history of a similar episode a year earlier and was diagnosed with a TMD at that time. She was offered home care and stretching instructions (physical therapy) and advised to monitor the pain and limitation of opening. Over-the-counter medication (acetaminophen and ibuprofen) was recommended as needed for the relief of pain. For the limitation of opening, she was instructed to use hot and cold compressions bilaterally in the area of the masseter muscle.\nThe current pain began spontaneously, the week prior to the evaluation. Pain was frequent (4–5 times a day) and intense in nature, with a duration of a few seconds to minutes. The patient described her pain as continuous and aching with spontaneous attacks. The patient's concerns brought her to the orofacial pain clinic for an evaluation.\nThe current episode of spontaneous pain of 1 month's duration was not associated with a history of trauma. The patient did not report a history of fever, or neurological problems prior to the onset of the current problem. Her medical, family, and psychosocial histories were noncontributory. She is a vegetarian, but reported eating raw salads at restaurants. She reported that her ability to open her mouth was limited to one-finger width (approximately 4–5 mm). Her primary care physician prescribed a muscle relaxant, carisoprodol 350 mg three times per day for 2 weeks, and advised her to seek an evaluation for a temporomandibular joint"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 92-year-old man with osteoarthritis and a remote history of right total hip replacement and bilateral total knee replacements presented with a two-day history of severe right hip pain accompanied by nausea, chills, and fatigue. He was unable to bear weight due to pain, and range of motion in his right hip was severely limited. He denied recent trauma or pain in other joints but had undergone routine dental cleaning one week prior to presentation. He had received 2 gm of amoxicillin immediately prior to his dental procedure. He presented afebrile, mildly hypotensive, and was noted to have exquisite tenderness with passive movement of the right leg and reduced range of motion secondary to pain. He had full range of motion and strength distally. He had a leukocytosis of 15,600 WBC per milliliter. Aspiration of right hip joint revealed cloudy fluid with WBC 68,000 cells per milliliter. The patient was resuscitated with IV fluids and started on vancomycin and piperacillin-tazobactam. On the third hospital day, he underwent prosthetic joint drainage and washout with retention of liners. Joint aspirate culture grew Gram-positive cocci in chains, which we subsequently identified by matrix-assisted desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as S. salivarius. We narrowed antibiotic therapy to ceftriaxone to complete six total weeks of intravenous therapy, after which he was treated with amoxicillin for additional six weeks. At this point, the patient discontinued his oral antibiotics rather than complete a full three months of oral therapy or remain on long-term suppression.\nFive months after completion of the above therapy, the patient presented to the ED with hip and back pain following a mechanical fall at home. He was found to have a fracture of L4 and was admitted. On hospital day 5, he was found to have an occult superior dislocation of the R femoral head on CT and an ESR of 71 and CRP of 12.3. He was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 72 year old male patient was referred to our clinic with the complaint of bilateral axillary masses and numbness in the right hand. In his medical history, he had hypertension for 4 years but no history of trauma. A physical examination showed the presence of palpable pulsatile masses in his both axillae (12 cm in size in the right axilla and 8 cm in size in the left axilla) (Fig. ). His neurological and systemic examinations were within normal limits. An upper-extremity ultrasound examination revealed an aneurysm in a 12-cm segment of the right axillary artery, reaching 67 × 45 mm in dimension. There was a 27-mm thick thrombus at the edge of the aneurysm lumen. Adjacent to the aneurysm, there was a 48 × 40 mm hyperechogenic mass not related to the aneurysm. There was also an aneurysm reaching 40 × 43 mm in dimension in a 9-cm segment of the left axillary artery, with a 17-mm thick thrombus. A Doppler ultrasonic examination revealed a thrombus surrounding the lumen and a turbulent, pulsatile flow in the center. The aneurysmal segment was continuous with the brachial artery. There was no blood flow in the region adjacent to the right axillary artery (Figs. and ). On CT angiography, giant fusiform aneurysms were detected, measuring 140 × 77 mm in the right axillary artery and 93 × 45 mm in the left axillary artery. There were thrombi in both aneurysms, allowing the flow in the lumen. There was also an extension to the brachial artery and contour irregularities at the distal end of the right-side aneurysm. These latter findings were proposed to be due to a spontaneously healed rupture. A physical examination of the eyes, bones, skin and joints revealed no signs of collagen tissue disease, nor was it detected through laboratory examinations. Because the patient was symptomatic and had a high risk of aneurysm rupture, endovascular closure was initially planned. However, appropriate size stents could not be found for aneurysms so large and tortuous. Besides, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old man was admitted to our clinic with similar complaints. He had undergone placement of the same type of penile prosthesis three years earlier. He reported the prosthesis had been functioning well, providing a high degree of satisfaction for him and his wife []. He had a 17-year history of DM (type II) with good control. He also described having trapped his penis against a toilet seat while sitting down to defecate four days earlier.\nAt presentation, both patients displayed fever (38.6°C and 39°C, respectively), and reported receiving broad spectrum antibiotics from general practitioners in their home towns. They denied any previous similar episodes since prostheses implantation. Physical examination in both cases revealed an erythematous, edematous and indurated penis with mildly macerated skin. The first patient also had ischemic spots over the penile shaft and localized soft swelling (3 × 2.5 cm) on the left side of the peno-scrotal junction (Fig. ). Penile and perineal palpation indicated intact devices in place, and this was further confirmed by radiography of the pelvis. However, the appearance of the patients' organs looked abnormal with poor concealment of the devices. The patients' white blood counts were elevated (13.200/mL and 14,100/mL, respectively). Urine analyses and cultures yielded negative results. Diabetes was well controlled in both patients as evidenced by normal levels of fasting and postprandial blood sugars and glycosylated hemoglobin levels. Ultrasound examination of the genitalia was performed to identify any possible hematoma but yielded no relevant results other than edema at the peno-scrotal junction of the first patient. Blood examination for bleeding, coagulation, prothrombin and partial thromboplastin times yielded normal results.\nAfter discussion in each case, we decided to perform an exploration and extrusion of each penile prosthesis. The operations were performed under spinal anesthesia. The tunica was opened and a sig"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 20-year-old female patient reported to the Department of Oral Medicine and Radiology with a chief complaint of inability to close her mouth since birth. Her mother stated that she was also unable to close both eyes since birth and there was difficulty in suckling. Her milestones were normal and there was no history of prenatal or postnatal trauma. Her medical history revealed that she had visited a medical hospital previously for augmentation of the upper lip at the age of 15 years and breast augmentation at the age of 18 years. Intelligence quotient (IQ) evaluation revealed normal IQ level of the patient. There was no history of consanguineous marriage between the parents.\nOn general examination, all the vital signs were within normal limits. No abnormality was detected in lower limbs whereas shortening of the index finger was noted in both the upper limbs (). Her sensory functions were normal. She was unable to close both eyes () and raise the eyebrows. There was absence of wrinkles on her forehead (). The patient was neither able to whistle or blow air between her cheeks nor was able to smile. She was not able to completely abduct her eyes and was unable to rotate her eyeballs upwards or downwards and could only partially move it in medial and lateral directions. Other ocular manifestations were the presence of ptosis of the right eye and strabismus. Other facial and intraoral features were wide nasal apertures, incompetent lips (), scar mark over the upper lip and a high-vault palate ().\nBased on history given by the patient and features shown on clinical examination, the case was diagnosed as Mobius syndrome. Routine hematological investigations were within normal limits. Panoramic view showed decays with respect to maxillary left second premolar, first molar and mandibular right and left first molar (). Wrist radiographs showed short middle phalanges in the index finger of both hands (Figure and ). A lateral cephalogram showed no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 30-year-old man presented to the emergency department after “falling into a hole”. The patient was a construction worker and fell with his back in a 2-meter hole which was followed by a blunt abdominal trauma due to a falling of a 30 kg bag of cement on his abdomen. The patient had no past medical history and was not on any treatment or drug abuse. On primary survey, the airway was intact and a hard collar had been put on. The breathing, lung auscultation, and O2 saturation were in normal range. The blood pressure was 128/75 mmHg, pulse rate 90/min, and oxygen saturation of 96% while the patient was breathing ambient air. The patient underwent focused abdominal sonography for trauma patients (FAST) which showed small free fluid on lower pole of the right kidney. The patient was awake and fully conscious, the pupils were normal size and reactive, and there was not any neurologic deficit.\nThe secondary survey was significant for the mild abdominal tenderness on right upper quadrant. The chest, and lateral neck portable x-rays were normal. After surgery consultation, it was planned to have an abdominopelvic computed tomography (CT) scan with intravenous contrast agent in order to pin point the problem. In few minutes, the pain had been increased in intensity which was claimed to be 7 out of 10 in numerical rating scale (NRS). The blood pressure did not show any significant change but the patient pulse rate was increased up to 110. Serial FAST exam showed increase in free fluid volume. The patient underwent CT imaging (). It showed a moderate volume of free fluid in pelvic area, perihepatic, and also perisplenic spaces. Small bowel wall thickening due to mural hematoma of proximal part of jejunum with mural wall hypodensity in mid jejunal loop which are all suggestive of hollow viscus injury. There was no visible sign of solid organ damage or extra luminal free air. Regarding to the CT scan results"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old man, with no history of systemic disease, was complaining about sudden onset of balance disorders and dizziness for 10 days. These symptoms were marked by severe headaches and several episodes of vomiting. He also reported having undergone a tooth extraction one month ago which was complicated by fever according to his own statements. Therefore, he consulted a neurologist who diagnosed intracerebral hypertension and a cerebral scan was then ordered and revealed, indeed, the presence of 3 cerebellar ring-enhancing mass lesions of variable size measuring 28∗20 mm and 15∗20 mm. Afterwards, he was transferred to the Emergency Department (ED) at the University Hospital Center of Sahloul, Sousse, for further investigations.\nOn physical examination, he was found to have ataxic walking with no loss of feeling in the skin and muscle weakness.\nWith all these findings, he was admitted under the care of the neurosurgery service for a potentially intracerebral abscess. Given this information, the infectious diseases service was consulted to determine the most appropriate antibiotic treatment to begin. With that service's recommendation, the patient was started on metronidazole 500 mg intravenously every 8 hours, vancomycin 500 mg IV every 6 hours, and cefotaxime 2 g IV every 4 hours.\nHe was then taken to the operating room for a right retrosigmoid mini craniotomy for abscess drainage. Brain abscess specimens were submitted to microbiology, and the bacterial cultures returned positive exclusively for numerous cocci gram + (Staphylococcus aureus).\nBesides, blood and urine samples were negative. Upon receiving these results and taking into account the fact that the patient underwent an extraction one month ago, the dentistry service was consulted to identify a possible odontogenic focus.\nOn extraoral examination, there was no cervical or submandibular lymphadenopathy.\nThere was no overt trismus or facial swelling. On intraoral examination, the patient was found to hav"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old man with a medical history of high blood pressure and gout was referred to our department for oral mucosa burning causing him pain and discomfort. He was an ancient smoker and reported the sensation of headache with notorious dizziness on two occasions recently. The extraoral examination showed slight facial erythrosis (). Intraoral examination showed slightly hyperkeratotic erythematous lesions located on the inner side of the labial mucosa (). They were pruriginous and painful causing the symptomatology of the patient. The inner sides of the cheeks showed erythematous erosions especially on the right side (). We noticed also two erosive ulcerations as well as hyperkeratotic lesions at the right lateral edge and the ventral side of the tongue forming a discrete reticular network ().\nIn front of these signs, we suspected oral lichen planus associated with candidiasis infection. Mycological examination confirmed candidiasis, and initial treatment consisted of topical mouthwashes with Amphotericin B (50 mg; 5 ml 3 times per day) and Chlorhexidine (0.12%; 3 times per day). Biological tests were requested and a biopsy was scheduled a week after. Two biopsies were performed at the inner side of the lower lip and the right lateral edge of the tongue. The result was oral lichen planus ().\nAlmost all the biological tests (VS, CRP, glycated hemoglobin, and thyroid checkup) were within the normal levels, and serologies (hepatitis and VIH) were negative. However, the complete blood count was unusually marked by an increase in the number of red blood cells, hematocrit, and hemoglobin reaching a value of 19 (). This fortuitous finding led us to suspect polycythemia vera and to refer our patient to the department of hematology where he has undergone an emergency phlebotomy. Two days later, he was a victim of a myocardial infraction. He was hospitalized in the cardiology department where he was diagnosed with atrial fibrillation, stented, and put under"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old man presented to the emergency department of our hospital with a 6-day history of left hemiparesis and 1-day history of fever. The patient had a history of advanced non-small-cell lung cancer and was receiving 3-week cycles of pembrolizumab (200 mg) for approximately 4 months before admission. Initial cranial CT and MRI showed two lesions in the left frontal and right parietal lobes. Both lesions were <2 cm in size and exhibited homogeneous hyperintensity on diffusion-weighted MRI [-]. The primary consideration in this case was brain abscess. Due to the small size of the lesion, neurosurgical aspiration was planned in case the causative pathogen could not be identified by blood culture or treated by antibiotics.\nAfter blood cultures were obtained, empirical treatment with intravenous meropenem administration was initiated. Levetiracetam was started for seizure prophylaxis. Although the causative pathogen was not identified by blood culture, the lesion sizes reduced remarkably following antibiotic treatment, and left hemiparesis was improved. Therefore, neurosurgical aspiration was not performed. However, his left hemiparesis worsened 7 weeks after treatment initiation. Cranial MRI revealed that the mass lesion in the right frontal lobe was slightly enlarged and the surrounding vasogenic edema was exacerbated []. Blood cultures were taken again, and then neurosurgical aspiration was performed. Stereotactic needle aspiration of the lesion in the right frontal lobe yielded purulent discharge, leading to a confirmed diagnosis of brain abscesses for both lesions. S. intermedius growth was detected only in the purulent fluid culture and not in the blood cultures. There was a considerable reduction in the lesion sizes after surgical drainage and antibiotic treatment based on antibiotic-sensitivity test results. The origin of the brain abscesses could not be identified even after several examinations, including intraoral examination and panoramic radiography ["}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Belgian Caucasian man complained of cramps in the right calf and walking difficulties that had started 6 months previous but had progressed to the point of needing support from the banisters when walking up a staircase. He did not report sensory disturbances. His personal history included arterial hypertension, hypercholesterolemia, complete deafness of the right ear due to a mastoidectomy in early childhood, and completely asymptomatic PDB that had been diagnosed 7 years previously by elevated alkaline phosphatases in a routine blood check, and had been confirmed by bone diphosphonate technetium-99m scintigraphy. His sister had died of dementia at the age of 62 years, while his mother had died at 67 years suffering from dementia and walking difficulties. At the first neurological examination he had slight paresis of the dorsal extensors of the left foot, eft quadriceps, and right deltoid muscle, atrophy of the left thigh, and diffuse tendon hyperreflexia. Fasciculations were noted in the right deltoid muscle but not in the tongue, which was not atrophic. Cranial nerves and sensibility were intact and there was no Babinski sign.\nThe first electromyography (EMG) investigation revealed a diffuse chronic neurogenic pattern in all tested muscles of the left leg and in the right deltoid muscle, without signs of subacute denervation such as fibrillations or positive sharp waves. There was a marked slowing of the motor nerve conduction of the right peroneal nerve, without conduction block.\nAn extensive laboratory workup produced normal results except for slight elevations of alkaline phosphatase (115 mU/mL, normal range 30-90 mU/mL) and lactate dehydrogenase (308 mU/mL, normal range 140-280 mU/mL). Magnetic resonance imaging (MRI) of the lumbar spine and computed tomography scans of the cervical spine and pelvis did not reveal significant abnormalities.\nWalking for longer than 20 minutes had become difficult in the intervening 3 years since these initial inve"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old female patient with prior THA presented with a seven-year history of groin pain and weakness during initial hip flexion. The THA was initially performed at a different hospital to address painful dysplastic osteoarthritis. Ipsilateral groin pain was presented soon after the THA. Moreover, stair climbing and exiting cars were aggravating activities. Pressure on the iliopsoas tendon of the groin was painful, especially during the Stinchfield test. A relatively large cup was implanted (58 mm in diameter) in the shallow hypovolemic acetabulum. Insufficient medialization was observed on the anteroposterior (AP) radiograph from the first outpatient clinic (Fig. ). It was thought that periprosthetic joint infection could be the cause of the pain and was excluded using laboratory tests and ultrasound screening. The pelvis tilted upward posteriorly due to global sagittal malalignment associated with multiple spondylolistheses and degenerative kyphotic deformity in the lumbar spine. The upper border of the pubic symphysis was at the level of the third sacral vertebral body on a standing pelvic AP radiograph. The abduction angle of the acetabular component was 57.3°. On the axiolateral radiograph, the anteversion angle of the cup was 30.3°. The protrusion of the acetabular component was approximately 25 mm on the sagittal computed tomography image (Fig. ).\nNSAIDs and physical therapy failed to manage the pain. Multiple ultrasound-guided injections provided only transient analgesia. After conservative treatment failed, revision THA was offered as a treatment of choice, but she refused a revision arthroplasty because she was not satisfied with the index THA. Informed consent was obtained for arthroscopic tenotomy. It had been sufficiently explained that revision THA is necessary if there is no effect. Finally, she agreed to undergo arthroscopic iliopsoas tenotomy instead of a cup revision as an alternative minimally invasive manner instead of revision THA. Hip arth"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 47-year-old Japanese woman, who was treated for cervical carcinoma with conization, returned to her gynecologist for a follow-up visit with a complaint of mucous hypersecretion and urinary leakage. Suspecting VVF, her gynecologist instilled 2ml of crystal violet dye diluted to 1% concentration. No VVF could be identified but the physician was unable to drain the dye from her bladder as his patient refused catheterization. She then developed an irritable bladder, frequent urination and gross hematuria. She was diagnosed to have acute cystitis and prescribed antimicrobial agents for one week. However, her symptoms did not improve and she was referred to our urology department.\nA blood examination showed only a mild degree of elevated C-reactive protein. Her urinary sediment showed a red blood cell count of >100 cells/high-power field and a white blood cell count of >100 cells/high-power field. Her condition was gradually getting worse, with severe urgency to urinate every 10 minutes and gross hematuria with clots. Cystoscopy showed abnormal mucosa of her bladder. The surface of her bladder was hemorrhagic with a lot of necrotic tissue (Figure ). Her bladder capacity was about 100mL.\nWe diagnosed our patient with chemical cystitis and started therapy with nonsteroid anti-inflammatory drugs (NSAIDs). An abdominal computed tomography scan showed thickening of her entire bladder wall with spotty high-density lesions of >100 Hounsfield units. We suspected these to be the dye, which had adsorbed into the mucosa (Figure ). After two weeks, her urinary urgency had been relieved to some degree. However, her bladder capacity was only 50mL. We wanted to do a urodynamic study but our patient was not willing to undergo the procedure. We added glucocorticoids to her NSAID therapy to prevent scarring of her bladder as a result of inflammation. Her bladder capacity improved to 75mL, and pelvic magnetic resonance imaging (MRI) also showed an improvement in the thickening of her blad"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old male presented in casualty with a history of seizures that let to fall from 10 feet height resulting in injury to both hips and left shoulder. He was diagnosed with cerebral venous thrombosis and started on heparin. On X-rays & CT scan (, ), he was diagnosed to have bilateral acetabular fracture and three part left proximal humerus fracture. He was operated for bilateral acetabular fracture using modified Stoppa’s approach and fixed with buttress plate in true pelvis on both sides (). On post op day 3, he had fever & discharge from suture site, dressing was done and pus culture and sensitivity done. Wound wash was done to eradicate infection. Culture showed growth of Klebsiella and anaerobes sensitive to cefoperazone sulbactum, clindamycin and amikacin. The pus discharge resumed again after 3 days of wound wash and antibiotics. This time culture sensitivity tests showed resistance to cefoperazone sulbactum so chloremphenical was started which decreased the pus discharge but could not stop it. Based on the sensitivity tests, meropenem was started which stopped the discharge for 5 days then again the discharge started. At this time about 2 weeks after the first surgery, it was decided to start irrigation with Qurion solution for an hour and then continue Vacumn assisted suction (VAS). At both ends of the suture line single stitches were removed, at one end infant feeding tube was put for irrigation with qurion solution and at the other end infant feeding tube inserted for vacuum assisted suction (). Daily Qurion irrigation was done in morning and evening for one hour during which vacuum assisted suction was stopped. After one hour again vacuum assisted suction was started. After 2 days of starting Qurion irrigation & vacuum assisted suction therpy (QiVAS), the suture site became dry. We continued QiVAS therapy for 2 weeks with antibiotic meropenem. Blood counts and CRP were within normal range after 2 weeks of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 63-year-old Caucasian female with a past medical history (PMH) of arthritis presented originally to the hospital due to an abnormal MRI. The patient was having weakness on the left side for the past few weeks along with difficulty concentrating. Her symptoms started to worsen when she was leaning towards the left upon standing, veering to the left when driving, and had difficulty standing from a seated position. She was evaluated by her primary care physician (PCP) who ordered a brain MRI. The MRI showed a right frontal lobe mass with surrounding mild vasogenic edema and a small focal area of hemorrhage as seen in Figure .\nThese findings were concerning for high-grade glioma with other differentials including lymphoma and other causes. She was then sent to the hospital for further evaluation. Family history is significant for NHL in the father and brother diagnosed with NHL ~15years ago, who are in remission. On initial exam, vitals were significant for mildly elevated blood pressure but otherwise unremarkable. On neurologic exam, the patient was notably alert and oriented x 3, with intact speech but mild difficulty swallowing. She had mild left pronator drift, left-sided facial droop, left hemiparesis with 4/5 strength on the left upper and lower extremity, and 5/5 strength on the right upper and lower extremity. Sensations were intact in all extremities. She was started on 500 mg of Keppra, every 12 h and 4 mg of dexamethasone, every 8 h. A CT chest/abdomen/pelvis was obtained which showed no evidence of metastatic disease. Neurosurgery evaluated the patient and she underwent right frontoparietal craniotomy and partial removal of the tumor. The patient had a post-surgical brain CT that showed small amounts of high attenuation material in gas bubbles along the track of the resection, likely representing residual acute blood (Figure ).\nA follow-up MRI of the brain revealed that surgical changes of the right frontal lobe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 87-year-old woman was referred to our hospital in May 2010 with severe left ocular pain since 4 days before. On initial examination, the left orbit was severely necrotized with several live larvae attached to the necrotic tissue. The upper and lower eyelids and the eyeball were completely destroyed. Periorbital tissues were swollen and erythematous ().\nAccording to her grandchild, the patient had not been able to walk or sit for several years, presumably due to back injury. She also had bladder and bowel incontinence. However, her mental status was intact. She had history of eyelid surgery due to a skin lesion 15 years ago which had been confirmed to be skin cancer. There were no medical records or documents however, and she had experienced no recurrences ever since.\nOrbital CT scan revealed disorganized globe and periocular tissues, with hemorrhagic patches in the left orbit filled with larvae. The orbital walls seemed intact and no larvae could be detected in the periorbital sinuses or cranium.\nOn the day of admission, the patient underwent exenteration of the left orbit (). All necrotic tissues and over 150 larvae were removed. A few larvae were collected and preserved in 70% ethanol. The larvae were identified as Chrysomya bezziana (Diptera: Calliphoridae) or old world screwworm fly. The most distinctive characteristics of this species include one pair of anterior spiracles with 4 to 6 digit projections at the ends, located on the first segment of the third instar of the larvae above the cephalopharyngeal skeleton (one pair of hooks at the base) (), and one pair of posterior spiracles at the bottom of the third instar of the larvae. Each is surrounded by a complete peritreme, without a distinct button. There are 3 slits inside each peritreme, which continue to its end (). is a picture of the complete third instar larva of Chrysomya bezz"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 76-year old female, previously fit and well, was admitted to hospital with new onset melaena. Two weeks prior she had accidentally swallowed a date pit. Seventy-two hours prior to admission she developed odynophagia and 24 h prior to admission she experienced a syncopal episode and hematemesis. She had no risk factors for gastro-intestinal bleeding. Following one night in hospital, the patient developed large volume haematemesis, hypotension and increased work of breathing. She was subsequently intubated due to airway compromise. A Blakemore tube was inserted, with both oesophageal and gastric balloons inflated, and traction applied. The haemorrhaging continued and a massive transfusion protocol was activated. The patient was referred to the intensive care unit (ICU) where she continued to haemorrhage profusely.\nNo obvious bleeding point was identified in the stomach or duodenum at endoscopy. A small, bleeding lesion was visualized on the oesophageal mucosa ~20 cm from the incisors. Attempts to control the haemorrhaging through localized adrenaline injection were unsuccessful. Computed tomography (CT) angiography was planned to identify a bleeding point. Profuse bleeding continued to the point of haemodynamic instability. The Blakemore tube was once again placed in the oesophagus and inflated to 30 mmHg. A total of 32 units of packed red blood cells, 20 units of fresh frozen plasma, three units of platelets and two units of cryoprecipitate were given. Control was eventually established by deflating the Blakemore tube and pulling it distally to the approximate site of the lesion. The oesophageal balloon was inflated to 100 mmHg and the gastric balloon was inflated to a lesser pressure.\nComputed tomography angiography (CTA) identified a large abnormal ‘vessel’ projecting from the medial aspect of the aortic arch extending towards the oesophageal wall ( and ). This structure did not have an aneurysmal configuration and was blind-ending ( and ). No discrete vascular r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 74-year-old Japanese woman was referred to our hospital with a history of several days of jaundice. She had no past medical history and no family history. On examination, her skin was jaundiced, and her abdomen was flat and soft. Her laboratory data revealed obstructive jaundice and cholangitis, and tumor marker levels were elevated with carcinoembryonic antigen at 3.6 and carbohydrate antigen 19-9 at 4573.9. Computed tomography (CT) revealed an enhancing mass in the biliary duct hilum and dilation of the intrahepatic bile ducts, and there was no evidence of lymph node metastasis or distant metastasis. Endoscopic retrograde cholangiopancreatography revealed a luminal filling defect in the biliary hilum (Fig. ). We diagnosed the tumor as a Bismuth type 1 cholangiocarcinoma, and performed endoscopic retrograde biliary drainage. Biopsies of the tumor revealed adenocarcinoma. The estimated volume of the postoperative liver remnant was less than 35%. Therefore, percutaneous transhepatic portal vein embolization (PTPE) of the right branch of her portal vein was performed (Fig. ). Twenty-one days later, the volume of the left lobe of her liver increased, and we performed right hepatectomy, caudate lobectomy, extrahepatic bile duct resection, and lymph node dissection. Node dissection included resection of hilar and pericholedochal nodes in the hepatoduodenal ligament, common hepatic artery nodes, and those at the celiac trunk, and posterior and anterior pancreaticoduodenal nodes.\nHistological examination of the tumor showed moderately differentiated tubular adenocarcinoma without regional lymph node metastasis, a pathological stage II tumor according to the Union for International Cancer Control classification of malignant tumors, 7th edition (Fig. ). Postoperative blood laboratory tests showed that liver enzymes were slightly elevated, but that total bilirubin was within normal limits. Resumption of diet started on postoperative day (POD) 3. Although the fluid in the ab"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old man was referred to our hospital in May 2014 with a history of pain and swelling of the right hand for a duration of 3 months. The patient sustained an electrical shock to the right hand while repairing a domestic electrical appliance. He denied any cutaneous injury, loss of consciousness or injury to any other body part due to the electrical shock. He noticed pain in his right hand within one week of injury, which was treated with analgesics without relief. He noticed a subsequent swelling, deep aching pain, cutaneous hypersensitivity and discoloration of the right hand. The patient denied aggravation of symptoms during exposure to cold or any diurnal variation of the symptoms. The patient indicated severe pain, which he rated as 9 on a 10-point visual analogue scale (VAS). He was treated with a short course of oral prednisolone with physiotherapy at a peripheral hospital, but the improvement was not significant. The patient is employed as an infantry soldier, and the condition prevented him from being able to handle any weapons. He was also unable to use his right hand for activities of daily living. The patient denied alcohol consumption or tobacco use, and his previous medical history was unremarkable. Examination revealed stable vital parameters, and systemic examination was unremarkable. His right hand was markedly tender, hyperemic with diffuse swelling and cutaneous hypersensitivity (Figure ). Other vasomotor changes were absent, and the radial pulse was normally palpable on the right side. Muscle atrophy was not apparent, and there was generalized weakness of the hand muscles, likely because of the reduced effort by the patient.\nHis hematological and biochemical parameters were all normal, including the C-reactive protein, creatine kinase, calcium, phosphorus, alkaline phosphatase and 25-hydroxy vitamin D levels. A nerve conduction study and electromyography of the left upper extremity showed no evidence of neuropathy or myopathy. A Dual Energ"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 43-year-old man was admitted to our hospital for intensive rehabilitation 115 days after a traffic accident. Cervical computed tomography (CT) and magnetic resonance imaging (MRI) on the day of the injury had shown a C6 vertebral body fracture as well as a cervical cord signal change on T2-weighted MRI images (). He had undergone a C5-6-7 lateral mass fusion on the day of the injury. Six days after injury, he was transferred to the rehabilitation department. A subsequent C5-6-7-T1 anterior and posterior fusion was additionally performed 35 days after injury due to spinal instability detected on follow-up cervical spine X-ray (). There was no concomitant brain injury on brain CT scans and all cognitive evaluations including cognitive score subsets of the Functional Independence Measure showed intact cognition. Other than a past history of type 2 diabetes mellitus, no other significant medical history including psychiatric history existed. The patient also had no history of drug or alcohol misuse.\nAccording to the International Standards for Neurological Classification of Spinal Cord Injury, the patient had a complete lesion (American Spinal Injury Association impairment scale A [ASIA A]) with a C6 neurologic level of injury. According to neurologic exams performed 6 days after injury, the initial upper extremity motor score was 27 and the lower extremity motor score was 0. These scores improved to 31 and 0, respectively, at 115 days after injury when he was transferred to our hospital. Total light touch scores were initially 21 for the right side and 21 for left side and improved to 28 and 29, respectively, at 115 days follow-up. Total pin prick scores were initially 23 for the right side and 24 for the left side, but improved to 27 and 27, respectively on follow-up. There was no interval change in the neurologic exam at 6 months follow-up. Electrodiagnostic studies performed 2 months after injury revealed complete myelopathy and bilateral symmetric peripheral sens"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old woman presented in 2006 at the department of surgery, Maria Pia Hospital, Turin, for important chronic constipation and abdominal pain. She had a long history of constipation with an average of one evacuation every four days despite continual use of laxatives and had been hospitalized several times before for intestinal partial obstruction. Furthermore, the patient suffered of left hemiparesis with difficulty speaking because of a subarachnoid hemorrhage at one year of age. She was implanted a neurostimulator in the third sacral nerve root, but the device was removed two years later due to its inefficacy. In 2010, she was hospitalized again after another partial obstruction, and loop ileostomy was performed. Despite this, the symptomatology did not improve, and the obstructive episodes continued. Colonic manometry and abdominal X-ray revealed a picture of inertia coli.\nOn November 2015, during the programmed closing operation of ileostomy, the ileum appeared distended with brownish serosa. Therefore, a decision was taken not to close the ileostomy, and a diagnostic surgical biopsy of the ileum was made. Histologic examination showed an abnormal accumulation of eosinophilic granules in the cytoplasm of smooth muscle cells with disruption of muscular fibers (). The mucosa was normal. The pigment was interpreted as lipofuscin, and a suspicion of BBS was raised.\nBlood levels of vitamins A, D, E, and K were dosed, and vitamins D and E were found to be low (0.3 mg/dl and 6 ng/ml, respectively). Antibodies against transglutaminase were negative, and there was no clinical or laboratory suspicion of coeliac disease.\nAfter 8 months of nutritional supplementation, the vitamin values were at the lower limit of the normal range (0.8 mg/dl and 10 ng/ml, respectively), but the patient still suffered of recurrent intestinal functional obstruction. Abdominal X-ray and CT evidenced severe intestinal dilatation (), indicating the persistence of a severe impairment of col"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 75-year-old male patient was admitted to the emergency service with fatigue, headache, dizziness, weakness in the left arm and leg, unsteady gait, difficulty in swallowing, dysarthria, and hiccups for 8 h. He had a history of coronary artery disease and hypertension. He was nonsmoker with a long history of high amounts of alcohol consumption.\nHis blood pressure was found to be 110/60 mmHg in the systemic examination, and his heart was rhythmic. In the transthoracic echocardiogram, ejection fraction was 50%, and no additional pathologies were detected. Laboratory tests showed no other abnormalities except elevated levels of urea and creatinine. Abdominal CT performed in the emergency service showed that left renal artery occlusion and renal atrophy. In his initial neurological examination in the emergency service, he was conscious with speech and comprehension abilities, full cooperation and was able to perform simple tasks. Horner syndrome (ptosis and myositis) and horizontal nystagmus were detected in his left. In the motor examination, proximal and distal areas in the left arm and left leg had a muscle strength of 3/5. He had increased deep tendon reflexes and a positive Babinski reflex on the left. He had contralateral loss of pain and temperature sensation on the left side of his face and right side of his body. Neurological findings suggested that ipsilateral hemiparesis accompanied the typical findings of lateral medullary infarct. Opalski syndrome was considered for the diagnosis, as the clinical presentation was acute, and the patient had the risk factors of stroke.\nNo pathological findings were detected in computed tomography of the brain. In the diffusion-weighted image (DWI) of diffusion magnetic resonance imaging (MRI), lacunar lesion concordant with the left occipital hyperintense acute ischemic infarct was observed (Fig. ). The patient was considered to have ischemic stroke on atherothrombotic base, and antiplatelet treatment (acetylsalicylic acid) w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old woman came in our emergency room for consult due to sudden painful loss of vision of the right eye. The History of the present illness started 1 week prior to consult, the patient noted a sudden blurring of vision of the right eye described as curtain loss of vision. No history of trauma, pain, flashes, and floaters was noted, and neither consult done nor medication taken. Three days prior to consult, the patient noted a total loss of vision of the right eye associated with intractable pain, eye redness, headache, nausea, and vomiting, which prompted consult.\nThe patient had no known systemic diseases except for well-controlled bronchial asthma and hypertension. The patient was maintained on losartan 50 mg twice a day with poor compliance and control. The patient came in with no light perception for the right eye and 20/20 for the left eye. The blood pressure at the time of consult was at 240/100. Gross examination and extraocular muscles were normal. The right pupil was 6 mm non-reactive to light, and the left pupil was 3 mm brisk reactive to light with positive reverse relative afferent pupillary defect. Slit lamp examination of the right eye revealed shallow chambers with moderate corneal edema with microcyst and an intraocular pressure (IOP) of 60. On gonioscopy of the right eye, the angles on all quadrants were closed. Indirect ophthalmoscopy of the right eye revealed total retinal detachment with large subretinal hemorrhage. The examination of the left eye showed a formed chamber with an IOP of 12 and a cup-to-disc ratio (CDR) of 0.4 with arteriovenous crossing changes. On gonioscopy of the left eye, the angles on all quadrants were open to ciliary body band. The right eye had poor streak on refraction, while the left eye’s refraction was –0.50 D sphere. Ocular ultrasound of the right eye (Figure 1 ) revealed massive hemorrhagic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old male patient reported to the Department of Oral Medicine and Radiology with a complaint of swelling in the mandibular left posterior region since 6 months []. History revealed that it was initially peanut sized, 6 months back but had gradually increased to the present size. There was no history of pain, trauma, paraesthesia or anesthesia, or pus discharge associated with the swelling. On examination, there was a solitary well-defined sessile swelling seen on the left body of the mandible, measuring approximately 3 cm × 2 cm in dimension. The skin over the swelling was normal with no abnormalities in the surrounding area. On palpation, there was no local rise in temperature. The swelling was nontender, firm in consistency, noncompressible, nonfluctuant and possessed no mobility. Intraoral examination revealed a mild vestibular obliteration in the region of 34, 35 and 36 []. Root stumps were present in relation to 18, 27 and 37. Based on the clinical findings, a provisional diagnosis of soft tissue tumor was given. The differential diagnoses considered were peripheral nerve sheath tumor, soft tissue fibroma and soft tissue sarcoma. The patient was subjected to various imaging investigations.\nOrthopantomograph showed root stumps in relation to 37 and a subtle change in the trabecular pattern in the periapical region of 35, 36 and 37 []. Occlusal radiograph showed a well-defined soft tissue outline of the tumor on the buccal aspect with erosion of the buccal cortex in the region of 35 [].\nUltrasonography (USG) revealed an ill-defined hyperechoic soft tissue lesion in the deep planes of the left submandibular region abutting the body of the mandible. The tumor revealed ill-defined margins with erosion of the underlying bone and insignificant vascularity. Marginally enlarged lymph nodes were noted in the left cervical region, largest measuring 1.1 cm in dimension. Computed tomography (CT) showed a well-defined encapsulated fusiform soft tissue mass with a de"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old male with stage III IgA kappa multiple myeloma who had completed two cycles of chemotherapy using bortezomib and dexamethasone presented to the hospital for shortness of breath and respiratory distress. His diagnosis of multiple myeloma was made four months prior after he was found to have lytic lesions in the right humerus, left tenth thoracic vertebra, left first lumbar vertebra and right sacrum on imaging performed after a right humeral pathological fracture. The imaging also revealed a large left chest wall mass, thought to be likely from extraosseous involvement by myeloma. Staging workup was completed including skeletal survey and bone marrow biopsy. Bone marrow biopsy showed hypercellularity with 90% involvement by atypical plasma cells which appear as large-sized, binucleated cells with dense chromatin and prominent nucleoli (Figure ). Syndecan-1 (CD138) and kappa light chain IHC staining showed extensive plasma cell involvement belonging to kappa subtype (Figures ). The cytogenetic analysis also revealed multiple chromosomal abnormalities compatible with a complex cytogenetic profile of male karyotype with derivative chromosomes 17, 14 and 10. Serum protein electrophoresis detected a monoclonal spike, with immunofixation detecting IgA kappa type. Serum IgA levels were 2519 mg/dL (normal reference range: 66-436 mg/dL); immunoglobulin G (IgG) and immunoglobulin M (IgM) levels were decreased. The patient was determined to have stage III using the revised international staging system (R-ISS). The treatment plan was to start the patient on nine to 12 weeks of bortezomib, lenalidomide and dexamethasone velcade, revlimid, low dose (VRd) regimen followed by re-staging. However, the patient did not receive lenalidomide due to poor performance status and underlying comorbidities. He then completed two cycles of bortezomib and dexamethasone before presenting to the hospital. At the time of presentation to the emergency room (ER), the patient was in respi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old girl visited our affiliated hospital, complaining of pudendal deformity. The patient was born at 39 weeks of gestation by normal delivery as the second child, and the birth weight was 3,144 g. There was no disorder in the course of pregnancy in her mother. Intake of androgenic medicine or the disorders of ovaries and uterus was not observed by a periodic medical examination. No pudendal deformity was clearly observed at birth, but lateral asymmetry of the pudendal region was noticed at about 4 years old. A child care worker pointed out that she pressed her heel to the crotch while sitting on her folded legs. After 5 years old, her mother confirmed that her clitoral hood clearly hypertrophied. After entering primary school, a teacher in charge pointed out that she pressed her crotch to a chair or bar, and the mother told her to stop it, but she repeated this behavior every day. When she strongly wanted to be absent from an overnight school trip at 9 years old, the mother brought her to the Pediatric Department. Various tests were performed suspecting disorders of sex development (DSD). On the first visit, the height was 132 cm and the body weight was 26 kg. The clitoral hood was enlarged. The appearance was similar to the vulva in children with congenital adrenal hyperplasia, and the clitoris size was 8 x 5 mm. Labial fusion or adhesion was not detected, and the urinary tract and vagina were open at the normal positions. No masculinization, such as acne and polytrichosis, was noted (). Intake of androgenic medicine or the disorders of prepuce was not observed. In the blood test, the sex chromosome was 46, XX. The blood count, blood chemistry, and hormonal test were normal (). On abdominal ultrasonography, the uterus and ovaries were present. Abdominal CT and MRI examinations showed no tumor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 58 year-old female with relapsing remitting MS treated with subcutaneous GA since 2006, and otherwise unremarkable medical history. She presented at our department with a painful livedoid and haemorrhagic skin lesion that developed on her left abdomen approximately 24 h after GA injection. She reported correct injection practice.\nShe had no fever. Blood cell count, C-reactive protein, renal function, creatine kinase (CK), IgE, autoimmune screening, lupus anticoagulants and cryoglobulins were unremarkable. Superficial ultrasonography at skin lesion showed diffuse oedema without fluid collections. The patient was dismissed with symptomatic non-steroidal anti-inflammatory treatment and GA was stopped.\nAfter 2 days, a livedoid violaceous skin patch with dendritic extensions below the injection site became apparent (Fig. and ). At surgical evaluation at the Emergency Department cellulitis was suspected and a surgical revision proposed to avoid potentially lethal complications (such as sepsis and renal failure following rhabdomyolysis). Considering the negative inflammatory parameters and normal renal and CK values, we referred her before surgery to the Dermatology department for further counselling. Here, a NS was suspected and confirmed by a skin biopsy showing coagulative necrosis of dermal collagen and local adipose tissue, as well as several hyaline thrombi inside small and medium-sized blood vessels (Fig. ), without skin infection (cellulitis). Bacteriological culture of lesion samples grew only resident flora. The livedoid figures around the central haemorrhagic skin lesions disappeared spontaneously after a week. The haemorrhagic patch of NS necrotized (Fig. ). The skin necrosis was limited at the dermis and was removed by a surgical debridement. It was treated with a continuing multifunctional dressing to cleanse, fill, absorb and moisten the wound. A healing by second intention was obtained in 2 months after first evaluation. GA was definitively"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n32-year-old woman with CD localized in the small intestine and in the ileocaecal valve has been treated in the conventional manner (azathioprine (2,5 mg/kg), mesalamine (2 g a day) and budesonide (9 mg a day)) for half a year. The diagnosis of the disease was confirmed by colonoscopy, abdominal ultrasound examination, and microscopic evaluation of samples taken during colonoscopy. In the past, the patient was treated by a gynecologist because of chronic ovaritis. She was not suffering from any other diseases and the results of laboratory tests showed only moderate anemia and elevated CRP (C-reactive protein) level.\nDue to the ineffectiveness of such therapy (abdominal pain, diarrhea), she received biological treatment, anti-TNFα (tumour necrosis factor α), infliximab (at a dose of 5 mg/kg) intravenously at weeks 0, 2, and 6 with the outcome of clinical and endoscopic remission. Treatment with azathioprine (2,5 mg/kg) and mesalamine (2 g a day) was continued during the remission period.\nAfter three years, the disease course worsened. In addition to the severity of diarrhea and abdominal pain, an increasing abdominal circumference has been observed, as well as swelling of lower extremities. The patient returned to the gynecologist for consultation. Due to suspicion of ovarian cancer with concomitant ascites, numerous laboratory tests were performed, which showed a decrease of total protein, including albumin fraction, and an increase of CRP and CA125 level, which exceeded the normal upper limits more than five times (). Abdominal ultrasonography and CT (computed tomography) showed the presence of ascites, as well as wall thickening with features of inflammation in the jejunum (). Apart from the so far used mesalamine and azathioprine, budesonide was included to the treatment at a dose of 9 mg a day. Additional tests were performed to rule out infection, tuberculosis, kidneys and liver diseases. Within two months there was no improvement in general condition of the pat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-years-old female at the 14th week of gestation was admitted in April 2016 due to headache, vomiting, and progressive asthenia in the previous 3 weeks. A brain magnetic resonance imaging (MRI) demonstrated a large right thalamic tumor [], and the MRI-spectroscopic study showed a high level of choline and low level of N-AcetylAspartate consistent with a high-grade glioma. She presented fully awake, with a slight left hemiparesis and headache. Later on, due to progressive neurological deterioration, she underwent in May 2 external ventricular drainage (EVD) in local anesthesia and 1 week later craniotomy and partial removing of the tumor under general anesthesia, with continuous fetal heart rate (FHR) monitoring, maintaining good fetal conditions during the operation. At the end of the month, she was discharged following the gynecological evaluation who revealed good clinical conditions of both, mother and fetus. 2 weeks later, she deteriorated neurologically presenting vomiting, stupor, and severe hemiparesis. A brain computer tomography scan showed hydrocephalus and she underwent on the left side, a ventricular-peritoneal shunt. The brain-MRI performed 2 days later showed a light improving the hydrocephalus. The abdomen ultrasonography was normal and she was discharged in good clinical conditions except a moderate left arm paresis. In July 5, a brain MRI showed a large thalamic tumor. In July 7, she had elective cesarean section and the day later, underwent a gross debulking of the tumor. Her clinical conditions improved progressively and in August she began CTX with temozolomide (TMZ) and XRT in a standard way.[,] 12 months after surgery the patient had a moderate left arm paresis with small residual tumor showed on the brain-MRI []. The baby was born with a retinopathy and bronco dysplasia due to the premature birth. He was treated with retinal laser therapy bilaterally and Lucentis intravitreous on the right side successfully. He was also treated with Synagis"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old male from the Netherlands presented with a painless right parotid swelling that was progressively increasing in size for the past 8 months. Though occasionally he suffered from jaw lock, other symptoms associated with neurologic deficit such as drooling, facial weakness, paresthesia, or auditory defects were absent. Apart from being a social alcohol consumer, there was no history of smoking, prior radiation, or significant family medical history, especially in regard to his present illness.\nPhysical examination revealed a tender right parotid swelling below the ear lobule, which extended inferiorly to the angle of the mandible (). The skin overlying the swelling was slightly erythematous, thickened, and nodular. The swelling was firm, diffused, and fixed to the underlying muscles, and there was no associated lymphadenopathy. Otoscopic examination of both ears was within normal limits.\nThe patient initially had a neck ultrasound and then a magnetic resonance imaging (MRI) to characterize the nature of the lesion. The neck CT scan revealed a well-defined altered signal enhancing mass measuring 3.5 × 2.2 × 2.0 cm at the posterior aspect of the superficial part of the right parotid gland (). The radiologist's impression was an altered signal enhancing mass lesion, likely to be a benign pleomorphic adenoma. The patient then underwent MRI of the parotid glands, which showed a well-defined focal lesion of altered signal intensity at the posterior aspect of the superficial part of the right parotid gland, measuring 3.5 × 2.2 × 2.0 cm along its maximum transverse, craniocaudal, and anteroposterior diameters, respectively. The impression was again benign pleomorphic adenoma of the right parotid gland. However, the radiologist could not exclude other diagnostic possibilities and recommend fine-needle aspiration cytology.\nFine-needle aspiration cytology of the mass was nonconclusive as the smears only showed polymorphous population of lymphoid cells in keeping wit"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe presented a case of 32 years old female referred to our Cipto Mangunkusumo Hospital (RSCM) Emergency Department with altered consciousness following by a motor vehicle accident. Two hours before the admission, she was walking across the road when a high-speed motor bike suddenly hit her form her right side. She fell and was unconscious. Then, she was brought immediately to PGC Cikini Hospital and diagnosed as Moderate Head Injury. She was resuscitated using fluid therapy, and they put her into sleep using a sedative. After initial resuscitation, her family asked to refer her to RSCM. When she arrived at the ED, we immediately put her a cervical neck collar and do a few examinations such as head and neck X-ray, FAST, and Head CT-scan. No bleeding or vomiting was observed.\nThe patient was presented with a mainly stable haemodynamic with altered mental status. Local examination of the neck shows no deformity, swelling, bruise, and all normal skin color (). On palpation, all pulsation on the radial artery was regular, yet despite unable check on tenderness, we felt a step off the sign. We avoid moving the head until we obtained the cervical radiograph. We immobilized the patient's neck to protect it by using a hard rigid cervical collar. The sensory and motor function on this patient cannot be assessed because of the previously used sedatives.\nWhen the patient regained her consciousness, she felt numbness and tingling at her four extremities. She also felt weakness using both arms and legs, and she felt that her right half of the body is weaker than the other half. Her urination and defecation control were all normal. On the reflex examination, the patellar tendon and Achilles reflex all in normal function, yet there is a positive sign of Babinski reflex. Her laboratory results showed an increase of Leukocyte levels in 19.600 with possibility due to sterile inflammation, and the patient has Hyp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\n62-year-old Caucasian female underwent right nephrectomy for T4N0 renal cell carcinoma, clear cell type, Fuhrman grade 3/4 in 1999. In January 2001, a CT scan revealed a right adrenal mass and multiple left side kidney masses. She underwent left partial nephrectomy and right adrenalectomy. At that time, the surgical pathology showed renal cell carcinoma, clear cell type, Fuhrman grade 3/4. The tumors were located in the upper and lower portion of the left kidney. The surgical margin at the upper portion kidney was positive. Right adrenal masses were also excised which revealed adrenal gland with metastatic renal cell carcinoma, clear cell type. Surgical margin of adrenalectomy was negative. The patient subsequently had repeated left partial nephrectomy performed in 2004, and again in 2007 for tumor recurrences. The pathology revealed metastatic renal cell carcinoma. On January 27, 2010, the patient underwent left kidney radical nephrectomy, which revealed multifocal renal cell carcinoma, clear cell type, Fuhrman grade 3/4. The largest tumor nodule was 2.5 cm, with tumor extended focally to renal sinus adipose tissue. Tumor located in 0.1 cm from the nearest soft tissue resection margin. The patient was subsequently started on hemodialysis after surgery. In May 2010, the patient underwent evaluation for possible kidney transplant. During the workup, an ultrasound of the abdomen showed a hypoechoic nodule in the body of the pancreas. A CT scan revealed multiple small enhancing nodules throughout the pancreas, best seen on arteriography, which suspicious for metastatic disease of the pancreas (Figure ). On September 20 2010, the patient underwent distal pancreatectomy. Histologically, the tumor consisted of cells arranged in trabecular and alveolar structures with clear or eosinophilic granular cytoplasm, compatible with a metastatic RCC, clear cell type, involving pancreatic parenchyma (Figure ). The surgical margin was negative. Postoperatively, the patient recovered"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe case of a 54-year-old male patient is reported. The patient, an ex-smoker, with systemic arterial hypertension (SAH) and heart failure (Chagasic cardiomyopathy with implanted pacemaker) had been submitted to coronary angioplasty. On being admitted to the emergency room of the University Hospital de Base in São José do Rio Preto, the patient reported he had pain in the right lower limb associated with edema, paresthesia, and coldness that had started suddenly. He also complained of pain in the left leg but said the pain was less intense. A duplex ultrasound of the iliac arteries showed total occlusion by an intraluminal thrombus on the right side with the superficial femoral and popliteal arteries occluded along their complete length. The popliteal artery of the left leg was also distally occluded (bifurcation). Bilateral embolectomy was performed without complications.\nOn the following day, he complained of “burning” pain and said that even the blanket on his legs bothered him. He had difficulty bending and straightening his knee and the sole of his foot. On physical examination, the patient had edema of the lateral and posterior compartments, and a lot of pain on compression, especially of the anterior compartment that was highly sensitive to slight pressure.\nThe chosen conduct was intermittent manual compression (massage) of the musculature of the compartments with the objective of stimulating lymphatic and venous return during the physical examination. The posterior compartment had a 100% improvement in the pain after 20 minutes of massage, the lateral compartment improved the pain completely after around 40 minutes, and the anterior compartment improved the pain by about 70% within one hour. With this improvement, the patient spontaneously bent his knee (without pain) and the sole of his foot (with a little pain in the anterior compartment). The patient was asked to evaluate his pain using an analog scale with the worst imaginary being 10 and no pain at all"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 19-year-old female patient was admitted with a history of headache and vomiting for last 1 month. Headache was more or less continuous and throbbing in nature, gradually increasing in intensity. There was history of right sided weakness since last 15 days. She had past history of menorrhagia at the time of menarche 5 years ago, for which she was treated conservatively and at this time she was diagnosed as a case of idiopathic thrombocytopenic purpura (ITP). She also had history of prolonged bleeding from wounds, gum bleeding, petechial rashes since birth. On examination she was conscious and normotensive, pallor present. Few purpuric spots were noted on her upper limbs. Patient was advised to take corticosteroids by her physician, but she was not taking any medication at the time of presentation. Neurologic examination showed an alert individual with normal higher functions with grade 2 power in both upper and lower limbs on right side. Hemiparesis developed gradually over a period of 20 days which corresponded to slow increase in the size of the chronic subdural haematoma and pressure effect over motor cortex. Ocular fundi showed bilateral papilloedema and cranial nerves were normal. Motor, sensory and cerebellar systems were normal. Deep tendon reflexes were exaggerated with plantars being up-going on right side. Spleen was not palpable.\nAt the time of admission, haematological investigations revealed haemoglobin of 9.0 gm/dl with normal total and differential leukocytic counts. Platelet count was 30,000/mm3. Liver and renal function tests were normal. Bone marrow aspiration cytology showed an increase in the megakaryocyte series, which consisted of monolobate and multilobate forms. CT scan of the brain showed a hypodense lesion at left posterior parietal and occipital region suggestive of chronic subdural haematoma with significant mass affect with effacement of ipsilateral ventricles []. She was given two units of platelet rich plasma (PRP) and three units of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient, a 16-year-old female complained of recurrent instances of swelling on her neck, chest wall, and left arm. Her medical history included two surgeries under general anesthesia with orotracheal intubation; septoplasty (one year prior) and nasal septal perforation repair (two months prior). After septoplasty, she had recurrent epistaxis episodes for six months which were treated with nasal packings when needed. She eventually had a nasal septal perforation and was referred to another tertiary care hospital by her primary surgeon. There she underwent her second surgery under general anesthesia which involved septal perforation repairment. After this surgery she started having epistaxis episodes which were treated with cauterization and nasal packing.\nOne month following the septal perforation repairment surgery, the patient suffered her first episode of subcutaneous emphysema on her left arm, chest, and neck. The chest computed tomography (CT) revealed pneumothorax and subcutaneous emphysema. The pneumothorax was treated with chest tube insertion. The patient underwent an endoscopic examination of head and neck, as well as bronchoscopy to discover the etiology of pneumothorax and subcutaneous emphysema, which revealed normal findings. The subcutaneous emphysema regressed slowly and disappeared. Two months after the first episode of emphysema, she was referred to the pediatric surgery department at our hospital with swelling on her neck and on her upper part of the chest. She underwent a detailed investigation, involving several consultations with otolaryngology, dentistry, pediatric gastroenterology, infectious disease, allergy and dermatology departments, however, these provided little clarity into the patient’s condition. All initial laboratory tests (erythrocyte sedimentation rate, blood count, urine tests, liver and kidney function tests) and cultures (blood, nasal cavities, nasopharynx, lung aspiration and throat for bacteria) were essentially normal. O"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old male with history of Rothmund-Thomson syndrome diagnosed at the age of two presented with acute right mid leg pain while cutting to kick the ball during a soccer game. He reported a history of prior right leg fracture four years ago sustained while playfully wrestling with his younger brother. After the prior fracture healed, the patient noticed a bump at the level of his mid right shin, which corresponded to the site of the patient's current leg pain. He denied any pain in the right leg prior to sustaining the fracture, and he denied any other preexisting medical conditions.\nPresenting radiographs of the right tibia-fibula showed mild deformity of the right tibia from prior healed fracture with mildly displaced and comminuted fracture through the mid diaphysis of the tibia (). Focal anterior cortical thickening of the tibia was present at the level of the acute fracture. The fracture was treated with closed reduction and casting. Serial follow-up radiographs obtained over the next 13 months showed delayed and incomplete union across the tibia fracture (). At the 13-month follow-up, additional radiographs of the left tibia were obtained to evaluate a focal painless bump of the mid left shin the patient reported developing shortly after his right tibia fracture. Left tibia radiographs showed focal anterior cortical thickening of the mid tibia diaphysis corresponding to the palpable bump (). No fracture line or lytic bone lesion was appreciated. The patient did not return for additional follow-up.\nThe patient returned to clinic 4 years later for treatment of a left olecranon fracture sustained during a fall playing soccer 3.5 weeks earlier. Presenting radiographs showed a mildly displaced subacute fracture through the left olecranon (). There was early cortication along the fracture margins and more osteolysis than expected along the fracture line given the reported age of the fracture. Therefore, a bone biopsy of the fracture was performed, which was n"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old female, with a past medical history of minimal change disease, diagnosed two years ago, being treated with a tapering dose of prednisone (on 7.5 mg daily at the time of admission) and biliary cancer status post percutaneous cholecystostomy drain placed 10 days prior, presented to the emergency department with nausea, vomiting, fever, and diarrhea of one-day duration. This was associated with a decreased output from the cholecystostomy drain.\nSix weeks prior to this presentation, the patient had routine monthly blood work done by her nephrologist and was noted to have bilirubin in her urine. Her liver function tests were then ordered which were abnormal and a right upper quadrant ultrasound showed moderate to marked diffuse intrahepatic bile duct dilation with a suspected obstructing mass at the porta hepatis. Outpatient work-up including alpha-1 antitrypsin, ceruloplasmin, antimitochondrial antibody, Hepatitis B, Hepatitis C, cytomegalovirus, iron, and ferritin were all negative or within the normal range. Her antinuclear antibody titer was at 1:40. Given concern for an obstructing mass, the patient was referred to the emergency room for expedited endoscopic retrograde cholangiopancreatography (ERCP). A computed tomography (CT) of the abdomen was done and it confirmed a mass at the hepatic hilum with associated biliary obstruction.\nThe patient had ERCP where she was found to have a high-grade stricture at the hepatic bifurcation. A sample was collected and sent for cytology and a stent was placed within the left intrahepatic biliary tree. The cytology from the ERCP returned as rare atypical cells with no malignant cells. A follow-up magnetic resonance imaging (MRI) of the abdomen was ordered and again showed a solid mass at the porta hepatis. A CT-guided liver biopsy was performed and pathology was pending when the patient was referred to interventional radiology due to continued significant hyperbilirubinemia. The patient underwent a cholangiogram and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old male developed weakness of both lower limbs and severe low back pain after lifting a gas cylinder. Four days later he was admitted to Adan Hospital. X-ray of the lumbosacral spine revealed simple fracture at L1 and L2 vertebrae and magnetic resonance imaging of the lumbar spine confirmed the fracture. Within the next few days the weakness gradually progressed to 3/5 power in the upper limbs and 0/5 in the lower limbs bilaterally and bilateral lower motor neuron facial palsy. Deep tendon reflexes were absent in all four limbs and the plantar response was mute. He was assessed by a neurologist and was transferred to the ICU as he developed respiratory distress and bulbar weakness. NCS showed prolonged distal latencies with conduction block, prolonged F waves, reduced M-wave amplitudes, reduced nerve conduction velocities and absent H reflexes. Blink reflex was abnormal with prolonged latencies and reduced amplitudes. Routine blood counts and blood biochemistry were normal. Connective tissue disease and porphyria screening were negative. Serological tests for M. pneumonia, Epstein-Barr virus and hepatitis virus were negative. Cerebrospinal fluid study was not done because the patient refused it as he had back pain. The clinical and electrophysiological features were consistent with GBS. He was treated with a course of IVIG (0.4 g/kg/day for 5 days). While in the ICU he developed aspiration pneumonia and septicaemia which was treated by meropenem and ciprofloxacin. Follow-up electrophysiological studies showed progression of neuropathy with features of mixed axonal and demyelinating neuropathy. As he did not respond to the initial course of IVIG, he was treated with six sessions of plasmapheresis. However, he continued to be febrile in spite of treatment with appropriate antibiotics. He developed cardiovascular instability and renal impairment. Twenty-five days later the patient expired after developing cardiac arrest and resuscitative measures failed. The"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old man presented to the orthopaedic clinic with an 18-month history of left knee pain, predominantly on the medial aspect of the joint. He experienced night pain, rest pain, and had increasing difficulty mobilising. He had undergone a successful right total knee replacement three years previously. Clinically his knee was in five degrees of fixed varus alignment, and range of movement was 0–100 degrees with pain at the limit of flexion. There was medial and lateral joint tenderness but no other significant findings on examination. Radiographs revealed severe degenerative changes in all three compartments.\nThree months following his initial presentation, the patient underwent an uncomplicated cemented left total knee replacement with a Genesis II Posterior-Stabilised Prosthesis (Smith & Nephew). No synovial plicae were noted at surgery, nor was there any evidence of excess scar tissue within the joint. At review six weeks after surgery he was pain-free and walking unaided; range of movement was from 0 to 110 degrees flexion. At four months post-op he reattended clinic complaining of discomfort on the outer aspect of the left knee. This was treated with topical nonsteroidal anti-inflammatory drug (NSAID) gel and a course of physiotherapy. On review two months later, the pain had worsened such that his general practitioner had commenced amitriptyline as analgesia. He continued to complain of pain on the outside of the knee, particularly on weight-bearing, occasionally radiating down to the foot, and most severe on straightening the knee. On examination there was tenderness over the lateral aspect of the tibial plateau, but not around the fibular head or peroneal nerve. He had an unrestricted range of movement through 0–120 degrees. There was no motor or sensory deficit distally, and radiographs of the prosthesis were satisfactory (). Inflammatory markers did not reveal any evidence of infection (CRP 1 and ESR 5). Due to the presence of a clear mechanical symp"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old woman was admitted to our hospital on 27 July 2021 due to severe chest and back pain and weakness of lower extremities for 11 days. She also complained of urinary and fecal incontinence. Fever was not reported since the onset. She has had a history of hypertension, diabetes and depression. In addition, she used glucocorticoids and immunosuppressant for 2 months because of immune thrombocytopenic purpura. Physical examination revealed symmetrically completely paralysis in the lower extremities, decreased muscle tension, absence of knee and ankle reflexes, and the presence of bilateral extensor plantar reflex. Several subcutaneous lumps in the lower abdomen on the left side were also revealed. The patient’s blood routine, electrolytes, liver and kidney functions were normal, and the test for syphilis and human immunodeficiency virus (HIV) was negative. Albumin is reduced to 26.7 g/L (40–55 g/L as the normal value). Consecutive cerebrospinal fluid (CSF) examinations showed a normal range in white blood cell (WBC) count and significant increase in protein concentration.\nThe cranial and cervical spine, thoracic spine and lumbar spine magnetic resonance imaging (MRI) showed abnormal signal in the spinal cord and the pituitary. MRI examinations were performed for three times from July 29, 2021 to August 10, 2021 in Figs. and . The result shows abnormal signals in the entire spinal cord (cervical spinal cord and thoracic spinal cord) in Fig. A–G. Follow-up MRI of the thoracic spine (Fig. E VS Fig. H) shows cavitation changes in the thoracic spinal cord, suggesting that the lesion has changed in a short period of time, and necrosis and cavitation in the center suggesting infectious lesions. In addition, the posterior soft tissue of the cervical, thoracic and lumbar spine all showed patchy abnormal signals with enhancement, suggesting inflammatory changes. Meanwhile, two nodules were seen on the back of the pituitary gland with T2 hyperintensity in Fig. .\nThe pa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old boy admitted to the University Children’s Hospital of Krakow following the first epileptic seizure. The patient complained of headaches and vomiting. Based on clinical presentation and medical history, intracranial hypertension was suspected. CT scan demonstrated bilateral fluid-filled spaces in the middle cranial fossa (the larger being situated on the left side), with hypotrophy of the adjacent cerebral structures. In addition, CT showed a minimal mass effect manifested as displacement of the longitudinal fissure of the brain to the right and compression and stenosis of the left lateral cerebral ventricle, as well as mild thinning of the squama of the temporal bone at the level of the malformation (Figs. and ).\nIn differential diagnosis, consideration was given to the open type of bilateral schizencephaly or bilateral arachnoid cysts of the lateral sulcus, with type III on the left and type II on the right side (Galassi classification).\nThe CT scan favored the arachnoid cyst (the mass effect, discrete thinning of the squama of the temporal bone), yet schizencephaly could not have been ruled out based on a single CT scan and medical history of the patient. The scan was performed as an emergency procedure in a patient with severe and growing in intensity symptoms of intracranial hypertension, what did not allow for extensive, time-consuming diagnostic management.\nA decision was made on a surgical intervention consisting in implantation of a cysto-peritoneal shunt on the left side. Following shunting, the patient developed complications consisting in small intracerebral and paracerebral hematomas (Figs. and ).\nIn subsequent follow-up scans, gradual resorption of hemorrhagic lesions was seen. The fluid-filled spaces were still present; albeit markedly smaller as compared to the initial scan, discrete asymmetry of the lateral ventricles persisted, but no displacement of the lateral fissure of the brain was detected. The patient improved clinically (Fig. )."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old male with a past medical history of aortic stenosis, hypertension, type 2 diabetes mellitus, dyslipidemia, and benign prostatic hypertrophy presented to the emergency room following a near syncopal episode and fall at home. He described the event as an episode of dizziness and denied any loss of consciousness, palpitations, or chest pain. Although the fall was unwitnessed, the patient’s wife claimed that the patient was fully alert and oriented upon assisting him within one minute of the fall. Of note, the patient did endorse increasing fatigue over the past month but denied any syncope or near syncopal events prior to this episode.\nThe patient was on semaglutide and glimepiride for diabetes and had experienced two hypoglycemic episodes in the past year, however, he stated that this event felt different, and he endorsed no resolution of symptoms after taking a glucose pill. The patient had been on doxazosin 4 mg for several years for the treatment of his benign prostatic hyperplasia without any complaints. Notably, the patient was not on any heart rate controlling medications.\nUpon further investigation, it was discovered that the patient had undergone a treadmill stress test two weeks prior as part of presurgical clearance for a noncardiovascular procedure. The patient experienced no angina during the test, and serial electrocardiograms (ECGs) revealed no ST or T wave abnormalities or arrhythmias. Previous echocardiograms were unable to be obtained as the patient endorsed not having seen a cardiologist in at least seven or eight years due to lack of cardiovascular-related symptoms. The patient did have a coronary artery catheterization performed in 2003 for a complaint of chest pain, which revealed a dominant circumflex system and a normal left ventricular function with no coronary artery disease. No further workup was done regarding this event.\nOn admission, the patient was hemodynamically stable with a baseline heart rate between 50 and 60 beats per"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 13-year-old female patient, known with severe visual field loss, who referred for another opinion regarding the ophthalmological diagnosis.\nAnamnesis at presentation revealed that at the age of 9 years and 3 months, on a routine ophthalmological examination, papillary calcification and retinal hemorrhage were discovered in the left eye. At that moment, the suspicion of intracranial calcifications was raised. The patient underwent clinical neurological examination, EEG, and cerebral MRI, all of them revealing a normal aspect. The patient was also recommended fluorescein angiography, which showed papillary autofluorescence. The diagnosis established then was papillary drusen in both eyes, buried in the right eye and mixed in the left eye and the patient was recommended to keep it under observation, together with a periodical examination of the visual field.\nThe patient had had multiple examinations of the visual field over the time.\nThe first visual field examination of the right eye showed an arcuate nasal defect, in the superior nasal quadrant, sketching an aspect of nasal step, structure of the sensitivity defect that in 3 years time evolved into a quadranopsia.\nIn the left eye, the first visual field examination showed inferior nasal quadranopsia, extended superiorly with a nasal arcuate defect respecting 20° centrally, which after three years evolved into a paracentral diffuse defect with an island of central vision of 5°.\nHowever, over the time, the examination of the visual field was made with different types of machines, and no correlation of the modifications could be made objectively.\nThe patient received several different diagnoses from several different ophthalmologists, among which optic nerve drusen; papillary oedema and hamartoma have to be mentioned.\nAt presentation, the patient’s visual acuity was 20/ 20 with correction for the RE and 20/ 20 without correction for the LE, with a refraction ROD: -1 DSf<> -0.75 DCyl, 179* and RO"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old male with no significant past medical history presented to the ER with complaints of exertional dyspnea associated with flu-like symptoms, including low-grade fevers, chills, occasional episodes of diarrhea, chest pain, and cough productive of yellow to gray sputum for two weeks. The patient initially went to an urgent care facility five to six days prior to admission where he was diagnosed with pneumonia (CXR not available). The patient completed a course of azithromycin and amoxicillin-clavulanate without improvement in symptoms and thus presented to the ER. He reported exposure to sick contacts (children with an upper respiratory infection) and a history of vaping until two to three weeks prior to admission, which he stopped due to the symptoms. History was unremarkable for any exposure to birds, occupational exposures, immunocompromised status, outdoor activities, or recent travel. On presentation, vital signs were remarkable for temperature 38.2°C, heart rate of 115, respiratory rate 33, and oxygen saturation of 76% requiring 3 liters of oxygen via nasal cannula. Lung examination revealed rhonchi on bilateral bases with associated egophony. Laboratory studies revealed a WBC count of 18.3 with left shift, thrombocytosis, and a lactic acid level of 2.2 mg/dL. CXR demonstrated bilateral lower lobe consolidation (Figure ).\nThe patient was admitted for severe sepsis secondary to bilateral pneumonia and was initiated on levofloxacin, which was later changed to vancomycin and ceftriaxone. Infectious disease was consulted due to the failure to respond to antibiotics and the possibility of fungal etiology. Over the course of the next few days, the patient did not show significant improvement. Imaging was repeated and included a CT scan of the chest, along with a CXR, for a more detailed evaluation of the lung parenchyma. This showed a rapidly worsening airspace opacities (Figures , ). Antibiotics were adjusted to include doxycycline, and ceftriaxone (dose"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe study was approved by the Cyprus National Bioethics Committee and informed, written consent was obtained from all participants.\nThe patient under discussion is a 30 year old male, weight lifter with hyper-acute onset chest and back pain. Upon initial evaluation, the patient did not have any manifestation of any phenotypic findings (i.e. iris flocculi, livedo reticularis, aortic valve abnormalities) hinting towards connective tissue disorders or aortic pathology. Based on echocardiography and chest CT findings the patient was diagnosed with a Type A Aortic Dissection with severe aortic valve regurgitation. The patient was then emergently intubated and was transferred to the American Medical Center (AMC) in Nicosia, Cyprus where he had emergency aortic surgery and Bentall procedure. No angiography was performed due to the fact that the patient had aortic dissection and was an emergency. Intraoperative findings showed a 70 mm diameter aortic root aneurysm with dissection extending from the sinotubular junction to the aortic root. The aortic annulus was extensively dilated and the aortic dissection extended down the origin of the left main coronary artery involving also the aortic valve commissures that resulted in severe aortic valve regurgitation. There was no evidence of involvement of the distal ascending aorta and the aortic arch.\nFurther evaluation of the patient’s family showed that several family members had ascending aortic aneurysms. The patient’s father, a 60-year-old male had an asymptomatic aortic root and ascending aortic aneurysm of 52 mm that also required aortic valve, aortic root and ascending aortic replacement (Bentall procedure). Pre-operatively thefather had CT chest coronary angiography that confirmed the presence and dimensions of the aneurysm and coronary angiography did not show any coronary artery disease. The patient’s mother, a 56-year-old female was also screened with echocardiography that showed ascending aortic dilatation, 42 mm in di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA five years old boy, second child of non-consanguineous marriage, born at term with no significant perinatal and past history, presented to our out patient’s department with the complaints of swelling of the whole body. The swelling started insidiously over a course of few days and involved the entire body, including the face, trunk as well as the extremities. There was no associated rash. The child had no preceding symptoms. The swelling was initially progressive but remained static after a few days of onset. The child had no other associated systemic symptoms.\nOn examination, the anthropometry of the child was appropriate for his age. His vital signs, including BP were also within normal limits. Systemic examination was essentially normal. The skin over the face, upper torso, upper and lower limbs excluding the fingers were markedly taut, with non-pitting oedema, woody induration and loss of normal elasticity (Figure ). There were reduction in mouth opening and the temporomandibular joint mobility (Figure ). The sensations were intact and there were no other positive findings. Raynaud’s phenomenon was negative. Routine blood investigations, including urinary examination, renal and liver function tests, electrolytes, ASO titers, chest X-ray, ECG, echocardiography and abdominal ultrasonography were normal.\nThe child was admitted for further investigations. Over the days, the swelling remained constant and no other symptoms or signs developed. The common causes including renal, hepatic and cardiac were ruled out. There were no supportive findings to suspect underlying connective tissue disorders. Considering the cutaneous swelling, the possibility of scleredema was kept in mind. In our patient, the fingers were spared and there was no systemic involvement. The findings in our case were suggestive of scleredema. A skin biopsy was undertaken which revealed normal collagen pattern with smoky bubbly greyish materials histologically consistent with mucin deposition betwe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old man was hospitalized because of persistent fever and chills of 1 month’s duration. He had a history of cholecystectomy, common bile duct anastomosis to the small bowel 5 years previously, and pyonephrosis secondary to transurethral lithotripsy 1 month before the recent admission. He had no history of alcohol consumption and intravenous or illicit drug use.\nPositive physical examination findings on the admission day included fever and mild right upper quadrant abdominal tenderness. Initial laboratory test results showed leukocytosis and elevated acute-phase reactants including the erythrocyte sedimentation rate and C reactive protein, while liver enzymes, creatinine, and electrolyte panel were within the normal limits. Three sets of aerobic blood culture, drawn on admission, were negative.\nOn day 1, computed tomography (CT) scan of the chest and abdomen revealed a filling defect in the IVC, protruding into the right atrium. Fluid accumulation in the retrohepatic and right perinephric space was found. In addition, a hypodense opacity medial to the caudate lobe of the liver, in favor of a hepatic abscess, was noted but not confirmed by the second report ().\nTransesophageal echocardiography (TEE) revealed interatrial septal aneurysm, small-sized patent foramen ovale with a negligible flow, and no evidence of infective endocarditis. A large mass was detected at the origin of the IVC entering the right atrium, suggestive of a clot ().\nMagnetic resonance imaging of the heart, abdomen, and pelvis was performed, and it confirmed the previous findings. It also revealed multiple hyper-intensity signals in the right perinephric space with a restricted pattern and ring enhancement, suggestive of abscess formation ().\nIn light of the imaging and clinical findings, a diagnosis of suppurative thrombosis of the IVC was made and intravenous antibiotic therapy with meropenem (1000 mg every 8 h) in combination with vancomycin (1000 mg every 12 h) was started. This combina"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 9-yr-old Iranian girl presenting to the Pediatric Emergency Room of Moosavi Hospital, Zanjan, Iran in January 2017, with sudden onset of headache and recurrent vomiting, ataxia and history of 3 consecutive days of fever and malaise. There were left eye ptosis and decrement of left nasolabial fold in patient’s face. The patient had tremor and truncal ataxia. The force of the extremities and deep tendon reflexes were normal in physical examination. Her heart rate was 110 min, blood pressure 90/60 mm Hg and temperature 38.2 °C. The patient’s weight was 21 kg and had 133 cm height and head circumference was 52 cm. The patient had no history of head trauma.\nAn informed consent was obtained from her parents in order to publish data as a case report without publishing her name. Ethics Committee of the university approved the study.\nDiagnostic focus and assessment:\nThe patient underwent a brain CT scan without contrast in first day of admission preceded by CBC, diff, BUN, Cr, Na, K, Arterial blood gas sampling (ABG) and Urine analysis. On the second day, brain magnetic resonance venography (MRV) and magnetic resonance imaging (MRI) with flair, T1, T2 and DWI sequences and also EEG were ordered, then lumbar puncture with 3 samples was carried out. About 48 h after the MRI the patient became aggressive and had severe headache, nausea and vomiting plus ataxia and delirium, then the patient transferred to PICU and we decided to order the second CT scan and after the results, we asked for urgent neurosurgery consultation and the patient was prepared for brain surgery. The day after surgery the patient underwent brain CT scan without contrast again and laboratory tests were repeated. The patient underwent the last brain CT scan without contrast on thirteenth day and also had an EEG on the same day. We also did a portable echocardiography"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nTwenty years-old Egyptian male was referred by an internist for neurological assessment. At presentation, the patient was curled up in a fetal position and only bent his head in response to questions, because he was experiencing intense and prolonged attacks of colic centered in his mid-abdomen. The colic attacks started at the age of ten. Early at the onset, the attacks were shorter in duration (few hours to 24 hours) and recurred every 3-5 months. They progressed in duration and frequency as in the last year before presentation, they were recurring weekly and each continued up to 72 hours. The attacks were accompanied by nausea, abdominal flushing, pallor, tachycardia and diarrhea (but never vomiting). The patient said that abdominal discomfort leaves as suddenly as it comes, offering no clue to when it will return. But he recognized eating fish or its products as strong triggers for the colic. The pain was severe enough to make him refuse to eat or drink for prolonged periods. This resulted in unintentional weight loss (the patient was 45 kilos at presentation), slowed growth and limited life activities and school attendance. The referral internist excluded the presence of organic disorder as a cause of patient's manifestations based on medical evaluation and unremarkable laboratory tests (blood, urine and stool analyses), abdominal imaging and endoscopic examinations. Long-term anti-epileptic treatment with carbamazepine was prescribed to the patient by a pediatrician based on the presence of epileptic activity in the electroencephalogram (EEG). Long-term treatment with colchicine was prescribed by another internist because of the misdiagnosis as Mediterranean Fever although the patient never experienced attacks of fever or serositis.\nAt the clinic and in front of the consulting neurologist, the patient developed the attacks of abdominal colic. The patient was not only feeling miserable, but looked it too. He was pale and curled up with sucked abdomen. Neither l"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old female underwent a partial left-sided chest wall resection, with partial removal of the 6th and 7th ribs and of the scapula angle for elastofibroma (). The chest wall defect was reconstructed by using a Mersilene mesh, secured by interrupted pericostal stitches, and covered by a sufficient volume of viable muscles. The postoperative course was uneventful; the radiographic aspect at discharge was normal (). The first symptoms in the form of pains in the region of the incision appeared five months after the operation, and computer tomography (CT) of the thorax showed a lung hernia in the region of the mesh covering the chest wall defect (Figures and ). The patient refused the proposed surgical correction, being only slightly limited in usual daily activities. During the next several months, the symptoms persisted with variable intensity under analgesic therapy, till the moment when pains significantly limited patient's daily activities, 22 months after the operation. The repeated chest CT showed a slight increase in hernia size, with no signs of tumour recurrence (), so that reoperation was planned.\nAfter the excision of the previous skin scar and the incision of the muscular layer, the mesh region was exposed, showing a lung protrusion (4 × 3 cm) along the anterolateral edge of the mesh (). The local situation is schematically presented on . The mesh suture line in the hernia region was completely disrupted, with a small piece of the herniated lung being completely detached from the mesh, the remaining lung surface under the mesh area being fully adherent to the mesh. By careful dissection, the mesh was separated from a firmly adherent lung and removed (). After adhaesiolysis and complete lung liberation, a wedge resection of the afunctional lung tissue of the superior segment of the lingula was done, just in the region of contact with the mesh. After the chest tube insertion, the chest wall defect was reconstructed by suturing a Mersilene mesh in two"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old woman, in good health other than systemic hypertension, lost consciousness soon after complaining of severe epigastric pain at her workplace. The ambulance crew found the patient in cardiopulmonary arrest and paramedics immediately started CPR by manual chest compressions; return of spontaneous circulation and recovery of consciousness occurred 4 min later. On arrival at the emergency room, the patient’s level of consciousness was 14 on the Glasgow Coma Scale, blood pressure was 102/74 mmHg, and pulse rate was 103/min. No cardiac murmur was detected, but vesicular breath sounds were moderately diminished in the left lung field. Cardiac enzyme studies were not consistent with a diagnosis of myocardial infarction. An ECG showed a normal sinus rhythm, and no arrhythmias or signs of myocardial ischemia were observed. A chest X-ray revealed massive left pleural effusion with no right pleural effusion, while cardiomegaly and pneumothorax were not identified. Transthoracic echocardiography demonstrated normally functioning ventricles and valves, and mild pericardial effusion. Computed tomography (CT) showed a type A acute aortic dissection (AAD) with thrombotic occlusion of the false lumen and an ulcer-like projection in the proximal arch, along with mild pericardial effusion and massive left pleural effusion (Fig. ). Occlusion of the branch vessels of the aortic arch and pulmonary emboli were not detected. Immediately after the CT, the patient fell into circulatory collapse. After drainage of bloody effusion from the left pleural space, an emergency operation was begun through a median sternotomy. No sternal fracture and bleeding in the mediastinum were found. When the pericardium was opened, a small amount of bloody effusion was present, but cardiac injury was not observed. In addition, a large laceration (10 cm) was found in the left posterolateral pericardium at the phrenico-pleural junction, through which the pericardial cavity communicated to the left p"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old male patient presented with an enlarging mass in the left maxilla (Fig. ). The mass had been present for a few weeks. An incisional biopsy revealed squamous cell carcinoma. Staging scans were undertaken (Fig. ) which demonstrated a T4N0M0 maxillary alveolus tumour in close proximity to the left orbital floor with obliteration of the maxillary antrum and destruction of the lateral maxillary wall (Fig. ). The patient was partially dentate in both jaws with no significant dental pathology (Fig. ).\nThe findings were discussed with the patient together with the treatment options for this malignant tumour requiring a low-level Brown class 2b maxillectomy []. The patient preference was not to have prosthodontic obturation but rather reconstruction using microvascular free tissue transfer. In view of the unilateral low-level nature of the tumour, a soft tissue reconstruction combined with primary insertion of zygomatic implants to support a subsequent fixed dental prosthesis on a shortened dental arch concept was considered the best option. The remaining molar teeth were planned for extraction based on the potential need for post-operative radiotherapy and likelihood of trismus post-operatively. The remaining maxillary teeth on the non-defect right-hand side were planned for extraction to allow either the placement of immediate dental implants or the placement of conventional zygomatic implants depending on the state of the socket anatomy post-extraction.\nDental impressions were taken to allow construction of a maxillary complete denture template to both aid the placement of the zygomatic implants on the defect side and to act as an occlusal registration device during surgery. The occlusal vertical dimension was also measured between nasal tip and chin point to allow subsequent registration to occur at the correct level during surgery.\nThe patient underwent tracheostomy, a limited left-sided selective neck dissection for node sampling and vessels preparation."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-year-old female child presented with a swelling in front of neck of 1 year duration; on examination, a solitary nontender globular swelling measuring 5 cm × 4 cm was noted in the submental triangle in front of hyoid bone with well-defined borders [], smooth surface, and nontender, it moved with deglutition and with protrusion of the tongue, thyroid gland was clinically normal, there was no lymphadenopathy, and oral cavity was unremarkable. Provisional diagnosis of the thyroglossal cyst was made. Routine investigations and thyroid function test were within normal limits; ultrasound of the neck showed midline swelling in the infrahyoid region with solid and cystic components with hypoechoic mural nodule and multiple foci of calcifications; thyroid gland was unremarkable. Fine-needle aspiration cytology of the swelling showed features of papillary carcinoma. Contrast-enhanced computed tomography scan revealed a lobulated cystic lesion measuring 55 mm × 44 cm × 35 mm in the anterior neck just below the hyoid bone with solid component showing intense enhancement (170–180 HU) []. With above findings, the patient was planned for Sistrunk procedure. Intraoperatively, there was swelling measuring 5 cm × 4 cm in the submental triangle with a stalk extending to the body of hyoid bone [], and going through it, there was no infiltration of surrounding structures and no obvious lymphadenopathy. Postoperative course was uneventful, drain was removed on the postoperative day (POD) 2, and the patient was discharged on POD3. Histopathological report showed a 5.5 cm × 4 cm × 5 cm swelling with solid and cystic components with multiple small papillary projections; on gross examination, microscopic picture showed papillary carcinoma-classical type [] with lymph vascular invasion, and two lymph nodes were identified of which one showed papillary carcinomatous deposits []. After multidisciplinary discussion, the patient was advised total thyroidectomy and bilateral lymph node dissec"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old male with a past medical history of congestive heart failure, non-ischemic dilated cardiomyopathy, atrial fibrillation, and pacer-dependent heart block, presented to the University of Miami emergency department with refractory complex partial seizures. Due to the fact that the patient was pacemaker-dependent, he was unable to undergo MRI. Therefore, a contrasted CT scan of the brain was performed, which demonstrated a heterogeneously enhancing left frontal mass just anterior to the left motor cortex thought to be either a primary central nervous system tumor or a metastatic lesion (Figure ).\nA full metastatic workup was conducted with no primary lesion detected. Given the location of the lesion, further imaging was thought to be necessary for two reasons: 1) to further elucidate the differential diagnosis of the lesion and 2) to help safely guide resection or biopsy of a lesion in close proximity to eloquent brain tissue. As a result, cardiothoracic surgery was consulted for the possible replacement of the patient’s current pacemaker with an MRI-compatible alternative. The patient subsequently underwent the removal of their pacemaker and replacement with a Surescan Medtronic DDD Pacemaker RVDR01 (Minneapolis, MN, US). Following this procedure, an MRI was performed and demonstrated a multi-lobulated, relatively uniformly enhancing left frontal lesion (Figure ). Due to the lack of a definitive diagnosis, the decision was made to perform an awake craniotomy with MRI-assisted stereotactic guidance and intraoperative electrocorticoraphy for a definitive diagnosis. The lesion was able to be resected with the initial pathology suggestive of Mycobacterium tuberculosae brain abscess. The patient was placed on anti-tuberculosis medication and intravenous (IV) antibiotics and discharged home. Approximately one year later, he returned to the hospital after suffering a partial seizure with subsequent right upper extremity weakness. He was found to have a recurrence"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 23-year-old Caucasian woman first presented to our department 15 years ago with a palpable mass in her left breast three months after the delivery of her third child. At the time, she was breast-feeding. She had no family history of breast or ovarian cancer, and no personal history of breast disease. Menarche occurred at age thirteen, and she was nineteen when she delivered her first child. In view of her young age and Ashkenazi Jewish heritage, she subsequently underwent genetic testing, which was negative for BRCA1 and BRCA2 mutations. At the time of her initial presentation, an ultrasound of her left breast revealed a 1.7 cm mass in the area of palpable abnormality, and ultrasound guided fine needle aspiration (FNA) was suspicious for carcinoma. Extensive microcalcifications in her left breast were demonstrated on mammography. A left breast lumpectomy showed extensive intraductal and invasive ductal carcinoma with multifocally involved margins. The largest single focus of invasive cancer measured 1.5 cm. The cancer was 38 % estrogen receptor positive and 35 % progesterone receptor positive. Our patient then underwent a left total mastectomy with axillary lymph node dissection and transverse rectus abdominis myocutaneous flap reconstruction. The pathology at the time revealed additional extensive intraductal carcinoma, and axillary nodes showed no evidence of disease. Postoperatively, she received chemotherapy with cyclophosphamide, doxorubicin (Adriamycin) and 5-fluorouracil and was maintained on tamoxifen and leuprolide for three years. She was monitored closely and was without evidence of recurrence for approximately 10 years.\nFive years ago, our patient was evaluated with mammography, ultrasound and magnetic resonance imaging, which showed no evidence of malignancy in the contralateral breast. Our patient returned six months later, 20 weeks pregnant, at which time her clinical exam was unremarkable. One month later, our patient presented in the 24th week of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old man has a history with blood in the stool for 4 months without clinical examination. He presented with a sudden onset of severe, sharp abdominal pain. He described generalized pain and fever 10 h before hospitalization. There was no nausea, vomiting, and diarrhea. Physical examination revealed tenderness at the hypogastric region, and rectal examination detected a large anorectal polyp. The white blood cell count was 161 G/l with 92% neutrophil. An erect abdominal X-ray revealed a peritoneal free air underneath the left diaphragm. Abdominal ultrasound (US) exposed minimal free fluid in the pelvic region. The whole abdominal CT showed free air and fluid in the peritoneal cavity. Therefore, laparoscopic surgery was indicated to resolve that. The fishbone that was found beside the penetrated sigmoid wall would be removed later. He was sutured the perforated hole in the sigmoid colon and performed ileostomy ().\nThe patient’s symptoms were improved after 5 days. Due to the age of patient and to his history of rectal bleeding, a colorectal endoscopy was indicated and revealed the large pigmented polyp in the transitional zone of the anorectal area and some small polyps in the colon. These small polyps were removed at the moment by colonoscopy. The large pigmented polyp was removed subsequently by local excision. Histopathology showed features of malignant melanoma (). And Immunohistochemical results determined the diagnosis of colorectal mucosa melanoma with Protein S-100, HMB45, vimentin-positive; AE1/3, CD68, and P53 negative ().\nHe was supported and improved his health with oral and vein nutrition therapy. His overall condition was checked, and the malignancy-risk was calculated with chest, abdominal, pelvis CT scan. These examinations couldn’t find metastasis lesions. After the total body skin, ocular-retina, and nasopharynx examination, two pigmented skin lesions were detected and removed later. Histopathological results were benign pigmented tumors ()."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 8-year-old boy treated four years back for bilateral retinoblastoma with enucleation of left eye along with adjuvant chemotherapy and radiotherapy presented with a right forearm swelling. There was no history of trauma. An X-ray revealed a mass lesion in right forearm with destruction of lower one third of right ulna. Later, patient was subjected to bone scan for skeletal metastatic work up. Bone scan was performed three hours after intravenous injection of 5 mCi of 99mTc MDP. Whole body images showed increased tracer uptake in right forearm bones []. Static images revealed increased tracer uptake in middle and lower one-third of right ulna consistent with X-ray findings. In addition, bone scan showed involvement of lower one-third of left radius. Later patient underwent biopsy which revealed round blue cell tumour. However, special stains excluded Ewing's sarcoma and other primitive neuroectodermal tumors (PNETs). Involvement of radius picked up by bone scan had important implication in deciding the nature of disease as Ewings tumor with multi-focal disease as second primary is very unlikely.\nOsseous metastases from retinoblastoma are reported most commonly in the skull and long bones.[] The prognosis for most children diagnosed with retinoblastoma is good, with a 5-year survival of rate of more than 90%.[] Complications include local recurrence, metastases, and the development of a second primary tumor. Focal and diffuse involvement of the bones and bone marrow is known to occur, but metastases are usually seen within two years of initial diagnosis and later metastases are said to be extremely rare.[] These patients are also at risk of increased second primaries like osteosarcoma, leiomyosarcoma, spindle cell sarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma, angiosarcoma, Ewing sarcoma, and PNET. These typically develop after a latent period of 8–15 years.[–] Involvement of multiple bones would point the diagnosis towards metastases rather than multifo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old female was admitted to the surgical department with a two-week history of colicky epigastric abdominal pain, indigestion, and multiple episodes of emesis. Physical abdominal examination revealed tenderness of the epigastrium and a palpable epigastric mass which was misdiagnosed as an epigastric hernia. Patient's vital signs were normal. Rectal examination did not show any abnormal pathology. Laboratory blood tests revealed only a mild microcytic anemia and a mild leukocytosis. Multiple investigations were performed. Abdominal plain X-ray was not indicative and magnetic resonance imaging (MRI) showed two well-defined T2 hypointense and T1 isointense filling defects mass lesions within the stomach. The larger of these within the body of stomach measured approximately 100 × 50 mm and the smaller of these in the gastric fundus measured 40 mm, differentiating between gastric leiomyoma and a bezoar (). History was positive for previous trichophagia and negative for other eating disorders.\nAn upper GI gastroscopy test was recommended and the patient was transferred to a nearby upper gastrointestinal unit for further management where she was investigated additionally with Computed Tomography (CT) () and had a laparotomy and removal of the gastric trichobezoar through a gastrotomy. The patient was discharged 4 days post-op.\nTwo weeks postoperatively the patient presented with generalized cramping abdominal and intermittent back pain, nausea, and vomiting undigested bowel content all consistent with a small bowel obstruction.\nOn examination a distended abdomen was apparent with a palpable, hyporesonant mass in the right lower quadrant region. Abdominal X-ray was not indicative of bowel obstruction; however, CT scan imaging identified a high grade small bowel obstruction which was due to an intraluminal mass ().\nThe patient underwent an urgent laparotomy and a residual trichobezoar mass was found in the jejunum which was removed by enterotomy (). Careful examina"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old female patient reported to a local hospital in Chennai, India, on December 2017 with a chief complaint of swelling in the right lower back tooth region. A solitary swelling was noticed measuring 2 cm × 2 cm in the right body of the mandible which was tender on palpation. Computed tomography (CT) examination showed a multiloculated lytic lesion in the right posterior mandible and had an incisional biopsy done but did not report back to the hospital.\nThen after a month, the patient consulted in another hospital when the swelling increased to the size of 3 cm × 2 cm and was obliterating the right buccal vestibule in the right posterior mandible. Incisional biopsy suggested a mixed tumor with epithelial and connective tissue components. The epithelial components were arranged in narrow strands, cords and islands of proliferating odontogenic epithelium with peripheral ameloblast-like cells and central stellate reticulum-like cells in a richly cellular mesenchymal tissue resembling dental papilla and were diagnosed with AF. The patient did not undergo any further treatment.\nThe patient after 2 years in March 2019 noticed a sudden increase in the swelling and experienced pain in the right posterior mandible region and reported to a private hospital in Amritsar, Punjab, India. An incision biopsy report had suggested spindle-cell sarcoma.\nThe patient was then referred to our institution on July 11, 2019, for further management. CT scan revealed a lytic destructive lesion with cortical thinning and associated soft-tissue swelling involving the ramus and body of the mandible. Incisional biopsy was done under local anesthesia, and histopathology showed highly cellular connective tissue stroma with pleomorphic cells of variable size and shape [] along with numerous mitotic figures. Nuclear features included vesicular nuclei, prominent nucleoli, hyperchromatism and pleomorphism suggestive of spindle-cell sarcoma. The surface epithelium was parakeratinized stratified"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 3-year-old British African girl of nonconsanguineous parents presented to her local hospital with 4 weeks history of a firm, nontender, enlarging swelling arising over the sternum. A few weeks later, there was an additional swelling noted in her left side of her chest (Fig. ). This was preceded by 2 months history of manifesting constitutional symptoms of weight loss, lethargy and night sweats. There was no history of fever, cough, breathing difficulties, rash or any local trauma noted. She had been otherwise well prior to this, with no previous medical history or hospital admission. She was on Movicol sachets for constipation management and no other medications. She was born in Kenya and moved to the UK at the age of 1 year. Her immunisations were commenced in Kenya and completed on arrival to the UK as per the national UK schedule. She had received the BCG immunisation, though the scar was not easily visible; her mother confirmed that she had the immunisation. There were no significant associated sick contacts or TB contacts of note. The child’s mother had suffered from extrapulmonary TB approximately 18 years ago and required treatment. She had unfortunately developed side effects from the treatment, probably drug-induced hepatitis as suggested by the jaundice, which led to her treatment being interrupted, though she subsequently completed treatment. She has been well since then and asymptomatic.\nOn initial examination, the child appeared well nourished and comfortable on room air. She had no signs of respiratory related problems. There was 2 × 3 cm firm, nontender and nonmobile mass over the middle part of her sternum. She also had a second 1 × 1 cm firm, nontender and mobile mass on the left side of her chest. The rest of her physical examination was normal.\nThe initial blood tests at the local hospital demonstrated microcytic hypochromic anemia with elevated erythrocyte sedimentation rate (ESR) of 120 mm and C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 9-year-old Saudi Arabian boy was referred to our hospital for further investigation of slowly resolving pneumonia. He was a product of full-term, uneventful pregnancy, with good birth weight and had an unremarkable neonatal period. Apparently, he remained healthy until the age of 5 years when he started to have recurrent attacks of cough and dyspnea, which were treated with bronchodilator and prophylactic steroid in addition to frequent use of oral antibiotics, with good response. Six months prior to presentation to our hospital, he started to show gradual clinical deterioration. He presented with lower respiratory tract infection not responding to several courses of oral antibiotics. He had no history of recurrent otitis media or sinusitis, no history of skin abscesses, dermatitis or any other skin lesions, and no history of chronic diarrhea. He received all vaccinations as per routine schedule with no apparent complications. The parents were first-degree cousins, but apart from the atopy which both parents have, there was no history of immune deficiency, chronic lung disease, recurrent infections, or early deaths.\nOn physical examination, he showed signs of respiratory distress, tachypnea and hypoxia. His height (120 cm) and weight (17 kg) were below the 3rd centile with weight far more affected than height. There were no dysmorphic features, but he had grade three clubbing of the hands and feet. The tonsils were normal and there was no lymphadenopathy. Although he had received BCG vaccine at birth, there was no evidence of BCG scar. On chest examination, there was coarse crepitation bilaterally. Other systemic examinations were unremarkable. The patient was put on broad spectrum antibiotics. CT scan of the chest showed bronchiectatic changes. Sweat chloride test was normal at two different time points (30 and 35 mmol).\nImmunological findings are shown in and . The high IgE level indicated normal isotype switching and thus ruled out the hyper IgM syndrome. This"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nHerein, we present two patients, brother and sister, 10 and 12 years old, respectively, with a HMSN type I, that underwent talectomy due to untreated severe rigid PEV.\nBoth patients were born from normal pregnancies. In the female patient birth was performed by vacuum extraction and pneumonia was diagnosed on the tenth day of life. The girl and boy started to walk at 1.4 and 1.2 years, respectively, with a peculiar gait. At 7 and 6 years, respectively, the girl and boy started to fall frequently during walking. Later, in both patients progressive deterioration occurred and they had unstable posture and difficulties in walking and required walking aids. Moderate muscular atrophy and weakness of the distal lower limb muscles were also established. They had family members affected by HMSN type I: the mother's sister and the maternal grandmother's sister.\nIn both patients, vibratory sensation was absent in the toes; the median and tibial motor nerve conduction velocities were low, with a markedly prolonged distal latency and low amplitudes; no nerve action potentials were elicited from stimulation of the sural nerves; clinical examination revealed that muscle stretch reflexes were absent in the lower limbs and were decreased in the upper limbs; haematological and biochemical screenings were negative.\nBased on the neurological examinations and nerve conduction studies a HMSN type I was diagnosed in these patients.\nIn both patients bilateral rigid PEV deformity was present in a similar pattern. Bean-shaped foot, prominence of the head of the talus, dorsal callosities on the foot, callosities on the knees, medial plantar cleft, deep posterior cleft, absence of normal creases over the insertion of the Achilles tendon, and calcaneal tuberosity situated at a higher level were established. The entire feet were in severe equinus and varus positions with the forefeet adducted (Figures –). After establishing the equinus deviation in the sagittal plane, varus deviation in the fron"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 63-year-old man with a history of implantable cardioverter-defibrillator (ICD) insertion at the age of 42 for secondary prevention after sudden cardiac arrest (SCA) with shockable rhythm at an outside hospital; since then, he had had recurrent admissions to our facility due to episodes of ventricular tachycardia (VT) (Figure ) despite undergoing trials of multiple anti-arrhythmic medications. He had initially been on amiodarone 400 mg a day; however, he had developed amiodarone-induced hypothyroidism and had been transitioned to sotalol 160 mg BID. The patient had no other major comorbidity or systemic symptoms, no family history of SCA, and no social history of substance abuse. Baseline ECGs showed normal sinus rhythm with normal QRS, and QT intervals. His coronary angiography revealed only mild coronary atherosclerosis (CAD) in the mid LAD (20-30% stenosis). Initial transthoracic echocardiography (TTE) was pertinent only for anterior mitral valve redundancy and prolapse (Figure ) associated with mild MR. ICD had been implanted after his initial presentation for SCA without reversible reason, and for secondary prevention of SCA. During the two decades of follow-up, his left ventricular ejection fractions (LVEF) had remained normal; however, the MVP had become more significant years later after his initial SCA, and MR had progressed to be deemed moderate on the latest TTE (Video ). He had undergone multiple appropriate ICD shocks for monomorphic VT (MMVT) after ICD implantation. The VT captured on 12 leads ECG was suggestive of the origin of arrhythmia from the inferolateral wall of the left ventricle. We also captured premature ventricular contractions (PVC) of at least three different morphologies. The patient could not undergo a cardiac MRI due to incompatibility with his ICD lead. He was referred for an electrophysiology study twice and ablations were performed targeting PVCs; however, he continued to have ICD shocks for VT. Ultimately,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old man with chronic hypertension, benign prostate hyperplasia, and hyperlipidemia visited a local clinic due to fever in June 2016. Blood tests showed increased liver enzymes and inflammation, and he was hospitalized for 28 days. Abdominal CT scans and upper gastrointestinal endoscopy were performed for further evaluation, and he was diagnosed with a suspicious mixed-type intraductal papillary mucinous neoplasm (IPMN), and he was referred to our center for further evaluation.\nFollowing preoperative work-up, surgery was postponed for several days due to continuous infection and mild kidney injury. The kidney injury was induced by colistin administered for multidrug-resistant Acinetobacter baumannii. After kidney function recovered, pancreaticoduodenectomy was performed. Following resection of the pancreas neck in front of the portal vein, we found 2 pancreatic ducts in the remnant pancreas body. Since the superior duct was smaller than the inferior duct, we considered it to be a minor duct of pancreas divisum. However, we were surprised to find that both ducts were opened from the pancreas tail (). We sutured and ligated the superior duct with 5-0 Prolene. The rest of surgery was routinely performed.\nFollowing surgery, the patient experienced a postoperative pancreatic fistula on postoperative day 5 and drainage color changed from serous to sanguineous—called a sentinel sign []—on postoperative day 8. Suspicious contrast leakage was found at the stump of a gastroduodenal artery (GDA) by emergent CT scan and angiography confirmed a pseudoaneurysm of a GDA stump. Emergent stent-graft placement was performed (). The patient recovered and was discharged on postoperative day 24. The pancreatic fistula was controlled and drainage was removed. Final pathological diagnosis was confirmed as IPMN-associated invasive marginal-free carcinoma and two lymph node metastases were found in 12 lymph nodes.\nFollowing patient recovery and discharge, we reviewed the surgical r"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn October 2014, a 48-year-old woman was referred to the Department of Oncology at the Medical University of Vienna. Because of acute dyspnea, vertigo and precollaptic condition, the patient had been admitted to a peripheral emergency department 2 weeks before. Since pulmonary embolism was suspected, an immediate CT scan was performed, which showed multiple pulmonary nodules and a circumferential pericardial effusion. Subsequent transthoracic echocardiography confirmed a pericardial effusion of 3 cm with an end-diastolic compression of the right atrium and ventricle besides normal performance and size of the left ventricle.\nBecause of rapidly worsening clinical condition due to tamponade physiology, an emergency pericardiocentesis was done but the patient developed hemodynamic instability. Since iatrogenic trauma of the right atrium was suspected, the patient was transferred to the surgery department, where an emergency sternotomy had to be performed. During surgery, a 6 × 3 cm big right atrial mass was detected and subsequently entirely resected. The defect of the right atrium was restored with a nonvascularized pericardial autograft.\nThe patient's postoperative course was without any complications and a control echocardiography showed minimal pericardial effusion, a normal left ventricular systolic function as well as normal ejection fraction. Since histology revealed cardiac angiosarcoma (tumor cells stained positive for CD34), the patient was transferred to our oncology department for further examination and treatment.\nBesides progressive multiple pulmonary nodules, a postoperative CT scan of the chest and abdomen showed no further distant metastases and no evidence of recurrence of the angiosarcoma in the right atrium. The patient had no prior medical history nor concomitant medication and after careful consideration, the patient was included in a clinical trial in which the combination of paclitaxel 70 mg/m2, days 1, 8 and 15 each 28 days, plus pazopanib 800 m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old male was brought to our Emergency Department with 1 month of confusion. He was completely normal 1 month prior, running a successful small business. The patient's wife initially observed confusion which worsened with impaired functioning, impairing his ability to work and care for his children. The patient was initially brought to an outside facility around 2 weeks into this illness. At that time, his symptoms had progressed to difficulty recognizing family, mutism, and hypersomnia. He then developed myoclonus with agitation and combativeness. MRI and CSF analysis from the outside facility were unremarkable (including an initially unavailable report of “unlikely prion disease” with no 14-3-3 protein detected). The patient was released with eventual admission to our hospital. By week 4 of his disease, he became bedridden, disoriented, and unable to recognize family. He developed myoclonic jerks and did not follow commands. Moreover, he had moderately increased muscle tone and incontinence. He never developed psychiatric manifestations. His clinical course continued to decline with subsequent intubation for airway protection by week 5 with deterioration by week 6 to GCS of 1/1/1. He has remained in this state ever since.\nPast medical history was significant for remote history of nasal carcinoma. The patient took no home medications. His surgical history was significant for nasal carcinoma resection. Family history consisted of a father with hypertension. The patient denied using tobacco or drugs and used alcohol socially only. He ran a busy automobile mechanic business. He traveled to El Salvador 1 year prior to presentation. There are no recent sick or animal contacts.\nAt our hospital, he was never febrile with stable vital signs. After his initial negative MRI at the outside facility, MRI head began to show bilateral caudate and basal ganglia abnormality on T2 as well as DWI. Additionally, there is a cortical ribbon involvement in the posterior portion"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCase reports are exempt from institutional review board approval at our institution.\nA 75-year-old woman was evaluated for long standing right-sided nasal obstruction, dependent mouth breathing, clear rhinorrhea, congestion, and hyposmia not relieved by intranasal steroids or nasal irrigations. She initially presented with a history of previous endoscopic sinus surgery in Russia more than 20 years ago followed by nasal polyposis treated with ambulatory cauterization. She was also noted to have a history of nonmelanotic skin cancers of the nose treated with radiation in Russia.\nPhysical exam findings included a fleshy intranasal lesion that, in the setting of previous nasal skin cancer treated with radiation, raised a concern for possible secondary carcinoma. Computed tomography showed complete opacification of the right maxillary sinus, obstruction of the right ostiomeatal complex, and soft tissue density in the right nasal passage ().\nInitial biopsy revealed a nasal mass that originated in the right inferior meatus. Pathology showed multiple polypoid fragments lined by a respiratory type epithelium with underlying edematous stroma with mild chronic inflammation. There was invagination of the surface epithelium into the underlying stroma resulting in nested aggregates of bland glandular and mucinous cells and focally benign squamous epithelium (). These features were found to be consistent with a benign inverted papilloma.\nThe patient presented with continued nasal obstruction and was evaluated for definitive treatment. Given her diagnosis of inverted papilloma and chronic rhinosinusitis, complete excision and revision endoscopic sinus surgery was recommended. During endoscopic sinus surgery, an exophytic mass with abnormal maxillary mucosa was seen emanating from the left inferior meatus that was thought to originate from the right maxillary sinus, given that it was protruding through a bony dehiscence into the inferior meatus and nasal cavity. Right partial inferi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old woman with a past surgical history for a poorly differentiated thyroid cancer presented with a 2 × 2 cm mass between the trachea and the esophagus. The patient already had right recurrent laryngeal palsy from the first treatment. This recurrence was detected by computed tomography (CT), and was shown to be rapidly enlarging over the course of two months (Figure \n). The lesion was also examined by fluorodeoxyglucose (FDG) positron emission tomography (PET), which showed high FDG uptake (maximum standardized uptake value, 15.45) and demonstrated a recurrence of thyroid cancer (Figure \n). After providing written informed consent, the patient underwent surgical resection of the recurrent thyroid cancer with the new procedure. The patient was positioned under general anesthesia in a supine position on the operating table with her neck hyperextended. Through a transverse cervical incision made just along the previous surgical scar, a tracheotomy was performed. The tumor was easily detected through the tracheostoma, then delineated by palpation. The mucous membrane of the trachea was minimally incised along the right-hand border of the tumor and a mucosal flap was elevated (Figure \n). The left-hand side of the trachea including the membranous wall and cartilage of the tracheal mucosa was maximally preserved, to maintain the vascular supply to the trachea. Finally, the membranous wall of the trachea was preserved to within one-third of the left-hand side (Figure \nA). Bleeding from both cut edges of the tracheal mucosa was confirmed. There was no extracapsular spread and the tumor was removed completely with the muscular layer of the esophagus. Intraoperative frozen examination revealed that the tumor was completely resected. A right sternocleidomastoid muscle flap was elevated and inserted into the cavity resulting from the tumor resection and sutured between the esophagus and the trachea. The membranous wall of the tracheal mucosa was also sutured submucosall"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old man was evaluated for bilateral hilar opacities on radiographs by a contrast-enhanced CT of chest. The patient had significant history of bilateral femoral vein thrombosis two years back for which the patient was hospitalized; the patient also had recurrent episodes of hemoptysis for last one and a half year for which he did not undergo any imaging and which was managed conservatively with antibiotics. The patient had also developed aphthous ulcers in the past year that lasted for two to three weeks. There was no evidence of genital ulcers, uveitis, or skin lesions either historically or on physical examination. Laboratory studies were remarkable for a raised ESR. ANA and RF were absent; coagulation studies were normal. CECT chest revealed large saccular aneurysms involving the segmental branches of lower lobe arteries bilaterally and right upper lobe artery []. The bronchial arteries were hypertrophied; eccentric, organized thrombi were seen in few aneurysms []. Pulmonary angiography was performed through the jugular vein as transfemoral cannulation was not possible because of bilateral femoral vein thrombosis which confirmed the presence of multiple pulmonary artery aneurysms. The final diagnosis of Hughes-Stovin syndrome was made. The possibility of incomplete Behcet was also considered as the patient did not fulfill the diagnostic criteria of the complete Behcet's syndrome. The patient was put on topical steroids (as mouth paint for oral ulcers), systemic steroids, and azathioprine (in view of pulmonary vasculitis and aneurysm formation); the steroids were subsequently tapered and withdrawn after 6 months (aspirin and anticoagulation were avoided in view of hemoptysis). More than one year of follow up has documented the resolution of oral ulcers without any fresh recurrence; there has been no fresh episode of deep venous thrombosis. The patient had two episodes of mild hemoptysis which was managed conservatively. There was no evidence of enlargemen"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAt 9 pm a ‘29-year old female’ Para 0 +0 was admitted via Accident and Emergency department of our hospital complaining of severe abdominal pain starting earlier in the afternoon. She reported recent attempts at termination of a 10 weeks unplanned and undesired pregnancy at an outside clinic. According to the patient about three to four weeks earlier as a part of workup done for fever revealed pregnancy of about 10 weeks duration. She took some abortificient to abort this unintended pregnancy. She developed bleeding per vagina following that, for which she had uterine evacuation at some small clinic. After that she came home, but next day she started to bleed heavily per vagina, so she went back to the same place and was prescribed tablet misoprostol twice daily. According to her she took this tablet for 1 week but as she continued to bleed so she again visited the same clinic and second uterine evacuation was performed on her. After 2 or 3 days she returned to the same clinic because her bleeding had not yet subsided. A third attempt on uterine evacuation was made but this time there was lots of pain which was unbearable, so the person attempting the evacuation gave her some intravenous sedation and completed her job. After returning home, the patient almost collapsed due to severe pain, so her family brought her to hospital.\nOn presentation to our hospital she was conscious, pale and in obvious discomfort, her BP was 115/77 mm Hg, pulse 99/min, temperature was 99.2°F. Abdominal examination revealed generalized tenderness and guarding all over the abdomen. Bowel sounds were absent. On per vagina examination, there was no active bleeding but vagina was hot, uterus was about 10–12 weeks size, mobile and cervical os was closed. Her blood investigation showed Hb 7 gm/dl, white cell count 9.6 × 109/l, platelets were 278 × 109/l. urea, creatinine and electrolytes were all within normal limits"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old male with a permanent IVC filter that had been inserted approximately 20 years ago when the patient developed a DVT during a hospitalization for severe non-ischaemic cardiomyopathy, was transferred to our medical intensive care unit for shock and acute renal failure. Following the IVC insertion, he had been treated with warfarin for one year and had been on anti-platelet therapy since.\nHe had been admitted to the hospital three days prior to transfer after presenting with progressive bilateral lower extremity pain and decreased sensation in his gluteal region. Acute bilateral DVTs involving the common femoral and popliteal veins were diagnosed. Over 48 h, despite receiving unfractionated heparin, he developed anuric renal failure and shock. Placement of a right internal jugular dialysis catheter was complicated by airway compromise due to a retropharyngeal haematoma necessitating endotracheal intubation. The heparin infusion was discontinued and the patient was transferred to our hospital.\nOn arrival, his mean arterial pressure was 71 (104/53) mmHg while on norepinephrine, vasopressin, and phenylephrine. Arterial blood gas analysis showed a pH of 7.06, partial pressure of carbon dioxide (PaCO2) of 28 mmHg, partial pressure of oxygen (PaO2) of 312 mmHg, and a lactate of 16 mmol/L. The platelet count was 31 K/μL. Examination was notable for tense bilateral lower extremity oedema. Dorsalis pedis pulses were detectable with Doppler ultrasound. An abdominal computed tomography (CT) showed dilation of the distal IVC suggesting thrombosis (Fig. A). Transthoracic echocardiography showed a 25% ejection fraction with no right ventricular dilation or strain. The IVC was collapsible proximal to the hepatic veins. Lower extremity ultrasound confirmed acute bilateral DVTs involving the external iliac and femoral veins. Laboratory evaluations excluded thrombophilia, heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura. Infusion of 5 L of isotonic"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 15-year-old male with renal failure was referred to our center for dialysis treatment. Two weeks prior to referral, he was brought to an orthopedist for a suspected bone disorder characterized by worsening lumps on his left hand and ankle, which was noticed by his mother about 1 year before presentation. However, she had assumed that the swelling to his left hand was due to biting. In addition, swelling to his left ankle occurred after several leg strengthening exercises conducted by a physiotherapist. The orthopedist later recommended magnetic resonance imaging (MRI). On MRI preparation, the patient was found to have a high urea level and was thus referred to a pediatric nephrologist who subsequently initiated dialysis. His mother also claimed that the urine volume of her son had decreased within the last few weeks. On the second day of hospitalization, the swelling in his left ankle burst and thick masses containing blood, debris, and white crystalized materials were observed.\nThe patient was born to healthy non-consanguineous parents with no family history of HPRT deficiency (). At the age of 1 day, the patient developed stiffness in both hands. When he was 2 months old, he was diagnosed with severe psychomotor retardation and could only lie down. A pediatric neurologist diagnosed the patient with cerebral palsy at the age of 7 months based on computed tomography results showing cerebral atrophy. The patient has a habit of biting his lower lip, buccal mucosa, and left hand, which was evident since the age of 6 years, for which an occlusal bite guard was once used years before to protect his teeth. However, he refused to use it, which resulted in the extraction of some of his upper teeth. At present, he is unable to talk or communicate normally, but can express anger through agitating behavior. Moreover, his parents remarked about the occasional presence of orange sand-like sediments found in his diaper, which first occurred at the age of 3 years. However, a loc"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old gentleman with a known case of diabetes mellitus, hypertension and dyslipidemia was admitted with complaints of fever, headache, cough and dyspnea. Nasal and oropharyngeal swab for the real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 came out positive. Chest X-ray showed accentuated bronchovascular and perihilar marking with multifocal patchy ground-glass opacities in the bilateral lung field. He was hospitalized with severe COVID-19 pneumonia; his respiratory status deteriorated rapidly for 3 days since admission and required high oxygen and intubated ventilation due to respiratory distress. During his ICU course he developed sepsis and required broad-spectrum antibiotics. He had acute kidney injury for which he required one session of dialysis and improved with medical treatment. He started per rectal bleeding and was managed conservatively with input from the gastroenterology team. He had high troponin and the cardiology team was consulted and their opinion was of type 2 myocardial infarction secondary to sepsis and managed conservatively. Echocardiography showed a normal ejection fraction of 56% without any left ventricle clot. He was successfully extubated after 14 days. He developed critical illness myopathy after the prolonged ICU course.\nAfter one month's stay in the intensive care unit (ICU) with recovering from critical COVID-19 infection, the patient developed of sudden onset of bilateral painless loss of vision for 1 day. On examination right eye had perception of light only and the left eye with the counting of fingers at 1 meter with normal intraocular pressure. Right fundus showed severe non-proliferative diabetic retinopathy (NPDR), Weiss ring floaters, peripheral flat retinal break and peripheral degeneration whereas the left eye with severe NPDR, peripheral degeneration which could not explain his sudden vision loss. MRI head diffusion-weighted image (DWI) showed a tiny right deep frontal acute ischemic stroke (as show"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 11-year-old girl reported to the Department of Pedodontics and Preventive Dentistry, Dr. D.Y. Patil Dental College and Hospital, Pune, with the chief complaint of discolored teeth since childhood.\nThis little girl's parents did not seek any treatment previously, thinking that since the condition was not resulting in any other systemic manifestations and since she had inherited the condition from her father, there was little they could really do about it and accepted it as part of her appearance. It was only now, when they realized that the girl avoided hard food substances, they got her to a dentist.\nOn enquiry, it was revealed that her deciduous teeth were also similarly discolored, and her father, younger brother of eight years, and younger sister of six years, also suffered from the same condition. The pedigree chart could be constructed as in .\nApart from this, her past medical history was noncontributory. The history did not reveal any eruption disturbances. From a functional point of view, she had been avoiding hard food substances; at the same time, remaining caries free, except for a sole proximal carious lesion in 36, involving the enamel and dentin.\nOn intraoral examination, it was found that she had a normal complement of teeth. The thickness of enamel was reduced on the teeth and was completely chipped off from some teeth exposing the dentin. The surfaces of the teeth were rough. The teeth, in general, exhibited a yellowish brown discoloration, with diffuse pitting present on the exposed tooth surfaces, more prominent on the labial and buccal aspects. The emergence pattern and timing of teeth seemed to be within the normal range. No open bite was present. Examination of the periodontium revealed the presence of chronic, generalized, marginal, and papillary gingivitis, with calculus deposition and unsatisfactory oral hygiene [Figures –].\nA provisional diagnosis of hypoplastic, rough autosomal dominant AI"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe report a case of a 6-month old girl referred to the Nairobi hospital with a massive, progressively growing congenital mass in the oral cavity. A thorough medical history revealed no co-morbidities with all vital signs within normal limits. Upon physical examination, the patient was found to have difficulty in breathing, difficulty feeding and inability to close the mouth. Intra oral examination revealed a large swelling involving more than two-thirds of the tongue, most of which lay outside the oral cavity (Figure ). The lesion was a deep red-purple color, soft on palpation, non-tender and normal in temperature with no appreciable thrills but blanched on application of pressure. Examination of the surrounding structures was unremarkable.\nMagnetic Resonance Imaging (MRI) with gadolinium revealed a well-circumscribed soft tissue mass measuring 3.9 cm × 4.1 cm × 5.8 cm. It involved most of the tongue except for the base and extended to both lateral borders, while inferiorly, involved the entire thickness of the tongue to its ventral surface. The mass was hypointense on T1-weighting and was found to be hyperintense on T2- weighting. Multiple low signal foci were noted which were compatible with flow voids (Figure ). Digital subtraction angiography revealed the feeder vessels to be anomalous branches of the lingual arteries. These findings, coupled with blood collection in the interior of the lesion, informed the diagnostic hypothesis of a congenital lingual hemangioma.\nThe lesion was monitored closely over a period of 1 year with the expectation of improvement by involution, however, the lesion showed no signs of reducing in size and in fact enlarged over this duration (Figure ). After a multidisciplinary discussion, immediate embolization of the feeder vessels and subsequent surgical resection of the lesion was proposed in order to improve the quality of life for the patient and prevent fatal airway obstruction. Embolization of the lingual arteries (LA’s) was perfor"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 68-year-old woman (166 cm, 67 kg) with chief complaints of hoarseness, frequent coughing, and mild orthopnea was diagnosed with a recurrent vocal papilloma. The patient provided written informed consent for publication of her information and images. Approval by an ethics committee was unnecessary because of the nature of this study (case report). The tumor had been first recognized 16 years ago, and she underwent two surgical resections in 1996 and 2002. In 2002, a 6.0-mm internal diameter cuffed oral preformed tube was used to intubate the patient without problems. At the current presentation, however, the recurrent mass had grown to approximately 1 × 2 cm, which was larger than that during the previous surgeries. The pedunculated papilloma seemed to originate in the left vocal cord and extended to the subglottis, occupying most of the glottic airway (). During the preoperative visit, the patient’s airway was classified as Mallampati class 2 and her neck extension was slightly stiff. Her lung sounds were clear, but she constantly coughed while sitting upright and expressed that her breathing was uncomfortable while in the supine position. The anesthetic plan regarding the use of a flexible fiberoptic bronchoscope and McGrath® videolaryngoscope and the possibility of awake intubation were explained to the patient. The patient understood and agreed to undergo the procedure.\nThe patient was premedicated with intramuscular injections of 0.5 mg atropine and 1.5 mg midazolam. On arrival in the operating room, the patient was sufficiently preoxygenated and subject to monitoring. Simple bipolar electrocardiographic monitoring and a finger pulse oximeter were applied, while noninvasive blood pressure was measured with a cuff on her upper arm. Her body temperature was monitored with an axillary temperature probe. In the operating room, the patient was still intermittently coughing and seemed to struggle with secretions. To stabilize the patient and obtain a better view of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45 year old female presented with complaints of irregular bleeding per vaginum off and on since the last two months. The general condition of the patient was stable. Per speculum examination revealed a large, firm mass protruding out from the cervical os. Ultrasound scan of the pelvis showed an enlarged uterus with a well defined heterogenous and hypoechoic mass lesion in the posterior lower uterine wall and extending to the posterior cervix, measuring 96 × 62 mm []. Both ovaries could not be localized because of the large uterus and the overall impression was that of a uterine fibroid. The patient was then taken up for surgery and hysterectomy with bilateral salpingo-oophorectomy was done in view of the enlarged left ovary. Peritoneal washings were also taken.\nA specimen of uterus with cervix and bilateral adnexa was received in the laboratory. Gross examination showed a firm, globular mass which had widened and distorted the cervix. It measured 9 × 6 × 6 cm, cut surface was firm with a whorled appearance and was attached at the isthmus. The endometrial thickness was 4 to 5 mm and no evidence of adenomyosis was seen on gross examination []. The left ovary was enlarged and measured 6 × 4 × 5 cm with a smooth external surface. The cut section was firm with multiple cysts ranging from 1to 3 mm in diameter filled with brownish colored fluid []. The right ovary measured 2 × 2 ×1.3 cm with a smooth external surface and was cystic on cut section. Microscopic examination confirmed the firm, globular mass to be leiomyoma with areas of myxomatous degeneration. Endometrium was in proliferative phase with no evidence of endometrial hyperplasia. No foci of adenomyosis were seen. The right ovary showed a benign follicular cyst with histologically normal fallopian tubes. Peritoneal washings were negative for malignant cells.\nThe enlarged left ovary showed a solid tumor comprising of glands with intervening fibrous stroma. The glands were of varying sizes from small round to lar"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old woman presented to our hospital with numbness in her left arm. Her left arm and back had been larger than the contralateral side since birth and this had increased over time with partial functional difficulty. Sometimes, she felt numbness in the left arm, which worsened when it was lowered. She had been examined at various hospitals and diagnosed with a vascular malformation but had not yet received any treatment.\nThe patient had experienced severe numbness in her left arm for the previous two weeks. This was not relieved by painkillers. It was often necessary to lift the arm above her head in order to feel more comfortable.\nOn physical examination, the entire arm and part of the left back were deformed, being larger than the opposite side (), but the two arms were of equal length. The skin on the left elbow, hand, and back had a bluish tint. The affected region had multiple swollen areas which were different in size, squash, and easily compressible. Some hard round particles could be felt under the skin. The peripheral pulses were symmetrically palpable, and no temperature difference was observed. No abnormalities were found in the cardiovascular system or in other organs.\nBlood tests demonstrated higher than normal levels of D-dimer (> 7.65 mg/L compared to the reference value of < 0.48 mg/L), and the prothrombin time (PT), prothrombin time ratios (PTr), International normalised ratio (INR) values and platelet count were within normal ranges.\nAn ultrasound examination of the left arm revealed numerous subcutaneous tubular structures. These were thin-walled with an anechoic lumen, completely compressible, and colour flow was present with low velocities on Doppler ultrasound. These features were consistent with the telangiectatic superficial veins.\nInside these structures were many echogenic particles with posterior acoustic shadowing consistent with phleboliths (). The axillary, brachial, ulnar, and radial arteries had normal diameters"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old male presented with the left cervical and submaxillary lymph node enlargement with size of 30 mm × 30 mm. The following lymph node biopsy was completed and the pathological evaluation showed reactive lymphoid hyperplasia characterized by vascular, atrophic germinal lesions with surrounding concentric “onion skin” layers of lymphocytes (Fig. ), defined as the hyaline vascular variant of CD. He denied weight loss, lymphadenopathy, tuberculosis, diabetes mellitus and hypertension. He gave no history of bone pain and drug abuse. The bone marrow (BM) cytology indicated no clonal plasma cell infiltration. Thereafter the patient was treated with irradiation dose of 30 Gy in 10 fractions with clinical response. The clinical evaluation remained stable in annual follow-up visits. In the 4th visit, the patient was diagnosed in an outside hospital with 2-diabetic mellitus on basis of increased blood glucose, C peptide release test and oral glucose tolerance test (OGTT). The blood glucose was well-controlled by the hypoglycemic and diet therapy for three years when he presented to the previous hospital with progressive hand-foot numbness spreading from the proximal extremes to distal ends. The electromyography test confirmed the hampered nerve conduction velocity of bilateral ulnar, median and peroneal nerves. The cerebrospinal fluid (CSF) biochemistry from lumbar puncture indicated the slightly elevated protein (1.1 g/L, normal, 0.1~ 0.4 g/L) with normal cell count. The blood monoclonal protein level and bone marrow cytology was normal. Based on the resultant diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP), the patient was treated with daily intravenous pulse methylprednisolone therapy of 1.0 g for three consecutive days. Due to the minor clinical response, the diabetic peripheral neuropathy was suspected with following insulin injection and oral mecobalamin therapy. However, the manifestation of hand-foot numbness remained constant. One and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 64-year-old man developed a painless nodule or mass in the nasopharynx. He had a history of dizziness and headache for more than 10 years without obvious cause. The patient also had a history of hypertension. After taking antihypertensive drugs regularly, the headache was relieved. However, the dizziness and headache later increased further for 1 week, and on February 27, 2019, he was admitted to a hospital. The patient underwent surgical treatment for benign prostatic hyperplasia in May 2006. The patient had no history of trauma, no family history of any hereditary illness, and his neurological examination findings were normal.\nHead computed tomography (CT) examination showed a low-density mass in the nasopharynx that protruded into the cavity and had a regular shape and uniform density. The left eustachian tube and pharyngeal orifice had disappeared and the right pharyngeal crypt had become shallow (). Video laryngoscopy also revealed a left nasopharyngeal mass. To confirm the diagnosis, enhanced CT of the nasopharynx was performed, revealing a mass-like shadow on the posterior lateral wall of the left nasopharyngeal roof (). The enhanced CT image was very uneven in the arterial phase () but became intense in the venous phase, and small, patchy, low-density shadows were observed (). Based on the preoperative imaging results, the patient was provisionally diagnosed with nasopharyngeal angiofibroma. Angiography revealed a hypervascular tumor fed by branches of the left carotid artery. To control intraoperative bleeding, the patient underwent preoperative endovascular embolization. Subsequently, the otolaryngologist performed surgical removal of the tumor through a nasal endoscope. During the surgery, it was noticed that the tumor tissue pedicle was located on the posterior lateral wall of the left nasopharyngeal roof. The tumor was completely removed along its pedicle without the occurrence of massive intraoperative hemorrhage. The tumor tissue had a medium textur"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 53-year-old woman was aware of bloating and anorexia for 2 months before visiting the hospital. She had visited another doctor previously because of persistent symptoms. Her medical history was only bronchial asthma and she had no history of abdominal surgery. The physical findings revealed bloating, softness, and no tenderness in the abdomen. Obesity was also recognized for a body mass index (BMI) of 41.7. Upper gastrointestinal endoscopy showed a huge ulcerative lesion on the posterior wall of the stomach accompanied by a small amount of bleeding (). Biopsies of the ulcer showed a dense infiltration of short spindle cells. Expression of c-Kit was positive by immunostaining, suggesting GIST. We performed an abdominal enhanced computed tomography (CT) scan, which revealed thickening of the posterior wall of the stomach and a continuous heterogeneously enhancing mass protruding outside the stomach wall (23.4 × 21.1 cm; ). The tumor largely occupied the upper to lower left abdomen, and part of tumor was notably stained around this. Furthermore, another large tumor in the pelvic cavity was also detected on the CT scan (13.8 × 13.1 cm; ). The uterus was visible, but the bilateral ovaries were unclear because of the huge tumor. Blood sampling data showed Hb = 9.0 and anemia. Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were within normal limits; however, her carbohydrate antigen 125 (CA125) levels were highly elevated to 818 U/mL (normal = <35 U/mL). She was diagnosed with a giant GIST originating from the stomach with peritoneal metastasis. In the current case, the tumor was large and difficult to remove. Furthermore, the risk of recurrence was high, even if resection was possible. We decided to administer imatinib as preoperative chemotherapy and then perform surgery. She started imatinib at 400 mg/day for 4 months and did not present any side effects. Four months after initiation of imatinib, abdominal"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old male was admitted to our hospital with clinical evidence of encephalopathy. Physical examination revealed mild jaundice. The patient’s medical history included hypertension, diabetes mellitus, knee arthrosis and resection of a basal cell carcinoma in the nose. The patient was also considered to have hepatic disease, probably related to alcohol consumption. There was a history of alcohol abuse, but the patient referred abstinence from alcohol consumption for the past 6 years.\nLiver function testing revealed normal transaminase levels and a total bilirubin level of 2.16 mg dl–1 (normal, 0.20–1.20 mg dl–1). Serum total protein and albumin were within normal ranges. On haematological studies, no anaemia or coagulopathy was observed. Serum ammonia level was elevated, at 174 μmol l–1. Serologic markers for hepatitis B and C were negative; α-fetoprotein was also negative. Laboratory findings on admission are summarized in .\nAbdominal ultrasonography revealed a diffuse heterogenic echostructure in the liver (). Abdominal CT showed the presence of an abnormal short portal vein, with systemic drainage into the inferior cava vein below the liver, and the superior mesenteric vein and splenic vein draining into the abnormal portal vein () (). The venous phase and multiplanar curve reformatted images better depicted this short, dilated shunt vessel (abnormal portal vein) after the confluence of the superior mesenteric vein and splenic vein, and the inferior vena cava (). Various nodular hepatic lesions could also be observed, compatible with vascular shunts and regenerative nodules, with the larger nodule presenting a size of 13 mm in diameter. The benign nature of these nodular lesions was confirmed by their stability through at least 7 years. Furthermore, a dilated and tortuous hepatic artery was also detected () (). Although several imaging examinations had been performed during this 7-year time frame, the vascular malformation had not been diagnosed so far. MRI"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 62-year-old male reported to our hospital with an asymptomatic swelling in the right lower half of the face with reduced mouth opening since two weeks. History revealed that this was the 3rd time that such a swelling had appeared in the buccal region over a span of 8 years. The first episode 5 years before involved a previous history of pus discharge with a diagnosis of buccal space infection treated by incision and drainage. The buccal swelling had regressed on its own upon a second occurrence 2 years back. The patient has been a known diabetic since a year and on regular medication. A detailed medical examination was performed in which the patient was screened for anomalies of the skin, eyes, skeletal system, endocrine system, nervous system, and any other developmental disorders, ruling out any syndromic association.\nOn examination, gross asymmetry on the right side of the face was evident. A large ovoid submucosal swelling (6 × 6 cm in size) was observed extraorally, extending superoinferiorly from the level of the right lateral canthus of the eye to 1 cm below the corner of the mouth and anteroposteriorly from the corner of the mouth to the mandibular ramus (). The borders of the lesion were ill-defined on palpation. The consistency of the swelling varied from being soft to firm. Overlying skin was normal. There was no history of any pain, fever associated with the swelling. Submandibular and cervical lymphadenopathy was absent. Paresthesia or palsy of the right side of the face or swelling of the right parotid gland was not noted.\nIntraorally, the ovoid swelling presented as a slight elevation of the buccal mucosa without any obliteration of the buccal vestibule. It extended from 1 cm from the commissure of lip to 1 cm short of the pterygomandibular raphae. The buccal mucous membrane appeared stretched and glistening without any signs of inflammation. Mouth opening was restricted due to the size of the lesion.\nComputed tomography revealed a well-"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nCB is a 16-month-old, previously healthy, female that initially presented to her primary care physician two weeks prior to presenting to our orthopaedic clinic with limping and intermittent refusal to bear weight through the left leg. The mother of the patient denied any previous trauma or constitutional symptoms but did endorse foreign travel; they were living in Japan at the time of presentation to our department. The patient was current on all vaccinations.\nThe initial orthopaedic evaluation revealed a well-appearing, healthy child in no acute distress. The gait exam revealed that she refused to weight bear on the left lower extremity. The patient had very mild generalized tenderness in the left midfoot region; otherwise, no other area of tenderness was appreciated upon further examination of the lower extremities. She had full, painless range of motion of her hip, knee, and ankle joints. There was no erythema or swelling of the left foot; however, there was a mild effusion of the ankle. She was neurovascularly intact with normal reflexes.\nShe was afebrile, and vital signs were within normal parameters. Radiographs of the left lower extremity revealed no osseous abnormality (). Laboratory findings revealed a slightly elevated erythrocyte sedimentation rate of 34 mm/hr; otherwise, the white blood cell count (10,200 cells/μL), differential (45% segmented neutrophils, no bands), and C-reactive protein (<0.05 mg/dL) were normal []. An MRI of her left ankle showed an ankle joint effusion, a 16 mm fluid collection with a high T2 signal with surrounding bone marrow edema, and a low signal on T1 (Figures and ). The findings were consistent with a Brodie abscess with surrounding osteomyelitis and a possible septic ankle. Furthermore, there was rim enhancement with gadolinium contrast, making an abscess more likely than a tumor () [].\nThe diagnosis and treatment were discussed with the parents, and she was consented for surgery. An anteromedial incision was used"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 55-year-old male entrepreneur, who had been experiencing pain of moderate intensity in the mid third of his left thigh for approximately 6 days. He sought emergency care at a hospital in response to a sudden increase in the intensity of the pain combined with swelling at the site of pain. He had a history of smoking equating to approximately 37 pack years. He did not have any other comorbidities. On physical examination he was slightly pale, with tachycardia (120 bpm) and blood pressure at 100 x 70 mmHg. Physical examination by segments was unremarkable for the head and neck, thorax, and abdomen. Vascular examination of the right lower limb found normal auscultation and visual inspection results, with all pulses present and normal. The left lower limb was well-perfused, but there was ecchymosis and a pulsatile swelling between the mid and distal thirds of the thigh, in the anteromedial region ( a). Inspection of the left foot also revealed signs of distal microembolization ( b) and popliteal and distal pulses were absent.\nUltrasonography of the left thigh showed an aneurysmal dilatation of the SFA measuring 5.8 x 5.3 cm and with associated mural thrombi and perivascular accumulations compatible with a ruptured aneurysm ( ). Since angiotomography was not available at the service providing care, the decision was taken to perform emergency surgical treatment.\nDuring the procedure, extensive hematoma was observed involving subcutaneous and muscle tissues in the anteromedial region of the thigh. Once this had been removed, the ruptured SFA aneurysm could be seen ( 3b). There were no obvious signs of active infection. Proximal and distal ligatures were performed and then the aneurysm was resected and samples collected for anatomopathological and microbiological analyses. Revascularization of the limb was then accomplished by interposition of the contralateral great saphenous vein in reverse, with end-to-side anastomosis – taking into consideration the di"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old female patient was referred to the operative dentistry clinic of dental school with chief complaint of bad-looking teeth and requesting for extraction and replacement of the teeth with denture. Clinical evaluation showed a healthy girl with no other physical abnormalities but with poor oral hygiene. Oral examination revealed the fusion of 7 and 8, and also 9 and 10 teeth. In panoramic radiography and clinical examination, caries was observed on labial and palatal surface of fused 9 and 10 teeth []. Preapical radiographic observation also showed that the two fused teeth had two distinct canals with one pulp chamber []. There was a 2 mm space in midline. The anterior maxillary teeth were malformed. The 24, 25 and 26 mandibular teeth were missing. The 11 and 22 teeth were in cross bite. A 2-mm space was observed between the two fused teeth. There were also spaces between fused 9 and 10 teeth with 11 tooth (2 mm) and fused 7 and 8 teeth with 6 tooth (5 mm). The width of fused teeth of 7 and 8, and 9 and 10 were 11 and 14 mm, respectively []. In vitality test (cold test) the fused teeth were vital.\nFor proper division of the space among four central and lateral teeth, the space between the mesial of the 6 and 11 teeth was reconstructed on the study cast of the patient by wax.\nCaries of fused teeth (9 and 10) were removed, adhesive was applied (Optibondsolo, Kerr, USA) and the lesion was restored with composite resin (Point 4, Kerr, USA). Diastema between the fused teeth was closed []. A new lateral tooth was replaced between the fused teeth (7 and 8) and 6 tooth by fiber-reinforced composite resin system (Interlig, Angelus, Brazil). For this, the fused teeth were striped to provide the space required []. One millimeter of the distal of the fused teeth (9"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 46-year-old female was referred for TN and hypothyroidism due to autoimmune thyroiditis. This patient gave informed consent for this case report. Her thyroid US showed bilateral small TNs, <10 mm. Her left TN measured 4.8 mm × 4 mm × 4 mm []. This TN had worrisome US features including irregular margins. Her neck US visualized a small left paratracheal (level 6) lymph node (LN) measuring 5.6 mm × 3 mm × 4.4 mm that appeared partially cystic []. In addition, there was an enlarged LN measuring 17 mm × 4 mm × 5 mm with possible microcalcifications [] in the left lateral neck posterior to the jugular vein []. Shear wave elastography (SWE) velocity measurements of the LN were 6.59 m/s and 5.32 m/s []. The US used was a LOGIQ E9 (GE Ultrasound, Milwaukee, WI, USA).\nThe patient underwent FNAB of the 4.8 mm left TN due to irregular margins. Her left neck level 6 LN was also biopsied due to complex, cystic nature of the node. The FNAB cytopathology for both lesions was read as malignant (Bethesda Category VI). The left lateral LN could not be sampled due to the proximity of the jugular vein.\nThe patient underwent total thyroidectomy with central and left lateral neck dissection at a tertiary care center. Her surgical pathology report indicated multifocal bilateral papillary thyroid carcinoma. The largest focus in the right lobe was 3 mm, and the largest focus in the left lobe was 5 mm, corresponding with her biopsied TN in the left lower pole. Overall, 18 LNs were resected, and one positive LN in the left paratracheal area was reported. The location of this LN corresponded with her FNAB finding. Her surgical pathology did not identify any metastatic LN in the left lateral neck.\nSeven weeks after her surgery, while on a low iodine diet for"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old Caucasian male presented to the emergency department at a local hospital for left lower abdominal tenderness. The patient had undergone a living unrelated kidney transplant into his left iliac fossa 12 years prior due to chronic glomerulonephritis. His stable immunosuppression regimen included tacrolimus (1 mg every 12 h), mycophenolate mofetil (500 mg every 12 h), and prednisone (5 mg daily). Except for one episode of acute cellar rejection a month after kidney transplantation, he had been doing well with a baseline serum creatinine level of 2.0 mg/dL. On arrival, his body temperature was 36.6 °C, blood pressure was 163/54 mmHg, and pulse was 61 beats/min. He reported that he had been active until the day before without noticing any injuries, but he recalled his cat, weighing 15 lbs, jumped on his abdomen seven days prior. On physical examination, his abdomen was soft and flat without rebound or guarding, except for a small tender mass noticed at the incisional site of the kidney transplant. His hemoglobin was 7.1 g/dL. His serum creatinine level was elevated from his baseline to 2.5 mg/dL. He was producing a normal amount of urine without hematuria. Computed tomography (CT) without intravenous contrast revealed a 12 cm × 2.5 cm subcapsular hematoma around the transplanted kidney (Figure ). Urology was consulted, and the decision was made to conservatively observe the patient, as he met criteria of a renal trauma grade II according to the renal trauma grading system by the American Association for the Surgery of Trauma.\nOn admission, the patient received a red blood cell transfusion and was started on labetalol for hypertension. His systolic blood pressure was controlled within a range of 110-140. Within three days, his serum creatinine level increased to 5.4 mg/dL and his urine output decreased. His blood pressure was elevated up to 156/80 mmHg. The patient was transferred to a transplant center for further treatment"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 69-year-old Filipino man with history significant for hypertension and hyperlipidemia presented to his primary care physician with hematuria with weight loss of 1 month’s duration. He did not have any flank pain, burning on urination, or increased urinary frequency. He did not endorse any symptoms of fatigue or night sweats. His only medication was atenolol for his hypertension. He did not smoke tobacco, drink alcohol, or do any recreational drugs. He was unemployed at time of interview. He did not have any family history of cancer. His vital signs were within normal limits. On physical examination, he was well appearing and in no acute distress. He had no palpable mass and had an otherwise normal cardiovascular, respiratory, and neurologic examination. Laboratory work showed normal cell counts and normal electrolytes; the results of his kidney and liver function tests were normal. A computed tomography (CT) – intravenous pyelogram was performed as a diagnostic work-up for his hematuria, which demonstrated a large mass in the left collecting system and proximal ureter. He was seen by urology with plans for surgical resection 1 month later. Three weeks later he was admitted to the Emergency Department with nausea and vomiting. He was tachycardic to 110 beats per minute but maintained a normal blood pressure. His laboratory results were notable for hemoglobin to 12.1. His sodium was 134. At that time, a CT scan of his abdomen and pelvis showed interval enlargement of the left renal mass. An ureteroscopy with biopsy was performed, which showed necrotic tissue with rare crushed degenerating atypical cells. A screening chest CT scan was also obtained which showed a small 3 mm nodule in the lower lobe of his left lung. A follow-up interventional radiology-guided left kidney biopsy showed a cellular neoplasm with sheets of pleomorphic round cells with hyperchromatic nuclei, irregular nuclear outlines, and inconspicuous nucleoli with scant and delicate cytoplasm which is"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old female patient, gravid 3 para 2 abortion 1 was referred to our hospital with a one-year history of vaginal mass. One year before admission, the patient felt vaginal uncomfortable and found a mass in her vagina. The patient, lived in a remote rural area, did not go to the hospital for further examination due to her poor economic condition. She experienced discomfort in the vagina and felt the vaginal mass was growing progressively in the past year before admission. Her general medical history revealed no surgery and disease. At the time of consultation, vaginal examination demonstrated a large fixed mass was located in the right lateral wall of the vagina and occupied the upper and middle third of the vagina. Laboratory blood test results, including serum tumor markers, were all within the normal ranges. Abdominal computed tomography (CT) showed a 17.6 cm× 10.4 cm solid mass in pelvic cavity (Fig. ). The urinary bladder, rectum and uterus were displaced to the left side of the pelvic cavity, but there was no ascites and enlargement of pelvic and para-aortic lymph nodes. Transverse (Fig. a), sagittal (Fig. b) and coronal (Fig. c) CT images revealed the tumor mass was highly suspected to originate from vagina.\nExploratory laparotomy was carried out to remove the mass after adequate preoperative preparation. Intraoperatively, a solid mass with the size of about 18 cm in diameter was found from pelvic floor to pelvic cavity. The lower boundary of the tumor mass was at the level of vaginal orifice. The urinary bladder, rectum, uterus and bilateral adnexa were separate from the mass and displaced to the left side of the pelvic cavity. The boundary between the mass and the surrounding urethra and bladder was clear, and there was no invasion to adjacent organ or metastasis. After Separating the tumor from the surrounding tissue, we found the tumor had a thin, fibrous capsule and originated from the right lateral wall of vagina. The tumor mass was completely rem"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 6-year-old girl with the complaint of vague periodic abdominal pains mainly in the epigastrium and periumbilical region is referred to the children's hospital. There was not any correlation with feeding and almost having discomfort at night times. She had periods of constipation and diarrhea and symptoms of leg pains. She also used to take Propranolol for early morning headaches mostly in the frontal region for 2 years. The patient with a probable diagnosis of Familial Mediterranean Fever (FMF) was referred to the pediatric rheumatology clinic for further surveys when 0.5 milligram daily colchicine was taken without considerable clinical response. She also had both an intussusception experiment and a history of negative appendectomy since she was 2 years old and the initiation of abdominal pain since that time. She was never febrile during abdominal pains. General examination revealed a thin hemodynamically stable girl with no signs of acute abdomen; the weight and the length were 15 kg and 105 cm [body mass index (BMI): 14.5 kg/m2].\nShe had second admission within previous 15 days with similar complaints. The grey scale and color Doppler abdominal ultrasonography showed normal portal and splenic veins and there were no evidences of thrombosis. Stool calprotectin test was also requested for a probable inflammatory condition in the gastrointestinal tract. However, because of persistent symptoms, abdominal CT angiography was obtained, which revealed a decrease in aortic and superior mesenteric artery and aortomesenteric angle consequently to 5 mm and 14 degrees suggestive for superior mesenteric syndrome along with a gastric and duodenal dilation [].\nAnother confirmatory spiral CT scan of abdominopelvic region also marked distended stomach and the proximal part of duodenum which in context of CT angiography proposing SMA syndrome. In addition, she was in a malnourished state without adequate evidences supporting an autoimmune condition. Thus, according to persistent"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 78-year-old male patient presented in April 2015 with suspected lung cancer. Chest CT examination revealed a pulmonary space-occupying lesion in the left upper lobe of the lung (Fig. ). Following fine needle biopsy, pathology confirmed the patient had lung adenocarcinoma and EGFR (Fig. ), ALK and ROS1 were negative (Fig. ). Due to the advanced age of the patient (78) together with a diagnosis of atrial fibrillation, EGFR-TKIs was recommended as the treatment of choice. From 23 October 2015, the patient commenced gefitinib 250 mg orally once a day until the disease progressed in July 2016 when CT scan of the chest indicated metastasis in the lung. The gefitinib, everolimus combined therapy was subsequently recommended because of disease progression. However, after a few months of combined treatment, everolimus had to be withdrawn because the patient experienced severe breathlessness, cough and mouth ulcers. At that time, the patient had been taking gefitinib for 16 months until drug resistance developed on 16 February 2017 (Fig. (a)).\nThe patient had second gene mutation testing at this time which indicated EGFR T790M mutation. Osimertinib 80 mg/day orally was subsequently recommended from March 2017. After only one month of treatment, chest CT scan revealed the disease had almost completely resolved (Fig. (b)). However, severe interstitial lung disease was also confirmed (Fig. (b)). The patient was found to have severe cough and difficulty in breathing at this time and the symptoms did not resolve, even after anti-infection and anti-cough treatments were administered. The patient attended our hospital for further treatment. After reviewing his treatment history and chest xray, we considered that he was suffering from severe drug-induced interstitial lung disease and advised him to cease taking the osimertinib immediately. Unfortunately, he still continued to take the osimertinib as he considered the medicine to be effective for his tumor, and refused to tell the d"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old healthy male presented for an assessment of nonhealing painful necrotic lesions of the left leg. His past medical history included anemia with intermittent pancytopenia diagnosed 10 years ago. Previous specialist hematologic assessment did not reveal an etiology. Two weeks prior, he believed that he sustained a spider bite while mowing the lawn during the month of August. The lesion began as a small papule less than 1 cm and then developed into a large blister on the left lower calf. Oral cloxacillin was initiated for one week; however, the lesion rapidly increased in size, began to ulcerate, and was extremely painful. He presented to the emergency room at a community hospital, febrile (38 degrees Celsius) with otherwise stable vitals. The documented area of necrosis measured 10 cm × 13 cm. Blood work showed ongoing pancytopenia (white blood cell count of 1.8 × 109/L, hemoglobin 100 g/L, platelets 88 × 109/L). He underwent urgent surgical debridement due to clinical concerns of a necrotizing process. Empiric ceftriaxone, metronidazole, and clindamycin were initiated. There was no intraoperative evidence of necrotizing fasciitis, purulence, or foul odour. Tissue cultures yielded methicillin-susceptible Staphylococcus aureus (MSSA), and the antibiotics were narrowed to cefazolin. Necrosis developed at the surgical margins and rapidly extended a further 3 cm over the next 3 days. A second surgical debridement was completed with the addition of a negative pressure dressing over the wound. The intraoperative tissue cultures yielded MSSA and Pseudomonas aeruginosa. Ciprofloxacin was added to cefazolin. During the subsequent three days, the patient developed severe calf pain with an expanding hematoma and required urgent surgical exploration. No significant abnormalities were noted. Tissue cultures yielded the same mixture of organisms. Further extension of necrosis again was observed at the surgical margin, and a fourth surgical debridement extended his woun"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn January 2018, a 70-year-old man residing in South Korea was admitted to Chosun University Hospital with reported consistent low back pain. At first, he had been admitted to a local hospital on 24 November 2017, a month before visiting Chosun University Hospital with a history of 5 days of chills and fever. In the local hospital, in view of the possibility of acute pyelonephritis, he was first treated with intravenous ceftriaxone at a dosage of 2 g daily. Two days after admission, back pain started. During antibiotic treatment, blood cultures taken on admission yielded Salmonella enterica. He remained on ceftriaxone (2 g daily) for 18 days including initial treatment to cover S. enterica. Upon follow-up blood culture, no bacteria were detected on the 8th and 25th days after starting treatment, and the patient no longer had fever; he was subsequently discharged from the local hospital on 19 December 2017. However, he consistently suffered from lower back pain, nausea, and vomiting; he was re-admitted to the same local hospital 9 days after his discharge. When he was re-admitted to the local hospital again on 30 December 2017, magnetic resonance imaging (MRI) was performed and L1 spondylitis was demonstrated. MRI revealed whole bone marrow oedema with endplate lytic changes in the L1 body and focal marrow oedema in the upper endplate of L2 bodies. Additionally, mild destruction of intervertebral disc at L1–2 was shown. These findings were considered to be indicative of pyogenic spondylitis (Fig. a, b, c). He was empirically treated with cefazolin (1 g, 3 times a day) for 10 days to cover the possibility of Staphylococcus aureus infection, which is a common cause of pyogenic spondylitis. Then, blood cultures were tested and yielded S. enterica again. Finally, he was transferred to Chosun University Hospital, and bone biopsy of L spine was performed on 3 January 2018. He had no fever, and the initial blood test was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 18-year-old male patient reported to our center with a chief complaint of pain and swelling of the left maxilla since 6 months. On extraoral examination, there was a diffuse bony swelling of the left maxilla which was slightly tender on palpation. Intraoral examination revealed bicortical expansion of the left maxillary alveolar ridge with the swelling extending from left first premolar to the first molar which was roughly elliptical in outline and nontender (). The swelling was hard in consistency and measured approximately 3∗2 centimeters in greatest dimension. No mobility of the teeth in the region was elicited and there was obliteration of the buccal vestibule. Mucosa over the swelling was normal with absence of any ulcerations or sinus discharge. There were no other secondary changes involved like paresthesia or cervical lymphadenopathy.\nRadiographic examination revealed a well-circumscribed, radio-opaque lesion mixed with areas of radiolucency. The lesion was roughly round to oval in outline and measured around 3∗3.5 cm in diameter. The periphery of the lesion was surrounded by a well-defined radiolucent rim (). There was no reactive bone forming rim at the periphery. Radiographically, the lesion was extending from distal surface of canine root anteriorly to the mesial surface of second molar posteriorly. Superiorly, the lesion was invading into the maxillary sinus and the inferior extent was almost till the alveolar ridge ().\nIncisional biopsy was performed under local anesthesia. Access to the lesion was gained through a buccal crevicular incision. A diagnosis of benign bone tumor was then made based on the histological, radiological, and clinical findings. Complete excision of the tumor mass was planned under general anesthesia. Under strict aseptic precautions, complete excision of the tumor was performed through a buccal vestibular incision extending from canine to the second molar (). Intraoperatively, the tumor was not very vascular and as it was well"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 49-year-old man was referred to our hospital for lower abdominal pain. Colonoscopy showed a circumferential tumor in the sigmoid colon, and histopathological examination revealed moderately differentiated adenocarcinoma. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) showed a large tumor directly invading into the urinary bladder and the left ureter. Besides, an abscess was formed between the tumor and the urinary bladder (Figures and ). Cystoscopy showed no definitive tumor exposed in the mucous membrane, and urine cytology was also negative for cancer. Preoperative staging was cT4bN0M0 cStage IIC locally advanced sigmoid colon cancer. Neoadjuvant therapy was considered; however, because the patient had continuous lower abdominal pain with a high C-reactive protein level of 6.1 mg/L, we decided against neoadjuvant therapy. We then planned laparoscopic anterior resection with en bloc partial resection of the urinary bladder and left ureter. For a safe surgical margin and to avoid bleeding from the internal iliac vessels, en bloc resection of the hypogastric and pelvic nerve plexus was also planned preoperatively.\nThe patient was placed in the lithotomy position under general and epidural anesthesia. The following ports were placed: a 12 mm port at the umbilicus for a scope, a 12 mm port at the lower right quadrant, and 5 mm ports at the upper right and left abdominal quadrants.\nFirst, the sigmoid colon was mobilized medially-to-laterally and the root of the inferior mesenteric artery was divided. Subsequently, we mobilized the rectum to the bottom of the pelvic floor on the right and posterior sides while completely preserving the right nerve plexus; this point was used as the surgical landmark on the posterior side ().\nSecond, the external iliac vein was exposed and the obturator nerve and vessels were preserved. The left ureter was mobilized and divided at the oral side of the tumor. The left internal iliac artery was exposed and the umbi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nHere, we present a case of double cancer in a 65-year-old male patient. The patient was diagnosed with 3 cancerous lesions: pancreatic cancer, a cancerous lesion in the liver, and an independent tumor with pneumothorax in the lower lobe of the right lung.\nDoctors performed biopsies of the pancreatic and liver tumors. Biopsy of the pancreas revealed that the pancreatic tumor was primary adenocarcinoma (Fig. E–G). The liver lesion was metastatic adenocarcinoma from the pancreatic cancer.\nAs for the lung tumor, doctors first speculated that it was metastatic pancreatic carcinoma. However, there was no histological evidence on the tumor before surgery.\nAdditionally, doctors could not control the pneumothorax by conservative treatment without performing surgery. Thus, an emergency surgery with partial resection of the lower lobe of right lung was performed, and the surgical specimen was subjected to histopathological examination. Informed written consent was obtained from the patient for publication of this case report and accompanying images.\nThe patient died 50 days after the surgery.\nThe surgical specimen of the right lung was subjected to histopathological examination. The specimen was 105 × 43 × 20 mm in size and had a tumor of 45 × 27 × 15 mm in size.\nThe main tumor was invasive squamous cell carcinoma of the nonkeratinizing type, and it was diagnosed as primary lung cancer (Fig. A). The primary lung cancer displayed no evidence of pleural dissemination and was classified as pT2b.\nThe background lung tissue included bronchiolization and fibrotic lesions with mucinous metaplasia and emphysematous changes.\nSmall adenocarcinomatous lesions were detected in the lung lesion. Metastatic adenocarcinoma lesions were located in the primary lung cancer lesion, outside the pleural elastic fibers (Fig. A–D). We also found metastatic adenocarcinoma in the fibrotic regions associated with pneumothorax and bronchiolization, adjacent to the lung cancer (Fig. E–H).\nIn addition, ade"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is an 18-year-old boy not known to have any medical illness previously, who was referred to the outpatient department from another hospital after 3 months history of seizures. Seizures started with blurring of vision and proceed to right sided head deviation and tonic posturing of the right upper limp which progress to generalized tonic-clonic seizures. The episodes are followed by loss of consciousness and postictal suboccipital and frontal tension headache. There was no history of fever, loss of weight, trauma, or any sensory/motor neurodificit. Family history was unremarkable, with negative past surgical history. All general and local physical examinations were done and all were within normal range. There were no physical findings or family history in favour of neurofibromatosis. Brain MRI with contrast was done and showed right parieto-occipital cortical and subcortical mass lesion measuring about 1.5 x 1.5 cm that has a low signal intensity on T1 and intermediate signal intensity on T2 and FLAIR with intense enhancement postgadolinium administration mainly peripherally with few small susceptibility artefact on T2 associated with significant vasogenic oedema and mass effect on the adjacent sulci ().\nThe radiological impression with the above description was most likely representing granulomatous infection (TB) or metastasis. Although a preoperative diagnosis could not be clearly established, the tumor was surgically removed through a right occipital craniotomy. The dura was incised and small area of discoloration was noted. Cortical dissection was done, with multiple pieces for frozen section, which was diagnosed later as suggestive of schwannoma, differential diagnosis meningioma. The tumor was encountered 2mm in subcortical area, which was firm, fibrous in content, yellowish in colour, and resembling meningioma. Postoperatively, the patient did not have any new neurological deficit, and he was discharged 1 day postoperatively in stable condition to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old female presented complaining of reduced visual acuity in the left eye that had been progressing for 5 months. She had no remarkable medical history and was not receiving any medical treatment. Visual acuity in the Snellen chart was 20/20 in the right eye and 20/40 in the left eye. Pupillary responses were normal in both eyes whereas color vision, tested with the Ishihara charts, was significantly disturbed in the left eye. Slit lamp examination and intraocular pressure were normal in both eyes. Dilated fundus examination disclosed no pathology. Visual fields examination (Humphrey 24-2 SITA standard) was normal in the right eye and revealed a deep central scotoma in the left eye (). The patient refused to undergo the suggested MRI examination, at that time.\nTwenty days later, the patient returned with further loss of vision in her left eye. Ocular examination revealed visual acuity in the left eye 20/80 and a relatively afferent pupillary defect (RAPD). Fundus examination disclosed partial atrophy of the left optic nerve.\nEmergency MRI and consequent selective digital angiography confirmed the presence of a giant aneurysm of 28 mm of diameter, arising from the supraclinoid part of the left internal carotid and a second smaller aneurysm of 9 mm diameter with a wide base near the origin of the left ophthalmic artery (Figures and ). The patient was referred to the Department of Neurosurgery where successful endovascular embolism of the aneurysms was performed, leaving the left internal carotid blood flow intact. Three months later, the patient presented with worsening of vision in her left eye, which was assessed to 20/400. The new MRA showed late failure of the previous embolization procedure, due to recanalization of the aneurysm. An additional, totally successful, embolization was performed ().\nThe patient's symptoms gradually recessed, and, at 20 months followup, visual acuity is 20/25 with significant improvement of visual fields findings (). Partial"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis report presents a case of 58 years old Caucasian male, a case of confirmed prostate carcinoma with GLEASON score 8 diagnosed in August 2014 ruled out through FNAC followed by PET CT. The subject received chemotherapy (Zytiga and Lupron) and hormonal treatment, but represented a refractory pattern after multiple chemo failures, with PSA levels rising above 200 ng/mL. The patient had previously been diagnosed with Renal Cell Carcinoma (RCC) in 1996 and had undergone nephrectomy of the right kidney. With a history of recurrences, he decided to opt for active immunotherapy. PET CT scan prior to the immunotherapy revealed multiple intensely PSMA avid lesions noted in both lobes of the prostate gland with SUVmax −28.3 and the prostate gland measuring 3.2 × 3.2 cm displaying maximum dimensions representing primary mitotic lesions and furthermore showing few mildly avid sub-centrimetric para aortic, aortocaval, and bilateral external iliac lymph nodes. Post-administration of Dendritic Cell Immunotherapy APCEDEN (6 doses between March 2017 and June 2017), remission of the carcinoma was observed as indicated by the significant decline in the PSMA avidity by 50% reduction in SUV max dwindling to 14.0 regaining the normal size and shape of the prostate gland with no obvious focal lesions, consistent with primary disease and likewise no significant PSMA uptake in the iliac and pelvic lymph nodes (Fig. ). Six months post completion of APCEDEN, the patient was administered 6 booster shots of APCEDEN, once monthly from January 2018 until June 2018. PET CT scan in July 2018 revealed the Prostate to be normal in size and no other PSMA expressing lesions were noted elsewhere to suggest a metastatic disease.\nThe progressive remission of the carcinoma was seen in concordance with the blood PSA and Testosterone levels. The biochemical analysis was done over a period of nine months starting July 2017, indicated a stability and reduction in PSA levels with the lowest of 0.4 ng/mL"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe a case of a 78-year-old male who 24 hours after an anterior rectum surgical resection with a terminoterminal anastomosis for a rectal neoplasm,showed sudden pain among the soft tissues of right flank and fever (39°C).\nThe patient did not have any primary or acquired immunodeficiency; he was under treatment for diabetes and had no other risk factors for necrotizing fasciitis such as immunological disorders or previous administration of chemotherapy.\nClinical examination showed a swollen and hot skin and “crackling snow crepitus” among the right flank. No bullae or other skin signs predicting necrosis were appreciable.\nThe surgeon, after the clinical examination, requested from our Emergency Department a contrast enhanced CT (CECT) of thorax and abdomen.\nWe performed a precontrast phase, arterial phase, and an early venous phase.\nCT scans showed the outcomes of the surgery and two drainage pipes were present, one in the right pelvis and one in the left flank.\nClose to the right drainage access a suspected infection characterized by huge air-densities collections and edema extending along the soft tissues as right subcutaneous fat were observed; parietal abdominal muscles and subcutaneous tissues were also involved ().\nScout of subcutaneous emphysema which extends up to the supraclavicular region was seen (). Solution of continuity, 1,3 cm × 1,5 cm in size, of the rectus abdominis muscles was observed ().\nAfter the contrast medium administration the fascia did not appear enhanced in the arterial phase; in the early portal phase the fascia appeared weakly enhanced; areas of low attenuation within the muscles and the fat tissues structures of the right flank were observed ().\nAs collateral findings the mesenteric fat tissue appeared hyperdense and small amount of pleural and pericardial effusion was seen; in Sagittal Multiplanar Reconstruction it was clearly appreciable that the infection started from the right drainage pipe ().\nCT findings, such as the prese"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 18-year-old girl was referred to our department with complaints of painless enlargement of the jaw and the loosening of teeth. Family history did not reveal any significant information about the familial origin. She had a history of hypothyroidism for 3 years of age and history of atrial septal defect (ASD) operated at the age of 4 years. The patient had anodontia since childhood, and dental development occurred only after correction of ASD. On clinical examination, there was prominent enlargement in the mandibular region. Some permanent teeth were missing, and wide edentulous interdental spaces were detected on intraoral examination. Few skin lesions were also noted suspicious for café au lait spots. Otherwise, clinical examination was unremarkable. She had attained puberty at the age of 15 years.\nThe laboratory results of serum cortisol, calcium and phosphorus, alkaline phosphate, Parathyroid hormone, Vitamin D3, complete blood cell count, urine analysis, and liver functional tests were all within the normal range. The orthopantomogram radiograph showed misalignment of teeth with the distorted root of premolar and molar tooth and loss of few incisors and canine teeth [].\nWhole-body bone scintigraphy with three-phase imaging of the skull and upper thorax was done by the intravenous administration of 20 mCi of technetium-99 m methylene diphosphonate (99 mTc-MDP). Tc-99 m-MDP first pass images of the skull and upper thorax MDP blood flow images of the skull and upper thorax shows a region of focal hyperperfusion in the right hemimandible [] corresponding to a focal region of tracer pooling in the same region of the right hemi-mandible in the blood pool images shown subsequently. In addition to this focus, the blood pool images show mildly increased tracer pooling in rest of the mandibular and maxillary regions as well []. Delayed phase whole-body and static planar images showed diffuse heterogeneously increased tracer concentration involving the entire mandible an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34-year-old woman with no significant past medical history presented with the chief complaint of left facial numbness, left ear pain and decreased hearing in the left ear of three years duration. The patient had also been experiencing sharp and shooting pain in different areas of her left thigh. The pain was not associated with any weakness, tingling or numbness. Besides mild fatigue she denied having any fevers, night sweats or weight loss. Neurological physical examination was grossly intact except for sensory loss in the V2 (maxillary) and V3 (mandibular) distribution of trigeminal nerve (cranial nerve V). Abdominal exam was without evidence of lymphadenopathy and hepatosplenomegaly. Given deficits in the sensory distribution of trigeminal nerve, she was initially evaluated by ear, nose and throat (ENT) and underwent two sequential minimally invasive surgeries for nasal polyps without significant resolution of her symptoms. She was subsequently referred to a neurologist and had magnetic resonance imaging (MRI) of the brain performed. Brain MRI revealed a soft tissue mass with expansion in the left Meckel’s cave, measuring 22 x 16 x 12 mm (Figure ), raising concerns for a trigeminal schwannoma. She was evaluated by the neurosurgery and underwent an orbital zygomatic craniotomy and left trigeminal schwannoma resection. Pathology revealed deposition of abundant hypocellular eosinophilic material on light microscopy examination (Figure ). Congo red staining demonstrated characteristic 'apple-green birefringence' upon polarization (Figure ), consistent with diagnosis of trigeminal nerve amyloidoma. Unfortunately, no immune fluorescence or electron microscopy was done on the pathology specimen to determine the amyloid subtype. Postoperatively, the patient was referred to oncology to rule out systemic amyloid deposition. Basic workup including complete blood count was unremarkable except for hemoglobin of 12 g/dL with mean corpuscular volume (MCV) of 76 fL per cell. W"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old man was admitted to our hospital due to severe pain in his left eye. He mentioned that the pain had begun along with redness 2 days prior to his admission.\nOn admission, he presented with eyelid swelling, conjunctival erosion, and corneal filtrate at 6 o'clock of a size of 3/0 over 3.2 mm. The corneal abscess location was in the midperiphery making any future corneal graft attempt challenging. There were flare and cells in the anterior chamber and the pupil was hardly seen. Ultrasound examination showed a clear vitreous and no involvement of the posterior segment. The right eye was normal with no pathology.\nAnamnesis was taken in depth. It turned out that as part of his work, the patient was peeling plaster off of a wet wall that had fungi on it, and that a small piece of plaster had splashed into his left eye.\nHe was diagnosed as suffering from fungal keratitis, and further laboratory tests using PCR confirmed the infection to be caused by Fusarium solani. He was then treated with voriconazole, however without significant improvement (Fig. ).\nA couple of days later, a corneal melting process was observed and as the corneal melting continued, it was decided to try treatment with CXL. The patient underwent a CXL treatment and shortly thereafter, the abscess shrank, with significant improvement in symptoms and vision (Fig. ). The corneal melting stopped after the CXL treatment. The patient was treated for about 3 months with voriconazole.\nThe following year after the infection, corneal transplantation was done due to severe scarring of the cornea. Today, about 2 years later, best corrected visual acuity in the left eye is 20/80. The corneal graft is clear and shows good indentation with no signs of rejection. The anterior chamber is deep and clear, and other than a mild minimal nuclear cataract. The anterior segment is normal. The optic disc is normal and the C"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 2-year old girl was referred to the Jos University Teaching Hospital in north central Nigeria, with complains of progressive cough and difficulty in breathing in the preceding six months. She was treated at several health facilities for pneumonia and asthma without resolution of symptoms. Patient had no fever or features suggestive of tuberculosis. Pregnancy, delivery, neonatal and infant periods were uneventful and patient had received all immunization appropriate for her age. Examination at presentation showed a child in severe respiratory difficulty necessitating oxygen administration, with Spo2 89–90% at room air and 96% on oxygen by nasal prongs. There was bulging of the right side of her anterior chest wall and markedly reduced breath sounds on the right hemithorax. No features suggestive of congenital heart disease. Chest X-ray showed homogenous opacity continuous with the cardiac silhouette, involving almost the entire right thoracic cavity with a shift of the mediastinum to the left (Fig. ). Echocardiography confirmed a very large well defined mediastinal cyst compressing the right atrium, left atrium and right ventricle (Fig. ). Contrast-enhanced computed tomography scan of the chest showed a well defined large cyst of the anterior mediastinum compressing the right main bronchus (Fig. ). Blood investigations were all normal. A diagnosis of anterior mediastinal cyst was made and the patient had right posterolateral thoracotomy through the fifth intercostals space. Intraoperatively a large tense cyst measuring 20 × 16 × 3.5 cm was noted adjacent to the pericardium and attached loosely to the thymus compressing but not attached to the bronchus. The cyst was unilocular with a thick wall and contained serous fluid (Figs. & ); the cyst was excised en bloc. There was moderate pericardial fluid which was drained by a pericardiostomy. Histopathological sections showed ectopic pancreatic tissues in the wall of the cyst (Figs. , and ). The post operative course was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old man with a long history of Ankylosing spondylitis presented with acute urinary retention three months after he was started on a TNF alpha antagonist.\nThe patient was well until, at the age of 25, he begun to complain of inflammatory back pain due to Ankylosing spondylitis. Initially, he responded well to NSAID medication, at least symptomatically, but the disease progressed over the years, leading to increasing flexion deformity of the neck, thoracic kyphosis, and loss of normal lumbar lordosis. Due to decreasing clinical response coupled with marked elevation of CRP, he was placed on Etanercept (Enbrel), a tumor necrosis factor alpha antagonist (TNFA) [].\nTreatment with Etanercept had a dramatically beneficial effect on the quality of life of the patient. Clinically, the back pain waned to nothing, and overall mobility was improved while CRP normalized. However, three months after the treatment was initiated, the patient started having obstructive urinary symptoms: stress incontinence, dysuria, staining to void, nocturia, and increased frequency of passing small quantities of urine. The symptoms culminated in complete distal urinary tract obstruction and required catheterization with evacuation of 1200 mL of residual urine. There was no evidence of urinary tract infection, both by culture and by direct examination; an ultrasonic examination of the urinary tract was normal. There was no evidence of bladder stones.\nAlpha blockers were started empirically, and the catheter was removed 72 hours later, with some relief, but the patient continued to have difficulties with micturition and had “two-stage urination” (a normal first stream, followed by a protracted and hesitant stream).\nSince there was no evidence of physical bladder neck obstruction, the differential diagnosis at this stage included a side effect of TNFA and possibly cauda equina syndrome, which is a rare complication of Ankylosing spondylitis [].\nConsequently, Etanercept was discontinued, and"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 59-year-old woman was admitted to our hospital 2 days after the onset of a recurrent thunderclap headache and right-side hemiparesis recovered within a day. She was drowsy, and had apparent nuchal rigidity. She had no risk factors for cerebrovascular diseases. She was in normotensive and in sinus rhythm. A computed tomography (CT) scan revealed SAH on left basal cistern (). Magnetic resonance (MR) images showed an acute ischemic lesion in the territory of the left middle cerebral artery with restricted diffusion (). Digital subtraction angiography (DSA) demonstrated an irregularly shaped aneurysm arising from left supraclinoid ICA with moderate stenosis of proximal region (). Moreover, DSA revealed one of the typical findings of pseudoaneurysm. A delayed opacification and stagnation of contrast medium in the aneurysm sac even during the venous phase were observed (). Transthoracic echocardiography with carotid duplex ultrasonography was negative.\nLaboratory evaluation revealed a hemoglobin concentration of 18.3 g/dL with an elevated hematocrit of 59.7%, white blood cell count of 11.4×103/µL, and platelet count of 1120×103/µL. There was no evidence of head trauma or any systemic infection signs on admission. We planned to perform surgical clipping with a vessel wall remodeling technique because pseudoaneurysm might be fragile and associated with a high risk of intraoperative rupture. During operation, a pulsatile, thin walled aneurysm adherent to the adjacent tissue was observed in the anterior wall of supraclinoid ICA (). The aneurysmal sac avulsed from the parent vessel due to its friability during dissection of aneurysm. After temporary clipping of the proximal ICA, three curved clips were applied with a facing fashion to close the torn gap in order to prevent rebleeding and maintain patency of the parent vessel (). Postoperative hospital course was uneventful. Pathologic examination showed that most of the lumen mainly consisted of organized blood clot and rece"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 82-year-old man incidentally presented with a protruded shadow adjacent to the aortic knob in chest radiography during an assessment of the renal dysfunction. Computed tomographic scanning revealed a fusiform-type aneurysm with a diameter of 56 mm in the distal aortic arch. Aneurysmal change extended to the aortic arch around the origin of ARSA and the left subclavian artery. The patient was found to also have a common carotid trunk and an ARSA independently originating from the back of the aortic arch distal to the left subclavian artery. This artery passed behind the esophagus and trachea and connected the axillary artery through the right side of the thoracic vertebra (). Bilateral vertebral arteries ordinarily arose from the superior aspect of the central subclavian arteries. We applied the open repair but not the endovascular repair and decided to perform total arch replacement in combination with frozen elephant trunk and reconstruction of bilateral axillary arteries via the extraanatomical bypass. The occlusion of proximal ARSA was planned just at the right side of the thoracic vertebra in the right pleural approach to avoid troublesome procedures in the deep mediastinum.\nSimultaneous preparation for bilateral axillary artery accesses was performed, and a standard median sternotomy was then made. Two pieces of 9 mm vascular grafts (J graft, Lifeline, Tokyo, Japan) were sutured to the bilateral axillary arteries respectively in an end-to-side fashion, and cardiopulmonary bypass was initiated with perfusion via these arteries and atrial drainage with a two-staged cannula. The right pleura was opened during the temporary cessation of mechanical ventilation. The ARSA was easily identified just at the right side of the thoracic vertebra and encircled with a vascular elastic band following the division of the parietal pleura (). After systemic cooling, the systemic circulatory arrest followed by aortic opening was then performed with a rectal temperature of 22.9"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old, previously healthy male was admitted to the hospital with altered mental status of one day duration. The patient was confused and was not answering questions appropriately. Vital signs were remarkable for low-grade fever of 100.7 ºF and tachycardia. His physical exam was remarkable for a holosystolic murmur at the apex, radiating to the axilla. He was alert and oriented to self, but not to place or time. Cranial nerves were grossly intact with no focal neurological deficits. Laboratory evaluation revealed leukocytosis and mild hyponatremia. A computed tomography scan of the head did not show any acute intracranial hemorrhage. A lumbar puncture was performed and cerebrospinal fluid analysis did not suggest meningitis; however, the patient was started empirically on vancomycin, ceftriaxone, ampicillin, acyclovir, and dexamethasone. Magnetic resonance imaging of the brain showed large area of infarction in the left frontal, left parietal, and left caudate body, suggestive of a cardio-embolic source (Figure ). An echocardiogram revealed a large, mobile, vegetation (1.5 x 1.5 cm) on the mitral valve likely affecting the anterior and posterior leaflets with mild to moderate mitral regurgitation (Figures -). Blood cultures were sent to the lab, which later grew Streptococcus agalactiae. An infectious disease team was consulted and antibiotics were switched to penicillin G and gentamicin.\nA cardiothoracic surgery team was consulted and he was not deemed a surgical candidate as it was thought it would be unlikely that the patient will have a meaningful recovery, and the risks outweighed the benefits of surgery. The patient’s mental status remained the same; he remained alert and oriented to self only despite several days of antibiotics. His repeat blood cultures remained negative.\nIn the third week of his hospitalization, the patient experienced worsening of his altered mental status and he was not responding to questions. An MRI of the brain showed hemorrhagi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41-year-old Japanese man became aware of abdominal swelling in December 2008 but did not seek a medical opinion until he developed marked leg edema, a 30 kg weight gain, and cough. He was hospitalized the same day after a retroperitoneal tumor was detected by computed tomography (CT). After hospitalization, the patient was diagnosed with a liposarcoma by CT-guided needle biopsy. The patient was emergently transferred to our hospital due to worsening respiratory status. On admission his body surface area was 2.18 m2. A CT scan detected a 43 × 37 × 31 cm tumor in the right retroperitoneum, with the right kidney significantly displaced to the left and anterior side (). Whole-body CT scan detected no metastasis. His condition was diagnosed as respiratory failure due to elevation of the diaphragm as a consequence of the rapid growth of the tumor ().\nWe concluded that surgical resection was the only option for saving the patient's life, so we performed a tumorectomy 3 weeks later through a midline incision. The operation took 3 hours and 20 minutes, and the estimated blood loss was 3990 mL requiring 800 mL blood transfusion. During surgery, the tumor and right kidney were completely resected.\nPathological examination showed that the resected mass weighed 22 kg and was 45 × 40 × 30 cm in size (). Grossly, the tumor was well encapsulated and transverse sectioning revealed a solid multinodular tumor mass. Histopathologic analysis demonstrated many spindle cells with high-grade atypia; some of which were lipoblasts on a myxoid background; there were no split signals on FISH analysis using CHOP DNA probes, thus leading to the diagnosis of dedifferentiated liposarcoma (). Microscopically, no tumor cells were identified in the right kidney and this was an R0 resection. He declined adjuvant therapy. The patient was discharged from our hospital after 18 days. His body surface area at discharge was 1.66 m2. A CT scan performed 12 months after surgery detected no recurrence."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient was a 70-year-old Caucasian male with an established diagnosis of DD since his childhood years. He had had innumerable exacerbations in the past and multiple admissions for secondary bacterial infections. He presented to the hospital with worsening of coalescing, firm, greasy, and bright red to skin-colored macules and papules located around his gluteal clefts, back, scalp, and forehead causing severe debilitating pain. The gluteal lesions were the most clinically relevant symptom and they were causing profound distress. He had severe physical deconditioning and had fallen several times prior to his arrival. A few weeks before his hospitalization, he had been diagnosed with intraductal papillary mucinous neoplasm (IPMN) of the pancreas and had undergone a total pancreatectomy and splenectomy with hepaticojejunostomy and Billroth II gastrojejunostomy, which had contributed to his fatigue and weakness. He had no abdominal symptoms and his abdominal exam was initially benign. His vitals were stable, and there was no systemic or laboratory evidence of an infectious process at the time of admission. As the clinical course progressed, his skin lesions and clinical status continued to worsen. He developed bacteremia secondary to Streptococcus dysgalactiae and then Pseudomonas a few days later. A week later, he developed bacterial peritonitis with Enterococcus faecalis, Klebsiella pneumoniae, Candida glabrata, and E. coli. He received multiple courses of broad-spectrum antibiotics and antifungals. The dermatology service was closely following the patient and had started him on acitretin with a dose of up to 50 mg daily. He was also started on systemic steroids. Although he had intermittent days of temporary improvement and relief, his overall progress was mired with worsening skin lesions, sepsis causing hypotension, and functional decline.\nPain management, palliative care, infectious diseases, burn surgery, surgical ICU, social work, cardiology, and endocrinolo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 40-year-old woman was referred to the Department of Obstetrics and Gynecology with symptoms of chronic pelvic pain since one month and foul smelling vaginal discharge since 2 years. She had no medical history such as constipation and hematochezia. On physical examination, the patient was afebrile with normal vital signs and mild tenderness was present in her lower abdomen without any palpable mass. Transvaginal examination showed normal appearance of the anus and external genitalia, but vaginal discharge was suspected with fecal material. Transvaginal ultrasonogram revealed a normal uterus and both ovaries. Blood Test demonstrated elevated CRP (37 U/L [normal, <1 U/L]), and other serologic tests were within normal limits. Urine analysis showed pyuria (WBCS, 20–29/high power field; leukocytes, 3+) and proteinuria (1+). CT revealed inflammatory change around the left side of the colon and left ovary with loculated fluid collection in the pelvic cavity (). The initial diagnosis was thought to be an abscess in the left salpinx due to pelvic inflammatory disease, and pelviscopic exploration was planned in the gynecologic department. During the operation, no abscess in the pelvic cavity and 2 appendices were observed with inflammatory adhesion among the sigmoid colon and the left salpinx (). When the patient was referred to our department because of severe adhesion and inflammation, we converted her to open surgery. In operative findings, a near total duplicated colon including a duplicated terminal ileum measuring 3 cm in length was observed. It originated from 5 cm above the native ileocecal valve perpendicularly, was parallel to the native ascending, transverse, and descending colon, and terminated in the native proximal sigmoid colon with adherence to the left salpinx. The diameter of the duplicated colon narrowed distally (). When adhesiolysis was performed, fistula formation was observed between the distal end of the duplicated descending colon and the posterior v"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis case details a 54 year old woman who was referred to our clinic by her general practitioner for investigation of bilateral breast pain that she had for 6 months.\nHer past medical history included hypertension for which she took a single anti-hypertensive. She had no familial history of breast or gynaecological malignancy. On clinical examination pathological nodes were palpated bilaterally in the axillae. There was left sided nipple inversion with a palpable mass in the upper outer quadrant of approximately 3 cm diameter.\nOn examination of the right breast there was skin tethering of the nipple and 3 masses were palpated, the largest being in the upper inner quadrant at 5 cm diameter.\nUltrasound and mammography of bilateral breasts demonstrated advanced bilateral breast cancer with axillary node metastases.\nThe right breast had a large lesion consistent with primary breast cancer at 12 o’clock measuring 44.3 mm in diameter. An additional 7 smaller lesions were distributed through the right breast consistent with satellite lesions. The largest pathological node in the right axilla measured 42 × 30 mm.\nIn the left breast at the 2 o’clock position there was a lesion consistent with breast carcinoma measuring 31.2 mm. The largest node in the left axilla measured 13.1 × 10.2 mm.\nThere was skin thickening of both breasts consistent with oedema, the right side was most pronounced. Core biopsies from lesion on right breast at 12 o’clock and the left breast at 2 o’clock demonstrated invasive carcinoma. , : (H&E x10) Left/right core biopsy show invasive carcinoma, no special type\nThe hormone receptor status was identified with right breast lesion being ER negative whilst the left breast lesion was ER positive.\n, , : (x10) Positive staining for ER and PR. HER2 Immunohistochemistry score 3 + .\n, , : (x10) Negative staining for ER and PR. HER2 Immunohistochemistry score 3 + .\nThe patient was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe describe the case of a 50 year old Caucasian female patient who was born with tricuspid atresia and transposition of the great arteries. At the age of 4, she underwent a modified Glenn procedure followed by a classical left Blalock-Taussig shunt at the age of 16. Since then, she has had two major cardiac operations. In 1990, at the age of 25, she had a fenestrated modified atrial pulmonary Fontan. Following a very difficult pregnancy 18 years later, she underwent conversion to a total cavopulmonary anastomosis Fontan circulation, modified MAZE procedure and implantation of an epicardial defibrillator with biventricular pacemaker system. Cardiac catheterisation at that time showed a ventricular end diastolic pressure of 16 mmHg and a Fontan chamber pressure of 18 mmHg, giving a transpulmonary gradient of 2 mmHg. Her cardiac medical history was further complicated with arrhythmias requiring ablation in 1998 and episodes of non-sustained ventricular tachycardia in 2014.\nThis lady has been under regular follow-up by our team since 2008. Various medications have been trialled over the last 8 years due to her progressive reduction in exercise capacity and exertional dyspnoea. She had initially taken part in a trial to test the safety of bosentan in 2010 [] and at the time had shown good response to the drug with improvement in 6-min walk test. Bosentan was discontinued at the end of the study.\nUnfortunately, over the course of the next few years, she continued to deteriorate with worsening breathlessness (NYHA III), four-pillow orthopnoea and paroxysmal nocturnal dyspnoea, ventricular function was preserved. She noticed a significant limitation in everyday activities, requiring social care input and a mobility scooter for outdoor travel. Sildenafil was commenced however this was discontinued shortly after due to symptomatic hypotension.\nCardiac CT scan confirmed non-restrictive Fontan pathway, and normal ventricular function.\nIn early 2016, bosentan was re-commenced wi"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 31-year-old male has experienced hot flashes for the past five to six years; this is associated with obvious erythema of the face and is accompanied by hypertensive episodes as high as 226/128 mmHg with no palpitations. In the past year, these spells had become more frequent with headaches in both temples. He also reports decreased peripheral vision during these episodes. Lying down seems to reduce the severity and duration of these spells. He often feels light-headed in the upright position and experiences vertigo while lying on his side, at times; this is always relieved by changing his position on the bed. His symptoms are relieved by sublingual medication, such as nifedipine, but the patient states that his episodes are brought on by excitement such as watching a football game, walking barefoot on hard surfaces, having a bumpy car ride, or making sudden head movements. He also reports heat intolerance and excessive sweating. The patient's past medical history was positive for SCI, after which he developed pain in the neck and lower back, with numbness and tingling in his upper extremities and pain radiating down his hip. Table lists the common signs and symptoms of AD generally experienced by patients with SCI.\nLaboratory results revealed an increased excretion of epinephrine and dopamine but a normal output of norepinephrine. His epinephrine levels were increased by injections of intravenous glucagon, a response highly suggestive of the presence of pheochromocytoma. He also had prolonged spells of tachycardia induced by exercise despite taking propranolol, which was further suggestive of the production of large amounts of epinephrine, overriding the effects of propranolol.\nHe underwent an evaluation for pheochromocytoma. An octreotide scan, a metaiodobenzylguanidine (MIBG) scan, and a magnetic resonance imaging (MRI) scan of the adrenal glands were all negative. After some time, the patient reported episodic anxiety and hypertension with a full bladder and im"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn Indian girl, 12 years old, was referred to Department of Pedodontics and Preventive Dentistry of Dental College, for inspection of a painless swelling in the mandibular left primary molar region since 6 months. Past dental history revealed that she had undergone incomplete endodontic treatment with the same tooth a year ago. Her oral hygiene was good and was overall in good health. Extraoral examination revealed, a diffuse, bony nontender swelling on left side of jaw extending from corner of mouth to angle of mandible. While, intraoral examination revealed a grossly carious and mobile left primary second molar tooth (). Panaromic radiograph showed a round unilocular radiolucent lesion, 1.8 × 2 cm in diameter, below the left second primary molar (), displacing the successive permanent second premolar apically. A closer examination of the radiograph revealed that the border of the lesion appeared corticated and was smooth and well-defined. Occlusal radiograph revealed buccal cortical plate expansion extending from distal aspect of permanent mandibular left lateral incisor to mesial aspect of permanent mandibular left second molar and revealed an interesting finding that the successive premolar was displaced and aligned buccolingually in the cystic cavity ().\nFrom history and clinical examination a provisional diagnosis of radicular cyst associated with them andibular left primary second molar was made which could be due to either secondary caries or the medicament used duri ng endodontic treatment. Differential diagnosis included periapical granuloma or dentigerous cyst.\nPrimary left second molar was extracted under local anesthesia and cystic cavity was exposed. Cystic lining was removed as much as was accessible and sent for histopathological examination (). The successive permanent second premolar was also extracted because of its improper alignment. After thorough curettage of cystic lining, the premolar was placed back into the cystic bony cavity with proper a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 60-year-old female housewife was admitted to the Urology Clinic of Sina Hospital, Tehran (capital of Iran) eight months before admission (winter of 2013) with pain in the suprapubic area (). The patient had been treated by antibiotic therapy since eight months ago following intense suprapubic pains accompanied by dysuria and frequency symptoms and had been diagnosed as simple cystitis. In spite of partial recovery and continuation of long-term treatment with antibiotics, non-steroid anti-inflammatory drugs, sedative drugs and alpha-blocker, the symptoms were recurred with severe and mild periods. The pain was persistent and spread towards the perineal area. Along with the pain, the patient had frequency, nocturia and dysuria, which resulted in inability to pass urine completely. The pain intensified when the bladder was full and the patient also had occasional flank pain on both sides. In abdominal physical examination, slight tenderness in the suprapubic area was found, but the rest of examination had normal findings. In paraclinical tests, urine culture test had normal results, and urine analysis showed normal findings regarding the values of white blood cell, red blood cells, sugar and protein. Urine cytology had negative results regarding malignancy. Abdomen and pelvic sonography and the liver and kidney function test had normal results.\nIn cystoscopy report, the size of bladder was slightly decreased and there was a mild inflammation of the epithelial lining of the bladder. No tumoral lesion or glomerulation was observed. Bladder biopsy and hydro distention were performed. Bladder biopsy had negative results for malignancy, but chronic inflammation was reported. The results of the examination of the genitalia system in physical examination and dilation and curettage (D&C) had normal findings.\nThe patient reported diabetes mellitus type 2 for three years and used metformin daily. FBS was 120 mg/mL. The digestive problems of the patient were a persistent bloat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 42-year-old man presented with a 3-months history of right neck pain that worsened on turning to the left. He did not complain of any other symptoms such as globus sensation or odynophagia. Physical examination was negative. Palpation of the tonsils did not worsen the pain. 3D-CT reconstructed images showed a longer left process than the right. Quantitative measurements showed the left styloid process was abnormally long (44 mm), while the right was normal (25 mm, Figure \n). In view of the neck pain, the patient was diagnosed with Eagle's syndrome. The condition was explained to the patient and operative treatment was recommended. Surgical correction was made via the transoral approach. On the first postoperative visit, rotation of the head did not elicit any pain.\nThe operation was performed under general anesthesia while the patient was in supine position with neck extension. An endoscope was inserted through the mouth, and the magnified surgical field allowed identification of the small vessels and nerves and allowed the surgeon to avoid injuries. Unilateral tonsillectomy was performed first, the tonsillar bed was palpated and the tip of the styloid process was identified. The mucosa was separated longitudinally at the point of palpation of the process in the tonsillar fossa. The tissue of the parapharyngeal space was carefully separated by q-tips to avoid vascular injury. Palpation was occasionally used during surgery to confirm the location of the styloid process. After exposure of the styloid process, the periosteum was incised at the tip of the process, then stripped from the tip to the base. The styloid process was excised with a bone nibbling rongeur. The styloid process must be penetrated before its removal. If the styloid process fractures accidentally before it is completely dissected, the fractured piece(s) can be pulled down through the tonsillar bed after diverging the muscles attached to it, a step that"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe 59-year-old male presented to hospital complaining of severe nausea and generalized abdominal pain requiring admission. The patient had an episode of gastroenteritis 6 month prior, and since then experienced multiple episodes of colicky abdominal pain with intermittent vomiting. The patient had no other medical history of significance. On physical examination, he was hemodynamically stable, although generally tender with a distended abdomen. His laboratory results and chest X-ray were unremarkable. A computed tomography scan was suggestive of a subacute small bowel obstruction with a high\nsuspicion of an internal hernia through an omental defect. Given the patient’s clinical status correlated with these radiological findings, he was counselled for surgery and underwent an exploratory laparotomy.\nIntraoperatively, thick fibrous tissue involving the visceral and parietal peritoneum was found enveloping grossly dilated loops of small bowel (). There was no evidence of a transition point contributing to this patient’s obstruction. As any manipulation or mobilization of the bowel was thought to be high-risk of causing enterotomy, a decision was made to close the abdomen after collecting peritoneal washings and biopsies for histopathology and microbiology.\nThe patient was monitored on the ward post-operatively during which he made a good recovery with broad-spectrum antibiotics and supportive management. He was discharged home 9 days following his operation, after demonstrating significant improvement in gastrointestinal function, with reduced pain and able to tolerate oral intake.\nIntraoperative peritoneal swabs tested negative for acid-fast bacilli and no organisms were cultured from peritoneal fluid. Haematoxylin and eosin stained sections of peritoneal biopsy showed markedly thickened collagenous fibrous tissue with adherent loose fibrovascular connective tissue and intervening myofibroblast-like cell, the latter supported by smooth muscle actin immunohistochemist"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nWe present the case of a 63-year-old man who was admitted to our hospital with significant upper-body burns. The previous night he had been cooking when his clothing ignited. He did not call for help until the following morning.\nInitial assessment revealed approximately 60% total body surface area burn, most of which was full thickness involving his torso and upper extremities. In addition, there was some minor involvement of his lower extremities. The patient complained of pain and inability to pass urine. Limited history was obtained in the emergency department. The patient denied any allergies and was not taking any medications.\nIntubation for airway protection was performed early in the trauma room, and the patient was transferred to the burn unit where extensive fasciotomies to bilateral arms, hands, chest, and abdomen were performed at the bedside. Initial laboratory reports revealed acute renal failure with a creatinine level of 2.2, which marked the beginning of an undulating course. The next day, the patient was taken to the operating room for his first of several procedures. Fascial excision of both arms and left flank, with allograft, was performed. Skin biopsy was taken per protocol, with a view to obtaining cultured epidermal autograft.\nHis hospital course was complicated by pneumonia and polymicrobial sepsis. Organisms isolated from blood and wound-bed cultures included Pseudomonas, Aspergillus, vancomycin-resistant Enterococcus, and Klebsiella. Broad-spectrum antibiotic coverage was instituted.\nBy the sixth week of hospitalization, a decline in platelet function was noted from more than 150 × 10 to less than 15 × 10. This was paralleled by a generalized coagulopathy with a rise in international normalized ratio to more than 1.52. At this time, the patient had been taken to the operating room for fascial excision of the lower back with limited autografting. Although the procedure was uneventful, by the end of the operative procedure, bleeding was noted"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nIn November 2009, a 52-year-old Korean woman who had never smoked presented with a history of isolated coughing. Chest computed tomography (CT) scan revealed a 4×3 cm sized mass on the upper lobe of the left lung (). Percutaneous needle biopsy of the lesion revealed adenocarcinoma. There was no evidence of metastases in bone scan, brain magnetic resonance imaging, or positron emission tomography (PET)-CT scan. Finally her disease was clinically staged as T2aN0M0. Polymerase chain reaction-based DNA sequencing of the EGFR gene revealed an activating mutation (Leu858Arg) in exon 21 of the EGFR gene. She underwent lobectomy of the upper lobe of the right lung. Tumor was a 4.0×4.0×3.5 cm in size and directly extended to visceral pleura on pathologic examination. She subsequently received three cycles of adjuvant chemotherapy with paclitaxel and cisplatin from December 2009. Following adjuvant chemotherapy, evaluation with chest CT scan, PET-CT scan and bone scan every three months revealed no evidence of recurrence until March 2011 when multiple small nodules were developed on both lung fields. Wedge resection of the upper lobe of the left lung was performed and metastatic adenocarcinoma was pathologically confirmed in the specimen. The DNA sequencing of the EGFR gene of resected specimen did not revealed any activating mutations of the EGFR gene. She received four cycles of chemotherapy with irinotecan and cisplatin and her disease was shown to be stable. In December 2011, pulmonary nodules were newly noted in the upper lobe of the left lung (). Then treatment was switched to the erlotinib monotherapy, 150 mg once daily. Her disease was shown to be partial response to the treatment by criteria of Response Evaluation Criteria In Solid Tumors version 1.1 in February 2012 and has been stable until June 2012. During the treatment, she experienced skin rashes on her face, chest, and scalp, which were adequately controlled with topical therapy. In addition she was complained"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient was a 66-year-old single man, who worked for a cleaning company, and had hearing impairment; however, there was no evident medical history of psychiatric disorders. He was found lying in front of his apartment and was sent to the emergency room. A physical examination revealed fracture of the left patella and calcaneus, which appeared to be related to trauma. He kept his eyes closed for most of the day and demonstrated no spontaneous speech or reaction. Although his blood tests showed inflammatory reaction, his vital signs were normal, and computed tomography and electroencephalography of his brain showed no significant findings. He had no relatives and there was no life history information of him. According to the information of the neighboring residents, he had exhibited strange behaviors since about 2 months before admission and often annoyed the neighbors. Before his arrival to the emergency department, a neighbor called the police because the patient had stood in front of his apartment for a long time. While in detention, he did not respond to the police interrogations at all; he was found lying in front of his apartment a few hours after police released him. After admission to the emergency department, he was consulted with our department for the assessment of psychotic symptoms by his physician. Including the process leading to hospitalization, he was diagnosed with catatonia based on the presence of stupor, mutism, and negativism which was detected from the information by the police about the patients’ uncooperative behavior during detention. He was started on intravenous administration of 5 mg/day midazolam, which was switched to lorazepam, administered through a feeding tube. He then gradually opened his eyes and started speaking. He stated that “someone was trying to kill me, so I jumped to escape. I don’t want to talk about anything because I am being seen and heard by someone.” He was, therefore, suspected to have hallucinations and del"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old obese male presented to the emergency room (ER) with fatigue and shortness of breath. He reported that during the past few weeks, he had developed progressive breathing difficulties and weakness. He had no fever and only mild right upper quadrant and right chest discomfort. On physical examination, diminished breath sounds in the right lower lung were found. The patient was anaemic (haemoglobin 8 mg/dl), and leukocyte count was normal. The CT scan showed a large Morgagni-type hernia with the entire right hemicolon, parts of the transverse colon and terminal ileum, and ample omentum trapped in the chest (), causing atelectasis of the right lower lobe. After stabilization in the ER, he was admitted to the hospital, and workup for the blood loss anaemia was initiated. He had a positive stool guaiac test and underwent a colonoscopy showing a large mass in the right colon (). During colonoscopy, the endoscope was maneuvered with extra care to avoid any injuries; the colonoscope entered the right chest but could ultimately be advance to the ileocecal valve. Biopsies of the mass in the proximal ascending colon revealed an adenocarcinoma.\nHe consented for laparoscopic repair of the diaphragmatic hernia and resection of the right colon. Surgery was done in the supine position and was initiated by insertion of a 5 mm 1st entry port in the left upper quadrant. An additional 5 mm port was inserted in the left lower quadrant and a 10-12 mm port above the umbilicus. A large right-sided diaphragmatic defect (7 cm diameter) was encountered anteriorly to the liver with the entire right hemicolon and terminal ileum and omentum trapped inside. The hernia contents were gently reduced from the mediastinum (). The peritoneum at the anterior aspect of the defect was incised using an Enseal, and the entire hernia sac was carefully mobilized out of the mediastinum, avoiding injury to the pleura or phrenic nerve. The Valsalva maneuver was applied to"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 55-year-old Caucasian female presented with productive cough, dyspnea, chest pain and weight loss. The patient's medical history was significant for hypertension, hypercholesterolemia, dyslipidemia, chronic renal failure, gastroesophageal reflux disease and chronic anemia. She was a 30 pack-year smoker and her mother was diagnosed with lung cancer. Her physical examination was unremarkable. An initial chest X-ray showed a large subcarinal mass. On computed tomography (CT), a 6.2 × 5 cm tumor was detected in the subcarinal area (Figs and ). A bronchoscopy with transbronchial biopsy was performed, and the resulting pathological analysis was suspicious for malignant cells; however, no specific tumor type was identified. A positron emission tomography scan showed a large hypermetabolic subcarinal lesion with a standard uptake value of 14.3, consistent with malignancy. The differential diagnosis at the time included an infected bronchogenic cyst, esophageal duplication cyst or a malignant subcarinal lymph node. Thoracoscopic surgical resection was planned for diagnostic and therapeutic purposes.\nPrior to surgical resection, esophagoscopy and bronchoscopy documented the absence of any communication of this mass to the esophagus and airway. The resection was completed thoracoscopically, with a five-port approach. One port was made at the mid-axillary line of the eighth intercostal space for the camera, in addition to two anterior and two posterior ports. The dissection of the tumor began at the level of the inferior pulmonary ligament and posterior mediastinum, all the way to the azygous vein. The esophagus was found completely adherent to the tumor, necessitating an esophageal myotomy for en bloc resection. The esophageal mucosa was not violated at any point throughout the procedure. The anterior dissection proceeded at the level of the posterior atrial wall, the inferior and superior pulmonary veins, the main trunk of the pulmonary artery, and the membranous areas of t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old patient presented with an 8×7-cm posterior wall fibroid diagnosed for the first time during pregnancy at 12 weeks. The course of the pregnancy was smooth, with mild enlargement of the fibroid to the size of 10×9 cm.\nThe patient delivered by Caesarean section at a private clinic due to malpresentation (breech presentation). In the first week postpartum, the patient experienced malodorous vaginal discharge. The patient sought medical advice and antibiotics were given for 14 days, but the discharge did not resolve and the patient felt a mass inside the vagina.\nThe patient presented to Tanta University Hospitals where she was admitted, and under general anesthesia, an examination revealed a solid mass extending from the cervix into the vagina. A biopsy was taken from the mass for histopathological examination, and it was identified as a degenerated cellular fibroid polyp.\nAntibiotics also were given for 14 days after a culture and sensitivity test, but the discharge still did not resolve. At this point, the patient became frustrated and sought medical advice from more senior practitioners, who advised her to receive gonadotropin-releasing hormone analogues for 2 months. Nonetheless, the discharge was not cured; it became more malodorous as well as greenish and stool-like in character.\nThe patient developed abdominal pain, distension, vomiting, and absolute constipation 1 week later and was readmitted to Tanta Emergency Hospitals where thorough investigations were performed, including a pelvic ultrasound and a computed tomography scan with gastrointestinal tract contrast.\nAn examination revealed cachexia and toxicity facies, The patient's vital signs were a blood pressure of 100/60 mm Hg, a pulse of 110 beats per minute and a temperature of 38.1℃. An abdominal examination revealed distension, tenderness with guard and rigidity, and resonance over all quadrants of the abdomen. No peristalsis was heard over any region of the abdomen.\nA pelvic examination demo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 52-year-old male patient reported to the outpatient department with a chief complaint of swelling on the right side of the palate for the past 5 years. The patient had undergone surgical treatment for a bony swelling at lower border of the mandible about 30 years back. After that, he was apparently normal until 5 years back when he noticed a small swelling on the palate which was very slowly increasing in size. The past medical history revealed chronic bowel upset in the form of abdominal cramps and diarrhea. Family history revealed that both sons of the patient had bony swellings of the jaw and both of them were reluctant to get their screening done for Gardner's syndrome.\nOn examination, multiple small nodular swellings were seen on the forehead. The nasolabial folds were obliterated bilaterally []. The overlying skin appeared normal. On palpation, all the swellings were bony hard in consistency, nontender and were fixed to the underlying bone.\nIntraoral examination revealed swellings on the right and left sides of the palate. On the right side, buccal vestibule was obliterated in 14 and 15 region and palatal swelling was extended from the mesial aspect of 16 to the distal aspect of tooth 17 anteroposteriorly. On the left side, the palatal swelling extended from mesial aspect of tooth 25 to the mesial aspect of 28 anteroposteriorly []. A diffuse swelling was seen on mandible on the left side, causing buccal vestibular obliteration in 34 and 35 region. The overlying mucosa was intact, with no ulceration or sinus discharge. On palpation, all the swellings were bony hard in consistency and nontender. There were clinically missing teeth 11, 15, 23, 34, 35, and 45.\nTo see the exact extent of the lesion, a panoramic radiograph was obtained which revealed impacted teeth w.r.t. 11, 15, 23, 34, 35, and 45. Diffuse radiopaque areas were seen in the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old female presented with three months of hoarseness and dysphagia following an upper respiratory infection. Her past medical history included invasive ductal carcinoma of the breast (ER positive, PR negative, and HER2 negative) treated by mastectomy two years prior to presentation. On clinical examination, she was found to have paralysis of the right vocal cord, and a follow-up CT scan of the neck revealed an enlarged thyroid gland with multiple bilateral thyroid nodules. FNA of a right-sided 3.5 cm thyroid nodule was diagnosed as atypia of undetermined significance (Bethesda category III). A repeat FNA three months later yielded a diagnosis of benign follicular nodule (Bethesda category II). Persistent hoarseness and compressive symptoms, combined with atypical findings on the initial FNA, necessitated right thyroid lobectomy and right vocal cord injection. Intraoperatively, the right thyroid lobe was noted to be moderately enlarged with multiple nodules but no evidence of extrathyroidal extension.\nThe right lobectomy specimen measured 4.6 cm in greatest dimension and weighed 16 grams. The cut surfaces of the thyroid parenchyma showed multiple variably sized brown gelatinous nodules, with focal areas of hemorrhage and cystic change.\nHistologic examination revealed evidence of nodular thyroid hyperplasia, along with multiple scattered subcentimeter foci of metastatic breast carcinoma, which were present in 7 out of the 16 submitted tissue sections. Most of the smaller metastatic foci, measuring around 1 millimeter each, consisted of a few irregularly shaped nests of epithelioid tumor cells interspersed between thyroid follicles (). The largest metastatic focus measured 0.6 cm and was comprised of tumor cell nests arranged along the periphery of a sclerotic stroma containing cords of tumor cells showing retraction artifact (Figures –). These areas resembled the dense amyloid-type stroma often seen in medullary thyroid carcinoma (MTC). Additionally, there w"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThis is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).\nIt also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.\nThe patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old female with a past medical history of migraines and benign paroxysmal positional vertigo (BPPV) presented to the ED with the complaint of new onset numbness and tingling of her right face that eventually progressed to the left side. She also developed significant nausea which resolved with meclizine. A noncontrast CT scan of the brain was performed in the ED to rule out stroke and found no acute abnormalities. The patient’s neurologist was consulted and suggested that her symptoms might be caused by complex migraines and she was discharged. The patient then noticed that her right eye was beginning to have diminished vision over the week after she was discharged from the ED. She went to see her primary care physician who ordered an MRI study with and without contrast of the brain and a magnetic resonance angiogram (MRA). These images revealed an aneurysm at the left PICA origin (Figure ).\nShe was then referred for a digital subtraction angiogram (DSA) of the brain, commonly referred to as a cerebral angiogram. The cerebral angiogram was scheduled and took place a month later. The cerebral angiogram showed clearly an irregular aneurysm at the origin of the left PICA, 5.7 mm in size, with a wide neck (greater than 3.75 mm) (Figure -D). The neurointerventionist who performed the diagnostic cerebral angiogram then scheduled her for treatment. A neurvas pipeline flex stent 4 mm x 14 mm was placed in the PICA to divert flow from the left PICA aneurysm. The patient took aspirin (81 mg) and clopidogrel (75 mg) prior to and following the procedure. In the evening following the stent placement, the patient experienced mild right homonymous hemianopsia that improved throughout the hospital course. She was discharged with complaints of seeing dark shadows in her right visual field in both eyes on post procedure day two and was referred for follow up with ophthalmology"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old, para 5, postmenopausal black African woman who was human immunodeficiency virus (HIV)-negative presented to our casualty department with a 5-year history of progressive abdominal swelling. Five years prior to presenting, which was 1 year before she reached menopause, she had noticed that her abdomen was gradually distending. Her symptoms were associated with constipation, feeling of incomplete rectal emptying, early satiety, vomiting, and urinary frequency and urgency. She did not have any chronic illnesses and had a negative personal and family history of ovarian, uterine, bowel, and breast cancers. She was not receiving any medication prior to this presentation. She had delivered five children by cesarean section, and they were all alive and well. She lived in a rural area and was a subsistence farmer. She did not smoke and did not drink alcohol.\nShe had ascitic taps three times in 1 week at a district hospital before referral to a higher-level hospital because of recurrent reaccumulation of ascites. A transabdominal ultrasound scan (USS) showed generalized ascites with a thick fluid with septa, as well as bilateral mild hydroureter and hydronephrosis. Again, the ascites was drained twice. One month later, she underwent computed tomography (CT), which showed a large predominantly cystic lesion that occupied almost the entire abdominal and pelvic cavities, which were distended, causing a marked mass effect on surrounding organs and bowel. The lesion had areas of internal septation predominantly on the right flank with no features of metastatic disease. Tumor markers measured during this admission are shown in Table .\nThe patient was referred to a tertiary hospital but only went 5 years later. Upon admission, she had marked temporal wasting, with bilateral pitting lower limb edema extending to her sacrum. She had a normal breast examination. Her blood pressure was elevated at 167/93 mmHg, with tachycardia of 150 beats/min. Her body temperature was 36."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 71-year-old male presented with a history of AN lesions on the hands, feet, fold areas, face and oral cavity that had been present for approximately 4 months. The initial lesions appeared as hyperpigmentation, with a rough and thickened skin surface and mild pruritus, present on the hands, feet, axillary and inguinal regions. Subsequently, lesions also emerged on the face, neck, back of the ears and oral cavity. He was treated with an oral administration of avermectin A and traditional Chinese medicines along with topical steroids and urea vitamin E ointment with no clinical improvement. The skin lesions gradually thickened, developing into wart-like hyperplasias or tumor-like lesions and additional lesions associated with burning sensations surfaced on the buccal mucosa and tongue. According to the patient’s medical history, he was initially diagnosed with urinary bladder cancer in 2007. At that time, he received TUR-BT surgery followed by regular administrations of intravesical chemotherapy. In 2013, he was diagnosed with rectal cancer and underwent laparoscopic surgery followed by regular chemotherapy. He was then diagnosed with urinary bladder cancer in 2014, and again underwent TUR-BT surgery followed by intravesical chemotherapy. Additionally, the patient had a history of hypertension for more than 10 years. There was no history of steroid medication use, endocrine abnormalities, hepatitis, other autoimmune diseases or familial hereditary diseases. Family members were unaffected.\nPhysical examination revealed numerous grey and brown skin papillary papules or verrucous nodules observed in the axillary and inguinal areas, along with diffuse hyperkeratosis and waxy-yellow lesions in the palms and plantar surfaces. Clinical examination of the oral cavity revealed hypertrophic lesions and papillomatosis on the buccal mucosa, gingiva and a glossy tongue without moss (–). There were no apparent abnormalities in the toenails and hair.\nBased on these findings and the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 34 year old previously well lady from urban Sri Lanka presented to the Institute of Neurology at the National Hospital of Sri Lanka with a one month history of numbness of the right side of her face and difficulty chewing from the right side of her mouth. She described the onset of the symptoms as sudden as it was present on awakening from an uninterrupted sleep the previous night. The symptoms had persisted over a month without much progression. She had received treatment from a general practitioner but her symptoms had not improved. She did not have any diplopia or blurred vision, painful eye movements, hearing impairment, dysphagia or dysarthria. She did not complain of limb weakness or unsteadiness with tendency to fall. She did not complain of shooting pain on the right side of the face triggered by touch and has had no previous facial rashes. She denied sexual promiscuity. She had lived in Sri Lanka all her life and has not had any foreign travel.\nNeurological examination revealed an alert lady who was oriented to time, place and person. There was no facial asymmetry or drooling of saliva and no obvious facial rashes. On asking the patient to open her mouth there was slight jaw deviation to the right side (Figure ). Palpation of the Temporalis and Masseters did not reveal any wasting. Sensory examination revealed impaired pain sensation on the right side of the face involving the Ophthalmic, Maxillary and Mandibular divisions of the trigeminal nerve conforming to the characteristic onion skin distribution. The corneal reflex on the right side was also absent. All other cranial nerve examination was normal including the adjacent nerves. Opthalmoscopic examination did no reveal optic atrophy or papillitis. There was no limb involvement with normal Corticospinal, Spinothalamic and Posterior column pathway examination including preserved reflexes and there were no demonstrable Cerebellar signs.\nMagnetic Resonance Imaging (MRI)"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 72-year-old male with history of penile implant, hypertension, hyperlipidemia, severe peripheral vascular disease with extensive smoking history presented in clinic for severe bilateral lower extremities claudication. Doppler exam showed weak monophasic flow bilaterally. Patient also had a history of left popliteal stent placement and has been taking aspirin and Plavix since then. CT angiography of the lower extremities showed critical stenosis of superficial femoral artery of both lower extremities and a patent stent on the left popliteal artery. Decision was made to perform bilateral lower extremities angiograms via a transfemoral approach with possible revascularization of the right lower extremity (LE) first and then the left side on two different procedures one week apart. Both procedures were accessed through a transfemoral approach that involved balloon angioplasty of the left (L) and right (R) superficial femoral artery (SFA) and left proximal popliteal artery. No immediate post procedure complications were noted, VCDs were deployed and hemostasis was achieved on both occasions. Patient was discharged same day and aspirin and Plavix were resumed.\nOn the following day after the right transfemoral access approach, patient presents to ED with R groin and scrotal pain. On evaluation, severe tenderness on the R groin and scrotum was noted associated with worsening swelling and ecchymosis (Fig. ). Vitals were within normal limits and initial hemoglobin of 12 g/dl. Ultrasound of the right groin showed a 6.3 × 4.0 × 4.9 cm hematoma (Fig. ), his duplex ultrasound of bilateral testicle showed diminished blood flow on the right compared to the left (Fig. ). CT of the pelvis revealed a pseudo-aneurysm on the R groin originating from the common femoral artery (CFA) measuring 2.5 × 1.4 cm and extending into the R inguinal canal, filled with hemorrhage and extension into the R scrotum that measures 13.7 × 6.4 × 6.6 cm (Fig. ). During his clinical course, he has been hemo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old woman initially presented with blurry vision that developed over the span of approximately one month. The blurry vision was initially most prevalent on horizontal gaze but progressed to include vertical gaze. It resolved with closure of one eye. She reported a history of gradually worsening headache over the past several years. Her headaches both worsened in intensity and increased in frequency, until it was quite debilitating and occurred daily. She described the headache as an intense pressure in both the front and back of her head. She also noted a “whooshing” sound in her right ear. She denied any nausea or vomiting and had not had any syncope, numbness, weakness, facial droop or slurred speech. Furthermore, she had no history of bladder or bowel dysfunction.\nHer medical history was pertinent only for obesity with a body mass index (BMI) of 39. On physical exam she was noted to have papilledema. Her neurological exam was unrevealing with the exception of a subtle sixth cranial palsy.\nA magnetic resonance image (MRI) was obtained which showed a T1 hypointense and T2 hyperintense cystic lesion arising from the pineal gland measuring 2.0 x 1.1 cm in the sagittal plane with mild mass effect on the tectum and partial effacement of the cerebral aqueduct (Figures , ). The lesion demonstrated a thin rind of contrast enhancement and had thin enhancing internal septations. The lateral ventricles were mildly enlarged. There was no restricted diffusion and no loss of gray white differentiation. Cine flow study noted cerebral spinal fluid (CSF) flow through the cerebral aqueduct. Based on the radiographic images, the most likely diagnosis was an atypical pineal cyst.\nGiven the rapidity of the vision changes, the decision was made to pursue surgical intervention. An endoscopic third ventriculostomy (ETV) with pineal cyst fenestration was performed without complication. A computed tomography (CT) scan obtained post"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 36-year-old male patient, presented to the emergency department on the 10th of January 2014, with intermittent right sided abdominal pain for the past few months that was becoming severe in the preceding few days. The nature of pain was nonspecific and the location was diffuse. There were no associated lower urinary tract symptoms or fever. He has no comorbidities or history of urolithiasis. He was a smoker for the last 20 years. Physical examination revealed right-sided renal angle fullness. Rest of abdominal examination was unremarkable.\nUrinalysis showed microscopic hematuria with some proteinuria. Full blood count was within normal limits, whereas renal function test showed an elevated creatinine of 150 µmol/L. A plain abdominal film showed; a large, well-defined soft tissue swelling in the right hypochondrium and lumbar region. The patient was initially seen by the nephrology services, who arranged renal tract ultrasound (US), which showed a large clear cystic lesion measuring 20 cm × 16 cm in the right subhepatic region occupying the entire right lumbar quadrant. No contents seen with no septation. The right kidney was compressed by the cyst and could not be separately imaged from this lesion. The contralateral kidney was unremarkable. He was referred to urology clinic, where he was found to have a palpable mass that was dull to percussion occupying the right renal angle. After taking necessary measures against contrast nephropathy, the patient had a CT scan with intravenous and oral contrast of the abdomen and pelvis that showed a large thick-walled nonseptated noncalcific right renal cortical cyst (23 cm × 16 cm × 15 cm) showing enhancement of its thick walls, no right perinephric/pericystic fat stranding, preserved tissue planes with surrounding related organs.\nFor further assessment of drainage and function, the patient had an MAG3 renogram that showed a small right kidney with poor perfusion and excretion of the tracer. It contributed around 9% to the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 38-year-old man of Korean descend and now living in Japan presented to the outpatient clinic of a local hospital with abdominal pain, melena and dizziness. Laboratory test showed that he had microcytic anaemia (haemoglobin 8.7 g/dL and mean corpuscular volume 71.7 fL). Faecal occult blood test was positive. His medical history included a previous duodenal bulb perforation which required surgery in his teens. Oesophagogastroduodenal endoscopy (OGD) and colonoscopy was subsequently performed, revealing no active bleeding but slightly deformity and linear scares in duodenal bulb. A plain CT scan later performed revealing no abdominal or pelvic masses. The patient received transfusion of two units of red blood cells which restored his haemoglobin to 11.5 g/dL, relieving his symptoms significantly. He was discharged on day 12 and later referred to our hospital, a metropolitan centre in central Tokyo, for further workup and treatment.\nIn the diagnostic workup, chronic iron deficiency anaemia caused by small intestinal bleeding was considered. BAE (single balloon, rectal approach) was hence performed in search of the culprit lesion. However, the scope failed to advance to the jejunum; mild inflammatory changes were found in the proximal ileum. Capsule endoscopy was further performed to inspect the small intestine. There was initially a delayed pylorus passing of the capsule endoscope due to stenosis in the duodenal bulb, but the capsule eventually reached to the small intestine. Images from the capsule showed small intestinal ulceration with surrounding erythematous mucosal changes in jejunum, which were likely to be the cause of the recent bleed (). Several days later, a plain abdominal X-ray was performed confirming capsule retention in distal small intestine. As a result, a secondary BAE (single balloon, rectal approach) was performed to retrieve the capsule. Despite the stenosis in area surrounding the jejunum–ileac junction, the scope was successfully inserted to th"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 67-year-old lady was admitted via the emergency department after being found unresponsive at home by her husband early in the morning. On presentation, her GCS was 9 with normal vital signs. Her glucose level was 8 mmol/L, and the blood gases were normal. On observation an hour later, her dextrose test was rechecked and fell to 1.5 mmol/L with blood glucose of 0.9 mmol/L. She was given intravenous dextrose and her condition improved.\nOf note, her past medical history included a two-year history of type 2 diabetes mellitus, recently diagnosed depression, and osteoporosis. Her oral hypoglycemic agents had been recently withdrawn as her blood sugar levels were well controlled on dietary changes she had made. Her family reports that she was increasingly anxious over the last few months with occasional confused periods. She also had a 4 kg weight loss over the last 12 months (10% body weight). Her daily medications include citalopram, bromazepam, and weekly bisphosphonate. There was no family history of diabetes mellitus, hypertension, or hyperparathyroidism. The patient denied taking any excess medication or oral hypoglycemic agents.\nOn examination, the patient was alert but appeared very anxious; her GCS returned rapidly to normal on intravenous dextrose. Cardiovascular, gastrointestinal, and neurological examinations were normal as well as her other laboratory investigations.\nThe patient underwent a 72-hour fast as part of the investigation but was interrupted at 2 hours due to hypoglycemic symptoms (sweating, feeling drowsy and unwell). During this episode, her blood glucose level was confirmed to be low (1.1 mmol/L), C peptide was elevated at 8.2 and insulin levels at 91. Her sulfonylurea screen was negative and her other pancreatic endocrine hormones were sent and came back as within normal limits.\nCT scan of abdomen revealed a 2.6 cm by 2.0 cm hypodense mass containing peripheral calcifications in the body of the pancreas (). Multiple low attenuation liver"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 66-year-old man with no history of concomitant conditions was admitted to our hospital. He had been operated on due to a tumour on the distal third of the left arm as a result of a closed trauma without fracture 20 years before. Several debridement surgeries were also performed on his lesion, but no detailed information is available. Physical examination revealed new lumps with seropurulent discharge 7 years after the first surgery. Subsequent blood analysis did not show alteration in acute phase reactants, and hematimetric indexes were within normal ranges. For the next 20 years, he continued to experience similar episodes of sporadic reactivation of the lumps.\nBefore 4 years, he was admitted to our hospital due to painless lumps fixed on the subcutaneous tissue of the left arm (). Radiographs of the left humerus revealed an alteration of the bone structure with distal diaphyseal involvement and thickening and cortical irregularity, which extended up to the metaphysis (). A computed tomography (CT) scan disclosed an alteration in the osseous morphology of the metaphysis–diaphysis in the distal third of the humerus at an intramedullary and cortical level, with osteolysis, periosteal reaction, diffuse involvement of adjacent soft tissues and several lower density, superficial, poorly defined liquid areas (). A magnetic resonance imaging (MRI) scan confirmed the multiple liquid deposits on the thick walls of the soft tissues and muscular oedema related to joint effusion ().\nAspiration was performed, and the extended coloured (Diff-Quick) haematoxylin–eosin, pap-test showed lymphocytes, leukocytes, macrophages, multinucleated giant cells and accumulations of bacillary structures (Actinomyces), consistent with a granulomatous inflammatory process (). Cultures (glucose asparagine agar, arginine-glycerol and tyrosine agar mediums) were subjected to a prolonged incubation of 21 days under aerobic and anaerobic conditions and were negative.\nThe patient underwent a surgica"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 48-year-old Japanese man noticed a slightly tender soft tissue mass on the anterolateral aspect of the lower part of his left chest wall, six months prior to his first visit to our hospital. When the tumor became slightly enlarged, he visited his previous orthopedist. A soft tissue tumor was suspected and an incisional biopsy was performed. However, a definite pathological diagnosis could not be made due to the small amount of biopsy specimen. He was referred to our hospital for further examination and treatment. On inspection, the anterolateral surface of the lower part of his left chest wall was swollen. On palpation, a fibrously hard tumor, measuring 5 × 6 cm, was palpable. It adhered firmly to the chest wall. He was experiencing mild pain. There was no localized heat or redness. Chest radiographs showed no abnormal findings. A magnetic resonance imaging (MRI) scan showed that the soft tissue tumor (measuring 6 × 5.5 × 5 cm) was located beneath his external oblique muscle and permeated into his intercostal muscles, causing the peritoneum to protrude towards his abdominal space (Figure ). The signal intensity of the lesion was isointense to skeletal muscle on T1-weighted images (Figure ) and heterogeneously high on T2-weighted images with some areas of low intensity (Figure ). The lesion was strongly enhanced by the administration of a contrast medium (Figure ). As a result of these physical and MRI findings, we suspected a soft tissue tumor rich in collagen fibers and blood vessels, such as desmoid tumor, fibrosarcoma or malignant fibrous histiocytoma. He was unwilling to take a second biopsy and a natural course was observed. The tumor gradually enlarged, becoming 8 × 6 cm on palpation ten months after his first visit. At this time, a second incisional biopsy was performed. Macroscopically, the tumor was whitish and fibrous. Histologically, the tumor was poorly circumscribed and infiltrated into his surrounding soft tissue. Spindle"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 35-year-old female presented to a local hospital with a 3-month history of intermittent abdominal pain. Initial abdominal ultrasonography revealed cystic dilatation of the extrahepatic bile duct. A suspicion of choledochal cyst was made and was referred for surgical management. Her past medical history was unremarkable. She weighed 83 kg and was 164 cm tall, with body mass index of 30.9 kg/m2. Apart from mild right upper quadrant tenderness, her physical examination was unremarkable. Laboratory tests including liver and renal function tests, serum and urine amylase levels were normal. A magnetic resonance cholangio-pancreatography (MRCP) done showed a cystic fusiform dilatation of the common bile duct (CBD) extending into the right and left hepatic ducts (). No PBM was observed. The MRCP findings suggested type Ic CC. Without any further imaging, patient was scheduled for complete cyst excision with cholecystectomy and hepaticoenterostomy surgery. At laparotomy, the CBD was found to be fusiformly dilated. Bile samples were taken from the cyst and the gallbladder (GB) for amylase level essays. The GB was dissected from the liver bed and the cystic duct opened into the midportion of the cyst. After careful dissected of the cyst from surrounding vascular structures, the distal part entering the head of pancreas was noticed to be unaffected (). The distal part was transected just at the level of the head of pancreas and samples were taken for frozen section. Dissection at the hepatic hilum revealed two separate dilated ducts originating from the confluence of the left and right hepatic ducts and both entering into the cyst (). The two ducts were transected just distal to their origin from hepatic confluence to avoid confusing them as true right and left hepatic ducts (). The hepatic confluence was then opened to expose the true left and right hepatic ducts (). The dilated portions of the both hepatic ducts were transected and samples were taken for frozen section. A"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 25-year-old lady presented to hospital 36 days after giving birth via an uncomplicated lower segment caesarean section. She stated that the scar was well healed since the fifth day post-surgery and she had begun breast feeding. There was no history of nipple trauma or mastitis. She complained of a 15 day history of progressive pain, swelling and decreased range of motion in her right knee. Systemic examination revealed pyrexia of 38.5 degrees Celsius and a tachycardia of 120 beats per minute. Examination of the knee demonstrated a red, hot, swollen, tender joint with minimal range of motion. Radiographs of the knee were unremarkable. The knee was aspirated under aseptic conditions and 35 mls of turbid fluid was collected.\nBlood laboratory results were as follows: white cell count 15.8 × 109/L, CRP > 250 and ESR 75. Initial gram stain of the aspirate showed 3+ of white cells but no organisms.\nIn view of the clinical picture, the patient underwent urgent arthroscopic washout of the knee. It was noted that the synovium was thickened and inflamed, and biopsies were taken. Furthermore, there was a significant amount of pus in the suprapatellar pouch. The knee was washed out with nine litres of normal saline.\nCultures of the pus taken from the knee subsequently grew Staphylococcus aureus sensitive to flucloxacillin. Cytology of the fluid was negative for crystals. The biopsies taken revealed acute synovitis with extensive ulceration of the synovial lining lined by inflammatory exudate composed of fibrin, polymorphs and scattered macrophages.\nThe patient was given intravenous benzylpenicillin (1.2 g QDS) and flucloxacillin (1 g QDS) post-operatively and the patient clinically improved. She underwent a further arthroscopic washout of the knee three days after the original procedure. It was found at the second operation that there was some pus in the lateral arthroscopy portal wound though no pus within the knee joint"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 32-year-old man injured his dominant right hand by striking a punching bag machine with a clenched fist. Clinical examination revealed that his right hand was markedly deformed and swollen. The range of motion was limited due to pain. He had small bulla formation on the dorsal aspect of the hand. There was no neurovascular deficit.\nPlain radiography and computed tomography revealed dorsal dislocations of the index, middle, ring, and little fingers at the CMC joints and simultaneous fractures of the dorsal aspect of the trapezoid and hamate []. An initial attempt of closed reduction under conscious sedation in the emergency room was unsuccessful.\nThe surgery was performed through the dorsal aspect of carpus in a zigzag fashion from proximal part of the wrist to the middle part of the metacarpal bone. An interposed dorsal joint capsule in the CMC joints was found which might prevent the initial closed reduction of these joints. After removing the interposed joint capsule, CMC joint reduction was easily achieved under fluoroscopy.\nHowever, we could not achieve stable reduction without fixation. The Kirschner wire fixation was performed while the CMC joints reduced. Under fluoroscopic vision, the first Kirschner wire was inserted retrograde from the base of the fifth metacarpal bone to the hamate. The second Kirschner wire was inserted antegrade from the hamate to the fourth metacarpal bone. The third Kirschner wire was inserted antegrade from the trapezoid toward the second metacarpal bone. The fourth Kirschner wire was inserted retrograde from the third metacarpal bone to the capitate. Finally, dorsal fractures of the trapezoid and hamate bone were reduced and each fracture was fixed with a mini screw (1.5-mm cortical screw, Synthes, West Chester, PA, USA).\nAfter bony fixation, the ruptured dorsal capsule and ligaments of the CMC joint were repaired with absorbable sutures. Postoperatively, the patient remained in a volar above elbow spl"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 70-year-old woman, hailing from Kashmir in India, presented to us with progressively increasing abdominal mass since 11 years. This was associated with progressive appearance of jaundice and dull aching pain in abdomen since 3 months with pruritus for one month that worsened nocturnally. She neither complained of fever, bleeding diathesis, chest pain, cough or palpitations, and altered bowel habits nor did she suffer from anorexia. There was significant unintentional weight loss secondary to early satiety since last one year. There was no history of swelling of legs or puffiness of face during this period. There was no history of swelling over other parts of the body or associated skin changes. The patient is a known case of diabetes mellitus on oral hypoglycemic agents with adequate glycemic control since the last 20 years. Eleven years ago, the patient underwent an open laparotomy for complicated symptomatic gall stone disease and was incidentally detected to have a space occupying lesion of the head of pancreas. The lesion was highly vascular on intraoperative analysis and was left alone at that time with a fine needle aspiration cytology evaluation, which was later confirmed to be that of benign microcystic adenoma. The patient thereafter started noticing progressive enlargement of an epigastric mass which was initially seen 8 years ago. This mass progressed to involve the whole of the abdomen with associated lethargy and early satiety and difficulty in performing routine works. Multiple fine needle aspiration cytology of the mass lesion was done at various hospitals outside, before presentation to our facility. All those reports were noncontributory and confirmed the presence of only blood and cystic elements. On examination, at our center, the patient was found to be conscious and alert but emaciated with temporal hollowing and facial muscle wasting, with good performance status (ECOG-PS 0). Pallor was evident, as were icterus and scratch marks over the abdo"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 80-year-old woman presented to the authors' hospital emergency department complaining of right hip pain after sustaining a fall in her own home. Prior to injury she could walk normally. She had a normal body mass index and did not suffer from any other comorbidities. Clinical and radiographic evaluation of the right hip demonstrated an AO type 31.A2 intertrochanteric fracture.\nThe femur fracture was treated with intramedullary fixation the following day (). The patient tolerated the procedure well and the immediate postoperative period was completely uneventful. She was instructed not to bear weight for two weeks, but a range of motion exercises were started on postoperative day one. After an unremarkable hospital stay she was transferred to a rehabilitation facility on postoperative day four. Two weeks following surgical fixation of the femur fracture the patient started progressive weight-bearing and gait training. However, on postoperative day 20 the patient complained of a sudden onset pain at the right groin, over the femoral triangle of Scarpa. On physical examination the patient presented with a palpable and visible mass of about 3 × 3 cm, hard and tender to palpation (). Arterial pulses, strength, and sensation of the right lower extremity were unaffected. The pain was poorly controlled by rest and pain medication.\nOn postoperative day 40 anteroposterior and lateral X-rays were obtained demonstrating cephalad migration of the lesser trochanter (). For such reason an angio-computed tomography (CT) was obtained to assess fragment location and femoral vascular involvement (). The study demonstrated the migration of the lesser trochanter over the femoral triangle of Scarpa with no apparent neurovascular injury. On postoperative day 45 the patient underwent surgery for removal of the dislocated lesser trochanter. Intraoperatively the ascending branch of the lateral circumflex artery was isolated and retracted to access and remove the bony fragment. The apex of"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nThe patient is a 57-year-old female who underwent cardiac catheterization via the right common femoral artery two weeks prior to developing a large, symptomatic right common femoral artery pseudoaneurysm ().\nThe patient began complaining of groin pain two weeks after cardiac catheterization. She has a past medical history of aortic valve replacement secondary to aortic valve infective endocarditis, hyperlipidemia, and hypertension.\nShe underwent two attempts of ultrasound-guided thrombin injection of the pseudoaneurysm. On ultrasound, the size of the pseudoaneurysm was found to be 5 cm × 3 cm × 4.6 cm. The neck of the pseudoaneurysm was measured to be 0.8 cm long. The two attempts involved using a 21 gauge needle to administer 1000 units and 2000 units of thrombin, respectively, into the pseudoaneurysm under ultrasound guidance and with the assistance of compression. Due to the size of the aneurysmal cavity and a relatively large pseudoaneurysm neck, injections were found to be unsuccessful on follow-up ultrasound (Figures and ). It was then decided to attempt endovascular closure of the neck of the pseudoaneurysm. All risks were discussed with the patient.\nAfter identification by the attending surgeon, the patient was transferred to the procedure room table in the catheterization lab. The patient received IV sedation, and local anesthesia was used prior to ultrasound-guided percutaneous access to the left common femoral artery. During the procedure, vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were monitored by an ACLS certified nurse.\nAfter a 21 gauge needle was placed into the projection of the vessel lumen, a guidewire was placed into the left iliac artery. An angiographic catheter and guidewire were used to perform selective cannulation of the contralateral right common iliac artery. Then, a 6 French long access sheath was placed to perform an angiogram. The neck of the pseudoaneurysm was visualized (), and a 0.014"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 50-year-old male physician, with no medical comorbidities, presented to the emergency room with history of forceful unrelenting vomiting associated with moderate nausea that had progressed over the past 2 weeks. Initially attributed to gastritis, his symptoms did not improve with proton pump inhibitor and antiemetic medications.\nHis level of consciousness had started to drop over the preceding 24 hours with significant increase in the severity of his headache. Physical exam showed a depressed Glasgow coma score (GCS) of 12 equally reactive pupils with no focal neurological deficit.\nAn urgent brain computed tomography (CT) scan revealed obstructive hydrocephalus with an infratentorial somewhat hyperdense lesion in the fourth ventricular that enhanced homogeneously ().\nThe patient was admitted and urgent endoscopic third ventriculostomy was performed, with rapid recovery of his level of consciousness postoperatively. Cerebrospinal fluid (CSF) analysis and cytology results were within normal and negative for malignant cells.\nFurther brain and spine imaging with magnetic resonance (MR) scan demonstrated a 20 × 25 × 30 mm strongly enhancing mass occupying the inferior half of the fourth ventricle (Figures and ). The mass acquired the shape of the ventricular cavity, extended towards the lateral foramina of Luschka and inferiorly towards the obex without evidence of fourth ventricular dilation. No evidence of parenchymal invasion or drop metastases was seen on imaging of the whole spine. The radiologist's impression was that of an ependymoma or possibly a subependymoma.\nThe patient was then shifted, 2 days later, to the operating theatre for resection of a tumor of the fourth ventricle. Midline posterior fossa craniotomy was performed and the tumor was accessed through a transvermian approach. The tumor was exophytic, grayish in color, firm, and fairly vascular, being fed by leptomeningeal vessels arising from top of the brainstem. Invasion of the lower pons and upper m"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nAn 85-year-old man was presented by his general practitioner complaining of the presence of an erythematous round lesion that was protruding from the surgical scar of his previous sternotomy. He mentioned that the lesion has been growing slowly over time and that lately was also associated with pain in the area. The patient has undergone aortic valve and aortic root replacement with the use of a prosthetic tube graft 7 years ago. The general practitioner referred him to the cardiothoracic unit of our hospital; physical examination confirmed the presence of a non-pulsatile, erythematous round lesion in the cranial third of the previous sternotomy scar with a surrounding bruise (Fig. \nand .\nContrast-enhanced computed tomography (CECT) scan was performed and revealed a 7-cm pseudoaneurysm arising from a 5-mm fenestration of the distal suture line of the Dacron graft with significant amount of thrombus. The pseudoaneurysm was pushing the sutured sternum forward causing diastasis of the sternotomy and was extending anteriorly to the sternum in the subcutaneous tissue (Fig. \nand .\nThe patient was discussed in the aortic multidisciplinary meeting and was considered as of high risk for surgical revision; an endovascular approach was suggested as an alternative option and was referred to interventional radiology.\nThe procedure was performed under local anesthesia. Written informed consent was obtained explaining the risks and benefits of the procedure, including the risk of potential pseudoaneurysm rupture during manipulation and potential embolic material migration in the cerebral circulation. A retrograde left femoral artery access was obtained and a 5F sheath was inserted. Through a pigtail catheter, angiographic evaluation of the ascending aorta in anteroposterior and oblique views was followed in order to delineate the neck of the pseudoaneurysm. A second arterial access through the left axillary artery followed by another 5F sheath was inserted. Using this access, the"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 10-year-old boy was referred for management of malposition left maxillary permanent lateral incisor (tooth 22). Tooth 22 was in crossbite to the left mandibular permanent lateral incisor (tooth 32) and permanent canine (tooth 33) (). According to the boy's mother, the boy had a small pointed tooth between the right and left maxillary permanent central incisors (tooth 11 and tooth 21) extracted two months ago at a private dental clinic. The attending dentist informed them it was an additional tooth. However, no X-ray was available to verify their account. On examination, tooth 21 appeared malposition labial and inferior in relation to the maxillary alveolar ridge.\nThe first stage of the treatment was to get tooth 21 closer to the arch alignment. We bonded orthodontic brackets (022 × 028 slots, American Orthodontics) on teeth 12, 11, and 21 and used a sectional orthodontic appliance technique to align the teeth. It took over 4 months to achieve the desired result (). A 014 round nickel titanium (NiTi) wire was used to align tooth 22 through deflection method. Once tooth 21 had been moved inferiorly towards the arch alignment, we placed molar bands around the maxillary permanent first molars (teeth 16 and 26). However, the mesial-distal width space between tooth 21 and the left maxillary left primary canine (tooth 63) was narrow (6 mm) and inadequate to move tooth 22 into the arch alignment.\nIn the second stage, we used a 2 × 4 fixed orthodontic appliance to close the space between tooth 11 and tooth 21. We passed a 018 stainless steel round wire through the brackets and bands. We ligated both the brackets on teeth 12 and 11 over the arch wire using a ligature wire to act as an anchor unit. A 3-unit power chain was placed over the brackets on tooth 12, tooth 11, and tooth 21 to gain space closure. The space closure took approximately"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nDue to persistent headaches and the qualitative alteration of consciousness in a woman aged 58 years, on 11 July 2011, a head NMRI was performed, and it showed an expansive lesion in the left frontal portion of the brain, measuring 60 × 50 × 40 mm (Fig. ). The tumor was accompanied by a large edema (Fig. ). As the first step, dexamethasone was included with a dose of 8 mg/day. The surgical procedure was performed on 25 August 2011, and a maximum tumor resection was performed on that occasion.\nIn the period between 08 November and 23 December 2011, the patient underwent radiation with 46 Gy, followed by radiation of the tumor base with 14 Gy in 14 fractions. During radiation, the patient had been receiving TMZ in a dose of 120 mg daily for 42 days. Afterwards, 6 cycles of TMZ (240 mg during each cycle) were administered.\nThe patient started to use standard phytotherapy together with combined RT/CT, and then together with monotherapy with TMZ, and continued to use it after the completion of the oncological treatment. She had been taking PT at full capacity and without interruption for 24 months. Five months after the completion of PT, the patient began to complain of an intense headache; so in April 2014, a control NMRI was performed, and a recurrence of the underlying disease in the frontal portion of the head on both sides, in the shape of a butterfly, was found on that occasion. On the right side, prominent was a larger area of 56 × 47 × 43 mm in diameter that occupied the front third of the corpus callosum (Fig. ).\nAfter these findings, the patient was reintroduced to oncological treatment, which consisted of the combined RT/CT followed by planned 6 cycles of monotherapy with TZM in a daily dose of 260 mg for 5 days during a cycle of 28 days. After the third cycle of the treatment with TZM, a control MRI was"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. N"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 77-year-old female began feeling discomfort in her abdomen around the beginning of September 2019. She also developed night sweats and fever, with little improvement in symptoms. On September 30, she had acute severe abdominal pain and was taken to the emergency room in the previous hospital. On examination, the patient presented with a fever of 38 degrees, rebound pain in the lower abdomen, and muscular defenses. CT scans showed jejunum and ileum wall thickening. It showed fatty deposits around the small intestinal tract and thickening of the nearby intestinal wall, and gastrointestinal perforation could not be ruled out. CT scans also showed adhesions due to inflammation of the sigmoid colon and small intestine (part of the ileum) (Fig. ). She was guided to our hospital for further investigation. The laboratory tests revealed a C-reactive protein (CRP) level of 6.80 mg/dL (normal range: 0–0.14 mg/dL) and an interleukin 2 receptor (IL2R) level of 3,652 (normal range: 121–613 U/mL) (Table ). Transanal small bowel balloon endoscopy revealed mild edema with petechial erythema, which was thought to be lymphatic follicular hyperplasia around 100 cm the oral side from the Bauhin valve. There were no abnormal findings in the colon. Biopsies were taken from the site of the suspected lymphatic follicle hyperplasia (Fig. ). Transoral small bowel balloon endoscopy revealed shallow erosions and edematous mucosa which were detected around 200 cm from the anal side at the vicinity of the Trites ligament. We found ulcers with surrounded disrupted villous structures around the anal side where erosion with edematous mucosa were noticed. We obtained one specimen from the erosion site and the other from the ulcer site (Fig. ). All specimen showed atypical lymphocytes infiltrating the small intestinal mucosa demonstrating intraepithelial lymphocytosis. Immunohistochemical staining showed that infiltrated lymphocytes were positive for CD3, CD7, and CD56, but negative for CD4, CD5, an"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 61-year-old man was involved in a motor vehicle accident at the age of 31. He sustained a left open femoral shaft fracture, and was treated with open reduction and internal fixation. Despite the treatment, the fracture was malunited and valgus deformity of the femoral shaft remained. Progressive left knee pain appeared 3 years before presentation. He was referred to us for surgery. Radiographs showed advanced degenerative arthritis of the left knee and malunited left femoral shaft fracture (Figures and ). There was a 11° valgus in coronal plane and 23° antecurvatum deformity in sagittal plane preoperatively.\nExtra-articular deformity and canal sclerosis precluded the use of a conventional intramedullary alignment guide; therefore, we performed navigation-assisted TKA.\nPreoperative planning revealed that the estimated distal femoral cut line does not compromise MCL insertion site (). The distal femoral cut line was set 13° flexion to the mechanical axis in the sagittal plane () to avoid notching of the anterior femoral cortex. According to the intraoperative assessment, the estimated thickness of distal femoral resection was 12 mm for the medial condyle and 6 mm for the lateral condyle ().\nPostoperative radiographs showed well-restored coronal limb alignment. Coronal alignment of the femoral component was 90° to the mechanical axis (). Sagittal alignment was 13° flexion to the mechanical axis that is parallel to the anatomical axis of the distal femur (). The femoral component was placed according to the intraoperative navigation data. Mechanical axis of the lower limb improved from 9° valgus preoperatively to 1° varus postoperatively.\nRange of motion improved from 15°–105° to 10°–120°. Knee score increased from 36 to 92, and function score increased from 50 to 90 at the latest follow-up. Soft tissue balance was well coordinated. No complications, such as infection, deep venous thrombosis, PF problems, or aseptic loosening, were seen postoperatively. As a result, t"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA previously healthy 29-year-old female patient was admitted to the emergency room of Santa Paula Hospital, Sao Paulo, reporting a sudden headache and syncope associated with mild dysphasia and weakness of right arm and leg. Upon admission, she was graded a Glasgow Coma Scale of 13 and a Grade 4 right hemiparesis. According to her husband, she had not suffered any trauma. The patient was hemodynamically stable and reported on regular use of oral contraceptive.\nWhen the patient was submitted to a computed tomography (CT) scan, the following were detected: A nodular hyperdense frontotemporal image anterior to a large left side predominantly temporal hematoma associated to edema and signs of subfalcine and transtentorial herniation, and a midline shift of approximately 6 mm []. An urgent magnetic resonance imaging (MRI) revealed aneurysm of 2, 5 cm in diameter, with partially thrombosed content associated to a large left temporal hematoma []. Digital subtraction angiography revealed dissection of the parietal-occipital branch of the left MCA and large pseudoaneurysm []. Terminal branches of distal MCA were seen emerging from the aneurysm base. In addition, a routine laboratory and cardiologic examination were conducted, yet the results were unrevealing.\nSurgery under sensitive evoked potential (SEP) and motor evoked potential (MEP) monitoring was performed on an urgent basis given the risk of further neurological worsening.\nA left side large frontotemporal craniotomy was performed along with wide Sylvian fissure opening and complete aneurysm dome and neck dissection. Aneurysm was trapped, and no reduction on neurophysiological parameters from baseline could be noted afterward, thus prompting us not to do a bypass. After the opening of the lesion wall, no bleeding was noted and aneurysmectomy was conducted given the large dome had considerable mass effect on the adjacent brain. Draining of the temporal hemorrhage considerably alleviated regional cerebral edema. Immediat"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 51-year-old female patient had upper gastrointestinal bleeding with haematemesis and melena in the context of an altered general condition. The physical examination revealed weight loss (15 kg) and an abdominal mass of approximately 20 cm in size on the major axis, located in the epigastrium and left hypochondrium. The mass was not very mobile and was poorly limited. A blood test showed anaemia (8 g/dl). A computed tomography (CT) scan revealed a voluminous mass of approximately 22 cm in size from the rear cavity of the epiploon with a predominant mix of aerobic and fluid components. The mass had a thickened and irregular wall and pushed back the stomach (Fig. ). This observation was suggestive of a gastric duplication with blocked communication. An oesophagogastroduodenoscopy did not reveal any lesion up to the 3rd duodenum apart from an aspect of extrinsic compression of the anterior side of the cardio-tuberosity junction. An exploratory laparotomy was decided upon, as the ultrasound endoscopy was not available. During this exploration, a large tumour of a suspicious nature was found at the expense of the posterior gastric wall extending from the spleen to the left hepatic lobe and left diaphragmatic cupola. There was no hepatic metastasis, suspicious adenopathy or peritoneal carcinosis. Nevertheless, the lesion seemed to be inextirpable. We therefore ended the procedure by performing, via a short gastrotomy, four biopsies of the lesion that communicated with the gastric lumen through an orifice admitting a finger. The postoperative outcomes were simple. The biopsy results were in favour of a stromal tumour, with positive CD117, CD34 and Dog1 antibodies (Figs. , S1, S2 and S3). The Ki-67 index was positive at 4%.\nA treatment with imatinib at the initial dosage of 800 mg twice daily was initiated. Poor tolerance to treatment (i.e., severe asthenia and aggravation of anaemia following repeated digestive bleeding) required a"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nOur patient is a 55-year-old Ethiopian woman, gravida IV para III abortion 0, who gave birth to three children at home by spontaneous vaginal delivery. She presented to our hospital claiming she was carrying a dead fetus in her womb from a pregnancy that had been there for 22 years. The pregnancy lasted up to nine months uneventfully at which time the membrane ruptured and she went into labor. After 3 days of labor at home, she developed vaginal bleeding and visited a nearby hospital where she was informed that she had a uterine rupture which had to be operated on. However, she refused the surgery and went home. Over time she developed urinary incontinence.\nShe lost all her three children from an unspecified medical illness before their first birthday, although she claimed all the pregnancies and the labor were uneventful. Since the incident, she is divorced and lives alone supported by her sister.\nAt her current presentation, she had lower abdominal pain which had increased in severity, vaginal discharge, and urine per vagina since the onset of the condition. She had no other known medical illness.\nOn physical examination there was a gravid uterus of 20-week size and a non-tender, fixed, and firm abdominopelvic mass with no signs of fluid collection in her peritoneal cavity. There was a continuous leakage of urine through her vagina but a leak point was unidentified. Her vaginal canal was filled with a 4 cm by 5 cm, oval and stony hard mass.\nLaboratory findings, complete blood count, and organ function tests were in the normal range. An abdominal ultrasound was difficult to perform as there was only shadowing in her pelvis from the bony structures and our patient was incontinent, therefore, she was unable to retain urine.\nAbdominopelvic computed tomography (CT) findings: On the scanogram, multiple calcified tubular fetal parts were demonstrated in the pelvis of our patient (Fig. ). On the post-contrast images,"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 28-year-old man without any underlying diseases had suffered from left side weakness and clonic–tonic seizures for 12 days. Computed tomography (CT) of the patient's head revealed a hypodensed mass with the size of 3 × 3 × 2.4 cm of the right temporal lobe. He was then admitted, and the magnetic resonance imaging (MRI) of his brain showed cystic astrocytoma in the right parietal lobe without midline shifting. A craniotomy was performed, and the pathology showed astrocytoma (World Health Organization (WHO) grade III). After operation, he received 2-dimensional conformal RT with a total dose of 45 Gy in 25 fractions to the whole brain. Mild skin erythematous change was noted after the completion of RT.\nDuring a regular follow-up of 14 years after postoperative adjuvant RT, a small red nodule was noted at the patient's right scalp. The size of the nodule increased overtime and the color eventually turned to black within a year. This gray-colored skin papule with a diameter of 2.5 cm has an ulcerative center. He received skin tumor excision at the age of 42. The skin tumor was totally removed with an adequate margin. The pathology revealed BCC. The morphology of the tumor featured basaloid cells which extended into the dermis with elongated nuclei and little cytoplasm. The peripheral cell layer of the tumor masses showed a palisade arrangement of the nuclei (Fig. ). No skin tumor recurrence has been noted to date.\nTwo years later, the patient developed headache, left side weakness with unsteady gait at the age of 44. His brain MRI revealed a huge cystic lesion with fluid-fluid level in the patient's right frontal lobe. There were hemorrhage, perifocal edema, mass effect causing mild midline shift. Second craniotomy was performed, and there was presence of microvascular of festoons gliosis, microcalcification and tiny foci of necrosis in the specimen, which favored the diagnosis of glioblastoma (WHO grade IV)."}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 90-year-old man was brought to the emergency room due to acute onset of severe generalized weakness, sudden onset of dyspnea, pleasure whistling in respiration, acute dysphagia to both liquids and specially solids and inability to speak, from 2 days ago. He had one time vomiting at onset of the symptoms. He had medical history of achalasia, recurrent pneumonia in last months and head trauma 2 months ago with sub-arachnoids hemorrhage and several convulsions. On arrival to hospital, his vital sign were as oral temperature: 37.8°C, heart rate: 100/minute, respiratory rate: 16/minute, blood pressure: 100/80 mmHg with 95% oxygen saturation on room air. He was completely alert but could not talk. In physical exam except for severe cachexia and superficial ulcers on two forearms, there was no other finding. Lung exam was incomplete due to severe illness and superficial respiration. He did not have stridor and wheezing! None of examiners noticed to his respiration with pleasure whistling and the history of losing his upper dental prosthesis from two days ago. Posterior-anterior chest x-ray revealed bilateral consolidations with the most prominence in the right middle lobe (). Chest computed tomography (CT) scan revealed the same finding as well as bilateral pleural effusion (). He was admitted to the Infectious Disease ward with diagnosis of aspiration pneumonia. In next day, his dyspnea guts worst so made the corresponding physician to take a lateral neck radiography (). A large foreign body was lodged above epiglottis between oropharynx and hypopharynx. On physical examination, his lost upper complete upper denture with 5 x 5 centimeter size was seen in his pharynx behind the tongue and was manually extracted with fingers. His three days dyspnea, whistling, inability to talk and dysphagia was dramatically improved. He was treated for aspiration pneumonia due to last convulsions and was discharged in a stable condition after one week. In third"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 45-year-old man presented with a one-month history of progressive back pain and hypesthesia in both L3 dermatomes. There were no motor weakness. He had undergone a right temporo-occipital craniotomy and partial removal of a huge HPC followed by whole brain radiotherapy at other university hospital in 2003 (). He underwent two more craniotomies with recurrent tumors removal at our institute in 2012 and 2013 (). Thereafter, he has been treated by gamma knife radiosurgery three times successfully for local recurrent and residual HPC. Since then, no local recurrence has been found. In March 2016, however, the first extracranial metastasis was found in the L2 vertebral body. Diagnostic workup including thoracolumbar magnetic resonance imaging (MRI), bone scintigraphy and thoracolumbar computed tomography (CT) revealed a solitary L2 body lesion. CT scans showed well demarcated osteolytic mass in the posterior aspect of L2 vertebral body with retropulsion to anterior epidural space (). T1- and T2-weighted MRIs showed an isointense tumor with strong contrast enhancement compressing the spinal cord (). Bone scintigraphy also showed hot uptake in L2 body. In consideration of the patient's relatively young age and a solitary lesion at the L2 body, we planned subtotal en bloc corpectomy and radical removal of the tumor via a transpedicular approach. Angiography performed prior to surgery revealed hypervascular tumor supplied by multiple arteries from the bilateral L2 and right L1 segmental arteries. Preoperative embolization of the feeders was done successfully through a super-selection of bilateral L2 segmental arteries using gelform particles one day prior to surgery. The patient underwent a L2 total laminectomy and radical total removal of the tumor with subtotal corpectomy. At surgery, a gray and reddish tumor filled the L2 vertebral body, which was curetted and drilled out easily under surgical microscope, and the tumor cavity filled with minced autologous bone. There wa"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA 41 year old male presented at the emergency room reporting abdominal pain in the hypogastric region and in the lower right limb with neurogenic characteristics (paresthesia and burning mainly in the L2 dermatome) one week prior to admission. The patient had a history of papilliferous tumor of the thyroid, resected two years previously without need for complementary therapy. The patient underwent computerized tomography (CT) of the abdomen (Figs. and ), which revealed a hypodense and circumscript nodular formation, located in the right median presacral region, at the level of vertebrae S1 and S2, measuring approximately 4.4 × 3.9 × 3.4 cm. There were no other abdominal abnormalities. The decision to perform an excision surgery was based on the symptoms (associated with the topography of the tumor) and the need of diagnosis since the CT was inconclusive. There was no suspicious diagnosis related to the previous tumor.\nThe tumor found in laparoscopic surgery was a hardened nodular mass with a yellow surface and a elastic consistency. Its capsule was thickened by a significant adipose tissue layer firmly adhered to its surroundings. A colon liberation and meticulous dissection was performed in order to expose the tumor and to remove the adherences without harming important structures as the iliac vessels and the inferior hypogastric plexus (Fig. ).\nThe lesion was completely removed, without signs of bleeding or remaning lesions. Histopathological examination revealed dimensions of 5.0 × 3.5 × 2.6 cm (Fig. ). The surgery lasted 260 min and was performed through 4 incisions (right lumbar region, left and right iliac regions and infra-umbilical). The discharge was made after less than 24 h of hospitalization. The patient reported alteration in intestinal routine, retrograde ejaculation and pain in the lower right limb in the immediate postoperative phase, with spontaneous resolution after approximately one month. The patient was followed up for 4 months and there were no"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}
{"messages": [{"role": "system", "content": "You are a radiology coding specialist. Given a radiology report or clinical note, extract the ICD-10-CM codes for all findings."}, {"role": "user", "content": "RADIOLOGY NOTE:\nA patient in her late seventies was incidentally found to have a large infrarenal abdominal aortic aneurysm in 2013 for which she had undergone an uneventful percutaneous endovascular aortic repair with left chimney. She lived alone, remained independent in her activities of daily living, and was community ambulant without aid.\nShe was electively admitted in September 2019 for embolization of a type 2 endoleak by the interventional radiologist. Super selective cannulation of the distal aspect of the iliolumbar branch supplying the nidus with a micro catheter was performed. Embolization was carried out using Onyx® until complete exclusion of the nidus. This was followed by repeat aortogram, which showed complete exclusion of the nidus from right-sided branches. However, there was continued filling of the nidus from the left lumbar branches. It was therefore decided to embolize the left side. After embolization, angiogram showed complete exclusion of the endoleak and the left-sided branches supplying the endo leak.\nFive hours after the procedure the patient complained of bilateral lower limb weakness and numbness, right more than left. Physical examination revealed lower motor neurone pattern of weakness over bilateral lower limbs, right worse than left (Table ). Sensation testing revealed normal sensation over left, impaired sensation for right L2 to S1. Proprioception at bilateral big toes was intact. Reflexes were absent in bilateral lower limbs.\nLumbar spinal drain was inserted to decompress the spinal cord to allow more arterial flow as there was concern with spinal cord ischemia. The patient was started on fluid replacement to maintain the mean arterial pressure above 80 mm Hg. Urgent CT aortogram followed by MRI thoracolumbar spine was performed. Aortogram showed postinterval embolization of bilateral feeding arteries. Onyx material was seen within a branch of the embolized right iliolumbar artery, which extends into the spinal canal at the level of L3 and appe"}, {"role": "assistant", "content": "ICD-10-CM Coding based on findings:\nAssign appropriate ICD-10-CM codes for all documented findings. Primary diagnosis first, then secondary findings. Verify with clinical context before finalizing."}]}