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

[User]
RADIOLOGY NOTE:
A five 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.
On 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.
The 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

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


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

[User]
RADIOLOGY NOTE:
A 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.
Positive 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.
On 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 ().
Transesophageal 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 ().
Magnetic 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 ().
In 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

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

[User]
RADIOLOGY NOTE:
The patient was a 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.
An 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.
Diagnostic focus and assessment:
The 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

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

[User]
RADIOLOGY NOTE:
Twenty 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.
At 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

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old 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.
After 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

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old woman, 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

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


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

[User]
RADIOLOGY NOTE:
A 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. ).
The 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.
Dental 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.
The patient underwent tracheostomy, a limited left-sided selective neck dissection for node sampling and vessels preparation.

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

[User]
RADIOLOGY NOTE:
An 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

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

[User]
RADIOLOGY NOTE:
A 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 ).
A 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

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

[User]
RADIOLOGY NOTE:
A 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.
Five 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

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

[User]
RADIOLOGY NOTE:
A 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 ().
The 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 ().
He 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 ().

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


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

[User]
RADIOLOGY NOTE:
An 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.
Osseous 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

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old 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.
An 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.
Two 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.
On 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 ().
The patient underwent an urgent laparotomy and a residual trichobezoar mass was found in the jejunum which was removed by enterotomy (). Careful examina

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


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

[User]
RADIOLOGY NOTE:
A 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.
Then 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.
The 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.
The 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

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

[User]
RADIOLOGY NOTE:
A 3-year-old 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.
On 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.
The initial blood tests at the local hospital demonstrated microcytic hypochromic anemia with elevated erythrocyte sedimentation rate (ESR) of 120 mm and C

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

[User]
RADIOLOGY NOTE:
A 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.
On 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).
Immunological findings are shown in and . The high IgE level indicated normal isotype switching and thus ruled out the hyper IgM syndrome. This

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

[User]
RADIOLOGY NOTE:
Herein, 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.
Both 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.
In 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.
Based on the neurological examinations and nerve conduction studies a HMSN type I was diagnosed in these patients.
In 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

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

[User]
RADIOLOGY NOTE:
We 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,

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

[User]
RADIOLOGY NOTE:
A 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.
Following 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.
Following 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.
Following patient recovery and discharge, we reviewed the surgical r

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

[User]
RADIOLOGY NOTE:
In 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.
Because 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.
The 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.
Besides 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

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

[User]
RADIOLOGY NOTE:
A 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.
Past 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.
At 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

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

[User]
RADIOLOGY NOTE:
Case reports are exempt from institutional review board approval at our institution.
A 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.
Physical 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 ().
Initial 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.
The 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

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

[User]
RADIOLOGY NOTE:
A 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
). 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
). 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
). 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
A). 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

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

[User]
RADIOLOGY NOTE:
A 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

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

[User]
RADIOLOGY NOTE:
At 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.
On 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

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

[User]
RADIOLOGY NOTE:
A 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.
He 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.
On 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

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

[User]
RADIOLOGY NOTE:
A 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.
The 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

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

[User]
RADIOLOGY NOTE:
A 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.
After 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

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

[User]
RADIOLOGY NOTE:
An 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.
This 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.
On 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 .
Apart 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.
On 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 –].
A provisional diagnosis of hypoplastic, rough autosomal dominant AI

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

[User]
RADIOLOGY NOTE:
We 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.
Magnetic 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.
The 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

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

[User]
RADIOLOGY NOTE:
A 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.
The 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

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

[User]
RADIOLOGY NOTE:
A 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.
A 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.
The 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

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

[User]
RADIOLOGY NOTE:
A 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.
The 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.
On 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.
Blood 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.
An 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.
Inside these structures were many echogenic particles with posterior acoustic shadowing consistent with phleboliths (). The axillary, brachial, ulnar, and radial arteries had normal diameters

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


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

[User]
RADIOLOGY NOTE:
A 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

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


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

[User]
RADIOLOGY NOTE:
A 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.
Head 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

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old 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

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old 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.
Liver 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 .
Abdominal 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

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old 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.
On 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.
Intraorally, 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.
Computed tomography revealed a well-

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


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

[User]
RADIOLOGY NOTE:
CB 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.
The 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.
She 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 () [].
The diagnosis and treatment were discussed with the parents, and she was consented for surgery. An anteromedial incision was used

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


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

[User]
RADIOLOGY NOTE:
The patient was a 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.
Ultrasonography 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.
During 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

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old 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.
For 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.
Caries 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

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old 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).
The 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.
The 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.
Seven weeks after her surgery, while on a low iodine diet for

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