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

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

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


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

[User]
RADIOLOGY NOTE:
An apparently healthy 32-year-old male patient complained of reduced strength in his left hand. Over the past few months this phenomenon occurred especially and repeatedly when holding a frying pan, but there was no pain or weakness in any of the other muscles. He had two operations on his left middle finger at the ages of 10 and 18 due to a macrodactyly. Neurological examination gave evidence for a reduced sensitivity for touch in his left middle finger. In neutral position, there was no deficit of strength. Electroneurography showed mild CTS, without sign of axonal lesion of the radial nerve. In abduction of the left arm, there was a slight weakness in pronation, radial deviation and elevation of his left hand. Occasional fasciculations were observed in his left brachioradial muscle. Overall, we hypothesized a possible brachial plexus pathology. MRI of the left brachial plexus (Fig. ) showed an accessory muscle, attached to the medial aspect of the first rib and superior border of the scapula near the base of the coracoid process. The muscle caused a significant narrowing of the costoclavicular space (Fig. b). No regular subclavius muscle could been identified on either side. Arm abduction or weight bearing would most likely accentuate the narrowing of the costoclavicular space, with subsequent compression of the brachial plexus.
Overall, NTOS with compression of the brachial plexus which increases with arm elevation and abduction was likely []. The muscle having this negative effect was identified as SPM which was first described by Rosenmuller [] and was recently described in a post-mortem study of a patient suffering from Edward’s syndrome []. In this Japanese study [], 124 corps were examined and SPM was found to be present in 11 patients (8.9 %) and identified as a possible cause of NTOS []. The first case report on the presence of SPM in a live patient with NTOS was published in

[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 lady with a long-standing history of dyspnea on exertion and cerebellar abscess 8 years back that was managed conservatively underwent right total knee replacement under spinal anesthesia for severe osteoarthrosis from a nearby center. She had no prior history of vascular risk factors or ischemic heart disease. The patient was well in the immediate postoperative period. On the second postoperative day, she was noted to have acute onset weakness of the left leg followed by right upper limb and was shifted to our center for further management.
On arrival, the patient was restless, drowsy with tachypnea and was having grade 0 power in the right upper limb and left lower limb with bipyramidal signs, without features of intracranial hypertension, cranial nerve dysfunction, fever or meningeal signs. She was evaluated with magnetic resonance imaging, which showed fluid attenuation inversion recovery (FLAIR) hyperintensities in the anterior and posterior circulation territories, some showing restricted diffusion suggestive of infarcts of varying ages [Figure –]. Vessel imaging was normal. Her chest radiograph showed multiple shadows, which was initially interpreted as secondary to aspiration []. Arterial blood gas analysis showed type 1 respiratory failure (on O2by mask 6l/mt-p O242.7, p CO231 hco3 26, p H 7.54). She was intubated and ventilated in view of altered sensorium, respiratory distress and hypoxemia.
Presentation in the early postoperative period following orthopedic surgery with focal neurological deficits, multiple cerebral infarcts and respiratory failure made us consider pulmonary embolism and postoperative stroke as the first possibility. There were no features to suggest fat embolism. Lower limb venous Doppler did not show any deep venous system thrombosis; however, the pelvic veins could not be studied. Her cardiac evaluation, including transthoracic echo and 24-h ECG, were normal.
The patient showed improvement in sensorium and weakness by th

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old female came to our clinic complaining of gradual loss of visual in the left eye for 5 months. She had been diagnosed with acute retinal necrosis in the right eye, and wide-field photograph of the right eye showed patchy and diffusive retinal necrotic lesions (Fig. ). Pars plana vitrectomy was performed due to retinal detachment of the right eye 5 months earlier. The visual acuity in the left eye at the time of initial presentation was 20/20. In the meantime, she noticed floaters in her left eye. Superior retinal necrosis had been detected and it was recorded in her previous medical chart. The aqueous fluid from the left eye was positive for herpes zoster virus (VZV). She received repeated (nine rounds) intravitreal ganciclovir injection (3 mg/0.1 ml) into her left eye, one injection every 2 weeks, and systemic antiviral therapy for 5 months. The patient noticed a decrease in the visual acuity of the left eye and was referred to our clinic.
When the patient came to our clinic, her best corrected visual acuity was 20/400 OS, 20/33 OS. The intraocular pressure was within the normal range in both eyes. There was no inflammation in the anterior chamber, and the lens was normal in the left eye. There was no posterior necrotizing involvement and no macular edema or exudation in the left eye. Indirect ophthalmoscope examination revealed pigmentary change in the superior peripheral retina of the left eye. Slight abnormality of the interdigitation zone in the fovea area of the left eye was detected on OCT. Angio-OCT revealed normal capillary density of superficial retinal capillary, deep retinal capillary, outer retina, and choriocapillaris layers in the left eye (Fig. ). The Humphrey visual field (central 24–2 threshold test) showed massive visual field damage in the left eye. The amplitude and implicit times of pattern visually evoked potential (VEP) and flash V

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 56-year-old female with history of syncope due to third degree atrioventricular heart block presenting initially with onset of stroke symptoms six days after pacemaker placement and two days after hospital discharge. At 5 PM she developed abrupt onset of left facial droop along with left upper and lower extremity weakness. The patient was initially treated at an outlying hospital and received alteplase at 6:35 PM for treatment of acute ischemic stroke.
A chest radiograph performed at the outlying hospital prior to alteplase administration demonstrated an enlarged cardiac silhouette when compared to prior radiographs showing only borderline cardiomegaly. Upon administration, the patient reported mild chest pain and was given nitroglycerine and morphine. Her chest pain resolved and she was transferred to our comprehensive stroke center for admission. The patient presented to our emergency department at 10:10 PM with a heart rate of 122 beats per minute (bpm) and a blood pressure of 109/41 millimeters of mercury (mmHg).
At 11:20 PM the patient went for a computed tomography angiogram (CTA) after an initial assessment by the emergency physician in consultation with the stroke-team attending physician. After CTA at 10:28 PM, she was documented to have a blood pressure of 49/25 mmHg and heart rate of 109 bpm. She was returned to the resuscitation bay for re-evaluation. Cardiac tamponade was suspected due to the extreme hypotension in the setting of thrombolytic administration after recent pacemaker placement.
On reassessment, the patient had become confused with a Glasgow Coma Scale of 14. The emergency physician performed a POCUS, which demonstrated a pericardial effusion with features of cardiac tamponade including diastolic collapse of the right ventricle (). At that point the diagnosis of cardiac tamponade was made. The patient was alert and responsive, so an intravenous bolus of normal saline was given while a stat surgical consult was obtain

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


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

[User]
RADIOLOGY NOTE:
We report a case of a 76-year-old Caucasian male with extensive past cardiac disease history who presented to the hospital with a complete heart block. The patient felt weak and lethargic over the last 2 weeks and it worsened before the admission so he took his blood pressure at home and found his pulse to be very low on the blood pressure machine so he called the ambulance to go to the hospital. There were no symptoms of volume overload like dyspnea on exertion, leg edema, or other symptoms of congestive heart failure (CHF) exacerbation. The patient had a history of a sinus of Valsalva aneurysm (SVA) as well as coronary artery aneurysms; so in the past he had a Bentall procedure, which included placement of a mechanical aortic valve (#23 St. Jude prosthesis) and a conduit replacing the ascending aorta (aortic reconstruction). At that time, there was also a single-vessel bypass using a vein graft to the right coronary artery due to right coronary aneurysm. This was in 1997. He was following up with his cardiologist who did periodic CT/MRI of the chest with contrast to follow the previously diagnosed aneurysms. The repeated chest imaging was showing an ascending thoracic aortic aneurysm as well as the sinus of Valsalva and coronary artery aneurysms and was controlled with medical therapy and follow-up. Warfarin was given for anticoagulation for the metallic aortic valve. The size of thrombosed SVA was gradually increasing over time with 6 cm in diameter in 1999 and then progressed to 7.5 in 2000 and then to 7.3 × 6.5 cm by 2003. By 2004, size went up to 8.5 × 6.4 cm. The size remained stable on the subsequent CT scans that were done regularly. In 2009, the size went up to 8.1 × 7.2 cm. There were multiple cysts throughout the liver, the largest of which were seen in the right hepatic lobe measuring up to 14.7 × 11.3 cm and in the left hepatic lobe measuring

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old (gravida 2, para 2) woman presented the nearby hospital complaining of persistent defecation disorder and vomiting. Although her family history was notable for pancreatic cancer in her father, there was no other familial history of cancer, including breast and ovarian cancer. Her past medical history is unremarkable. Her past surgical history includes right ovarian cystectomy for a dermoid cyst at the age of 30. A computed tomography (CT) scan showed a large pelvic tumor adjacent to the rectum. Laboratory findings showed that her serum level of cancer antigen (CA) 125 increased to 315.2 IU/ml. Magnetic resonance imaging (MRI) demonstrated that a 93 × 65 × 62 mm-solid tumor with cystic parts was located immediately dorsal to the rectum (Fig. ). CT and MRI showed no evidence of dissemination, lymph node metastasis, nor distant metastasis. Colonoscopy showed strong extrinsic compression at the rectum with intact mucosa; however, biopsy of the rectum and the tumor site was not performed during colonoscopy. Based on the MRI finding that a perirectal cystic tumor was present without peritoneal dissemination, stage IA ovarian cancer was suspected, and she was referred to our hospital for treatment. At laparotomy, the tumor was located dorsal to the rectum and existed entirely in the retroperitoneal space (Fig. a). There were no apparent lesions in the peritoneal cavity including bilateral adnexa, uterus, and peritoneum. Peritoneal washing cytology was negative. After bilateral salpingo-oophorectomy and total abdominal hysterectomy, en bloc resection of the retroperitoneal tumor together with lower anterior resection of the rectum was performed (Fig. b). Whereas the tumor was adhered to the rectal wall, the tumor itself was relatively well-capsulated and easily separated from surrounding fat tissues. Based on pathological diagnosis of the retroperitoneal tumor: high-grade serous carcinoma, she received 6 cycles of adjuvant chemotherapy with carboplatin, paclit

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


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

[User]
RADIOLOGY NOTE:
In 2004, an 80-year-old Caucasian male underwent bilateral cordectomy for Tis carcinoma in the left cord and microinvasive T1 carcinoma at the right one. In the same year, he was diagnosed with prostatic carcinoma (Gleason score 3 + 3) which was treated with radiation therapy for a final total dose of 64 Gy. Since then, he has been controlled regularly on a 6-month basis. His family history was negative for cancer, but he suffered from mild hypertension that has been treated with a sartan drug for 17 years, and he also suffered from mild dyslipidemia without any medication besides dietary control.
In January 2014, he was admitted at the dermatologic unit of our institution for a pigmented cutaneous lesion at the occipital region of the scalp and an ulcerated lesion in the left temporal region, which were both radically excised. The pathologist reported a BRAF, c-KIT, and N-RAS wild-type lentigo maligna melanoma in the occipital scalp, while the ulcerated lesion at the temporal region was classified as an actinic keratosis. Full skin and ocular examinations, chest X-rays, and abdominal sonogram excluded the presence of clinical detectable neoplastic deposits. Due to his medical history, the patient was admitted to a three-month follow-up program. In January 2015, for the appearance of a swelling in the left parotid gland, he received an MRI and a subsequent biopsy, which led to a diagnosis of pleomorphic adenoma.
In May 2014, he was diagnosed with hypochromic, iron-deficiency anemia in the absence of overt clinical signs of bleeding and normal urine analysis. Fecal occult blood test was strongly positive. The patient was put on oral iron therapy without positive results for three months and therefore was referred to the endoscopy unit for upper and distal gastrointestinal tracts examination. Esophagogastroduodenoscopy showed the presence of several nonbleeding, bluish to black, gastric lesions of a few millimeters in diameter (Figures and

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


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

[User]
RADIOLOGY NOTE:
We describe the case of an 11-year-old right-hand-dominant White Portuguese girl who presented with pain in her right elbow following a fall onto the outstretched hand that occurred while she was riding a bicycle. She was unable to move her elbow actively due to pain. A physical examination revealed mild swelling and tenderness over the lateral aspect of the distal part of her humerus. The child had a restricted range of motion of her elbow, especially with flexion. Joint stability was considered normal and no neurovascular signs were observed. The diagnosis was made on a lateral and an oblique radiograph (Figures and ), which revealed a displaced fracture of the capitellum of her right elbow, a typical Hahn-Steinthal or Type I fracture. An anteroposterior radiograph of the distal part of her right humerus did not reveal a definite fracture. No other injuries were detected.
Our patient was treated by open reduction and internal fixation. Under general anesthesia, an attempt was made at closed reduction but complete reduction could not be achieved that way. With a pneumatic tourniquet in place, a posterolateral incision was made (Figure ). Further manipulation of the fragment allowed reduction that was held in the correct position with two temporary Kirschner wires. The final fixation was performed with two 3.0 mm cannulated screws. The screws were inserted in a posteroanterior direction through the posterior surface of the lateral condyle. An intraoperative dynamic examination showed satisfactory stability of the osteosynthesis and anatomic articular congruity. A protrusion of the tip of the screw on the articular surface was carefully avoided (Figure ). Postoperatively, her elbow was immobilized in a long arm cast at a right angle, with the forearm in a neutral position for three weeks. The postoperative outcome was uneventful, allowing our patient to leave the hospital 48 hours after surgery.
The follow-up period was of one year with regular clinical examination a

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


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

[User]
RADIOLOGY NOTE:
A 5-month old female Swiss Mountain dog presented to the local veterinary practice for clinical evaluation of gait abnormalities of the hind limbs. The orthopedic examination revealed lameness in the lower right hind limb and a bony thickening at the level of the metatarsophalangeal joint between the II and III digit phalanges, covered with normal skin. The complete blood count, serum chemical and electrolyte analyses were within normal limits, apart from elevated levels of calcium and phosphorus, which were attributed to the young age (5 month) of the animal (Table ). The dog underwent a radiographic examination. Two well-defined lesions within the right II and IV phalanges of the right pelvic limb were found (Fig. a), in the shape of well circumscribed, mineralized new bone formation with a trabecular pattern. The dog underwent surgery to remove the lesion on the II phalange, and the excised tissue was sent for a histopathological examination. This revealed well-differentiated bone tissue, hyaline cartilage, and fibrous tissue in addition to hematopoietic tissue and connective tissue. Based on the histopathological findings, multiple cartilaginous exostoses (ostechondromatosis) were diagnosed. In the 1 month follow-up examination, the dog showed progressive ataxia of hind limb, a stiff gait and hyperesthesia in the thoracolumbar vertebral column. Radiographs of the hips and vertebral column exposed similar lesions to those in the pelvic limb. They were located in the distal part of the femur, on the tail and on the thoracic spinous processes of the lumbar vertebral bodies (Fig. b, c) and on the ribs (Fig. b).
At the age of 8 months, the dog was presented to the Wrocław University of Environmental and Life Sciences at the Department of Internal Medicine with Clinic of Horses, Dogs and Cats for neurological assessment. The neurological examination revealed a wide-based stance and proprioceptive ataxia in the hind limbs, moderate proprioceptive deficits in the hind l

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old female presented to the emergency department in our hospital with acute bilateral eye vision loss. Her past medical history included an undocumented splenectomy, diabetes mellitus, and hypothyroidism. Two weeks prior to the onset of visual symptoms, she reported flu symptoms, including fever, myalgia, and dry cough. The patient neglected these symptoms and did not benefit from any treatment. Fifteen days later, the patient presented with a sudden drop in visual acuity in the left eye without pain, eye redness, or headache which became blinding after 24 hours with involvement of the contralateral eye after four days, associated with right hemibody weakness. Her admission parameters were as follows: pulse 94 beats per minute (bpm), blood pressure 135/88 mmHg, temperature 38.2°C, and oxygen saturations were 85% on room air.
Her neurological examination on admission revealed complete bilateral blindness with no perception of light. Pupil responses to light were abolished with horizontal nystagmus and unremarkable fundoscopic findings. No other obvious abnormal findings in cognitive function, cranial nerves, or neck rigidity were demonstrated. Motor system examination revealed normal bulk in all four limbs. There was hypotonia, most marked on the right side. Power was grade 4/5 in the right hemibody and 5/5 in the left side. There was no involuntary movement or seizures. Plantar reflexes showed bilaterally Babinski signs. All modalities of sensation were conserved. Clinical examination of other systems revealed no abnormalities She presented with breathlessness a few hours after her admission to the neurology department. She was then transferred to the intensive care unit following clinical deterioration and continued increasing oxygen requirements where she was started on non-invasive ventilation.
The patient had magnetic resonance imaging (MRI) (1.5 Tesla) of the brain and orbits with and without contrast, which revealed right parietal nodular signal abno

[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 71-year-old woman visited Nara Medical University Hospital with complaints of hoarseness and a left-sided neck mass (45x30 mm) in October 2018. Left vocal cord paralysis was confirmed endoscopically. The larynx was displaced to the right by a slow-growing left thyroid lobe tumour. We were unable to identify the border between the larynx and the tumour. Computed tomography showed a calcified thyroid tumour extending from the left side of the thyroid cartilage to the upper part of the cricoid cartilage (). Positron emission tomography/computed tomography showed no evidence of distant metastasis. The tumour was histologically diagnosed as papillary thyroid carcinoma (PTC) with no evidence of poorly differentiated carcinoma or ATC. Subsequently, the patient was diagnosed with PTC (cT4aN1bM0, stage III).
Total thyroidectomy with hemi-laryngectomy and neck dissection was performed. The laryngeal defect was reconstructed using a prefabricated anterolateral thigh (ALT) flap and free rib cartilage grafts in order to maintain laryngeal function.
After tumour excision, bilateral paratracheal and left lateral neck dissection was performed. The dissected tissues were gathered toward the thyroid, and the thyroid was dissected from the trachea with relative ease. We resected from the thyroid cartilage to the superior edge of the cricoid cartilage in order to complete en bloc extirpation of the lesion because the tumour involved these structures. We resected approximately 40% of the laryngeal defect, which would have resulted in loss of airway and phonatory function. To compensate the laryngeal defect, grafting using an ALT flap and free rib cartilage was performed as follows: First, the left ALT flap (15x7 cm) was harvested and laid over the surgical defect, and microscopic vascular anastomoses were established. The flap had two perforators based on the left lateral circumflex femoral artery descending branch. The left superior thyroid artery was used as the recipient artery and

[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 63-year-old male patient with large anterior mediastinal mass was referred to our hospital for treatment. The patient was pathologically diagnosed as cervical schwannoma and underwent surgical resection twelve years ago. He had re-operation because of the recurrent neck tumor four years ago. No specific neural, cardiovascular and respiratory disfunction and neoplasms his history contained as well as his family history. The patient suffered from chest oppression and shortness of breath for four months, and these symptoms gradually became worse. The Preoperative CT confirmed that the patient was diagnosed as TM and large anterior mediastinal mass (Fig. ) Due to occasion of severe airway overreaction during the process of his endoscopy, fiber bronchoscopy was not finished.
Consideration of potential risk from serious TM, the patient was intubated with guidance of fibreoptic bronchoscopy in the supine position, then underwent median sternotomy and tumor resection followed by tracheal suspension. The prime procedures of this surgery were briefly depicted by hand drawings (Fig. a: tumor site exposure; Fig. b: further sculpture of removed autogenous rib cartilage; Fig. c: anchoring malacial tracheal rings and membrane by fresh graft) and details of surgical procedure were as follows:
Step 1: Tumorectomy. After medisection of sternum followed by opening pretracheal fascia, upper principal bronchus and frontage of cervical schwannoma were revealed. Along the line between the tumor and its adjacent tissue,the tumor was underwent entire resected.
Step 2: Fabrication of scaffold. Partial autogenous rib cartilage was removed from 5th rib, and its top and bottom parts were penetrated with flexible steel needle to form two channels available for thread, which could manufactured a scaffold to anchor the extensive malacial tracheal rings and membrane (Fig. ).
Step 3: Tracheal suspension. Free rib cartilage graft, fixed with bilateral tracheal rings, were deposited in front of mala

[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:
62-year-old male patient working as a farmer and suffering from type 2 diabetes was admitted to the Neurology Department due to paraplegia of lower extremities, sphincters disturbances and sensation disturbances from the level of Th6. During the last 14 days preceding hospitalisation he moved with significant difficulty and reported weakness of the lower extremities. 4 days prior to admission he spent most of his time mainly in bed and suffered from paraplegia of lower extremities. After admission to the Neurology Department, initial diagnostics showed the presence of destructive changes within vertebral bodies, arches and spinous processes in the thoracic segment (Th5–Th6).
CT scans revealed destruction of the thoracic vertebras, infiltration changes in paravertebral soft tissues and pathological mass in the spinal canal. Initial diagnosis included infiltrative malignant tumour of the vertebral column. Consulting neurosurgeon recommended MRI examination. Examination revealed the presence of changes suggesting inflammatory process of the thoracic spine Th5–Th6, inflammatory changes within intervertebral discs and vertebral bodies and changes inside the spinal canal suggesting fluid mass empyema compressing the spinal cord (Figs. , ).
Additional information collected from the patient and his family revealed that the patient suffered from the zoonosis, erysipeloid, 2 months priori to admission and was treated. Infection occurred after skin cut on the right leg with the fragment of the pig bone. Patient observed the presence of skin inflammatory process; subsequently, the process spread in the form of phlegmon of the right leg integuments. Patient was initially treated in the Department of Surgery and referred to the Orthopaedic Clinic due to skin phlegmon. Bacteriological tests revealed E. rhusiopathiae. Patient underwent drainage of the subcutaneous tissues. Targeted antibiotic therapy was implemented and continued for about 3 weeks after operation. As the family rep

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


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

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

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 30-year-old male patient who was treated initially in another facility for SS of the left thigh. He underwent wide excision with free margins. The tumor measured 3 cm in its greatest diameter. Anatomopathological examination showed: a monophasic spindle cell synovial sarcoma in a fascicular arrangement. Immunohistochemistry showed positivity for bcl2, cytokeratin, epithelial membrane antigen (EMA), CK, and negativity for chromogranin A, synaptophysin, and vimentin. About 6 months later, he was admitted to our institute for a local recurrence confirmed by biopsy. A thoracic-abdominopelvic computed tomography (CT) scan was performed and didn’t reveal any secondary locations. The patient underwent a wide excision, with a vascular replacement of the femoral artery and coverage with a flap of the left rectus abdominis muscle. The following operations were straightforward. The Surgical limits were free. The search for the SYT-SXX fusion transcript was not completed. The patient underwent six cycles of ifosfamide-based chemotherapy followed by adjuvant external radiotherapy at a dose of 54 Gy. After 15 months of regular clinical and radiological follow-up, the patient presented a pancreatic mass diagnosed on a CT scan. The mass was located on the tail of the pancreas. It was heterogeneous, solid, enhanced after the injection of the contrast agent. Tumor markers: ACE, CA19-9, and NSE were negative. A biopsy under CT scan was performed and the histologic exam confirmed the metastatic nature of the pancreatic mass. The patient was reluctant to surgical treatment, and he was lost of view for 4 months. Due to the onset of transfixing abdominal pain and the increase in abdominal volume, the patient consulted after 4 months. An abdominal ultrasound showed an increase in the size of the lesion to 15 cm. The thoracic-abdominopelvic CT scan was performed and it showed a pancreatic mass invading the transverse colon without any other metastatic localizations (

[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 Caucasian woman with no significant past medical or family history presented to her primary care provider with a one-year history of sore throat and dysphagia to solid foods. She reported a remote smoking history in her teens and rare alcohol consumption. Workup included a barium swallow study with a persistent filling defect in the upper esophagus measuring 5 cm × 1.8 cm originating from the posterior right wall of the esophagus. Differential diagnosis included both benign and malignant lesions of the upper esophagus. Upper endoscopy with endoscopic ultrasound revealed an ulcerated, friable mass extending from 15 to 19 cm from the incisors with evidence of invasion into the muscularis propria and suspicion for regional node involvement (Figures and ). Biopsies from the upper endoscopy were positive for moderately differentiated invasive adenocarcinoma (Figures and ).
The patient was staged as T3N1M0 after a PET/CT of the neck demonstrated a hypermetabolic esophageal mass with adjacent right paratracheal and superior mediastinal lymphadenopathy. CT scan of the chest, abdomen, and pelvis were negative for distant metastases. Six weeks of definitive/neoadjuvant chemoradiotherapy were delivered according to the Ilsen regimen (cisplatin 30 mg/m2 and irinotecan 65 mg/m2 on weeks 1, 2, 4, and 5 of radiation). Radiotherapy consisted of a total of 64.8 Gy to the primary esophageal tumor and adjacent nodes plus 39.6 Gy to superior mediastinal nodes. Follow-up PET/CT 14 weeks after completion of definitive chemoradiation therapy revealed continued hypermetabolic activity in the proximal esophagus and repeat upper endoscopy revealed residual tumor. Otolaryngology performed a cervical esophagectomy, lymph node dissection, and left radial forearm microvascular free tissue transfer reconstruction of the cervical esophagus. The pathologic specimen contained moderately differentiated adenocarcinoma of the esophagus undermining the squamous epithelium, with metastasis

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


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

[User]
RADIOLOGY NOTE:
A healthy six-year-old female was transferred to the pediatric intensive care unit at the Ann and Robert Lurie Children's Hospital of Chicago at Northwestern University (a quaternary care institution) for a persistent barking cough and increased respiratory distress. Earlier that day, she had presented to a local immediate care facility due to a cough that had worsened over the prior two days. She was admitted to the hospital at the immediate care facility due to wheezing and shortness of breath that continued to worsen despite nebulized albuterol, nebulized racemic epinephrine, and subcutaneous epinephrine. Intravenous (IV) ampicillin/sulbactam was also given. The decision was made to transfer the child to a quaternary care facility for further workup and treatment. While in route, an anterior-posterior (AP) radiograph and a lateral chest radiograph (CXR), which had been taken prior to transportation, was reviewed and it revealed a circular foreign body extending from C3 to C6 (Figures and ). This was the patient's first documented radiograph. Upon arrival, the patient had her first evaluation by a pediatric otolaryngologist.
The patient's parents reported that the patient had a barking cough and hoarseness that had varied in severity over the last 9 months. She had been diagnosed with recurrent croup. Upon further questioning, the family revealed that the child had a choking event while playing with a rubber band 9 months earlier. She was evaluated in a local emergency department shortly after the choking event and had had 4 to 5 emergency room and/or primary care physician visits over the last 9 months due to the barking cough and hoarse voice. She had received dexamethasone and oral steroids three times over the course of 9 months. This did often provide temporary relief of her symptoms. She did not have a direct or an indirect laryngeal exam, and no radiographs were taken.
Upon arrival at the quaternary institution, the patient was in mild distress. Her oxygen

[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 35-year-old lady with a known history of controlled hypertension, avascular necrosis of the right hip, lupus nephritis status post cadaveric renal transplant in 2014, with chronic graft rejection, and a history of abdominal pain that was attributed to an abdominal wall hematoma diagnosed previously by ultrasound (US) abdomen, presented to an outside facility with severe 10/10 stabbing chest pain radiating to the back that started suddenly while the patient was sitting down; she also complained of some abdominal pain that was mild as compared to her chest pain. At the outside facility, the patient was noted to be hypertensive. Serial electrocardiograms (EKGs) and troponins were done, and they were unremarkable. The patient was later found to have acute kidney injury with a creatinine of 7.4 and her last known creatinine was around 4.2. Given the patient’s acute kidney injury, computed tomography (CT) abdomen without contrast was done to evaluate the renal graft, which eventually came back unremarkable. The patient was then transferred to our facility due to the availability of transplant services in our hospital with a working diagnosis of acute on top of chronic kidney disease secondary to worsening chronic graft rejection.
Upon initial presentation to our hospital, the patient had a blood pressure reading of 214/89 as well as an episode of chest pain. The patient's pain and blood pressure slowly improved after receiving 1 mg of hydromorphone hydrochloride, with blood pressure returning to 130/70 mmHg. The patient's home blood pressure medications were then resumed.
From that point onward, the patient was no longer complaining of any chest or abdominal pain. Her blood pressure ranged around 113/70 throughout her stay. Upon questioning the patient about her blood pressure control, she said that it was always controlled and that it was only high on presentation because of the severe pain she was in. A complete physical exam was done on admission, including bilateral

[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 eleven year old male patient reported with a complaint of the presence of a small sized tooth in the upper front region of the jaw since 4 years. Extra orally the patient presented with a symmetrical face and with a convex profile. Intra oral examination revealed that he was in the late mixed dentition period with retained maxillary primary left central incisor (61) and non eruption of the left permanent central incisor (21) [] and Angle's Class I molar relation. The radiographic examination consisting of intraoral periapical [], occlusal and panoramic views with an orthopantomogram revealed an irregular radiopaque mass suggesting of an odontome like structure between 21, 61 and 22 along with impacted 21 close to the nasal floor. A preliminary diagnosis of impacted permanent left central incisor due to the odontome like structure was made. The treatment plan included surgical removal of the calcified mass and guided eruption of 21 using Closed-Eruption technique.[] The following treatment objectives were established for this patient:
Surgical removal of the calcified mass Guiding the eruption of 21 and to align it orthodontically To achieve good gingival attachment and symmetrical gingival margins for both the maxillary central incisors; and To create a stable functional occlusion.
Under local anesthesia, a full thickness mucoperiosteal flap was reflected from 11 till 22. The bone covering the odontome like structure was carefully removed and the calcified mass was retrieved along with the extraction of primary central incisor. Six supernumerary teeth were retrieved from the calcified mass, four teeth were conical in shape and two were in tuberculate form []. A final clinical diagnosis of an impacted maxillary central incisor due to multiple supernumerary teeth was made. The lingual surface of the exposed central incisor was etched, washed and a flat Begg bracket was attached to it. Elastomeric chain was engaged to the bracket on one side and the other end was le

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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 40-year-old male who complained of pain in the right inguinal region underwent abdominal ultrasonography, which revealed a 6-cm sacciform tumor in the right lower abdomen. The patient had no medical history including surgery, trauma, or inflammatory disease, and he was referred to our hospital for further evaluation. Enhanced computed tomography (CT) showed continuity between the cystic tumor, which measured 66 mm×72 mm, and the right external iliac vein (EIV) (). Further, vascular ultrasonography indicated that the mass was a section of the ectatic vein. The mass was diagnosed as a right EIV aneurysm without stenosis or obstruction of the proximal flow. Although the patient did not present with any symptoms, 99mTc-macroaggregated albumin scintigraphy revealed a pulmonary thromboembolism in the inferior lobe of the right lung. Venography revealed a large saccular aneurysm of the EIV with flow stagnation (), whereas arteriography of the common iliac artery did not indicate any sign of an arteriovenous fistula. Preoperative anticoagulant treatment with warfarin was initiated, and aneurysmectomy was recommended to prevent disastrous complications, such as massive pulmonary embolism and rupture.
One month after the aneurysm was diagnosed the patient underwent resection to treat the right EIV aneurysm. With the patient under general anesthesia, the aneurysm was exposed via a retroperitoneal incision in the right lower quadrant (). The aneurysm did not adhere to the surrounding tissue and did not have feeding vessels. The border between the normal venous wall and the aneurysm was easily detectable. An abnormal venous wall occupied more than one-third of the circumference of the vein; therefore, compared to venorrhaphy, patch plasty was considered suitable to preserve the lumen. Following the intravenous administration of heparin (7,000 U), the proximal and distal portions of the aneurysmal sac were clamped, and longitudinal venotomy was performed. The excess vein wall w

[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 34-year-old- male patient, is a known case of advanced keratoconus in the left eye, for which he underwent deep anterior lamellar keratoplasty (LK) 2 years ago. The patient had quiet post-operative course and all sutures were removed 8 months after the surgery with BCVA of 2030 but eventually his vision started to decrease to a BCVA of 20400 at presentation. Upon examination, he was found to have quiet conjunctiva. Examination of the cornea showed suture-less corneal graft with sub-epithelial non-vascularized elevated corneal opacity that was more prominent in the temporal aspect of the graft measuring about 2.5 × 3 mm with faint smooth borders. The nasal aspect of the opacity was less dense compared to the temporal one with sparing of the visual axis. Otherwise, the graft was relatively clear with no evidence of underlying edema (a).
Topographically, there was an irregular corneal surface on the sagittal curvature map due to massive flattening effect caused by the corneal opacity temporally with total anterior astigmatism of 16 diopters, also there is evident anterior elevation corresponding to the area of opacity. on pachymetry map there was marked thickening at the area of the opacity temporally (b).
The patient was counseled regarding the surgical option for visual rehabilitation of his condition and he was offered simple peeling in the minor operating room under topical anesthesia, which was done in a similar fashion as in case 1 with no complications. The excised tissue was identical to the other 2 cases with thick irregular corneal epithelium, absent Bowman’s layer and sub-epithelial fibrosis but there was a small focal area of degenerative non-inflammatory pannus (c and d). Three weeks after the procedure the BCVA improved to 20100 with more clear graft (e). On topography, there was pronounced regularization of the anterior curvature map with reduction of astigmatism of about 4 cylinders due to mechanical removal of this sub-epitheliual opacity. Also

[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 African American male with a past medical history notable for chronic pancreatitis, insulin-dependent diabetes, hypertension, peripheral arterial disease, and gout presented to the emergency room complaining of acute left upper quadrant abdominal pain. At baseline, he was fully functional, has held office jobs, smoked a few cigarettes per day over the course of a few years but quit over 5 years prior to initial presentation, and reported drinking around four alcoholic beverages daily. Home medications include insulin, metformin 500 mg daily, lisinopril 40 mg daily, amlodipine 10 mg daily, metoprolol 25 mg twice per day, rosuvastatin 40 mg per day, aspirin 81 mg, clopidogrel 75 mg per day, and allopurinol 100 mg. Family history was notable for insulin-dependent diabetes and hypertension in his mother and hypertension in his father. Eighteen months prior to the current presentation, he presented to the emergency room with postprandial abdominal pain. Physical examination revealed an uncomfortable but alert patient who was tachycardic to 110 beats per minute and had decreased breath sounds at the bilateral lung bases. Abdomen was nontender but mildly distended. Neurologic examination was unremarkable. Computed tomography (CT) imaging of the abdomen was notable for necrotizing acute pancreatitis and a fluid collection between the pancreas and stomach measuring 7.1 × 2.8 × 8.8 cm (Fig. ). He was managed supportively and discharged. A few months later, he was admitted for diabetic ketoacidosis secondary to pancreatic necrosis; no abdominal imaging was obtained at that visit. Repeat CT abdomen 5 months after the initial episode, or 2 months after his diabetic ketoacidosis admission, revealed no change in size of the pancreatic pseudocyst (not shown).
On the current presentation, the patient presented with 4 days of postprandial, sharp abdominal pain with radiation to his back. The patient stated the pain was of different character than the original episode of

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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:
After due patient consent and approval from the institutional ethical committee, we present the following report:
A 63-year-old old woman, menopausal since 20 years presented at the Gynecology OPD at All India Institute of Medical Sciences, Raipur, with a chief complaint of discharge per vaginum since 6 months. Per speculum examination revealed a cervix flushed with vagina and friable tissue at the external os. There was a 2.5 cm × 2 cm firm mass in the posterior fornix confirmed on per rectal examination. Bilateral parametria and rectal mucosa were free from tumor. Pap smear and biopsy revealed a squamous cell carcinoma. Ultrasound reported a uterus of size 6.8 × 3.2 cm. The endometrial cavity was distended with echogenic content and minimal fluid. Both ovaries were normal suggesting a diagnosis of “asymmetrical hetero echoic thickening of the endometrium with collection in the endometrial cavity, suspected carcinoma endometrium.” Magnetic resonance imaging (MRI) abdomen and pelvis [] revealed a fluid-filled endometrial cavity, an irregular, circumferentially thick, intermediate to high signal intensity endometrium surrounded by thin hypointense rim seen in the fundus, body, and lower uterine segment. The endo-myometrial junction was mildly obscured, and the visualized myometrium was normal in signal intensity. The lesion was seen extending into the cervical canal reaching just proximal to the external os, and the internal os was seen mildly widened by the lesion. A small nodule was noted in the stroma of the anterior cervical wall with signal characteristics similar to the endometrial lesion, and it was suggested to represent local spread. The uterine serosa, parametrium, mesorectal fascia, urinary bladder, and lymph nodes were not involved. Bilateral adnexa was reported normal.
There was a “diagnostic dilemma” given findings of cervical malignancy on biopsy but predominant endometrial lesion on imaging studies.
A Type III Radical Hysterectomy with bilateral pelvi

[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 33-year-old man was involved in an automobile accident and was brought to our hospital by ambulance. He had been in the front passenger seat and had been wearing a three-point seatbelt. He reported severe back pain, but showed no neurological deficit.
Anteroposterior and lateral radiographs of the spine showed an increased gap between the 1st and 2nd lumbar spinous processes and 2nd lumbar vertebral fracture (figures not shown). Magnetic resonance imaging (MRI) of the spine also demonstrated an L2 vertebral fracture and disruptions of the posterior ligamentous complex between L1 and L2, in combination with extensive subcutaneous hematoma ().
Computed tomography (CT) of the spine in the sagittal orientation and 3-dimensional (3D) CT further revealed the involvement of the superior end plate of the L2 vertebra, comprising horizontal splitting from the left pedicle, through the left transverse process, and reaching the center of the neural arch (). The right-sided L2 pedicle was intact.
After checking the general condition of the patient and excluding intra-abdominal injury by enhanced CT and ultrasonography, the patient underwent L1-L2 single-level instrumented fusion using a posterior approach. Initially, monoaxial pedicle screws with conventional trajectory were placed at L1 and L2 pedicles on the right side (intact pedicle side). A rod slightly bent in lordosis was then introduced and connected with these pedicle screws with a compression force applied between screws. This procedure achieved reduction and the fracture gap at the left L2 pedicle and lamina was completely closed. Polyaxial pedicle screws were used on the left side. A pedicle screw with a conventional trajectory was placed at the left L1 pedicle. A CBT pedicle screw was then inserted through the fractured L2 pedicle under fluoroscopy. This CBT screw was used as an alternative to an osteosynthesis screw. A rod was introduced on the left side, bilateral facet fusion with local bones obtained from the

[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 female patient without serious intercurrences underwent surgery for grade 2 invasive endometrial uterine carcinoma. After adjuvant brachytherapy, the patient was regularly followed up. Twenty-three months after the primary surgery, she developed vertigo and temporary left-sided hemiparesis. Brain MRI showed a solitary lesion in the right temporal lobe (Fig. ). Considering its favorable location, the patient's good general condition, and the absence of extracranial illness, the patient was indicated for neurosurgery and underwent radical resection without any sign of residual tumor on the postoperative CT scan. Histology confirmed metastasis of the adenocarcinoma. Adjuvant RT was not indicated, and observation by control MRI 3 months after surgery was recommended. This MRI, performed 2.5 months after the surgery, unfortunately showed early local recurrence with an enhancing lesion localized ventral from the resection cavity and widely touching the dura with perifocal edema (Fig. ).
Considering the patient's continuing good general condition, confirmed absence of extracranial disease, and operability of the newly discovered recurrence, the patient was indicated for a second resection, which resulted in a subtotal resection limited mostly in areas infiltrating the dura mater. Histology verified metastasis of a partly necrotic tumor of a similar appearance to that in the previous resection.
The patient was indicated for postoperative RT, and planning of RT started exactly 1 month after the operation, when the patient underwent planning MRI. Unfortunately, there was further progression of the tumor on this MRI, with distinct propagation along the adjacent meninges, especially more rostrally. No third operation was planned anymore, and the patient, with rapidly progressing metastasis, was indicated for palliative RT. Considering the character of the primary disease, the absence of extracranial metastases, and the locally aggressive behavior of the known macr

[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 80-year-old Japanese man was referred from another hospital presenting with altered mental status, loss of appetite, and urinary retention. He had been in a long-term care facility for 10 years due to mild sequelae after measles, which he had contracted when he was young. He was able to ambulate with the aid of a walker and independently perform all activities of daily living. Two and a half months prior to his visit to our hospital, surgical treatment was performed for a left femoral neck fracture resulting from a ground-level fall. Since then, the patient had needed a wheelchair due to his inability to cooperate and difficulty with rehabilitation. One week before his visit, he had fallen when he got out of his wheelchair independently. Three days after the fall, he was taken to a local clinic because of fever and urinary retention and was diagnosed with a urinary tract infection. On the day of his visit to our hospital, he presented with progressive altered mental status and loss of appetite over 3 days, which brought him to the psychiatric hospital, where no abnormal findings were revealed by head computed tomography (CT). Thereafter, he was referred to our hospital for further evaluation.
On arrival, he appeared lethargic, poorly responsive to questions, and unable to follow commands, which did not allow us to acquire an informative history and perform a thorough physical examination. The patient’s vital signs were as follows: Glasgow Coma Scale score of 13 (E4V4M5), 24 breaths per minute, heart rate of 70 beats per minute, blood pressure of 107/70 mmHg, oxygen saturation of 98%, and temperature of 36.7°C. Lower abdominal distention was evident without any remarkable findings on chest exam. Apparent weakness in his bilateral lower extremities was noted. The patient denied back pain. Blood test results showed elevated blood urea nitrogen of 63 mg/dL and creatinine level of 2.93 mg/dL. CT scan of the torso identified transverse fracture

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


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

[User]
RADIOLOGY NOTE:
We report on a 63-year-old female patient who presented in January 2016 with the following symptoms: complaint of cold sensation affecting the upper arms on both sides (left > right), weakness and arm claudication, with an increasing inability to perform work on the computer, and symptoms of a fatigue syndrome. The patient was unable to perform her employment as a hospital secretary. Clinically, pulselessness of the brachial and radial artery on both sides was noted. Bruits were discovered in the left and right subclavian artery. A blood test revealed increased levels of the inflammatory markers C-reactive protein (CRP 47.9 mg/dL) and an increased Erythrocyte Sedimentation Rate (ESR 74 mm/h). The patient had a history of hypertension, hyperlipoproteinemia, and osteoporosis; she was a former smoker and reported moderate daily alcohol consumption.
A neurological examination, an MRI of the cervical spine, and myocardial scintigraphy were without pathological findings. Duplex ultrasound of the carotid artery and upper extremities revealed noticeable intima-media thickening. For suspected large-vessel vasculitis, a diagnostic angiography was carried out, which revealed bilateral stenosis of the axillary artery at the transition to the brachial artery and, on the left side only, an additional stenosis in the proximal segment of the brachial artery. TA was diagnosed based on the American College of Rheumatology criteria, with four out of six criteria met.
The patient was admitted to a rheumatological specialist clinic in March 2016. Treatment with prednisolone 20 mg daily was started, but there was no improvement of the arm claudication. Therefore, the patient received cyclophosphamide 15 mg/kg body weight × 0.75 (=600 mg) plus prednisolone (75 mg/d initially, reduced in stages to 30 mg/d at the time of hospital discharge). Six cycles of cyclophosphamide at 3-week interval were planned, at the end of which treatment with methotrexate 15 mg subcutaneously once a week accomp

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old female was admitted to the Emergency Department of Sekghoma Memorial Hospital, Serowe village, Botswana, past midnight with progressive swelling of her face, tongue and breathing difficulty for about 8 h. The family gave a history of change of antihypertensive medication recently. She has been started on tablet enalapril, 20 mg, once daily, orally, 2 days back. On examination, she was conscious, coherent but very anxious. Her heart rate was 123/min, regular. Blood pressures were high and reading was 180/96 mmHg. Her room air oxygen saturation was 91% (SpO2). There was no stridor. On auscultation of chest, air entry was good bilaterally and there were some conducted sounds from pharynx due to excessive secretions. The tongue was grossly swollen, hard in consistency, it was wedged between the teeth and she was not able to close her mouth []. Lot of secretions were pooling in and dribbling from the mouth. There was no space in oral cavity for oral intubation. Only possible airway managements were a blind nasal intubation or surgical airway. It was not possible to transfer this case to a tertiary care hospital by helicopter as there were landing issues in darkness. Transfer by road was risky for patient as it would have taken 5 hours. It was decided to go ahead with management locally. The patient was started on oxygen support at the rate of 5 l/min by facemask for building up her oxygen reserves in case of airway emergency. Lateral view X-ray of neck was done which showed airway patency as fine []. Elective blind nasal intubation as a proactive airway management was risky due to less chances of success and more risk of further airway compromise. There were no ear, nose, and throat (ENT) specialists available for either evaluation or surgical airway management. She was injected with 100 mg of hydrocortisone, intravenously and 0.5

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old white male was found down in the field after he reportedly grabbed a “live” electrical wire. On the way to the local hospital, he regained consciousness but remained confused thereafter. He had sustained second-degree burns at the entry wound in the right palm and had a small exit wound in the right foot. Ecchymosis was also noted on right side of the body over the knee, thigh, and shoulder. A pan CT scan of the body did not reveal any major abnormality, including fractures. He remained hemodynamically stable but was pleasantly confused with a nonfocal neurological examination. A CT scan of the brain showed multiple hypodensities in the left parietal region and frontal region bilaterally. All serology labs were normal except total creatinine kinase levels, which peaked at 1100 U/L. Hence, he was transferred to the burn unit in our hospital for further management of burns with rhabdomyolysis. On examination, he was a pleasant gentleman with complete amnesia of the inciting event. He was alert but disoriented to all spheres. Most of the responses were limited to either head nodding or a few words associated with tangentiality and paraphasia. Repetition was impaired, but comprehension was preserved for simple commands. The cranial nerves and motor and sensory systems were clinically normal except limitation of the right arm's movement due to pain. MRI of the brain using 1.5 Tesla MRI machine showed multiple areas of diffusion restriction in the bilateral medial frontal lobe and bilateral basal ganglia along with watershed areas in the left frontal and temporal regions (). Susceptibility-weighted images showed hemorrhage in the left basal ganglia and insula (). T2-weighted images showed hyperintensity in the corresponding regions. MR angiogram did not reveal any filling defect or obvious vasospasm but showed aplastic A1 segment of the right anterior cerebral artery (). Based on these findings, acute stroke was diagnosed, likely due to vasospasm

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old female with achondroplasia presented with an 8-month history of progressive weakness in the upper extremities with numbness and a gait disturbance. A neurological examination revealed weakness (grade 3/5) in the bilateral intrinsic muscles and hyperreflexia in the bilateral upper extremities with a positive Hoffmann sign; the knee and ankle reflexes were also increased bilaterally. She had decreased sensation in the bilateral upper extremities and a spastic gait with clumsiness of her hands, although she had no bowel or bladder difficulties. Lateral radiographs showed hypoplasia of C1. Computed tomography (CT) disclosed bony canal stenosis caused by the C1 posterior arch and edge of the occipital bone [], and magnetic resonance (MR) imaging demonstrated atrophy of the spinal cord and a high-intensity intramedullary lesion at the C1 level [].
The patient underwent posterior decompression of the CVJ. We resected the C1 posterior arch and the rim of the occipital bone (approximately, 7 mm from the edge of the foramen magnum). Intraoperative ultrasonography confirmed sufficient resection of the bony structure. At this stage of operation, the dura matter did not expand significantly. The thickened reactive fibrous tissue band was noted between C1 and the occipital bone []. Because sparing this fibrous tissue band carefully from dural matter did not improve compression at CVJ, the band and the dura mater underneath were carefully dissected longitudinally to achieve decompression, and the dura mater was left open without a patch graft. The arachnoid membrane was preserved []. The patient's motor weakness and gait disturbance improved immediately after surgery. Although the arachnoid membrane appeared intact during the surgery, the output of suction drainage indicated CSF leakage. One week after the surgery, she complained of a severe headache and nausea. Postoperative MR imaging revealed a moderate collection of CSF at the surgical site. Brain CT demonstrated

[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 71-year-old female patient was presented with an approximately 3 cm peri-areolar mass in the 12 o’clock position in her right breast on physical examination, with no nipple retraction, skin dimpling or palpable axillary lumps. Bilateral mammograms showed very dense breast tissue with a suggestion of an asymmetric density in the right retro-areolar area. It was however difficult to characterize the lesion due to increased breast density (Figures , ). Subsequent ultrasound examination of the whole right breast revealed a 26-mm ill-defined, somewhat heterogeneous, lobulated mass in the area of the palpable abnormality, mostly isoechoic to surrounding normal breast parenchyma. Ultrasound-guided core biopsy of the palpable mass was performed using a 14-gauge needle with three passes from the medio-lateral approach (Figures , ). Histopathology showed invasive mucinous carcinoma of the breast and the diagnosis was given to the patient 12 days after the biopsy. At the second visit, two separate masses were felt on physical examination, one mass in the 12 o’clock and a further adjacent hard nodule at 2 o’clock in the sub-areolar location. A second ultrasound scan was performed, which showed a new 12-mm heterogeneous, cone-shaped nodule contiguous with the main mass pointing medially and towards the skin (Figure ). Since the new palpable abnormality developed following the biopsy and aligned to the expected location of the biopsy needle tract, post biopsy organizing hematoma was suspected with a differential diagnosis of tumor displacement and growth in the biopsy tract. Dynamic contrast-enhanced MRI was performed to determine disease extent and to exclude additional lesions and tumor growth in the biopsy needle tract. The main tumor mass measured 25 mm which exhibited predominantly type 2 (plateau) time-signal intensity curves. Linear enhancement was demonstrated medial to the mass in keeping with the biopsy tract. Although this vague linear enhancement showed type 1 (stea

[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 male was referred to the authors after undergoing chest X-ray (CXR) with evidence of left-sided rib fracture and pleural effusion on 27 January 2015. The patient had developed an intractable cough in December and was started on prednisone and antibiotics by a pulmonologist. The patient was admitted with COPD exacerbations twice in January for intravenous steroid and antibiotic therapy. Following the second time of hospitalization, the patient had some improvement and was discharged on a steroid taper.
Three days following discharge, CXR and dedicated left-sided rib films showed a displaced left 8th rib fracture and left-sided effusion. Physical examination was notable for a 10 × 15 cm mass of the left chest flank associated with ecchymosis. The patient was also seen to have paradoxical motion of this mass with respiration. When lying in the right lateral decubitus position, there was note of concavity at the left 8th rib space. The patient denied respiratory distress but did exhibit decreased breath sounds on the left side. A CT was obtained with evidence of rupture of the left hemidiaphragm measuring 11.4 cm with herniation of omentum, splenic flexure, stomach, and anterior spleen into the chest cavity. There was displacement of bilateral 7th and 8th ribs with a left-sided 8th rib fracture and herniation of the abdominal contents through the intercostal space (Figures and ). This herniation transcended the diaphragmatic injury and involved a subdiaphragmatic abdominal intercostal hernia on the left side. An abdominal intercostal herniation was also evident on the right side in the space created by the 7th and 8th rib displacement.
Given the complex nature of the injury, surgical repair of the diaphragm and hernia was required. The patient underwent a left posterolateral thoracotomy; the incision was made over the defect in the chest wall. Omentum, transverse colon, and stomach were encountered in the extrathoracic hernia sac. These structures were mob

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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 previously well, 16-year-old man presented after sustaining with a major traumatic injury to pubic and the scrotal region; this occurred as a consequence of an autonomous motorcycle accident during a motocross race occurred about 12 hours before hospital admission. Physical examination revealed extensive scalp injury of the pubic and scrotum skin involving bilateral testis and penis (); the patient underwent emergency surgery for evacuation of a haematoma and debridement of necrotic tissue. Preoperatively brain, lung and abdominal computed tomography (CT) scan did not showed bleeding internal lesions. The emergency colordoppler ultrasound (CDU) of the testis demonstrated the bilateral integrity of the tunica albuginea; in addition, an apparent normal flow of intratesticular vessel was recordered. Surgical esploration showed the testes anchored to the gubernaculum testis and the bilateral section of spermatic cord () in correspondence of the abdominal-pelvic tract, therefore abdominal incision was performed to search the proximal spermatic cord tracts those presented a full section without active bleeding. A vascular anastomosis between the dissected spermatic cord was not recommended by vascular surgeon therefore a suture to prevent bleeding was performed. Although the bilateral spermatic cord section both testes did not showed the typical necrotic color () therefore hoping that cremasteric and deferencial vessels could spray the testicles a conservative management was adopted. The next morning the patient underwent bilateral intratesticular sperm biopsy for cryopreservation and a total of 14 spermatozoa were picked up and deposited at the assisted reproduction center. After 1 week the testosterone level was equal to 1 ng/ml therefore hormonal substitution therapy was given; in addition, CDU of the testis did not showed intraparenchimal blood flow that was confirmed by microbubble contrast agent Sonovue administration. The patient was discarged 20 days from trauma

[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 male with a medical history of right inguinal hernia repair during childhood, presented with a history of left groin swelling for three months. There was a progressive increase in its size. Initially, he had been able to reduce the mass, but now it had become irreducible. His history revealed no symptoms of bowel obstruction.
On examination, he looked comfortable with normal vital signs and no signs of distress. On palpation, a large mass was found in the left inguinal region extending to the left scrotum, about 10 cm in diameter. Cough impulse was present; the transillumination test was negative; and the mass could not be reduced.
As the presentation was not typical for an incarcerated hernia, further investigations were done. An ultrasound examination of the area revealed normal testes with no hydrocele; it also showed that the mass had increased vascularity most likely representing omentum.
The patient was prepared for surgery and taken to the operating room where the left inguinal canal was explored. The content of the hernia could not be reduced, so the hernia sac was opened and a piece of omentum was seen extending from the internal ring to the scrotum. The incision was then extended into the scrotum and a large encapsulated mass was encountered attached to the omentum []. The mass was easily delivered out of the scrotum as it was not attached to the scrotum or the testes and it was completely excised along with a small piece of omentum to get a clear margin. The hernia was then repaired using a prolene mesh. The patient's postoperative course was uneventful and he was discharged from hospital after one day with no complications.
Grossly, the mass measured 19 × 9 × 7 cm and was well encapsulated. The cut surface had a yellowish myxoid appearance [].
The histopathological examination revealed that the tumor consisted of bland spindle-shaped and satellite cells evenly distributed in a collagenized and myxoid stroma [].

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old male patient was referred to the Stomatology Department complaining of an increased gingival volume in the region of the mandibular anterior teeth. According to the patient, the lesion grew within one month. The patient also reported being alcoholic and a former smoker. His medical history included hypertension and diabetes mellitus type 2 and the patient reported a basal cell carcinoma detected five years ago. No additional information about infectious disease as C hepatitis or AIDS was reported. The extraoral examination revealed no lymphadenopathy. The intraoral examination revealed poor oral hygiene, general periodontal disease, and a sessile nodular lesion located on the buccal and lingual gingiva of the mandibular incisors extending to the floor of the mouth. The patient had lost all maxillary teeth in the past because of periodontal disease. The lesion presented a lobulated surface, flabby consistency, and dark red color, measuring 2 cm in diameter (). The teeth involved had biofilm accumulation, calculus, and mobility, hampering masticatory functions. A panoramic radiograph showed significant horizontal bone loss adjacent to the anterior teeth, extending to the mandibular left first premolar (#34).
Accumulation of calculus was also observed, suggesting a condition of chronic periodontal disease (). The hypothesis of a reactive hyperplastic lesion related to the severe gingival inflammation was considered. In this context, the potential diagnoses included pyogenic granuloma, focal fibrous hyperplasia, peripheral giant cell granuloma, and peripheral ossifying fibroma. Additionally, squamous cell carcinoma and lymphoma were also suspected in face of the rapid progression of the lesion.
Considering these hypotheses, an incisional biopsy was performed under local anesthesia. The histopathological exam showed a diffuse proliferation of atypical large lymphoid cells, displaying numerous mitotic figures ().
Predominantly, the neoplastic cells presented

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old multigravid female was visiting our private clinic for a routine antenatal transabdominal ultrasound check at 16 weeks gestation. Two foetuses joined at the chest and abdomen were identified by two-dimensional ultrasound, and further confirmation was made by three- and four-dimensional ultrasound. There was blood incompatibility between the parents (the husband was A+ whereas the mother was A–). Anti-D was previously administered after delivery of her first child, a single viable healthy male baby. She had no history of abortion or miscarriage. Her height was 165 cm, weight 63 kg, looked normal, was neither anaemic nor hypertensive and had no history of chronic diseases.
The last menstrual date of this twin pregnancy was unknown. The mother did experience normal foetal movements. She had no vaginal discharge or hyperemesis gravidarum. Her abdomen was slightly large for the date of pregnancy. There was no family history of twins.
A Voluson 730 ultrasound machine from GE Healthcare (Waukesha, WI) was used. The transabdominal ultrasound was performed and two conjoined female foetuses were detected; each foetus was with a single head and a pair of arms and legs. The twins were joined at the lower chest and the upper abdomen. Only one functional foetal heart was observed centrally between both the foetuses with slight tendency towards one of the foetuses ( and ). Single anterior placenta was seen with the umbilical cord and a normal amount of liquor. The colour Doppler study showed two aortic arches emerging from the single functional heart (). On the basis of these findings, a diagnosis of dicephalic thoraco-omphalopagus conjoined twins was made ().
The parents were informed of the malformation and the likely outcome if the twins survived after delivery. They decided to terminate the pregnancy and refused further evaluation and investigation. A CS was performed at the request of the parents in the hospital and the delivery of viable conj

[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 male patient visited the endocrinology department with increased blood sugar for 5 years. During a routine abdominal computed tomography (CT) examination, an abnormal shadow was incidentally found in the right liver. Further magnetic resonance imaging (MRI) of the mass revealed signs of a malignant liver tumor. Therefore, he was transferred to our hepatobiliary surgery department for further treatment. Since the onset of disease, the patient had no obvious discomfort, except for weight loss of approximately 8 kg within 4 months. He had a history of chronic viral hepatitis B for 5 years and is regularly treated with tenofovir at 300 mg/day. Blood test results are summarized in . The levels of alpha-fetoprotein, serum carbohydrate antigen (CA) 19-9, total bilirubin, and direct bilirubin were abnormally elevated. Abdominal CT scanning of the tumors was then performed. Plain scanning revealed a giant hypointense mass (10 × 7 × 6 cm) involving the right liver that was oval-like, irregular, and with septations inside (). On dynamic CT scanning, the tumor edge showed irregular ring-like enhancement with strengthened septations, moderate enhancement in arterial phase (), continued enhancement in portal vein phase (), but attenuation in the equilibrium phase (). On MRI, the lesion appeared as an inhomogeneous high and low intensity on T1-weighted images () and T2-weighted images () with septations inside. On enhanced MRI scanning, the arterial phase of the enhancement scan was slightly inhomogeneously intensified, there was no signal enhancement in the inner part, and slight edge and separation enhancement (), with the enhancement range gradually increasing in the portal vein phase and attenuating in the equilibrium phase (). A sub-focus with a diameter of approximately 8 mm was found in the lateral segment of the left liver, which presented as slightly enhanced (). The tumor was accompanied by an embolus in the right posterior portal vein ().
The patient was d

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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 29-year-old G4P3003 at 34 weeks and 4 days of gestation was transferred from an outside hospital to our tertiary care center with left upper quadrant pain and newly diagnosed splenic artery aneurisms. Initial evaluation was with an abdominal ultrasound followed by CT () and CT angiogram which showed two SAA of 2.3 cm and 1.9 cm in the hilum (Figures and ).
The nature of the pain has been intermittent and present since her last pregnancy four years ago. However, the pain worsened acutely and persisted requiring her to seek emergent care a day prior to her admission. Her past medical history was significant for abnormal pap smears, history of herpes, recent urinary tract infection that was treated, bilateral renal stones, and iron deficiency anemia. The total timeframe between worsening of the pain prompting the diagnosis of the aneurysm and thereafter labor onset followed by delivery was less than 24 hours.
Family history was significant for maternal autoimmune hepatitis and primary biliary cirrhosis.
On examination, vital signs and physical exam were normal except for tenderness in the left upper quadrant on abdominal exam, but without rebound or guarding. Fetal monitoring showed reactive and reassuring tracings, and tocometry revealed irritability without regular contractions. On admission, preterm labor workup was negative (cervical length 3.5 cm by transvaginal ultrasound, cervix 1 cm dilated, 60% effaced, fetal station -3, and negative fetal fibronectin). Also, laboratory studies were performed including liver enzymes, amylase, and lipase that were within normal.
Regarding management, the care of this patient was approached in a multidisciplinary fashion involving the general obstetrics team, maternal-fetal medicine, vascular surgery, general surgery, trauma surgery, interventional radiology, and the neonatal intensive care team. A contingency plan for exploratory laparotomy, neonatal delivery, and control of the maternal hemorrhage was made with the team in c

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female was referred to our medicine dental department in UHC Sahloul, Sousse, for treatment of tooth #46. She suffered from major coronal destruction and needed to have her first molar restored. The medical history was noncontributory. Radiographic and clinical examinations were performed initially, and an extensive glass ionomer cement restoration of a nonvital tooth (46) was identified (Figures and ). The tooth was treated endodontically. The patient had an acceptable oral hygiene and a favorable occlusion. After removing the restoration, an endocrown restoration was recommended because of the amount of remaining tooth structure and the thickness of the walls (). The prosthetic decision was to restore tooth (46) with an endocrown fabricated from lithium disilicate ceramic (IPS e.Max CAD). The preparation for the endocrown is different from the conventional complete crown. This monolithic, ceramic adhesive restoration requires specific preparation techniques to be suitable for especial biomechanical needs.
This is aimed at achieving achieve an overall reduction in the height of the occlusal surface of at least 2 mm in the axial direction and to get a cervical margin or “cervical sidewalk” in the form of a butt joint. The cervical margin has to be supragingival and enamel walls less than 2 mm have to be eliminated.
Differences in levels between the various parts of the cervical margin should be linked by a slope of no more than 60° to escape a staircase effect. We used a cylindrical-conical diamond bur held parallel to the occlusal plane, to reduce the occlusal surface. Then we used a diamond wheel bur to control the orientation of the reduction and to guarantee a flat surface thanks to its shape.
We used a cylindrical-conical diamond bur with a total occlusal convergence of 7° to create continuity between the coronal pulp chamber and endodontic access cavity. The bur was orientated along the long axis of the tooth; the

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old male presented with a chief complaint of painful swelling of the left upper jaw; he had had the swelling for 2 months. The swelling was associated with decreased vision and watering from the left eye for this period. The patient's past medical history and family history were non-contributory. He had had the habit of smoking and alcohol consumption for 30 years.
Extraorally, a solitary swelling was observed involving the left middle third of the face, which was non-tender and hard in consistency with no changes in surface temperature (). Intraorally, a well-defined swelling was located on the alveolus of the left maxilla in the region of the first, second, and third molars with obliteration of the buccal vestibule. On palpation, the swelling was non-tender, and firm to hard in consistency ().
Periapical radiographs () showed a characteristic "ground glass" appearance and symmetric widening of the periodontal ligament space in relation to the left maxillary canine and the first and second premolars. A panoramic radiograph () revealed complete destruction of the left maxillary antral walls and zygomatic process of the maxilla, and the center of the lesion exhibited numerous calcifications.
The coronal section of the CT scan (bone algorithm; ) revealed a hypodense mass involving the left maxillary antrum with complete destruction of the superior, inferior, medial, and lateral walls, with invasion of the mass into the nasal fossa, orbit, and the hard palate. There was also destruction of the conchae of the left nasal fossa. The inferior aspect of the lesion showed a micro-multilocular pattern, whereas the rest of the areas exhibited calcifications distributed haphazardly.
Axial sections of CT (soft tissue algorithm) showed calcifications at the left maxillary alveolar process as well as in the left maxillary antrum. Complete destruction of all walls of the left maxillary antrum was observed with diffuse calcifications ().
Based on the radiological

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old white Caucasian man, without prior history of heart disease was admitted with symptoms of weakness, dizziness and chest discomfort for several hours. Physical examination revealed low blood pressure (85/50 mmHg) and a weak, regular and rapid pulse. The electrocardiogram (ECG) showed a wide-complex tachycardia with LBBB morphology and left axis deviation. Because of continuing hemodynamic instability, the patient was cardioverted to sinus rhythm with a single 300 J shock.
The ECG during the episode of the tachycardia was consistent with sustained VT of right ventricular origin. Post-cardioversion ECG showed negative T-waves at the inferior and precordial leads with a QRS duration of 110 ms and the presence of an epsilon wave in V1 (Figure ).
Chemistries were normal with the exception of troponin I which was positive. The patient was subsequently started on metoprolol. Continuous ECG monitoring revealed multiple episodes of non-sustained VT. Cardiac ultrasound examination showed a normal left ventricle and a slightly enlarged right ventricle with local dyskinesia and diastolic bulging of the free wall (Figure ).
As a diagnosis of ARVC was most likely, the patient underwent simultaneous cardiac catheterization and electrophysiological study. His coronary arteries and left ventricle were normal. Right ventriculography in the right anterior oblique view confirmed the local hypokinesia of the free wall with diastolic bulging. During the electrophysiological study, a sustained VT was provoked with identical morphology to the one on admission. The VT responded to antitachycardia pacing and the defibrillation threshold was 17 J.
A magnetic resonance imaging (MRI) scan that followed revealed diffuse areas of fat tissue at the right ventricular wall especially localized at the free and lateral segments, while multiple small aneurysms were also present (Figure ). Right ventricular ejection fraction was 30%. Left ventricular free wall and intraventricular septum we

[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.