[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 white 17-year-old male student was admitted to the ear nose throat department following referral from the accident and emergency department of our hospital. The patient presented with a 3-day history of dysphagia that was not associated with pain. He reported greater difficulty in swallowing solids than liquids. Furthermore, during the past weeks his sleep was disturbed due to a sensation of foreign body in the throat, causing him a nonproductive cough. This progressed to difficulty in swallowing his saliva on the day of presentation and prompting him to attend the accident and emergency department.
Physical examination showed a well-developed white male in good general health with no past medical history or allergies. Blood pressure was 145/77, pulse was 78, SaO2 was 98, respiratory rate was 16/min, and temperature was 36.4°C.
On examination of his oral cavity, depression of the tongue revealed a large oval, pale pediculate mass protruding from the upper pole of the right tonsil and partially obstructing the airway (). The rest of the oral cavity, nasopharynx, and laryngopharynx were normal. No significant neck lymphadenopathy was observed. Examination of head, ears, and nose was unremarkable.
The patient underwent a right tonsillectomy under general anesthesia. The tonsil and the pediculate mass were removed by dissection, and hemostasis was performed by diathermy and ligation. The specimen was sent for histology. There were no postoperative complications, and the patient was discharged the following day.
Histological examination showed macroscopically a tonsil 28 × 22 × 8 mm in size with an exophytic polypoid nodule measuring 26 × 10 × 8 mm. The cut surface of the tonsil showed normal crypt architecture. Microscopy examination of the polyp showed a core of loose fibrous tissue with dilated vascular spaces containing proteinaceous material and lined by sparse bland endothelial cells. There were foci of well-organized lymphoid tissue. The pedicle showed some well

[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:
51 year old male presented with low back ache with radiation of pain to the right lower limb for 1 ½ months duration. He had pain at rest which aggravated on walking. He walked with a limp. Patient was given epidural injection 3 weeks before he presented to us at another center. There was no relief of pain post injection. Currently he did not have relief with analgesics and physiotherapy and had no relief from epidural injection. There was no history of any previous interventions to the spine or bowel or bladder symptoms. Ankle jerk was absent on the right side. Plantar reflex was equivocal on the right side and down going on the left side. There was no motor power loss or sensory deficit. MRI done showed hypointense lesion that appeared intraradicular in S1 root (arrow mark) with a clear layer of CSF all around the lesion (). Gadolinium MRI did not show any enhancement. There was a clear gap between the dura and the fusiform swelling in the nerve root with no evidence of disc prolapse. A diagnosis of nerve root tumor was made and surgery was advised. Surgery was done with a midline incision with patient in the prone position. Ligamentum flavum on the right side was removed.
The upper edge of the S1 lamina was nibbled and the swelling exposed. Due to the long intra spinal course of S1 root, the swelling could be very well exposed.
The swelling was seen at a distance from the dura with a definite segment of normal looking nerve root in between (). The swelling was opened longitudinally. Fluffy disc like materials came out from n between the nerve fibres (). No CSF came out from the incision. Material was sent for histopathological examination. The nerve sheath was repaired with 8-0 prolene under microscopic vision. Histopathology report was consistent with degenerated disc material with collagenous tissue showing characteristic cell clusters [] ().
Post operatively the patient was relieved of his symptoms except for

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


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

[User]
RADIOLOGY NOTE:
A 45-year old man on home haemodialysis presented with a 6-h history of severe right-sided abdominal colic, non-radiating and associated with rigors and nausea but no vomiting. The pain had not been relieved by simple measures including a change of posture or over the counter analgesics. Twenty-four years previously he had undergone a panproctocolectomy and ileostomy for Crohn's disease. His ileostomy had been functioning normally with no recent change in content or output. He had been anuric for over 12 months prior to this presentation and described no new lower urinary tract symptoms.
He had developed end-stage renal disease secondary to chronic pyelonephritis at the age of 36 years and had been receiving home haemodialysis treatment for the preceding two years after a failed renal transplant. He was awaiting a parathyroidectomy for tertiary hyperparathyroidism. He had suffered an episode of right ureteric obstruction secondary to a calculus 11 years previously, when dialysis independent, which was treated successfully with a right nephrostomy. An antegrade nephrostogram at the time of nephrostomy insertion demonstrated a lucent filling defect in the upper third of the right ureter. A repeat nephrostogram one week later demonstrated clearance of the previously identified filling defect and the nephrostomy was removed. He had also presented two years previously while on dialysis with painless visible haematuria which resolved spontaneously. A computed tomography (CT) scan of the kidneys, ureter and bladder at that time demonstrated a 6-mm right-sided distal ureteric stone (Figure ). It was decided at that point to adopt a watchful waiting strategy and he remained completely asymptomatic for the following two years.
On examination he was afebrile, blood pressure 165/98 mmHg, heart rate 102 bpm. Abdomen was soft and non-distended but tender on palpation over the right flank with no signs of peritonism. Bowel sounds were normal, and a functioning ileostomy was noted

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old woman, known patient of UC on steroids for the past one year, presented with headache for one day. Next day she developed sudden onset of weakness of right upper limb and lower limb, associated with progressive inability to speak and comprehend. She did not have vomiting, seizures or loss of consciousness. She also complained of irregular bloody diarrhea and was on amino salycilic acid. There was no history of rash, joint pains or jaundice. She had unexplained first trimester abortions twice. On examination, she had pallor without significant lymphadenopathy. She was conscious and had global aphasia. She had right hemianopia, bilateral papilledema, right upper motor neuron facial nerve palsy and right hemiplegia with power of 1/5 in right upper limb and 2/5 in right lower limb. CT and MRI brain showed hemorrhagic infarct in left parietal region [Figures and ]. MR venogram revealed thrombosis involving superior sagittal sinus and right transverse sinus, later confirmed by digital subtraction angiography []. Other laboratory investigations revealed microcytic hypochromic anemia with hemoglobin of 8.5 g/dl. HIV, antinuclear antibody and anticardiolipin antibody was negative. Prothrombotic work up (APLA, Lupus anticoagulant, Protein C, Protein S, Antithrombin 3, ANA, homocysteine) was negative. Colonoscopy revealed multiple hemorrhage prone erosions involving the sigmoid colon. Initially she was started on Low molecular weight heparin for 24 h. As her clinical status continued to worsen, she was taken up for intra sagittal sinus thrombolysis. A catheter was advanced through the right femoral vein to the occluded sagittal sinus. After confirmation of catheter tip, intra sagittal sinus urokinase was given initially as a bolus of 100,000 units which was followed up with continuous urokinase infusion at the rate of 70,000 units per hour by keeping catheter in situ. Check venogram was done at 12, 24, and 48 h. Venogram at 48 h showed partial opening up of super

[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 13-year-old Caucasian male sustained diaphyseal fractures of the left radius and ulna three months prior to the presentation in focus. The fractures were managed surgically with closed reduction and 3.0 mm intramedullary elastic nailing of the ulna and open reduction and internal fixation (ORIF) of the radius with a 3.5 mm dynamic compression plate (DCP). Follow-up at two months confirmed satisfactory progress and radiological evidence of the union. The patient was scheduled for elective removal of the elastic nail at three months.
One week prior to metalwork removal the patient tripped and fell onto his outstretched left hand. He presented with severe clinical deformity of the forearm and severe distal neurovascular deficit (Figure ). The hand was pale with an absent radial pulse, prolonged capillary refill time (CRT) and no digital signal on pulse oximetry. Furthermore, both sensory numbness and motor weakness in the distributions of both median and ulna nerves were noted.
Emergent closed reduction in the emergency department was only partially successful in restoring alignment, with restoration of the CRT but persistent neurological deficit. Post-reduction radiographs revealed persistent angular deformity of sixty degrees. Re-fracture of the ulna with plastic deformation of the flexible nail was again noted, as was a periprosthetic fracture at the distal margin of the radial plate (Figure ).
In view of the persisting neurological deficit, the patient was taken to the operating theater expediently. Further attempts at closed manipulation under general anesthesia were unsuccessful. The IM nail- though deformed- was intact allowing successful removal via the routine method from the proximal ulna entry point; however, satisfactory reduction could still not be gained. The radius was approached through the previous volar approach and re-plated, ensuring use of a longer 3.5 mm DCP to account for the previous screw holes. The ulna was then approached directly and inter

[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 woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).
The patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.
We performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral

[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:
45 year old female patient was brought to our hospital with 4 months history of loss of interest in routine daily activities and inactiveness. The symptoms were insidious in onset with rapid progression over 4 months and sudden worsening in 1 week prior to presentation. There was no history of emotional lability, hallucinations or memory disturbances. There was no history of falls, and no sensory or motor deficits.
Her general examination and vital signs were unremarkable. Neurological examination revealed severe apathy and impaired attention span and needed repeated coaxing to cooperate. Speech was hypophonic. She could follow single commands. Naming was normal but reading and writing were impaired. Mini Mental State Examination (MMSE) score was 18/30. Bilateral Papilledema and reduced abduction of both eyes was noted. The other cranial nerves were normal. There was evidence of rigidity in all four limbs and bradykinesia was present. Power was normal and all reflexes appeared exaggerated. Plantars were extensor. Gait was slow with narrow base and slow shuffling associated with body bradykinesia. There were no signs of meningeal irritation.
Her baseline hematological and biochemical investigations were normal apart from peripheral blood smear which revealed microcytic hypochromic picture. Magnetic Resonance Imaging (MRI) brain was done () revealing diffuse deep white matter and periventricular T2 and FLAIR hyperintensities bilaterally which was followed by Digital Subtraction Angiography (DSA) (), which revealed torcular and Superior sagittal sinus DAVFs with arterial feeders from Internal Carotid Artery (ICA) via marginal tentorial artery and from External Carotid artery (ECA) through occipital and middle meningeal artery branches.
In view of the presentation with rapidly progressive dementia with parkinsonism and clinical findings of apathy, cerebral dysfunction, raised ICP and parkinsonism with features of pyramidal dysfunction all likely due to venous congestion

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


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

[User]
RADIOLOGY NOTE:
A 6-month-old boy was referred for a right lower cheek mass and a left thoracic subcutaneous mass both present for 3 months. He was asymptomatic and healthy with no significant medical, surgical or familial history. The thoracic lesion was small (1,0 × 1,6 cm) and mobile. The cheek lesion presented as a deep and firm soft tissue submucosal mass adherent to the mandible (Fig. ).
Ultrasound (US) examination of both masses showed hypoechoic lesions with small calcifications and scant vascularization. Magnetic resonance imaging (MRI) of the neck showed a soft tissue mass of 3.4 (AP) × 2.2 (T) × 3.8 cm (CC), with lobulated contours and a cystic center (Fig. ). The lesion was located within the right buccinator and masseter muscles and showed bony invasion of the right mandible and peripheral enhancement with injection of gadolinium. To rule out other synchronous lesions, cardiac and abdominal US and brain MRI were performed and were negative.
The thoracic lesion was excised and the oral lesion biopsied. The histopathology was similar and showed spindle cell tumors with a storiform pattern (Fig. ) compatible with infantile myofibroma.
Throughout the treatment, the conduct was coordinated by an adult head and neck oncology – reconstructive otolaryngologist and a pediatric oncologist. On multiple occasions, the patient was presented at a multidisciplinary pediatric oncology clinic for medical aspects and at a multidisciplinary head and neck oncology clinic for surgical aspects. The first surgery (debulking) was done jointly by an adult head and neck oncology - reconstructive otolaryngologist and a pediatric otolaryngologist. All other ablative and reconstructive surgeries were performed jointly by two adult head and neck oncology - reconstructive otolaryngologists. Surgical treatment of the mandibular tumor was initially judged too morbid and chemotherapy was started with Methotrexate and Vinblastine. After six cycles, the patient presented feeding difficulties. A computeri

[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 64-year-old woman, with a history of double vessel coronary bypass surgery (CABG) in 1998, presented with five months of increasingly frequent exertional chest tightness and dyspnea. In 1998, the patient presented similarly with a few months' history of exertional chest heaviness, dyspnea, and jaw numbness. After a positive treadmill stress test demonstrating ST depressions, diagnostic coronary angiography was complicated by severe hypotension immediately upon catheter engagement of the left main artery, with blood pressure falling to less than 50 systolic and accompanied by severe chest pain. Limited angiographic images obtained demonstrated an 80% left main stenosis, with angiographically normal vessels in the remainder of the coronary tree. The patient was kept in hospital and sent for double vessel CABG, receiving a left internal thoracic artery (LITA) graft to LAD and saphenous vein graft to obtuse marginal. Since 1998, the patient had been relatively asymptomatic up until five months prior to current presentation.
Her current symptoms were similar, though not identical to her initial presentation in 1998, but they were still provoked by activity and relieved with nitroglycerin spray and rest. She also reported a significant decrease in energy and her usual activities were limited due to exertional dyspnea. Review of systems was otherwise noncontributory. Notably, she was an active user of tobacco, smoking half a pack a day for the past ten years, was a social drinker, and had a mother who died from a heart attack in her early 60s. Her medical history was significant for gastroesophageal reflux, hypertension, dyslipidemia, and hypothyroidism. Her medications included atenolol, ezetimibe, rosuvastatin, paroxetine, and l-thyroxine. She had also recently been placed on topical nitrate patch. Her new-onset symptoms prompted a referral for repeat coronary and graft angiography, and possible percutaneous intervention if appropriate. Based on her cardiovascular hist

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old gentleman was admitted after he developed acute kidney injury and major upper gastrointestinal bleeding. His urea levels measured 50 mmol/L and creatinine levels 1500 µmol/L. A decision was made to commence haemodialysis. A temporary dialysis catheter was inserted into his right femoral vein initially, but it was then decided to change this to a temporary internal jugular dialysis catheter to minimize the likelihood of catheter-related infection.
The left internal jugular vein was punctured under ultrasound guidance and a temporary dialysis catheter was inserted without difficulty. There was good flow in both arterial and venous lumens of the dialysis catheter. A routine post-line insertion chest X-ray was performed (). The chest X-ray showed that the dialysis catheter was following an abnormal course by passing down the left side of the mediastinum rather than crossing the midline via the brachiocephalic vein to enter the superior vena cava on the right side. Aspirated blood gas analysis confirmed that the catheter was in a vein.
A contrast venogram was requested to define the anatomy and ensure that the dialysis catheter remained safe to use. The venogram showed that the patient had a persistent left-sided superior vena cava (PLSVC) or possible double SVC and the dialysis catheter tip was in the distal part of the left-sided SVC. He was started on haemodialysis after the dialysis catheter position was confirmed with the venogram.
After 4 h of haemodialysis in the dialysis unit, he was transferred back to the ward. Approximately 24 h after dialysis, the patient started complaining of breathlessness. An urgent chest X-ray () showed the presence of cardiomegaly, a new left-sided pleural effusion and subcutaneous emphysema over the left clavicle.
An urgent chest computed tomogram () was performed and showed the presence of bilateral pleural effusions (left more than right) and a 1.2 cm, presumed new, pericardial effusion. There was also left-sided basal

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old female with hypertension, untreated hyperlipidemia, hypothyroidism, but without prior history of CAD or angina symptoms was referred to a cardiologist's office for a treadmill exercise test secondary to new onset palpitations. She denied any chest pain or pressure, shortness of breath, exertional dyspnea, or leg swelling. She quit smoking 36 years ago and has no family history of early cardiovascular diseases. She has a very distant cardiac work-up years ago, including a stress test and an echocardiogram, which the patient reported were unremarkable. Vital signs prior to the test were a blood pressure of 140/78, heart rate of 80, and a respiratory rate of 14. Physical exam was unremarkable except for a systolic ejection murmur that was graded II/VI at the base. EKG was at baseline with a normal sinus rhythm, normal axis, and occasional premature ventricular complexes (PVCs).
The patient underwent an exercise stress test using the Bruce protocol and was able to complete stage 1 with exercise for three minutes at a speed of 1.7 mph and a 10% incline. The test was terminated due to dyspnea and fatigue without chest pain. She reached a heart rate of 141 beats per minute which was 98% of predicted for her age. She accomplished 4.5 metabolic equivalents of exertion. With exercise, she had occasional atrial premature complexes and PVCs with a ventricular couplet in recovery. She started to notice tightness in her chest. Her peak blood pressure at the time was 218/90.
The patient was transferred onto a stretcher, and an IV line was started. She was given sublingual nitroglycerin, 325 mg of aspirin to chew, and one 5 mg IV push of metoprolol tartrate. She then received nitroglycerin paste and metoprolol tartrate IV every 5 min for two more doses. At that time, her EKG on the stretcher showed ST elevations in leads I, aVL, V5,

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old man was referred to the department of Oral Medicine of the Isfahan University of Medical Sciences, Isfahan, Iran. He was complaining of exophytic painless mass in dorsal surface of his tongue. He expressed that the lesion had appeared 2 years ago and lasting ever since. The mass had negligible growth rate when he first noticed, but had grown rapidly over the past 2 months to attain the present size. The patient's chief complaint was his fear of speaking because it might make the relatives shocked and wonder and also his phobia of transmission to others or whether it might have a cancerous nature.
Medical history of the patient showed history of epilepsy begining at age 10, taking anti-seizure medications since childhood, and his dental history showed multiple chronic oral ulcers diagnosed as drug-induced lichenoid reaction which were presumed to be related to anti-seizure medications. The list of medications included phenytoin sodium (300 mg/d) and carbamazepine (600 mg/d). It seemed that the patient was of a low socioeconomic status and had not followed his treatment and was taking his medicaments irregularly. Evaluating his laboratory tests revealed anemia, leucopenia, transient thrombocytopenia, folic acid deficiency, and increased liver enzymes. In the study of peripheral blood smear and bone marrow aspiration, mild relative erythroid hyperplasia was diagnosed for him. Symptoms of hirsutism due to phenytoin were evident in his head and face. Despite of long-term phenytoin consumption, there was no gingival hyperplasia.
Clinical examination revealed a reddish-yellow exophytic, pedunculated mass which centered on the dorsal surface of tongue, measuring 4 × 3 × 1 cm3 in size. The lesion was lobulated with a smooth surface. The base of the lesion was so tightly stuck to the bed that the interface was always slightly bloody []. Neither any traumatic factor in the oral cavity, nor palpable cervical lymph nodes were detected. The diagnostic hypotheses wer

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


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

[User]
RADIOLOGY NOTE:
The patient was a 50-year-old male, 173 cm tall, and 85 kg in weight (body mass index (BMI): 27.7 kg/m2). He had a medical history of urinary tract cancer, type 2 diabetes mellitus, hypertension, and Hashimoto's disease. He underwent a robot-assisted radical cystectomy in lithotomy position. The total operation time was 419 min. The operative position was lithotomy position with his lower leg flexed and elevated by soft stirrups. Continuous compression devices on both calves were used for venous thrombosis prophylaxis throughout the procedure. No bleeding-promoting drug was used before and after the surgery.
Sixteen hours after the surgery, he complained of severe bilateral lower leg pain and swelling. Initial evaluation of lower extremities revealed foot drop, swelling and tightness of the anterolateral aspects, and stretch pain on passive ankle planter flexion. No remarkable finding was appreciated on the posterior aspects of his lower legs. Serum creatine kinase was elevated to at 28000 U/l. The compartment pressure was measured by an arterial line set with simple 18-gauge needle under the diastolic blood pressure of 98 mmHg. The measurement was performed at three places of each compartment, and the average value was recorded. The anterior and lateral compartment pressures in both legs had increased to 200 mmHg despite normal posterior compartment pressure (35 mmHg) or thigh compartment pressure (35 mmHg). Contrasting computed tomography (CT) showed swelling of the bilateral muscles in the anterior and lateral compartments without contrasting effect compared to the posterior compartments (). Based on these findings, WLCS localized in the anterior and lateral compartments was diagnosed.
An emergency fasciotomy was performed twenty hours after initial surgery. Anterior and lateral compartments were released with single incision (). Discoloration of the muscles improved within a few minutes after the fasciotomy (). Shoe-race procedure was added to prepare for second

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


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

[User]
RADIOLOGY NOTE:
The patient was a 71-year-old male diagnosed with renal AL amyloid nephrotic syndrome in March of 2007 and underwent a stem cell transplant in December of 2007, obtained an organ response with urinary protein falling from 10.5 g/24 h to 1.5 g/24 h. The patient developed congestive heart failure in July of 2013 and underwent an endomyocardial biopsy that demonstrated amyloid. Proteomic typing demonstrated that this patient had TTR cardiac amyloid, and genetic studies demonstrated the TTR gene to be wild-type, so-called senile cardiac amyloidosis. He died at the age of 79 of progressive heart failure 39 months following the diagnosis of TTR cardiac amyloidosis. Comment: This patient had two types of amyloidosis. He had AL amyloidosis successfully treated and had not relapsed after 9.5 years but subsequently developed age-related cardiac amyloidosis that could have easily been misdiagnosed as relapsing AL if cardiac biopsy and proteomic analysis had not been done.
Over 15 years ago, it was common to identify amyloid in a patient with a monoclonal gammopathy and assume that this was AL type. However, in 81 patients with TTR amyloidosis, an M protein was found in 20 of the 81 and an abnormal free light chain ratio in 8 of the 81. A second study of wild-type TTR amyloidosis also demonstrated a monoclonal protein in 25% of patients. Finally, even when AL is diagnosed with proteomic analysis, this does not indicate whether the amyloidosis is localized or systemic. Attention must be given, particularly to those patients who present with amyloid in a skin biopsy, bladder biopsy, laryngeal biopsy, or at the edge of a colonic ulcer or polyp, that the amyloid may be a localized AL amyloidosis that requires no intervention.
Many specialists, when encountering a patient with biopsy of an organ containing amyloid, refer to a cancer care provider uncertain of the type of amyloidosis. The first step for all biopsied tissues, shown in an algorithm (Fig. ), would be mass spectroscopic

[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 40-year-old gravida 4 para 4 was referred to our centre for an abdominal and perineal mass that gradually enlarged over the past 3 years. She complained of abdominal distension, slow transit with 1–2 stools per week, and difficulty in voiding. There was no abdominal pain. She lost 8 kg over the past 3 years. On physical examination, the patient had a large, firm and indolent abdominal mass that emerged through an incisional hernia of the abdominal wall. We also noted a second mass, measuring 40 cm and occupying the internal part of the gluteal region. Its pedicle extended into the pelvis through the right ischiorectal fossa (). Perineal examination revealed a grade IV hysterocele. Computed tomography (CT) showed a huge, well-demarcated solid, homogeneous mass with moderate enhancement occupying the abdomen and pelvis herniating through the perineum (). The core needle biopsy findings were consistent with myxoid neurofibroma. Exploratory laparotomy showed a firm multilobed mass () that contracted intimate adhesions with the pelvic colon, right ureter and rectum. Resection was performed without organ involvement through a combined perineal approach. Tumour resection was macroscopically completed except in the perineum, where the tumour was left (R2 resection) to avoid anal sphincter injury. The operative specimen weighed 5.842 kg. Histological analysis showed a spindle cell tumour with a myxoid matrix without atypia or mitosis. On immunochemistry, the tumour was negative for PS 100 and CD 117 and positive for nuclear β-catenin and smooth muscle actin. It was diagnosed as a desmoid tumour. During the immediate postoperative period, wound infection and partial dehiscence were noted. Flatus and liquid stool incontinence were also observed. The incontinence completely improved during the 12th postoperative week. Adjuvant treatment with tamoxifen at an initial dose of 150 mg/day and indomethacin (100 mg per day) was given for the incomplete excision (R2). Tamoxifen was t

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old female presented to the emergency room with a three-day history of right hip pain. She reported decreased range of motion and difficulty ambulating. She denied constitutional symptoms or fever. She had undergone intra-articular steroid injection of her right hip three days prior. Review of systems was otherwise unremarkable. Her past medical history was relevant for hereditary spherocytosis with splenectomy at age 14 and chronic right hip osteoarthritis. Her only medication was celecoxib as needed. She denied any drug allergy. She was unaware of her immunization history. She worked as a flight attendant, denied smoking or recreational drug use, and had not recently travelled outside of Canada. On initial examination she was afebrile and her vital signs were within normal limits. On examination of her right hip she had limitation of internal rotation with reproducible pain, but her physical exam otherwise was unremarkable. Her initial investigations showed elevation in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at 22.9 mg/L and 25 mm/hr, respectively. Her white blood cell count was not elevated. An X-ray of her right hip showed severe joint space narrowing with osteophytosis consistent with severe osteoarthritis. Arthrocentesis was performed and synovial fluid samples were directly inoculated onto solid culture media, including blood agar and chocolate agar. Two of three samples also underwent cytospin centrifugation and direct Gram stain. Gram-negative bacilli were observed in one sample though heavy neutrophils were observed in both. Synovial fluid analysis for cell count and chemistry was not performed due to insufficient sample. She was admitted to hospital for 24 hours of observation and was subsequently discharged with instructions to return to hospital if her symptoms worsened or if cultures subsequently grew a pathogenic organism.
Three days later she was seen in a follow-up clinic. In the interim she had developed a fever

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


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

[User]
RADIOLOGY NOTE:
The patient is a 37-year-old man with a past medical history of hypertension, diabetes mellitus, extensive hypercoagulable history, and a remote history of exploratory laparotomy for an embolectomy of the superior mesenteric artery and a small bowel resection of the jejunum. He presented to the Emergency Department with an 8-hour history of worsening, crampy abdominal pain, nausea, vomiting, and multiple episodes of hematemesis. He had a bowel movement prior to arrival, but otherwise his review of systems was unremarkable. Physical examination was notable for hemodynamic stability and a mildly distended abdomen with epigastric tenderness but without guarding or rebound tenderness. Given his prior surgical history, a computed tomography (CT) of the abdomen was obtained, which showed dilated loops of bowel with a transition point in the region of the proximal ileum, just distal to his prior bowel anastomosis. The distended proximal small bowel loops contained fecalized material, and the distal small bowel loops were also decompressed without evidence of ascites, bowel wall enhancement, or free air ().
The patient was admitted and initially managed nonoperatively with fluid resuscitation, pain control, bowel rest with nasogastric tube decompression, and serial abdominal exams. Following return of bowel function, the nasogastric tube was discontinued on hospital day 2 but reinserted hours later due to persistent, new-onset vomiting, and worsening abdominal distention. Without significant improvement in symptoms, the patient was taken to the operating room urgently for an exploratory laparotomy. Intraoperatively, the small bowel was dilated to approximately the midjejunum, where an intraluminal obstruction was palpated and subsequently identified to be a phytobezoar. Consequently, a longitudinal enterotomy was performed to evacuate the phytobezoar measuring 4 cm by 3 cm and was closed in a transverse fashion in two layers (). The phytobezoar seemed to be composed of fibe

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old female with diagnosis of Cushing's disease (ectopic ACTH syndrome) had undergone adrenalectomy in 2000. She was kept on low-dose steroids postoperatively. The patient started having pain in the left hip 2 years postadrenalectomy, for which she was given analgesics and calcium supplementation. Her BMD (T score: –3.3; lumbar spine and –2.6; proximal femur) and radiological examination suggested severe osteoporosis. She subsequently suffered pathological fracture neck of femur for which she was operated and valgus osteotomy was done. Postoperatively, she was advised alendronate 70 mg once a week with calcium supplementation along with low-dose steroid for post adrenalectomy supplementation. After 6 years, the patient again started having pain in the right hip and thigh. Her BMD was found to be improving (T score –1.1) and there was no radiological evidence of osteoporosis as well. She was advised analgesics, exercises, along with the previous treatment, but her pain did not subside. After 5 months, she had aggravation of pain and on radiological evaluation was found to be having pathological subtrochanteric fracture for which she was operated and internal fixation with long proximal femoral nail was done []. The fracture united at 10 months and pain in thigh and hip subsided []. The patient continued to take alendronate along with low-dose steroid for post adrenalectomy supplementation. Two years later the patient started having diffuse dull ache, insidious in onset, activity related pain in the right foot which did not subside completely with analgesics and physical therapy for 3 months. The radiographic evaluation showed incomplete, transverse, diaphyseal fracture of fifth metatarsal shaft with thickening of lateral cortex []. Patient's BMD showed normal mineral density (T score –0.7). She was advised plaster. Alendronate therapy was discontinued and teriparatide therapy 20 mcg subcutaneously was started and continued for 6 months. She improved and the

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman was clinically monitored for primary hyperparathyroidism since 2005. She had a medical history of arterial hypertension and in 2015 she underwent a laparotomic left nephrectomy for hydroureteronephrosis caused by recurrent kidney stones.
In March 2017, she had a neck ultrasound showing a nodule with a size of 9 × 5 mm in the lower third of the left thyroid lobe, consistent with left parathyroid. Subsequent T99m single-photon-emission computed tomography (SPECT)/CT scans did not show any uptake of the radioactive tracer at the level of the lower left thyroid gland different from the surrounding glandular tissue. A left parathyroidectomy was scheduled and preoperative laboratory tests showed elevated PTH at 453 pg/ml, low Vitamin D at 25.1 ng/ml, elevated serum calcium of 12.9 mg/dl, slightly reduced level of phosphorus. A neck CT was performed, not showing solid growing mass in the cervical district, in the absence of observable thyroid or parathyroid lesions.
Intraoperative PTH at the beginning of surgery was 440 pg/ml. The intervention started with a Kocher cervicotomy and cervical exploration at the left lower thyroid lobe. Here, there was a voluminous lesion with adipose appearance and texture. After identification and preservation of recurrent laryngeal nerve, the lesion was completely excised. On macroscopic investigation it was multilobulated, with a size of 7 × 7 cm, containing a little and poorly defined lump consistent with a pathologic parathyroid (). The sample was sent to obtain frozen sections and definitive histological examination. Frozen sections revealed the presence of adipose and connective tissue with tubular epithelial basaloid proliferation made of little cells without significant nuclear atypia, with focal areas of possible oncocytic differentiation. In those sections, the morphological features did not allow to distinguish between a thymic or parathyroid origin of the proliferation. After the excision intraoperative PTH dr

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


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

[User]
RADIOLOGY NOTE:
A 24 year old male was examined in the cornea services of our institute in January 2013 with the chief complaint of noticing a mass in the left eye for the last 6 months which was increasing slowly in size. He also complained of severe itching in both eyes for many years for which he had been prescribed various topical medications. He underwent a complete ophthalmic examination bilaterally. Ocular examination revealed an unaided visual acuity of 20/20 OU and intraocular pressures of 16 and 18 mm of Hg in OD and OS, respectively, by Goldman applanation tonometry. Anterior and posterior segment ocular examination OD was unremarkable except for the presence of papillae on the upper palpebral conjunctiva. There was no limbal involvement in the right eye. On eversion of the left upper lid, an intense papillary reaction was seen diffusely associated with several large “cobblestone” papillae measuring 1.5–2 mm in the centre and lateral side of the lid (). These were associated with a ropy discharge. The temporal limbus in the left eye revealed the presence of a reddish sessile papillary mass extending for 2 hours from 2 to 4 o'clock (). The surface showed the presence of multiple capillary fronds appearing as red dots, with focal areas of keratinization on the inferior border of the lesion (). The mass was freely movable and the temporal edge of the mass was associated with engorged conjunctival vessels. The rest of the limbus did not show any evidence of thickening, and anterior and posterior segment examination was noncontributory. The surface of the mass stained significantly with rose bengal. Clinically, the diagnosis of bilateral, though asymmetric, palpebral VKC (left eye being more involved than the right) was made. For the limbal mass in the left eye, the possibility of epithelial hyperplasia was entertained but OSSN could not be ruled out. Excision biopsy with wide margins was performed

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old lady underwent an elective laparoscopic Nissen fundoplication. On the second postoperative day she deteriorated with persistent vomiting, pyrexia, and low oxygen saturations and was promptly admitted to the intensive care unit (ICU). Oesophago-gastro-duodenoscopy (OGD) was performed with dilatation of a tight gastro-oesophageal junction (GOJ).
She then continued to be hypoxic and hypotensive and a chest X-ray revealed a right sided pneumothorax which was managed with a right chest drain. Serial arterial blood gas samples did not reveal any acid-base disturbances at this stage. A gastrografin swallow ruled out any perforation in the oesophagus and was otherwise nonspecific. After a short period of noninvasive ventilation, she remained hypoxic and was consequently intubated. A second chest drain was inserted on the left side due to worsening bilateral pleural effusions on a subsequent chest X-ray.
A repeat OGD revealed a normal GOJ with a rotated and distended stomach but there was no evidence of gastric outlet obstruction. As the patient continued to deteriorate, a computerised tomography (CT) scan was done () which confirmed herniation of the stomach into a congenital postdiaphragmatic space. At exploratory laparotomy, the anterior wall of the stomach was noted to be herniating into a congenital space behind the diaphragm pushing the liver and the inferior vena cava anteriorly. There was no evidence of a gastric volvulus. Following the retrieval of the herniating segment, the wrap was noted to be congested with an area of ischaemia which recovered promptly following reduction and no resection was necessary. The wrap was undone revealing a defect in the anterior wall of the stomach. The margins of the defect, which were of doubtful viability, were trimmed and the defect was closed with nonabsorbable sutures and covered with omentum. The stomach was then fixed to the anterior abdominal wall with nonabsorbable sutures. No defect was noted in the diaphragm

[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 30-year-old woman visited our clinic with a 4-year history of tremor in both hands and a 6-month history of gait disturbance. The patient reported that the tremor in both hands and gait disturbance were progressively aggravated. On neurological examination, postural tremor was noted in both hands, but rest tremor was not observed. Rigidity was present in the extremities but not in the neck. On walking, arm swing was decreased. Mild bradykinesia was observed while the fingers were tapped, hands were closed and opened, and when foots were stomped on the floor. Facial expression was normal. Although postural tremor and rigidity were similar between both hands, brandykinesia was more severe in the left hand and arm swing on walking was more decreased in the left side. The patient showed independent walking with minor gait impairment and mild postural instability on the pull test; she recovered with 5 steps backwards for recovery without help. She complained of orthostatic dizziness but did not have orthostatic hypotension. Her consciousness was clear and orientation was well maintained. She revealed normal findings in the motor and sensory test, neurological tests for cerebellar function and eyeball movements, and deep tendon reflexes.
There was neither a notable history of medical disease nor a history of drug ingestion causing bradykinesia. Routine physical examinations including fundoscopy showed no abnormal findings. Nor were abnormal findings in the routine blood test, biochemical test, electrolyte test, thyroid function test, syphilis test, human immunodeficiency virus test, serum vitamins, serum cupper, serum ceruloplasmin, chest X-rays and electrocardiograms.
The patient was diagnosed with parkinsonism based on bradykinesia of both hands, rigidity and postural instability. Her score on the Unified Parkinson Disease Rating Scale was 22 points. Magnetic resonance (MR) images showed an ill-defined mass in the anterior third ventricle and hypothalamus, which had p

[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 nulliparous, 30-year-old female, presented to the infertility clinic with complaints of primary amenorrhoea and infertility, with chronic pelvic pain for more than ten years duration. The general physical examination was unremarkable with normal secondary sexual characters. The routine laboratory investigations for amenorrhoea and infertility were normal including normal hormonal profile. Pelvic examination revealed a normally developed vagina and cervix and anteverted nulliparous uterus. The patient had prior been investigated several times, including sonography of pelvis, outside our institution, with all inconclusive reports.
The patient underwent ultrasound in the radiology department of our institute, which demonstrated the presence of a normal sized anteverted uterus, oriented more toward the left side of pelvic cavity. The endometrial cavity was distended with echogenic fluid. The left uterine tube was dilated and filled with fluid of similar echogenecity. The cervix and left ovary were normal. A complex mass comprising of solid and cystic components was found on the right side. There was no separate visualization of right ovary. The patient was advised pelvic magnetic resonance imaging (MRI) to better characterise the ultrasound findings.
MRI of the pelvis showed presence of two asymmetric uterine horns, smaller on the right side with thin myometrium and normal sized left with normal myometrium. Both endometrial cavities were distended with hemorrhagic contents and showed no communication to each other. There was associated hematosalpinx on either side. The cervix and vagina were normally developed, however there was no demonstrable communication between the endometrial cavity and the endocervical canal. Both the ovaries were normal. On the basis of MRI findings, a diagnosis of unicornuate uterus with cervical dysgenesis and a cavitated, noncommunicating rudimentary horn on the right side, was made [].
The patient was taken up for laprohysteroscopy. The ce

[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 43 years old, Latin American woman, right-handed, height 170cm, weight 106 kg, without relevant comorbidities except for obesity, suffered a pathological fracture of her right femur in May 2018. Consequentially she was treated with the resection of the fragment involved in the fracture and its substitution with a cylindrical-shaped implant of bone cement, stabilized with double carbon-PEEK fiber plates. The pathologist report was positive for malignant PECome tumor, a low-grade neoplasm, without any indication for further treatment. After a couple years of wellness, even though the function of the right low limb was reduced, the patient suffered in January 2020 a sudden atraumatic pain localized on the synthesized zone; After a radiological exam, implant failure was diagnosed (). As a routine follow-up was performed, a series of instrumental exams was carried out, comprehensive femur X-Ray, a PET-CT with FDG and chest CT scan in March 2020, which evidenced some pulmonary nodules of a probable metastatic nature. New surgical treatment was performed with distal femur resection and implantation of a megaprosthesis implant. The histological exam, in the latter case, was positive for malignant PECome tumor. During the hospitalization a specific anamnestic collection focused on the bone fragility and osteoporotic risk factors was performed in addition to routine laboratory tests for bone metabolism (protein electrophoresis, complete blood count, 24-hour urine calcium excretion and creatinine levels, serum level of calcium, albumin, phosphorus, vitamin D, alkaline phosphatase, blood urea nitrogen and creatinine) and densitometric bone evaluation of lumbar spine and both hips. It was also performed a biopsy from quadriceps muscle of both legs. No personal or familiar risk factors for generalized osteoporosis were highlighted. Laboratory test showed only a slightly increased PTH (43 ng/L ; normal values 8 ng/L -40 ng/L). Hand grip test was performed and no significant diff

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old female had experienced unstable gait for 3 months. Because her disability was gradually progressing, she consulted a local hospital. When she came to our hospital for further examination 1 week later, she could not move without a wheel chair. Neurological examination revealed cerebellar truncal ataxia without Romberg's sign. Magnetic resonance imaging (MRI) of the head showed a cystic lesion in the foramen of Magendie, which was compressing the inferior part of the vermis and the medial part of the cerebellar hemisphere without causing hydrocephalus [].
She had previously consulted her local hospital with a complaint of headache 3 years ago. MRI performed at that time revealed the same cystic lesion to be present. The intensity of the cyst was similar to that of the cerebrospinal fluid (CSF), and the cyst was divided into two portions, suggesting the presence of a multilobular cyst. Because the patient's symptoms were believed to attribute to the presence of this cystic lesion, surgical decompression was planned.
Median suboccipital craniectomy was performed such that after the dural incision, the cyst was exposed. The retromedullary cistern was open, but the cyst had not shrunk, and the cyst was found not to communicate with the surrounding cistern []. Most of the cyst wall was successfully removed. A small part of the cyst that was still attached to the choroid plexus at the foramen of the Magendie was allowed to remain [], and the fourth ventricle was not opened via the obex.
Pathohistological examination demonstrated that the cyst wall was composed of a collagenous membrane lined by multiple layers of arachnoid cells []. Chronic inflammation and hemosiderin pigmentation were absent on the wall. This result confirmed the diagnosis of the cyst as an AC.
The patient's postoperative clinical course was excellent and her neurological recovery was remarkable. She regained her mobility and could walk without a cane. MRI performed 2 weeks after the operati

[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 woman presented for a routine annual examination to her primary care physician. She had no significant past medical or surgical history. There was no family history of breast or ovarian cancer. Physical examination of the breast was unremarkable. She had never undergone routine screening mammography, so as part of her annual examination, a screening mammogram was ordered. The bilateral digital screening mammogram with tomosynthesis showed heterogeneously dense breast parenchyma, with calcifications in the upper central left breast, Breast Imaging-Reporting and Data System (BI-RADS) 0, for which diagnostic mammogram and breast ultrasound were recommended. A digital diagnostic mammogram showed heterogeneously dense breast parenchyma, with a single 5-mm area of calcifications in the upper outer quadrant of the left breast having very unusual morphology, with a lacy appearance (). The indeterminate calcifications were not typical for macrocalcifications and were not associated with ducts. The findings were assessed as BI-RADS Category 4, suspicious, and stereotactic biopsies were recommended. Ultrasound revealed no cystic or solid mass in either breast. Multiple left breast core needle biopsies were obtained under stereotactic guidance with vacuum-assisted needle biopsy. A specimen radiograph confirmed the targeted calcifications in the cores.
Pathologic findings: The core needle biopsies consisted predominantly of adipose tissue with only a few benign breast ducts and lobules. One of the core biopsies had 2 foci of OM with calcifications, each 0.5 mm, characterized by small anastomosing bony trabeculae without associated bone marrow elements (). These foci were located in benign adipose tissue, devoid of epithelial breast parenchymal components. Benign breast ducts and lobules were located in the same core, 4 mm from the hemangioma. Hemangioma with capillaries, postcapillary venules, and small veins lined by bland endothelial cells were present in the foc

[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 51-year-old male with a history of nonischemic cardiomyopathy with a left ventricular assist device was admitted for expedited heart transplant evaluation. The evaluation included an elective colonoscopy in light of a family history of colorectal cancer in his mother who died at age 61 from the disease. The patient had his first screening colonoscopy at age 45 and was diagnosed with benign polyps, which were removed, and left-sided diverticulosis. The procedure was uncomplicated and he was advised to repeat a colonoscopy in five years.
The patient was without GI symptoms at the time of his colonoscopy. He denied tobacco, alcohol, or illicit drug use. His medications included amiodarone, aspirin, famotidine, levothyroxine, lisinopril, metoprolol, sildenafil, and intravenous heparin as well as torsemide, acetaminophen, docusate sodium, and melatonin as needed. On examination, he had a left ventricular assist device port entering at the upper abdomen, but otherwise the abdomen was soft and nontender to palpation with normal bowel sounds and no appreciable masses or ascites.
The patient underwent a standard bowel preparation which included a clear liquid diet the day prior to the procedure and 20mg of Dulcolax with 4 liters of polyethylene glycol the night prior to the procedure. Monitored anesthesia care sedation was administered with propofol. The colonoscopy was performed at night without difficulty with good bowel preparation. Abdominal pressure was briefly required to maneuver around the splenic flexure. The colonoscope was advanced to the cecum with identification of the appendiceal orifice and ileocecal valve. Findings included multiple sigmoid and descending colon diverticula and two, small (<5mm) sessile polyps that were removed using cold forceps.
The night of the procedure the patient had no pain or nausea and ate dinner and breakfast the following morning without incident. He then developed epigastric abdominal pain in the midmorning approximately 12-14 ho

[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 woman presented with abdominal pain in 2018. Computed tomography (CT) imaging revealed a 3.9 × 3.7 cm heterogenous soft tissue mass in the ascending colon near the hepatic flexure with invasion of the right anterior pararenal fascia and the second/third portion of the duodenum. There were associated enlarged and necrotic portacaval and mesenteric lymph nodes and a 1 cm hypodense lesion in the right hepatic lobe. Colonoscopy with biopsy confirmed a diagnosis of adenocarcinoma, and subsequent immunohistochemistry (IHC) showed loss of MLH1 and PMS2 gene expression consistent with MSI-H/dMMR. The patient was started on 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX), but continued experiencing symptoms of partial bowel obstruction including severe nausea, emesis, abdominal pain and dizziness from hypovolemia. CT imaging at this time is shown in . Given no evidence of response to chemotherapy for 2 months, she was transitioned to pembrolizumab (anti-PD-1). Shortly after initiation of pembrolizumab, she developed a partial large bowel obstruction secondary to the tumor. This was relieved by placement of a percutaneous gastrostomy tube and she was started on total parenteral nutrition (TPN) and resumed immunotherapy. Following three cycles of immunotherapy, imaging was consistent with partial response in the primary tumor and associated lymph nodes and the patient was also able to transition to an oral diet. However, after 8 months on immunotherapy she developed complete bowel obstruction, though imaging showed continued response in the primary tumor and metastases. The bowel obstruction was thought to be from adhesions and inflammatory changes and not progression of the patient's primary disease. Following multidisciplinary discussions between the patient and her treatment team including Medical Oncology, Surgical Oncology, and Palliative Care, the decision was made to proceed with surgical intervention. She underwent an internal colonic bypass with ana

[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:
After a multidisciplinary evaluation, at the end of November 2019, a 13-year-old girl attended the Pain Therapy Clinic of the Ospedale Pediatrico Bambino Gesù in Rome, where acupuncture is also practiced as an analgesic technique. She reported pain in the left wrist and hand, with intensity 10 on the Numeric Pain Rating Scale (NRS), pulsating, and always present, thus preventing any movement. Marked hypersensitivity and allodynia were present at the level of the left fingers, wrist and hand. Pain was present in both flexion and extension of the wrist and caused a marked reduction in strength in the left wrist and hand, making a handshake impossible for the girl. There was no redness but swelling and sweating at the level of the fingers of the left hand. The pain was so intense that it interfered with her regular attendance at school, generating social withdrawal phenomena, which are unfortunately very frequent in patients with chronic pain.
Pain began three months before the consultation, after an accidental fall with trauma to the left wrist. It gradually increased and did not respond to either NSAIDs or limb immobilization. The diagnostic tests performed at the time (X-ray, Doppler ultrasound and magnetic resonance imaging) were negative, as were the blood chemistry tests ( and ).
From the age of 8, the girl was followed by a pediatrician in our hospital for a history of cramps and pain in the lower limbs, especially in the ankle and left knee, both in the absence of trauma or caused by frequent falls. In the following years, clinicians found bilateral flatfoot (with subsequent surgery), mild ligamentous hyperlaxity and vitamin D deficiency. In addition, borderline cognitive level with motor coordination disorder and executive function deficit, as well as stuttering, were then diagnosed. Elements of anxiety emerged from the administration of Self Administered Psychiatric Scales for Children and Adolescents (SAFA-A, D and S)

[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 man was referred for resection of a cecal mass that was found on routine colonoscopy (Fig. ). The patient denied history of blood per rectum, change in bowel habits, abdominal pain, nausea or weight loss. The patient had a significant past medical history for prostate cancer for which he underwent prostatectomy and chemo-radiation therapy. He also underwent open repair of bilateral inguinal hernias in the remote past; the operative notes were not available to us. Tumor markers (CEA and CA19-9) and routine blood tests were unremarkable.
The mass was found in the cecum during routine colonoscopy (Fig. ); it had raised borders, did not have a stalk and was not associated with mucosal erythema or ulceration. Biopsies showed normal colonic mucosa. A computed tomography (CT) scan of the abdomen showed a 3.3 × 4 cm mass that compressed the wall of the cecum. There was no associated lymphandenopathy or liver lesions (Fig. ). Based on these findings, we could not conclude if the aforementioned mass was intramural or extramural to the cecum. Due to the uncertainty about the location of this mass (intramural versus extramural) and the inability to rule out a neoplasm, we proceeded with a diagnostic laparoscopy with the possibility of resection of the cecum. Intraoperatively, we found that the right inguinal hernia had been repaired using a plug-and-patch technique. The mesh plug was fixed in the preperitoneal space and had not violated the peritoneal layer. The ‘Plug’ had not fully deployed in the preperitoneal space and had retained a cone-like shape. The wall of the cecum appeared normal and there were no masses in its anterior wall. An intraoperative colonoscopy was done to confirm the absence of a mass; upon insufflation of the colon, it became apparent that the cecal wall was pressed against the non-deployed plug thereby creating the impression of a mass

[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 January 2013, a 73-year-old man presented to the Department of Oral and Maxillofacial Surgery, complaining of a painful mass in the mandible on the right side. He had also a history of deep neck pain for 3 months, but it had been disregarded. A review of patient's medical history revealed that he had an acute myocardial infarction 2 years before, which was treated by percutaneous coronary angioplasty. The patient had a 30-year history of cigarette smoking and opium use. Physical examination showed a firm, well-defined swelling measuring about 3 × 3 cm in the body of the mandible on the right side. The skin over the mass was normal in color and texture. No palpable submandibular and cervical lymph node was evident. Intraoral examination showed that the involved mandibular area was edentulous and the mucosa over the mass was intact.
An orthopantomogram radiograph demonstrated an ill-defined radiolucent lesion in the body of the mandible causing pathologic fracture of the involved bone [].
The results of laboratory tests were normal with the exception of prostate-specific antigen (PSA) level which was 52 ng/ml.
Intraorally, an incisional biopsy was performed under local anesthesia. Histological sections stained with hematoxylin and eosin revealed a metastatic tumor of epithelial origin; however, it was unclear from which primary site the metastasis occurred. Histologically, the neoplastic cells arranged in glandular patterns had low mitotic index and were composed of round hyperchromatic nuclei and acidophilic cytoplasm [].
Because of concern over raised PSA level and high suspicion of prostate malignancy, the patient was referred to an urologist for further evaluation. In pelvic ultrasonography, a significantly enlarged prostate was observed. A biopsy of the prostate was done; the histopathological examination was consistent with prostatic adenocarcinoma. Whole body skeletal survey using bone scintigraphy revealed a bone lesion of the right mandible plus a destruct

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old male smoker presented in December 2013 at the CHU Sud Réunion with pain in his left ring finger and in the ribs, both secondary to indirect trauma a few weeks ago. Severe pain discouraged the patient from using his left hand in daily activities. He had no other complaints and was in good general condition. On physical examination of the hand, the left ring finger was edematous at the proximal interphalangeal joint (fig. ). The finger movement was restricted. His left ring finger measured 80 mm in circumference, while the contralateral healthy finger had a circumference of 55 mm.
We performed an X-ray of the rib cage, which showed a lytic lesion of the eighth rib. An X-ray of the left hand showed a lytic bone lesion with the destruction of the bone cortex in the proximal phalanx and a swelling of the surrounding soft tissue (fig. ). A CT scan of the chest showed several suspicious opacities, one in the left lung hilum, a stellar image at the apex of the right lung, and a lytic lesion of the anterior arc of the eighth rib (fig. ). The pneumologist performed a bronchoscopy, but the first biopsies were negative. Then a biopsy of the rib mass identified an infiltration of the parietal pleura and striated muscle tissue by a pulmonary adenocarcinoma, moderately differentiated TTF1+, KRAS mutant, BRAF wild type, EGFR wild type, and with no ALK rearrangement. The bone scintigraphy showed multiple bone metastases on the rib cage, the spine, and the left scapula. The patient's left ring finger was very painful. He was given a nonsteroidal analgesic. The pain was morphine resistant. The patient received radiotherapy for his left ring finger in March 2014 (dose of total 30 Gy/10 fractions, 5 fractions/week, 6-MV X-rays with 5-mm bolus). Over the next month, the left ring finger became much less painful. Analgesics were no longer

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old Caucasian woman with chronic kidney disease, diabetes mellitus type 2, heart failure, previous nephrectomy due to clear cell renal cell carcinoma, and previous upper right lobectomy of the lung due to adenocarcinoma was admitted to the hospital because of acute hypercapnic respiratory insufficiency. She needed respiratory support with non-invasive ventilation. She was also hemodynamically unstable.
CT angiography of the pulmonary arteries was performed. The CT scan revealed left-sided subsegmental pulmonary thromboembolism and a suspicious mass in the left atrium. She was treated for pulmonary embolism. The previous CT scan of her thorax, which she had undergone a couple of months before for her pulmonary carcinoma follow-up, had shown a normal image of the heart, proving the mass in the left atrium grew de novo. The transthoracic and transesophageal echocardiography discovered a massively enlarged left atrium, fibrous changes of the mitral valve and a mobile tumor formation measuring 2.8 × 3.6 cm that arose from the posterior annulus (shown in Fig. ).
The stem of the discovered formation was broad but did not reach the leaflet of the mitral valve. The tumor prolapsed through the mitral valve and caused severe mitral stenosis with minimal regurgitation. The tumor seemed to have caused postcapillary pulmonary hypertension as well. Cardiologists suspected it was myxoma and referred the patient to cardiac surgeons. A preoperative PET scan showed high metabolic activity in the left atrium that pointed to the possibility of the tumor's more aggressive origin, such as metastasis or a primary malignant tumor of the heart rather than myxoma. The patient underwent an open mitral valve replacement and extirpation of the tumor of the left atrium. At the time of open-heart inspection, the tumor was not encapsulated, but grew inside the atrial wall with root-like extensions. It hung on a stem that masked its appearance as myxoma on echocardiography. It did not over

[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 36-year-old Indian man with a medical history significant for CKD and hypertension presented to the ED after a witnessed episode of new-onset seizure at home that was followed by another episode of generalized tonic-clonic seizure in the ED. The seizures each lasted for less than two minutes and were followed by a postictal state. He complained of generalized body weakness, loss of appetite, nausea, and vomiting for the past three days, and there was no history of a fall or trauma. Patient assessment revealed a heart rate of 96 bpm and a blood pressure of 150/111 mmHg. He was alert and oriented with a Glasgow Coma Scale score of 15. However, we observed that the patient had a locked jaw and was unable to close his mouth. The patient also had tenderness of the right shoulder, and the range of motion of both his hips was reduced. His creatinine and urea levels were significantly elevated, and venous blood gas analysis revealed high anion-gap metabolic acidosis with hyponatremia, hypokalemia, and severe hypocalcemia. Therefore, he was moved to the resuscitation area of the ED for urgent hemodialysis (HD). The patient was consciously sedated, and his jaw was reduced using the traditional technique. Two attempts at closed shoulder reduction proved unsuccessful (Figure ). A central venous catheter was inserted into the right femoral vein, electrolytes were administered, and HD was started. The patient still had a complaint of bilateral hip pain; therefore, pelvic X-ray was performed. To our surprise, the X-ray showed bilateral femoral neck fractures (Figure ). Given the unexpected significant finding of bone injuries, we requested pan-CT to rule out other injuries. The pan-CT showed a single rib fracture and bilateral displaced femoral neck fractures (Figure ) but was otherwise unremarkable.
The patient was admitted to the surgical ICU, and the right shoulder dislocation was reduced under conscious sedation (Figure ). He underwent Permcath insertion, 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 77-year-old lady presented to the emergency room with acute onset left hemiparesis.
The patient had a history of hypertension and Chronic Obstructive Pulmonary Disease (COPD) but was otherwise healthy and functionally independent. She was being treated with 2 antihypertensive medications: 5 mg amlodipine OD and 50 mg valsartan OD.
The patient had experienced a slight weakness in their left arm and left leg on the morning of admission but had not contacted the emergency services before a gradual worsening of the symptoms later that same day.
The paramedics found the patient to be awake with a left hemiparesis, left facial palsy and a mild dysarthria. The paramedics suspected an acute onset stroke, and the patient was admitted to our hospital as a stroke code.
Upon physical examination in the emergency room the patient had an National Institutes of Health Stroke Scale (NIHSS) of 11. The temperature was 36.7 °C, pulse of 90 beats per minute and blood pressure of 169/71 mm Hg. The initial prehospital oxygen saturation was 65% while on room air, subsequently increasing to 92% while breathing oxygen through a nasal cannula at a rate of 3 liters per minute. The respiratory rate was 22 breaths per minute.
An arterial blood gas obtained while the patient was receiving high-flow oxygen through a nasal cannula at a rate of 3 liters per minute showed a pH of 7.27, a partial pressure of carbon dioxide of 81 mm Hg (10.8 kPa), a partial pressure of oxygen of 60 mm Hg (8.0 kPa), a bicarbonate of 37.3 mEq per liter and a base excess of + 10.5 millimoles per liter.
A CT scan was performed including a pre- and intra- cerebral angiography. A subsequent perfusion scan was also performed. The CT examination was performed using the Siemens Somatom Definition Flash using GE Healthcare Omnipaque intravenous contrast and standardized protocols for

[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 Caucasian man was admitted in 2012 to the Surgical Department of Iaşi Regional Institute of Oncology with a painless tumor mass of 6 cm in the left breast. The tumor had grown increasingly fast in the past 4 weeks and clinical examination identified inflammatory signs and skin invasion (Fig. ). No lymph nodes were identified in the left axillae or in other regional stations. The patient had no relevant medical, family, or psychosocial history. The most important diagnostic concern was to determine the benign versus malignant nature of the tumor, which is why we first performed a breast ultrasound that revealed a complex cystic tumor mass of 60 mm in the left breast, with both anechoic (cystic) and echogenic (solid) components, with ill-defined margin. The anechoic component was dominant and there was a clear invasion of the skin.
After complete clinical staging, which showed no axillary lymph nodes and no systemic extension (cT3N0), the case was discussed in the multi-disciplinary tumor board (MDT). Because of the cystic character of the lesion, we decided to perform surgical resection and extemporaneous evaluation, rather than a tru-cut biopsy. The extemporaneous assessment showed a solid (invasive) papillary intracystic carcinoma which is a rare tumor composed of circumscribed large cellular nodules separated by bands of fibrosis.[ At this point, the surgeon decided to complete the resection and not to perform axillary lymph node dissection.
The histological report described 1 nodule with focal infiltrative margins, with a biphasic aspect due to the presence of 2 populations of cells. The lesion was composed of epithelial cells with oval-shaped nuclei, minute nucleolus, and eosinophilic cytoplasm. The epithelial cells were cuboidal or cylindric, and they were arranged in glandular-like structures, distorted, and compressed by the myoepithelial cells that were spindle or polygonal in shape with clear cytoplasm.
In some areas of the tumor, the myoepith

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


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

[User]
RADIOLOGY NOTE:
A 1-year-old girl presented with a large growth protruding from her oral cavity, gradually increasing in size since 5 months of age. Her feeding was poor. On examination, she weighed 3.6 kg (<3rd centile). A lobulated, spherical mass, 8 cm in diameter, was seen protruding from the oral cavity and seemed to arise from the maxilla. The mass was bony hard, immobile, nontender, and pigmented. It was an exophytic mass of bone with desiccated mucosa covering it. X-ray suggested dense calcification within the mass. Computed tomography (CT) scan revealed a large bone forming exophytic mass arising from the maxilla []. The initial plan was to amputate the exophytic portion for tissue diagnosis and to have satisfactory mouth closure. As intubation was difficult, a tracheostomy was done to secure the airway. At surgery, the mass was found to be made of extremely dense bone and required a powered instrument to amputate. A central area within the mass had a grayish soft fleshy tissue speckled with pigment. The solid mass was enucleated and sent for biopsy. A palatal flap was used to cover the bony defect. Oral feeding was rapidly re-established and tracheostomy was removed after 2 weeks. The biopsy showed a biphasic tumor with tubular or alveolar pattern with large melanin-containing cells with abundant cytoplasm and pale nuclei suggestive of MNTI. As the lesion seemed to arise from the right maxilla, a maxillectomy was planned and the reconstruction post resection was a challenge. The poor nutritional status, risks, and potential for poor cosmetic outcomes led to significant delays. During this time, the baby did really well. A review 3 months later showed no progression of the lesion. A plain X-ray showed a remarkable degree of bone remodeling toward normal. A CT scan 6 months later showed completely normal facial bones with no recurrence []. The child was counseled regarding the risk of recurrence and was kept on close follow-up

[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 13-year-old girl presented to the Emergency Department with a 1-week history of coryzal symptoms and severe headaches. In the week leading up to her presentation the headache intensity had continued to increase up to the point where she could barely move. The presence of bilateral periorbital swelling, particularly on the right side, and reduced range of motion indicated an emergency ophthalmology review within 24 hours.
The patient had a past medical history of recurrent headaches and dizziness which first presented 5 months ago, however an MRI brain taken during this period showed no pathological changes and at the time she was discharged.
The provisional diagnosis at the stage of initial presentation included preseptal or orbital cellulitis most likely secondary to pansinusitis, with a differential diagnosis of subperiosteal or orbital abscess.
She was admitted and started on intravenous antibiotics on admission: ceftriaxone, vancomycin, and metronidazole. The initial ophthalmology review indicated preserved optic function; however, this was associated with a significant soft tissue swelling along with reduced color vision. Both were seen in conjunction with diplopia and painful eye movements, which warranted close monitoring of her vision and further radiological investigation.
As shown in below, a CT scan of the head and sinuses indicated a 20 × 18 × 3 mm right subperiosteal orbital collection insinuating around the superior orbital margin, extending posteriorly into the orbit for approximately 14 mm. Furthermore, a right frontal intracranial, extradural collection, with a depth of approximately 5 mm was noted.
These findings were consistent with a diagnosis of pansinusitis and orbital cellulitis with abscess formation. Due to the presence of the abscess without apparent involvement of the cavernous sinus, a diagnosis of orbital abscess was made (Stage 4 as per Chandler’s Classification).
The results of a brain and sinus MRI in the subsequent week showed a re

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


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

[User]
RADIOLOGY NOTE:
The patient was an 87-year-old male in whom a mass accompanied by pressure pain was found in the left inguinal region (axillary lymph nodes) and who subsequently visited a hospital in Seoul on November 29, 2015 where he received PET-CT and CT scan as well as aspiration and biopsy of the bone marrow and right iliac crest. The PET-CT and CT scan results showed hypertrophy of multiple lymph nodes. In the subsequent bone marrow finding, a number of cells were in metaphase and, therefore, the metaphase quality was adequate. In the analysis of 20 cells in metaphase, no clone with chromosomal abnormality was observed and the karyotype was normal. Therefore, it was concluded that there was no evidence of bone marrow involvement of the lymphoma. Finally, the patient was diagnosed with atypical peripheral CD4 T cell lymphoma (follicular helper type, stage IIIA) and was recommended to receive chemotherapy at the hospital in accordance with the standard treatment guideline. However, first of all, his guardian and medical doctor suggested that the patient was unlikely to withstand chemotherapy, considering his age. Secondly, the patient was not within the normal range of standard body weight. Thirdly, the patient rejected chemotherapy due to unbearable pain and poor appetite and general weakness. Subsequently, the patient visited our hospital on December 23, 2015. At that time, there was no chief complaint caused by the diagnosis, and the patient complained of low energy and indigestion, among others. In the images he brought to our hospital, we found abnormal lymph node hypertrophy in the left intracarotid lesion, both cervical level II, left supraclavicular, both axillar, both mediastinal and interlobar, common hepatic artery, aortocaval, left iliac chain, right external iliac and inguinal lymph nodes. The blood pressure of the patient was 127/84 mm Hg, his temperature was 36.0°C, his pulse rate was 91, his respiration rate was 18, his weight was 47.95 kg

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old man was referred to our outpatient clinic presenting with a small mass in his right nasal cavity. The lump, which the patient first noticed 5 years ago, had been growing insidiously over time and by the time of presentation had become visible at the right anterior naris. The patient did not complain of any symptoms but sought consultation as his wife was concerned by the cosmetic appearance of the mass.
Examination revealed a large firm mass arising from the right side of the anterior nasal septum with approximately 0.5 cm attachment to the anterior cartilage of the septum. The left and right nasal cavities were otherwise unremarkable. Clinically, the mass had the appearance of a papilloma confined to the nasal cavity with an attachment to the septum only and therefore further imaging was not undertaken. The differential diagnoses considered at the time of presentation were: nasal polyp, squamous papilloma or inverted papilloma.
The patient subsequently underwent excisional biopsy of the right nostril mass under general anaesthetic using a circumferential subperichondrial incision with a small margin. Intraoperatively, the mass had the macroscopic appearance of a 0.5 cm × 2 cm × 2 cm calcified nodule. Due to a small 0.5 cm base, subsequent healing was achieved by secondary intention aided by the routine application of topical antibacterial cream. Histopathological analysis showed the nodule to contain cartilage and aneurysmal bone covered in stratified squamous epithelium with keratinisation (Figs. and ). Histopathological diagnosis was made using a haematoxylin & eosin stain. These findings were consistent with a diagnosis of a nasal chondromesenchymal hamartoma.
The patient was followed up in clinic and was discharged after 2 years having shown no signs of recurrence. Furthermore, a telephone interview was conducted 4 years post operation and the patient reported no recurrence of the nasal mass. He confirmed that he had no post-operative complication

[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 male who had a history of liver cirrhosis was referred for evaluation of a pain, swelling, and erythematous changes of the anterolateral aspect of his left leg. His symptoms started a month ago without any specific trauma. He had a history of open reduction and internal fixation performed for a tibial plateau fracture that occurred when his left knee was pinned under a tree 18 years ago. He had sciatic nerve injury at the time of the fracture. He had an open reduction and internal fixation as well as a stent insertion in the femoral artery 8 years after the initial trauma due to a distal femur fracture and femoral artery rupture. At that time, a widespread radiopaque mass was observed on plain radiographs of left leg, and obstruction of popliteal artery with abundant collateral circulation was observed on angiography. The patient had no difficulty with his daily life functions until the aforementioned symptoms appeared, except for limited motion in the ankle and toes and sensory reduction in his foot owing to the sciatic nerve injury.
After admission, the patient maintained with a long leg splint. Two weeks after the admission, the erythematous changes in the left leg localized to the anterior aspect in the middle of the leg and formed a fluid-filled, erythematous mass. A draining sinus had developed on the erythematous mass spontaneously and a thick fluid with a chalk-like material was discharged through the shiny skin via the sinus. The range of motion of the knee was 0 degrees to 100 degrees of flexion; ankle dorsiflexion was 0 degrees, ankle plantar flexion was 5 degrees, and all of the toes had clawing deformity. As for the motor strength of the ankle, the dorsiflexion was grade 0 and plantar flexion was grade 3. He had no sensation in the first web space and on the medial aspect of the foot, and had sensory reduction in the lateral, dorsal, and plantar aspects of the foot, in order of decreasing sensation.
The radiographs of the left leg taken 10

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male patient was admitted to the pain department due to cancer pain in the right lower abdomen and inguinal area. He was diagnosed as having hepatobiliary adenocarcinoma with retroperitoneal metastasis. He had received multiple anti-tumor treatments during the past 3 years, and had had a pain in the right side of the abdomen for 8 months. Imaging revealed enhanced soft tissue thickening around the right paraspinal site at T11–12 (Fig. A). Thus, the patient underwent paravalvular palliative radiotherapy at a dose of 25 Gy. However, the analgesic effect of radiotherapy was negative. He complained about a persistent dull, burning pain and soreness accompanied by paresthesia in the T11–12 dermatome, with an average VAS score of 6 points (8 points at its worst, 3 points at its least), and an average DN4 of 6 points. The patient received oxycodone (120 mg/day) and pregabalin (300 mg/day), but his pain scores were not reduced as a result of the treatment. In addition, his sleep quality was severely affected and he could not even lie on his right side. According to the diagnostic criteria of the expert consensus, we diagnosed the patient as having refractory cancer pain. Then, this case was introduced through our multidisciplinary channel, and further analgesic strategy for this patient was developed by multidisciplinary decision making and a comprehensive informed consent. We decided that the neuraxial neurolysis could be one of the best next analgesic approaches for him because the metastasis was indenting the thecal sac at the T12 level, which is a potential contraindication for intrathecal pumps. In addition, further palliative radio- and chemotherapy or surgery were infeasible according to the experts’ decisions. However, we are still concerned about the outcome of the neurolytic blocks because the tumor invades around the block target. Therefore, an ultrasound-guided paravertebral block with 1% lidocaine in 5 mL was first performed. Fortunately, the

[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.