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

[User]
RADIOLOGY NOTE:
This patient is a 68-year-old female, known case of hypertension for the last eight years, presented to us with complaints of anterior neck swelling for about 40 years which had gradually started increasing in size for the last four years. She developed progressive difficulty in swallowing and breathing for the last three months. On examination, there was a presence of large neck swelling, multinodular, which moved on deglutition, with lower limit of swelling not palpable. Prominent dilated veins were appreciated on the neck. A computed tomography scan was done which showed enlarged thyroid with multiple internal calcifications and retrosternal extension up to the level of ascending aorta with multiple collateral vascular channels around mass lesion in anterior mediastinum (). She also underwent total thyroidectomy, sternotomy, and excision of mass lesion. The intraoperative findings were enlarged multinodular goiter with thyroid gland reaching the manubrium. The mediastinal component was also large and separately capsulated from cervical component, extending up to the arch of aorta and superior vena cava with compression of brachiocephalic vein (). The mass was carefully dissected from the above vessels. Specimen was sent for histopathology. Postoperatively, the patient remained well. She was given intravenous analgesia and deep venous thrombosis prophylaxis. She developed respiratory distress on 2nd post-op day, and a chest X-ray showed elevation of the right hemidiaphragm (most likely due to iatrogenic right phrenic nerve injury) and right lower lobe atelectasis and hence was shifted to the intensive care unit for observation. She was managed conservatively with chest physiotherapy, nebulizers, and application of BIPAP. She responded to supportive therapy and recovered well. She also developed asymptomatic hypocalcaemia and was managed with both intravenous and oral replacement. She was discharged from the hospital on eighth postoperative day.
She did well on fol

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old male with a history significant for alcohol abuse presented to our facility with a 3-week history of nausea, vomiting and abdominal pain. Patient had been discharged from our facility approximately 7 weeks earlier after initially being transferred from another facility after respiratory failure secondary to aspiration pneumonia; at the time of transfer from the outside facility patient was found to have elevated amylase and lipase; however, CT did not show any signs of pancreatitis at that time.
Upon readmission to our hospital another CT was done which showed numerous fluid collections surrounding the pancreas with enhancing rims, representing numerous pseudocysts. It was noted that several of these pseudocysts interconnect. One was noted to measure 8.7 × 10.1 × 12 cm in the undersurface of the body and tail of the pancreas, another measuring 7.8 × 5.9 cm extending towards the lesser curvature of the stomach, and another measuring 9 × 5 cm lateral to the head of the pancreas. CBD was also enlarged at 12.5 mm. Because of the enlarged CBD an MRCP was then ordered which showed some narrowing in the intra-pancreatic portion of the CBD, likely secondary to the inflammatory process secondary to pancreatitis.
Patient then underwent EUS/ERCP with cystogastrostomy. EUS evaluation confirmed what was seen on prior imaging. We then proceeded with ERCP. After introducing the ERCP side-viewing scope into the stomach, pus was seen coming out of a fistula in the antrum. We then passed a jag wire into the cyst using a hydratome. A cystotome was then introduced to form a tract. A 15 mm × 6 cm balloon was then introduced and the tract was dilated. Finally a 10 mm × 4 cm fully covered SEMS was placed. The pseudocyst was irrigated with 200 cc of saline. Large amount of pus drained into the stomach during the procedure. The patient’s pain improved the following day, patient was started on a clear liquid diet

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

[User]
RADIOLOGY NOTE:
49-year-old gentleman presented to the outpatient department of Head and Neck Oncology services of our institution with complaints of a large lesion in the oral cavity for a duration of one month. The patient also complained of dyspepsia, generalized weakness, malaise and loss of appetite. On examination, the general condition of the patient was poor in view of cancer related cachexia. He had a soft tissue lesion of the upper alveolus extending from the right upper canine to the right superior retro-molar trigone involving the entire upper alveolus and extending into the upper gingivobuccal sulcus (). The mass bled to touch but was non tender. Medially, it extended onto the hard palate for about half a centimetre. On abdominal examination, a mass was palpable in the right hypochondrium extending to the epigastrium. Rest of the abdomen was soft and non-tender. On further evaluation with a contrast enhanced computed tomography of the thorax, abdomen and pelvis, a 7×7×7 cm hypodense mass was noted in the segment VII and VIII of liver, which showed enhancement on arterial phase with washout on venous phase (). The mass was infiltrating the hepatic capsule with a peritoneal deposit abutting the diaphragm and muscles of the chest wall. Enhancing tumour thrombus was noted in the distended main portal vein and its branches. On upper gastrointestinal endoscopy, no varices were noted. Serum alpha fetoprotein was 2440 ng/ml. Liver function tests were normal. He was detected to be positive for Hepatitis B surface antigen. Blocks of the alveolar growth biopsy done elsewhere were reviewed at our hospital and was found to be a metastatic deposit of hepatocellular carcinoma positive for HepPar 1, arginase and focally positive for Glypican 3 whereas negative for CK7, p63, and DOG1 on immunohistochemistry (IHC) (). An ultrasound guided biopsy of the liver lesion was suggestive of hepatocellular carcinoma, positive for Glypican 3 on IHC

[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 Thai male patient, aged 46 years, presenting with chronic abdominal pain for 3 months. He frequently visited hospital in 3 months about chronic abdominal pain with unidentified cause—recurrent hyponatremia. He underwent upper gastrointestinal endoscopy and ultrasonography of upper abdomen but showed within normal limit of both examinations, so he was treated as chronic dyspepsia and symptomatic treated about hyponatremia but he still not improves. In admission day, he re-visited hospital with abdominal pain and his blood chemistry showed hyponatremic hypokalemic metabolic alkalosis, so gastric outlet obstruction was provisional diagnosis. Saline loading test showed delayed gastric emptying time. Patient was sent for computed tomography of abdomen because previous upper gastrointestinal endoscopy showed normal study. Computed tomography resulted in 5 cm long, enhanced wall thickening at duodenojejunal junction in left lower abdominal region, abutting adjacent sigmoid colon with preserved fat plane separation and markedly dilatation of the proximal duodenum and stomach is detected as in Fig. . The diagnosis of obstructed proximal jejunum was made and exploratory laparotomy was decided. In operative field, a 5 cm Cauliflower mass at proximal jejunum, 15 cm distal to ligament of Treitz, causing proximal duodenal dilatation and distal small intestines collapse was found as in Fig. . No liver, omental or peritoneal nodule was found. Radical segmental proximal jejunal resection (with 5 cm proximal and distal margins, with mesentery that vascular supplied resected jejunal segment) with primary small intestinal anastomosis was done. Operative time was 48 min and estimated blood loss was 50 mL. After operation, patient fully recovered but superficial surgical site infection was found and pus culture showed Proteus mirabilis and Escherichia coli. Pathologic examination showed well differentiated adenocarcinoma of jejunum with extension into perienteric fatty tissue, free all

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old woman experienced choking, chest tightness, and back pain.
The patient had experienced choking and chest tightness 2 years prior without any causation and had experienced back pain 1 year ago. Recently, the above symptoms had gradually been aggravated. The patient underwent gastroscopy that showed normal findings.
The patient had no other past illness except choking, chest tightness, and back pain.
The patient had no remarkable personal and family history.
The physical examination was unremarkable.
The patient was previously healthy and showed no abnormalities in the laboratory examinations.
CT revealed a soft-tissue mass approximately 4.2 cm × 3.7 cm × 2.6 cm in the right posterior mediastinum, for which the boundary between some areas and the esophagus was unclear, and the trachea was also compressed (Figure ). In the enhanced CT scan, a contrast agent was injected into the right upper limb. In the early arterial stage, the superior vena cava and the azygos vein arch were filled with the contrast agent, and the azygos vein arch was nodular. The density did not decrease in the venous phase, and there seemed to be a blood shadow during coronary reconstruction. The posterior mediastinal tumor showed delayed enhancement, and its internal density was not homogeneous. No definite filling defect was found. The tumor was connected to the superior vena cava, whose degree of enhancement was the same as that of the superior vena cava, and the boundary between the tumor and the esophagus was clear. The azygos vein valve was observed. The esophagus was compressed by an azygos vein aneurysm (Figure ). These findings indicated that there was a giant hemangioma originating from the azygos vein arch.
The tumor was dissected, which revealed enlarged and dilated thin-walled blood vessels with intact endothelial cells on the wall, in which the medial muscle layer was thinned; a large number of red blood cells were found outside the lumen. Multiple red

[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 years old Iranian woman admitted in our hospital due to progressive solid dysphagia and 10 kilogram weight loss in the past three months.She had a history of heart valve replacement surgery at 3 years ago. Physical examination revealed mild temporal muscle atrophy and abnormal heart sound secondary to her known valvular heart disease. Vital signs, lungs, abdomen, pelvic, central nervous, and the musculoskeletal examination were all normal. The patient's laboratory findings including blood cell count, erythrocyte sedimentation rate, and kidney and liver function tests were also normal.
As the patient history was suggestive for an esophageal malignancy, an upper gasteroenterointestinal endoscopy was carried out. Endoscopy revealed a short (two centimeters) circumferential symmetrical smooth narrowing in the mid part of the esophagus (from 25 to 27 cm of incisors); the gross appearance of this stricture was normal suggesting external compression. The gastroscope passed through the stricture easily. Other part of esophagus, stomach, and duodenum were normal. Barium swallow confirmed the endoscopic findings but didn't reveal more diagnostic information ().
Contrast Computerized Tomography (CT) scan of the chest was performed for further clarifying the nature of the lesion. CT scan revealed an abnormal Soft tissue density with irregular borders in the posterior mediastinum that was encircling the carina, left main bronchus, esophagus and the mid thoracic aorta ().
Due to the external pressure the lumen of the involved segment of esophagus did not appear in CT scan. The upper segment of the esophagus proximal to the lesion was dilated and had air-fluid (oral contrast) level. Other parts of thorax including the lungs, pleura, ribs, sternum, and thoracic spines were normal.
The patient had no respiratory symptoms but since mediastinal lesion seen on the CT scan was taking over the left bronchus and was in close contact to it, bronchoscopy was performed; there was fine m

[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 female presented with a history of breast lump for past 6 months. There was a history of rapid increase in size with pain and ulceration for 1 month. She had lost 6 kg of weight in 2 months. There was no history of breast malignancy in the family. On examination, left breast showed a huge foul smelling fungating mass with absent nipple and areola, occupying almost entire left breast. Axillary lymph nodes were palpable. Trucut biopsy elsewhere reported as phyllodes tumor. Mammogram was not done as the tumor was ulcerated. Positron emission tomography scan revealed large hypermetabolic mass in the left breast and few hypermetabolic lymph nodes in the left axilla. There was no evidence of metastasis elsewhere in the body. With the diagnosis of phyllodes tumor probably malignant with skin ulceration, mastectomy with axillary dissection was done.
Specimen revealed a large tumor ulcerating and erupting out through the skin. Nipple and areola were absent. The tumor measured 15.5 cm × 13 cm × 7 cm with lobulated margins. An another firm tumor measuring 2.5 cm with spiculated margin was seen at the periphery of large tumor, abutting it []. Histology of the larger tumor showed stromal predominance occupying a low power field [], increased cellularity, spindle cells with moderate atypia, and increased mitosis [] of 13/10 high power field (HPF). Scattered ducts in clefts and leaf like pattern were seen with double layered epithelium. Tumor was ulcerating the skin with surface necrosis. At its periphery, an epithelial tumor is seen without transition zone in between [], consists of cells in tubules and trabeculae with stromal desmoplasiar []. Moderate atypia increased mitosis, and lymphovascular emboli were noted. Eleven axillary lymph nodes were involved by invasive carcinoma. A diagnosis of malignant phyllodes tumor with ulceration with coexisting invasive carcinoma of no special type was rendered. She was currently on

[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 man was referred to our hospital for treatment of a rectal SMT detected during a medical checkup at another hospital. Digital examination of the anus and rectum revealed a 20-mm elastic hard tumor palpable on the right and ventral sides of the anal canal and located 2 to 3 cm proximal to the anal verge. Laboratory examination showed no elevation of either carcinoembryonic antigen or cancer antigen 19-9. Colonoscopy showed a 20-mm SMT in the anal canal (Fig. ). Abdominal computed tomography (CT) showed a 20-mm cystic tumor on the right site of the lower rectum with no evidence of lymph node or distant metastases (Fig. ). Magnetic resonance imaging (MRI) also showed a 20-mm cystic tumor on the right site of the lower rectum (Fig. ). These findings strongly suggested a benign cyst in the anal canal; therefore, the patient underwent trans-sacral resection for precise diagnosis of the tumor. The pathological diagnosis of the resected tumor was a mucinous adenoma with high-grade dysplasia (Fig. ) with negative surgical margins. The patient was observed in ambulatory practice. Follow-up CT and MRI 14 months after surgery showed a new cystic lesion near the site of the removed tumor (Fig. ). To evaluate whether the new cystic tumor was a recurrence, the patient underwent trans-sacral resection of the cystic tumor again. Pathological examination of the second resected tumor revealed that the tumor was a mucinous adenocarcinoma of the lower rectum (Fig. ) with a possible remnant tumor at the local site. After providing sufficient informed consent, the patient underwent anal sphincter-preserving intersphincteric resection (ISR) with partial resection of the external sphincter along with prophylactic lymph node dissection. Pathological examination showed that the tumor cells were located at the anal gland under the mucosa of the anal canal and that these cells produced mucin and fibrosis (Fig. ). Immunohistochemical analysis showed that the tumor cells were positi

[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-year-old Caucasian woman, a mother of three sons, at 30 days post-partum after a full-term pregnancy without any complications and concluded by a vaginal delivery, suffering from diabetes on oral antidiabetic medication, presented to the emergency department with left flank pain with hematuria of one week’s duration. A clinical examination revealed an alert patient, febrile at 38°C, with blood pressure of 158 over 67mmHg, heart rate of 90 beats per minute, respiratory rate of 20 breaths per minute, suffering from pain in the left flank (visual analog score (VAS) = 5), this pain was exacerbated by palpation, which found lumbar contact. Diagnostic studies in the emergency room revealed a urine analysis with 104 white blood cells (WBCs), gross hematuria, and a C-reactive protein level of 88. Her blood cell count revealed anemia at 9g of hemoglobin; blood electrolytes and renal function with serum creatinine levels were normal.
An abdominal ultrasound scan showed discrete pyelocalyceal cavities dilation with a slightly enlarged left kidney and without visible urinary obstruction. A CT urography and angiography scan was performed and showed an ectatic left renal vein, seat of a large hypodense thrombus extending from the segmental renal veins to the inferior vena cava, with a large heterogeneous and hypodense region located in the medium and lower poles of the left kidney without urinary tract dilatation or tumoral lesions; this aspect concluded in a perfusion abnormality (renal venous infarction) (Figures
 and
).
Anticoagulation heparin therapy was started and our patient was admitted to a medical center for further investigations. Her proteinuria and blood cultures did not show any abnormalities, and her serum albumin levels were normal. The thrombophilia assessment, with protein C or S deficiency, mutation of coagulation factors II and V, lupus and antiphospholipid antibody syndrome (APS) tests, were negative. The outcome was favorable with disappearance of pain

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old female underwent abdominal hysterectomy with bilateral salpingo-oopherectomy 2 years and 3 months ago. Histopathological examination of the biopsy specimen showed UPSAC. Adjuvant chemotherapy was given after the abdominal hysterectomy. The patient's Glasgow Coma Scale score was 12/15 at the time of admission to our hospital. She presented with a 20-day history of headache and left hemiparesis, and she could not walk or use her left arm and left hand. Cranial magnetic resonance iaging (MRI) showed three lesions; two were located in the parenchyma of the cerebellum and had perilesional edema. but had no shift effect or obstruction on the fourth ventricle and the third lesion was located in the right frontobasal frontal lobe, and caused a large hemispheric edema and subfalcine herniation []. All the three lesions exhibited contrast enhancement following gadolinium injection. The lesions’ characteristics are shown in Figures -.
The patient underwent frontal craniotomy with gross total extirpation of the tumor located in the right frontal lobe on September 12, 2012. There were no surgical complications, such as bleeding or adhesiveness adjacent to the brain tissue during the removal of the tumor. The other two lesions located in the posterior fossa were left untouched because they had no mass effect. Histopathological examination of the biopsy specimen was consistent with metastatic UPSAC [].
The patient was able to walk with the assistance of a walker, and underwent follow-up cranial computed tomography (CT) 2 days postsurgery [], which showed that there was no residual tumor in the frontal lobe, the midline shift and subfalcine herniation improved, and less edema than presurgery. The patient was followed-up for 9 months postsurgery and via telephone (last contact on May 14, 2013) reported that she was able to walk independently, and use her left arm and left hand without any difficulty, and that she had undergone 10 days whole cranial radiotherapy and che

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

[User]
RADIOLOGY NOTE:
A 23 year old married female presented in the surgical OPD with complaint of pain in abdomen for past 1–2 years, and loss of appetite and vomiting post meals for 6 months. On observation, the patient had thin built and appeared pale with body mass index (BMI) of 13.3 kg/m2. On clinical examination, she was found to have a 7 × 3 inches large lump in the epigastric region which was freely mobile. Recent blood investigations revealed Hemoglobin to be 11.6 gm/dL with no electrolyte abnormalities. USG epigastrium revealed a well-defined mixed echogenic mass lesion predominantly hyperechoic in echotexture of size ~ 65 × 75 mm. A contrast enhanced CT scan of whole abdomen was performed which revealed over-distended stomach and large heterogeneous intraluminal mass with mottled appearance and small air pockets. Smooth wall thickening of stomach was also seen. A contrast enhanced CT scan of whole abdomen was performed which revealed over-distended stomach and large heterogeneous intraluminal mass with mottled appearance and small air pockets. Smooth wall thickening of stomach was also seen []. On interviewing, her mother mentioned about patient's habit of eating her hair since the age of 3 years. Hence, a diagnosis of trichobezoar was formed and patient was taken for surgical treatment. Laparotomy with gastrotomy and removal of trichobezoar under general anaesthesia was performed. Laparotomy with gastrotomy and removal of trichobezoar under general anaesthesia was performed. []. Postoperatively, patient was sent for psychiatric consultation.
On psychiatric evaluation, patient reported history of eating hair since childhood. She would keep hair in mouth when stressed but would not realize that she was swallowing the hair too. Parents made her aware about her hair eating behavior when she was around 6 years old. This behavior would increase whenever she was scolded or had an argument with her family. She also provided history of fainting always following stress

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

[User]
RADIOLOGY NOTE:
We report the case of an 83-year-old female patient with a previous history of breast surgery with axillary dissection in 1997, followed by adjuvant chemotherapy due to invasive ductal carcinoma of the left breast. The family history was negative for neoplastic diseases, both mammary and belonging to the gastrointestinal tract. Oncological follow-up was negative, and the patient considered disease-free for almost 15 years. During 2012, an X-ray of the spine, performed for the appearance of lumbar pain, revealed the presence of vertebral metastases. The patient was treated with radiotherapy and spinal stabilization. In addition to this, a deep venous thrombosis episode was reported in 2017, and treated with anticoagulant therapy. In the same year, multiple myeloma associated with mild chronic kidney disease was diagnosed. Neither myeloma nor kidney disease had requested specific treatments.
In July 2018, the patient was admitted to the emergency department for sepsis and an episode of acute kidney failure, anuria and fever. Right-upper quadrant abdominal pain triggered by food intake and abdominal tenderness was also present, placing the diagnostic suspicion of biliary sepsis due to acute cholecystitis.
This condition was conservatively treated with intravenous antibiotic therapy with renal adjusted dose of piperacillin-tazobactam and hemodialysis for two weeks. Subsequently, kidney function improved, diuresis had an increasing glomerular filtration rate and sepsis was cured. Abdominal CT-scan performed during this hospitalization had shown a diffuse thickening of the gallbladder’s wall associated with stones as well as pericholecystic fluid (
). The CT-scan didn’t highlight pathological findings on the liver, such as enlarged regional nodes. A dilated common bile duct with the presence, in its proximal portion, of tenuously hyperdense material was described.
Endoscopic ultrasound was performed, and it confirmed the presence of both gallbladder and common duct stones

[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:
Written informed consent was obtained from the patient for this case report.
A 57-year-old male presented at another hospital with hoarseness that had gradually worsened over a 4-year period. No pain was present. A laryngeal flexible-endoscopy examination revealed a 5-mm diameter red tumor at the anterior commissure of the larynx and a swelling of the right vocal fold. Resection of the red tumor and biopsy of a white submucosal tumor on the right vocal fold were performed by means of laryngeal microsurgery. Histopathological examination indicated that the possibility of malignancy could not be excluded. The red tumor then recurred at the same site 4 months after the resection, and the patient was referred to our hospital. Neither neurological signs nor skin signs such as cafe au lait spots were found. The patient had never received radiation therapy and had no co-morbidities. He had a history of smoking 20–40 cigarettes a day and drinking 500 ml of beer daily.
At the initial visit to our hospital, a laryngeal flexible-endoscopy examination showed a red tumor on the anterior commissure of the larynx and a diffuse swelling of the right vocal fold (). Immunohistochemical examination of the previous surgical specimen indicated the possibility of MPNST because hyperchromatic spindle cells in which MIB-1 labeling index was 20%, P53 protein was overexpression and S100 protein was sporadically positive were identified (Table). In addition, Sox10, CD34 and p16 protein expression was negative. Removal of the recurrent red tumor and several biopsies at different sites in the white submucosal tumor of the right vocal fold were performed again (). The removed red tumor measured 15 × 9 mm. The recurrent red tumor and associated swelling on the anterior commissure of larynx, as well as the midmembranous vocal fold lesions (biopsy 2 in ), were high-grade MPNSTs immunohistochemically; the lesion on the ventral side of the right posterior vocal cord (biopsy 4 in ) was less malignant

[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:
During preoperative preparation for posterior cervical decompression in a 66-year-old Caucasian man, an anesthesiologist used ultrasound to access our patient's right internal jugular vein (IJV) to place a venous catheter. After what was presumed to be successful ultrasound-guided venous access, a 7-Fr triple-lumen catheter was inserted. The anesthesiologist noted an arterial waveform arising from the catheter tracing. The catheter was left in situ out of concern that removing it could lead to uncontrollable bleeding, without the ability to directly compress the arterial puncture. The surgical procedure was postponed.
Our patient was transferred from the operating room to the angiography suite and remained under the general anesthetic. Angiography via the misplaced catheter revealed a flow of contrast in the aortic arch because of the arterial position of the catheter. The decision was made to perform a formal angiogram via his femoral artery to better visualize the catheter entry point into his arterial system. Access through his femoral artery was achieved. An angiogram showed the entry point of the misplaced catheter in his proximal right subclavian artery, just beyond the origin of his right vertebral artery (Figure ). An angiogram of his right vertebral artery revealed a dominant vessel with prominent spinal arterial feeders. A consultation with the cardiothoracic surgeon revealed that, despite the proximal entry point of the misplaced catheter into the subclavian artery, the surgeon would not be able to directly visualize or palpate the artery during surgical exploration. Placement of a covered stent was an attractive alternative. An analysis of the images acquired determined that the dominant right vertebral artery would probably be occluded by the placement of a covered stent and so it was determined that our patient was not a good candidate for the safe placement of a covered stent.
The decision was made to remove the catheter and close the puncture site wi

[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 PLS was scheduled for a left breast simple mastectomy with axillary level I lymph node dissection for recently diagnosed ductal carcinoma in situ. The patient's PLS symptoms included significant deconditioning and generalized muscle weakness requiring wheelchair use, generalized muscle spasms, and dysarthria. At the time of surgery, the patient had no home oxygen requirement. Her documented peak cough flow rate (measure of respiratory muscle weakness) was 70 liters per minute (indicating ineffective cough). Her comorbidities included an increased body mass index (29.9) and hypertension. Preoperatively, the patient's heart rate was 106 beats per minute, blood pressure 143/73, respiratory rate 20 breaths per minute, and oxygen saturation 95% on room air. EKG and chest XR were within normal limits. No pulmonary function tests were available prior to surgery. The patient's pulmonologist and primary medical doctor strongly recommended avoidance of general anesthesia for the surgery due to concerns about increased risks of prolonged mechanical ventilation and postoperative respiratory complications related to her condition. During the preoperative visit, the patient refused general anesthesia and requested a minimally invasive approach. After discussing with the patient and surgery team all the risks and potential complications associated with general anesthesia, including respiratory depression, postoperative mechanical ventilation, and pulmonary complications, the patient's medical condition, anesthetic requirements for the procedure and alternatives, plan was made to proceed with a peripheral nerve block and multimodal monitored anesthesia care. Discussion was also held regarding general anesthesia not being used as a backup plan and aborting the procedure in case of inadequate anesthesia or patient discomfort.
For the thoracic paravertebral block placement, the patient was positioned sitting upright with the arms resting on a Mayo

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

[User]
RADIOLOGY NOTE:
A 7-year-old boy was brought with a history of fever of four days duration with cough and cold. The boy was earlier treated with an injection outside by a private practitioner. On examination, he was toxic with high fever of 102° F, congestion of eyes and throat with maculopapular rash over his face and neck []. He was tachypneic with bilateral crepitations and decreased breath sounds in the right infrascapular region. He was admitted and treated with injection ampicillin for the respiratory infection. On the next day, the rashes increased and appeared on the chest and upper extremities with increasing congestion of eyes. He was thought to have measles as he had contact with a person who had similar illness few weeks back near his home. He was treated with vitamin A, oxygen by face mask, nebulized salbutamol and intravenous fluids. Since fever spikes were persistent and TLC was elevated (21,000/cu.mm) with neutrophilia (90%), antibiotics were changed to injection ceftriaxone after test dose. After a period of two hours he was found to have increasing rashes with audible wheeze, loose stools and vomiting. By this time the rash was found throughout his body with clearing from face. Salbutamol nebulizations were increased in frequency and the child was monitored closely.
Over the next eight hours child became better, was able to sit up comfortably with minimal distress and he was taking oral feeds. The rashes appeared less prominent. He received the second dose of injection ceftriaxone that afternoon and following that he felt dizzy, vomited and began to have distress. His rash once again increased and became prominent, this time, throughout the entire body involving the face with urticarial lesions in-addition to macula-papular lesions []. He appeared red and was warm with itching all over the body, especially around his ears. Drug allergy was suspected and was promptly treated with oxygen, parenteral pheniramine maleate,

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

[User]
RADIOLOGY NOTE:
The patient was a 49 years-old male who was a herder living in Inner Mongolia, the northern part of China. He did not receive any treatment involving corticosteroid nor did he intake large amounts of alcohol. The patient first presented with recurrent fever. A few days later pain in bilateral sides of hips showed. He was admitted to the local hospital, the experimental test indicated that the patient is infected with Brucella spp., plain radiography showed normal contour of the femoral head on the left side whereas the right side had already developed into ARCO Stage IIIA (Fig. ), he did not receive standard treatment for Brucellosis at that time. The patient was also diagnosed with spondylitis and have a history of chronic hepatitis B. His symptom of hips aggravated only after a few months and the patient has been treated with doxycycline and rifampin for 6 weeks at the local hospital. Before discharging the Rose-Bengal Plate Agglutination Test (RBPT) showed weakly positive, the Wright test showed a titer of 1:50 and the Cysteine test showed a titer of 1:20. At the time the patient admitted to our center, both sides of the femoral head were aggravated to ARCO Stage IIIC in plain radiography (Fig. a), and the necrotic lesion showed in magnetic resonance imaging (MRI) (Fig. b). The patient showed limited active and passive hip movement, the abduction and adduction were significantly restricted, Patrick test and Thomas sign were both positive on both sides, Harris Hip Score were 54 on the right side and 45 on the left side. The Agglutination test of Brucella showed weakly positive, and erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels and aspartate aminotransferase (AST) were within the normal range. We performed bilateral total hip arthroplasty (THA), during the procedure, we used iodophors soaking the wound for 3 min and then irrigated before and after intramedullary

[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 59-year-old male with a postoperative union of a left tibial plateau fracture who, after open reduction and internal fixation, underwent surgery for implant removal at a local hospital (Fig. ). The first day after surgery, at approximately 9 a.m., he complained of severe pain in the wound region and developed a fever in which the highest temperature reached was 39 °C. Upon examination, the patient was conscious without chills and other discomfort, and the incision was severely swollen and filled with hemorrhagic content. Analgesic therapy was given, but the patient did not feel pain relief. Early on the second morning, the patient started to become irritable and apathetic and the incision was inflamed. The following afternoon, at approximately 3 p.m., the patient felt increasing pain out of proportion to the physical findings accompanied by progressive swelling, numbness, and weakness of the limb. The skin around the wound was darkened, and tension blisters were visible (Fig. ). The patient was delirious on the third morning after surgery, the systemic skin turned yellow, and there was a large amount of dark red, bloody discharge drainage from the incision with bubbles of gas, and a foul, sweetish, unpleasant odor was smelled in the incision. A physical examination revealed subcutaneous crepitus extending along the length of the limb, roentgenograms revealed the accumulation of gas in soft tissue (Fig. ), the lower limb skin temperature decreased, the dorsal artery of the foot could not be touched, and the patient had no response to pain in the lower extremities. Anaerobic infection gas gangrene was highly suspected, and the patient was transferred to our hospital at approximately 7 p.m.
Left lower extremity incision decompression was carried out immediately. Upon incision, the musculature was found to be extensively necrotic and crepitant, the appearance of the affected muscles was purplish red and brown with a characteristic foul odor,

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old, non-smoking female patient with a medical history of diabetes mellitus (DM) and hypertension (HTN) presented to the Urology Department of King Fahad General Hospital with a three-month history of hematuria. She denied any history of flank pain, dysuria, urgency, fever, or weight loss, or appetite. Clinical examination was normal, laboratory findings were within the normal range, urine analysis showed >40 red blood cells (RBCs) per high power field, and urine culture showed no bacterial growth. Bladder smooth muscle cell markers (smooth muscle actin (SMA), desmin, and calponin) were positive. B-catenin and CD117 were negative. An abdominal and pelvic CT scan with contrast was done and showed a large submucosal urinary bladder mass. An abdominal/pelvic MRI was performed and revealed a large submucosal well-defined round mass with a slightly lobulated smooth margin originating from the submucosal layer of the left anterolateral wall of the urinary bladder. It measured 5 x 7 x 4.5 cm and was isointense to the T1 weighted image's muscle and heterogenous with the cystic component on the T2 image. No suspicious lymph nodes in the pelvis and no infiltration into the adjacent organs and tissues were found. The finding suggests bladder leiomyoma and solitary fibrous tumor (Figure ).
An ultrasound-guided biopsy sample was taken and sent for histopathological examination and revealed a spindle cell tumor. On cystoscopy, a normal urinary bladder wall with no obvious exophytic masses and both ureteric orifices were seen, and a urine jet was present, but there was a massive indentation in the left posterolateral site of the urinary bladder extending to the dome of the bladder. The patient then underwent an open partial cystectomy (Figure ). A specimen of 7 x 5 x 3.5 cm was obtained and preserved in formalin for histopathological examination. A well-encapsulated white firm mass measuring 3 x 2.5 cm was found and the histopathological

[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 73-year-old Caucasian woman was admitted for elective shoulder replacement for an arthritic shoulder. She was being treated for hypertension with beta-blockers and thiazide diuretics and her blood pressure was well controlled. She had a history of diverticulitis and varicose vein surgery with an uneventful outcome. Her body mass index (BMI) was 34 during pre-operative anesthetic evaluation. She had no family history of DVT/PE. Blood investigations including electrolytes, liver function tests and coagulation screening were normal. Results of her electrocardiogram (ECG) and chest X-ray were unremarkable. The comorbidities were well optimized and she was admitted a day before her operation.
The patient was operated under general anesthesia supplemented with an interscalene block for postoperative analgesia. An intermittent calf compression device was used for mechanical thromboprophylaxis intraoperatively. The operation was performed through an anterior deltopectoral approach. The patient had no intraoperative complications. The patient recovered satisfactorily from general anesthesia and was monitored in a high dependency care unit for postoperative optimization. The operated shoulder was supported in an arm sling support for comfort. The patient was prescribed postoperative opioid analgesics and antibiotic prophylaxis with three doses of cefuroxime. No chemical or mechanical thromboprophylaxis were used postoperatively.
The patient was already feeling well on the next postoperative day and her blood parameters were satisfactory. Her pain was well controlled and her arm continued to be immobilized by the sling. There was no excessive oozing from the surgical wound and there were no distal neurovascular deficits. The patient's calves were soft and nontender and she was ambulating well postoperatively. A systemic examination of the patient was unremarkable. However, while being monitored she suddenly became breathless, hypoxic and hypotensive and experienced intense s

[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 35-year-old woman had presented in the outpatient services of psychiatry with multiple episodes of seizure for the past 6 years. The episodes of seizure were of generalised tonic-clonic type with a frequency of two to three episodes in a month. She was treated with phenytoin 300 mg/day with partial control of seizures (frequency of seizures was decreased). However, non-adherence to treatment resulted in worsening of seizures. She was diagnosed with hypothyroidism 2 years ago and was on thyroxine supplementation (50 μg/day). There was no history of any other medical illness. There was no history of psychiatric illness or substance use. Her family history was also uneventful. Premorbidly, she was well adjusted to life. She had expressed her concerns and worries related to seizure over the past few months prior to psychiatric consultation. Her distress was not persistent and often increased when seizures occurred more frequently. Current psychiatric evaluation did not reveal any significant psychopathology, other than apprehension about seizures.
Her general physical examination and systemic examination did not reveal any abnormality. There were no focal neurological deficits. Her cognition was intact. Lobar function tests also did not reveal any abnormality. The patient was investigated for seizure. CT scan of head revealed calcification in bilateral basal ganglia, frontal lobes and cerebellar hemispheres (). On the mental status examination, she had an anxious affect and worries related to persistent seizure. She was diagnosed with Fahr’s disease. Her psychological symptoms were not persistent and mild in severity, so no psychiatric diagnosis was made. It was planned to keep the patient on regular follow-up to see the evolution of symptoms over time. Her routine haemogram, liver function tests and kidney function tests were within normal limits. Her serum calcium (ionic) was 2.84 mg% (normal range: 4.5–5.5 mg%). Parathormone (PTH) level was 14.37 pg/mL (normal rang

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


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

[User]
RADIOLOGY NOTE:
An 11-month-old Caucasian boy was referred to this department for investigation of a raised urea and creatinine. He was born at 37 weeks’ gestation to unrelated parents. He had difficulties with bottle-feeding in the first 2 weeks of life and at the time of weaning he was noted to choke on solids. He was also found to have bilateral profound sensorineural hearing loss on routine screening, which led to him receiving cochlear implants at 18 months. At 8 weeks, he was not fixing and following and was noted to be hypotonic. At 10 months, he became unwell with fever, lethargy and rash. His urea was 44 mmol/L but reduced to 14 mmol/L after rehydration therapy.
At the time of his referral he had global developmental delay, truncal hypotonia, delayed visual maturation and bilateral sensorineural hearing loss. He was not on any regular medication. Results of initial blood and urine tests together with serial plasma lactate levels from presentation are shown in Fig. and Table respectively.
A renal ultrasound scan showed right and left renal lengths were 6.2 cm (30th centile) and both kidneys were echogenic. The presence of renal impairment and echogenic kidneys on ultrasound prompted renal biopsy, which showed significant tubulointerstitial damage with immature glomeruli (Fig. a, b). Electron microscopy of renal tissue revealed abnormal mitochondria affecting the tubular cells (Fig. c). Assessment of oxidative enzyme histochemistry in a muscle biopsy revealed a mosaic pattern of cytochrome c oxidase (COX) activity (Fig. d), which was confirmed by direct measurement of respiratory chain enzyme activities; complexes I and IV were both severely decreased with complex III activity decreased to a lesser extent, and evidence of complex II activity being spared (Fig. e). Taken together, these data are consistent with a generalised disorder of mitochondrial function.
Brain magnetic resonance imaging (MRI) of the proband was reported to show abnormal signal in the cerebral white matt

[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 years old right hand dominant gentleman presented to our orthopedic specialty clinic with fracture distal end radius on left side. On further evaluation, there was deformity in ipsilateral shoulder joint and asymmetry was present as compared to opposite side. There was an anterior globular bony swelling palpable with well defined margins. Transmitted movements from humerus were present confirming it to be bony humeral mass. There was wasting of deltoid muscle as compared to opposite side. Range of motion were flexion upto 170 degrees (), extension up to 10 degree (), internal rotation up to L3 (), and external rotation up to 30 degree () and abduction up to 120 () in both active and passive movements, further movements were restricted and mildly painful. Patient did not have any history of significant trauma to shoulder in past. However he gave a history of seizure attacks three years back following which he had shoulder pathology. He had taken antiepileptic treatment; however no treatment was taken for the shoulder. There were no further epileptic episodes and he was taking antiepileptic treatment. Radiographs of shoulder joint were taken which confirmed anteriorly dislocated humeral head (). Further views of shoulder joint were taken to check for any bony changes. They didn’t show any significant abnormality. CT scan showed anteroinferior dislocation with neocavity with pseudojoint formation (,,). Chronic hillsachs lesion was also seen. MRI Scan showed anteroinferior shoulder dislocation with intact rotator cuff muscles (,) Since the patient had good functional range of movement we explained him the treatment options. He opted for non surgical line of management. Hence was given shoulder mobilization exercises. Presently patient is being followed up with no fresh complaints and maintained join movements.
Anterior dislocation of shoulder unlike posterior dislocation is most commonly traumatic in nature. The mechanism of anterior dislocation following trauma is

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


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

[User]
RADIOLOGY NOTE:
We report a case of a 51-year-old man diagnosed with NF1, addressed to our consultation for oral pain in his wisdom tooth 48. During anamnesis, the patient informed us about cutaneous café au lait spots since childhood, and that at puberty cutaneous neurofibromas located on the head, abdomen, back, and arms appeared, followed by the occurrence of oral neurofibromas around the age of 20. NF1 was then diagnosed and multiple cerebral MRI were carried out without revealing any lesion. Furthermore, he related having been diagnosed with idiopathic thrombocytopenia during childhood which required high dose corticosteroid treatment leading to side effects such as weight gain and increased hairiness. At the age of 31 years, he sustained surgical excision of multiple neurofibromas in the head and neck region in France. He also mentioned a tibial fracture which occurred five years earlier while skiing which led to an osteoporosis diagnosis, treated by intra-venous denosumab monoclonal antibody (Prolia) twice a year since then.
The clinical examination revealed numerous cutaneous neurofibromas on the neck and back of the head as well as on the abdomen and the back, arising to the gluteal fold (). Apart from the infection related to the tooth 48, the intra-oral examination disclosed vestibular gingival nodules on the right side, measuring about one centimeter in diameter, covered by normal mucosa; the anterior one had a round aspect in comparison to the posterior one which had an elongated appearance most certainly due to the dental occlusion (). The patient had however, no complaint in regard of those intra-oral nodules. A facial cone beam CT was performed and revealed no intra-osseus lesions linked to NF1.
Tooth 48 was removed. However, its infection was not in relation with NF1. Two excisional biopsies of the maxillary lesions were also performed to assess a diagnosis and to allow the patient to have better oral hygiene. The histopathological analysis confirmed the diagnosis

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old male presented with a pulsatile mass () in his left hand 3 weeks following an open carpal tunnel decompression under general anaesthetic with tourniquet application. Tourniquet application time was less then 30 minutes, and it was released after wound closure and application of pressure dressing. Patient was discharged 24 hours after the surgery, and warfarin was restarted 72 hours after surgery with low molecular weight heparin cover.
His early postoperative course was complicated by surgical site abscess formation that was drained on postoperative day 7. There were no signs or symptoms of an embolic phenomenon secondary to infective endocarditis, since he was clinically well with no signs of generalised sepsis.
The patient had a past medical history of pulmonary embolism for which he was on warfarin along with previous ischaemic heart disease and minor asthma.
A Doppler ultrasound of his hand was performed which revealed arterial blood flow within the pulsatile swelling. CTA confirmed the lesion to be a pseudoaneurysm of the superficial palmer arch. Once the diagnosis was established, the patient's case was discussed in the vascular multidisciplinary meeting. He was provided with the options of open operative procedure under general anaesthesia versus endovascular technique, the latter was chosen by patient. Hence, coil embolization of both sides of the palmar arch (Figures and ) was carried out. A postprocedural US confirmed no flow into the aneurysm. His recovery was uneventful, and he was symptom free at 3-week followup.
An initial diagnosis of mycotic aneurysm was made on the basis that patient initially presented with an abscess at the wound site on 7th postoperative day. This was drained in accident and emergency department under local anaesthetics. And the subsequent swelling appeared 2 weeks later.
The patient did not have any history suggesting he suffered from “hypothenar hammer syndrome”, since he was a retired librarian, and there was no

[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 41-year-old female presented to our clinic as a new patient for excision of a previously diagnosed right heel leiomyoma. Six months prior, she had consulted a dermatologist for a painful area on her right heel that had been present for approximately three to six months. The area was raised, tender, firm, and was increasing in size. Physical exam at that time revealed a 2 cm raised, firm, noncompressible nodule on the posterior right heel, which was tender to palpation without any redness or streaking. X-rays were nonspecific and revealed that the soft tissue shadow was “not connecting to bone.” A punch biopsy taken at a follow-up visit with the dermatologist revealed a leiomyoma of the heel. She continued to experience pain (8/10 in severity) and was seen in our clinic for evaluation six months later. She had no other areas of bleeding, itching, or pigment changes of the skin. Physical exam revealed a palpable 2 cm x 1 cm nodule on the posterior aspect of the right heel which was freely mobile and tender to palpation (Figure ). Pulses and sensation were normal throughout in both lower extremities and no other gross abnormalities were noted.
The patient did not have a history of frequent running, gout, diabetes, constitutional symptoms, or weight loss. Due to the unusual location of this leiomyoma, Reed’s syndrome was considered in the differential diagnosis, and the patient was referred for a gynecological oncology appointment. However, because she had no personal or family history of other similar soft tissue masses, uterine fibroids, renal cell carcinoma, or skin cancer, there was a low index of suspicion. Her past medical history was nonspecific for any condition predisposing to cancer.
She was scheduled for surgery two weeks later. The tumor was excised (Figures -) and sent for pathology confirming cutaneous leiomyoma (Figure ). Follow-up visit at two weeks status post-excision showed a well-healing

[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 man was admitted to our hospital, complaining of hematochezia which had lasted for 1 month. His past history involved a high anterior resection of the rectum in our hospital due to intussusception caused by Peutz-Jeghers polyposis (Fig. ). He was hospitalized for 1 month after the procedure. Unfortunately, details of the surgical procedure that had been performed and the reason for his extended postoperative hospitalization were unknown, because clinical records from his previous admission were not available. He was followed up for 3 years after the procedure, during which he had no abdominal symptoms. He remained symptom-free until the month prior to readmission when he began to suffer from hematochezia. On this admission, hematochezia was his only symptom and there were no abnormal abdominal findings on physical examination. Blood test results, including levels of tumor markers, were all within normal limits. Colonoscopy revealed a hemorrhagic tumor with a smooth surface protruding from the anastomosis of the previous high anterior resection, at a distance of 10 cm from the anal verge; a second examination 4 days later revealed that the tumor had disappeared (Fig. ). The biopsied tumor and other small polyps were histologically diagnosed as adenocarcinoma and hamartomatous polyps, respectively (data not shown). We performed a low anterior resection of the rectum, including the anastomotic site with the adenocarcinoma, combined with a resection of the ileum for strong adhesion. The patient was discharged from our hospital 42 days after the operation.
Gross appearance of the resected rectum showed a defect of the rectal mucosa with a smooth edge and a mucosal bulge located at the anastomotic site (Fig. ). Cut surfaces demonstrated a submucosal tumor mainly occupying the proper muscle layer under the defect (Fig. ). Microscopically, the submucosal tumor comprised an adenocarcinoma and a bone lesion at the anastomotic site (Fig. ). The surface of the tum

[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 65-year-old female patient with well-controlled type 1 diabetes mellites (HbA1C 6.7) presented to a private clinic with a massive abscess on the back area. The cause of the abscess was unknown, but a private surgeon incised it at multiple sites and drained the content. The patient was supposed to take care of the wound dressings herself, but she and her family were overwhelmed by the copious amount of odorous exudate and needed professional wound care. After three weeks of irrigating the wound with saline and using regular gauzes, the patient presented to the wound clinic for help. At the first visitation (a, Day 0), the patient had a low-grade fever, was not feeling well with nausea and dizziness, and had severe pain on the whole back (score of 8 out of 10 on a visual analog scale []). She stated that she is depressed, anxious, and stressed, afraid of losing her life. The abscess covers the area of the whole trapezius and part of the latissimus dorsi on the left side of the trunk and upper part of the right trapezius, and wounds are subcutaneously connected. Infection and inflammation were present with a heavy odorous purulent exudate. The tissue was necrotic with the presence of slough and some granulation visible at the base of the wound after irrigation with the edges of the wound rolled and indented. Because of the severity of the infection, a swab was taken to identify the bacterial origin of the infection.
Irrigation of the wound was performed with a saline solution via a tube adapted to a syringe. Subsequently, wound cavities were filled with L-Mesitran Soft and covered with regular nonadhesive, superabsorbent dressings. After two days, odor and exudate levels decreased. Laboratory results confirmed the presence of multiresistant Staphylococcus aureus (resistant to clindamycin, erythromycin, fusidic acid, and penicillin) and nonresistant Pseudomonas aeruginosa, and because of the uncertain

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


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

[User]
RADIOLOGY NOTE:
We report a 7 year old boy who was referred to the Cardiac Center in Addis Ababa with dyspnea on moderate exertion and palpitations of about 2 years duration. The child was found to have a cardiac murmur at the age of about 2 years but was not subjected to echocardiography due to lack of skill and equipment in his locality. He was not on any medication at the time of presentation.
On physical examination, he appeared to be well-grown and healthy-appearing boy with a weight of 39 kg, height of 132 cm and body mass index of 22.4. His blood pressure was 127/55 mmHg and his pulse rate was 84 bpm. His oxygen saturation was 88% on room air. There was no remarkable cyanosis or clubbing of the fingers. Peripheral pulses were palpable. He had a parasternal lift, systolic thrill and a 4/6 ejection systolic murmur, best heard over the left 2nd intercostal space and a pansystolic murmur of grade 3/6 intensity, best heard over the left lower sternal border. There was no hepatomegaly or peripheral edema.
His chest X – ray showed marked cardiac enlargement with clearly decreased pulmonary vascular markings. The electrocardiogram showed sinus rhythm with a rate of 88 beats per minute, incomplete right bundle branch block, right ventricular hypertrophy, right atrial enlargement and right axis deviation. Echocardiographic examination showed normal abdominal and atrial situs, with normal position of the heart in the left chest and normal venoatrial, atrioventricular and ventriculoarterial relationships. The right ventricle looked markedly dilated and hypertrophied. The right atrium looked dilated. Right ventricular systolic function appeared grossly reduced on visual inspection and Tricuspid Annular Plane Systolic Excursion (TAPSE). There was a patent foramen ovale with right to left flow by color Doppler. The interventricular septum appeared intact. The mitral and aortic valves were structurally normal. The tricuspid valve looked thickened. The pulmonary valve was thickened

[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 29-yr-old woman presented with colicky lower abdominal pain. Her abdominal pain had developed 3 yr before intermittently, but it had worsened over the past 6 months. She was unable to sleep well due to her abdominal pain, which aggravated after eating meals. She also experienced episodes of abdominal distension, constipation, and urinary frequency or urgency. Other symptoms, as well as her past medical history and family history, were otherwise unremarkable.
The patient had a height of 164 cm and weight of 59.6 kg, for a body mass index of 22.2. Physical examination revealed a slightly distended abdomen, but the remainder of the examination was unremarkable. Routine blood tests, including renal function and urine analysis, were normal.
Computed tomography (CT) of the abdomen and pelvis revealed a homogenous fatty mass in the lower abdominal cavity (). The entire small bowel loop was displaced upward by the mass, and one segment of the ileal loop was slightly straightened by entrapment of the bowel. Small bowel series revealed ileal loop entrapped in fatty tissue and associated ileal diverticula ().
Laparoscopic surgical resection was recommended because of her symptoms. The laparoscopic surgery showed an encapsulated, yellowish mass originating from the ileal mesentery in the lower abdominal cavity. The mass extended to the antimesenteric border of the small bowel and was free of any adhesions or signs of necrosis. Some segment of the ileum appeared to be "stretched" over the fatty mesenteric mass with edema, however, its luminal patency was preserved in spite of luminal narrowing by compression. Lymphadenopathy or fluid collection was not observed. Surgical removal of the fatty mass and the affected ileal loop was performed without difficulty under a laparoscopic magnified view. The resected mesenteric mass was a soft, yellow mass and 19×10×5.1 cm in size (). Microscopically, the mass was characterized by homogenous mature adipose tissue without cellular atypia,

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


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

[User]
RADIOLOGY NOTE:
An 87-year-old woman presented with sudden headache, transcortical sensory aphasia and mild right sided weakness. Initial computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed an acute hemodynamic cerebral infarction of the left frontal and parietal lobes and a focal severe stenosis of the proximal left ICA. Echocardiography showed no evidence of abnormalities of the cardiac valves or of left ventricular dysfunction. Three days after admission, cerebral angiography showed a focal severe stenosis (75%) of the proximal left ICA without abnormal findings in either common carotid artery (). However, six days after admission, fever (40℃) suddenly developed with NIH Stroke Scale (NIHSS) score deteriorating from 4 to 10, due to additional aphasia and worsened weakness. Three days after the onset of fever, brain MRI showed no newly developed acute lesion, and echocardiography showed a newly visible 6×5 mm valvular vegetation of the non-coronary cusp of the aortic valve (). Blood cultures were positive for Staphylococcus aureus 4 days after the onset of fever as the offending microorganism. Intravenous antibiotic therapy was started immediately with a combination of cefazolin and gentamycin. Seven days after antibiotic therapy, the patient was diagnosed with bacterial meningitis, and cerebrospinal fluid (CSF) analysis revealed a white blood cell count of 240/mm3 (leucocytes, 71%; lymphocytes, 29%), red blood cell count of 2900/mm3, glucose concentration: 50 mg/dL, protein concentration: 216 mg/dL, and pH 8.0. Twenty-six days after admission, chest CT, which was performed with the suspicion of the Lt. pleural effusion as the cause of the fever, showed an incidental 22×20 mm thin walled saccular vascular structure located 2 cm distal to the origin of the left CCA suggesting a mycotic aneurysm because of acute development, presence of ongoing fever and inflammatory infiltration around the saccular vascular structure (). Three days after the chest CT,

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old woman with past medical history of hypertension and hyperlipidemia, presented with a right cheek nodule in December 2015. Biopsy result was consistent with ulcerated malignant melanoma, nodular type, Breslow depth of at least 2.7 mm. The nodule was locally resected, pathology results were consistent with extensive residual malignant melanoma, Breslow depth of 6.05 mm with multiple microsatellite metastases present, angiolymphatic invasion was identified and one sentinel lymph node was negative for melanoma (0/1). Melanoma in situ extended to the superior margin and medial and lateral specimen tips, therefore procedure was followed with Mohs surgery which showed no residual disease. Six months later, patient presented with two new nodules on her right cheek below the area of her prior excision. At that time, she was also noted to have right submandibular lymphadenopathy. Excisional biopsy of the nodule and FNA of submandibular lymph node showed recurrent malignant melanoma. Staging CT chest/abdomen/pelvis and brain MRI showed no evidence of distant metastatic disease. Multidisciplinary teams agreed on deferring surgery and proceeding with systemic therapy. Patient was subsequently started on anti-PD-1 therapy with Pembrolizumab at a fixed dose of 200 mg every 3 weeks. Patient continued to show a positive response until fourteen months of therapy when restaging CT scans demonstrated a left upper lobe nodule concerning for metastatic disease. PET scan demonstrated a high SUV uptake of 15, also consistent with metastatic disease. A left lung needle biopsy was subsequently completed which was consistent with metastatic malignant melanoma. Mutational analysis revealed double KIT mutations at V559 and N822I, therefore, Imatinib; a tyrosine kinase inhibitor known as Gleevec, was started at a dose of 400 mg daily. This was given in combination with Pembrolizumab at 200 mg every three weeks. Shortly after, patient developed a pruritic rash on her back and shoul

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


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

[User]
RADIOLOGY NOTE:
A healthy looking, 50-year-old Nepali man came to our clinic with a complaint of multiple growths on his scrotum for 15 years. The growths started as a single lesion on the right side of his scrotum, with the gradual appearance of similar lesions on other parts. Several of these lesions coalesced at various places to form large-sized nodules. The condition was mostly asymptomatic with an occasional complaint of itching. There was no history of pain, burning sensation, trauma, ulceration, or discharge. The lesions did not interfere with urination or sexual activities. He was worried because of the increasing size of the growth and hence came to us for advice. He did not give a history of any systemic illness including metabolic, autoimmune, or malignant disorders. There was also no history of a similar complaint in his family.
On physical examination, multiple pink to brown nodules ranging in size from 0.5 × 0.5 × 0.5 cm to 3 × 3 × 1 cm involving almost half of his scrotum were noticed (Fig. ). The skin over the nodules was shiny with several yellowish points indicative of underlying calcium deposition. The skin surrounding the nodules, testis, and penis was normal on palpation. The nodules were painless and firm in consistency. On laboratory examinations the following were found to be within normal limits: serum calcium, phosphorus, parathyroid hormone, and vitamin D hormone levels; uric acid; alkaline phosphatase; and lipid profile. Based on clinical features and laboratory reports, a diagnosis of ICCS was made.
He was advised a scrotectomy under spinal anesthesia, which he refused. The nodules were excised under local anesthesia in several sittings. The skin was sutured using chromic catgut (4–0). His postoperative period was unremarkable with good cosmetic result and no evidence of recurrence in a 1-year follow-up period. The cut section of nodules showed solid white to yellow homogenous areas.

[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 65-year-old male presented to our department complaining of recurrent epigastric and upper right abdominal pain radiating to the back for the last 3 months. No other complaints were prominent. The patient had undergone an uneventful laparoscopic cholecystectomy 2 years earlier. His family history was consistent with a father who suffered lung malignancy and a mother who expired due to hepatoma.
An ultrasound performed prior to his admission revealed a hypoechoic 4 × 4 cm lesion close to the pancreatic head. On admission, abdominal examination revealed a soft, nondistended abdomen with local tenderness in the upper right quadrant. No other findings were noted. His blood tests were all within normal limits. CEA and CA 19-9 were normal. Abdominal tomography revealed a 5 × 5 cm, rounded, soft density lesion adjacent to the root of the superior mesenteric artery (SMA) and pancreatic head (fig. ). It was not possible to distinguish the origin of this lesion.
The patient underwent endoscopic ultrasound examination that demonstrated a hypoechoic-heterogeneous solid lesion behind and adjacent to the SMA and superior mesenteric vein. No other pathology was demonstrated in the pancreas itself (fig. ).
Pathology obtained by fine needle aspiration from the lesion revealed fragments of mesenchymal tissue that was positively stained for c-kit and actin. DOG immunohistochemistry was negative. Laparotomy revealed a large, 7-cm, hard tumor adherent to the medial border of the pancreatic uncinate process laterally, to SMA medially, posterior to the portal vein and anterior to the inferior vena cava and left renal vein (fig. ). The lesion was successfully dissected from these structures and was completely excised and removed.
The patient was discharged after an uneventful postoperative course. The pathological report revealed leiomyosarcoma stained to actin and desmin. The proliferative index Ki67 was 10%. He received radiotherapy, and at 4 years of follow-up, the patient is healthy

[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 22-year-old man was admitted to the hospital for 2 days because of left knee joint pain and limited movement caused by a traffic accident. Physical examination on admission showed that the left knee joint was swollen with local tenderness, but no open wounds were present. The floating patella test was positive, and the muscle strength of the left lower extremity was normal. Preoperative imaging revealed a comminuted fracture of the left patella (), determined to be type 34-C3 according to the AO/OTA classification.
Before the operation, both sides of the patella were scanned by computed tomography (CT) with a scanning thickness of 1 mm. The collected CT data were imported into Digital Imaging and Communications in Medicine format, and a 3D model was established by Mimics 19.0 software (Siemens, Berlin, Germany). Next, a mirror-image model of the healthy patella was used as a template to virtually reset the affected patella. This allowed us to further design and print the complete patella and the distal and proximal fractured patellar reduction guide plates with the cartilage surface as the mask. The patella model after virtual resetting and the data for the three corresponding reset guide plates were imported into the 3D printer in stereolithography format, and the model and guide plates were then printed out ().
The patient underwent spinal anesthesia and was placed in the supine position, and an anterior median incision was made in the left knee joint. First, the local reduction guide plate of the proximal patella was placed behind the articular surface of the patella, and the large pieces adjacent to the cartilage surface were identified. The proximal patellar reduction guide plate was used for splicing, and a 1-mm fine Kirschner wire was used for temporary fixation in the coronal direction. All bone fragments with the cartilage surface at the proximal end of the patella were assembled together and temporarily fixed with a fine Kirschner wire, allowing the prox

[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 16-year-old obese male, with no medical history, presented in emergency room with a closed trauma of the left knee secondary to a traffic accident. He was hit by a car while biking. The mechanism of the injury was a hyperextension and a valgus stress of the left knee. General examination revealed no other significant injury. On physical examination, the patient was totally unable to step on or move his left lower limb. There was a significant swelling around his left knee with no skin defect. The pulses of the A. poplitea, the Arteria tibialis posterior, and the Arteria dorsalis pedis were well palpable. The capillary filling of the toes was present. No motor or sensitive defect was found. Plain radiographs of the left knee showed a Salter and Harris Type 1 physeal fracture of the distal femur with an important displacement of the metaphyseal fragment (). At that time, in front of the spectacular femoral injury, the diagnosis of a Type 3 slightly displaced physeal fracture of the proximal tibia was missed. The patient was operated in the same day. Under general anesthesia, the patient was placed in supine position with the left lower limb pulled in its axis using a fracture table. After a gentle continuous traction, a downward pressure was applied on the distal epiphysis of the femur with the tight been locked. The reduction was found good when checked using the fluoroscopy. Fixation was done using two crossing 24 mm K-wires. A long leg cast was made. Post-operative radiographs showed a good reduction of the distal femur (). At this time, the tibial injury was diagnosed. The slight displacement of the epiphyseal fragment of distal tibia was accepted. Close physical observation in the first post-operative 24 h found no secondary vascular thrombosis. The cast was kept for 6 weeks. After the same period, healing of the fracture was obtained (), hardware was removed, and full weight bearing was allowed. 2 years

[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:
Our second case is a 26-year-old male patient with homozygous sickle cell (HBSS) disease. He also had chronic kidney disease which progressed over 3 to 4 years to end stage renal disease (ESRD) requiring hemodialysis. Patient had frequent presentations for painful crises amounting to 16 ER visits and 82 inpatient days in the preceding year at our institution. His painful crises were notably more frequent since he developed ESRD and were localized in his hips and collar bones.
Most recent HPLC showed HbA of 81.8%, HbF < 1%, HbA2 of 2.7%, and HbS of 14.5% indicating that patient had recently received multiple blood transfusions. Hemogram showed WBC count of 12, Hb of 7.1 g/dL, and platelet count of 333. Blood chemistry was significant for elevated Ca on multiple occasions with a peak of 11.8 mg/dL. Phosphate was high on multiple occasions with a peak of 9.1 mg/dL. PTH was elevated on multiple occasions with a peak of 4078 pg/mL. Vitamin D levels ranged from 13 to 20 ng/mL. Predialysis blood urea nitrogen ranged from 60 to 80 mg/dL and creatinine ranged from 8 to 10 mg/dL. Patient was treated with cinacalcet for secondary hyperparathyroidism but became refractory to treatment after a period of time with persistently elevated calcium and PTH levels. Based on the above investigations, we reached a diagnosis of tertiary hyperparathyroidism due to ESRD.
Imaging studies were done to localize the parathyroid lesion. Radionuclide parathyroid imaging using technetium sestamibi scan showed slow washout in the right lower thyroid region () but CT scan of the neck with contrast showed moderately enhancing foci inferior to the left and right thyroid lobes and superior to the left thyroid lobe which raised suspicion of parathyroid hyperplasia and warranted exploration of all four parathyroid glands. Plain radiography revealed bony resorption typical of untreated hyperparathyroid bone disease at the greater trochanters of both femoral bones and lateral

[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 patient presented to the emergency room (ER) on account of a 3-month history of hemoptysis as well as a 2-week history of right upper extremity weakness and numbness.
Hemoptysis was associated with pleuritic right-sided chest pain as well as orthopnea and had been previously treated with two courses of empiric antibiotics and steroids at an outside hospital without improvement prompting his presentation to our emergency room.
Weakness and numbness of the right upper extremity were initially associated with a painful right palmar rash which was resolved with self-administered topical corticosteroids at home.
Past medical history was significant for untreated latent tuberculosis (TB) diagnosed about forty years prior to this presentation as well as coronary artery disease requiring stent placement twice in the past.
On presentation, the patient was not in acute distress but was tachycardic at 100 beats per minute, with a respiratory rate of 16 cycles per minute and an oxygen saturation of 100 percent on room air. Blood pressure was 144/87 millimeters of mercury, and temperature was 99 degrees Fahrenheit.
On physical examination, he was afebrile and had normal breath sounds and heart sounds without murmurs. Neurological examination was notable for reduced sensation to light but not crude touch over the right hand with reduced strength of 4/5 in that in same extremity. Laboratory studies were significant for a white blood cell count of 18,400 per microliter with 76.3 percent neutrophils, an erythrocyte sedimentation rate of 90 millimeters per hour, and a C-reactive protein level of 167 milligrams per liter.
Imaging done on admission revealed multifocal lung opacities () concerning for community-acquired multifocal pneumonia (possibly secondary to a resistant organism as patient had completed courses of cefdinir and levofloxacin at the outside hospital without resolution of his symptoms). Other considerations were for possible septic emboli of undeterm

[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 woman with one-week-old swelling in the left mandibular angle was admitted to our oral and maxillofacial surgery department with the complaints of recurrent episodes of vertigo and consciousness. The vertigos gradually increased in frequency and intensity since they started one month prior her admission. Physical examination revealed a discrete raised, painless mass occupying the left parotid area witch adhered to underlying soft tissue, extending approximately 2 cm in diameter in the sub- and retromandibular regions. There were no restrictions on the cranial nerves supplying this area. No odontogenic cause or any other inflammatory factors could be responsible for the parotid gland swelling. There was no palpable lymphadenopathy in the left neck. Blood pressure was 115/62 mm Hg and the heart rate was 63 beats per minute. Routine laboratory investigations were normal. 24-hour Holter monitoring revealed several episodes of sinus arrest. Ultrasonography showed a well-defined space-occupying lesion of about 31 mm in length and 17 mm in width, which was hypo echoic and located in the deep lobe of the left parotid gland. The rest of the gland showed a homogeneous parenchyma.
Computerized tomography (CT) showed a large mass extending into the carotid space and protruding into the parapharyngeal space (Figure ).
A left parotidectomy was performed. The resected gland was a hard mass, which had spread over the bifurcation of the left carotid artery without invading the vessel wall itself. The tumor was oval-shaped, encapsulated, and partially nodular without any regional lymph gland involvement. Upon opening the mass viscous, white-colored fluid was released (Figure A/B).
The pathology report showed a lymphoid tissue with multifocal double-row hypereosinophilic epithelium with retention of thickened secretions in the lumen as well as squamous cell metaplasia consistent with typical parotid gland cystadenolymphoma (Figure A/B).
The patient started ambulating fro

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


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

[User]
RADIOLOGY NOTE:
An 11-month-old Egyptian female baby was referred to our institution for an evaluation of poor growth. She was the first child of healthy and unrelated Egyptian parents. The pregnancy was normal and there was no history of hyperthermia, hypertension, diabetes or exposure to toxic, traumatic or infectious agents or radiation. Delivery was through Cesarean section, at term. Her birth weight was 2,900 g (10th centile) and her length was 45 cm (third centile). A right cleft lip-palate and limb anomalies were noted at birth. On examination, her length, weight and head circumference were below the third centile; she had delayed motor and mental development and she had the scar of repair of her right cleft lip, which was done at the age of two months. An examination of her mouth revealed the presence of a cleft palate. Her scalp hair was sparse and hypopigmented and her skin was dry and rough. Both hands showed a classic lobster claw deformity: her middle digit was absent and the remaining four fingers were parted, two on either side, the cleft almost dividing the palm into two (Figure ). The second and third toes of both her feet were missing and the remaining three toes were divided by a cleft into two parts, the big toe on one side and the other two toes on the other side (Figure ). Her external genitalia were female. Laboratory tests, including a complete blood count, electrolytes and liver tests and kidney, thyroid, anterior and posterior pituitary functions tests, showed no abnormalities. A chest radiography, abdominal ultrasound, echocardiography, ophthalmologic examination, fundus examination, cerebrospinal fluid pressure and hearing tests were normal. Skeletal X-rays (with the exception of the described limb anomalies) were all normal. Her karyotype was 46, XX and a genetic study demonstrated no mutations in any of the coding regions of TP63. In addition, no chromosomal abnormalities have been identified in her parents.

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


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

[User]
RADIOLOGY NOTE:
A 79 year-old male was referred to our hospital with pus discharging for one month from an unhealed intraoral wound in the mandibular symphysis area. The panoramic radiograph showed that there was a 4 x 3 cm size radiolucent lesion over the mandibular symphysis with an irregular border (Fig. ). There was no palpable lymphadenopathy over the bilateral neck area during the physical examination. The patient had a history of NPC one year previously, and had received a complete radiation therapy course (total dose of 6500 Gy), without chemotherapy. A tentative diagnosis of osteomyelitis of the mandible was made. In order to eliminate the possibility of NPC metastasis, a chest radiograph, conventional bone scanning and liver scanning were arranged. The results were negative. CT scanning did not reveal any cervical lymph node involvement in the neck area. Under general anaesthesia, tooth extraction, sequestrectomy and marginal bone resection were performed with a 2 mm safe zone (Fig. ). The tissue specimen was whitish in colour and soft with a granular texture. The wound was marsupialized and an iodoform gauze dressing was placed for 2 weeks. The histopathology report showed an undifferentiated carcinoma with frequent mitoses. In-situ hybridization revealed that the specimen contained Epstein-Barr virus RNA. The ENT department performed a nasopharyngeal examination for the possibility of recurrent NPC and the result was negative. The case was classified as Ho’s stage II, T1N1M1.
A CT scan was taken one month after the operation. The mandible had healed in the upper border region, but no healing was evident over the lower margin after surgery (Fig. ). The patient was referred for radiotherapy. After the supplemental dose of 50 Gy, further lesion expansion was stopped and early bone formation in the inferior lingual aspect of the lesion was noted in the following CT scan (Fig. ). The remaining apparent discontinuity of the bone in the grafted area most probably represents in

[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 Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung (Fig. ). The vertebral lesion was situated on the left transverse process and was separated from the spinal canal (Fig. ). Biopsy specimens of both lesions were histologically similar and showed spindle cell neoplasms with a bland appearance; however, we could not make a definitive diagnosis, owing to the small size of the samples. The patient was placed under close observation with suspicion of multiple metastases from an unknown primary tumor.
Five years later, a CT scan indicated that the pulmonary nodule had slightly increased in size. Magnetic resonance (MR) imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good pos

[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.