[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 man presented with a large exophytic lesion of the chin, which had been present for 10 years with recent enlargement over the previous 6 months (Fig ). He denied pain or bleeding, but recently noted some ulceration in the central portion of the lesion. Physical examination showed a 1.5 × 1.0 cm mobile lesion centrally located at the mental crease of the chin. There were no notable sensory or motor nerve abnormalities and no palpable lymphadenopathy of the submental, submandibular, anterior, or posterior triangles of the neck. Intraoral examination was normal. Biopsy of the lesion demonstrated eccrine carcinoma. Computed tomography imaging of the neck showed no evidence of metastatic disease.
Treatment plan involved initial wide excision of the lesion and surrounding borders, including skin and subcutaneous tissue. The defect was closed using a full thickness skin graft from his right neck. Permanent pathology demonstrated eccrine carinoma with positive deep and peripheral margins including platysma muscle invasion. Reexcision involved wider and deeper margins, which were inclusive of the entire chin subunit up to the vermilion border. Frozen sections done at the time of surgery were negative. The total defect measured 9 × 5 cm (Fig ).
The submental artery island flap design for defect coverage utilized a fusiform-shaped flap with the superior aspect of the flap beginning 1.5 cm inferior to the bony mandibular margin of the defect, and lateral edges extending to the approximate level of the mandibular angle bilaterally. The total flap skin paddle measured 13 × 6 cm. The submental artery was identified bilaterally just inferior to the mandibular angle. Dissection of the flap proceeded in the subplatysmal plane and right and left pedicles were identified. Marginal mandibular nerves were identified and preserved. The left pedicle was ligated to allow inset of the flap as an island based on the right-sided perforator. Subsequent to passing under a skin brid

[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 12-year-old female patient was referred by a private practitioner who detected a mass of soft tissue on the palatal aspect of tooth 11. The patient had a history of alveolar cleft repair done about 1 year back. Clinical examination revealed an extensive soft tissue mass in a palatal defect of tooth 11 []. Gentle exploration revealed that besides loss of the palatal enamel there was also loss of enamel from the interproximal areas of the tooth. However, the labial surface of the tooth was intact. The tooth responded to thermal and electric pulp testing within normal limits. A periapical radiograph revealed a large irregular radiolucency in the coronal region of the tooth extending mesiodistally and slightly into the coronal radicular dentin []. A diagnosis of Class 2 external cervical resorption was made.
Glycerol was applied to the adjacent tissues to form a protective film. Isolation was achieved using the cuff rubber dam technique. A small cotton pellet was then dipped in 90 percent trichloroacetic acid and the excess was removed by dabbing it on a piece of gauze. The cotton pellet was then applied over the resorptive tissue mass with gentle pressure for about 1 minute. The tissue mass underwent necrosis with repeated application of trichloroacetic acid which was curetted out till a sound dentinal base was revealed []. Care was taken to see that the interproximal areas of the tooth were thoroughly debrided. The cavity was then refreshed with a high speed bur and restored with glass ionomer cement [].
Trichloroacetic acid is a chemical escharotic agent that causes coagulation necrosis and renders the resorptive tissue avascular.[] The use of trichloroacetic acid does not necessitate raising a flap to gain access to the lesion. This eliminates the possibility of active resorbing cells present in the flap from being repositioned over the repaired root surface.[] However, due to the caustic nature of the acid, certain guidelines need to be followed as outlined

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old Caucasian man, a full-time student, 1.8 m tall, 77 kg in weight, with no significant medical history, a non-smoker, taking no medications and with no substance misuse, was riding a motorcycle while wearing a helmet; he collided with a moving automobile and was ejected over 30 m into the air. He sustained multiple injuries including a large chest wall avulsion and a severe partial amputation of the left arm. The limb was not salvageable, requiring amputation, with a small residual fragment of the left scapula remaining (Figure ). Left scapulothoracic dislocation and severed left brachial plexus were also found intra-operatively. His head, right arm and lower extremities were grossly intact.
He received 10 weeks of acute care in our surgical medical unit, where surgical intervention included repair of the chest wall and internal organs, after which he was transferred to the acute rehabilitation unit where, almost immediately, phantom limb pain became his major issue.
He reported his pain episodes as variable in number, ranging from three to six per day. Described as searing, aching or cramping as if his missing hand was clenched in a fist formation, the pain episodes often occurred at random intervals during the day, ranging from 15 minutes to up to an hour and a half. On average, he rated the pain at between 8 to 10 out of 10 on a visual analog scale (VAS).
As his entire left upper limb was missing, including the shoulder and parts of the clavicle and scapula, 'stump' pain did not actually apply to his description. Instead, he consistently experienced the feeling that his left fist was severely clenched and he could not release it from the cramping that became a burning, searing pain.
This persisted despite a series of aggressive pain management methods through the administration of naproxen 250 mg three times a day, tramadol 50 mg

[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 70-year-old woman was admitted with severe abdominal pain, which began a few hours before admission. She had neither a specific past medical history nor any underlying illness. The abdominal pain was continuous and diffuse without localization. The initial blood pressure was 120/80 mmHg, the pulse rate was 84 beats per minute, the temperature was 36.4°C, and the respiratory rate was 32 breaths per minute. On physical examination, the abdomen was soft but moderately tender throughout without rebound tenderness. The laboratory values were as follows: white blood cell count, 11,900/mm3; AST, 26 IU/L; ALT, 11 IU/L; amylase, 210 IU/L; lipase, 316 IU/L. An ultrasonographic examination showed that the gallbladder had no abnormal findings but the small intestine showed diffuse dilatation and wall thickening (, ). A computed tomographic examination of the abdomen and pelvis performed with the intravenous administration of contrast media showed severe thickening of the small intestinal wall and small quantity of ascites without any evidence of bowel perforation or acute appendicitis (). During the next three hours, the patient’s blood pressure fell to 80/50 mmHg and the temperature rose to 38°C. Her abdominal pain worsened with newly developed rebound tenderness and rigidity on abdominal palpation. After deliberating on the patient’s age, clinical manifestation and radiological findings, abdominal angiography was performed to rule out the possibility of acute intestinal ischemia. Abdominal angiography showed multiple stenoses at the superior and inferior mesenteric artery and extensive spasms at the branches of the superior mesenteric artery (). An exploratory laparotomy was performed on with the impression of small bowel necrosis due to acute intestinal ischemia. On exploration, there were neither intestinal necrosis nor intestinal perforation. Only bile-colored ascites was noted. Although the gallbladder appeared normal, bile leaked on a localized focus of the gallbladder

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old-male patient presented initially with lower abdominal pain in March 2006. He was diagnosed with appendicitis based upon his exam and history. A CT scan of the abdomen was performed at that time and demonstrated extensive inflammatory changes in the right lower quadrant with possible interloop abscess (). Two nonspecific calcifications were noted radiographically and the differential diagnosis included appendicitis, ileitis, or diverticulitis. He did not have any urinary complaints at that time. He underwent an uneventful open appendectomy and had resolution of his initial symptoms and no further follow up.
The patient presented again in August 2011 with right flank pain and urinary symptoms. A noncontrast CT scan of the abdomen was performed and demonstrated a right ureterovesicular junction calculus with mild right ureteral dilation (). Again, calcifications were noted near the anterior fundus of the bladder (). He was managed medically and discharged with instructions to follow up with an urologist as an outpatient.
He subsequently presented again 3 weeks later with severe abdominal pain and induration of his lower abdominal wall. CT imaging now demonstrated interval enlargement of a complex cystic mass inseparable from the anterior superior wall of the urinary balder and abutting the posterior margin of the abdominal wall (). The radiographic diagnosis was an urachal remnant abscess versus tumor. He denied any urologic complaints at that time. He was started on antibiotics, and surgical consultation was performed. After an extensive discussion with the patient regarding his radiographic diagnosis and suspicion of complications related to an urachal remnant, he was scheduled for cystoscopy and surgical exploration.
At the time of surgery, cystoscopy did not demonstrate any abnormalities of the bladder. Exploratory laparotomy was performed and an indurated mass and abscess were encountered near the area of the anterior abdominal wall and bladder. The

[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 female with a past medical history of hypertension, peripheral arterial disease, asthma, gastroesophageal reflux disease, and diabetes mellitus presented to our otolaryngology clinic with the complaint of a “nodule” behind her left ear. She stated that the mass had been slowly increasing in size over the last 5 years. It was described as nonpainful and she had never experienced any discharge from the area. Her only other complaints were decreased hearing, xerostomia, and hoarseness; no dysphagia or weight loss was reported. Past surgical history was significant for angioplasty and stent placement in her legs. Social history was significant for a 20-pack-year tobacco history. No significant family history was reported. On physical examination pertinent findings consisted of a left posterior auricular mass approximately 2 centimeters (cm) that was fixed and nontender. All cranial nerves, most notably the facial nerve, were intact. No cervical adenopathy was palpated. Nasopharyngeal laryngoscopy demonstrated arytenoid edema consistent with reflux but the true vocal folds were mobile and no other lesions were visualized. Treatment plan at that time consisted of smoking cessation and a computed tomography (CT) scan with contrast of the neck.
The CT scan revealed a multilobulated and cystic mass in the left parotid gland with an infiltrating appearance consistent with neoplasm. There was no pathologic cervical lymphadenopathy reported. The differential diagnosis at this time included benign mixed tumor, Warthin's tumor, epidermoid tumor, and adenoid cystic carcinoma. A fine needle aspiration was performed at this time and the results were nondiagnostic. The decision was made to proceed with a left parotidectomy.
Left superficial parotidectomy with facial nerve monitoring was performed approximately one month after presentation. A 2 × 2 cm lesion was removed from the tail of the left parotid gland. The gross description was an encapsulated, lobulated mass wit

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old Sri Lankan unmarried woman presented with worsening hand, feet, and perioral numbness for 6 months duration and muscle cramps of the lower limbs for 3 years. There were no seizures, headache, chest pain, or features of heart failure. She did not have features supportive of thyrotoxicosis including loose stools, sweating, or palpitations. She did not have limb weakness.
She gave a history of reduced appetite and unintended weight loss of 4 kg over 4 months. She did not have evidence of other endocrine abnormalities, including adrenal insufficiency, and there were no features supportive of an autoimmune process, to suggest a polyglandular autoimmune syndrome. She did not have chronic cough, joint symptoms, or skin rash to suggest a granulomatous or infiltrative disorder. She was consuming an average diet with adequate amounts of fish, meat, and milk and getting adequate exposure to sunlight. She did not have a history of diarrhoea or steatorrhoea or a family history of celiac disease to suggest an ongoing malabsorptive process. Her urine output was normal, and she did not have features of uremia. She was not on any drugs such as bisphosphonates or chemotherapeutic agents such as cisplatin which could lead to hypocalcemia.
She was diagnosed with follicular carcinoma of the thyroid at the age of 27 for which she underwent total thyroidectomy with lymph node excision 33 years ago. Histology revealed well-differentiated follicular carcinoma with multifocal capsular invasion and lymph node metastases. Operative notes indicate that parathyroid glands had been identified and preserved during the surgery. She was given Iodine-131 treatment once after the surgery. Her records did not reveal an immediate postoperative hypocalcemia. However, she was empirically treated with calcium and calcitriol in the immediate postoperative period for 3 months, after which it was stopped. Following surgery, she was regularly followed up and managed at an oncology unit, and there

[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 was admitted to our hospital with a pulsatile mass swelling over the left cervical region and right hemiparesis after cough for 1 day. She had a history of fibromatosis, but no previous history of trauma, operation or inflammation in this region. On physical examination, a 5-cm large pulsatile swelling with blowing bruit was found over the left cervical region and multiple fibromas were found in regions of face, neck, and trunk. Neurological examination revealed muscular strength of grade IV according to the ‘manual muscle test (MMT)' grading system and hypoesthesia of right limbs, including touch and pain sensation. Computed tomography angiography (CTA) and DSA revealed a left high-flow internal carotid-jugular fistula at the first cervical level and twisted left internal carotid artery (ICA) (Figures ). Blood flow from the vertebrobasilar artery and right ICA via the circle of Willis supplied the left anterior cerebral artery and middle cerebral artery and drained backwards into the petrosal segment of left ICA (Figures ).
We chose embolization of both the fistula and parental artery, because no appropriate covered stent could be used to pack the fistula in the condition of reservation of left ICA. The purpose of first endovascular treatment was to isolate the fistula, by blocking both the backward blood flow from right ICA and the forward blood flow from left ICA. A Headway-21 stent catheter was selectively inserted into the distal part of fistula in the segment of carotid cavernous sinus, meanwhile an Echelon-10 microcatheter was placed in the distal part of stent catheter. One LVIS 5.5*30 mm stent, with its characteristic relatively compact mesh, was used to cover the distal part of fistula to avoid coils being pushed into internal jugular vein and heart (Figure ). However, the 3.5 cm fistula could not be covered by the LVIS stent. Therefore, 10 coils were additionally used one by one

[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 28-year-old Asian male patient was admitted to our hospital for a refractory migraine of 3 years. He complained hours of pulsatile pain with photophobia, haphalgesia of the scalp, and fatigue during each attack. His medical history was unremarkable, and his magnetic resonance imaging and computed tomography angiography revealed no imaging anomaly. Accordingly, he was treated with naproxen (0.5 g qd) and flunarizine hydrochloride (10 mg qd) with poor improvement. Thus, treatment with an ultrasound-guided stellate ganglion block on each side a time was planned as a complementary therapy.
With the patient's informed consent, the first block was successfully performed on the right side with temporary Horner syndrome, decreasing attacks on the first day. Thus, the next block for the other side was administrated the day after. During the practice, the patient laid in the supine position with a thin pillow under his shoulder to ensure the extension of the anterior neck. Before the procedure, the patient was instructed to raise his hand if he felt any discomfort but was not allowed to speak or swallow. He was monitored by pulse oximetry and noninvasive blood pressure. We adopted the in-plane approach because of the clear ultrasonography at the level of the 6th cervical vertebra (C6) transverse process and prepared 4 ml of 1% lidocaine with a 22-gauge needle and 12-MHz linear probe. During the procedure, the needle was supposed to be inserted between the carotid artery and thyroid toward the prevertebral fascia anterior to the longus colli muscle (Fig. ). However, we lost track of the tip when the inserting the needle, which passed the fascia of the artery and thyroid. Hence, the operator cautiously jiggled the needle to detect the tip. After the tip was confirmed by the concomitant jitter of the target tissue (the surface of the longus colli muscle), 0.5 ml of 1% lidocaine was injected; however, the injectate

[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 patient is a 20-year-old female who initially presented to an outside hospital in July 2017 with a 1-month history of progressive low back pain. Initial magnetic resonance (MR) showed a destructive, osteolytic, expansile lesion measuring 4.8 × 3.8 cm centered in the left aspect of the sacrum at the level of S2–S3 with areas of anterior cortical destruction extending into the left sacral neural foramina from S2 to S4. There was also a heterogeneously enhancing soft tissue component that was measured at 6.4 × 3.7 cm that was along the left piriformis muscle. A CT-guided core needle biopsy performed in August 2017 yielded an initial diagnosis of a high-grade osteosarcoma. She was subsequently treated as an osteosarcoma patient with MAP chemotherapy. She completed a total of 12 weeks of chemotherapy, with cumulative doses of cisplatin 360 mg/m2, doxorubicin 225 mg/m2, and methotrexate 24 g/m2. Surgical intervention was determined to result in substantial morbidity, and therefore, the patient underwent proton beam radiation in three fractions for a total dose of 54 Gy. However, due to the lack of increased bone mineralization in response to chemotherapy, the question of osteoblastoma rather than osteosarcoma was raised.
After reviewing the initial pathology, a second pathologist described the tissue specimen as a cellular tumor composed of proliferating osteoblasts with atypia and frequent mitotic figures associated with trabecule of woven bone. Neoplastic cells demonstrated mild cytologic atypia and scattered mitoses of normal configuration. In different areas, the tumors had undergone secondary hemorrhagic and cystic changes. Although difficult to definitively differentiate between the two, an overall impression of osteoblastoma was favored. As a result, a second biopsy was later obtained in December 2017. It in fact demonstrated no neoplastic cells, but instead a cystic wall with bland-appearing spindle cell proliferation, hemosiderin deposition, lamellar and wove

[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 male presented to our hospital, having been previously treated at another institute. Spme nine days prior, he had developed severe chest pain following retching. A chest x-ray then had showed a hydropneumothorax. Emergency intercostal drainage (ICD) insertion was done and a water-soluble contrast study had showed a leak from the lower oesophagus []. An endoscopic stapling was performed at the other institution where he was managed and that leaked on the third postoperative day. The patient presented to us with septic shock on day nine following the original perforation. A CT scan showed a free leak into the pleural space with a large collection. A new ICD was inserted, but it failed to clear the pleural space. We then decided to proceed with thoracoscopic mediastinal toilet. The patient was administered general anaesthesia with a double-lumen endotracheal tube. He was placed in the lateral decubitus position. A thoracic epidural catheter was placed for postoperative analgesia. A working port was established in the sixth intercostal space in the midaxillary line and two other 5 mm ports were placed. A 30 degree telescope was used for the procedure. A thorough mediastinal toilet was given []. The site of the perforation was identified but was too friable for attempting any form of closure. Local decortication was done. The thorax was drained with two IC drains. A laparoscopic-assisted feeding jejunostomy was carried out. At the end of the procedure, a left-sided cervical loop oesophagostomy was performed. The entire procedure lasted 150 minutes and blood loss was approximately 300 cc. No ventilatory support was required postoperatively. Jejunostomy feeds were started on the second postoperative day. On the fifth postoperative day, the patient was off IV antibiotics and on full jejunostomy feeds. During the course in the hospital he developed lower zone consolidation, which was treated with aggressive chest physiotherapy and IV antibiotics. The cervical o

[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 herein present a case that was recently managed at our institution, the Department of Surgery of the San Camillo Forlanini Hospital of Rome, Italy.
A 53-year-old man with previous history of alcohol-related liver cirrhosis presents to our department for routine follow-up. His comorbidities include hypertension managed with oral antihypertensive drugs and diabetes mellitus type 2. He has no significant allergies and never underwent any surgical procedure. He brings an ultrasound, which shows a 4 cm heterogenous mass in segment 8. His alfafetoprotein level is elevated to 76 ng/mL. He has no symptoms and looks in good performance status. We scheduled him for a triphasic CT scan, which shows a lesion of 4.3 cm with brisk arterial contrast and venous washout. According to the LIRADS classification, this lesion could be considered a class 5 with diagnostic features of hepatocellular carcinoma. The patient was discussed in our multidisciplinary tumor board including hepatobiliary and transplant surgeons, hepatologists, radiologists, pathologists, oncologists, and interventional radiologists. The plan was to submit the patient to curative intent treatments given his early presentation according to the Barcelona Clinic Liver Cancer Staging System (BCLC), namely surgical resection or liver transplantation; radiofrequency ablation was excluded given the tumor’s dimensions. Given the good performance status, the position of the lesion (which was right below the Glissonian capsule) and the liver function of the patients, the MDT decided to schedule the patient for surgery. We therefore saw the patient in clinic and discussed the procedure. Informed consent was signed, and liver function was tested using ICG retention rate. We used 0.5 mg/Kg corresponding to 40 mg in this 80 kg patient. The DICOM data of the CT scan of the patient were then submitted to our radiologist who performed a 3D reconstruction of the patient’s anatomy and the relationship of the lesion with the major

[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 14-year-old male was referred to the Department of Dental Medicine complaining of occasional pain and a mucous fistula which persisted for one year in his upper right central incisor. When history was elicited, the patient revealed that there was a fall two years back in school due to which he sustained fracture of his maxillary permanent central incisors. Both teeth underwent endodontic treatment in a private office. According to his medical history, the patient exhibited no systemic disease.
His extraoral examination was noncontributory. Intraoral examination revealed enamel-dentin fracture involving the incisal edge in tooth #11, in the upper right lateral incisor region (). Periodontal probing revealed deep narrow pockets on both facial of tooth 12 and palatal root surfaces of tooth 11 of 5 and 6 millimeters, respectively, while the other teeth showed a nonpathologic probing depth of value of 2-3 mm. Pulp sensibility tests showed a negative response in tooth #12. Radiographic evaluation was performed using a film holder which showed the relationship with tooth #12; both central incisors were endodontically treated (). Endodontic treatment of tooth #12 was planned (). A 3-month follow-up appointment and coronal restoration of teeth #12 and 11 was scheduled, followed by another appointment 3 months later, but the patient consulted us only 2 years later complaining of the recurrence of the Fistula. A periapical radiograph with film holder has built evidence to show the relation with tooth #12 (). A Periapical surgery was carried out and revealed a proliferation of granulation tissue around the apex of the lateral incisor (). Periapical curettage followed by a 3 mm root-end resection of tooth #12 () was conducted. After Retrograde root preparation, retrograde filling was performed with glass ionomer cement. The radiological control after root-end filling showed cement excess ().
A follow-up appointment was given 3 weeks later. The reappearance of the sinus tract w

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old Indian man presented to our Out-patient Department with complaints of pain and pus discharge from his left proximal leg for four weeks. He was unable to bear weight on his left leg and had a stiff left knee. He had sustained a left frontal extra-dural hemorrhage with depressed frontal bone fracture and an open fracture of his left proximal tibia in a road traffic accident five weeks ago. He was treated elsewhere with excision of the depressed skull bone fragment and evacuation of the extra-dural hematoma. Open reduction and internal fixation of the proximal tibia fracture with a medial locking compression plate (LCP®; stainless steel) was performed on the same day using a ‘Mercedes-Benz’ incision. Post-operatively, he was given a knee brace. Our patient developed pus discharge from the surgical wound in the proximal third of his leg three to four days after surgery. As the infection could not be controlled with antibiotics, he was referred to us for further management.
On examination, there was a Y-shaped scar over the left knee reaching up to the middle third of the leg with three sinuses on the suture line. There was an infected wound of size 4×4cm over the proximal third of the leg exposing necrotic, infected patellar tendon. The medial LCP® implant was also exposed (Figure
). The left knee was mildly subluxed posteriorly and he had a 10° fixed flexion deformity of his left knee with minimal further flexion. He also had an equinus contracture of his left ankle. A pus sample was sent for culture and sensitivity testing and it showed heavy growth of Pseudomonas, sensitive only to imipenem and meropenem. We decided to perform a single stage debridement, with removal of the exposed LCP® implant, reconstruction of the extensor mechanism and fracture stabilization with a knee-spanning external fixator. He was counseled about the need for surgery and the proposed treatment plan and the prognosis was also discussed.

[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 female patient in her 30s was referred to our institution with a complaint of persistent cough. Chest radiography revealed a mass in the right middle lung field (). Noncontrast CT showed a mass approximately 8 centimeters in diameter with relatively smooth margins in the right lung segment 6 (). A malignant lung tumor was suspected and fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) was done. FDG accumulation was seen in the lung mass (standardized uptake value max. 3.6) as well as in the mediastinum suggesting a malignant lung tumor with mediastinal lymph node metastasis (). Bronchoscopy revealed a tumorous lesion obstructing right B6 (). Biopsy of this lesion showed proliferation of spindle cells raising suspicion of sarcoma or spindle cell carcinoma.
Next, contrast-enhanced CT was done, and it showed that the mediastinal lesion pointed out on FDG-PET/CT was actually a continuous extension of the lung mass into the right main pulmonary artery. A skip lesion was also suspected in the periphery of the pulmonary artery trunk ().
Lung ventilation-perfusion scan showed that the right lung was not perfused although sufficiently ventilated. On echocardiography, heart wall motion was intact and no signs of right heart failure were seen.
Collectively, a sarcomatous lung tumor with extension into the right pulmonary artery trunk or PAS with extension into the right lung was suspected. The patient underwent surgical resection of the tumor under cardiopulmonary bypass through a median sternotomy. The existence and localization of the skip lesion was first confirmed by transthoracic and transesophageal echocardiography. Venous cannulas were placed in the right atrium and the femoral vein, and an arterial cannula was placed onto the femoral artery, and surgery was carried out with the heart beating. The left pulmonary artery was carefully dissected so as not to perturb the skip lesion and was clamped just proximal to the origin of left A3. Although the tumor fill

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old man presented in neurology service with pain in the legs, bilateral foot drop and numbness in the medial aspect of the left forearm of 2 weeks duration. Examination showed pupura and on positive questioning he admitted bleeding from gums starting 2 days prior to neurological symptoms. At the age of 12 years, he had multiple blood transfusions and was told to have aplastic anemia, but a detailed medical report was not traceable. At the age of 22 years, he had an acute hepatitis B infection when the blood counts and hematocrit were documented to be normal.
At the time of index admission, he had anemia and multiple purpuric skin lesions []. Systemic examination otherwise was normal. Clinical neurological examination revealed sensory motor involvement of the left radial, left ulnar, right common peroneal and left sciatic nerves suggesting a mononeuritis multiplex. No significant hematomas were seen on the overlying skin of these nerves. An electrophysiology evaluation showed the sensory motor involvement of the left ulnar, left median, left radial, right median, right common peroneal and left sciatic nerves confirming mononeuritis multiplex. There were conduction blocks demonstrable in right peroneal and left ulnar nerves []. After the neurological investigations, he was referred to a Government teaching hospital where his subsequent hematological workup was done.
His hematocrit was 33%; total leukocyte count, differential count, and erythrocyte sedimentation rates were normal. The platelet count was grossly reduced to just 5000 cells/cu mm and the bleeding time was prolonged to 9 min. Clotting time, prothrombin time and activated partial thromboplastin time were normal. Corrected reticulocyte count was 2.9% and peripheral blood smear showed marked thrombocytopenia []. The serum bilirubin was marginally elevated to 1.86 mg/dl with the predominant indirect component. Both direct and indirect coomb's tests were negative. Measurements of serum sodium, potassi

[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 75-year-old woman was admitted to our hospital for 1 h of persistent severe chest pain. Apart from smoking, she had no cardiac risk factors. At the time of admission, the electrocardiogram showed ST-segment elevation in leads I,avl. Laboratory data showed that the serum creatine kinase and troponin I had elevated. According to the results of electrocardiogram and laboratory data, STEMI was definitly diagnosed. Primary percutaneous coronary intervention (PCI) was indicated immediately. The coronary agiography (CAG) revealed triple vessel disease with left circumflex as the culprit which was occluded in the proximal segment (Fig. ).
With the indication of aspiration thrombectomy and percutaneous coronary balloon dilatation, the coronary reperfusion therapy was achieved (Fig. ). The symptom of chest pain was relieved. Meanwhile, the cardiac surgeon was invited for consultation, and his recommendation was to complete the CABG surgery after the acute phase of AMI. We ended the operation because the goal of primary percutaneous coronary intervention was achieved. The initial course went well, and the patient’s condition was stable gradually after PTCA. However, she suddenly exhibited severe chest pain, dyspnea, agitated, and profuse sweating 6 days after hospitalization. Physical examination indicated a blood pressure of 79/44 mmHg, a heart rate of 98 beats/minute. An electrocardiogram examination did not show ST-segment elevation again. She was given dopamine to raise the blood pressure and fluid to maintain the circulation capacity immediately. The patient presented cardiac syncope suddenly following the onset of atrial fibrillation with a heart rate of 140 beats per minute after half an hour. In consideration of further hemodynamic impairment caused by tachyarrhythmia, electrical defibrillation was urgently administered to restore sinus rhythm. Emergency echocardiography demonstrated pericardial tamponade. After pericardiocentesis with ultrasound guidance and continu

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

[User]
RADIOLOGY NOTE:
A 45-year-old female patient presented initially to the primary care clinic with symptoms of dyspnea, cough, and wheezing along with anterior abdominal wall tenderness. She had a medical history significant for bilateral venous insufficiency, smoking, obesity, and bipolar type II disorders. The patient tested negative for coronavirus disease 2019 and was sent home with a provisional diagnosis of viral respiratory infection. Her condition showed mild improvement with conservative supportive treatment.
After four months, the patient presented to the emergency department with complaints of epigastric abdominal pain, nausea, vomiting, and diarrhea for the past month. Initial laboratory workup in the emergency department was significant for an elevated creatinine of 1.42 mg/dL, C-reactive protein (CRP) of 6.2 mg/L, and an erythrocyte sedimentation rate (ESR) of 41 mm/hour. The polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 was negative. Before diagnostic imaging, a 2 L bolus of normal saline fluid was administered intravenously followed by maintenance fluid. CT scan of the abdomen and pelvis with contrast was significant for RPF, periaortitis involving the distal aorta and its bilateral common iliac arteries, decreased perfusion of the left kidney with mild hydronephrosis, and obstruction of a portion of the left distal ureter (Figure ). A high-resolution chest CT scan reported multiple small areas of clustered cystic and/or emphysematous changes scattered throughout the lungs and a few ground-glass nodules in the right lung apex.
Interventional radiology was consulted for a percutaneous biopsy of retroperitoneal fibrotic tissue but it was not completed due to a safe window being inaccessible. In addition, urology was consulted due to left hydronephrosis and for intra-ureteral biopsy. X-ray urography with left retrograde pyelogram showed stricture of the left ureter at the distal third region. Therefore, a stent was placed in the left

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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:
Our patient was a 58-year old female, diagnosed with CLL in 2002. Abnormal lymphocytes showed expression of CD5, CD19, CD20, CD22, CD23 and immunoglobulin kappa light chain by flow cytometry. Ubiquitous enlarged lymph nodes were detected. The patient was asymptomatic. First line treatment was required 2003 due to increasing leukocytosis and lymphocytosis accompanied by advancing anemia and thrombocytopenia. The patient was treated with chlorambucil and prednisone (Knospe protocol) according to local standards and therapeutic possibilities at that time. After achieving a partial remission persisting approximately one year, the patient was retreated with continuous chlorambucil for one month but showed no response. Four cycles of oral fludarabine were administered achieving a partial remission for four years. The following two relapses of the disease were treated again with fludarabine, of which the latter course was mainly due to patient’s preference. After documenting resistance to fludarabine the patient agreed to administration of five cycles rituximab in combination with bendamustine. A partial remission could be achieved. Rituximab and bendamustine were used for treating the following relapse 1.5 years later, achieving a partial remission for another eight months. Afterwards the patient received ibrutinib within a clinical trial, but showed progression of disease after only four months of treatment. Massive progression of lymphadenopathy was apparent at that time. Therefore, a lymph node biopsy was done showing a diffuse infiltration with small lymphocytic cells partially resembling centroblasts or immunoblasts, though transformation to an aggressive lymphoma could not be demonstrated. According to the clinical behavior of the disease, rituximab plus CHOP were administered but progression occurred after three cycles of treatment. Alemtuzumab was then administered achieving stabilization of the disease for another year. Ultimately, the patient was treated with le

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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 34-year-old female with no past medical history was transferred to our emergency department from an outside hospital due to concern for intra-abdominal bleeding. She initially presented with lower abdominal pain immediately following vaginal intercourse described as nonvigorous with the patient mostly ‘on top’, and no history of foreign body use or trauma. CT of the abdomen and pelvis with IV contrast performed at the outside hospital revealed an intra-abdominal hematoma with extravasation of contrast questionably from one of the branches of the left internal iliac artery (Figs and ). No adnexal lesions were identified on the CT. Upon arrival, the patient was complaining of constant, sharp, severe bilateral lower quadrant abdominal pain, nausea and fatigue. There was no history of loss of consciousness, vomiting, vaginal or rectal bleeding, or hematuria. A past surgical history consisted of appendectomy. Her last menstrual period was 19 days prior to presentation.
On examination, the patient was in painful distress. Vital signs were stable. Abdominal examination revealed bilateral lower quadrant and suprapubic tenderness with guarding. Perineal and genital examination revealed no evidence of trauma. Laboratory investigations revealed a white cell count of 12 200/mm3 and hemoglobin of 9.5 g/dl. Basic metabolic panel, partial thromboplastin time, international normalized ratio, lipase, ethyl alcohol level and urinalysis were normal. β-hCG was negative for pregnancy.
Based on the CT scan findings, interventional radiology was consulted and selective left internal iliac artery angiogram was performed and identified no active extravasation or pseudoaneurysm. Exploratory laparotomy was then performed to identify the source of bleeding. Preoperatively, blood pressure was 97/47 and the heart rate was 76 bpm. Upon entry to the peritoneal cavity, 900 ml of hemoperitoneum was observed and washed out. Active bleeding was identified from a ruptured area on the left ovary and c

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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:
This was a 40 year old, premigravida patient who initially presented to the infertility clinic at our institution for desired pregnancy. Her past medical history was significant for primary infertility. A successful intrauterine pregnancy was achieved via intrauterine insemination. Due to advanced maternal age, the patient underwent extensive prenatal testing and monitoring through the course of her pregnancy. All tests were normal, with the exception of a left ovarian mass that was incidentally detected by ultrasound during the third trimester. The patient was closely followed without prenatal surgical intervention. Her pregnancy advanced uneventfully, and labor commenced at 40-week gestation. Due to failure to progress, a caesarean section was performed resulting in the delivery of a healthy female infant. At the time of caesarean section, a left oophorectomy was performed.
The specimen was received fresh for intraoperative pathology consultation. On gross examination, it consisted of an intact, unilocular, thin-walled cyst measuring 15 × 12 × 5 cm and filled with clear fluid. Both the outer and the inner surfaces of the cyst were smooth. The cyst wall ranged from 0.1 cm to 0.8 cm in thickness and showed marked edema. Based on the gross findings, an intraoperative interpretation of benign ovarian cyst was made. No frozen section was performed.
On subsequent microscopic examination, the cyst was lined by single to multiple layers of large cells with abundant eosinophilic cytoplasm (Figure ). Most cells showed small, round and regular nuclei, but focal cells displayed enlarged and bizarre nuclei with hyperchromasia and occasional mitosis (Figure ). The outer fibrous wall of the cyst showed edema and nests of luteinized cells that were morphologically similar to the cyst lining cells. Special stain showed reticulin fibers around nests of luteinized cells in the cyst lining (Figure ) and in the outer cyst wall. Adjacent residual ovarian tissue exhibited a corpus luteu

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old man with history of prior myocardial infarction presented to our hospital with chest pain and shortness of breath; 8 months previously, the patient had been treated at the local hospital for ST segment elevation myocardial infarction with acute high lateral wall injury. He was treated with thrombolytic therapy. The patient was discharged without an echocardiogram and cardiac catherization due to limited resources, and he had not had a follow-up with a cardiologist because both doctors and the patient did not pay much attention to his condition as the symptoms had almost disappeared by then. Recently, our patient had been complaining of intermittent and slight chest pain, shortness of breath at rest, and frequent awakening due to chest distress at night for a duration of 2 weeks.
Results of a physical examination indicated a blood pressure of 145/85 mm Hg, a heart rate of 88 beats/minute, a slightly expanded left margin of the heart, and a continuous 3/6 grade murmur between the third and fourth intercostal spaces at the left sternal border. An electrocardiogram examination revealed qR in leads I and aVL and inverted T-waves in leads I, II, aVL, and V3 to V6. Echocardiography showed a 13.1 × 8.8 cm limited oval anechoic area with a distinct boundary at the lateral posterior of the left ventricle, which was connected to the left ventricle at the basal segment of the lateral posterior wall of the left ventricle. Color Doppler sonography showed two streamlines of blood flow with a distance of 0.7 cm between the anechoic area and the left ventricle. Three-dimensional ultrasound indicated an echo dropout in an oval area in the basal segment of the lateral left ventricular wall, with a stroke volume (SV) of 70 mL, an ejection fraction (EF) of 63% and a cardiac output (CO) of 5.3 l/min. It indicated AMI and a perforation in the lateral wall of the left ventricle suggestive of a ventricular

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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 25-year-old woman presented with four days of moderate to high fever (104oC) and headache followed by progressive weakness. On the third day, she was suffering from vomiting five times in three hours, which ultimately weaken the patient. After four days of fever and headache, she consulted a doctor who had prescribed her paracetamol and advised to perform some clinical investigations such as complete blood count (CBC), dengue NS1, and the Widal test. The Widal test report was found to be negative, but the dengue NS1 test was reported positive. After consultation with the doctor, she got admitted to the hospital.
After hospitalization, all the tests were conducted again, including the immunoglobulin M (IgM) antibody test and the factor VIII test. The results confirmed DF along with haemophilia A. On examination, the patient was found to be severely dehydrated with low blood pressure (60/85 mmHg) and was managed with continuous intravenous infusion of a multivitamin containing normal saline. Paracetamol was continued as the only drug for the treatment but headache and body pain were not alleviated. Platelet count was decreasing rapidly and due to continuous intravenous (IV) infusion, the patient developed cold and nasal congestion. Xylometazoline hydrochloride 0.1% drop was prescribed to treat nasal congestion, as the patient experienced mild breathing problems. On the second day, after the automatic cell counting test, the patient was found to be suffering from lymphopenia and leukocytopenia (Figure ).
The different haematological parameters were monitored continuously during the hospital stay (Table ).
On the fourth day, in the morning, the platelet level dropped to 31 x 10^9/L and the patient experienced bleeding from the nose with a mild earache. Tranexamic acid 100 mg/ml was administered to reduce the bleeding, which stopped completely after two days. An ultrasonogram of the whole abdomen revealed mild hepatomegaly with infiltration of the liver, splenomegaly,

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old girl was having a bath at approximately 11 pm. She wore a moisturising gel mask covering most of her face, the only exposure to the air was via the apertures over her eyes and mouth. The lower half of her body lay completely submerged beneath the water, leaving her upper chest, arms and head above water. She had been using a commercially available pliable bubble foam spray manufactured to produce bubbles in the bath, and these had covered the surface of the water. The windows of the bathroom were left opened throughout and scented tea candles were placed along the peripheries of the bath. She accidently tipped one of the scented tea candles into the bath causing an immediate purple flash flame which engulfed her upper torso. She immediately commenced first aid comprising of a cold water shower over 20 min. She then presented to the local regional burns centre. On examination, her airway was patent with no sign of inhalational injury on oropharyngeal examination. However, she sustained partial thickness burns to her lips, face, right upper breast, neck and right arm which were patchy in distribution. There was also singing of eyelashes bilaterally but sparing of the eyebrows as these were covered by the face mask. Her lips appeared grossly oedematous and were the worst affected area, this was probably due to the aperture in the gel mask exposing this area. No ocular injury was noted on fluorescein examination. Final estimation of total burn surface area (TBSA) post debridement of blisters was approximately 1.5% superficial partial thickness burn with larger areas of surrounding erythema. She was managed conservatively with topical paraffin ointments and silicone dressings. Given the severity of lip burns, and the nature of flash burn which occurred in a small room, she was admitted for overnight for airway observation and pain management, and was discharged 24 h later ().

[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 37-year-old female patient presented with the chief complaint of swelling in the right side of the palate of 1-month duration associated with dull, intermittent pain. History revealed that the patient had applied rock salt over the swelling to alleviate pain. Medical history revealed that the patient was undergoing infertility treatment for 7 months and had undergone surgery for uterine fibroid 6 years back. There was no history of dry eyes, dry mouth, joint pain or weight loss. The patient was a nonsmoker and nonalcoholic and had no tobacco chewing habits.
On intraoral examination, a single diffuse ovoid swelling measuring approximately 1.5 cm × 1 cm was present on the right side of the posterior hard palate []. The surface of the swelling was predominantly smooth with a focal shallow ulceration in the center. On palpation, the swelling was nontender, soft to firm in consistency and fluctuant. No tooth in the quadrant was tender on percussion. There were no clinical signs of dental caries or periodontal disease.
Intraoral periapical radiograph of the right maxillary first molar and maxillary lateral occlusal radiographs revealed no significant changes. Cone-beam computed tomography of maxilla revealed a soft-tissue shadow in the right side of the hard palate in relation to maxillary right first molar with pressure effect on adjacent bone and thinning of cortical bone with no evidence of breach in the continuity of bone [Figures and ]. There was no periapical lesion in relation to maxillary right premolars and molars. We excluded a palatal abscess or a cyst by clinical and radiographic examination. The ulceration was shallow, associated with a smooth swelling and likely to have been caused by the abrasive effects of rock salt and hence necrotizing sialometaplasia was considered unlikely. Hence, a provisional diagnosis of benign salivary gland tumor or cyst was made with the differentials of malignant salivary gland tumor and nonodontogenic soft-tissue neoplasms.
U

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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 forty-year-old G3, now P2012, underwent a spontaneous vaginal birth after cesarean section presented to labor and delivery in active labor at term. The patient delivered a viable female infant weighing 3757 grams with APGARs of 8 and 9 at 1 minute and 5 minutes, respectively. Following spontaneous delivery of the placenta, the fundus was noted to be slightly prolapsed through the internal os. A fourth degree laceration occurred at the time of delivery due to the emergent maneuvers utilized to replace the uterus. Brisk vaginal bleeding was noted and 500 cc of blood clot was removed the uterus. Given the patient's inability to tolerate the exam, 1000 mcg of cytotec was placed rectally and the patient was moved to the operating room where general anesthesia was administered. Manual exploration of the uterus was again performed and an additional 1000 cc of blood clot was removed and an anterior fibroid with partial prolapse of the uterus was noted. The fundus was manually replaced superiorly and attention was then turned to the 4th degree laceration which was repaired in standard fashion without complication. Following the 4th degree repair, the uterus was noted to be atonic again and uterine massage and manipulation elicited an additional 500 cc of blood clot. The patient was given two doses of hemabate 250 mcg and the uterus was noted to be firm and hemostasis was confirmed. Total blood loss at the time of delivery was estimated to be 4.5 liters and the patient received 8 units of packed red blood cells (pRBCs) and 4 units of fresh frozen plasma. The postpartum course was uncomplicated and she was discharged home on postpartum day three.
At seven weeks postpartum the patient presented to the local health department with complaints of persistent vaginal bleeding since delivery. Upon speculum exam, she was noted to have a 5 cm prolapsed vaginal fibroid and was referred to the local tertiary center. Initial gynecology exam confirmed a prolapsing vaginal fibroid and she

[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 48-year-old female came to our observation due to a limitation in mouth opening range. She also reported crepitus sounds at the left TMJ as well as pain, exacerbated by function (e.g., chewing) and increasing in intensity over the past three months. Clinical assessment showed a limited mouth opening (i.e., 22 mm) and pain with palpation at the left joint and all the main masticatory muscles, more severe on the left side. At the first appointment (T0), mandible manipulation was performed to achieve a forced opening of about 40 mm. A magnetic resonance (MRI) was prescribed to assess the disc-condyle relationship as the possible source of limitation in mouth opening and to gather some pictorial evaluation of the presence of joint effusion (). Despite the clinical suspicion of TMJ arthritis, computerized tomography was not prescribed at this stage due to the expected low impact on treatment planning decisions.
MRI showed a regularly shaped condyle, with an anteriorized disc at closed mouth. At the maximum mouth opening, the condylar translation is reduced and the disc is not recaptured. Joint effusion of severe entity is also present. A conservative approach to provide pain relief and to manage muscle tension was provided, based on counseling, a home program of self-exercise and a stabilization appliance to wear at night. After three months, symptoms improved only partially, with a reduction of pain with muscle palpation but a steady pain at the left joint.
Based on that, a cycle of five arthrocentesis plus viscosupplementation with hyaluronic acid (Sinovial, IBSA) has been performed weekly. Clinical data has been recorded at each time point before each injection and 15 days after the last one ().
After one month from the last arthrocentesis plus viscosupplementation, the patient still showed some pain and, more important, still felt a limitation in the unassisted mouth opening and right laterotrusion. A diagnosis of TMJ intermittent locking on the left side was thus

[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 45-year-old man, long time tobacco smoker, presented with two week history of marked thyroid pain and swelling. He also reported fever (up to 39 °C), weight loss and hoarseness. The patient’s GP initially diagnosed SAT based on the pain, fever and high ERS and started treatment with NSAID with initial pain relief. After a few days the severe pain relapsed despite treatment, and the patient was referred to hospital. In our Department his ESR was 93 mm/h and biochemical features of thyrotoxicosis were present, which may indeed strongly suggest SAT. In the neck, there was a hard, painful tumour, about 7 cm in size. The laboratory results obtained in our Department are presented in Table . US revealed slightly enlarged right thyroid lobe and significantly enlarged left lobe (65 × 57 × 101 mm) dominated by a heterogeneous tumour size of 55 × 50 × 72 mm, with numerous calcifications and a heterogeneous fluid space corresponding to abscess (Fig. ). Tumour vascularisation was reduced. Almost the entire left lobe showed a faded structure of the parenchyma, with no evidently visible capsule, with features of infiltration of the neck structures. FNAB confirmed the presence of abscess, and after introduction of antibiotic therapy, the concentration of free thyroxine (FT4) gradually normalized. In the remaining FNAB material only blood and numerous granulocytes and macrophages were described. Neck CT revealed large tumour of the thyroid, with visible compression and displacement of the trachea and infiltration of the surrounding structures (Fig. ). In chest CT, in both lungs, numerous milk-glass areas were present and the CT image corresponded to the diagnosis of lympangiosis carcinomatosa. The patient was referred to a surgery clinic, where only a small piece (20 mm) of the neck tumour was wedged to release the trachea; the complete surgery was impossible due to the extent of infiltration and hardness of the tumour. Histopathologically purulent necrosis was mostly observed, b

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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:
Our patient is a morbidly obese (375 lbs) 58-year-old woman who presented to the head and neck surgery clinic with a right parotid mass and intact facial nerve function. She underwent a fine needle aspiration which was consistent with a Warthin's tumor. CT imaging demonstrated a 5.8 cm right parotid mass. She was scheduled for surgery, but was lost to followup. She presented again to the head and neck surgery clinic one year later with significant interval growth of the mass and a partial right facial paresis (Figures and ). A CT scan demonstrated a 11.2 × 9.4 × 10.7 cm mass centered in the right parotid effacing the jugular vein and abutting the mandible and skull base with extension along the facial nerve to the geniculate ganglion (Figures and ). She was taken to the operating room and underwent a radical parotidectomy with facial nerve sacrifice, radical neck dissection, parapharyngeal space resection, and lateral temporal bone resection (Figures , , and ). The tumor was found to be invading the jugular foramen requiring occlusion of the sigmoid sinus and packing of the jugular foramen for vascular control. The tumor was also noted to be extending medially to the geniculate ganglion of the facial nerve. Gross tumor removal was accomplished (). We were not able to obtain a negative margin on the proximal facial nerve; thus, the ipsilateral masseter nerve was grafted to the buccal and marginal mandibular branches of the distal facial nerve. Her face was further rehabilitated with a static palmaris longus sling and temporary tarsorraphy, which was later replaced with a gold weight. The defect was reconstructed with a large cervicofacial rotation flap and a radial forearm free flap (). Pathologic examination revealed a 14 cm low-grade acinic cell carcinoma with extensive perineural and lymphovascular spread. The lymph node dissection yielded 29 lymph nodes, all of which were negative for malignancy. Postoperatively, she received 6000 cGy in 30 fractions using intens

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

[User]
RADIOLOGY NOTE:
A 35-year-old gravida 4 para 3 with a history of three previous cesarean deliveries presented at 16 weeks 6 days of gestation for follow-up ultrasound of perigestational hemorrhage seen at 10 weeks and 4 days. A large uterine cavity pseudoaneurysm measuring 4.2 × 3.8 × 3.7 cm and appearing to arise from abnormal placentation at the previous cesarean scar was identified (). Repeat ultrasound six days later revealed a normal active fetus in breech position compressing the pseudoaneurysm upon contact. An unenhanced MRI one week later confirmed a 4 cm hypointense lesion projecting into the lower right uterine cavity at the inferior margin of the placenta (Figures and ). Management options were discussed to include conservative imaging observation versus embolization. Due to high maternal mortality risk from spontaneous hemorrhage, elective termination was also discussed but was rejected by the patient.
A novel use of dynamic time-resolved contrast-enhanced MRA utilizing a functional MR urography protocol™ was performed for enhanced characterization of feeding arteries and treatment planning/mapping []. The specific MRA parameters utilized can be viewed in detail online at . Although not FDA-approved for a second trimester fetus, Gadobutrol® contrast agent was selected to reduce risk of gadolinium deposition. Gadobutrol is a macrocyclic agent that imparts strong chelation of the substrate to gadolinium. It reduces potential toxicity from free gadolinium and, at the time, was the only FDA-approved agent for patients below 2 years of age (down to 37 weeks of gestation). Gadobutrol was dosed per the manufacturer's protocol with recommended weight-based dosing of 0.1–0.3 mmol/kg. Informed consent was obtained for this unique use of MRA at 20 weeks of gestation.
MRA revealed two suspected feeding vessels: a branch off the right ovarian artery parasitized to the uterine arcuate artery () and a branch off the right uterine artery parasitized to the uterine arcuate and radial ar

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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:
Our hepatobiliary surgery outpatient department accepted a 66-year-old woman, who presented with a year-long history of aggravating abdominal discomfort that was mainly associated with distension and symptoms such as epigastric fullness, eructation, decrease of food intake and early satiety. She did not report any loss in body weight. A physical examination revealed a palpable mass in the upper abdomen, extending from the right hypochondrial region to the left hypochondrial region, with ordinary consistency and a smooth surface. Her liver and spleen were not palpable distance from the costal margin, and were not tender on palpation. All routine blood and biochemical markers were normal. The levels of tumor markers assessed, including carbohydrate antigen 125 and carcinoembryonic antigen, were within the normal ranges.
An upper gastrointestinal barium series revealed the antrum, fundus and body of her stomach, as well as the jejunum, were prominently compressed and infraplacement (Figure ). However, the gastroscope examination did not show any abnormality. An abdominal ultrasound revealed a sharply defined mass with an intact capsule and opaque dark areas of fluid detected in the middle region, suggestive of a huge cystic solid myoma. We were not able to identify any connection between the adjacent organs and the mass because the tumor was too large to obtain a clear view.
Enhanced abdominal computed tomography (CT) scans demonstrated a deformed liver of abnormal size and structure, and a large low-density region featuring a well-circumscribed border that overlay the entire left liver and partially overlay the right liver. The tumor contained inhomogeneous cystic components mixed with solid elements (Figure ). In the arterial phase, complete filling of the tumor with contrast material was never observed; patchy enhancement indicated possible tumor necrosis in the low-attenuation areas. The area of lower density also did not enhance completely on delayed scans. There

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

[User]
RADIOLOGY NOTE:
An 87-year-old male presented 9 months post TAVR at another institution with PVR complaining of NYHA class III symptoms of increasing fatigue, dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. A 26 mm Edwards Sapien 3 bioprosthetic TAVR valve had been implanted, but the intraoperative sizing at that time was based on transesophageal echocardiography (TEE) instead of CT scan imaging. Unfortunately, that procedure was also complicated by a Stanford Type B descending thoracic aortic dissection that required emergent thoracic stent coverage to treat visceral malperfusion. The patient developed mesenteric ischemia requiring bowel resection. After a prolonged hospitalization, he was found to have moderate aortic regurgitation on follow-up echocardiography, which was managed medically until his presentation to our center.
Physical exam revealed a diastolic murmur and 1+ lower extremity edema. A TEE revealed moderate paravalvular aortic insufficiency comprised of two jets: the largest was along the postero-medial aspect including approximately 20% of the valve circumference, while a smaller jet was along the antero-lateral aspect of the valve and involved an additional 10% of the valve circumference. TEE also showed dilation of the mitral annulus with subsequent moderate mitral regurgitation and reduced left ventricular ejection fraction of 40% to 45%.
Given his frailty, comorbidities and history of aortic dissection he was not an open surgical candidate. Transcatheter methods including Amplatz plug versus redo-TAVR were considered and the patient underwent computed tomography evaluation of the aortic root and review of his previous left heart catheterization.
Given the multiple jet PVR consensus formed that ViV TAVR would be a superior solution to surgical or transcatheter placement of vascular occluder devices. Based on repeat computed tomography and transesophageal imaging we hypothesized the initial valve was undersized, resulting in the multiple foci of

[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, a 30-year-old Tibetan man, was treated in the Lhasa Hospital for right tibiofibular fracture December 2012 (Fig. ). After the swelling subsided, he underwent right tibia fracture intramedullary internal fixation. Two weeks after the operation, the patient was able to walk with double crutches without load, and was able to walk without crutches and with some load 3 months after the operation. However, the patient complained of pain in his right lower extremity, especially when moving downhill or down stairs, and experienced a limping gait and obvious tenderness at the fracture end. Three years after originally presenting at Lhasa Hospital, the patient was experiencing persistent pain in the right lower extremity, and his daily activities were severely affected. Thus, he was re-diagnosed with nonunion of the right tibial fracture after internal fixation (Fig. ). The main causes of the nonunion of the fracture were considered to be the excessively thin intramedullary nails and unstable fixation of the fracture. The operation was repeated with replacement of the crude intramedullary nails and grafting of iliac bone (Fig. ). Three months after the operation, the tibial fracture had failed to heal, and further surgical treatment was performed. The proximal locking screw of the intramedullary nail was removed with an expectation to eliminate the stress shielding effect and to promote fracture healing by increasing the microdynamic force while retaining the static interlocking nail. Five months after the operation, the patient abandoned the crutches and was able to walk with a heavy load. Nevertheless, 2 years after the operation, active pain of the right leg persisted with some tenderness around the fracture, especially when moving downhill or down stairs. August 2018 the patient was admitted to our hospital. Physical examination revealed that two old incision healing scars, approximately 2 cm in length, were present at the proximal and distal ends of the righ

[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 57-year-old man who presented in July 2009 with decreased vision bilaterally, left sided facial weakness, ataxia, and short-term memory loss. The patient had also presented previously with a history of seizures, most recently a few months prior to the current presentation. A craniopharyngioma or another parasellar mass was suspected, and an ophthalmology consult was obtained.
MRI showed a large intrasellar mass with considerable suprasellar extension and chiasmatic compression with the displacement of the inferior frontal lobe. There was also hydrocephalus with gross enlargement of the lateral and third ventricles (). A hormone panel showed increased levels of FSH and LH of 46.3 mIU/mL and 12.3 mIU/mL, respectively. Plasma ACTH, IGF-I, growth hormone, prolactin, total cortisol, and testosterone were all within normal limits. CSF analysis identified no malignant cells.
The patient was determined to be an excellent candidate for surgery, the only other comorbidity being glaucoma treated with Lumigon. Because of the location of the tumor, it was decided that the patient would undergo a right pterional craniotomy/transsylvian approach for the resection of the tumor and the placement of a ventriculostomy catheter. After placement of a ventriculostomy catheter, the major part of the craniotomy followed. The first line of incision was made in a curvilinear fashion that began at the area 1 centimeter anterior to the tragus of the ear near the root of the zygoma. It curved superiorly up around the temporal bone and parietal bone and then extended toward the midline frontal bone. Dissection proceeded to expose the appropriate amount of cranial anatomy. The tumor was eventually exposed by opening up the sylvian fissure to separate the frontal lobe from the temporal lobe. The tumor was noted to have both cystic and solid components. Fluid aspirated from the cystic component was thick and yellow, with the appearance of oil or cholesterol. There were odd appearin

[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 man presented to the emergency department of a general hospital with progressive weakness of the right side of his body and speech difficulties, 3 years after his first transient ischaemic attack. Five days previously he had attended the emergency department because of loss of strength in his right foot. Examination at that time, at the department of neurosurgery, revealed a disc herniation, providing an explanation for his symptoms, and surgery was planned. In the following days, he developed new complaints, with difficulty speaking and movement problems of both the right arm and right leg. When he could no longer take care of himself, he again attended the emergency department, where investigation revealed a semirecent ischaemic stroke.
He had a history of diabetes mellitus type II, a transient ischaemic attack in 2016 (occlusion of the arteria cerebri media on the right side) with complete recuperation, and back surgery. On clinical examination, he was alert, but showed delayed movements on the right side. Cranial nerve examination was normal, except for a slight paresis of the facialis nerve on the right side. There was a right-sided hemiplegia, hyperreflexia and sensibility disturbances. There was spasticity grade 2 on the modified Ashworth Scale in the upper extremity and grade 1 in the lower extremity. There was dysarthria and word-finding problems. An unexpected sign was that he was unable to release his grip in the Jamar and pinch test. He was oriented in place and time, but there were moderate deficits in concentration and attention. There were no arguments for visual neglect. There were slight extrapyramidal symptoms, which were new and had not previously been described in his medical history. For treatment of his extrapyramidal symptoms, the neurologist was started medication (Prolopa, Levodopa, Roche Belgium) without further investigation.
Brain magnetic resonance imaging (MRI) revealed hyperintense signal changes periventricular to cortic

[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 was referred to our hospital with liver masses in an ultrasound study that was requested because of vague upper abdominal pain. She also mentioned mild nausea that started one month earlier. Medical history revealed three normal vaginal deliveries and she was receiving medroxyprogesterone acetate injections every 3 months for contraception.
The patient’s physical examination was normal as well as her laboratory tests, which included complete blood count (CBC), liver biochemical tests, tumor markers, sedimentation rate (ESR), and C-reactive protein (CRP) (). Esophagogastroduodenoscopy (EGD) was done, which showed only Los Angeles grade B reflux esophagitis.
The initial ultrasound study showed three hypoechoic subcapsular nodules with maximum diameters of 25 mm in the right hepatic lobe in a background of normal liver parenchyma (). Abdominal and pelvic computed tomography (CT) with intravenous/oral contrast revealed two hypodense lesions of 10 and 12 mm diameters in the anterior segment of the right hepatic lobe and one 25 mm diameter lesion with more density in the posterior segment of the right hepatic lobe. Red blood cell single photon emission computed tomography (RBC-SPECT) was performed to rule out hemangioma (). Ultrasound guided liver biopsy was done to make a definite diagnosis. Two 1×10 mm biopsy specimens were sent for histopathological study. Hematoxylin and eosin stained (H&E) sections of liver specimens showed multiple foci of proliferating bile ducts composed of bland cuboidal cells and duct formation in the fibrotic and inflamed portal spaces. Bile duct proliferation was compatible with BDA (). Immunohistochemical (IHC) staining was done for CK7 and P53, which showed positive for CK7 and negative for P53.
As no risk factors were known to have a relationship with BDA, the patient was advised to discontinue medroxyprogesterone. A proton pump inhibitor was started to treat the esophagitis. She was then followed up for two years by rou

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


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

[User]
RADIOLOGY NOTE:
In September 2008, a 43-year-old woman presented to the Emergency Department at Frenchay Hospital with a 3-month history of back pain, right hip and knee pain, right leg weakness, constipation and urine incontinence, altered sensation in the limbs, and visual disturbance with flashing lights in the left eye. Two weeks prior to this admission she was seen at Frenchay Hospital with cauda equina symptoms. She has had an MRI of the spine, which showed a disc prolapse but did not explain the symptoms. The patient was discharged. However, her pain continued to worsen, and sensation changes progressed across the whole of the perianal region. She was unable to sit down for 8 weeks due to pain on flexion and started using a stick as her right leg was weak.
On examination she had a decreased sensation in the perianal area. Neurological examination of the upper limbs revealed a slight numbness of the radial side of the forearm. Neurological examination of the lower limbs revealed the following: reduced power in the right hip flexion (1/5) and extension (2/5), the power in the left leg was 4/5, absent reflexes in both legs, reduced sensation in the right medial aspect of the distal right calf dorsum of the foot sole and the lateral dorsum of the left foot and the sole of the left foot. On examination of her visual fields, she demonstrated a loss of outer vision in her left eye.
CT and MRI of the head showed metastases in the right parietal occipital region, together with some smaller metastases associated with the dura and skull base (fig ). MRI of the spine revealed fairly diffuse infiltrating nodules in the nerve roots of the lumbosacral plexus. Her performance status was 3 due to progressive leg weakness.
The diagnosis was meningeal carcinomatosis with brain metastasis from breast cancer. No other signs of metastatic breast cancer were seen on CT at this point.
A year prior to presentation, she had been diagnosed with 4 × 3 cm grade

[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 man presented to the outpatient department with complaints of an intermittent headache and a right swollen ankle, which became worse after activity. His history included a craniocerebral trauma related to a fall during alcohol intoxication. In the first quarter of 2015, during the removal of cranial epidural hemorrhage, percutaneous catheterization of central veins via the right femoral vein was attempted because of the need for intravenous infusion. After the surgery, the patient was sent to the intensive care unit for postoperative care. A few days later, the patient was discharged home; he demonstrated a slight weak muscular tension in his right upper extremity and had difficulty in speaking extended sentences. Approximately 1 and a half months after the surgery, the patient was re-examined by CT. The CT scan showed that 1 guidewire had ascended in the superior vena cava and the heart. Despite this finding, the hospital was unable to perform the surgery to remove the guide wire, and the doctors suggested that he should have a follow-up visit in every few months. The patient ignored the guide wire, took no medication, and continued to lead a normal life. In January 2016, the patient received another CT scan which revealed that the guide wire had arrived at the cerebrum. However, the patient did not have any symptoms of discomfort. The doctors suggested that the patient should go to a better hospital for further treatment.
At this point, the patient presented with swollen ankle and headaches, and as a result, he wished to have the guidewire removed. The patient then underwent a comprehensive CT scan, which revealed that the guide wire had broken into 2 segments. One segment (with a diameter and length of 2.0 mm and 535 mm, respectively) had arrived at the right brachiocephalic vena cava, and the other segment (with a diameter and length of 1.2 mm and 323 mm, respectively) had arrived at the cerebrum (Figs. and ). Both the diameter and the length

[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:
Clinical case 2: a 48-year-old female patient who, since 2009, has been showing weight gain, predominantly on the face and thoraco-abdominal area, with facial erythrosis and joint pain. She was admitted to our department for diagnosis and treatment. Physical examination on admission showed: a height of 145 centimeters; a weight of 82 kilograms; a blood pressure of 180/85 mmHg; capillary blood glucose at 0.91 g/l, with a typical clinical picture of hypercorticism with the presence of pain on palpation of the thoracolumbar spine. A hormonal panel found a UFC level elevated to twice the normal at 520 μg/24h, plasma ACTH was at 18 μg/ml (10-60). Adrenal CT scan showed a right adrenal gland containing a nodule which is enhanced shortly after injection of contrast agent and measures approximately 28 mm, the left adrenal was of normal non-hypertrophic morphology. High blood pressure, left ventricular hypertrophy shown on echocardiography and depression were all complications of hypercorticism that were found in the patient.
Once the diagnosis of Cushing's syndrome was made, a laparoscopic right adrenalectomy was performed. Histological examination showed a right adrenal gland measuring 45 x 30mm. The multiple samples examined show an adrenal parenchyma surrounded by a thin and sometimes moderately thick fibrous shell with emanations towards the parenchyma. On microscopic examination, it was a hyperplasia of the adrenal parenchyma involving the cells of the medulla and the cortex with a predominance of spongiocyte, as well as the presence of small foci of compact cells with nuclear atypia. In conclusion, it was macro nodular adrenal hyperplasia. Five years after the surgery, clinical evolution was marked by the regression of the signs of Cushing syndrome and the persistence of a slight facial erythrosis, the weight went from 82 to 64 kilograms, although the patient kept residual high blood pressure, it was less severe, measured at 160/90 mmHg. On the paraclinical level, pla

[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 20-year-old male patient presented with a history of pain in the left hip for the past 6 months. The pain was insidious in onset, intermittent, occurred predominantly at night, progressively increasing with time, 6/10 on a visual analog scale and was present over the anterior aspect of the left hip. It was non-radiating and there were no aggravating factors for pain. However, he got some relief with over-the-counter analgesics. There was no history of antecedent trauma and the remaining history and general examination did not reveal any significant abnormalities. Local examination revealed diffuse tenderness over the anterior aspect of the left hip. There was no palpable swelling or wasting of the leg muscles. The range of motion of the left knee and ankle joints was normal and there was no neurovascular deficit distally.
X-ray left hip showed the small radiolucent area with sclerotic margin in the left femur neck along its superior border (). CT scan of the left hip showed, presence of osteoid osteoma in the region of the superior border of the femoral neck of diameter 0.5 cm (). After all the necessary investigations, the patient was planned for radiofrequency ablation of the tumor under CT guidance. Magnetic resonance imaging hip showed a rounded cortical based lesion with internal specs (nidus) suggestive of osteoid osteoma ().
After all the necessary investigation and routine workup, the patient was taken for the procedure under the CT guidance.
Under all aseptic precautions, the procedure was started. CT scan was obtained to precisely localize the lesion and multiplanar reconstructions were used to plan the optimal transcutaneous approach. Close attention paid to the adjacent blood vessels and nerves, since these structures must carefully be avoided. A penetration cannula with an inner stylet was introduced through the skin and soft tissue according to the previously established access route. New CT images are then obtained to verify the correct position of

[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:
Mrs. A. A, a 40-year-old Para 2-+-0 with no living child, (last child birth was 3 years and last menstrual period was 2 weeks prior to presentation) was seen at gynecological clinic with a history of abdominal distension of 3 years duration. The distension started gradually in the suprapubic region: - it later progressed to involve the entire abdomen. There was no change in the menstrual period and cycle. There was no change in urinary or bowel habit. There was no vomiting, cough, jaundice or abnormal vaginal bleeding. There was associated with mild abdominal discomfort and weight loss. She had been taking herbal medications since the onset of the above problem. When the mass became very large, it prevented the patient from carrying out her normal activities. The patient sought medical care at Awka General Hospital where a diagnosis of ovarian tumor was made. She was subsequently referred to Nnamdi Azikiwe University Teaching Hospital, Nnewi for expert management. She attained the age of menarche at 14 years. She was neither aware of Pap smear nor contraceptives. The past medical history was not contributory. There was no family history of such ailment. She was the third wife of her husband who was a farmer. She did not take alcohol or tobacco in any form.
On examination, she was chronically ill looking and pale. She was neither jaundice nor febrile. The pulse rate, blood pressure, and temperature were normal. Her body weight and height were 63 kg, and 160 cm, respectively. The cardiovascular and respiratory systems were normal. Abdominal examination revealed grossly distended abdomen, which was tense and visible veins [Figures and ]. The abdominal circumference was 126 cm measured at the level of the umbilicus. The liver, spleen and kidneys were difficult to assess due to the tensed abdomen. On vaginal examination, the vulva, vaginal and cervix appeared normal. The uterine size and adnexae were also difficult to

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


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

[User]
RADIOLOGY NOTE:
In March 2016, a 47-year-old male patient was admitted to the Oral and Maxillofacial Surgery and Traumatology service of a public hospital, referred by the medical team with the chief complaint of respiratory difficulty after the appearance of a soft palate lesion. On anamnesis, the patient reported rapid weight loss, drug use for more than 10 years, and the development of a hard palate lesion three years earlier, which was left untreated. In addition, the patient reported the development of a soft palate lesion one month earlier. Intraorally, an extensive mass of mucosa-like color was present in the palate region, which obstructed the oropharynx and consequently caused dyspnea.
The sagittal computed tomography (CT) image reveals a soft tissue mass in the nasal cavity extending to the posterior portion of the nasopharynx and the lower part of the sphenoid sinus, with lowering of the entire musculature of the soft palate (A). The coronal CT image shows density loss of the septum in the nasal cavity and nasal conchae, maxillary sinus opacification, and lesion extending to the sphenoid cavity floor (B). The axial CT image reveals the soft tissue mass observed in the nasal cavity with opacification of the maxillary sinuses (C).
After the initial examinations, the patient was submitted to tracheostomy (A) and intraoral incisional biopsy under general anesthesia (B). Intraoperatively, the tumor had a fibrous consistency and showed normal bleeding. The specimen was sent for histopathological analysis (A). Microscopically, the presence of a densely collagenated connective tissue was observed, with numerous blood vessels that were usually of small caliber and sometimes congestive; also, foci of hemosiderosis were visible (B). Based on the microscopic reports, clinical-radiological characteristics and physical examination, the diagnosis of NA was established.
The patient was referred for excision of the lesion. However, due to the extension of the lesion and the patient's sys

[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.