[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 21 year old male presented to the emergency department with severe acute abdominal pain. He had been playing football earlier and was struck in the abdomen by an opponents shoulder. At the time, the impact was considered to be trivial. Subsequently, he developed abdominal pain and was brought to hospital. He had a history of Crohn's disease and was being managed by the gastroenterologists as an out patient. A Barium enema several months previously had shown evidence of Crohn's disease in the terminal ileum and ascending colon. He had no previous surgery and was not on steroids at the time.
On examination he was hypotensive and tachycardic. His abdomen displayed signs of generalised peritonitis.
Blood test showed mildly raised inflammatory markers and an erect chest x-ray showed no convincing evidence of pneumoperitoneum. The patient was fluid resuscitated and given he was haemodynamically stable; a CT was performed to diagnose further prior to surgery. Clinically, a splenic injury was the working diagnosis. Computed tomography scan revealed free gas and a perforation of the ascending colon (fig ). There was no evidence of splenic laceration or subcapsular haematoma of the liver. He proceeded to laparotomy.
There was evidence of Crohn's disease involving the distal 10 cm of small bowel and right colon up to one third the way of the transverse colon. 2 perforations were evident in the ascending colon, which was thickened. There were no apparent strictures distal to the perforation that could have resulted in a distended area of bowel that ruptured. A right hemicolectomy and primary anastamosis was performed. The resection involved 10 cm of terminal ileum, which corresponded to the diseased segment of small bowel as shown on the barium study done previously. Histology of the specimen confirmed macroscopic and microscopic features of Crohn's disease. Unfortunately, the patient developed a post-operative wound infection that resulted in a return visit to theatre for a

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old girl was referred to our department following the discovery of cardiomegaly on the chest X-ray during recent exploration for recurrent lower respiratory infections.
Her personal history was uneventful until the age of 5 weeks when she was hospitalized for viral bronchiolitis. At that time, a first echocardiography was performed because of a cardiac murmur and was considered normal. Since then, she showed recurrent wheezing and - lower respiratory tract infections. Allergic asthma and a gastro- esophageal reflux were excluded. Additionally, at the age of 7 months, transient hypo-gammaglobulinemia was diagnosed that was treated for 12 weeks by immunoglobulin substitution until normalization of the immune status. Symptomatic treatment did not lead to significant improvement of the clinical condition. Instead, chronic cough and wheezing persisted as well as frequent lower respiratory tract infections requiring frequent antibiotic administrations. In the course of her chronic disease, the patient underwent at least 10 chest X-Rays in different institutions that always showed a cardiomegaly. The last one led to cardiological assessment.
At clinical examination, weight and height were on the 25th and 50-75th percentile, respectively. Blood pressure and transcutaneous oxygen saturation were normal. The precordium was hyperactive over the right ventricle and the apex beat was deviated left- and backwards. The rest of the examination was normal.
ECG showed a right axial deviation, a first-degree A-V block and an incomplete right bundle branch block.
At echocardiography there was an axial deviation of the heart to the left, an enlarged right ventricle and dilated trunk of the pulmonary artery. The right pulmonary veins appeared enlarged while the left ones could not be depicted with sufficient precision. The atrial septum was intact in all its portions. No cardinal vein could be identified.
An additional imaging with angio-computed tomography (CT) was performed t

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.
She reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.
During her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.
The oncology team became involved at this time. Her CLL was the suspected etiology of the neck mass and lymphadenopathy, and intravenous fluids and allopurinol were started to prevent tumor lysis syndrome. Further laboratory workup showed the predominantly lymphocytic, elevated WBC count as before and a normocytic anemia, hemoglobin 10.6 g/dL. Smudge cells were present on the peripheral blood smear. Iron studies, B12, and folate were normal. Flow cytometry

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old, 7-months pregnant primigravida visited the Department of Obstetrics and Gynecology of our hospital for routine antenatal checkup. Physical examination revealed distended abdomen with fundal height corresponding to 30–32 weeks of gestation. Multiple fetal parts were felt and a single fetal heart sound was auscultated below the umbilicus toward the left of midline. On per vaginal examination, the os was found to be closed with uneffaced cervix. Three months earlier, her first ultrasound scan taken at a peripheral hospital was misdiagnosed as a single live intrauterine fetus of 18 weeks gestational age. Later she was referred to the Department of Radiology, and the ultrasound images showed twin monochorionic, diamniotic intra-uterine pregnancy with a viable, normal-appearing first twin and amorphous structured second twin []. The placenta was located in the left lateral region of the upper uterine segment []. On further examination, the first twin showed normal morphology and growth with gestational age of 31 weeks in cephalic presentation. Fetal Doppler and echocardiography revealed normal parameters without any signs of cardiac failure in the first twin. The second twin showed disrupted growth and incomplete formation with absent head, upper limbs, heart, and thoracic structures. It had well-developed lower limbs and poorly developed lower abdomen with an abrupt ending at the top to form a blunt end. There was gross, diffuse soft tissue edema in the second twin []. Umbilical cord was seen entering the second twin with intact blood flow and pulsed Doppler study revealed reversal of the flow on the spectral pattern []. Ultrasound findings were consistent with TRAP sequence twin with an acardius acephalus which was confirmed on Magnetic Resonance Imaging. Magnetic resonance imaging showed twin monochorionic, diamniotic intrauterine pregnancy with the normally developed first twin in cephalic presentation on the left and malformed, small, grossly edematous

[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 3-month-old male was seen in our pediatric oncology department because of a growing parotid gland mass. The mass was congenital and was followed by the pediatric oncology team with a prediagnosis of hemangioma. The patient’s magnetic resonance imaging (MRI) scan showed an infantile hemangioma in the proliferative phase filling the parapharyngeal space ().
The child then received propranolol therapy, but despite this treatment the mass continued to grow, and the child was referred to our department at the age of 10 months. The otorhinolaryngological examination revealed an 8×7-cm mass filling the left parotid region, with normal facial nerve motor functions (). Histopathological diagnosis of the mass was provided by an incisional biopsy as sialolipoma.
We planned to perform total excision of the mass with a transparotid approach. The facial nerve was monitored intra-operatively, and surgery was performed under magnification using surgical loops. A standard modified Blair incision was used, flaps were raised (), then the facial nerve was identified in a standard fashion using a tragal pointer and posterior belly of the digastric muscle as landmarks.
The main trunk of the facial nerve was found to be unusually elongated before pes anserinus. A soft lobular mass was encountered. A tumor involving the superficial parotid lobe was first dissected, then the deep lobe of the parotid gland and portion of the tumor filling the parapharyngeal space were gently dissected under the facial nerve (). A Jackson-Pratt drain was inserted into the wound after the excision of the tumor.
On macroscopic examination, the mass was found to be a lipomatous specimen, 9×8×4 cm in size. The cut surface was consistent with the appearance of a lipoma. Histopathologic examination confirmed the diagnosis of a sialolipoma. The lesion was composed of mature adipose tissue mixed with acinar, ductal structures of a normal salivary gland ().
The postoperative period was uneventful. The patient’s faci

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old woman (married, having 3 children) presented with a painless mass in the right breast discovered by self-examination one year before reporting it. She had no other symptoms or previous breast problems and no family history of breast cancer.
On clinical examination, palpation of the right breast revealed a painless, mobile, hard mass at the 1-o'clock position (upper inner quadrant) that measured 5.0 cm in width and 4.0 cm in height. There was no tethering of the skin or peau d' orange, and there were no enlarged lymph nodes in the axillary region. The opposite breast and the axilla were normal. Hematological investigation results were within normal limits, and chest X-ray, electrocardiogram showed the heart and lung functions were normal. A large mass was also noted in the mid-lower right part of the abdomen. Clinical diagnosis of the right breast mass and abdominal mass was ambiguous.
Ultrasound scan of the breast showed a hypoechoic area measuring approximately 28 cm in anteroposterior diameter in the upper half of right breast. Meanwhile, it was demonstrated that a relatively circumscribed complex echoic mass with posterior enhancement and uneven density and abundant vessels existed in this area. Calcifications were found focusing in the breast lesion, and several axillary lymph nodes were highly suspicious of metastasis. There were no other focal lesions noted on the scan. Mammography demonstrated an increased density with smooth contour corresponding to the palpable mass. The patient had also undergone an initial computed tomography scan, which revealed a spherical multicystic mass in the right abdomen that measured 259 mm in length, 170 mm in width, and 106 mm in height.
Fine-needle aspiration cytology and intraoperative frozen sections demonstrated and confirmed the malignancy of the mass in the right breast as infiltrating ductal carcinoma (IDC). Upon review of the biopsy specimen from the breast tissue at a multidisciplinary meeting, the diagno

[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 21-month-old Hispanic girl presented to the emergency room with 10 days history of progressing left periorbital swelling. She was initially treated with antibiotics without improvement. The patient did not have any fever, vomiting, cough, eye discharge or sick contact.
On examination, she had swelling with proptosis at the left eye without erythema. There was a localized mass that was palpable, restricting the movement of the left eye. Incidentally, the patient found to have pubic hair Tanner stage III but no breast buds or clitoral hypertrophy. The remaining physical exam was unremarkable. There was a significant past medical history of a third-line family member with a diagnosis of uterine cancer at the age of 40 years and a second-line family member with a history of recurrent thyroid nodules.
Initial laboratory work up including complete blood count, basic metabolic panel, and liver function test were all normal. Computed tomography (CT) scan of the head revealed a single left orbital mass that has retro-orbital and postseptal extension. This mass measured 2.5 × 3.5 × 1 cm and was not associated with focal bone erosion or invasion to the optic nerve [].
Because the patient had evidence of precocious puberty, the differential diagnosis at this point was broadened to include rhabdomyosarcoma, neuroblastoma, germ cell tumor or concurrent episode of childhood neoplasms. The patient subsequently underwent further evaluation with whole body positron emission tomography (PET) scan that showed another mass (6 × 6 cm) in the left suprarenal area []. Bone scan, bone marrow biopsy, and urine catecholamine were all negative.
Due to concern of adrenarche, the patient had endocrine work up that showed advanced bone age with significantly elevated dehydroepiandrosterone sulfate (DHEAS).
The previous finding raised the possibility that those two masses might be two different tumor entities. She underwent a subtotal surgical resection of the left retro-orbital lesion (about 75

[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 African American female was following up for her chronically elevated alkaline phosphatase levels. She had a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, allergic rhinitis, and chronic lower back pain. Patient has a family history of arthritis, cardiovascular disease, and diabetes mellitus; she denies ever using alcohol or tobacco.
With the onset of elevated alkaline phosphatase level and vague abdominal pain in 2013, an abdominal ultrasound performed in December showed hepatic steatosis. Viral serologies for hepatitis during 2013 were negative, as a gastrointestinal consult was required to determine the need for a liver biopsy. A liver biopsy was subsequently performed, which showed focal mixed micro and macrovesicular steatosis. Portal tracts showed minimal focal chronic inflammation, no significant fibrosis, and no iron deposition.
The vague abdominal pain that she was experiencing waxed and waned for two years. Additionally, the patient experienced some vague chest pain and dyspnea that prompted an echocardiogram in February of 2015, which demonstrated a left ventricle ejection fraction of 44%. Consequently, a left heart catheterization in the following month showed no significant coronary disease with a dilated left ventricle with an ejection fraction of 50%. A 2-year follow-up in July of 2015 showed suspicious cirrhosis by Computed Tomography (CT) scan (), possibly due to granulomatous changes and chronic inflammation. A CT scan was determined to be necessary for our patient because of rising alkaline phosphatase without other explainable etiologies, in addition to the patient's appetite suppression and vague abdominal pains. Patient's weight during this time was 207 lbs (93.89 kg) and was advised to diet and exercise. After 4 months of continuous symptoms, especially with abdominal pain, a laparoscopic cholecystectomy was performed with a liver biopsy that showed subsequent granulomatous changes in September of 2015. The li

[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 17-year old male professional runner was transferred to our musculoskeletal tumor centre on recommendation from his team doctor. Currently a member of a national biathlon junior team, the patient was one of the best track and field athletes of his age group for mid-distance running disciplines (1500 m & 3000 m) on a competitive level at the time of initial diagnosis. Besides daily workout in the gym for strentgh and endurance, his training schedule included up to 4 h running 6 days per week. However, ongoing pain in both of his shins prevented the young athlete from training and competition despite intensive conservative treatment for 5 months. Before admission to our hospital, symptoms were treated for shin splints without success until MRI was conducted. Extensive cyst-like bone lesiosn were found in both diaphyseal tibiae (Figs. and ). Imaging was completed by plain radiography of both tibiae (Figs. and ).
As multimodal conservative treatment for MTSS demonstrated unsuccessful and MRI revealed the most likely reason for the patient’s symptoms, surgical therapy was indicated after thorough analysis of all clinical and radiological findings. In favour of a fast return to a competitive sports level we abandoned our standard surgical procedure for UBC consisting of open curettage and autologous cancellous bone grafting from the iliac crest. Due to the dimensions of both tibial lesions, this would have been associated with a long recovery and potential major donor site morbidity both seriously jeopardizing the young athlete’s competitive sports career. Based on promising reports of minimally invasive surgery for treatment of UBC of the humerus from Hou et al. [, ] we performed a customized surgical technique for the first time at the lower extremity beginning with the more symptomatic left lower leg. Surgery was conducted in a supine position without use of a pneumatic tourniquet to prevent possible muscular impairment. The exact dimension of the cyst and its distan

[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 male patient presented to the accident and emergency department with worsening central chest pain for 1 day. He experienced chest pain that was not related to exertion for 1 month, associated with night sweats. There was no history of fever, palpitations, or weight loss. He was a chronic smoker and had a history of childhood asthma. On admission, the patient was in respiratory distress, however, was hemodynamically stable.
The initial chest radiograph [] revealed a large soft-tissue opacity over the medial aspect of the left upper zone. In view of the clinical possibility of acute aortic dissection, urgent computed tomography (CT) angiography was performed. CT showed no evidence of dissection or an aneurysm in the thoracic aorta. There was, however, a lobulated heterogeneously enhancing soft-tissue mass seen in the anterior mediastinum, partially encasing the aortic arch, almost completely encasing the left common carotid artery and fully encasing the left subclavian artery []. No calcifications or fat densities were noted within the mass. The mass displaced the left upper lobe pulmonary artery laterally. No thrombus was seen within the pulmonary artery. This mass also displaced the trachea and esophagus to the right [ and ]. Blood tests including tumor markers were all unremarkable. Radiological differential diagnoses of anterior mediastinal mass including lymphoma, germ cell tumor, and invasive thymoma were made. Subsequently, an 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan was performed, showing the anterior mediastinal mass to be hypermetabolic with maximum standardized uptake values measuring 19.8 []. A hypermetabolic left cervical lymph node metastasis was also detected [].
The mediastinal tumor was considered unresectable since it encased the aorta and its branches. The patient underwent video-assisted thoracoscopic surgery and biopsy of the mediastinal mass was taken. Histopathological examination [] revealed sheets

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


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

[User]
RADIOLOGY NOTE:
A 6-year-old girl with the complaint of vague periodic abdominal pains mainly in the epigastrium and periumbilical region is referred to the children's hospital. There was not any correlation with feeding and almost having discomfort at night times. She had periods of constipation and diarrhea and symptoms of leg pains. She also used to take Propranolol for early morning headaches mostly in the frontal region for 2 years. The patient with a probable diagnosis of Familial Mediterranean Fever (FMF) was referred to the pediatric rheumatology clinic for further surveys when 0.5 milligram daily colchicine was taken without considerable clinical response. She also had both an intussusception experiment and a history of negative appendectomy since she was 2 years old and the initiation of abdominal pain since that time. She was never febrile during abdominal pains. General examination revealed a thin hemodynamically stable girl with no signs of acute abdomen; the weight and the length were 15 kg and 105 cm [body mass index (BMI): 14.5 kg/m2].
She had second admission within previous 15 days with similar complaints. The grey scale and color Doppler abdominal ultrasonography showed normal portal and splenic veins and there were no evidences of thrombosis. Stool calprotectin test was also requested for a probable inflammatory condition in the gastrointestinal tract. However, because of persistent symptoms, abdominal CT angiography was obtained, which revealed a decrease in aortic and superior mesenteric artery and aortomesenteric angle consequently to 5 mm and 14 degrees suggestive for superior mesenteric syndrome along with a gastric and duodenal dilation [].
Another confirmatory spiral CT scan of abdominopelvic region also marked distended stomach and the proximal part of duodenum which in context of CT angiography proposing SMA syndrome. In addition, she was in a malnourished state without adequate evidences supporting an autoimmune condition. Thus, according to persistent

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old male resident of a nursing home facility of Hispanic descent was brought to our emergency department (ED) for respiratory distress and altered mental status. He was intubated promptly on arrival to the ED. His past medical history was significant for intracranial aneurysm with bleeding following VP shunt placement, ischemic stroke with aphasia and paraplegia, and percutaneous endoscopic gastrostomy (PEG) tube placement. His vital signs and clinical laboratory results are presented in Table .
The clinical picture was suggestive of septic shock. We ordered a sepsis workup including two sets of blood cultures and urine culture. The patient was treated with aggressive intravenous fluid hydration and broad-spectrum antibiotics (vancomycin and meropenem).
A non-contrast computed tomography (CT) of the chest, abdomen, and pelvis revealed bibasilar pulmonary atelectasis without focal infiltrate and the presence of a right-sided VP shunt catheter traversing the right neck, the right chest, and the right abdominal wall; the tip of the catheter was located within the gastric lumen and had likely entered through the PEG tube insertion site (Figures -). The PEG tube was outside the gastric lumen, terminating in the abdominal wall that was evidenced in the repeat CT scan confirmed that patient had abdominal wall cellulitis and localized abscesses around the PEG tube insertion site (Figure ). Medical records from another facility confirmed previously normal positioning of the PEG tube and normal intraperitoneal positioning of VP shunt catheter one year prior.
Given the malposition of the VP shunt inside the gastric lumen, we suspected VP shunt infection or meningitis/encephalitis and subsequently lumbar puncture was performed; the results of the cerebrospinal fluid (CSF) analysis were unremarkable. Blood cultures and urine culture results were negative.
The wound culture was positive for Proteus mirabilis sensitive to carbapenems and piperacillin/tazobactam. We debr

[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 37-year-old female with a known history of giant hepatic hemangioma was referred with one-year history of increasing abdominal pain associated with progressive nausea, 60 lbs weight loss and constipation. The hemangioma was initially diagnosed during a workup for lower back pain two years before the onset of abdominal pain. General surgical consultations were sought, and expectant management was advised. The patient had subsequently been treated conservatively for lumbar disk herniation and newly diagnosed irritable bowel syndrome. In our clinic, she appeared pale and malnourished with lumbar lordosis. The abdominal exam revealed generalized distention with a palpable liver edge below the right subcostal margin.
Magnetic resonance imaging (MRI) of the abdomen revealed 18.5 (AP) × 19.2 (TV) × 25.3 (SI) cm mass located in the right posterior hepatic lobe consistent with giant hemangioma (). A review of radiological records indicated the hemangioma had grown steadily in a diameter from 13 cm in 2015 to 25 cm in 2018. Laboratory evaluation was significant for pancytopenia ().
Consent for surgical resection was obtained. A surgical set-up has been described earlier. [] A midline incision with right subcostal extension was placed. The hemangioma arose from the right posterior lobe and was compressing the remaining liver and surrounding structures. Due to tumor size, the right lobe could not be mobilized and access to the vena cava was severely limited. It was therefore decided to proceed with “anterior approach” and resect the mass by creating a plane between the displaced right hepatic vein and the hemangioma. Monopolar coagulation and Cavitron Ultrasonic Surgical Aspirator (CUSA, ValleyLab, USA) were then used to transect the liver parenchyma just lateral to the right hepatic vein. Blood loss was limited through intermittent use of the Pringle maneuver in addition to low central venous pressure anesthesia. The mass was removed uneventfully with an estimated blood loss

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old female presented with sudden onset posterior neck and right shoulder pain with progressive right side weakness while falling asleep. During consult, she had reported taking anti-hypertensive medication for 20 years and was followed regularly for hepatitis C. She reported no trauma history or physical exertion for the past few weeks. Neurological examination resulted in alert mental status and the detection of right hemiparesis. Motor power of her right upper limb was grade III and ipsilateral hand grasping power was grade II. In her right lower extremity, motor power was grade IV, and her left whole extremities were intact. Right side hypoesthesia was also observed. Based on her medical history and clinical symptoms, the physician working at the emergency department ordered brain CT to rule out intracranial hemorrhage. However, brain CT did not show any positive findings (). Subsequent brain diffuse MRI was taken to rule out cerebral infarction, but it was also negative (). Cervical MRI was performed to rule out a cervical lesion based on the patient's report of posterior neck pain and revealed a mass like lesion in the right posterior epidural space at the C3-6 level compressing the right side of the spinal cord. The mass was isointensive to the spinal cord on T1WI and heterogeneously hyperintensive with central high signal foci on T2WI. At the C5 level, the MRI showed an ovoid, enhancing, nodular lesion, which was a suspected tumorous condition such as hemangioma or hemangiopericytoma (). Initial laboratory tests showed only severe thrombocytopenia (45,000/mm3). As her neurologic signs were getting worse with time, we decided to perform surgical intervention. Under general endotracheal anesthesia via light wand intubation, right C5 unilateral total laminectomy and C6 partial hemilaminectomy were performed. The mass lesion was pure hematoma and was removed (). We could find neither vascular malformation or an active bleeding point. She went into rehab

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old male patient presented to Emergency Department (ED) following a run over injury. The patient described the mechanism of injury as moving his body over his run over foot. On clinical examination, there was obvious deformity and swelling of the right ankle. Dorsalis pedis pulse was felt but weak compared to the contralateral side with a capillary refill time under 3 s. The posterior tibial artery could not be palpated because of the deformity. X-rays showed posterior ankle dislocation without associated fractures (Fig. ). Urgent reduction of the dislocation was done under sedation in ED. The knee was first flexed to relax the tendon Achilles then longitudinal traction with gentle forward force applied to the heel with immediate reduction of the deformity achieved. The foot was reassessed for vascular status. Triphasic pulse in both drosalis pedis and posterior tibial artery was detected with hand held Doppler. Ankle was immobilized in posterior below knee back slab to accommodate for swelling and check x-rays confirmed reduction of the ankle joint (Fig. ). CT scan was done afterwards to define any subtle incongruity or osteochondral fragments entrapped in the joint. CT did not show any associated fractures and showed congruent reduction of the ankle joint (Fig. ). Patient was mobilized touch weight bearing for first 2 weeks. The back slab was changed for weight bearing short leg cast and progressive weight bearing was allowed for the following 4 weeks. At 6 weeks follow up, plaster was removed and on examination patient still had moderate tenderness over the medial joint line and deltoid ligament area. Also, patient had limited range of plantar and dorsal flexion. Referral for physiotherapy was done for start of functional rehabilitation and range of motion exercises and in mean time MRI was done to delineate extent of ligamentous injury. MRI showed bone bruising of the lateral malleolus, medial malleolus and lateral talus (Fig. ). The anterior talufibul

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old man presented at the emergency room with complaints of retrosternal discomfort during swallowing for 7 days, and a history of tarry stool and hematemesis were found in the last 12 h. He gave a history of swallowing a bone by mistake. The patient felt dizzy and nauseous. There was no other digestive tract symptom or systemic symptom such as fever. He had a past history of alcoholism, but no history of chronic liver disease or peptic ulceration. His blood pressure was 105/70 mm Hg, pulse rate was 105 beats per minute and respiratory rate was 22 breaths per minute. He was administered 20 ml of 5% glucose and omeprazole 80 ml static push, 100 ml of 5% glucose and 40 mg omeprazole continuous infusion, 0.9% sodium chloride 500 ml plus 6 U insulin. No abnormality was detected on physical examination, except diaphoresis and mild pallor. Haematological investigations revealed mildly elevated white cell count 11.8 × 109/l, with neutrophilia of 10.34 × 109/l. His hemoglobin was 97 g/l. Standing chest and plain abdominal radiographs were normal. Computed tomography scan of the mediastinum showed indistinct esophagus middle, slightly higher density of the esophageal wall, the surrounding fat tissue had disappeared, part of the descending aorta showed aorto-esophageal fistula, and there was an esophageal foreign body. Emergency endoscopy revealed no upper esophageal FB. There was a fresh red thrombus at 26 cm, with no active bleeding. The foreign body was not visible. Foreign body was also not found during surgery with thoracoscopy. Then a second endoscopy examination was performed, and the blue cotton method was conducted after water washing, then a small piece of cotton was located at 26 cm, and a tiny part of a fish bone was found under the cotton (). The foreign body was extracted by the endoscope. The patient was discharged without any complications after 23 days.

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


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

[User]
RADIOLOGY NOTE:
A 13-year-old female of the Marshallese origin presented to the emergency department with complaints of nausea; nonbloody, nonbilious vomiting; and abdominal pain []. The patient denied any recent fevers, and no rash was reported. Review of systems was notable for the left ear drainage. Immunization status was unknown, and she was not reported to have been previously treated for any significant illness, though the history was limited by the patient's custodial circumstances. She lived in a small house in rural North Carolina with 21 other Marshallese immigrants and was cared for by relatives who had assumed care for her at the time of her immigration five years before.
Examination during the initial hospital visit revealed dehydration and acute otitis media with rupture of the tympanic membrane. Laboratory results revealed leukocytosis, prerenal azotemia, elevated liver enzymes, and mildly elevated lipase (). Computed tomography (CT) showed scattered focal pulmonary infiltrates, splenomegaly, and a markedly distended stomach without an obvious focus of mechanical obstruction (). Cytomegalovirus and Epstein–Barr virus serology were requested with results suggesting prior exposure. She was admitted with a presumptive diagnosis of gastroparesis secondary to a nonspecific viral infection and possible mild pancreatitis. An NG tube was placed resulting in high volume output. Her symptoms gradually improved over several days with IV fluid support and bowel rest; her NG was successfully removed, and she was discharged home tolerating a regular diet.
Two days after discharge, the patient returned with recurrence of her prior symptoms. The patient appeared acutely ill with dehydration. On lung exam, scattered crackles were noted. She was also noted to have diffuse small nodular lesions most apparent on her hands, feet, lower legs, and face (). An advocate placed with the family reported her concern for additional symptoms of chronic weight loss and productive cough with postt

[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 75-year-old female patient visited our hospital with bilateral weakness (left>right) which had suddenly developed and persisted for 15 days. She also had hypertension and unstable angina which had been treated with antihypertensive and antiplatelet medications for 10 years. She had no history of diabetes mellitus, hyperlipidemia, and smoking, etc.
On neurological examination, bilateral hemiparesis (left : Grade IV, right : Grade IV+) was detected. The brain computed tomography scan showed a low-density area only in the right post-central gyrus, and diffusion weighted-magnetic resonance imaging (d-MRI) showed bilateral anterior cerebral artery-middle cerebral artery borderzone infarction (), and MR angiography showed high grade stenosis of both proximal ICA ().
Catheter angiography was performed 4 days after admission. Common carotid angiography showed 85% stenosis of the left ICA origin () and 90% stenosis of right ICA origin (). Vertebral angiography showed total occlusion of the right VA and multifocal stenosis of the left VA with faint flow to basilar artery (BA) (). PComAs on both sides were well visualized and filling to both posterior cerebral arteries (PCAs) (). However, retrograde flow to BA was not seen. Meanwhile, right occipital artery (OA) from right ECA supplied right VA and then BA to basilar tip ().
We performed stent-angioplasty for left ICA stenosis first under local anesthesia immediate after the catheter angiography (). During the procedure no remarkable events took place, and the neurologic symptoms of the patient remained unchanged after the procedure. Two days after stent-angioplasty for left ICA stenosis, treatment for right ICA lesion was performed under local anesthesia (). During the procedure no remarkable events took place, and the neurologic symptoms of the patient remained unchanged immediate after the procedure. After the 2nd session of angioplasty, we control the patient's systolic blood pressure (BP) about 120 mm Hg because of 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 3-year-old boy was referred for management of acute acquired comitant esotropia. His family noticed sudden inward deviation of his left eye 9 months ago, and as time passed, this deviation became increasingly noticeable. On first presentation, the angle of esodeviation was 50 prism diopters (PD) at distant and near fixation. The patient's visual acuity and sensory status were not checked, but he demonstrated alternate fixation. There was no lateral incomitance and no deficit of abduction bilaterally (). No difference in the size of the deviation was found with fixation of the right versus the left eye. The cycloplegic refraction with 1% cyclopentolate revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on fundus examination. No nystagmus was noticed, and there was no family history of strabismus or amblyopia. There was no preceding trauma or febrile illness before the onset of acute strabismus. Review of old photographs demonstrated that at 1 year of age, the patient's corneal light reflexes were centered.
He was referred to a pediatric neurologist, but the neurological examination did not reveal any additional pathological findings. A brain MRI revealed a 5 cm mass with an enhanced peripheral rim at the midline of the cerebellum as well as hydrocephalus (). The tumor was completely excised and a shunt was placed. Histological examination of the excision confirmed the diagnosis of pilocytic astrocytoma.
Three months after neurosurgery the patient's visual acuity was 20/125 in each eye and the angle of esodeviaton increased up to 60PD at distance and near fixation without any deficit of abduction. Alternating six-hour occlusion therapy was initiated. Eight months after the initiation of occlusion therapy, the patient's visual acuity had improved to 20/50 in the right eye and 20/40 in the left eye. The angle of esodeviation was reduced to 50PD at distance and near fixation, and the esotropic angle did not show any sign of decrease.
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 74-year-old Caucasian woman was referred due to gradual worsening of dyspnea with aggravation during a recent skiing trip. Her previous medical history included mild asthma and osteoporosis, surgical treatment for rectal cancer 30 years prior to presentation, and an evaluation for dizziness 4 years previously when a computed tomography scan of the cerebrum was without any positive findings.
The patient denied palpitations but reported occasional retrosternal oppression and two incidences of near syncope. Aside from age, she had no risk factors for ischemic heart disease.
A physical examination revealed an arterial blood pressure of 132/70 mmHg, a heart rate of 40 bpm, normal oxygen saturation, normal body temperature, and no dyspnea at rest. Further examination revealed jugular vein distension while sitting upright in bed and a discreet systolic murmur. The electrocardiogram (ECG) showed atrial fibrillation and complete atrioventricular block. Blood tests were normal except from consistent low-grade elevation of the cardiac troponin I. An echocardiogram showed severely dilated left atria, mild mitral regurgitation, borderline dilated LV with near-normal systolic function and no hypertrophy. Acute coronary syndrome was not considered present and our patient underwent an uneventful implantation of a dual-chamber pacemaker (DDDR). Following discharge, the patient was followed by her private cardiologist. It was later noted that cardiac hypertrophy and a slight decrease in LV ejection fraction had developed, the latter possibly considered secondary to cardiac pacing.
Over the next 5 years, our patient was repeatedly admitted to the emergency department with dyspnea. At our institution, the echocardiogram was repeated when our patient, at the age of 78 years, was admitted with severe respiratory distress interpreted as pulmonary edema. Her LV ejection fraction had decreased to 15% (Fig. ). A subsequent coronary angiogram was without any coronary artery lesions 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 24-year-old male reported to the Department of Periodontology, HPGDC, Shimla, HP with a chief complaint of extruded and badly positioned mobile upper left front tooth. On examination the upper left lateral incisor was found to be below the level of the occlusal plane of adjacent teeth, was buccally drifted and had Grade II mobility with a 10 mm deep periodontal pocket. Radiographic evaluation revealed vertical bone defect extending until the middle one-third of root, there was no bone defects or loss of attachment in the rest of the dentition []. Endodontic consultation was taken to rule out any pulpal pathology. There was no medical history associated. A primary diagnosis of severe localized chronic periodontitis resulting in extrusion and misalignment of the affected tooth was made based on the clinical findings. A two-pronged treatment plan was devised with the main aim to preserve the tooth by treating the periodontal disease and promoting the regeneration, followed by orthodontic treatment to align the tooth in the arch for long-term maintenance and esthetic reasons. Clinical pictures and cast (models) were made and decision was taken to start the Phase I periodontal therapy which included SRP and oral hygiene instructions. Once the Phase I periodontal therapy was completed, it was noticed that vertical bone defects and clinical attachment loss were still persistent, therefore the decision to initiate Phase II periodontal therapy was taken to reconstruct the lost periodontal support. Open flap debridement using Kirkland flap was done under local anesthesia and the bone defect was filled using bio-oss* (Bone graft material). The flap was re-approximated and sutured. The sutures were removed after a week, and the patient was placed on a maintenance and recall program, which included a recall visit every 2 weeks for first 1-month, followed by every 3 weeks for 6 months postoperatively. At the end of 6 months, there was a gain in clinical attachment gain by 7 mm,

[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 white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).
Tissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.
On the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.
An emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging (

[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 21-year-old woman with SCD presented frequently to the medical casualty department with severe pain due to sickle cell VOC. For the last 2 years, her sickle cell pain included intermittent pain in the left ankle. Her recurrent severe VOCs were treated with opioids, as they are the general treatment in such patients. She had experienced osteomyelitis in the right ulnar bone 12 years previously, which resolved after intravenous broad-spectrum antibiotic treatment. Additionally, she underwent splenectomy 4 years ago to reduce blood transfusion requirements because of her congenital hemolytic anemia. She was referred for a triple-phase bone scan and complementary bone marrow and infection imaging as part of the SCD research project. A plain radiograph of the left foot was normal, but SPECT-CT revealed an increased uptake in the shoulders, knees, and sternum on blood pool and delayed images, consistent with marrow expansion. A similar uptake pattern was seen during bone marrow study, confirming bone marrow expansion around the large joints. There was a mildly increased blood pool and bone uptake in the left ankle involving the proximal talus and the region of the medial malleolus, with focal increased uptake in the left talus. This nidus of activity appeared to correspond to a round lucent area surrounded by a dense sclerotic rim and sinus tract formation together with a fracture line in the proximal talus on CT. The WBC scan showed no evidence of significant uptake, and the bone marrow scan showed asymmetrical uptake between the two ankles without a cold lesion in the left talus, which is consistent with moderate bone marrow expansion. The CT and bone scan findings suggested Brodie’s abscess in the proximal left talus with possible surrounding chronic osteomyelitis. Intravenous antibiotics were administered for 10 days with no response. The abscess was then treated with surgical curettage under general anesthesia and antibiotic administration for 10 days. At 18 months

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


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

[User]
RADIOLOGY NOTE:
A 31-yr-old female visited our department in October 2002. She had a history of endotracheal intubation for a week to maintain her airway after an inhalation burn, and she then developed dyspnea after the treatment. Prior to the inhalation injury, she had no family history of disease or any notable medical conditions. On physical examination, the mobility of both vocal folds was found to be intact; however, we observed upper tracheal stenosis. The patient's airway was severely compromised with less than 30% of the normal function due to the stenosis. A neck computed tomography (CT) scan showed a tracheal stenosis lesion around the 6th cervical spinal level. The narrowest diameter of the lesional trachea was about 0.7 cm and the lesion length was about 3cm. Slight enhancement was also visible on the stenotic lesion, which most likely due to granulation tissue. We performed bronchoscopy and balloon dilatation procedures. The 10 mm balloon dilatation was initially successful, but further procedures could not be performed because of the patient's unstable vital signs. We decided to perform a resection with end-to-end anastomosis in November 2002. We performed a hyoid release and resection of a 2 cm segment of the trachea (from the 2nd to 5th tracheal rings) 2 months after the burn injury. Two months later, the dyspnea symptoms reappeared and the tracheal stenosis was found. Tracheal ballooning and stent insertion were then performed, but the stent was removed after 1 month due to displacement. Granulation tissue was observed a few months later at the previous operative site. LMS was performed next to remove the granulation tissue and mitomycin C was applied. In 2006, upper tracheal stenosis due to a fibrous stricture of the tracheal mucosa was found. A neck CT scan revealed a narrowed airway with hour-glass-shaped tracheal rings on the 6th cervical spinal level (). The narrowest diameter of the trachea was about 0.6-0.7 cm and LMS then was performed two more times. Five

[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 Turkish 13-year-old boy was referred to our clinic fifteen days after a car accident. Clinically, the cooperation level of the child with the dentist was high, but oral hygiene was poor. After assessing medical history, the patient was examined for extraoral signs. He had no facial swelling, facial asymmetry, limited mouth opening, and pain on palpation. Intraoral examination revealed severe intrusive luxation in tooth 12 and moderate intrusive luxation in tooth 11. The tooth 11 was not mobile and did not interfere with the occlusion (). The patient was in the mixed dentition, had a deep bite, and tooth 13 was still erupting.
At the first appointment, pulp sensitivity of all anterior teeth was evaluated with an electric pulp test. Teeth 21 and 22 gave positive responses, while teeth 11 and 13 gave negative responses. Radiographs confirmed a complete root formation in all permanent anterior teeth, and periodontal space was absent (). Given that multiple severe luxation traumas, it was decided to perform surgical re-positioning. A photograph was requested from the family to see the anterior teeth positions. The patient and his parents were informed about treatment options and the expected prognosis of each procedure.
The difficulties encountered during surgery were i) reaching stability after re-positioning in adjacents multiple luxation teeth on the arch; ii) re-positioning of intruded teeth 11 and 12 in the alveolar socket due to the start of remodeling in the bone in 15 days. The teeth 11 and 12 were surgically extruded and stabilized in a position similar to the symmetrical teeth by 0.5 mm stainless steel splint (). Because the tooth 13 continued erupting, it was left to the spontaneous eruption and not included in the splint.
After surgery, Augmentin (625 mg, 2*1), a penicillin-derived antibiotic, a mouthwash containing chlorhexidine, Parol, an analgesic agent, were prescribed for 7 days to the patient against 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 50-year-old man presented with progressive left wrist pain and swelling, following a trauma one year back, in which he fell on his left upper extremity. He was operated by percutaneous pinning for the extra-articular lower end radius fracture. Post operative period was uneventful but then patient started developing pain and fullness over the operated wrist on removal of the cast 6 weeks post-operatively with loosening of pins, which were removed. Patient continued to have fullness with gradual & progressive loss of wrist movement. Patient was treated on the lines of CRPS by local physician with non-steroidal anti-inflammatory agents. No improvement was observed and the stiffness and pain progressively worsened for the last 9 months. Past medical history was non-significant. He had no history of tuberculosis (TB) or any other immune-suppressive disease. There was neither any family history of TB infection nor of any rheumatic or autoimmune disease. He had been immunized with BCG vaccine at birth. Constitutional symptoms such as fever, anorexia, fatigue and weight loss were absent. He was not receiving any regular medications. When seen in our institute, he had considerable pain and severely restricted range of motion of the left wrist. The rest of the musculoskeletal examination was normal.
Routine laboratory investigations including biochemical tests, complete blood cell count were all normal apart from an elevated ESR (42 mm in 1st hour; normal: <20 mm in 1st hour) and CRP (8.93 mg/L; normal: <5 mg/L). Serological tests for Anti-Nuclear Antibodies (ANA) and hepatitis viruses were negative. Tumour markers and HIV test, as well as test for Brucella antibodies were also negative. The result of tuberculin skin test (5 tuberculin units) was strongly positive with induration of 17 mm diameter. His chest x-ray was normal with no evidence of any active pulmonary disease.
An antero-posterior radiograph of the left wrist indicated soft tissue swelling, loss of joint

[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 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.
Her history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.
Endemic Zika was identified in Haiti per the CDC early in the epidemic []. When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy []. She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.
The patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks

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


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

[User]
RADIOLOGY NOTE:
We present a case of 21-year-old female patient with a negative medical and surgical history. She presented to the gastroenterology clinic for chronic epigastric pain for several months, associated with postprandial episodes of nausea and vomiting. Her physical examination was insignificant. She was prescribed proton pump inhibitors and prokinetics.
However, her symptoms didn't improve much, so a diagnostic upper esophagogastroduodenoscopy was done and showed normal mucosa but with external compression on the second part of the duodenum (
). Computed tomography (CT) scan of the abdomen and pelvis was ordered due to characterize the external compressing mass. It showed a diverticulum at the second part of the duodenum (D2) measuring approximately 41 mm × 28 mm, filling the duodenal lumen (intraluminal diverticulum) and obstructing it (
). Finally, an endoscopic ultrasound was done to delineate the diverticulum and have a clearer view of the surrounding structures. It showed again the intraluminal duodenal diverticulum (IDD) in D2, with a thin and regular wall. The endoscopic ultrasound also confirmed normal pancreatic appearance and normal Wirsung's duct and biliary tract.
The patient was presented with her options and after a surgical consult, and due to her intractable symptoms, it was decided to go with surgical treatment. Written consent was taken from the patient. She was prepared for the operating room.
Intraoperatively, the duodenum was first completely exposed. Then, an intraluminal mass was palpated at the level of D2. Through a longitudinal duodenotomy, the intraluminal diverticulum was identified. The diverticulum was identified 20-mm proximal to the papilla. The papilla was intubated to avoid injury during traction of the mucosa. Excision of the diverticulum was then performed and the mucosa was approximated using absorbable sutures.
The postoperative course was unremarkable and the patient was discharged on day 6 after regaining bowel movement and tolera

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old woman presented with a lump in her neck, which had gradually increased in size during the previous two months. Physical examination revealed a firm nodular mass in the right lobe of the thyroid gland. Her past medical history was unremarkable. Thyroid function tests were within normal range. Ultrasonography revealed a round, relatively well-defined, mixed echoic nodule in the right lobe. The nodule had a markedly hypoechoic portion in the lateral side and had a slightly hypoechoic portion in the medial side. Color Doppler imaging showed increased blood flow within the markedly hypoechoic portion of the nodule ().
The fine needle aspiration in this nodule exhibited clusters of cuboidal cells with features of papillary carcinoma. The smear also contained spindle cell groups with non-cohesive arrangement among the tumor cells of PTC. The spindle cells were in a pale to eosinophilic background with associated lymphocytic infiltrate. They had vesicular nuclei, small nucleoli, and indistinct cytoplasmic membrane. Neither significant atypia nor mitotic figures were identified (). Total thyroidectomy with central lymph node dissection was performed.
Grossly, the right lobe of the thyroid gland showed a well-circumscribed yellow to white, partially encapsulated mass, measuring 2.3×2.0×1.8 cm. Histologically, the tumor consisted of two distinct components: stromal and epithelial. The stromal component consisted of spindle-shaped cells arranged in interlacing fascicles and an abundant fibromyxoid matrix accompanied by thick collagen fibers. The stromal cells had neither nuclear atypia nor mitotic figures. Occasional lymphocytic infiltration or extravasated red blood cells were also identified in the center and periphery of the tumor stroma. Epithelial components had features of PTC (). The tumor was confined to the thyroid parenchyma. Metastatic tumor tissue was detected in four of five resected central lymph nodes without stromal components. Immunohistochemicall

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old Thai female G2P0A1 at 37+1 weeks of gestation presented with a 1-week history of pruritic erythematous papules and plaques starting on the lower abdomen. The rash spread to all extremities and the trunk; however, mucosa, palms, and soles were spared. Neither abnormal symptoms nor signs of systemic involvement or fetal distress were detected.
She had been receiving regular antenatal care since she was 8 weeks pregnant. Her medications were 1 ferli-6 tab per day and 1 g calcium carbonate per day, which she had been taking since an antenatal care visit. She had undergone an abortion during the eighth week of pregnancy 5 years earlier. There was no history of a similar skin condition. She denied any previous herpes simplex infection. Physical examination revealed generalized discrete and confluent erythematous papules and plaques with central dusky red areas (targetoid lesions) on the trunk and extremities (fig. ). Some tiny pustules and vesicles were noted on both arms and the chest wall. Conjunctiva and oral and genital mucosa were unremarkable.
A Tzanck smear from the vesicle showed the presence of polymorphonuclear cells but the absence of multinucleated giant cells. Gram staining of the pustules showed no organisms. Direct immunofluorescent study was negative for herpes simplex virus antigen. Additionally, a skin biopsy taken from the targetoid lesions on the left forearm illustrated focal parakeratosis with scale crust formation, irregular acanthosis and focal spongiosis of the epidermis, superficial perivascular infiltration of lymphocytes, and eosinophils with red blood cell extravasation. Direct and indirect immunofluorescent studies (HG factor) were all negative. Due to the diversity of skin manifestations, excluding the cause of the targetoid lesions and the negative result of laboratory investigations, PEP was diagnosed.
Systemic corticosteroids were prescribed at the patient's first visit because pemphigoid gestationis could not be excluded. H

[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 59-year-old right-handed Caucasian lady, known to have migraine with aura and type-2 diabetes mellitus presented to our emergency department center with dysarthria, left upper motor neuron facial weakness and left-sided hemiparesis affecting the upper limb more than the lower limb. The patient presented with signs of a right middle cerebral artery (MCA) stroke with an National Institute of Health Stroke Scale (NIHSS) of 10 and unfortunately was out of the window period for intravenous thrombolysis as it was a wake-up stroke and last seen well (LSW) was unknown. A MRI of the brain was obtained on an urgent basis which showed an established infarction in the anterior third of the right MCA territory secondary to the occlusion of the superior M2 branch of the right MCA ().
Upon further workup, CTA showed a filling defect in the right V4 segment of the right vertebral artery which was suspected of being a dissection or a FFT, with normal flow in the left vertebral artery and the basilar artery and its distal branches ().
The attending neurologist in the referring hospital discussed the case with our neurovascular on-call team and the patient was then transferred urgently to our hospital for emergent endovascular therapy (EVT).
The patient was transferred to King Fahad hospital of the university the same night. An urgent angiogram was performed through a 5-F femoral sheath and a diagnostic catheter, under local anesthesia. The left ICA injection showed a normal flow into the MCA territory as well as the anterior cerebral artery (ACA) territory, with no cross flow to the right hemisphere. The right ICA injection showed the previously mentioned occlusion of the superior M2 branch with deficient collaterals to central MCA core territory. The left vertebral injection showed normal flow in its intracranial segment with no reflux into the right vertebral artery with normal flow into the basilar artery and its distal branches (). The right vertebral artery was accessed just a

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male patient was transferred to the emergency department after a road traffic accident. He had a fall from his bike and his right arm was crashed by the following car. On clinical examination, he had pain and obvious deformity in the shoulder while he was unable to move his arm in any direction, especially in external rotation. He had numbness in the regimental badge region of the axillary nerve and normal radial pulse at the wrist. Radiological examination showed an anterior shoulder dislocation with impaction of the humeral head underneath glenoid and associated fracture of the greater tuberosity (Fig. ). He had no other skeletal or visceral injuries. After conscious sedation, an effort for closed reduction (3 attempts) was performed in the emergency room but was unsuccessful. For reasons unrelated to the patient or the disease a CT-scan of the shoulder was not possible to be performed at that time. The patient was transferred immediately to the operative theatre for closed manipulation under general anaesthesia in order to reduce the dislocation and avoid further neurological compromise; a CT-scan and/or MRI has been scheduled for the next morning. Despite prompt sedation and muscle relaxation the shoulder was still unable to interpose. Open reduction was accomplished thereafter using the deltopectoral approach; the biceps tendon was found entrapped posterolateral between the humeral head and the tuberosity fragment preventing once again reduction of the glenohumeral joint. (Fig. ). Tenotomy and tenodesis of the frayed biceps at the level of pectoralis major was performed using a bone anchor; the transverse ligament at the bicipital groove had been torned. Next, the subscapularis was incised, 1 cm medial to its insertion at the lesser tubercle, and retracted medially after separated from the capsule. The latter was incised and the labrum was clearly visualized and was found to be intact inferomedially. Using longitudinal traction and finger manipula

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


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

[User]
RADIOLOGY NOTE:
A 16-year old male patient reported to the Department of Oral Medicine and Radiology with a complaint of progressive flattening of left side of face since the age of 2 years which was continuous to date. Patient gave a history of pigmentation of his left face since birth which had been gradually fading over the years. No history of trauma or surgery was reported and there was no positive family history of facial atrophy. Neither was there a family history of consanguinity. His delivery was not assisted, per vagina. The medical history was not contributory, and he was not on any form of medication. Patient denied history of smoking or alcohol intake. Patient was moderately built and nourished.
On physical examination, he was conscious, oriented, and afebrile. His general condition was fair with vital signs within normal limits. On extraoral examination, facial asymmetry was detected due to hypoplasia of left malar region (). There was atrophy of left masseter muscle and fat with prominence of the left infraorbital ridge and zygoma. The right face appeared normal. Examination of the face revealed no sensory or motor deficits on both sides. The left eye appeared depressed in the socket (enophthalmos) due to loss of periorbital fat with minimal drooping of the left eyelid ( and ). Increased lacrimation was associated with enophthalmos. There was a deviation of mouth angle to the affected side at rest. Pigmentation was noticed on the left cheek which also involved the left palpebral conjunctiva (). Systemic examination of the central nervous system was normal. Fundus examination was also normal.
Based on the clinical findings and history, a clinical diagnosis of Parry-Romberg syndrome was made. Routine blood investigations revealed all values within normal limits.
As a part of radiographic investigations, a panoramic radiograph was taken. The radiograph revealed no significant findings (). Axial and coronal computed tomographic (CT) images revealed hypoplasia of the left

[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 five-year-old male child presented to the pediatric department with complaints of gradual abdominal distension developing since few months as well as fever and bluish discoloration of the limbs since few days. The mother complained that her son got tired easily on exerting himself during activities such as playing.
Under the routine admission protocol, the entire panel of blood markers was sent, electrocardiogram was performed, and the patient was then sent to the radiology department for an ultrasonographic evaluation and radiography. The hemoglobin was 9 gm/dL, and the packed cell volume (PCV), mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC) too were below the lower limit of normal. The total leucocyte count at 23,900/μL was significantly raised, and differential leucocyte count revealed eosinophils at 60%. The electrocardiogram revealed a right bundle branch block with right ventricular strain pattern.
Ultrasonography (USG) of abdomen and pelvis revealed an enlarged midline liver with two sets of dilated hepatic veins; multiple splenules were seen on the right side with empty left splenic region. Due to the enlarged liver, the right kidney was noted at a significantly lower position with respect to the left kidney (Figure ). There was intestinal malrotation with stomach located on the right side and small bowel loops clustered together on the left side; large bowel loops were clustered together on the right side; and sigmoid colon is noted in the lower half of right-side abdomen.
The radiograph revealed cardiomegaly with a cardiothoracic ratio of 0.7. In view of the above findings, an urgent two-dimensional echocardiography was performed, which revealed a severely dilated right atrium at the right ventricle with a moderate ostium secundum and bidirectional atrial septal defect; patent ductus arteriosus and severe tricuspid regurgitation and pulmonary artery hypertension too were observed (Figures , ).
The CT revealed visceral

[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 2017, a 60-year-old female presented to her General Practitioner (GP) in Scotland with a slow-healing 1 cm wound on her right finger. She had sustained a minor burn to the finger 9 days prior to her attendance. A swab was taken by the attending clinician. This swab subsequently grew toxigenic . This result was telephoned to the out-of-hours local health protection team, 8 days after the case presented to her GP.
The case lived with her partner and owned two German Shepherd dogs. One dog had a history of a long-standing skin complaint, which had been documented as quiescent. The case worked in retail and had no recent travel history. She had not eaten unpasteurized dairy food nor visited any farms within the last 2 weeks. Her most recent diphtheria vaccination was in 2009.
A nose and throat swab were collected from the patient and she was treated with diphtheria vaccine and a 2 week course of clarithromycin. She was excluded from work under the Public Health Act Scotland (2009) until completion of antibiotics and clearance swabs, one from each site (nose, throat and wound) were negative. Four close contacts were identified who required nose and throat swabs to assess for carriage of , of whom two were healthcare professionals who had dressed the wound. Contacts were all given diphtheria vaccine and a 1 week course of erythromycin. The two healthcare workers were excluded from work until nose and throat swabs were culture negative. One contact (husband) was identified as carrying in his nose and required a repeat swab following completion of antibiotics to check for clearance. His repeat swab was culture negative. Initial swabs for the fourth contact (a close friend) were negative.
A local veterinary practitioner examined the dogs, which revealed one had an infected skin lesion, which was swabbed. Throat swabs were also collected from both dogs. Toxigenic was recovered in culture from the skin lesion and throat swabs of both dogs. They

[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 15-year-old boy presented to Fujian Medical University with giant scrotal elephantiasis and swelling of both lower extremities. The penoscrotal edema began fifteen years earlier, soon after his birth, and it resulted in bilateral lower extremity edema with the penis becoming buried by the scrotum. His scrotal size was massive, and for the past 5 years, the glans penis was not visible nor palpable (Fig. a–c). He had undergone circumcision 13 year earlier and had no history of travel in filariasis-endemic areas. There was also no family history of scrotal elephantiasis or known genetic disorders.
Upon examination, the patient had a massively enlarged scrotum, with a volume of approximately 16 cm × 13 cm × 7 cm. The anatomical structures and urethral orifice were visible as a deep depression on the scrotum. Both lower extremities exhibited generalized swelling, which was especially noticeable on his ankles. His thigh circumference was 52 cm on the left and 56 cm on the right.
Tissue biopsy of the lower extremities was performed 13 years earlier and revealed lymphangioma and connective tissue hyperplasia. A urinary system ultrasound examination was performed 14 months prior to presentation at our hospital, which confirmed diseased subcutaneous scrotal soft tissues with no abnormalities in the bilateral testicular morphology and blood supply. The results of lower limb lymphoscintigraphy demonstrated that the lymphatic drainage of the lower extremities was obviously tardy. The development of bilateral inguinal and iliac lymph nodes was obviously tardy (Fig. ). The lower limbs and anterior pelvic position was imaged after injecting with the tracer (99mTc-SC) subcutaneously between the first and second toes. The images demonstrated that the lymphatic drainage in both lower extremities were unclear. In the early stage, the images showed that the bilateral inguinal and iliac lymph nodes were blurred, which was obvious on the left side. The concentration of imaging agent (99

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


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

[User]
RADIOLOGY NOTE:
The patient was a 36-year-old male, admitted to a specialist trauma center on 24 December, 2019, at 21:00, having suffered wounds caused by a cold weapon. He had exhibited hemodynamic instability during transport, but after fluid resuscitation he was stable when he arrived at the hospital. The most notable findings of the physical examination conducted in the emergency room were subdued vesicular murmur in the left hemithorax, heart rate of 125 bpm, mean blood pressure (MBP) of 70-75 mmHg, and multiple wounds to the anterior and posterior chest ().
After administration of packed red blood cells and prophylactic antibiotics, angio-CT of the thorax was conducted (
), showing contrast leakage from the thoracic aorta and left sided hemothorax. Left pleural drainage and arteriography of the thoracic aorta were performed.
The decision was taken to proceed directly to definitive endovascular treatment. Intraoperative aortography () was performed, confirming the damage to the thoracic aorta (at the level of T8) with adjacent tamponade, and a 20/20/82 mm straight thoracic endograft was deployed in the descending thoracic aorta. The endovascular intervention was conducted at 01:00 on December 25, 2019. Control aortography performed after implantation () showed no evidence of contrast leakage.
The patient remained in the intensive care unit during the immediate postoperative period. On the first postoperative (PO) day, the patient suffered acute myocardial infarction of the lateral wall, but without compromise to cardiac or hemodynamic function. He was discharged to the wards on PO day 3. The patient had a collection in the left hemithorax due to retained hemothorax, and underwent videothoracoscopy and decortication, conducted by the thoracic surgery team. His recovery was otherwise uneventful and he was discharged from hospital on the 10th day after admission. He is currently in outpatients follow-up with the specialties and is asymptomatic. He had a control chest angio-CT 30

[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:
Patient 2 was a 7-year-old girl referred to our department for further evaluation of a hard tumor involving the right side of the face (). She was placed on an observation protocol after a thorough diagnostic workup ruled out any endocrinopathies or syndromes.
Neither patient exhibited trauma and/or associated infections, and both had normal laboratory test findings. The facial CT images of patient 1 showed an expansive lesion with the ground glass appearance that involved the skull base and the right maxillary, zygomatic, sphenoidal, temporal, frontal, and mandibular bones ().
Involvement of the orbital bone resulted in a decrease in the socket volume and optic canal diameter, which explained the exophthalmia and vision loss. Bone scintigraphy showed osteogenic activity in the right craniofacial region, without involvement of other skeletal structures. The clinical features and laboratory and radiographic findings confirmed the diagnosis of MFD. The patient underwent osteoplasty of the affected maxillary, zygomatic, mandibular, and temporal bones for the restoration of facial harmony. The surgery was preceded by virtual planning ().
In case of patient 2, because of the early development and slight facial deformity, a clinical follow-up protocol was selected. During the growth spurt between 12 and 13 years of age, she developed significant occlusal alterations, facial asymmetry, and difficulty in supporting her eyeglass stem because of sharp growth in the right mastoid apophysis. Laboratory test findings were within normal limits, and bone scintigraphy showed intense osteogenic activity on the right side of the skull. CT revealed volumetric osteofibrous thickening of the maxillary, mandibular, zygomatic, sphenoidal, temporal, mastoid, and parietal bones, with preservation of the internal acoustic meatus, optic canal, and stylomastoid foramen.
At the age of 15 years, the patient underwent osteoplasty of the right mastoid and zygomaticomaxillary bones for esthetic com

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old Caucasian male presented with a 6-month history of a neglected rapidly growing lesion on the proximal left thigh. He had no relevant past medical history and took no medications, but admitted to binge drinking on weekends and a 10 pack-year history of smoking. He sought attention when the lesion became painful and malodorous. On examination there was a large approximately 30 x 30 cm geographic lesion centered in the left groin, with heaped edges lying 2 cm proud of the normal skin contour, and an ulcerated raised heterogeneous center. It extended superiorly to the lower abdomen, inferiorly 10 cm below the base of the buttock, laterally to the lateral aspect of the inguinal crease, and medially to involve the scrotum, penile base and contralateral perineum (). In addition there was 2 x 2 cm pigmented polypoid lesion at the dorsal penile base. He had stiffness within the proximal left thigh, had lost 25 kg over the last 6 months and had an ECOG performance status of one. CT of the abdomen and pelvis confirmed a large plate-like lesion lying superficial to the adductor muscle group and femoral vessels, as well as left inguinal and external iliac lymphadenopathy up to 5.2 cm in greatest dimension. A chest x-ray was normal. An incisional biopsy confirmed moderately differentiated squamous cell carcinoma, and he was staged as cT3 cN1 cM1. His disease was prohibitively large for either surgery or radiotherapy so he proceeded to palliative chemotherapy as follows: Cisplatin 75 mg/m2 and Docetaxel 75 mg/m2 every 3 weeks. He tolerated 7 cycles; the first 2 at full dose strength and the last 5 at 75% dose strength (55 mg/m2) due to myalgias, oral mucositis and 2 episodes of febrile neutropenia requiring hospitalization and G-CSF support. The visible lesion showed an early and sustained significant response to therapy (), however, after 7 cycles CT

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old female was admitted to the hospital due to severe suicidality. At the time of admission she complained about an irritating feeling in her nose, which made her constantly grimace in the area around the nose. She was excessively worried about having a serious illness of her nose (secondary hypochondriacal delusions) and was suicidal as a consequence. Her belief persisted even after any underlying medical condition of the nose has been ruled out by extensive medical examinations. She also presented with disorganized behavior, stereotypical movements, emotional instability and lability, and a below average level of intelligence during hospitalization. On the PANSS, her symptoms scored 29/23/70 (for the Psychotic, Negative and General Psychopathology Scale, respectively). Brief neurological examination revealed no abnormal neurological signs. As ascertained by the history taken from the patient and her mother, she had a history of school phobia that began at the age of 12 years, emotional disorders, normal cognitive and physical development, and a three-year history of chronic headache. She managed to complete primary and secondary education with the help of school counseling services given to her on account of school phobia. She had not received any psychiatric care before the described admission. A diagnostic evaluation for chronic headache at the University Children’s Hospital was undertaken a year before admission.
Calcium, phosphate and parathyroid hormone blood levels were normal. Vitamin D levels were decreased with decreased calcium levels in the urine. No signs of calcium depositions in organs other than the described brain regions were determined by ultrasound. Ophthalmological, ear-nose-and-throat examination and electroencephalography were also normal.
Detailed neurological examination revealed dysfunction of pursuit eye movement, dystonic positioning of both arms when stretched ahead, discrete ataxia of the arms and legs, and a pathological ext

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 60-year-old female who presented to the hospital with complaints of dull substernal chest pain. She had chronic atrial fibrillation, chronic obstructive pulmonary disease with home oxygen, osteoarthritis, and anxiety disorder as her comorbid conditions. On examination, she did have chronic dyspnea and was on home oxygen. She did not have any cyanosis, palpitations, paroxysmal nocturnal dyspnea, or orthopnea.
She was initially evaluated with a nuclear stress test that did not show any reversible ischemia but dilation of the right ventricle (RV); ejection fraction was identified to be 54%. The patient was further evaluated by a transthoracic echocardiogram (TTE) in order to evaluate the RV dilatation. TTE identified a complete absence of IAS and a CA (). The findings were confirmed with a positive bubble study (). Transesophageal echocardiogram (TEE) was performed that confirmed the absence of IAS, demonstrated free mixing of color flow, moderate to severe tricuspid regurgitation, normal mitral valve structure, normal left ventricular ejection fraction, and enlarged right atrium (RA) and RV.
The patient was evaluated with cardiac computed tomography angiogram (CCTA) that demonstrated the right coronary artery to be the dominant artery, all coronary arteries to be ectatic/aneurysmal and measuring up to 8-10 mm, a complete absence of IAS, marked dilation of CA and both ventricles, a coronary arteriovenous fistula (CAF) between the distal left anterior descending and coronary sinus, massive dilation of pulmonary arteries, and no mitral or aortic valvular abnormalities; left ventricular ejection fraction was measured to be 59% (Figures –).
The patient underwent an invasive angiography (IA) which demonstrated many abnormal findings. It showed that the patient had coronary artery aneurysms measuring 0.7 cm to 1 cm (). IA was instrumental in taking measurements regarding oxygen saturation and pressure at multiple levels identifying a large interatrial

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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 70-year-old man who previously had not undergone catheter examination or treatment presented with progression of chest oppression. He had no history of Kawasaki disease during childhood and other aneurysms. Cardiac catheterisation revealed double-vessel disease in the left descending artery (LAD) and right coronary artery (RCA), with a giant saccular coronary aneurysm of the LMT. Coronary artery CT (CACT) demonstrated a giant saccular CAA with a diameter of 40 mm on the posterior side of the main pulmonary artery. Blood flow was additionally noted from the RCA and the left circumflex artery into the aneurysm. According to the cardiovascular team’s assessment, the LMT site of entry of the aneurysm was too large to be treated by covered stenting and the margin was too short to touch up covered stenting at the LMT. There was also the problem of treating the feeding arteries. Therefore, surgery was recommended.
The patient underwent surgery to prevent rupture and angina (). Cardiopulmonary bypass (CPB) was established via cannulations of the ascending artery and both the vena cava. On the anterior surface of the pulmonary artery, meandering vessels that seemed to flow into the aneurysm were ligated. Coronary artery bypass was performed at the RCA and LAD with saphenous veins. Then, peeling of the adhesion off the surrounding tissue of the CAA was attempted; however, the pulmonary and ascending arteries were so severely adhered. As a result, the aneurysm was exposed just enough to access between the ascending aorta and the main pulmonary artery. Following aortic cross-clamping and cardiac arrest, the wall of the aneurysm was dissected at the right side of the main pulmonary artery. A large amount of thrombus filled the aneurysm. After removing the thrombus, the LMT site of entry of the aneurysm was examined by administering antegrade cardioplegia. The site of entry was of pinhole size, and therefore we were able to close it directly with 5–0 and 4–0 Prolene sutures 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.