[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 85-yr-old man was admitted to hospital with community-acquired pneumonia on December 21, 2007. He had been suffering from dyspnea due to right fibrothorax associated with pulmonary tuberculosis. His baseline pulmonary function test revealed FEV1/FVC of 89%, FEV1 of 25%, and FVC of 18% predicted values. He was treated with mechanical ventilation for three months and received long-term care at the intensive care unit (ICU) for four months. After removal of the ventilator, the patient was transferred to a general ward for further planning of rehabilitation treatment. However, the patient suffered new-onset atrial fibrillation, after which his oral intake decreased. His general condition deteriorated and he became dehydrated. Therefore, a central venous catheter was placed in the right internal jugular vein for more intensive treatment, including bedside fluid and nutritional therapy, without imaging guidance. Three days after the procedure, he slept all day. When awakened, he answered only briefly with slurred speech. He tended to gaze toward the right. No movement of the extremities on the left side was seen. At this point, he had no circulatory impairment. DWI was performed to evaluate neurological problems and revealed extensive hyperintensity with decreased apparent diffusion coefficient (ADC) value in the right cerebral hemisphere suggesting acute cerebral infarction. There were mottled areas of low signal intensity within the acute infarct area, which were considered to be air bubbles (). With a diagnosis of suspected paradoxical cerebral air embolism, brain and chest CT were performed simultaneously. An extensive area of low attenuation suggesting acute infarction in the right cerebral hemisphere as well as air bubbles mainly in the border zone areas of the right hemisphere were observed on brain CT (), and free air was detected in the right atrium on chest CT (). Transesophageal echocardiography (TEE) revealed microbubbles in the aorta without visible intrac

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female presented to our OPD with chief complaints of right superomedial eye swelling for last 2 years. The swelling was associated with excessive watery discharge and pain in right eye as well as pain in right frontal region. There was no history of diplopia or decreased vision from right eye. There was no history of nasal discharge or nasal obstruction. There was previous history of endoscopic marsupilization of mucocele by a private practitioner 2 months back but it recurred again. On physical examination, there was fluctuant swelling present in superomedial region above the right eye. There was mechanical ptosis due to swelling and the eyeball was pushed inferiorly and laterally. Vision was normal in right eye with full extraocular movements in all directions except in supero-medial direction. Pupillary reaction to light and accomodation were normal. Fundus examination was normal. On anterior rhinoscopy, nose was normal. On contrast-enhanced CT, there was large expansile cystic lesion was found to be present involving right frontal sinus containing hypodense contents with expansion of both anterior and posterior table of frontal sinus []. The swelling had so much eroded the anterior and posterior table of frontal sinus that frontal lobe of brain was in direct contact with the eyeball and it was compressing the eyeball and blocking the sinus ostia []. On MRI, the swelling was isointense on T1 and hyperintense on T2. The swelling was in close contact with both orbit and frontal lobes and was almost adherent to both these structures.
The patient was planned for surgery through the combined ENT-neurosurgical approach. A bicoronal flap incision was made and right-sided frontal craniotomy was done. The anterior and posterior wall of frontal sinus was eroded. The mucocele wall was adherent to dura and the supraorbital wall. Mucocele was dissected slowly from dura and orbit. Mucosa was carefully removed up till the frontal recess area. Complete removal

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (
). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.
The woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.
To better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (
). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.
The following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.
After a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (
). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative

[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 54-year-old female presented to hospital for new onset of double vision. The patient denied having a similar episode in the past. Additionally, she had persistent left ear ache for 5 months. The patient stated that the earache started as dull, achy pain that had been progressively getting worse requiring multiple office visits. She had been treated with oral and topical antibiotics without any significant relief. Her past medical history includes diabetes mellitus, hypertension, obesity, hypothyroidism, and fibromyalgia. The patient's presenting vitals were stable. The ear exam revealed granulation tissue on the left tympanic membrane and serosanguinous fluid was present. The patient had painful left external ear structure upon gentle traction. The neurologic exam findings were significant for inability to abduct the left eye beyond midline (). When looking left, the patient would have double vision. There were no other focal neurologic deficits, cranial nerve palsies, or abnormal cerebellar signs.
A CT scan of the head was inconclusive (). A magnetic resonance image (MRI) of the brain showed an enhancement of left skull base that raised the suspicion for active infection (). These findings were further assessed with Gallium-67 citrate (Gallium-67 scan), which revealed a strong possibility of active infection (). Based on imaging and clinical findings, the patient was diagnosed with temporal bone osteomyelitis (TBO) due to malignant otitis externa. She was empirically treated with cefepime for possible Pseudomonas species infection. The patient underwent bone biopsy, which did not grow any organisms. The patient was treated with IV cefepime for 6 weeks. After the completion of antibiotic therapy, a repeat Gallium-67 scan showed improvement in the inflammation (). The patient was then treated with oral ciprofloxacin. The Gallium-67 scan five months after the initial scan showed complete resolution of the inflammation. Her diplopia has markedly improved (). The pati

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old man consulted us for visual disturbance with corneal opacity in his left eye (). He had received topical medication for chronic open-angle glaucoma for over 5 years. We did not obtain significant information on the etiologic factors related to neoplasm induction. His visual acuity was 20/20 and 20/200 in the right and left eye, respectively. Intraocular pressure (IOP) in his right eye was 14 mmHg, but IOP could not be precisely measured in his left eye due to the elevated lesion on the corneal surface. A whitish elevated, plaque-like isolated lesion without neovascularization was observed in the central area of his left cornea. The cornea of his right eye did not show any abnormality or signs of intraocular inflammation. The whitish plaque-like lesion was removed under topical anesthesia. The lesion was easily peeled off from the underlying basement membrane. The epithelial defect produced by the removal of the lesion was resurfaced by normal-looking epithelium in a couple of days. No recurrent lesion was observed after seven months of surgery (). Stroma beneath the neoplasm is opaque (). The removed lesion epithelium was fixed, paraffin-embedded, and subjected to histology/immunohistochemistry examinations with hematoxylin-eosin (HE) staining, direct fast scarlet 4BS (DFS) staining, and immunohistochemistry for intermediate filaments of mesenchyme and ocular surface epithelial cells such as vimentin, keratin 12, keratin 13, and keratin 14, as previously described [].
The epithelium of the lesion was occupied with atypical dysplastic epithelial cells as revealed by HE staining (). The specimen was not labeled for DFS staining and thus the lesion was not related to an amyloid disease. Immunohistochemistry of cell lineage-specific intermediate filaments, for example, vimentin of mesenchymal cells, keratin 14 of a basal cell of stratified epithelium, keratin 12 of corneal epithelium, and keratin 13 of conjunctival epithelium, showed that the dysplastic ce

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


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

[User]
RADIOLOGY NOTE:
A 42 year old male presented to his primary care physician with a 20 pound unintentional weight loss over a 3 month period and new left axillary lymphadenopathy. A core biopsy of his axillary mass revealed metastatic malignant melanoma. He had no prior history of a primary melanoma. A staging PET/CT revealed abnormal FDG uptake in his left axilla and small bowel. A left axillary lymph node dissection was performed and revealed 2 of 19 lymph nodes involved with metastatic melanoma, BRAF wild type, the largest of which measured 10.1 cm. His medical history was significant for oligodendroglioma, which was surgically resected eight years prior to presentation, followed by radiation therapy for recurrence five years prior to presentation. He received four doses of systemic ipilimumab for his metastatic melanoma without incident. Post-treatment imaging revealed disease progression with new diffuse subcutaneous, lung, liver and bilateral axillary lymph node metastases.
He subsequently enrolled on a genetically engineered T-cell trial, targeting tyrosinase. He received fludarabine and cyclophosphamide as a conditioning regimen, then his engineered T-cells were infused, followed by one week of low dose IL-2, (72,000 U/kg IV q8 hours). Per the treatment protocol, unfractionated creatinine kinase (CK) levels were obtained just prior to and for two weeks after infusion of the genetically engineered T-cells. The CK levels were within normal limits during the course of this treatment. He initially experienced disease response, however, four months after his T-cell therapy, he again developed diffuse progression with new hilar lymphadenopathy and progression of his lung and axillary lymph node metastases.
He was next treated with three doses of pembrolizumab but post-treatment imaging again revealed disease progression in his lungs. CK levels were not checked during treatment with either ipilumumab or pembrolizumab. Despite multiple lines of therapy, the patient continued to have

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


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

[User]
RADIOLOGY NOTE:
We report a case of Mrs. GO, a 38-year-old Para 2+0 with 2 living male children whose last menstrual period was May 22, 2019. She presented to the gynecological emergency department on July 19, 2019, with a history of amenorrhea of 8 weeks and 2 days. Her complaints on admission were vaginal spotting of 4-day duration and sudden onset of abdominal pain of 4 h. There were associated dizziness and fainting attacks but no loss of consciousness. She was brought to the hospital due to increasing fainting attacks. There was no history of the use of hormonal contraception, treatment of pelvic inflammatory diseases, or use of fertility-enhancing drugs. She had a history of two cesarean sections in her previous deliveries.
On examination, she was in painful distress and pale. Her radial pulse rate was 100 beats per min, and the blood pressure was 100/60 mmHg. Her abdomen was distended and tender on palpation with positive rebound tenderness and guarding and absent bowel sounds. Her vulva was blood stained. Speculum examination showed a bulging posterior fornix and blood trickling from the cervical os. Bimanual pelvic examination revealed a bulky uterus with cervical excitation and bilateral adnexal fullness and tenderness. The pouch of Douglas was full. A bedside serum pregnancy test was positive. Abdominopelvic ultrasound scan showed an empty uterus with thickened endometrium and left adnexal mass with a significant amount of free fluid in the abdomen and pelvis and normal right adnexa.
A diagnosis of ruptured left tubal ectopic pregnancy was made. The diagnosis was explained to her. Intravenous access was secured in both arms, and blood samples were taken for laboratory investigations. Her hemoglobin concentration was 8 g/dl, and 3 units of whole blood were grouped and cross-matched and made available for her. She was resuscitated and taken up in emergency for exploratory laparotomy and partial left salpingectomy after written informed consent was obtained. Intraoperativel

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman presented in our neurosurgical emergency ward with severe headache accompanied by nonspecific radiating neck pain. The headache persisted for 3 days, and due to an exacerbation, the patient was admitted to the hospital.
Medical history revealed that the patient fell in the last few weeks due to a known right-sided hemiplegia. The physical examination did not show any sign of external injury like abrasions, hematomas, etc. The neurological physical examination showed an oriented but aphasic patient with a preexisting high-grade right-sided hemiparesis (3/5). The aforementioned hemiparesis resulted from an earlier (around 1976) hemorrhage of an AVM on the left hemisphere with accompanied intraventricular bleeding. The pupils were equal in size, reactive to light, and there was no relative afferent pupil defect. Moreover, an exophthalmus of the left eye was revealed as well as a known strabismus divergens and a facial nerve paresis on the right side. Furthermore, signs of meningeal irritation in form of a stiff and painful neck were detected. A brain computed tomography (CT) imaging was conducted to investigate any intracranial pathology responsible for the headache symptoms as well as the hemiparesis. The results of the CT imaging were similar to those of 10 years ago, detecting no pathological findings. Thus, we proceeded with a cervical spine CT scan due to the accompanied cervical symptoms. The latter revealed an unstable fracture through the base of the dens, type II based on the Anderson and d’Alonzo classification []. There was no evidence of a spinal hematoma. Moreover, an extended osteolysis was revealed with reactive sclerosis of denses and axis’ endplate and margins, as shown in and . The dens fracture was evaluated as a pathologic fracture. The fall incident could not explain the expanded osteolysis. Our assumption, based on the conducted imaging processes, is that the fracture was caused by a large AVM, which extended from the right sid

[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 male with medical history significant for uncontrolled hypertension admitted to the hospital for acute onset bilateral hearing loss. Symptoms had started four hours prior to presentation while he was watching television. Initial admission computed tomography (CT) scan was negative for any acute infarcts or other intracranial processes. His initial physical exam was significant for mild gait impairment, with Weber and Rinne test consistent with bilateral neurosensory hearing loss. Patient was initially admitted as a possible stroke rule out. Work up for stroke including carotid ultrasound, Cardiac echo were all negative except for Magnetic Resonance Imaging (MRI) which showed some periventricular and deep white matter lesions demonstrating T2 hyper-intensity without enhancement consistent with questionable demyelinating disease as seen in Figure . Given the non-specificity of his symptoms and unknown sexual history, a decision was made to evaluate for syphilis. Rapid plasma reagent (RPR) test was ordered, and it came back positive with a 1:16 titer. A confirmatory Treponema pallidium fluorescent treponemal antibody absorption-Ab was also positive which confirmed the diagnosis of syphilis. A lumbar puncture was then performed prior to the beginning of treatment and cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) was positive with a 1:4 VDRL titer establishing the diagnosis of neurosyphilis. Considering the initial MRI scan in Figure below, was concerning for demyelinating disease, CSF protein analysis and oliclonal band was also obtained. Both CSF protein and oligoclonal band were noticed to be elevated, but in the setting of neurosyphilis and possible meningeal inflammation with increased likelihood for false elevation in CSF protein and negative family history, a decision was made to focus management on neurosyphilis. Patient was started on Penicillin G IV 3mmu (million units) daily for a total period of 14 days, and daily 30mg of

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old man was admitted to our clinic with a sudden and progressive headache and binocular diplopia. His symptoms had appeared 2 months before his first visit to the clinic. He had also experienced a similar attack 6 months earlier, but he was in a good general condition. The neurological examination revealed right-sided abducens nerve palsy. A brain computed tomography (CT) scan was acquired, which showed a suspected lesion in the cerebellopontine angle. Brain CT angiography was also performed, which did not reveal any prominent findings. The brain MRI showed an extra-axial pontomedullary lesion with the classic appearance of a CM, that is, a reticulated salt-and-pepper core, surrounded by a halo rim []. With the diagnosis of brain stem CM with a history of multiple hemorrhages, progressive neurological deficit, and pial presentation of the CM, the patient was enlisted for the surgical resection of the lesion.
The patient underwent surgery using the suboccipital retrosigmoid approach with intraoperative neuromonitoring. The procedure was performed through general anesthesia as the patient laid in a lateral position, and his head was fixed in a three-pin Mayfield headrest. After opening the dura, a CM was detected, arising from the sixth cranial nerve, with no invasion to the brainstem or the surrounding tissues. Since the lesion could not be separated from the nerve and its integrity was unclear, we resected the CM by cutting the proximal and distal portions (before the Dorello’s canal) of the sixth cranial nerve []. Intraoperative monitoring was used to detect changes in the function of the nervous structure. Motor and somatosensory evoked potentials were normal during the surgery. Direct nerve stimulation of the sixth nerve was also performed during the surgery. The response to stimulation was normal when stimulating distal to the lesion and weak proximal to the lesion.
The greater auricular nerve (>3 cm) was harvested as an interposition nerve graft. An 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:
Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a trea

[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 25-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of severe pain in the left upper back region of the mouth since 3 days. Pain was continuous and aggravated with the intake of hot and cold beverages. Clinical examination revealed deep mesial caries approximating pulp with respect to tooth # 26. The tooth was not tender to percussion and palpation. Pulp vitality testing using an electric pulp tester (Parkell, Farmingdale, NY, USA) showed exaggerated response lasting for several minutes. Further, the maxillary lateral incisors were missing and the deciduous right maxillary first molar was overretained. Intraoral periapical radiograph of tooth # 26 revealed deep caries involving the pulp space []. Also, a single root with single canal was seen in relation to 26 and 27. Based on the clinical and radiographic findings, the diagnosis of acute irreversible pulpitis was made and patient was advised root canal treatment in relation to tooth # 26. After obtaining patient's consent, an emergency pulpotomy was performed at the same visit under local anesthesia. In order to confirm the apparent finding of the IOPA radiograph, the patient was referred for CBCT imaging of tooth 26 with 3D reconstruction. The results of the CBCT showed the presence of a single root with the Vertucci's type I canal configuration,[] and the same was observed for tooth 27 []. Thereafter, the root canal treatment was initiated. The tooth was isolated using rubber dam and access preparation was modified to completely de-roof the pulp chamber, which showed the presence of a single wide root canal orifice. Working length was calculated using an electronic apex locator (Root ZX II™, Morrita, Tokyo, Japan) as well as the radiographic method. Working length radiograph also suggested positioning of endodontic files in a single canal []. The coronal shaping was carried out using Gates Glidden burs (Dentsply, New Delhi,

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


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

[User]
RADIOLOGY NOTE:
A 39-year old Caucasian female with known NF1 presented herself in the emergency department of an outside hospital with acute symptoms of thoracic pain and dyspnea. Her history was otherwise significant for an extensive thoracic myelomeningocele and status post-surgical correction of a thoracic scoliosis using a tibia bone graft 27 years earlier.
On physical examination at the outside hospital, she was awake, afebrile, blood pressure of 80/40 mmHg and a heart rate of 100 beats per minute. The initial haemoglobin was 12.5 g/dl, quickly deteriorating to 8.4 g/dl in the following hour. Chest x-ray (Figure ) was performed 40 mins after admission and revealed an extensive mediastinal shift. Subsequent computer tomography (Figure ) was performed 1h later at the outside hospital and revealed a massive hemothorax on the left side. The patient was intubated orotracheally because of hemorrhagic shock and imminent cardiopulmonary arrest and received seven packed red blood cell concentrates. A thoracic drainage was inserted prior to transfer. 4 h 10 min after admission to the outside hospital the patient was transferred to our institution and arrived there 1h later.
On admission, she was highly catecholamine-dependent. We found one left-thoracic suction drainage installed using Monaldi technique with 50 ml of blood in the drainage bottle. During placement of venous and arterial lines she suffered a cardiocirculatory arrest. Resuscitation was immediately initiated and we proceeded with performing an emergency exploratory left antero-lateral thoracotomy in the intensive care unit. Thereupon 2 liters of blood exsanguinated spontaneously. Despite massive blood transfusions (16 packed red blood cells, 2 thrombocyte concentrates, and 4 fresh frozen plasmas) and intravenous fluid administration no sufficient circulation could be established. Due to massive bleeding and very difficult operative conditions it was not possible to perform either an exploration of the thorax or an open car

[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 male with known Down syndrome and epilepsy and taking carbamazepine was brought by his family to the emergency room with a large protruded tongue within 30 minutes of the incident ().
The patient was vitally stable; however, he was slightly agitated. The otolaryngology team had been consulted immediately for further evaluation of the patient's status. History from the patient's family showed that they believed the patient was engaging in aggressive behavior, and he has a history of multiple tongue tractions leading to sudden severe tongue swelling. The examination was unremarkable, except for a huge protruded swollen tongue, which was diffused with no confined collection or sign of hematoma. Fixable nasolaryngoscopy relieved bilateral vocal cord movement, and there was no laryngeal edema. The neurology team was consulted to rule out active seizure, and they cleared him. The decision was to intubate the patient to secure the upper airway and then admit him to the intensive care unit (ICU). The patient consented to endotracheal intubation and possible tracheostomy in case intubation failed. The patient was successfully undergoing orotracheal intubation in the operating room. Then, a CT scan was done, which revealed some artifacts due to endotracheal intubation, with evidence of an enlarged diffused edematous hypertrophic tongue muscle protruded outside the oral cavity and deviated to the left side due to tube insertion from the right side (Figures and ). In addition, the CT scan showed no evidence of mass lesions, collection, abnormal enhancement in postcontrast series, or sizable lymphadenopathy. Thereafter, he was transferred while intubated to the ICU, and he was connected to mechanical ventilation. He was kept on midazolam, fentanyl, and dexamethasone at 8 mg intravenously for Q6h to relieve swelling, as well as pantoprazole for 4 days. Furthermore, a removable bite block was placed on the teeth to prevent tongue biting, and wet gauze was applied to

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


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

[User]
RADIOLOGY NOTE:
An 11 year old male child presented with a history of high grade fever with chills, right flank pain and progressive pyuria for two months. He had a prior history of surgery for vesical calculus and anterior urethral calculus for which he underwent open cystolithotomy and urethrolithotomy four years back. The chemical nature of the stone was calcium oxalate dihydrate. Medical work-up did not reveal any cause for the calculus.
On examination, the child was emaciated, febrile with pallor. There was diffuse tenderness in the right lumbar region with renal angle tenderness. X-ray showed radio-opaque shadow in the right lumbar region measuring 2 × 2 cm. Abdominal computerised tomography (CT) revealed a dilated pelvicalyceal system with necrotic debris at the lower pole of right kidney and a thrombus in the renal vein extending into the infrahepatic vena cava. Pyonephrosis, parenchymal calcification along with marked retroperitoneal and porta hepatis lymphadenopathy were also seen on the CT. Blood urea and serum creatinine were within normal limits. Gram negative bacilli, Pseudomonas aeruginosa were isolated from thick pus aspirated from the right renal pelvis. The urine culture was sterile.
Open nephrostomy was done which drained only pus and no urinary drainage. Following a renal biopsy diagnosed as chronic pyelonephritis (end-stage changes), the patient underwent subcapsular right nephrectomy. Kidney exposure was accomplished through the flank extraperitoneally using a 12th rib cutting incision. There were dense adhesions of the kidney and Gerota's fascia with the surrounding structures. It was decided to do a subcapsular nephrectomy. When the kidney was reached, the capsule was incised and is freed from the underlying cortex. The capsule was stripped from the surface of the kidney, and an incision was made all around the capsule where it was attached to the hilum. The vessels were protected by placing a finger in front of the pedicle while cutting the capsule. The adh

[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:
Case two was a 61-year-old female, who developed a huge retroperitoneal placeholder as indicated by examination. The patient had neither chest tightness, shortness of breath, difficulty in breathing, nor abdominal discomfort. Upon physical examination, the abdomen was flat and soft, with no palpable mass. Plain chest and abdominal CT scans showed a huge soft tissue mass shadow fused by multiple nodules of varying sizes on the right retroperitoneum, approximately 164 mm × 150 mm × 116 mm in size. Heterogeneous density and extensive low-density cystic areas were seen, with CT values of 25 to 40 HU, and clear boundaries with the surrounding organs. There was a shift in the heart, and the liver and right kidney were under compression, as well as the aorta and inferior vena cava. Varicose veins in the abdomen were also observed. The solid part of the mass in the arterial phase was moderately and heterogeneously enhanced, with a CT value of about 83 HU, and a plexiform disordered vascular shadow was visible (Figure A). The solid part of the scanned mass in the venous and delayed phases was more enhanced in a sustained and heterogeneous manner, with CT values of 99 to 123 HU. No enhancement was observed in low-density cystic areas although a significant enhancement in the envelope was visible. Multi-planar reconstruction displayed the tumor size, location, and relationship with the surrounding tissue more clearly (Figure B–D). Due to the high surgical risks as determined by consultation, a retroperitoneal tumor biopsy was performed under CT guidance. The tumor cells were in fusiform shape in a bundle-like, spiral arrangement under the microscope, rich in sinusoids, and interstitial collagen denaturation in the focus area (Figure E). Immunohistochemistry showed CD34 (++), bcl-2 (++), CD99 (++), F8 (+); CD117 (-), Desmin (-), S-100 (-), and CK (-). Because of the rich vascular supply and the potential risks of surgery, 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 22-years-old Caucasian female was referred to our department, complaining of a 5-year history of intermittent pain in her right knee. She did not suffer from any medical condition, she was not on any medications and never smoked. Her symptoms started insidiously, following a minor soft tissue injury (no fracture). On clinical examination, she was found to have a right knee effusion and limitation of movement (ROM 10-90°). She had severe pain over her knee. She could weight bear with significant discomfort. Her blood tests were all normal, including the coagulation screen and all inflammatory markers. The X-rays performed were unremarkable (). An magnetic resonance imaging (MRI) scan was performed which suggested the presence of a suprapatellar fluid collection with cysts arising from the synovium. Following these results, an arthroscopy was performed. The cysts were excised and biopsied. The biopsies revealed normal synovium. Following the procedure, the patient remained asymptomatic for approximately 3 years. She then returned with similar symptomatology. A second MRI was performed showed the presence of a suprapatellar fluid collection measuring 4.7 × 2.1 cm at the suprapatellar area. No hemosiderin was noted within the collection and no local erosion. Surgical exploration was performed, and a poorly encapsulated vascular mass was encountered extending from the distal belly of the vastus intermedius to the knee. Excessive use of electrocautery and ligation of the numerous vessels were performed during resection. The histological examination of the mass revealed a dilated vascular space containing fibrous papillary projections and organized thrombus. It was suggestive of IPEH (Masson’s Tumor) ( and ). The patient’s symptoms recurred 2 years later. An MRI scan was repeated showing a 1 × 3 × 10 cm cystic lesion of the distal anterior thigh. The patient was then referred to the vascular department for embolization of the vascular supply of the tumor. Following this

[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 72-year-old Caucasian female who underwent adjuvant chemoradiotherapy for a Grade 2 invasive ductal carcinoma of the left breast. She had no other significant past medical history, including dermatological history, and took no regular medications. She was a non-smoker and did not consume alcohol. Presenting from the national screening programme, she underwent a wide local excision with axillary lymph node clearance. Her tumor was estrogen receptor positive, HER2 negative and had 7/28 lymph nodes positive. Weekly paclitaxel treatments were stopped after four cycles due to anaphylactoid hypersensitivity. She underwent 40 Gy of radiotherapy in 15 fractions over 3 weeks to the left breast and left supraclavicular fossa. Before commencing radiotherapy, she had no noted skin changes.
Upon routine review 8 weeks post completion of radiotherapy, oedema and erythema with blistering and desquamation of the skin were noted over the left breast and chest wall. There was also an area of desquamation on the patients’ back consistent with a radiotherapy exit field. The patient had been using simple moisturizers as instructed and managing pain with simple analgesia. The skin changes were first apparent 4 weeks after completion of radiotherapy. Initially, the skin lesions were confined to the radiotherapy field. She was afebrile with otherwise normal observations. Differentials included radiation-induced skin changes with superimposed cellulitis, autoimmune bullous disorder or a paraneoplastic process. An admission for further treatment was organized where intravenous antibiotics and antivirals were commenced alongside a regular skin treatment regimen. This consisted of Viscopaste and Tubigrip, Hydromol and Dermovate ointment as required. An initial superficial skin swab showed mixed skin flora only.
Despite optimal medical management, her skin continued to deteriorate, with a new area of desquamation over the right hip. The patient also developed painful oral

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line 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:
We describe the case of a 55-year-old, para 7, postmenopausal black African woman who was initially seen with a history of vulval itching of 3 years’ duration and at that stage there were no lesions to report and the itchiness was treated with topical steroids with an initial good response. Seven months prior to seeing a gynecologist she noted three warty-like lumps on her right labia majora. She then presented to a gynecologist and an excisional biopsy was done. Histology surprisingly showed infiltrating moderate to well-differentiated adenocarcinoma with malignant glandular structures that were lined by tall columnar epithelium with stratification and mucin production. The warty lesions eventually became florid as shown in Fig. .
Since this was an unusual histological type for vulval cancer, immunochemistry was requested which showed mucin, strongly positive cytokeratin (CK) 20 and CDX2, and negative CK7. There was minimal patchy staining for p16 and features suggestive of large bowel or pancreatic primary tumor. Several years back, she had a hysterectomy for abnormal uterine bleeding and histology showed several leiomyomata and no evidence of uterine or cervical cancer. In view of the unusual histology, a mammography was done which showed a solitary benign lesion in her right breast. Computed tomography with contrast of her chest and abdomen showed multiple parenchymal shadows suggestive of metastasis in her lungs and there was rectal thickening of uncertain significance with no obvious large bowel or pancreatic lesions.
She underwent sigmoidoscopy; the findings were essentially normal. A biopsy of an enlarged left groin lymph node showed the presence of metastatic adenocarcinoma with an immunohistochemistry profile again consistent with spread from colonic or rectal adenocarcinoma. When she moved to Zimbabwe she presented to the gynecological clinic with a history of lumps on her vulva. These warty lesions were biopsied and sent for histology and immunohistochem

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old Asian woman had bilateral uneventful cataract surgery for central cortical opacity. Phacoemulsification via clear corneal incision and implantation of hydrophilic acrylic intraocular lens (IOL) with polymethylmethacrylate modified C-loop haptics were done in the left eye first and the right eye later with interval of 2 days. The left eye was operated first among three operative cases of cataract and the right eye was operated third among four operative cases of cataract. Preoperatively, the cornea was clear with normal specular microscopic finding, and inflammation was not detected in the anterior chamber of both eyes. The patient had not have any systemic or ocular disease other than diabetes that was controlled well under medication, and diabetic retinopathy was not presented in both eyes.
On postoperative day 1 of each eyes, right eye had grade 1+ white blood cells in the anterior segment with uncorrected visual acuity (UCVA) of 20/25, while left eye had trace of white blood cells with UCVA of 20/25. Levofloxacin and prednisolone acetate 1% eye drops were prescribed 4 times a day in both eyes. On postoperative day 7 of right eye, anterior inflammation improved and prednisolone acetate 1% was switched to fluorometholone 0.02% in both eyes. On postoperative day 11 of the right eye, the patient visited appealing mild right ocular pain, and the UCVA was dropped to 20/30 presenting diffuse corneal edema. Grade 2+ white blood cells and puff balls were shown in the anterior chamber and inflammatory plaques on the surface of IOL were also found []. However, the cell was not found in the vitreous and it was so clear enough to examine the retina []. Intraocular pressure of right eye was 17 mm Hg. In the left eye, cell reaction was not found in the anterior chamber and the vitreous. Since anterior segment inflammation had been controlled with prednisolone acetate 1% immediately after cataract surgery and the vitreous did not present inflammatory cells, the pat

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old female patient was known to have left-sided ulcerative colitis (UC) since 2005 under treatment with oral (2 to 4 g/day) and rectal mesalamine with good clinical and biological response. She presented flare up in 2013 and 2015 with rapid clinical and biologic response to steroid therapy. She was in clinical and biologic remission since 2016. On January 2018, after 13 years of initial diagnosis and while she was clinically asymptomatic, a screening colonoscopy for colorectal cancer showed diffuse superficial ulcerations surrounded by an erythematous inflamed mucosa from the rectum to the splenic flexure (), a solitary sessile well circumscribed polyp in the cecum with normal adjacent mucosa, not amenable to endoscopic resection (Figures , , and ). Histologic examination revealed mucosal extension supported by submucosa consisting of a variable mixture of inflammatory tissue, which is histologically consistent with an inflammatory pseudopolyp ()
Two weeks later, she developed moderate flare up with bloody diarrhea and diffuse abdominal pain with no signs or symptoms of obstruction. Laboratory findings showed normal hemoglobin, albumin of 3.7 g/dl, normal liver function tests, and C-reactive protein of 25 (normal < 5). Infectious causes including cytomegalovirus and clostridium difficile were ruled out; a rectosigmoidoscopy revealed diffuse superficial ulceration with pseudomembranes in the rectum and the sigmoid; upper limit of lesions was not seen. Biopsies showed architectural mucosal distortion with polymorph nuclear infiltrates and abscesses, compatible with active UC with no cytomegalovirus (CMV) inclusion. She was started on intravenous (IV) steroids as an induction therapy with marked clinical and biological improvement. Adalimumab infusion, subcutaneously, was initiated as a maintenance therapy at a dose of 160 mg followed by 80 mg after 2 weeks and then 40 mg every other week. Eight months later, a surveillance colonoscopy showed complete regress

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old woman visited our clinic with pain on the right inguinal area and lateral aspect of the thigh, which spontaneously started 3 months ago and had become aggravated a week before. The pain intensity in the visual analogue scale (VAS) was about 80 of 100. Her height was 164 cm and body weight was 62 kg. She was a caddie, and had no specific medical or trauma history. She was experiencing right groin and thigh pain precipitated by walking, which made it difficult for her to walk normally. Lumbar magnetic resonance imaging (MRI) done at a previous clinic showed otherwise normal (). In the previous clinic, lumbar epidural steroid injection was done twice in combination with medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants for 2 months; however, these failed to improve her symptoms. She has even had a gynecological examination to rule out the disorder such as pelvic inflammatory disease, yield to normal. On physical examination, she complained of tenderness over the right buttock and the anterolateral aspect of the thigh, as well as pain with flexion and internal rotation of the right hip joint. Both the straight-leg-raising test and the flip test were negative, as concordant with previous MRI showing non-specific finding. Motor weakness and sensory alteration on the lower legs were not observed. Her body temperature was 36.3℃, and laboratory findings such as complete blood count, erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor were normal. We checked the hip radiograph and found a small amorphous calcification near the right anterior inferior iliac spine (AIIS)-the attachment site of the rectus tendon-suggesting calcific tendinitis of rectus femoris. Additionally, it was more visible in frog leg lateral views around the bony structure (). On initial ultrasonography scanning on the tender area over the hip, oval- shaped calcification was seen with surrounding hyperechoic fat suggesting inflammatio

[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 male patient aged 47 years presented with a chief complaint of worn-out lower front teeth. A complete oral examination followed by a detailed medical and dental history was done and recorded. The oral hygiene status of the individual was fair [Oral hygiene index (OHI) score=1.5]. Medical history revealed that the patient was a known diabetic under medication Glipizide once daily (OD). He presented with a history of occasional grinding of teeth.
Intraoral examination revealed, congenitally missing teeth in relation to 31, 41. All the remaining teeth showed signs of attrition, without any specific symptoms. Most of the posterior teeth showed class V fillings, which suggests that the lesions could be due to stress caused by the parafunctional habits like bruxism and clenching. Lower anterior teeth in relation to 32, 33, 42 and 43 were severely attrited with inadequate clinical crown length. Teeth numbers 11, 12, 21 and 22 were slightly palatally tilted, and the palatal aspects of these teeth also showed gross attrition, due to deep bite. Teeth numbers 21, 22, 32 and 33 were already endodontically treated as he had a history of pain and recurrent infections in relation to these teeth [Figures and ].
Evaluation of vertical dimension of occlusion did not reveal any signs of loss of vertical dimension of occlusion (VDO). Occlusal analysis was done intraorally, and it revealed that there was no definite anterior guidance; and, thereby, absence of any mutually protected occlusion. Lateral movements of mandible showed that on the left working side, there was group function; and on the right nonworking side, there were interferences in the molar regions (46, 47 and 48). On the right working side, there were canine and premolar occlusions, with nonworking side on the left showing interferences in the second and third molars (37 and 38). Even with these clinical signs, the patient did not present

[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 woman had noted moderate pruritus in the upper area of her left breast and sensed annoying mass in the same area, 15 months before she was referred to Al Zahra hospital where we took her history notes. One month after the initiation of pruritus, bilateral diagnostic mammography (4 films) showed a 1 cm spherical mass with spiculated edge in the upper zone of the left breast suspected to a malignant lesion and suggested fine-needle aspiration cytology for further studies according to breast imaging-reporting and data system (BIRAD V). Breast sonography revealed normal skin, nipple and subcutaneous fat but a 8.2 × 7.2 mm irregular contour, hypo echo lesion, 1 cm from nipple in the position of eleven o’ clock. Solid mass did not existed in the right breast. Due to these findings the patient underwent partial mastectomy and left axillary dissection 2 month after onset of mass sensation. Post operative pathobiopsy showed an invasive ductal carcinoma. Pruritus subsided immediately after surgery. Lung metastasis and post surgical collection were reported in multi 64-slice CT scan with contrast, 20 days after operation. Lungs were free from any pathologic infiltration. There were multiple pulmonary nodules (one 7 mm in the right upper lobe and three tiny foci in the left lung with mean size of 4 mm) in lung fields. No mediastinal or hilar lymphadenopathy, plural effusion and thickening were seen.
During 6 sessions of chemotherapy and 31 sessions of radiotherapy, the patient had no considerable symptom or problem until 1 week after last session of radiotherapy when she presented with severe scattering pain of the whole left upper limb with a radiation to scapula. Multiform blisters appeared 1 week after, when the scattering pain was decreasing. The watery/vesicular blisters were in the distal flexor surface of the arm in different sizes, dominantly in the cubital area lasted for 3 weeks. These clinical manifestations were diagnosed as herpes zoster activation an

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


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

[User]
RADIOLOGY NOTE:
Written informed consent was obtained to report the case. A 34-year-old G2P1 pregnant woman diagnosed with AS presented at the obstetric outpatient clinic at 18 weeks of gestation. She experienced back pain when she was 25 years old; these symptoms made walking difficult during her first pregnancy at 31 years old. Following her first vaginal delivery, she was able to walk although pain persisted to a lesser degree than during pregnancy. Radiography revealed osteosclerosis of the posterior surface of cervical vertebrae and osteoarthritis of the right hip with joint space narrowing (Figure ). The initial diagnosis of AS was made at 33 years of age.
Pain was managed by the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. After the present pregnancy was diagnosed, only acetaminophen continued to be administered, but pain increased during the present pregnancy. She complained of right hip pain, with a visual analog scale (VAS) score of 7/10. A dosage of 5 mg of oral prednisolone was administered daily from 18 weeks of gestation, and thereafter, the symptoms temporarily improved to 0/10 on the VAS. Unfortunately, the symptoms relapsed at 31 weeks of gestation. At 32 weeks of gestation, she complained of restricted neck mobility with difficulty gargling, restricted lumbar mobility that caused difficulties in bending her back, and restricted right hip joint mobility with a limitation of 10º of abduction, which also affected internal and external hip rotation. Peripartum management was discussed and planned by obstetricians and anesthesiologists. Given that only hip abduction and rotation, but not flexion, were limited, it was considered that an attempt of vaginal delivery would be possible when spontaneous labor occurred. However, if an emergency cesarean section (CS) was necessary during labor owing to other obstetric complications such as nonreassuring fetal status, special anesthesia management may be required because of the possible fai

[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 27-year-old Saudi male who had been bed-bound with a history of congenital anomaly of severe kyphoscoliosis, bilateral lower limbs deformity with paraplegia, and a ventriculoperitoneal shunt since early childhood. He was brought to the emergency department (ED) with right flank pain associated with fever and difficulty in breathing. The patient had no complaints of chest pain, palpitations, cough, rhinorrhea or nausea, and vomiting. He could not comment on symptomatic urinary issues due to his baseline paraplegic status. The patient had a past medical history of recurrent urinary tract infection (UTI) characterized by up to two incidences per year and renal stones. He had been discharged four days prior to this admission from a different hospital's ICU, with a diagnosis of sepsis. On physical examination, his vitals were as follows: temperature of 38 °C, heart rate of 165 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 144/95 mmHg, and oxygen saturation of 94% on room air. Cardiovascular examination revealed a normal S1+S2, no added sound, and intact peripheral pulses without peripheral edema. Chest examination showed bilateral decreased air entry with restricted chest movement due to kyphoscoliosis. Abdominal examination revealed a soft and lax abdomen with right upper quadrant tenderness. Lab investigations showed elevated WBC, metabolic acidosis, coagulopathy, elevated inflammatory markers (Table ), and a positive urinalysis for UTI. His ECG demonstrated sinus tachycardia and pulmonary hypertension, and tricuspid regurgitation was found on his transthoracic echocardiogram. CT imaging of his chest and abdomen was performed with negative results for a pulmonary embolism but showed a mass on the right kidney suggestive of XGP (Figure ).
The patient was started on 1000 mL of 0.9% normal saline IV, paracetamol 1 g IV, and ceftriaxone 1000 mg IV in the ED. He was referred to the urology department as a case of severe uro

[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:
Female patient, white, 20 years old, with no systemic history, attended the dental clinic in 2005 reporting a slow, painless increase in volume in the mandible region (right side) over the last 5 years, producing facial deformity. During physical examination facial asymmetry was observed due to an increase in the size of the mandibular body on the right side, of solid consistency, pain-free, and without adenomegalies. Intraoral examination showed a hard-textured increase in the alveolar ridge on the right side; the adjacent mucous tissue was normal. A panoramic X-ray was done () in which alteration was observed in the pattern of the cancellous bone in the right hemimandible; it was then decided to do an incisional biopsy, resulting in a definitive diagnosis of fibrous dysplasia. Bone gammagraphy was indicated plus an endocrinological study to eliminate polyostotic forms which produced a negative result. Monostotic fibrous dysplasia in the right hemimandible was diagnosed. The treatment options were discussed jointly and it was decided to carry out monitoring with a sequence of imaging studies, with the patient being recalled for control.
When the patient returned for control four years later, in 2009, she expressed interest in treating the facial deformity produced by the pathology. She reported that she had received surgical treatment to remove two teeth which were retained in the mandible on the right side. After clinical examination, a panoramic X-ray was done () in which it was observed that pieces 4.5 and 4.8, which were retained, had been removed. Furthermore there was a radioopaque area of the image with the appearance of ground glass in the right hemimandible. A more detailed examination by cone-beam computed tomography (CBCT) not only confirmed the existence of the bone lesion in the right hemimandible (), but also allowed the location and extent of the tumour to be determined precisely, from which the surgical procedure indicated could be

[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 November 2012, a 30-year-old woman presented for evaluation of bilateral thyroid masses. A 4×5 cm hypoechoic nodular lesion was detected on the right and a 6×7 cm hypoechoic nodular lesion was detected on the left. The lesions were diagnosed as papillary thyroid carcinoma, and we recommended total thyroidectomy. However, the patient did not wish to undergo total thyroidectomy because she was afraid of the large surgical scar that would remain on her anterior neck. Two years earlier, the patient had been in a traffic accident, as a result of which she had a 10 cm keloid scar on the left lateral neck area (). For this reason, she had a growing fear of skin incision that we planned to perform endoscopic total thyroidectomy via a keloid scar incision.
Under general anesthesia, the patient was placed in the supine position. The neck was extended to a greater degree than with the conventional transcervical approach to provide sufficient working space (). A skin incision was made on the lateral keloid scar about 10 cm in length (). A skin and subcutaneous dissection was carried out from the incision line toward the thyroid area, carefully retracting the sternocleidomastoid (SCM) muscle (*) inferiorly and strap muscle superiorly (). We then met the left thyroid gland, preserving the recurrent laryngeal nerve and parathyroid gland around the thyroid (). Thereafter the left thyroidectomy was done (). In frozen biopsy, the left thyroid mass was confirmed to be papillary thyroid carcinoma.
After that, the subcutaneous flap (including the strap muscle) and the SCM muscle were pulled with a retractor to make a tunnel to approach the right thyroid. As the size of the thyroid was large, it could be identified easily while approaching it laterally. A flexible endoscope (10 mm, 0 degrees; Olympus, Tokyo, Japan) was inserted through a subcutaneous tunnel, which provided a good view of the right thyroid area. The assisting surgeon kept the endoscope

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old male, heavy goods vehicle driver was referred by his general practitioner with a 5-month history of frequency of micturition and a right groin swelling. He reported that pressure exerted on the groin swelling made him void more urine after he had finished his initial void. On examination, the right groin swelling was indeed noted to decrease in size when compressed after voiding.
An ultrasound scan of the renal tract and right groin demonstrated a right inguinal hernia containing the urinary bladder [Figure and ]. The findings were subsequently confirmed by a magnetic resonance imaging (MRI) scan of the abdomen and pelvis, which suggested a right inguinal hernia, containing a large bladder diverticulum []. At flexible cystoscopy, a large bladder diverticulum with a narrow neck was noted. The patient was offered an elective laparoscopic right inguinal hernia repair and excision of the bladder diverticulum.
The procedure was performed under a general anesthetic with antibiotic prophylaxis. Four ports (2 × 12 mm and 2 × 5 mm excel bladeless trochars) were inserted after establishing pneumoperitoneum via Hassan's technique. Laparoscopy revealed a large direct right inguinal hernia containing the bladder diverticulum. Following right inguinal dissection, herniotomy was attempted via traction and external pressure. This was unsuccessful; therefore, a small incision was made laparoscopically in the conjoint tendon which enabled the hernia to be reduced.
The neck of the diverticulum was identified and confirmed by simultaneous flexible cystoscopy. The diverticulum was subsequently transected using a 35-cm harmonic scalpel (Ethicon harmonic ace). The bladder defect was closed with 4.0 vicryl in a continuous running suture. Flexible cystoscopy confirmed no leak of urine from the bladder following which an 18 Charriere silver-coated urethral catheter was inserted. A 10 × 15 cm Dacron mesh (Cousin Biotech) was tacked over the inguinal defect. This type of mesh was

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


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

[User]
RADIOLOGY NOTE:
A 65 year old woman, presented with stuffiness and headache, referred to our clinic. She has had these symptoms for three years and increasing for three months especially at the right side of her face. The patient had no associated symptoms such as; epistaxis, rhinorrhea, diplopia, cerebral or the other opthalmologic symptoms. She had no history of surgery, trauma or chronic infection. At physical examination there was no deformity on her face. Anterior rhinoscopy showed bilateral inferior conchal congestion and a mass at posterior of the right inferior concha. A solid mass with smooth surface that extend to the choana was found in right nasal cavity on endoscopic examination (). Other physical examinations were normal. A paranasal sinus computerized tomography (CT) scan revealed a 4x3 cm lesion of osseous density arising from the right lamina papyracea and extending to the choana, posterior ethmoid air cells and frontal reses (). Except from the lamina papyracea, there were no insertion of the mass to the lateral wall. There was a soft tissue density in the right maxillary sinus secondary to the ostium obstruction.
An endoscopic excision planned under general anesthesia. After uncinectomy and anterior ethmoidectomy, the margins of the osteoma evaluated. The bony medial orbital rim were cut by a drill without excision of the lamina papyracea and the mass was mobilized. Posterior part of the nasal septum was resected for excision of the osteoma. It was pushed to the choana and got out from mouth. Merocel package was done for hemostasis. After removal, the giant osteoma was found to measure ~ 4×3×2 cm (). There was no complication after surgery and the lamina papyracea was intact. Meroceles were got out two days later, there was no hemorrhage and the patient was discharged. The histopathologic report confirmed a diagnosis of osteoma with osteoblastic and osteoclastic activity. An endoscopic examination and CT showed that the patient

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


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

[User]
RADIOLOGY NOTE:
We describe the case of a 34-year-old gravida II para l woman, with a gestational age of 26 + 3 weeks at admission, who had a relatively healthy 4-year-old child with her 40-year-old husband of non-consanguineous marriage. She had been on injectable contraception for 2 years and had regular menses for 6 months before the pregnancy. She had antenatal care at a local health center and was vaccinated with tetanus toxoid once and supplemented with iron for 3 months. She was screened for retroviral infection, hepatitis, and syphilis and it was documented nonreactive. She had no anatomic scan at early gestation. She came to Felege Hiwot Referral Hospital with the chief complaint of severe and persistent headache of a day’s duration which was occipital in location associated with blurred vision and generalized body swelling of 1 week’s duration. She had no other danger signs in pregnancy. Her past gynecologic history, medical history, and surgical history were uneventful. She is Amhara by ethnicity. She had no known family history of hereditary or chromosomal disorders.
Her blood pressure at admission was 180/120 mmHg and pulse rate was 84 beats per minute; her respiratory rate was 22 breaths per minute and she was afebrile. She had pink conjunctiva and non icteric sclera, 24 weeks-sized gravid uterus, no abdominal tenderness, no organomegaly, no sign of fluid collection in her abdomen, and the fetal heart beat was positive. She had no vaginal bleeding or discharge. She had pedal and pretibial edema. She was conscious and oriented to person, place, and time. Her deep tendon reflex was +2 and her motor and sensory examinations showed no motor or sensory problems. Other parts of systemic examinations were normal.
Her hypertension was controlled with intravenously administered hydralazine 5 mg two doses at our emergency department. In her complete blood count her white blood cells were 7300 cells/micL,

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


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

[User]
RADIOLOGY NOTE:
The patient is a 29-year-old G3P2002 woman at 39-week and 1-day gestation, who was referred from a health center for management of fetal demise. She had attended 03 antenatal visits at the same health center wherein the fundal height was documented at each visit and routine care given. Except for occasional painful fetal kicks, she was otherwise well throughout the antenatal period. Three days prior to admission into our service, she experienced reduced fetal movements for which she consulted at the said health center and a diagnosis of fetal demise was made. On admission to our unit, she had stable vital parameters. There was no abdominal tenderness and an apparent fundal height of 32cm was measured, fetal parts were not easily palpable, and fetal heart tones were not perceived. There were no signs of per vaginal bleeding. Her cervix was long, posterior, firm, and closed. An emergency ultrasound scan was requested which confirmed fetal demise (gross cranial deformation was noted) but failed to diagnose an intra-abdominal location.
Cervical ripening was started with 50µg of misoprostol vaginally every 6 hours and after 4 applications; the cervix remained unchanged. A decision for operative delivery was made, indicating failed induction and in a bit to reduce the risk of disseminated intravascular coagulation. The intraoperative findings were a third-degree macerated female fetus floating freely in the peritoneal cavity, weighing 2650g with a tight cord round neck and with no amniotic sac (). The uterus was about 14 weeks () and the fallopian tubes and ovaries were normal. The placenta was implanted on the ascending colon and mesocolon. The placenta was left in place. No intraoperative complications were encountered. Postoperatively, she was placed on ampicillin, gentamycin, and metronidazole parenterally for five days. She also received 50mg of methotrexate every other day (04 doses) with 5mg of folinic acid each day proceeding the methotrexate. She was discharged o

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


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

[User]
RADIOLOGY NOTE:
A 2-month-old female infant was admitted due to a fast-growing tumor of the right side of the maxilla, disfiguring the right cheek, nose and upper lip. The first symptoms occurred when the girl was 6 weeks old, when a tooth within the hard palate surrounded by a small, hard, non-painful bulge was found by the mother (). It was diagnosed by a GP as a neonatal tooth and a decision was made to wait and see. However, during the next two weeks, the mass rapidly increased in size. Magnetic resonance (MR) displayed a pathological, well defined, solid mass measuring 23 × 22 × 18 mm, located within the alveolar process on the right side of the maxilla, reaching the midline. The bud of the right incisor was visible within the mass. The tumor bulged outside in the region of the nasal alar and invaginated into the mouth. No evidence of destruction of the hard palate, penetration into the orbital or nasal cavities and no evidence of enlarged lymph nodes (LN) were found ().
The tumor was resected in the otolaryngology department; however, clear margins were not achieved. The histopathological examination revealed MNTI with typical morphology and immunophenotype (). Three weeks after the surgery, a local recurrence was observed and the patient was referred to the department of Pediatric Oncology. MR revealed a mass measuring 16.5 × 16.5 × 22 mm visible in the postoperative area (). The mass was invading the nasal concha and reaching the medial angle of the right eye; however, it did not penetrate into the orbit. Because the tumor was deemed unresectable without severe mutilation, a neoadjuvant CHT was introduced to reduce its size and extent. The patient received several courses of CHT according to the protocols for neuroblastoma (NBL) and sarcoma. The responses to particular courses of CHT varied () but eventually, after eight courses, a partial regression of the tumor was achieved which enabled its complete non-mutil

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old male patient reported with the chief complaint of swelling and mobility in lower posterior teeth since six days. On examination there was a periodontal pocket of 7 mm and 8 mm on distal aspect of 46 and 47 respectively [Figure and ]. Radiograph showed infrabony defects distal to 46 and 47 [Figure ]. The treatment plan was to perform an open flap debridement in 46, 47 region and utilize autogenous bone procured from maxillary tuberosity to fill the osseous defect.
A mucoperiosteal flap was raised from the 45-48 regions using simplified papilla preservation flap[] to achieve maximum coverage of the grafted site. No vertical incisions were given and the flap was extended to one tooth on either side for adequate reflection [Figure ]. A thorough debridement was carried out and after complete removal of granulation tissue, 5.5 mm and 5 mm defects were present distal to 46 and 47 respectively [Figure and ].
The site selected for procurement of the autogenous graft was the right maxillary tuberosity. A mucoperiosteal flap was raised and site exposed with adequate reflection []. Autogenous chips were collected from the site [] and placed into the defects []. The flaps were sutured with close approximation of both the flaps using interrupted sutures starting from the distal aspect of 47 and last suture placed between 45 and 46.
The patient was instructed on proper plaque control in all areas except the quadrant of surgery where he was instructed not to brush. A 0.12% Chlorhexidine mouthwash was prescribed for rinsing twice daily. The sutures were removed 10 days after surgery and the patient was advised to continue the Chlorhexidine mouthwash for two weeks. After this he was advised to start mechanical plaque control in the operated quadrant using soft brush and roll technique.
The patient was put on regular recall at 1,3,6,9 and 12 months. The clinical picture had improved considerably at the time of three-month

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old Caucasian lady presented to the Maxillofacial outpatient clinic via her general practitioner with a 12-month history of tenderness around the left side of the oropharynx. She reported painful swallowing mostly with solid foods and felt it was getting worse. She also reported that she was unable to lie flat due to severe pain. Based on these symptoms, the patient had been diagnosed with gastroesophageal reflux and had been placed on regular proton pump inhibitor (esomeprazole) by her general practitioner. This medication failed to control or improve her symptoms. It was also noted from her medical history that she had previously suffered with a tonsillar carcinoma on the left side and had been treated with surgery and radiotherapy years earlier.
Physical examination revealed an edentulous patient with an irregular red lesion in the left side of the soft palate with a bony hard, slender mass protruding into the mouth covered by mucosa (Fig. ). There was no evidence of ulceration, induration or any other lesions present in the mouth. Extraoral examination was completely normal with no clinical evidence of cervical lymphadenopathy. An orthopantomogram demonstrated an elongated styloid process.
The patient was clinically diagnosed with an elongated, medially deflected and symptomatic styloid process. The proposed management plan was for surgical reduction of the protruding process via an intraoral approach.
Under a general anaesthetic, a mucosal incision over the protruding process was made with monopolar diathermy. Periosteal elevators were used to free all the soft tissue attachments off the styloid process (Fig. ). Once cleared, 2.5 cm of the styloid was removed with a Rongeurs bone nibbling forceps. This was judged clinically to be a sufficient length to clear the oral cavity of any interference from the protruding styloid process. Bleeding was controlled with bipolar-diathermy forceps and the mucosal incision closed with 3.0 vicryl interrupted sutures.

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old African man presented to our surgical emergency with a week history of bleeding per urethra following nocturnal penile erections. He admitted to have introduced a broken transistor radio antenna into his urethra a week before to serve as an improvised ‘itchstick’ to ease a bothersome itchy urethral condition. The object subsequently migrated proximally out of reach. He made several unsuccessful attempts at self-retrieval prior to presentation and remarkably reported no difficulty with voiding. He had no history of psychiatric disorder, alcoholic or drug intoxication and had no prior history of similar or other self-injurious behaviour. He, however, had a bothersome perineal and itchy urethral condition which was worse at nights.
Physical examination revealed a hard rod-like mass in the proximal part of the penis extending to the perineum; the mass had only minimal mobility. A pelvic X-ray done showed a rod-like radio-opaque foreign body in the region of the penile and bulbar urethra []. A diagnosis of foreign body in the male urethra was made. After obtaining informed consent, removal of the foreign body was planned. Under caudal regional block with 2% Xylocaine gel instilled into the urethra, an attempt at ‘milking out’ the foreign body was made but failed. Endoscopic removal was considered but deemed inappropriate as the distal end of the object was jagged (irregular) and appeared impacted in sub-urethral tissue. External urethrotomy of the anterior urethra was performed with the incision made into the proximal penile urethra at the distal tip of the foreign body which was then easily extracted []. The extracted foreign body, an aluminium tube transistor radio antenna measured 13 cm in length [], urethral swab for microscopy and culture was taken and urethrotomy closed over a 16 Fr Foley's catheter. The patient was discharged after 48 hours and the catheter removed after a week at the clinic. The urethral swab

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old male volleyball player presented to the clinic with a three-week history of lower back pain. The patient was otherwise healthy, with no history of trauma. Spinal extension with his arms overhead during jumping elicited lower right back pain (Figure ).
A review of systems did not reveal any other pertinent findings. On examination, the patient showed normal responses to the straight leg raise test and no neurologic signs. His range of motion was normal with extension and flexion of the lumbar spine, but associated pain occurred over the paravertebral muscles. Palpation of the proximal lumbar spine vertebrae revealed mild tenderness. Paraspinal spasms were noted. No signs suggestive of inflammation were evident. The stork test caused mild pain over the lower back (Figure ).
Conservative treatment was initiated which included rest for two weeks and icing of the painful area of his back for 15-20 minutes a day, up to three times a day. The patient was also advised to avoid any activities and positions that might lead to back pain. He was advised to take ibuprofen as needed for pain and cyclobenzaprine as needed for spasms. He was referred to physical therapy for local modalities and core-strengthening exercises. His back pain had resolved by the two-week follow-up. Approximately three weeks later, he was pain-free, even during activities.
Diagnosis
In this athlete, treatment was geared towards mechanical back pain and spasms, and it appeared to be effective. The patient had expressed desire at the time of the consultation to participate as soon as possible in a college-level volleyball competition. The lengthy symptomatology (three weeks) in this adolescent collegiate athlete who performed repetitive hyperextension as a volleyball player who was planning to participate in an upcoming competition, combined with the physical examination findings and positive stork test, indicated a need for radiography due to increased suspicion of spondylolysis [-]. An

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


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

[User]
RADIOLOGY NOTE:
A-40-year old female, previously fit and well, presented with pain and swelling of the left side of her neck of four days duration, in association with a sore throat and chest tightness. The pain radiated to the left axilla and shoulder. There was no history of fever or night sweats, and she had lost about 8 lbs in weight in the previous 3 months. She had no cough, and clinical history was otherwise unremarkable. She had no relevant past medical or surgical history and was not taking any medications.
On examination, there was diffuse tender swelling on the left side of neck with marked engorgement of the superficial veins over this area, also involving the upper part of chest and upper left arm. There were a few scattered small tender lymph nodes in the posterior triangle of the left side of the neck. The remainder of clinical examination was normal.
Initial laboratory investigations showed a normal full blood count, with a raised erythrocyte sedimentation rate of 58 mm and elevated C-reactive protein of 45 units (normal range is 0–10 units). Urea and electrolytes, liver function tests, and thyroid function tests were normal, and chest X-ray was also unremarkable. A thrombophilia screen was negative, and serum ANA was weakly positive.
She was referred initially for ultrasound examination of the neck which demonstrated extensive thrombosis of the left internal and external jugular veins (Figures and ).
Ultrasound also demonstrated enlarged lymph nodes in the left supraclavicular fossa which were suspicious of malignancy ().
She was initially treated with intravenous antibiotics and was anticoagulated with low molecular weight heparin followed by warfarin. Subsequently she underwent computed tomography (CT) of the neck, chest, abdomen, and pelvis which confirmed venous thrombosis of the left jugular veins. CT also showed multiple enlarged left supraclavicular nodes, an enlarged right retro-crural lymph node, and extensive portal and para-aortic adenopathy extending do

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old gentleman was diagnosed as a case of left-sided RCC in June 2004, which was treated with radical nephrectomy and adjuvant radiotherapy at an outside hospital. In October 2006, he presented to our hospital for second opinion in view of progressive metastatic deposits in both the adrenals, lungs, and mediastinum. He was started on interferon (INF-α, 5 MIU daily subcutaneous doses), which he continued till December 2007. Subsequently, he presented with swelling in throat in March 2009. It was biopsied and confirmed to be metastases from RCC. He was advised external beam radiotherapy for the base tongue lesion but refused treatment due to personal reasons. In December 2009, he presented again with increasing difficulty in swallowing and alteration in voice. He was barely able to swallow liquids orally and had lost 2-3 kg of weight. On clinical examination, he had a large (5 × 5 cm) exophytic swelling in the oropharynx with epicenter in the right base of tongue []. It involved the tonsillar fossa and adjacent soft palate on right side, crossing midline. Tongue mobility was normal. There was no palpable cervical lymphadenopathy. Computerized tomography (CT) scan of the face, neck, thorax, abdomen, and pelvis was suggestive of widespread visceral and osseous deposits apart from the base tongue lesion []. No adenopathy was noted (which corroborated with secondary from RCC as it is uncommon for large oropharyngeal primary of squamous carcinoma to present without neck nodes). In view of predominant symptom of dysphagia and exophytic growth, he was first planned for palliative radiotherapy with escalating doses followed by Sunitinib. The patient received radiotherapy to a dose of 50 Gy in 25 fractions over 5 weeks with limited portals. Protracted regimen (prolonged fractionated course of radiotherapy over 5 weeks as compared to the most commonly used short course of palliative radiotherapy) was chosen expecting sustained and relatively quicker relief of symptoms.

[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 and 60 kg weight male patient was admitted in kidney transplant unit with a history of end-stage renal disease (ESRD) and on maintenance hemodialysis twice weekly since 21 months. He was having type 2 diabetes mellitus since 7 years and was on oral hypoglycemics. He was also hypertensive since 18 months and was on nifedipine retard 20 mg TID, clonidine 100 μg TID, metoprolol 50 mg OD, and furosemide 40 mg BID. During preoperative evaluation, the patient was New York Heart Association Class III having a history of breathlessness and dyspnea on exertion. Jugular venous pressure was raised. Mild ascites was present without evidence of organomegaly. His daily urine output was around 500 ml. His 12-lead electrocardiogram (ECG) showed left ventricular hypertrophy with strain pattern. Two-dimensional echocardiography revealed moderate mitral regurgitation, moderate tricuspid regurgitation, dilated left ventricle with global hypokinesia, and LVEF of 15% with moderate pulmonary artery hypertension (right ventricular systolic pressure = right atrial pressure + 44). Coronary angiography was normal. His routine blood investigations were within normal limits except hemoglobin of 8.7 g% and a serum creatinine of 6.9 mg/dl on preoperative visit. His creatinine value before starting of dialysis 21 months earlier was 9.4 mg/dl. His chest radiograph showed cardiomegaly with cardiothoracic ratio of 0.7. On airway examination, his mouth opening was 3 cm with normal dentition. He was Mallampati Class 2 with a full range of neck movements and a thyromental distance of 7 cm. All antihypertensive medications were continued as prescribed. Heparin-free hemodialysis was done 24 h before surgery. A written informed consent for surgery and anesthesia was obtained along with high risk of cardiovascular events and postoperative mechanical ventilation.
In the operating room, an 18-gauge intravenous (IV) cannula was secured in the right upper limb and 5-lead ECG, noninvasive blood pre

[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 undernourished boy presented to our outpatient department with a 1-month history of progressive breathlessness on exertion. He had a history of intermittent fever of mild to moderate grade and dry cough since 4 months. His breathlessness had progressed relatively rapidly over 1 month and now limited his daily activities. He also had associated anorexia and weight loss. He had been treated symptomatically by his local physician and later underwent investigations for the persistence of symptoms. A chest X-ray [] showed a complete white-out of the left lung with ipsilateral mediastinal shift suggesting complete lung collapse. A contrast-enhanced computed tomography of the thorax showed an endobronchial lesion in the left main bronchus with complete collapse-consolidation of the left lung; it also showed an endobronchial lesion in the right lower lobe []. He underwent a fibreoptic bronchoscopy which confirmed a left main bronchial growth and a right lower lobar bronchial growth and a guided biopsy of these endobronchial lesions [] was done. The histopathology report of the left sided lesion was necrotic tissue and the right sided lesion was reported as a neuroendocrine tumor (carcinoid tumor).
Subsequent to these investigations, he was transferred to our hospital for increasing the severity of his symptoms. He presented to our hospital in respiratory distress and required endotracheal intubation with mechanical ventilation. We performed a bronchoscopy which confirmed the outside report and repeated endobronchial biopsies. Review of these and the external biopsies showed a high-grade malignant tumor composed of sheets ofhighly pleomorphic cells containing a moderate amount of eosinophilic cytoplasm and eccentrically placed hyperchromatic nuclei and prominent nucleoli. Few cells showed wreath like/horseshoe-shaped nuclei []. On immunohistochemistry (IHC) the tumor cells were strongly and diffusely positive for leukocyte common antigen, while negative for cyt

[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.