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

[User]
RADIOLOGY NOTE:
A 16-year-old male presented to medical attention with a history of intermittent headache since last 1 month, particularly after doing strenuous activity. Patient advised for computed tomography (CT) scan [] of the brain that showed a large mixed density lesion with mass effect for which he was referred to us. On examination patient was conscious, cooperative, and oriented to time, place, and person. His vitals were within normal range. He had no significant medical history, previous radiation exposure, or family history of vascular malformations. There was no sensory or motor deficit. His both fundus appears to be normal. Magnetic resonance imaging (MRI) of the brain [] showed a large heterogenous partially hemorrhagic, multilobulated mass (68 mm × 69 mm × 74 mm) in right frontal lobe with perilesional edema and midline shift of approximately 15 mm to the contralateral side. Magnetic resonance spectroscopy performed and was nonconclusive for neoplastic pathology. CT angiography of the brain was negative for any Arteriovenous vascular malformation. After interdepartmental discussion and words with Neuroradiologist provisional diagnosis of arteriovenous malformation (AVM) with bleed or a high-grade malignancy with hemorrhage was made. After taking written and informed consent, the patient was taken for surgery. On operation table, his head end was elevated so that cerebral venous drainage improved. Question mark incision made and frontotemporoparietal craniotomy done. Dura opened after applying dural hitches. The brain was tense and edematous. A small opening was made over middle frontal gyrus, and cystic part of lesion aspirated out with help of suction. Cystic fluid was like old blood. Solid part of lesion was soft to firm in consistency and was purple green in appearance. Soft part of lesion was a suckable, but firm part was taken out in piecemeal. There was gliotic reaction all around the lesion that was left in situ. Overall, during surgery parts of the lesion b

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old male presented in February 2016 with increasing dysphagia. There was no history of prior abdominal infection or surgery. On esophagogastroscopy, a necrotic and circumferential friable tumor was seen at 33 to 40 cm from the incisors, with an endoscopic appearance of involvement of gastroesophageal (GE) junction and the proximal 2 cm of the stomach. Biopsies of the distal esophageal tumor confirmed poorly differentiated adenocarcinoma. The patient was anemic with a hemoglobin of 89 g/L. Staging endoscopic ultrasound suggested a breach of muscularis propria and four enlarged paraesophageal nodes. Neoadjuvant chemoradiotherapy followed by esophagectomy was initially considered; however, a staging positron emission tomography (PET) scan demonstrated 18-fluorodeoxyglocose (FDG) uptake not only in the primary tumor, but also in the paraesophageal region near the GE junction and upper abdominal lymph nodes extending as far inferiorly as the right renal vessels, in a retrocaval location (Figure ).
A radiation oncology consultation was sought regarding treatment options of such extensive lymphadenopathy. Palliative radiation therapy (RT) was recommended. The patient was also evaluated by a medical oncologist who advised that chemotherapy may be considered after assessing the response to palliative radiotherapy.
From March 21, 2016 to April 5, 2016, the patient received palliative RT to the symptomatic primary tumor and closest adjacent nodes using a pair of anterior and posterior fields. A total dose of 30 Gray (Gy) was prescribed over 10 daily fractions. As the lymphadenopathy in the lower abdomen was not symptomatic, and would have contributed to increased toxicity, this region was deliberately excluded from the high dose RT volume (Figure ). Other than very mild odynophagia, the patient had no other RT-related side effects. On the first follow-up visit, one month following treatment completion, he had improved swallowing function and a weight gain of six poun

[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:
Male, 46 years old, with complaints of a lump in his penis. The lump first appeared 5 years ago and was removed by another surgeon, but the lump has reappeared in the last 2 years. The lump started to grow like cauliflower (). A tumor encircling the entire penis and scrotum was detected upon physical examination, while the glans penis was free of the lesion. Wide excision of the penile mass was performed with total penectomy, orchidectomy, and perineostomy (). The wound was closed using the Keystone flap technique involving an elliptical incision pattern (), after which the flap is incised on all sides and bluntly dissected down to the fascia. The donor tissue was taken from the right inguinal. A drain was placed beneath the flap. The incisional biopsy revealed squamous cell carcinoma. 2 weeks after the surgery, the patient was given five HBOT sessions (). After the surgery and HBOT sessions, the patient was undergoing chemotherapy.
Penile carcinoma is a type of invasive epithelial tumor that develops on the penis’ skin or mucosa. There are many causes and risk factors for penile cancer, but the most common cause is human papillomavirus (HPV). The glans penis, coronal sulcus, and foreskin are common sites for penile cancer. Invasive ulcerative penile cancer can harm the root of the penis, causing it to dilate and leading to the organ’s spontaneous amputation. It can even affect the lymph nodes in the inguinal region. The mechanism of HPV infection has several pathways: the disruption of tumor suppressor gene p53 and pRB proteins. Diagnosing cancer requires pathological histological examination. Histologically, penile squamous cell carcinoma has several subtypes, and these have variable rates of metastasis. Penile cancer surgery is performed using several methods depending on the size of the tumor. One such is the Mohs surgery technique, in which the tumor is excised to the bottom layer or until the tumor tissue is

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

[User]
RADIOLOGY NOTE:
A 28-year-old pregnant woman was found unconscious in bathroom of her house by her husband. At arrival in the ED, she had a Glasgow Coma Score of 3/15 and dilated sluggish pupils. Additionally, there were no heartbeats or respiration. Cardiopulmonary resuscitation (CPR) was immediately instituted and cardiac monitoring revealed ventricular fibrillation. She was treated with 200 J of direct current energy delivered twice. Intravenous epinephrine (1 mg) was administered after the second rescue shock. Neither atropine nor antidysrhythmic agents were administered. After 2 minutes of CPR, her rhythm has restored to sinus rhythm. Advanced cardiac life support measures were initiated (such as controlled intravenous fluid support, administration of dopamine, adequate oxygenation, and support of respiration with bag ventilation) in ED. There was no tobacco, alcohol or illicit drug use in her history. Her husband stated that she had a brief episode of discomfort palpitations and shortness of breath three weeks prior to her cardiac arrest. However, there was no history of cardiac or respiratory disease. Transabdominal ultrasound confirmed 36 weeks pregnancy with fetal cardiac activity. Noncontrast cranial computerized tomography was nondiagnostic. Laboratory studies taken on admission and urine drug screen were not remarkable. A bedside emergency transthoracic echocardiogram (TTE) demonstrated moderate to severe mitral regurgitation with an estimated regurgitant fraction of 45% (). Additionally, there was no hypokinesis, effusion or ventricular dysfunction. During her emergency department course, the patient began to response from painful stimuli. Propofol was initiated for sedation. Three hours after admission to the ED, she was transferred to the ICU for optimal care. Support of respiration with mechanical ventilation and general supportive measures were provided in ICU. The clinical course of the patient was uneventful. She did not require vasopressors or antidysrhythmics d

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

[User]
RADIOLOGY NOTE:
A 44-year-old otherwise healthy male presented to the local emergency department on four different occasions over a two-week period with complaints of acute onset, progressive posterior neck pain, and stiffness. On the fourth visit, a two-day history of severe pain causing limited neck mobility and associated odynophagia was described. The patient initially denied any trauma, but in retrospect recalled sustaining a seemingly insignificant fall at work approximately one week prior to the onset of initial symptoms.
A noncontrast CT scan of the cervical spine was performed in the emergency department revealing a retropharyngeal fluid collection extending from C2 to C6 over a distance of approximately 6 cm, measuring 1 cm in thickness and 2.5 cm in transverse dimension. A small area of calcification was identified at the superior margin of this fluid collection, anterior to C2 (). The otolaryngology service was consulted with the presumed diagnosis of retropharyngeal abscess.
On physical examination, the patient was afebrile with normal vital signs and in no obvious distress, except upon neck movement. Flexible nasolaryngoscopy was unremarkable, with no evidence of abnormal protrusion or fullness of the posterior pharyngeal wall. The C-reactive protein level was elevated at 72.4. The white blood cell count and all other bloodwork were normal, with no evidence of an infective process. A CT scan of the neck was repeated with IV contrast showing no enhancement around the fluid collection and a 5 mm focus of calcification within the longus colli muscle anterior to C2 ().
Based on the clinical picture and pathognomonic CT scan findings, a diagnosis of calcific tendinitis of the longus colli (CTLC) muscle was made. The patient was admitted to hospital to complete his workup and manage his discomfort. He was managed successfully with medical therapy, including 3 doses of intravenous steroid followed by a short course of oral NSAIDs. An initial dose of antibiotic was administer

[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's mother was 36 years old, with a total of 5 pregnancies and 1 live birth. Eleven years ago, she gave birth to a healthy boy via cesarean section. She previously had 2 artificial abortions and 1 spontaneous abortion, with no family history of hereditary diseases. Ultrasound test result was normal at gestational week 6. At gestational week 12, nuchal translucency of 1.3 mm was observed, with no positive findings. Non-invasive DNA analysis showed low trisomy 21 risk, low trisomy 18 risk, and low trisomy 13 risk. At gestational week 24+5, ultrasound examination showed abnormal development of the long bones of the limbs (the length of the long bones was shorter than 1% controlled to the same gestational week of normal fetus), thick metaphysis in the right lower limb, irregular vertebral arrangement, and a narrow and small thorax (Fig. A–D). The patient's parents decided to terminate the pregnancy at 27 weeks of gestation considering this as a lethal skeletal dysplasia.
After the termination of pregnancy at week 27, the gross examination of the fetus showed a flat face and nose bridge, short limbs, asymmetric short lower limbs, and bilateral clubfeet with bilateral ankle joint contracture (Fig. A, B). The autopsy report indicated that the left humerus bone was 2.5 cm long; the right humerus bone, 2.0 cm; the left femur, 3.0 cm; and the right femur, 2.2 cm; all were significantly shorter than 4SD measured at the same gestational age. In addition, the shapes of T3 to L3 were abnormal, the vertebral bodies appeared fused, the thorax was small with a maximum circumference of 16 cm, and the abdominal circumference was 26 cm. The autopsy also found subcutaneous edema in the head and face and thick metaphysis in the lower limbs. X-ray imaging showed short femur and humerus bones, a narrow and small thorax, thick metaphysis with a thick “splashed paint

[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 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. As part of our ongoing study “Vaginal delivery after caesarean section”, she underwent saline contrast sonohysterography 6 months after the caesarean section. The caesarean scar had a small indentation and the remaining myometrium over the defect was 7.5 mm (Fig. ).
In the current pregnancy, she had a dating scan at around 11 weeks with no remarks. She came for a transvaginal ultrasound examination at around 13 weeks as part of our study. This scan revealed a duplex pregnancy with one viable intrauterine fetus with normal anatomy and placenta located high on the anterior wall and a small gestational sac (8 mm) with a yolk sac without embryo was located in the caesarean scar (Fig. ). There was no extensive vascularity surrounding the sac. One corpus luteum was found in each of the two ovaries. She was asymptomatic.
She was informed that not enough evidence existed to advise a specific management of this condition. After discussion with her and her husband, expectant management was chosen with a new ultrasound examination after 5 weeks.
She came to our ultrasound department at 18 weeks, 22 weeks, and 30 weeks of gestation. She remained asymptomatic. The ectopic gestational sac was not visualized with transvaginal or transabdominal scans at the 18 weeks examination (Fig. ). The niche in the scar and the thickness of the thinnest part of the remaining myometrium appeared unchanged at all visits. The intrauterine pregnancy developed normally with no signs of abnormal placentation. At 30 weeks of gestation the ultrasound appearance of the scar area did not indicate any contraindications for vaginal delivery. The thickness of the lower uterine segment (LUS) was 4.9 mm (Fig. ). In agreement with our patient, vaginal delivery was planned. The staff of the labor ward was fully informed.
She was admitted to the l

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old female initially presented for evaluation of a left supraclavicular neck mass. The patient underwent fine needle aspiration of the mass, which revealed adenocarcinoma favoring renal cell. CT scan of the chest, abdomen, and pelvis revealed a large left renal mass 9 cm in diameter. The scan incidentally also detected a possible filling defect in the transverse colon. The patient underwent colonoscopy, and a mass was visualized and biopsied. Histological examination found the mass to be positive for invasive adenocarcinoma.
Physical examination of the patient revealed an overweight woman with a past medical history of hypertension. The patient denied any changes in bowel habits or urinary complaints other than intermittent left flank pain. The patient reported that her family history was negative for cancer or polyps. General physical examination revealed a small nodule palpable in the left supraclavicular region of the patient's neck. Laboratory findings were normal except for presence of iron deficiency anemia.
The patient then underwent left radical nephrectomy with periaortic lymphadenectomy and extended right hemicolectomy. Histological examination of the left kidney confirmed a 7.5 cm Fuhrman grade 4, clear cell RCC limited within Gerota's fascia with no lymphovascular invasion. The tumor was present in 5/5 periaortic lymph nodes that were resected (T2aN1Mx). The resected large bowel specimens demonstrated tubular adenoma present in the cecum and hepatic flexure; also noted was moderately differentiated invasive adenocarcinoma extending into the submucosa of the transverse colon (T1N0M0) (). Microsatellite instability staining was ordered; results were positive for hereditary nonpolyposis colorectal cancer (HNPCC). Given this patient's negative family history of colon cancer, this was likely a spontaneous mutation. The patient developed chylous ascites and peritonitis with acute kidney injury postoperatively and returned to the operating room for ev

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

[User]
RADIOLOGY NOTE:
A 20-year-old female patient attempted suicide by ingesting a large amount of OP insecticide. She was admitted in a private hospital in an unconscious, gasping state with frothing from the mouth, smelling of insecticide. Pupils were miotic and fasciculations were evident. She was immediately intubated and was kept on synchronized intermittent mandatory ventilation (MV).
Seven days later she was brought to Medical and Neurological Intensive care unit of our hospital on MV. On admission, she had poor respiratory effort. She was conscious, oriented, had grade four muscle power in upper and lower limbs, without sensory symptoms. On day 12, lobar pneumonia was diagnosed. She had copious purulent secretions which necessitated tracheostomy. She was treated with Piperacillin-Tazobactam. Chest physiotherapy along with respiratory muscle training by inspiratory muscle trainer with threshold resistance for strengthening of weak respiratory muscles proved an adjunct for the weaning off of the patient from mechanical ventilation. In stepdown care, her muscle power slowly reduced to grade two in upper limb and grade three in lower limb. Three days post-extubation, she developed rapid onset deterioration in muscle power to grade zero and absent deep tendon reflexes, but without respiratory deterioration. She developed bilateral foot drop and claw hand deformity. Nerve conduction studies indicated pure motor axonal neuropathy. Patient developed stridor when an attempt to close the tracheotomy was carried out. Bronchoscopy revealed tracheal stenosis 2.3 cm distal to the vocal chords along with bilateral adductor vocal cord paralysis indicating involvement of recurrent laryngeal nerve, which explains aphonia evident during partial closure trial of tracheostomy.
Forty five days from the ingestion of OP insecticide, she developed grade II spasticity according to Modified Ashwarth Scale in bilateral upper and lower limbs with flexor spasms in lower limbs and exaggerated deep tendon refl

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

[User]
RADIOLOGY NOTE:
An otherwise healthy 69-year-old white male followed at our outpatient clinic for a bilateral sensorineural hearing loss presented to the Emergency Department of our hospital with a right facial palsy arisen suddenly 2 days before. Four months earlier, he had been diagnosed with a right trigeminal neuralgia, which was treated with gabapentin and oxcarbazepine. The initial diagnosis made at his arrival at the Emergency Department was right Bell's palsy for which he was given prednisone 50 mg for 5 days and 25 mg for the following 5 days in association with valaciclovir 500 mg twice per day for 5 days. In the following days, he showed no improvement of both the facial palsy and the trigeminal neuralgia. Laboratory work-up results were all within normal limits. At the ENT (ear, nose, and throat) evaluation, the patient showed a grade V right facial palsy according to the House–Brackmann grading system. Endoscopic evaluation of the nasal fossae, nasopharynx, and larynx showed no lesions, otoscopy revealed a right effusive otitis media, and audiological evaluation showed a right type B tympanometry, a left profound sensorineural hearing loss (diagnosed a few years before), and a right mixed hearing loss. A gadolinium-enhanced magnetic resonance imaging (MRI) of the head showed an abnormal mass with homogeneous enhancement involving the deep lobe of the right parotid gland, the upper portion of the right parapharyngeal space, the Eustachian tube, and the infratemporal fossa with both the pterygoid muscles, extending along the third division of the trigeminal nerve, through the foramen ovale, to the Meckel's cave and the intracisternal portion of the fifth cranial nerve (
). Moreover, computed tomography (CT) scan showed enlargement of the right foramen ovale and the greater petrosal nerve canal. We ordered also a positron emission tomography (PET)-CT scan that confirmed a hypermetabolic focus corresponding to the previously identified mass. The primary diagnostic hypothes

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

[User]
RADIOLOGY NOTE:
A 38-year-old white male who is an avid skier presented with left calf pain described as sharp on the medial aspect that started after he fell while skiing about two weeks prior. During the fall, his left ankle was forced into extreme dorsiflexion. He had immediate onset of severe pain and had to stop skiing that day. He noticed swelling in the medial calf along with bruising of the area over the next few days. After about a week, he was able to ski again but had pain aggravated by active plantar flexion.
On physical examination of his left leg, his knee and ankle both appeared normal and had normal strength and range of motion with no tenderness. Sensation and pulses were normal. There was tenderness over the medial head of his gastrocnemius with a palpable, firm, four-centimeter ovoid mass. Pain was elicited during resisted plantar flexion. His right leg was completely normal.
Radiographs of the lower leg obtained in the ED were normal. A POCUS was then performed in the ED with specific focus over the mass in the medial head of the gastrocnemius, revealing a swollen, heterogeneous, disorganized mass in the medial head of the gastrocnemius, as demonstrated in –. Comparison views to the unaffected extremity, as seen in , further clarified the findings. We made a diagnosis of muscle tear in the medial head of the gastrocnemius.
The patient was instructed on exercises for strengthening and range of motion of the calf and ankle and specifically eccentric exercises that he should complete after an initial rest period of two weeks. On follow-up two months after the initial visit, his symptoms had nearly completely resolved. He reported mountain biking several times per week with only minimal pain after a long ride. The mass in the calf resolved, and he relayed no concerns about his leg for the upcoming ski season.

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman (height 155 cm, weight 60 kg) first presented to our hospital with left hip pain, limited range of motion, and limping. Trendelenburg gait was observed. She did not have a history of treatment for DDH. She developed hip joint pain and underwent right DTT at the age of 20 years. Her hip pain had improved after the surgery; however, she started to feel pain again at 2 years after DDT. She underwent right-sided THA at another hospital at the age of 47 years.
Radiographs showed severe osteoarthritis of her left hip joint and the left greater trochanter, which had moved to the level of the lesser trochanter. The past THA on the right hip joint was visible as well (). The LLD was 55 mm.
The right THA was performed at the age of 47, and the left THA was performed at the age of 50. The THA procedures comprised conventional cementless THA in the same way as in Case 1 (anesthesia, surgical approach, implants, and rehabilitation).
Intraoperatively, the surgeon had to pay close attention to identify the gluteus medius and minimus muscles and prevent damage to the same muscle due to hypertension during the reduction after implant placement, similar to the circumstances of case 1. The operation time was 60 min, and the total blood loss was 488 g (intra and postoperative blood loss). The leg lengthening was 27 mm, and 28 mm of the LLD persisted.
As in Case 1, the pain improved remarkably; however, the patient presented with LLD due to an abduction contraction following extension of the leg length. The abduction contraction improved within two months under physical therapy. No other complications, such as dislocation, neurovascular abnormality, or infection, were observed. Final radiographs at 11 years after left THA did not show subsidence of the stem or any type of loosening around the cup or stem (). The preoperative JOA hip score was 39 points,

[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 1: A 56-year-old female presented to our institution with progressive vision loss. Her medical history was non-contributory. An ophthalmological evaluation showed a right central scotoma. Cranial MRI showed a mass suggestive of a carotid artery aneurysm. DSA revealed a 25.3 × 18.5 mm aneurysm with a 4.5 mm neck arising from the medial wall of the right ophthalmic segment (Figure ), and the BOT of the ICA and Allcock’s test were performed to understand the condition of cerebral blood flow compensation. To clip the aneurysm and reconstruct the right ICA, she was offered both surgical and endovascular treatment, considering the risks and benefits. The management plan was formulated to proceed with the hybrid operation as an elective procedure. During the operation, we placed the balloon in the C2-C3 segment of the ICA due to a relatively narrow-necked aneurysm (D/N ratio of 5.6). Then, we performed craniotomy via a pterional approach using the IAC technique to remove the ACP. We found that the right optic nerve was compressed by the giant aneurysm and that the optic nerve was crossed by the aneurysm neck; removal of the ACP and dissociation of the optic nerve from the aneurysm neck sufficiently revealed the aneurysm neck (Figure and ). After the placement of the first clip, first intraoperative DSA showed that the aneurysm had been clipped and that there were small amounts of residue of the aneurysm neck (Figure and ). A supplementary miniature clip was placed during the operation. Second intraoperative DSA showed that the aneurysm had been completely clipped. However, stenosis occurred in the ICA with poor visualization of the optic artery and poor visualization of the distal branch vessel of the ICA (Figure and ). A miniature clip with angular tips was used to replace the original clip. Third intraoperative DSA showed that the aneurysm was completely clipped. The ICA with stenosis was relieved, and visualization of the optic artery and distal branch vessel 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 10-year-old girl first noted a swollen left knee and underwent repeated arthrocentesis. At age 13, she underwent arthroscopic surgery and was diagnosed with benign TGCT. She subsequently underwent numerous synovectomies to treat local recurrences and radiation therapy to her left knee joint at age 15. Ultimately, her disease spread to her upper calf and posterior thigh. At age 32, her upper calf lesion was resected, and the tumor in her posterior thigh was treated with radiation. At age 34, swelling of an inguinal lymph node was noted and fine needle aspiration was consistent with malignant TGCT. Other staging scans revealed a pelvic mass and a sub-centimeter pulmonary nodule. Her disease remained stable after four cycles of doxorubicin/ifosfamide and she subsequently received gemcitabine/docetaxel as well as radiation therapy to her pelvis with stable disease for three months. She underwent left-sided above the knee amputation and excision of the intrapelvic masses. Eight months later, enlarging pulmonary nodules were resected. She was treated with sirolimus (rapamycin) and remained disease-free for eight months until a pulmonary nodule and two inguinal masses were noted. In 2007, at age 37, she was referred to our hospital and treated with sorafenib for four months with mixed response. She subsequently began on sunitinib 37.5 mg daily. Interval restaging scans showed no evidence of progressive disease for 15 months. She had significant interval progression of a right-sided pelvic mass while she temporarily stopped sunitinib in the perioperative setting of resection of painful metastatic nodules near the amputation stump (Fig. a, b, and c). Given that the drug had a significant role of controlling the disease, her sunitinib was restarted in combination with sirolimus (rapamycin). Her disease was under good control for eight additional months until she had progressive disease in the pelvis and underwent hemipelvectomy. She died of the disease at age of 39, six yea

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old female presented in July 2007 to a peripheral general hospital with progressively enlarging mass in the anterior abdominal wall of one-year duration. On physical examination, she was well built with normal vital signs. A 7 x 6 cm firm irregular subcutaneous mass was felt in the right lower para-umbilical area of the anterior abdominal wall. On palpation, the abdomen was soft and lax with no intra-abdominal masses. There were no palpable lymph nodes. Her cardiac and respiratory examinations were unremarkable. Computerized Tomography (CT) scan of the abdomen revealed a mass within the abdominal wall. Her laboratory investigations were within normal limits. A plain chest X-ray was unremarkable.
Wide local excision with safety margins of the tumor was done. The postoperative period was uneventful, and she was discharged on the second postoperative day in a satisfactory condition.
Gross examination of the specimen showed an ellipse of skin that measured 13 x 10 cm with subcutaneous fatty tissue measuring 11 cm in thickness. On cut section, a well-defined nonencapsulated grayish yellow mass measuring 7 x 6 cm with foci of necrosis was seen. No skin infiltration or abdominal skeletal muscle involvement was noted.
Microscopic examination revealed well-defined but nonencapsulated subcutaneous mesenchymal neoplasm composed of irregular islands of large cells with mostly round to oval pleomorphic vesicular nuclei, with markedly granular cytoplasm, and several large eosinophilic globules (). The nuclear cytoplasmic ratio was variable, with several cells having large nuclei. The tumor nests were surrounded by bands of fibrous connective tissue ().
Many foci of tumor necrosis and scattered mitotic figures, 4 per 10 HPF at a magnification of 200, were identified (Figures and ). Margins of resection were free of tumor.
Immunohistochemical stains show the tumor cells to be strongly positive for vimentin, S100 and CD68 (Figures , , and ). Stains for cytokeratin (CK), sm

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old woman presented with a painless swelling in the distal aspect of the right humerus of 1 month's duration. She did not report any trauma to the arm. Physical examination revealed a firm, nontender swelling deep to the triceps just above the elbow. The function of the right upper limb was normal, with a full range of movements in all joints and without distal neurovascular deficit and no regional lymphadenopathy.
Plain X-rays showed a dense sclerotic bony protuberance arising from the posterior cortex of the distal aspect of the humerus (). The MRI showed an exostosis measuring 6 cm in its long axis terminating immediately proximally to the level of the olecranon and with involvement of the underlying medulla (). Chest CT scan and whole body bone scan confirmed no evidence of disease elsewhere. A core needle biopsy was performed which showed features consistent with a parosteal osteosarcoma.
Reconstructing a segmental defect at this site is fraught with difficulties. Although we have reported good results with distal humerus replacements [], we anticipated long term complications such as aseptic loosening using this option in a 12-year-old. Reconstruction with bone transport was not attractive because of the length of time that would have been required and the associated risk of elbow stiffness. Reconstruction with strut allografts requires an adequate bone banking service and presents inherent risks of graft rejection and imperfect fit of the donated graft to the recipient bone defect. Therefore we planned to do an en bloc resection of tumor bearing bone, extracorporeal irradiation of excised bone segment to eradicate the tumoral cells, and reimplantation of the autograft with preservation of the elbow joint. We resected 10 cm of the humerus, stopping 2 cm from the elbow joint and dividing the bone a further 10 cm proximal to this. We then stripped the tumor from the bone surface and underlying intramedullary canal using osteotomes, curettes, and a burr

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old female presented to our center with a telangiectatic osteosarcoma of the humerus. There was no history of malignancies within the family.
MRI examination and open biopsy were performed by the previous physician. At the time the results were thought to be malignant lymphoma. After several diagnostic trials, the patient visited our center to seek advice about her telangiectatic osteosarcoma (A).
We observed a circumferential mass on the distal part of the right arm with a slight deformity of the arm, with marked venous engorgmnt and distal edema. The mass was warm and solid on palpation. Function of the right hand was still preserved. From the laboratory findings, there were marked elevation of the alkaline phosphatase and lactate dehydrogenase. From humerus X-ray, there was mixed lesions along the humerus with pathological fracture on the midshaft (A). T2-weighted MRI showed iso-hyperintense and expansile lesions along the humerus (A). For the metastatic workup, chest X-ray showed no coin lesions or metastatic characteristics. Patient also had a PET scan and the result was unremarkable. From the Clinico Pathological Conference (CPC) forum, it was concluded that the diagnosis was osteosarcoma of the right humerus stage IIB according to the Enneking classification.
Patient took neoadjuvant chemotherapy regimen with Doxorubicin and Cisplatin for three cycles from January to March 2016. At the end of the third cycles, clinical and radiological evaluations were performed. Clinically the mass was not getting bigger compared to before chemotherapy (B). From x-ray, the mixed lesions became more marked compared to the previous x-ray (B). MRI showed that the mass was slightly became larger compared to the previous MRI with no involvement of neurovascular bundle (B).
Six months after the initial complaint, the surgery was performed. We used extensive deltopectoral approach with anterolateral extension through the proximal part and curved backward to complete the p

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old immunocompetent Caucasian male presented to the emergency department with 1 week of left hand clumsiness. Physical examination was consistent with mild left upper extremity neglect but otherwise benign. The patient had no relevant past medical history. Computed tomography (CT) scan demonstrated a large hypodense lesion in the right parietal lobe suspicious for neoplasm (). Subsequently, MRI revealed a heterogeneous thick-walled peripherally enhancing lesion of the right parietal lobe with central necrosis and an extensive degree of surrounding vasogenic edema (). Neither T1-weighted imaging nor gradient echo sequences demonstrated evidence of subacute hemorrhage. Initial differential diagnosis included glioblastoma, anaplastic astrocytoma, metastasis, or PCNSL. A metastatic workup was negative. The patient was started on dexamethasone (16 mg per day for 5 days) while hospitalized with improvement in his presenting neurologic symptomatology. Upon discharge, he was prescribed a 6-day dexamethasone taper to 1 mg per day to continue until outpatient follow up. Per patient preference, stereotactic debulking of the lesion was scheduled for 5 weeks from his initial presentation.
The patient was admitted to the hospital 4 weeks later (1 week prior to scheduled surgery) with new onset lethargy and respiratory distress. Repeat CT compared to 4 weeks prior demonstrated a dramatic reduction in vasogenic edema and apparent size of the lesion (). The patient was diagnosed with bacterial pneumonia and remained hospitalized for medical treatment and optimization. One week later, a repeat MRI was ordered to evaluate the significant changes seen on repeat CT as well as to determine extent of future operative intervention. Repeat MRI compared to 5 weeks prior revealed a dramatic reduction in contrast enhancement, vasogenic edema, and apparent size of the lesion (). These imaging findings raised suspicion for PCNSL. As such, a stereotactic biopsy was planned to attain tis

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

[User]
RADIOLOGY NOTE:
The patient was a 70-year-old female whose past medical history was significant for arthritis and a right total hip arthroplasty approximately 9 years ago. A laparoscopic cholecystectomy (LC) for acute cholecystitis was performed approximately at another hospital approximately two months prior to presentation. She developed a surgical site infection with Escherichia coli (E. coli) bacteremia following her LC and was treated successfully with intravenous (IV) antibiotics. The postoperative course was also complicated by choledocholithiasis requiring an endoscopic retrograde cholangiopancreatography (ERCP) with stone pulverization and placement of two plastic 10F × 12 cm biliary stents. Two days prior to admission, she was hospitalized at an outside facility in septic shock with fevers, chills, lethargy, altered mental status, and blood and urine cultures positive for E. coli. At that time, she endorsed right hip pain and an inability to move her hip or leg. A computed tomography (CT) scan of her right hip revealed two partly calcified soft tissue masses associated with the right iliopsoas and obturator internus muscles (). A CT-guided fine needle biopsy of the right hip and psoas locules aspirated 100 mL of frank pus notable for a nucleated cell count of 344,000 (98% PMNs) with growth of E. coli. As a result, the patient was transferred to our institution with concerns for an iliopsoas abscess and a periprosthetic infection.
On admission, she was febrile to 102.7 F without any significant distress. Her physical examination was remarkable for a well-healed, right lateral hip incision with no erythema or drainage. She experienced pain with right hip flexion and internal rotation. Laboratory studies showed WBC, hemoglobin and hematocrit, basic metabolic profile, and liver function tests all within normal limits. A 3 cm hepatic abscess was identified on CT scan of the abdomen and pelvis. An MRI of the right hip showed a large air- and fluid-filled collection tracking alo

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

[User]
RADIOLOGY NOTE:
An 8-year-old male with no significant past medical, surgical, or social history initially presented to an emergency department in October 2013 with a chief complaint of right, radial-sided wrist pain after a fall on his right arm while playing soccer. No fracture was seen on radiographs, and he was placed in a removable splint for comfort and discharged. The patient was scheduled for follow-up but would not present to an orthopaedic clinic until three years post injury, at age 11. At age 11, when the patient was seen at an outside orthopaedic clinic, he reported continued wrist pain from his initial injury three years prior. He described dull pain in his right wrist with intermittent swelling after several minor falls while playing soccer. Radiographs did not reveal a fracture or other pathology, and the patient was again diagnosed with a wrist sprain and given a brace for comfort. He was compliant with the brace, but 8 months later, he again returned to his pediatrician with continued pain. Interval radiographs revealed a right-sided, displaced scaphoid waist fracture (). He was referred to our clinic for further management. He was noted to have tenderness located at the anatomic snuffbox but full range of motion. A magnetic resonance imaging (MRI) scan was ordered to further evaluate for AVN and osseous bridging given the chronicity of his symptoms, and he was placed in a thumb spica wrist brace. His MRI demonstrated the scaphoid waist nonunion with concerns for AVN (). At this point, the patient and parents elected to undergo surgical fixation of his nonunion. Due to the concern for AVN on MRI, utilization of a vascularized bone graft was considered. However, it was felt that given the young age of the patient, drilling of the bone would be sufficient to stimulate bone growth and avoid the more aggressive procedure.
The patient underwent surgery at 11 years and 3 months of age. Open reduction and internal fixation was performed using a dorsal approach centered 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 52-year-old female presented with anorexia and abdominal pain since 2 years. Patient gave history of undergoing hysterectomy eight years back, for endometrial carcinoma. Postoperatively radiotherapy was advised; but due to extreme morbidity, she could receive only 10 fractions. Details of this treatment were not available as she was treated at a different hospital. Clinically, the patient's vital organs were stable. On per abdomen examination, a 12 × 10 cm firm mobile lump was palpable in the left lumbar region. Her hemoglobin and counts were normal. Renal functions were also normal. Abdominal USG revealed an echogenic mass, 8 × 7 cm, showing posterior acoustic shadowing, probably inspissated fecal matter. A repeat USG performed 4 days later after giving water enema showed the mass unchanged in size and echotexture. CT scan indicated a mass with peripheral calcification [], but was unable to differentiate whether it was in colon or small bowel loops. There was no evidence of any recurrence or metastatic lesion of the endometrial primary. Barium enema revealed an entero-colic fistula with an enterolith at the site of the fistula []. Colonoscopy showed a fistulous opening in region of sigmoid colon. A clinical and radiological diagnosis of enterolith with entero-colic fistula was made. Patient underwent an exploratory laprotomy under general anesthesia after bowel preparation. At laprotomy a fistula between mid-ileum and sigmoid colon was seen, containing a hard nonmobile mass. Rest of the small bowel and colon was normal, no diverticuli were detected. Gall bladder and common bile duct were normal. Segmental enterectomy with sigmoidectomy [] was done and patient had an uneventful recovery. Cut-section of the specimen showed presence of an enterolith obliterating the lumen of the fistulous connection between the two bowel loops. The mucosa appeared normal. Histopathology was unremarkable, showing congestion and acute on chronic inflammation. The presence of enlarged

[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 66-year-old female with no significant past medical history was brought to the emergency department by emergency medical services (EMS) with a complaint of left-sided chest pain. She was in her usual state of health when she went to a scheduled appointment with a vascular surgeon for outpatient elective sclerotherapy for the cosmetic treatment of varicose veins. Shortly after being administered an injection of polidocanol, she began experiencing severe left-sided chest pain radiating to her left back with left arm numbness. She also complained of nausea, one episode of vomiting, pressure in her jaw, and lightheadedness. Prior to being transported to the emergency department by ambulance, she was given two doses of aspirin 81 mg.
On arrival to the emergency department, she reported that her symptoms had subsided. Her initial electrocardiogram (ECG) was remarkable for T-wave inversions in leads V1-V3 and sinus bradycardia at 54 beats per minute (), with no prior ECG available for comparison. No ST-segment abnormalities were present. Initial laboratory studies were also notable for an elevated troponin I level of 0.62 ng/mL.
The patient was admitted to the inpatient telemetry unit for suspected acute coronary syndrome. Repeat assessment of her cardiac enzymes six hours after her initial bloodwork revealed that her troponin I level had risen to 2.26 ng/mL, at which point the patient had been started on continuous unfractionated intravenous heparin. She remained asymptomatic. The patient was offered cardiac catheterization but initially declined. In a third set of cardiac enzymes, her troponin I level had trended down to 1.15 ng/mL.
Further studies, including echocardiogram and nuclear stress testing, were pursued to better define her cardiovascular function. A transthoracic echocardiogram revealed an ejection fraction of 50%, suggestive of mild systolic dysfunction, in addition to the presence of apical hypokinesis (). Grade II diastolic dysfunction was also noted. He

[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 7-year-old boy was evaluated for a two month history of atypical movements presenting in the evening, and lasting an hour after eating. These stereotypical movements with the head and chest bending forward and to the left side, accompanied by a grimace were associated with sensation of breath locking without cyanosis. Pain and dysphagia were absent. The neurological examination was normal. The possibility of Sandifer syndrome posturing occurring with gastroesophageal reflux disease (GERD) was considered but neither pain nor back hyperextension were associated with the atypical movements. PPI did not improve his symptoms. Various prokinetic agents (metoclopramide, motilium, cisapride and erythomycin) were also inefficient.
Upper endoscopy and esophageal biopsy did not reveal eosinophilic esophagitis or other abnormalities. ENT exam was normal. A severe gastroparesis was demonstrated on milkscan study. Two 24 hour esophageal pH probe studies pointed out severe GER. High resolution manometric evaluation of the oesophagus revealed normal sphincter pressures and relaxations with no dysmotility of the esophageal body. Electroencephalography and polysomnography were normal. Because of the unexplained dyspnea associated with this abnormal posture, a head MRI was performed and revealed a CM I: cerebellar tonsils extending to 12 mm, with syringomyelia (D4-D5) (Figure ).
For a long period of time, the child abnormal movements were only considered to be tics and the CM I was considered a fortuitous finding. Since the child remained symptomatic despite medical treatment, it was eventually decided to proceed with surgery. The operative procedure was done one year after the onset of his symptoms. He underwent posterior fossa decompression with upper cervical laminectomy and expansion duroplasty. No postoperative complication occurred. Postoperative MRI confirmed adequate decompression. His atypical posture and dyspnea completely resolved in the week after surgery. More than two

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


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

[User]
RADIOLOGY NOTE:
A 3-year-old girl suffered cervical spine injury after a motor vehicle collision while sitting in the car without wearing a seatbelt. ATLS protocol was performed on the patient at a local hospital and she was referred to the emergency department at author’s hospital within 12 h of the injury. The pediatric surgeon and our orthopedic team re-evaluated that the status of the patient showed head injury with alteration of consciousness, intubation, cervical spine protection with hard collar and first rib fracture without pneumohemothorax. The emergency radiographs x-ray and CT brain including cervical spine showed no intracerebral hemorrhage but the cervical spine suffered unilateral cervical C4–C5 facet dislocation. Radiographic features showed anterior dislocation of the affected vertebral body less than the vertebral body in anterior posterior diameter, discordant rotation above and below involved level, facet within intervertebral foramen on oblique view, widening of the disk space and “Bat wing sign” appearance of the overriding facet (Fig. a-c). The patient was taken to the pediatric intensive care unit (PICU) for resuscitation and closed monitoring after hemodynamic was stable. The patient was evaluated by MRI for preoperative planning, and no spinal cord injury was visible. In the next 24 hours, the patient’s neurovascular status examination was fully conscious and no neurological deficit (Frankel grade E) then extubation followed. The team discussed with her parents treatment plan and complication. Her parents then denied surgery. The authors applied closed reduction maneuver with minerva cast under sedation. The patient was in Frankel grade E without complication after closed reduction and the cervical spine had good alignment in radiographs (Fig. d). The minerva cast was removed at 8 weeks, at which point neck muscle stretching rehabilitation program started. At one-year follow up, the child was asymptomatic, had full active cervical motion and good function.

[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 Caucasian male aged 14 years attending an orthodontic clinic for a routine assessment presented with an incidental radiographic finding. A well-defined calcified mass was visible at the apex of the maxillary right permanent canine on the orthopantomogram (OPG) radiograph ().
A lateral cephalometric radiograph showed that this mass was significantly superior to the dentition in the antral inferior nasal region (). The mass was a well-defined spherical lesion, measuring 1.5 by 1 cm with a radiopaque, homogeneous internal structure. It lay superior to the canine fossa and anterior to the maxillary sinus anterior wall.
This calcified mass had not been present on the OPG radiograph taken previously, at age 10 years ().
From the age of 12, it was reported that the patient suffered with facial AV. He attended a consultant dermatologist who treated the condition successfully. The calcified mass was previously assessed at dermatological review. Despite the fact that it was a solitary lesion, it was diagnosed as dystrophic calcinosis cutis. The dermatologist advised no intervention as there was a significant risk of facial scarring if surgically removed. The mass was asymptomatic and presented little risk of infection. The patient was placed on annual review with his dermatologist.
Although the mass was palpable and mobile, the patient's dermis was intact and acne-free. The mass was not visible clinically on extraoral examination. Facial profile and contour were normal. Orthodontically, he presented with a Class III incisor relationship on a Class III skeletal base with crowding in the maxillary arch. Both the patient and his parents were given the option of orthognathic surgery to treat his malocclusion and underlying significant skeletal relationship discrepancy. After extensive discussions and reviews with a maxillofacial surgeon, they opted for orthodontic treatment only, namely, alignment of the maxillary arch teeth on a non-extraction basis, followed by permanent rete

[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 male presented with a history of weakness and constipation, for which he underwent colonoscopy, revealing a submucosal mass in the right colon, compressing on the lumen extrinsically. The mucosa overlying the mass was intact and colonoscopy showed an adjacent 12 mm polyp, which turned out to be a tubular adenoma. He had history of removal of previous tubular adenomas on prior colonoscopies. Computed tomography (CT) imaging showed a 7.0 cm lobulated mass arising from mid-ascending colon with exophytic growth and foci of calcifications. CT findings were consistent with a mesenchymal tumor and carcinoma was less likely. No fatty component was reported (). Subsequently, the patient underwent laparoscopic right hemicolectomy and tumor was resected.
Gross examination of the right hemicolectomy specimen demonstrated a firm and calcified intramural mass in the posterior wall of ascending colon, extending into the mesocolic fat, without involvement of the mucosa. Microscopically, distinct histological patterns were identified, with the majority of the tumor being composed of a central ossified core surrounded by a minor component of a high-grade mesenchymal nonlipogenic tumor and adipose tissue. The central bone forming component showed areas of osteoid matrix with highly atypical cells resembling a high-grade osteosarcoma as well as areas of more mature appearing woven bone trabeculae with intervening mildly atypical spindle cells similar to a low-grade osteosarcoma (LGOS). A thin rim of a high-grade sarcoma composed of atypical spindled and pleomorphic cells was identified in the periphery of the bony mass. In addition, small foci of mature-appearing adipose tissue containing rare atypical hyperchromatic stromal cells were detected adjacent to the high-grade sarcoma and at the retroperitoneal resection margin, raising consideration of a WDL (Figures and ). The findings suggested that WDL may have arisen in the retroperitoneum and secondarily involved the colo

[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 postmenopausal 56-year old woman, mother of three children, presented with swelling and discharging lesions on the right side of vulva and groin since past 14 months. The lesion first appeared 14 months ago on the right side of vulva and gradually extended to the right groin. There was no history of any kind of bite, trauma, operative procedure, or insertion of intrauterine device in the past. She had normal vaginal deliveries without any operative intervention. There was a history of occasional sexual intercourse, in the past 10–15 years. General examination revealed no physical abnormality. On local examination, multiple nodules were seen on the right vulva extending up to the right inguinal region []. There was a mild serosanguinous discharge in the inguinal area. Closer examination revealed yellowish white granular deposit on top of the nodule, which on further examination, turned out to be sulfur granules []. There was edema over groin, right thigh, and leg []. Inguinal lymph nodes were enlarged on the right side. Routine gynaecological examination was within normal limits. Investigations including hemogram, urinalysis, kidney and liver function tests, ELISA for HIV, and Mantoux test were within normal limits. Chest radiography and ultrasonography of abdomen and pelvis were normal. Cervical Pap smear did not show any evidence of malignancy. Acid fast staining of the purulent material was negative. Crushed sulphur granules on staining with haematoxylin and eosin showed multiple active colonies with surrounding neutrophilic infiltration []. Each colony on staining with MGG stain showed basophilic filamentous centre, and radiating peripheral projections in a sunray appearance (Gupta bodies) []. Fine-needle aspiration cytology from an inguinal nodule on staining showed similar findings along with giant cells and neutrophils. Actinomyces colonies could not be demonstrated in aerobic as well as anaerobic culture media.
Thus the diagnosis of actinomycosis involving

[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 the case of a 70-year-old Caucasian man, with no significant clinical background, who presented to our casualty department with a three-week history of headache and maxillary pain on the right side, together with the recent appearance of dysphonia and dysphagia for solids. No urinary disorder was reported. A neurological examination revealed a paresis of cranial nerves IX and X, manifested by the displacement of the soft palate to the right and difficulty swallowing. Paresis of cranial nerves XI and XII was also observed, indicated by the lowering of the right shoulder and hypotonia of the right trapezius muscle, and was accompanied by displacement of the tongue toward the right, right-side hypotonia and muscle twitching (Figures and ). Results of the rest of the physical examination were normal.
Blood analysis results revealed an alkaline phosphatase level of 350 UI/L (normal range 44 to 147 UI/L) but no other significant alterations. In view of the paresis of the four lower cranial nerves, a CT scan of the larynx and neck was performed; the CT scan revealed an asymmetrical union between the clivus and the right occipital condyle, adjacent to the jugular foramen, with increased ground-glass bone density. There was no visible lesion to the bone cortex or soft tissues. This study was complemented with an MRI scan, which revealed a bone lesion producing a hypointense signal at sequences T1 and T2. Administration of a gadolinium contrast agent produced a moderate degree of enhancement at the base of the skull, affecting the right occipital condyle and part of the right side of the basilar bone (Figure ). The image corresponded to a moderately space-occupying blastic lesion, visible in the CT scan, which slightly decreased the caliber of the jugular foramen and the condylar canal. Therefore, fibrous dysplasia, Paget's disease and metastasis were considered in the differential diagnosis.
Subsequently, an additional radiographic examination of the lumbar column

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

[User]
RADIOLOGY NOTE:
A 34-year-old woman was referred to our outpatient clinic during her 31st week of pregnancy suffering from shoulder pain of the right side after lifting her 11-month-old first born. During the first pregnancy, one and a half year ago she started noticing dyspnea which was still present at the time of her presentation in our clinic. At that time, this symptom was considered as pregnancy-related therefore no special examination was arranged. Several months later the patient became pregnant again. She was still reporting of dyspnea especially at physical activity and new symptoms, cough and hemoptysis, had appeared. Due to persistent symptoms, the general practitioner arranged a chest X-ray that showed a tumor mass in the right lung in close relation to the scapula (Fig. ).
Clinical examination showed a patient in good general health. There was a local swelling at the medial border of the right scapula with dull pressure pain. The movement of the shoulder was painless at full range of motion and strength. The auscultation of the lung presented a vesicular respiratory sound which was slightly attenuated at the right side. The patient did not suffer from pain. Family anamnesis revealed a breast cancer of the patient’s mother and a bronchial carcinoma of the father. B symptoms were not reported.
The case was primarily presented to the department of obstetrics in 31 4/7 weeks of gestation. Ultrasound showed a large for gestational fetus (2205 g, 93rd percentile) with normal amniotic fluid and normal feto-placental perfusion of a 34-year-old gravida 2 para 1 (one spontaneous delivery 1 year ago) with no pregnancy-related complications. A diaplacental cancer cell transmission seemed unlikely for the type of expected tumor.
MRI scans (magnetic resonance imaging, Fig. ) of the cranium and the thorax were performed and revealed several highly suspicious lesions in the right lung, the mediastinum, the inferior angle of the right scapula with soft tissue component,

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

[User]
RADIOLOGY NOTE:
A 74-year-old male patient (168 cm, 53 kg) visited our institution complaining of difficulty in swallowing for the past 8 years and the frequent occurrence of aspiration pneumonia for the past 1year. Lateral radiography of the cervical spine demonstrated extensive osteophyte formation from C2 to C4 () and decompression of the osteophyte was planned. His medical history was significant for diabetes. He had been diagnosed with stable angina but rejected PCI. Preoperative electrocardiogram and echocardiogram revealed tolerable status. Blood chemistry revealed hyperglycemia, but hepatic and renal function and coagulation were normal. On physical examination, the patient was alert and afebrile; and his vital signs were stable. Oral examination was unremarkable and neck extension was normal. He had minimal dyspnea in the supine position. Indirect laryngoscopy revealed a large hard mass protruding from the posterior wall of the hypopharynx that concealed the arytenoids cartilage (). A preoperative neck CT showed slight narrowing of the airway at the level of the epiglottis. Vocal fold mobility was preserved. No narrowing of the subglottic region was observed when flexible endoscopy was performed. Preoperative tracheostomy was done under local anesthesia and general anesthesia was induced with thiopental sodium 250 mg and rocuronium 50 mg and maintained with sevoflurane. Complete decompression of the osteophyte was performed for 210 minutes using an anterolateral transcervical approach, which proceeded without any complications. The postoperative course was uneventful. On the second postoperative day, indirect laryngoscopy was performed by an otolaryngologist to decide if removal of the tracheostomy cannulawas appropriate. However, this examination revealed significant laryngeal edema including the epiglottis and posterior laryngeal wall (). On 29th postoperative day, flexible endoscopic examination was performed again and copious secretion, decreased vocal cord mobility an

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

[User]
RADIOLOGY NOTE:
A 64-year-old woman was referred to our hospital for the treatment of chest wall necrosis. She had undergone Halsted surgery and postoperative radiation therapy with cobalt-60 (30 Gray) and megavoltage X-rays (30 Gray) 25 years earlier. Following the treatment, her left upper limb became completely paralyzed.
Six years earlier, she had sustained a left clavicle fracture due to osteonecrosis, and she had subsequently developed a chronic cutaneous fistula measuring 1 cm in diameter. The fracture and cutaneous fistula failed to heal, and she experienced bleeding from the fistula since 1 year. Two months before visiting our hospital, she was hospitalized in the Department of Breast Surgery at another hospital for massive bleeding and local infection. She was treated with antibiotics and cleansing of the fistula and the infection subsided 2 months thereafter. She visited our hospital after discharge.
At initial examination, her height was 153 cm and weight was 34 kg. Necrosed clavicle was exposed through the 6-cm-wide skin defect in the left clavicular region, and air entered and exited the opening from deep within the chest while breathing (Fig. ). Computed tomography (CT) revealed the part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Her upper left limb was nourished by retrograde blood flow from the thoracodorsal artery; however, blood flow was weak to the skin of the arm, the surface of which was cold, resulting in complete paralysis of the upper extremity. Several rounds of debridement eliminated the necrotic tissue, and the local infection was completely resolved. Debridement revealed a tissue defect measuring 4 cm × 8 cm and 4 cm deep at the base and approximately 10 bronchial stumps on the surface of the collapsed lung covered in granulation tissue, from which exhaled air and sputum were effusing (Fig. ). She presented with severe emaciation and malnutrition, but no

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


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

[User]
RADIOLOGY NOTE:
A male Caucasian baby was born by spontaneous vaginal delivery at 35 weeks of gestation to a 26-year-old gravida 3, para 1 mother. The mother had well-controlled type 2 diabetes mellitus and two previous miscarriages of unclear etiology. No evidence was found of congenital malformations on prenatal ultrasounds. No family history was known of spontaneous thrombosis. The birth weight was 2353 g and appropriate for gestational age. At 20 minutes of life, he became severely tachypneic. A sepsis evaluation was performed and intravenous antibiotics were begun. Chest radiography revealed a right tension pneumothorax and complete left lung field opacity. The infant was intubated and a chest tube was placed. An echocardiogram at 10 hours of life revealed right ventricular dilatation and hypertrophy with flattening of the ventricular septum, consistent with persistent pulmonary hypertension of the neonate (PPHN). Left pulmonary artery (LPA) blood flow could not be visualized and a thrombus appeared to occlude the LPA (Figure ). Inhaled nitric oxide was administered. Computed tomography angiography (CTA) at 16 hours of life was performed and showed an intact tracheobronchial tree and a markedly hypoplastic left lung (Figure ). The main and right pulmonary arteries were normal in caliber, with an occlusion of the LPA by a low-density mass suggestive of a thrombus (Figure ). In addition, large collateral vessels originated from the distal thoracic aorta and supplied the left lung (Figure ).
A screening evaluation for a possible inherited thrombophilia disorder was completed in this baby. Blood levels for protein C, protein S, antithrombin activity, concentrations of clottable fibrinogen, plasminogen activity, activities of coagulation factors VIIIC and XII, lipoprotein (a) and homocysteine concentration were within normal limits. DNA-based assays (that is, factor V G1691A mutation and factor II G20210A variant) were also normal []. The mother did not complete a thrombophilia scr

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

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male presented to our hospital due to intermittent claudication of both legs and swelling in his left leg. The claudication had started 4 weeks earlier and was ongoing at the time of presentation, and the pain had worsened. His left lower limb had become swollen 2 weeks before admission. On admission, the pulsation of his bilateral femoral, popliteal, and anterior tibial arteries was weak. The ankle-brachial index (ABI) was significantly low bilaterally.
Ultrasonography showed that there were massive thrombi in the veins extending from the left external iliac vein to the left popliteal vein (). At the same time, there was no discernible arterial blood flow from the infrarenal abdominal aorta to both the common iliac arteries. Further, the inside echo of the occlusion site was low, so the occlusion seemed to be due to a thrombus. Pulmonary thromboembolism was ruled out by echocardiographic examination. The echocardiography showed normal left ventricular function (left ventricular ejection fraction 73%), mild left ventricular hypertrophy, and no tricuspid regurgitation. We considered that if pulmonary thromboembolism had occurred, the grade was not severe. In the computed tomography (CT) findings, the terminal aorta was occluded with thrombus and there was a venous thrombus in his left iliac vein that appeared in the proximal site that was compressed by the left common iliac artery (). The patient was diagnosed with Leriche syndrome accompanied with DVT. His thyroid function tests were normal and his hypercoagulable workup including serum protein C, protein S, anti-cardiolipin antibodies, and lupus anticoagulant antibody was found to be negative.
On day 1, a temporary inferior vena cava (IVC) filter was inserted to prevent pulmonary embolism. Oral warfarin administration and intravenous heparin infusion were started for DVT. Oral cilostazol (200 mg/day) was started for ischemia of the lower extremities. Coronary angiography (CAG) and aortography were don

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old male patient presented to the outpatient department with left-sided epiphora and chronic dacryocystitis, without any record of head trauma or previous surgery of the nose or paranasal sinuses. On nasal endoscopy no abnormalities were noted. A diagnosis of saccal NLDO was made by clinical examination including lacrimal irrigation and fluorescein tests (Jones I and II tests) as well as probing of the canaliculi with a blunt probe up to bony contact with the lacrimal sac fossa performed by an ophthalmologist. The imaging studies (CT scan) revealed a 1 cm osteoma of the ventral half of the medial wall of the left maxillary sinus causing total obstruction at the level of the lacrimal sac (Figures , , , and ).
Under general anesthesia, an endonasal endoscopic dacryocystorhinostomy (DCR) without flaps [] using a cutting- and diamond-burr drill as well as the osteoma removal using a cutting-burr drill was performed. A temporary silicone stenting of the nasolacrimal duct system was applied. No postoperative complications occurred. An oral antibiotic therapy (amoxicillin and clavulanic acid 1 gr twice a day) was initiated on the day of surgery and continued for 5 days. A concomitant topical therapy with antibiotic and steroid solutions (tobramycin and dexamethasone ophthalmic suspension 2-3 drops twice a day for 5 days) was also given. The patient's total hospital stay lasted 1 day.
A lacrimal duct system irrigation with natural saline solution into the inferior canaliculus was performed by an ophthalmologist once a week during the first month and twice a month during the second month. An endoscopic endonasal examination to test the patency of the duct system was performed 15, 21, and 30 days postoperatively. The silicone stent was removed 6 weeks postoperatively. An anatomical and functional obstruction of the DCR-window due to granuloma formation at the DCR-window area was noted 8 weeks after surgery on 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 74-year-old man consulted our clinic with a complaint of swelling in the right buccal region. The patient noticed the swelling 5 years ago and had received aspiration therapy repeatedly to reduce the swelling. He was generally healthy and had no medical history. On examination, an elastic firm, movable mass of 50mm was palpable in the right buccal region (Fig. ). The overlying mucous membrane was normal.
The mass was not adhesive to either the mucous membrane or the skin. The maxilla was totally edentulous and only bilateral canines and the left first premolar were present in the mandible. Hypoesthesia or palsy of the right face, trismus, swelling of cervical lymph nodes or the right parotid gland was not observed. CT examination revealed a well-circumscribed oval cystic lesion of 35 mm with the density slightly less than that of muscle in the anterior region of the masseter muscle (Fig. ). On MRI, the lesion showed a low signal on the T1-weighted image and a heterogeneous high signal on the T2-weighted image including intermediate signal in the under portion (Fig. ). Aspiration through the buccal skin revealed whitish liquid with squamous cells and shadow cells with a few neutrophils and lymphocytes in the cytological examination.
The clinical diagnosis of epidermoid cyst at the right buccal mucosa was made. The lesion was intraorally extirpated under general anesthesia through the incision along the anterior border of the mandibular ramus (Fig. ). Detachment of the lesion from the surrounding tissue was relatively easy. Stensen’s duct was not related to the lesion. The wound was closed after placing a silicon drain. Wound healing is good and no sign of recurrence has been observed for more than 4 years after the surgery.
The lesion was cystic, 30 × 25mm, weighed about 6g and contained brown serous liquid with a few cellular debris or keratin scale (Fig. ). Histologically, the lesion was lined with squamous epithelium

[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 with a history of hypertension, 20 pack-years of smoking, thyroid cancer in remission with partial thyroidectomy, and chronic obstructive lung disease (COPD) presented to the emergency department (ED) with acute abdominal pain. Abdominal ultrasound showed gallstones with no evidence of cholecystitis or biliary obstruction. The patient was diagnosed with biliary colic and discharged home with a plan to perform an elective cholecystectomy. Computed tomography (CT) scan of the abdomen was performed as an outpatient as part of the preoperative workup which showed evidence of gallstones, small bilateral pleural effusions, and moderate pericardial effusion with high density suggestive of hemorrhage (). Consequently, the patient was referred to the emergency department for further workup. Upon arrival, the patient was asymptomatic, his vital signs were normal, and his physical examination was unremarkable. An electrocardiogram (EKG) revealed a nonspecific interventricular conduction delay. Chest x-ray showed a mildly enlarged cardiomediastinal silhouette with prominent perihilar opacities suggestive of a prominent vasculature (). Complete blood count and basic metabolic profile were within normal limits. Further laboratory workup showed normal erythrocyte sedimentation rate, rheumatoid factor, complement level, and procalcitonin with negative serology for antinuclear antibodies and double-stranded DNA antibodies. A transthoracic echocardiogram (TTE) showed a large pericardial effusion without signs of tamponade, moderate aortic regurgitation, and normal left ventricular ejection fraction and size. Given the large volume of pericardial effusion, a pericardial window was attempted. A total of one liter of hemorrhagic fluid was drained. Pericardial tissue biopsy showed acute and chronic inflammatory cells with thickened pericardium, and no malignant cells were detected (). Tuberculosis quantiferon assay, acid-fast bacilli staining, and fungal and bacterial

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old, previously healthy, African American man presented to an emergency department 45 minutes after the acute onset of left facial droop and right-sided weakness (Fig. ). A thorough history confirmed an episode 1-week prior, during which he developed sudden onset of dizziness associated with nausea and vomiting that resolved within hours. He denied any past medical or surgical history and was taking no medications. He has no family history of tumors. In the emergency room, his vital signs were within normal limits. His physical examination was significant for a left facial droop and right hemiparesis. Auscultation of his chest revealed a regular rate and rhythm with no appreciable murmur. No additional significant findings were noted. Stroke protocol was initiated. A chest X-ray was normal and an electrocardiogram showed normal sinus rhythm. A head computed tomography (CT) scan was negative for signs of intracranial hemorrhage. He was subsequently started on tissue plasminogen activator (tPA) therapy. Magnetic resonance imaging (MRI) of his brain demonstrated a right basal ganglia infarct and an old left cerebral infarct. A carotid ultrasound was negative. TTE demonstrated a 1 cm by 1 cm mass on the posterior leaflet of the mitral valve with a moderate mitral regurgitation In addition, TTE revealed a questionable mass on the left coronary cusp of the aortic valve. These findings were confirmed with TEE (Fig. ), which verified no sign of endocarditis and no atrial septal defect. A complete hypercoagulable workup was negative. Stroke protocol continued with the working diagnosis of cerebrovascular accident secondary to emboli from the mitral valve mass. Within 24 hours, he regained function of the right side of his body and had complete resolution of symptoms. He was diagnosed as having transient ischemic attack (TIA) and discussion was undertaken regarding surgical excision of his mitral valve mass.
A median sternotomy was performed and cardiopulmonary bypa

[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 man presented with symptoms of right-sided chest pain, not related to physical activity or exertion. He also complained of shortness of breath on exertion. There was no history of cough, fever, or weight loss. Physical examination did not reveal anything significant. His haematological parameters were normal. The chest radiograph (PA view) showed a well-defined radio opaque shadow with no calcification or cavitations with its medial border merging with the right border of the heart, which was suggestive of an anterior mediastinal mass (). Lateral view confirmed the anterior mediastinal location of the mass (). An axial CT scan showed a heterogeneously enhancing right anterior mediastinal mass with areas of necrosis which was adherent to the pericardium (). Bronchoscopic examination showed extrinsic compression of the trachea and the right main bronchus. With a provisional clinical diagnosis of a lymphoma versus a teratoma, surgical excision was planned through an anterolateral approach. Per operatively, a 6 × 7 cm mass was found in the anterior mediastinum which had a smooth surface. The mass showed plenty of adhesions to the right lung and pleura. The mass was removed in piecemeal and was sent with a portion of the lung for histopathological evaluation.
The gross specimen consisted of about 250 gm of grey white soft tissue with extensive areas of necrosis. Also received was a lobe of lung measuring 9 × 9 × 2 cm. On microscopic examination, a biphasic neoplasm was noted with well formed glandular epithelial structures admixed with a spindle cell component (). The spindle cell component was monomorphous and showed a fascicular arrangement. The cells showed elongated vesicular nuclei with mild to moderate nuclear atypia. Mitosis ranged from 3–5 per 10 high power fields. The glandular spaces were lined by cuboidal cells with vesicular nuclei and moderate cytoplasm and showed eosinophilic secretions within their lumens which stained positively with the Alc

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old male with no known history of cancer presented to our institution with a lump in the left breast that had been gradually increasing for 14 months.
A physical exam revealed a large, fixed 10 cm mass occupied the entire right breast (-A). The mass itself was adherent to the chest but it did not invade the skin. There was no ulceration, nipple discharge, or retraction. There were no palpable lymph nodes. Clinical presentation had supposed initially as a sarcoma of the breast.
Preoperative unenhanced CT imaging showed well-defined round heterogeneous soft tissue density with hypo dense areas (-B), necrosis and peripheral and central calcifications measuring 07 cm × 10 cm × 11 cm. It was localized in the 4; 5 anterior thoracic rib. The tumor involves the intercostal muscles but respect the lung. CT scan detected no metastatic tumor.
A core-needle biopsy was taken, which was suggestive of chondrosarcoma grade II.
Surgery was initiated for wide excision. Intra-operatively, it was found to be arising from the 4; 5 th rib and pushing the lung without invading it. The whole tumor was excised en-bloc along with 4 th, 5th and 6th ribs with a surgical margin of more than 2.0 cm (-A, B). This resection left a defect measuring 23 × 15 cm on the anterior chest wall. Reconstruction of the defect was undertaken with polypropylene plate and ipsilateral pedicle latissimus dorsi muscle flap was placed on the alloplastic mesh (-D). Intercostal drain inserted. The patient was extubated one days after surgery and discharged in 10 days without complication.
In final histopathology report, grossly the tumor has blue-grey color and was attached to bone on one margin and covered by the breast in on one surface. The mass measured 18 cm × 14 cm×13 cm.
Histological section showed mesenchymal proliferation organized in lobulated architecture with abundant cartilaginous matrix and myxoide areas separated by fibrous

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male came to the emergency room of our hospital and stated that a hand-made silicon rod had accidentally passed into his rectum 12 h prior to presentation. He could not remove it on his own. His vital signs were stable, and a physical examination showed that his abdomen was soft and without tenderness. There was a palpable elastic, hard mass in the lower abdomen and no signs of peritonitis. A digital rectal examination by palpation located the end of the foreign body in the deep rectum. An attempt to manually remove it in a transanal manner failed due to its shape, large size, and deep position. Laboratory data were essentially normal, with the exception of slightly elevated C-reactive protein (1.76 mg/dL). Plain abdominal X-ray imaging showed a foreign body in the pelvic area and absence of free air (Fig ), while computed tomography (CT) revealed an 18 × 4 cm foreign body with a cylindrical shape in the rectum (Fig ). No severe complications, such as perforation or obstruction, were seen. We decided to attempt removal in a transanal manner under endoscopic and X-ray fluoroscopic observation.
Following intravenous administration of 15 mg of pentazocine, a scope (PCF-Q260AZI; Olympus, Japan) was inserted transanally with the patient in a left lateral decubitus position to directly visualize the foreign body. The lateral pelvic view obtained by X-ray fluoroscopy showed the foreign body in the rectosigmoid position. We attempted removal with endoscopic instruments, including a snare, biopsy forceps, grasping forceps, and net, though that failed because of the round shape and large diameter. When manually compressed from the abdominal wall under endoscopic and X-ray fluoroscopic observation, we noticed that the axis of the foreign body changed (Fig ). Thus, we were able to guide it using manual abdominal compression with endoscopic and X-ray fluoroscopic assistance. Once the object moved to the lower rectum,

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female with one-sided nasal obstruction and rhinorrhea in her nose for more than five months referred to our center in the ENT department of Khalili Hospital (Shiraz, Iran) in 2014. She was a known case of papillary thyroid carcinoma with metastases to the pelvic and lung. She had a history of severe bone pain and haemoptysis (more than a year) and was a candidate for total laryngectomy and thyroidectomy due to her advanced thyroid cancer. However, due to the dissatisfaction of her visitors, she only underwent total thyroidectomy. Examination of the patient revealed an ulcer mass covered with crust in the anterior and inferior part of the right-sided nasal cavity.
Patient’s PNS CT with contrast revealed an irregular border mild enhancing tumoral solid mass measuring 30×30 mm at the anteroinferior of the right nasal cavity without calcification or lytic osseous lesion at adjacent bone and PNS were clear (). Based on the roll out of vascular lesion, a biopsy was done. The biopsy result indicated high suspicious to carcinoma. Thus, the patient was scheduled for mass excision with functional endoscopic sinus surgery (FESS). After a general and local anesthesia, bilateral endoscopic sinus was done. The left nasal cavity was normal for mucosal lesion, but a mass measuring approximately 3×3 cm was seen in the anteroinferior part of the right nasal cavity that involved uncinate posteriorly and inferior turbinate inferiorly. The mass was removed with inferior turbinate. Right uncinectomy, right antrostomy and right anterior ethmoidectomy were done. Right maxillary sinus was viewed with endoscope and showed no mass involvement. Septum showed neither mass nor involvement. The mass was sent for pathology and the report revealed metastatic papillary cell carcinoma (figures -). The patient was symptoms free at 6-month and 1-year follow-up after the surgery.
Written informed consent was obtained from the patient for the publication of this case report and any

[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.