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

[User]
RADIOLOGY NOTE:
A 21-year-old female patient presented with progressive exertional dyspnea and irregular palpitations for 3 months. She had past surgical history significant for excision of a cutaneous myxoma in her left arm. Physical examination revealed a high jugular venous pressure and a diastolic murmur. An electrocardiogram showed atrial fibrillation. Laboratory investigations were within normal limits except for a low TSH and elevated free T3 and T4. Transthoracic echocardiography (TTE) showed a large echogenic mobile mass with central constriction attached to the interventricular septum (IVS), occupying the entire right atrium and right ventricle (RV) and obstructing the flow of the tricuspid valve. There were two other masses of the same echogenicity: one was occupying the left ventricle (LV) and the other was in the left atrium attached to the interatrial septum at the site of fossa ovalis (, Videos ). The left ventricular dimensions and function were normal. Cardiac magnetic resonance showed similar findings with no septal invasion and tissue characterization suggestive of multiple myxomas (). Computed tomography of the chest, abdomen, and pelvis revealed the same findings () in addition to an enlarged thyroid nodule and a left adrenal cyst that measures 65 × 57 mm (). Ultrasonography of the thyroid gland revealed a markedly enlarged right lobe of the thyroid with normal vascularity. Serum aldosterone, dexamethasone suppression test, dehydroepiandrosterone sulfate, and 24-hour urine metanephrines were within normal limits.
The patient underwent surgery where all three masses were excised. However, the tricuspid valve was inseparable from the RV mass; hence, it was replaced with a tissue prosthesis. The masses were grossly reddish grey in color, fleshy, and gelatinous in consistency (). The histopathological examination of the excised masses revealed myxomatous cellular proliferations with sparse collagen fibers consistent with multiple myxomas (Figures and ). The patient

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old male patient presented with the chief complaint of pain and swelling in the upper right anterior region for the past 8 months. The patient gave a history of trauma in the same region, after which the swelling had developed and gradually increased in size. The patient was prescribed with analgesic and antibiotic by a local physician, but there was no relief in the symptoms, and hence referred to the institute. Extraoral examination revealed a diffuse swelling of size 4.5 cm × 3.5 cm present on the right side of the face (maxilla), anteroposteriorly 1 cm behind the ala of the nose to the lobe of the ear and superoposteriorly occupying themed region of the face. The swelling had evolved over a period of 8 months. The swelling was firm in consistency and painful, and no local rise of temperature was found [].
On intraoral examination, erythematous growth was seen on the right side of the maxilla extending from 14 to 17 [].
Radiographic examination revealed ill-defined radiolucency and significant bone loss on the right side of the maxilla. Destruction of the lower orbital margin can also be seen. Root resorption of 16 was seen [].
Based on the clinical examination and radiographic finding, a provisional diagnosis of ameloblastoma was considered. Differential diagnoses of odontogenic keratocyst, primary intraosseous carcinoma and metastatic neoplasm were considered.
After obtaining an informed consent, an incisional biopsy was performed to arrive at a definitive diagnosis.
Microscopic examination of hematoxylin and eosin stained histopathological revealed the presence of odontogenic epithelium in various patterns, predominantly in follicular pattern. Sheets like arrangement of the odontogenic epithelial cells were also seen with hyperchromatic nuclei and scanty cytoplasm. Few of the follicles showed stellate reticulum-like cells. There was evidence of increase in cellular atypia and mitotic activity. Connective tissue stroma was fibrocellular [].
Based on h

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old Caucasian female patient presented to our eye casualty with a sudden onset of painless loss of vision in the left eye. She had no past history of ocular problems or trauma. Because of metastatic adenocarcinoma lung with the tumour demonstrating a mutation in exon 19 of the EGFR gene, she was considered suitable for primary palliative treatment with gefitinib and has been started on this medication three months earlier. Medical history also included palliative radiotherapy on her spine and right shoulder and treatment with morphine sulphate, diclofenac, and gabapentin.
On examination, her left eye had very poor vision of perception to light only. Slit-lamp examination revealed a shallow anterior chamber and a perforated corneal ulcer that measured 4.7 × 5 mm, which was plugged by the iris (). The eye was white with no conjunctival injection or anterior chamber cells. There was no evidence of meibomianitis or trichomegaly. It was difficult to visualise the fundus due to the corneal pathology but ultrasound examination demonstrated choroidal detachment with no evidence of intraocular metastasis. The right eye showed no abnormality with good vision.
As it was suspected that gefitinib could be the cause of her corneal ulcer, her oncologist decided to stop the medication due to the potential ocular toxicity, although gefitinib treatment had reduced her lung tumour size. Initial ophthalmic management included a bandage contact lens to reform the anterior chamber and topical antibiotics. A subsequent tectonic 6.25 mm corneal graft was performed without complication ().
Post-operatively, her eye remained quiet, however, because of the development of a dense cataract, her vision only improved to hand movement. Two months after stopping the gefitinib treatment and while awaiting cataract surgery, she developed severe left retroorbital pain. On examination, she had iris prolapse through a melting corneal graft, and the crystalline lens was extruded (). This was ma

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old woman with a known history of giant cell tumor of the left first metatarsal was evaluated for worsening left medial midfoot pain. She had previously undergone curettage and polymethylmethacrylate (PMMA) cementation of a biopsy-proven giant cell tumor of the first metatarsal two and a half years prior at a different institution. Six months following the index surgery, she had a recurrence treated with repeat curettage, liquid nitrogen local adjuvant, and placement of bone substitute graft. After the second procedure, she was ambulatory, but occasionally used a boot for comfort and avoided high-impact activities. Physical examination demonstrated a prominent first metatarsal base and a well-healed dorsal incision. She exhibited tenderness to palpation throughout the area of the scar.
Radiographs of the left foot showed an expansile, radiolucent lesion of the first metatarsal base surrounding the known cement implantation of the first metatarsal (). Magnetic resonance imaging showed a large soft-tissue mass surrounding the first metatarsal circumferentially and abutting the second metatarsal (). There was high T2 signal with no T1 signal changes at the base of the second metatarsal. Computed tomography (CT) scan demonstrated an expansile lucency at the proximal aspect of the first metatarsal base toward the dorsal lateral side (). There were some areas of cortical breach, and the bone was expanded and abutting the base of the second metatarsal. There was no evidence of direct extension into the second metatarsal or areas of osteolysis within the second metatarsal base. She was diagnosed with a second recurrence of giant cell tumor of bone of the first metatarsal base. As the tumor was recurrent, with destruction of the articular surface and little residual bone of the first metatarsal base, a wide resection of the tumor was recommended.
The procedure began by harvesting iliac crest bone graft (5 cm in length, 2 cm in depth). The prior dorsal incision was

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old woman was admitted to the Pulmonary Outpatient Clinic complaining of fluctuating cough and dyspnea. She had been under immunotherapy for 2 years due to allergic asthma, and, spontaneously, she complained of sore throat and mild haemoptysis. Clinical examination revealed scattered wheezes from the lungs without any abnormal findings from the pharynx. Spirometry showed a typical obstructive pattern, attributed to asthma. Her medical history was remarkable of subclinical hypothyroidism, adequately treated with levothyroxine.
The patient was lost to follow-up and returned 3 years later with increased dyspnea, neck discomfort, deepening voice, and wheezing. On examination, she had prolonged expiration with wheezing and worsening in the spirometric parameters. Despite oral corticosteroid administration, the symptoms gradually deteriorated and she developed inspiratory stridor and severe dyspnea with spirometric evidence of severe upper airway obstruction. She was admitted to the Intensive Care Unit for further investigation and management.
Computed tomography (CT) scan of the neck and mediastinum revealed an abnormal lesion (3.5 × 2.8 × 3.7 cm), originating from the right lobe of the thyroid gland, invading and severely obstructing the lumen of the trachea (). No lymph nodes or other abnormalities were observed. In view of severe dyspnea, a low tracheostomy was performed. An open biopsy from an unstable mass penetrating the anterolateral wall of the trachea and from the endotracheal mass by endoscopy was obtained. The biopsies were compatible of highly differentiated PTC with additional extensive inflammatory lesions and necrotic hemorrhagic material. Eventually, the patient underwent a total thyroidectomy and resection of the endotracheal part of the mass along with the corresponding anterior portions of 3 tracheal rings (). To maintain the patency of the airway, a Montgomery T-tube was placed. The patient was easily extubated, and breathing and speech were

[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 67-year-old woman had previously undergone posterior fixation surgery (T12, L1, and L3) for an L2 compression fracture when she was 63 years old and had no other specific medical history. She had no symptoms after the surgery until the age of 67 years but developed numbness and muscle weakness of both her lower limbs 4 months ago and visited another doctor before visiting us.
Her previous doctor suspected metastatic spinal tumor based on the initial radiography and magnetic resonance imaging (MRI). She was diagnosed with metastases of thyroid follicular carcinoma by a subsequent bone biopsy and was referred to our hospital after total thyroidectomy 2 months before she visited us for the treatment of the spinal lesion.
The patient's main complaints were numbness and muscle weakness of both lower limbs. We confirmed deformation of the L2 vertebral body by the initial radiography and MRI from the previous facility revealed hyperintensity/hypointensity of the L1, L2, and L3 vertebral bodies and compression of the spinal canal by the tumor at the same level (Figures and ). After posterior fixation surgery, the vertebral arch (T12–L3) in a CT scan indicated a complete bone union and bridge formation (). PET/CT revealed no uptake in the posterior element, thus demonstrating no residual metastasis (). Assessment of bone density by dual energy X-ray absorptiometry (DXA) indicated osteopenia in the femoral neck (t score: −1.7). Since the primary disorder was thyroid cancer without metastases in other viscera and bones except spinal vertebral bodies and the general condition of the patient was favorable (Performance Status grade 1), we decided to perform radical surgery according to the spinal metastatic tumor scoring system (Tokuhashi score 12 points/Tomita score 3 points) [, ]. We performed radical surgery by posterior fixation and excision of the anterior segment of the vertebral body and reconstructed the anterior segment via the posterior-anterior approach. Successful s

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old Turkish man who had fallen on his flexed right knee while walking on ice was referred to our hospital. He suffered from pain and inability to move his right knee. Physical examination revealed prominent swelling and tenderness over the right patella. Plain radiographs showed comminuted displaced inferior pole fracture of the patella (Figure ). His extremity was immobilized initially through a cast brace, and he was then operated under general anesthesia on the following day. During the operation, it was found out that the patellar fracture could not be reduced and repaired. Because of this, a partial patellectomy was performed and his patellar tendon was sutured to the patella with No. 2 polydioxanone (PDS) sutures and augmented with a cerclage wire (Figure ). A long leg cast was then applied and we advised our patient to move using two crutches and bear no weight for three weeks. At the end of the third week, he was started on active and passive ranges of motion exercises of the knee.
On his follow-up visit after six weeks, he was already able to flex his right knee by about 100°. After that period, however, he started to experience a gradual decrease in knee movement. Two months after the operation, the active flexion of his knee was only 60°. A lateral radiograph of his right knee showed extensive ossifications at the resected part of the patella and calcifications in the patellar tendon (Figure ). Excision of the ossifications and implant removal were thus planned. During that period, he felt a sudden pain over the tibial tubercle of his right leg while he was descending the stairs. He was unable to extend his right knee.
Plain radiographs revealed the presence of patella alta. As a result, another operation was performed. It was then discovered that the patellar tendon with ossification throughout its length was avulsed from the tibial tubercle. The cerclage wire from the previous surgery

[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 current disease story of our 68-year-old Caucasian male started two years ago, when this patient observed a hard lesion in the anal canal, which, in the first months since he observed it, was neither officially diagnosed nor treated. Ten months after that, he underwent cholecystectomy due to cholelithiasis, and the perioperative diagnostic examination revealed some suspicious lesions in the anal canal and some enlarged pelvic lymph nodes. His comorbidities included only gout, and his Karnofsky performance status was 90. He has never been treated with radiotherapy, and he had a second-degree family history for malignancies. At that time, a digital rectal examination identified mild prostatomegaly, with a palpable suspicious nodule in the left prostate lobe, without any signs of the extracapsular extension. Also, a large ulcerated mass was palpable at the dorsal anal canal wall, without lymphadenopathies in the inguinal region. Subsequent colonoscopy confirmed the presence of a suspicious lesion on the posterior anal canal, extending above up to the anorectic junction. A magnetic resonance imaging (MRI) for the regional staging confirmed an infiltrative lesion of the anal canal with a maximum diameter of 3.2 cm, with a high-grade suspicion of sphincter infiltration, and two enlarged lymphadenopathies in the mesorectum and in the right internal iliac region, respectively, both with a maximal diameter of 2 cm, which is suspicious of tumour metastases. Further, an area with a maximal diameter of 2 cm within the left prostate basis having a restricted diffusion with a lower apparent diffusion coefficient (ADC) than that in the surrounding healthy prostate tissue, which appeared hypointense on ADC maps but hyperintense on the diffusion-weighted maps, was also described. Afterwards, biopsies confirmed a poorly differentiated squamous cell carcinoma of the anal canal, as well as a moderately differentiated prostate adenocarcinoma, with a Gleason score of 7 (3 + 4) in bot

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old primigravida with 6-week pregnancy was brought into emergency department with severe abdominal pain which started two days earlier and had worsened suddenly in the morning she was admitted. She was referred with a suspected diagnosis of ruptured ectopic pregnancy. Initial examination showed tachycardia of 124 beats per minute, marked pallor, and generalised tenderness in abdomen. The rest of her physical examination was normal. There was no history of vaginal bleeding. Her initial blood counts showed haemoglobin of 4.5 g/L. A FAST (Focused Assessment with Sonography in Trauma) scan appeared to suggest intraperitoneal bleed. Abdominal pain with pallor, low haemoglobin, and positive FAST scan was very suggestive of ectopic pregnancy. Therefore, a CT scan of abdomen was arranged. The scan showed large left retroperitoneal hypodense mass with hyperdense strikes. There was evidence of compression on the left kidney, pancreas, and bowel loops with associated moderate amount of ascites. Findings were consistent with massive retroperitoneal haematoma extending from diaphragm (Figures and ) displacing left kidney (Figures and ) and extending into pelvic cavity. The pregnancy was however found intact within uterus (Figures and ).
The haematoma was causing marked displacement of the left kidney and was showing varying shades of hyper- and hypodensities. Varying shades of hyper- and hypodensities were suggestive of haemorrhages of different ages which were periodic and of slow episodes (Figures and ). The main source of bleeding was found to be the apical portion of left kidney which appeared as a cystic lesion in continuity with the haemorrhage ().
Patient was kept in intensive care unit under observation and blood was transfused to her to support haemodynamics and achieve a target of Hb% of 10 G/L. Unfortunately, the lesion could not be evaluated with MRI due to technical problem with the MRI scanner.
Initial attempt of embolisation of the lesion failed and next

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male patient who underwent radical cystectomy with an ileal conduit for muscle-invasive urothelial carcinoma of the bladder 4 years ago presented with the complaint of progressive swelling in the root of the penis. A large, painless, and penoscrotal mass was detected on physical examination. On pelvic magnetic resonance imaging (MRI), it was a 95 × 65 × 65 mm (AP × T × CC) cyst extending along the proximal half of the penile shaft. Solidified material and septa, probably belonging to an organized hematoma, were noted within the cyst []. The cyst wall, as well as the penile crura and residual urethra, showed enhancement following gadolinium administration []. The cyst was then aspirated, and the material was a dark brown viscous liquid containing clot and purulent material. Cytology revealed invasive urothelial carcinoma, and cyst excision with partial urethrectomy was performed. No connection was detected between the cyst cavity and the urethral lumen during surgery. Comprehensive imaging studies showed no other signs of local recurrence or distant metastasis, and the patient’s routine clinical and radiological follow-up continued.
Two years after the cyst excision, the patient presented with a painless hard penile mass. Pelvic MRI revealed a lobulated lesion measuring 52 × 32 × 27 mm (CC × AP × T) in the penile root. The penile mass extended from the cystectomy stump posteriorly into the penile shaft, invading the penile crura, and urethra []. The mass showed heterogeneous high signal in T1-, T2-, and fat-suppressed T2-weighted sequences, consistent with a complex hemorrhagic cystic lesion. There was no anal canal or puborectal muscle invasion, but both corpora cavernosa were invaded. The mass exhibited intense heterogeneous enhancement following gadolinium administration []. A total penectomy was planned. However, the patient did not consent to the operation due to his body image concerns. Therefore, cisplatin-containing combination chemotherapy was

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male patient presented with a firm, subcutaneous nodule in the right upper eyelid []. The lesion was present for 10 years, slowly growing and painless. The mass was round, relatively hard and moved freely under the skin, without pain on palpation or mobilization. The overlying skin showed no inflammatory signs or abnormal pigmentation. There was no restriction in ocular movements, and the remaining ophthalmological examinations were unremarkable.
The patient underwent an orbital CT scan that revealed an extra-conical mass, adjacent to the lateral rectus insertion, with no distortion of the globe or invasion of the bone or muscular structures. The mass had a heterogeneous density, and two cysts were present in its superoanterior portion [].
An excisional biopsy was performed over the upper eyelid dermis, through a 15 mm horizontal incision in the lateral third of the eyelid crease. The tumor was well circumscribed with no adhesions and was easily dissected and removed in its entirety []. The lacrimal gland was found to be independent of the mass, with a normal appearance. The incision was closed with a 6.0 polypropylene suture. The postoperative appearance can be observed in [].
On gross pathologic examination, the nodule was well-defined with dimensions 20 mm × 15 mm × 12 mm. A smooth and tan cutting surface was found, with tiny cavitated areas containing a pasty whitish material. The entire specimen was submitted to histologic examination. The tumor was totally encapsulated and presented a biphasic pattern, consisting of a chondromyxoid stroma and an epithelial component []. The epithelium was arranged in nests, cords, and tubes, or glandular branching structures layered by a double epithelium in which the inner epithelial layer exhibited apocrine features, such as decapitation [Figure and ]. There was no significant atypia. Numerous cysts were present in the tumor, lined by metaplastic stratified squamous epithelium and containing keratinized epithel

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male patient presented to the surgical consultation with recurrent attacks of epigastric pain, melena, and epigastric fullness.
Upper and lower GIT endoscopies were performed during the first admission which showed no abnormal findings.
During the last presentation, the patient was admitted to the surgical unit.
The patients had negative drug history. The family history was negative for any genetic diseases, and the psychosocial history was negative.
The general examination revealed pale conjunctivae, palms and oral mucosa. There were no cyanosis or jaundice.
The blood pressure was 100/60 mmHg on admission, the pulse rate was 95 beats/minute, the temperature was normal and the body mass index was 38.
The abdomen was soft with no areas of tenderness. There were no dilated veins over the abdomen with no stigmata of chronic liver diseases.
Investigations were performed for the patient. The hemoglobin level was 8 gm/dl with normal serum electrolytes, normal liver and renal function tests. The patients received 2 units of compatible blood and arrangement was done to perform another endoscopy.
The endoscopy this time revealed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. .
CT-scan of the abdomen was normal with no abnormal findings.
Arrangement was done to perform surgical intervention, during surgery we adopt an upper midline incision, exploration of the abdominal cavity showed normal liver, spleen, and omentum, with no ascites and no dilated veins.
Mobilization (kocherization) of the duodenum was performed, the anterior wall of duodenum was opened, and a pedunculated polyp (about 4 cm in size) was found which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. , .
Excision of the polyp with its base was performed and was sent for frozen section examination during surgery which revealed a benign lesion with no signs

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old female patient in Medan, Indonesia, came to a dental clinic with a primary complaint of a lesion on the left dorsal surface of the tongue, which caused the difficulty in chewing and speaking. The lesion was of the size of a pea when the patient first noticed it but had grown to attain the size of 8 × 7 × 3 mm over a period of 2 weeks. The lesion had started to bleed when she was presented to the clinic. The patient's medical history was unremarkable. She mentioned that she previously went to a general practitioner and was prescribed amoxicillin, dexamethasone, and mefenamic acid. She consumed the medications for 5 days and reported no improvement. Intraoral examination revealed a single, spherical-shaped, and reddish pink lesion. The lesion had a distinct border and irregular surface (Figure ). The surrounding tongue mucosa appeared to be normal, and the growth was located on the left dorsal surface of the tongue. The lesion had a soft-to-firm consistency and blanched upon pressure.
The management of the lesion was a surgical excision, which was carried out under local anesthesia. A thread was tied around the base of the lesion. The lesion was then stretched upward to facilitate accessibility. It was subsequently excised out, and interrupted sutures were placed (Figure ). During the surgical procedure, minimal amount of bleeding from the site was observed. The specimen was then sent for a histopathological examination. After the surgery, the patient was instructed to keep the oral cavity clean by teeth and tongue brushing three times a day followed by chlorhexidine mouthwash. The patient was then asked about whether she had prior history of allergic reactions in relation to the use or consumption of beehive products such as honey, bee pollen, or propolis. She confirmed that she never had any allergic reaction to any beehive product. The patient was then instructed to also apply the commercially available hydroglyceric propolis extract to

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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:
The patient was a 65-year-old male who presented with a swelling of the posterior surface of the proximal third of his left leg. His prior history included a prolonged stay in hospital for treatment of bacterial endocarditis, when two mitral valve replacement operations were performed. He had also previously undergone two abdominal operations to treat an intestinal tumor and one varicose veins surgery.
Physical examination revealed a pulsating mass in the posterior region of the proximal third of the left leg. Femoral, popliteal, and dorsal pedal pulses were palpable and normal in both lower limbs. The posterior tibial artery pulse was absent, whereas the posterior tibial artery pulse was palpable in the right lower limb.
Magnetic resonance angiography showed a saccular dilatation in the tibioperoneal trunk with a 4.4 cm diameter, at the level of the origin of the posterior tibial artery. The posterior tibial artery was also occluded ( ). Investigation was supplemented with laboratory tests (inflammatory activity tests, coagulation tests, and complete blood cell count), which all returned normal results, in addition to blood cultures, which were negative.
Having ruled out other probable etiologies and active infections, in view of the history of bacterial endocarditis, it was decided to perform a less invasive treatment, considering the inflammatory/infectious pathophysiology and the size and site of the pseudoaneurysm. A covered, self-expanding stent (Gore VIABAHN 6.0 × 50 mm) was therefore placed in the tibioperoneal trunk, preserving fibular artery patency and excluding the aneurysm. The transition between the tibioperoneal trunk and the fibular artery was ectatic, because of the pseudoaneurysm, which minimized difficulties caused by reduction of the distal diameter. A control magnetic resonance angiography showed that the aneurysm sac was no longer perfused and the fibular artery was patent ( ).
The patient was followed up for 10 years after treatment and during

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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 78-year-old woman presented with dysphagia of solid food for 1 month, which was associated with occasional nausea and vomiting. The patient denied noticeable weight loss, hoarseness, caustic ingestion, and a history of tuberculosis and tumors, among other conditions. After admission, gastroscopy was performed, which demonstrated concentric narrowing of the esophageal lumen at 30 cm from the central incisor; the lumen was approximately 4 mm in size, and the gastroscope could not reach beyond this point. The mucosa overlying the stricture was smooth, and biopsy was performed at this site (Fig. A). Subsequently, the patient underwent barium esophagography and contrast-enhanced thoracic computed tomography (CT). Barium esophagography showed a narrowing of approximately 1.5 cm in length in the middle and lower esophagus without visible disruption of the mucosa; lumen expansion was limited, but the barium was still able to pass through the area (Fig. B). Contrast-enhanced thoracic CT revealed that the wall of the middle and lower oesophagus was obviously thickened, which indicated possible malignancy (Fig. C). However, the biopsy results suggested squamous epithelial hyperplasia (Fig. D).
For this patient, gastroscopy indicated only luminal stenosis without the presence of ulcers or masses in the mucosa, and the biopsy was negative for malignancy. However, CT examination revealed a significant thickening of the esophageal wall. It was necessary to determine a better method by which the esophageal lesions could be diagnosed in this patient. EUS revealed that the mucosa overlying the esophageal lesion was significantly thickened and was approximately 8.7 mm thick in the thicker region, with a low echo; the layers of the esophageal wall could not be clearly recognized (Fig. A). Then, in Doppler mode, we performed EUS-FNA 3 times at the thickened esophageal wall (Fig. B). The aspiration smear was sent for aspiration cytology, and the tissue strip was sent for pathological e

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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 16-year-old male with neurofibromatosis type 1 was referred to our hospital for management of left superior mediastinal tumor. The surgery in this case reports is for the patient at the time of the fourth surgery for malignant peripheral nerve sheath tumor (MPNST). For the first surgery, owing to the rapid growth of the tumor and presence of dyspnea, he underwent an emergent operation through trap door thoracotomy (Figures and ). The tumor was 123 × 120 × 88 mm in size and was originated from the left thoracic vagal nerve distal to the bifurcation of the recurrent laryngeal nerve. We could barely exfoliate the tumor from the LCCA and LSA, and it was diagnosed as MPNST with 56 mitosis cells per 20 high-power fields. Radiotherapy of total dose 60 Gy was administered to the mediastinum owing to pathologically positive margins. In the second operation, a hook approach was used to perform combined resection of the left chest wall including the 2nd-4th ribs for locally recurrent tumor. In the third operation, a distal pancreatectomy was performed for metastasis to the pancreas. Ten months after the first operation, we observed rapid growing local recurrence in the left superior mediastinum. The recurrent tumor was not found on examination a month ago. Chest computed tomography (CT) showed that the recurrent tumor attached the left clavicular head, the first rib, upper sternal bone, the LCCA, and LSA (Figures and ). Preoperative cranial magnetic resonance angiography showed a normal vertebral-basilar system, and a tumor measured 35 mm in size in the occipital lobe. We prioritized the operation of the thoracic tumor due to its rapid growth, and we planned an endovascular technique to avoid intraoperative fatal bleeding. We obtained written informed consent from his parents for the off-label use. An 8 mm in diameter and 60 mm in length polytetrafluoroethylene-covered stent (PTFE-CS) for biliary tract (Fluency®; Bard, Karlsruhe, Germany

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


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

[User]
RADIOLOGY NOTE:
An 18 year old male presented with pain in his right upper arm after trying to put out a fire in his hand in June 2005. On physical examination, tenderness, swelling, angulation, and crepitus on right upper arm were noticed. Radiographs of the arm revealed a humeral shaft fracture with intramedullary patchy signs of osteoporosis []. After correlating with history, physical examination and radiographs, a diagnosis of pathologic fracture shaft humerus was made. Bone scan and magnetic resonance imaging (MRI) of the right arm were then performed. Bone scan revealed mild nonspecific uptake intensity on shaft of humerus []. No other skeletal abnormalities were noticed on the scan. On MRI, T1-weighted image showed medium intensity at the bone marrow, and high signal intensity at the same area was shown on T2-weighted image. Findings also revealed cortical bone erosion and heterogeneity around fracture lesion with multiple bone absorption []. MRI findings suggested avascular tumor such as hemangioendothelioma or hemangioma. Blood parameters such as calcium, phosphate, alkaline phosphatase, osteocalcine, and calcitonin were all within normal range. Rheumatoid factor was negative. Patient then underwent the curettage with biopsy with open reduction and internal fixation using Limited Contact Dynamic Compression Plate (LC-DCP, Synthes©, Paoli, [PA], USA) on June 2005. Intra operative findings revealed a fibrotic mass located in the medullary cavity and signs of cortical thinning. Histopathological result was chronic inflammation with vascular proliferation. Therefore, he wasn’t diagnosed as Gorham's disease. 7 months postsurgery, the patient consulted the emergency room complaining of right upper arm pain that occurred while trying to stand up after leaning on his right side. Radiographs showed enlarged and new developed radiolucent areas suggesting a nonunion fracture of the humerus. A periprosthetic fracture on the distal plate was also noted []. On January 2006, the patient

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male patient, a tailor by profession, attended to the department of oral medicine and radiology, with a chief complaint of a swelling in the lower-right facial area for the past 1 month []. At first, it began as a small swelling and gradually increased to the present size.
Medical history was positive for persistent weight reduction from 6 months and he also had occasional fever and cough. Family history was noncontributory. Social history was positive for tobacco smoking. A general physical examination demonstrated that the patient was conscious, cooperative, well oriented, and moderately nourished with signs of anemia. The weight was 52 kg and temperature was 99°F. The extraoral examination revealed mild facial asymmetry with conspicuous bilateral submandibular lymph nodes in which a single, firm, and nontender node on the right side >1 cm fixed to the underlying structures was evident. The local examination also demonstrated a solitary swelling of size 4 cm × 5 cm on the right lower 1/3rd of the face with extension of the lesion 2 cm away from corner of the mouth to 2 cm in front of the tragus of the ear anteroposteriorly and ala-tragus line to mandibular angle superoinferiorly. The swelling was asymptomatic.
Intraoral examination uncovered an exophytic growth of size 5 cm × 6 cm extending out from teeth 44 to 48, which was covered by pseudomembranous slough and erythematous areas over the mucosa with everted margins []. On palpation, it was tender and firm in consistency. Missing teeth in relation to 46 and 47 were also noted. The teeth were self-extracted by the patient. The remaining dental examination was not significant except with the grade 1 mobility in relation to 44 and mandibular anterior teeth. Based on the history and clinical findings, a provisional diagnosis of primary malignant neoplasm of the mandible was arrived. Differential diagnosis like tubercular granuloma, central mucoepidermoid carcinoma of the mandible, NHL, Hodgkin

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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:
The patient is a 69-year-old man with history of carcinoma rectum with abdominoperineal resection done 30 years ago. No adjuvant therapy was given postoperation. He had no follow-up afterwards. He presented to us for metachronous tumor over descending colon complicated with large peristomal abscess (Fig. ). Contrast CT found mural thickening ~7 cm in span just proximal to stoma exit with adjacent 3.7-cm thick-walled rim-enhancing lesions around the stoma site. Another 3-cm thin wall fluid collection was noted at the anterior abdominal wall just inferior to the stoma site. Features were suggestive of inflammatory collection. There was an 1-cm left groin lymph node as well. There was no liver or peritoneal metastasis.
Colonoscopy was done via the colostomy showing circumferential stenotic ulcerative growth 3 cm proximal to stoma end and scope failed to negotiate through. Biopsy confirmed to be adenocarcinoma. Incision and drainage of abscess were performed. Intra-operation found 5-cm abscess cavity at 6 o’clock of colostomy extending close to stoma with surrounding cellulitis. There was a circumferential tumor mass 3 cm proximal to stoma end. Tissue for histology confirmed adenocarcinoma. Excisional biopsy of the 1-cm left groin lymph node confirmed no malignancy. The wound was clean with granulation tissue after daily dressing for 2 weeks. The patient underwent wide resection, resiting of stoma and reconstruction of abdominal wall defect with a pedicled ALT flap in a joint-team approach.
Procedure: The initial stage was preparation of the flap. ALT flap was designed along a line drawn between the anterior superior iliac spine and the superior lateral border of the patella, with the line midpoint located at the proximal portion of the flap to obtain more pedicle length. The surgeon localized the large caliber perforating vessels of the LCFA with Doppler ultrasound, and then mapped out the proposed flap on the skin of the ALT based on the anticipated size of the defect

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


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

[User]
RADIOLOGY NOTE:
The patient was a 22-year-old nulliparous Japanese woman. Her medical and family histories were noncontributory. She had no previous history of smoking, habitual alcohol drinking, or drug abuse. She was referred to our hospital for fetal anatomical evaluation because of severe oligohydramnios at 13 weeks and 6 days of gestation. The gestational age was calculated from the first day of her last menstrual period. At her 10 weeks and 6 days' visit to the previous clinic, the crown-rump length of the fetus was 34.7 mm and no remarkable abnormalities of amniotic fluid volume were recorded. However, at 13 weeks and 4 days of gestation, a remarkable decrease in the amniotic fluid volume was found. At the first visit to our hospital, we carried out an antenatal ultrasonographic scan and a single live fetus was noted. The crown-rump length, biparietal diameter, and nuchal translucency of the fetus were 66.1 mm, 23.6 mm, and 2.1 mm, respectively. Because of severe oligohydramnios (), ultrasonographic images were not very clear, and no clear 3D images were obtained. As far as we could check, no structural abnormalities were found in the fetal cranium, brain, upper extremities, thorax, and heart. However, the lower extremities remained in the fixed extension, but all long bones were visible (). The lower extremities stayed in the same position, and no individual movements of the two legs were seen, which suggested the fusion of the two lower extremities. Color Doppler ultrasound revealed a single umbilical artery (). Neither kidneys nor the urinary bladder was visualized. Therefore, the diagnosis of type I sirenomelia was made prenatally.
The couple was informed about the findings and the suspected poor prognosis of the fetus. They then opted to have a termination of pregnancy, which was performed at 15 weeks and 1 day of gestation. On the postnatal examination, the baby weighed 60 grams and the

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old woman in her first pregnancy presents at 20 weeks’ gestational age with shortness of breath, small-volume hemoptysis, sinus tachycardia and left-leg edema. She has no significant past medical history and the pregnancy up until the point has been uncomplicated. Chest X-ray is unremarkable.
Pregnancy increases the risk of VTE, with an overall 1–2 in 1000 rate of venous thrombosis [,,]. Similar to the general population, no specific clinical sign or symptom is sufficiently specific or sensitive for diagnosing VTE. For example, shortness of breath is a common occurrence in pregnancy and can be caused by a broad differential of both physiologic and pathologic processes [].
The LeFT score can be used to refine the pretest probability of DVT in pregnancy [,]. The LeFT score includes three clinical criteria: symptoms in the left leg (L); edema with a calf circumference difference ≥ 2 cm (E); and first-trimester presentation (Ft). In the derivation cohort, no DVTs were diagnosed in patients with zero of the above risk factors. Patients with one risk factor had a DVT prevalence of 8.8% and those with two or more risk factors had a DVT prevalence of 58% [].
In patients with clinical concern for DVT, ultrasound is the recommended first imaging test, even if there is also concern for PE []. This takes into account the increased risk of lung imaging to both the fetus and mother during pregnancy []. As treatment generally does not differ between patients with DVT and PE and those with only DVT, ultrasound is a safe and accessible mechanism to inform treatment in pregnancy. In patients in whom a DVT is found, imaging for PE is generally not required in pregnancy. However, in patients being evaluated for PE without features of DVT, the diagnostic yield of screening ultrasounds is low and likely of limited utility [].
Back to the case: The patient has clinical features of both DVT and PE. Applying the LeFT score

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old man with a history of schizophrenia fell and was transferred to our hospital by ambulance. Upon initial physical examination, tenderness and swelling were noted over the right trochanteric region. His right leg was immobile because of severe right hip pain. Moreover, he had no neurovascular deficits or other extremity or systemic injuries. Radiography revealed an AO type 31A2.2 [] and Jensen type 3 [] trochanteric fracture in the right femur (). For treatment, the patient underwent a closed reduction and internal fixation with a gamma 3 long nail (Stryker, Kalamazoo, Michigan, US) according to the manufacturer's instructions. The lag screw was the appropriate length and reached to the subchondral bone of the femoral head. However, the lag screw was inserted anteriorly and a varus malalignment remained (Evans classification was type 1 group 3) in AP view () []. Complications did not occur during the surgery or throughout the 1-month period of hospitalization. The patient was an elderly and had a history of schizophrenia; hence, rehabilitation did not proceed after surgery. Thus, he was unable to walk by himself and was wheelchair-bound when he was discharged. One year after surgery, the patient presented to the clinic for a regular follow-up. Although there were no additional falls or subjective symptoms, radiograph revealed that the intramedullary nail was disassembled with bone fragment displacement. The lag screw penetrated into the pelvis through the femoral head and acetabulum (). No intra-abdominal organ injuries were confirmed on a contrast-enhanced computed tomography scan. The lag screw was located between the internal and external iliac vessels, and tangent to the small intestine; however, no signs of pneumoperitoneum or hematuria were present ().
To prevent future concomitant injury of the blood vessels, ureter, and intestine, we decided to remove the implants. If the lag screw had been adhering to the intestine, the threaded part of the 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:
A 62-year-old female, who had a history of chronic headaches, previous lumbar decompression and fusion at L3-4 for degenerative lumbar stenosis, presented to the clinic with low back pain. She was found to have an adjacent segment disease at L2-3 with recurrent stenosis at L3-4. The patient failed non-operative management including physical therapy and steroid injections. Consequently, she elected for surgery and underwent a revision lumbar decompression with anterior and posterior instrumentation for spinal fusion, as well as a repair for an incidental durotomy. The patient did well after surgery and was discharged home nine days later.
Approximately 24 to 36 hours after discharge, the patient fell due to weakness in her legs. She was seen in the emergency department and was found to have progressive weakness, numbness, and areflexia in her bilateral lower extremities. Over the course of the ER visit, she developed ascending paralysis as well. She denied any fever, chills, or symptoms of infection. The initial laboratory workup was negative for infection. At that time, a magnetic resonance imaging (MRI) only showed postsurgical changes. Neurology was consulted and did not recommend a cerebrospinal fluid (CSF) sample due to the recent surgery.
Because of a clinical suspicion for GBS, she was admitted to the neurological intensive care unit (ICU) and started on intravenous immunoglobin (IVIG) therapy for six days. The patient’s hospital stay was complicated by the development of respiratory failure, which required intubation. She was eventually converted to a tracheostomy and was finally decannulated. An electromyography (EMG) showed diminished motor and sensory responses in terms of amplitude and conduction velocity in her upper extremities and absent amplitude and conduction velocities in her lower extremities confirming the diagnosis of GBS.
After an approximate four-week hospital admittance, the patient was discharged to a rehabilitation facility and continued ag

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old man presented to the emergency department at our hospital on October 2012 with a 4-month history of worsening lower back pain. There was no history of trauma or falls. He was unemployed and lived with his mother. He took no medications or supplements, did not smoke, consume excessive alcohol, or use illegal drugs, and had never been treated with corticosteroids. He had no history of prior fractures. Family history was negative for gonadal, endocrine, or bone diseases. Review of systems was remarkable for markedly delayed puberty for which he had received testosterone injections starting at 16 years of age. Three years later, testosterone replacement therapy was terminated by the treating physician, after he responded well in terms of growth and development of secondary male sexual characteristics. He remarked decreased libido for several years and absence of morning erections.
On examination, he was a well-nourished gentleman in obvious distress due to pain at the level of the lower thoracic/lumbar spine. He had an eunuchoidal body habitus with the arm span (181 cm) exceeding the height (174 cm). The pupils were round, equal, and reactive to light. Visual fields were normal to confrontation. The skin turgor was normal, the mucous membranes were moist and the teeth were in good condition with no decay. Examination of the head and neck was remarkable for hyposmia to a number of odorants. The cardiovascular, respiratory, and abdominal exams were within normal limits. There was no edema in the extremities and neurological assessment was normal. Examination of the integument was remarkable for sparsity of pubic hair. The penile length was normal but testicular volume was decreased (approximately 5 cm3 as determined using the Prader orchidometer).
On biochemistry, serum levels for luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, and estradiol were extremely low while baseline values for serum creatinine, electrolytes, thyroid funct

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


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

[User]
RADIOLOGY NOTE:
A 14-month old boy presented with respiratory distress, wheeze and hypoxia. This was preceded by 24 h of coryza, fever and reduced feeding. He was admitted directly to intensive care, where he was diagnosed with pneumonia. Treatment was started with empirical antibiotics. He was intubated and ventilated for 4 days, after which he was extubated and stepped down to high dependency unit (HDU) on continuous positive airways pressure (CPAP) ventilation. He continued to have persistently increased work of breathing, persistent expiratory wheeze and symptoms and signs of air trapping.
Though he did not progress to respiratory failure, weight gain and oxygenation was achieved only by initiation of Heated Humidified High Flow Nasal cannula therapy (HHHFNC).
Polymerase chain reaction (PCR) testing of nasopharyngeal aspirates (NPAs) revealed the persistence of rhinovirus and adenovirus for 10 weeks in both NPAs and bronchoalveolar lavages (BALs), with parainfluenza type 3 found in just one NPA sample. Adenovirus was also found in blood by PCR testing. Rhinovirus is not normally tested for in blood samples and there was no validated assay available for this. One BAL and one urine sample were screened for cytomegalovirus (CMV) by PCR also, and found to be negative. One stool sample was tested and found to be negative for rotavirus and adenovirus (despite the persistence of adenovirus in the respiratory samples at this time).
There was no significant family history of any genetic diseases and the patient was born at term. Mum is a smoker but states that she did not smoke during her pregnancy. During pregnancy, intrauterine growth restriction was identified. At the time of admission his weight was < 0.4th centile, but this was increasing. His parents report poor feeding since birth and an increased work of breathing from 5 months old. He is known to the allergy services for severe eczema and faltering weight, and has been diagnosed with cow

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


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

[User]
RADIOLOGY NOTE:
An Iranian 24-year-old primigravid woman from Kordistan province presented to our hospital with left flank pain. She had had the pain for a few days and had received adequate prenatal care until her referral to us. She was diagnosed as having had gestational diabetes mellitus since the 12th week of gestation (her fasting blood sugar was between 106 and 116 mg/dL). Insulin therapy was started at a dosage of 4 units of neutral protamine Hagedorn at bedtime. All fasting and postprandial blood sugars had been controlled well.
She also complained of having had pulsatile bi-temporal headaches for 2 years prior to her referral to us. Her headaches responded well to common analgesics. She also mentioned that she had hypertension of 140/90 mmHg at one of her prenatal visits during the 32nd week of gestation. However, the physician had not diagnosed hypertension by rechecking her blood pressure at that time. Although her gynecologist had assessed proteinuria via 24-hour urine sample, no proteinuria was detected (119 mg/dL). Her liver enzyme, creatinine, and platelet counts were all in normal range.
At the 37th week of gestation she had presented to us with left flank pain and no urinary symptoms. We did not detect costovertebral tenderness, fever, hypertension, or tachycardia at the primary examinations. Urine analysis was completely normal, so we did ultrasound imaging of fetus and kidneys. Ultrasound imaging revealed no problems with her kidneys, but we found a solid mass with fine cystic component of 119 × 87 × 79 mm above her kidney, highly suspicious for an adrenal-originating tumor. The fetus had no abnormality at the ultrasound imaging.
To evaluate the mass, we consulted with an endocrinologist to definitely diagnose the incidentaloma. Abdominopelvic magnetic resonance imaging without contrast showed a well-defined 100 × 95 mm heterogeneous mass in her left adrenal region above the kidney which contained some cystic areas and showed some restriction foci on diffusion-w

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


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

[User]
RADIOLOGY NOTE:
The patient in question was a 45-year-old Hispanic female who had lived in Canada for the previous 11 years. She reported a long history of manual labour and subsisted on similar occupations since arriving in Canada. At the time of her presentation, her occupation required prolonged periods of standing. The patient's chief complaint was chronic low back pain. There was no antecedent trauma, bone surgery, or history of cancer. The onset of low back pain was described as insidious, with constant achy pain of at least two years duration which was progressively worsening. The pain remained localised to the central lower back in the area of the lumbosacral junction. The pain was rated at 3/10 (verbal scoring) at its best and 8/10 (verbal scoring) at its worst. An increase in pain was associated with an increased level of physical activity during the day, with the pain typically worse in the evening. During periods of increased pain, there were intermittent incidences of pain radiating to the right-sided posterior thigh and leg with "pins and needles" in the lateral toes of the right foot. Treatment to date had consisted of non-steroidal anti-inflammatory medication, which she felt had been of limited benefit. There had been no use of acupuncture, massage therapy, therapeutic exercise, or any manual therapies for this condition. The patient was referred to the department of Medical Imaging for evaluation of chronic lower back pain.
The patient reported that no spinal imaging had been performed in investigation of these complaints. This was confirmed by a review of the patient's records.
Imaging specialists typically do not examine patients who are referred into an imaging department for investigation. As such, no physical examination was performed in this case. Permission was granted after the images were interpreted only to interview the patient for this case report.
A three-phase bone scan was performed with 99 mTc(Technetium)-MDP (methylene diphosphonate) including blo

[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 second patient is a 72-year-old woman with a past medical history including hypertension, type II diabetes, and obesity, who presented with weight loss and steatorrhea. As her symptoms were suggestive of pancreatic exocrine insufficiency, and with the associated weight loss, she underwent a CT scan for additional evaluation. This demonstrated a suspicious 2.5-cm complex cystic pancreatic head mass with associated pancreatic gland atrophy and a dilated pancreatic duct. She was also noted to have fatty infiltration of the liver (although not overt cirrhosis) and ascites.
She was then referred for further evaluation. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography demonstrated diffuse dilation of the pancreatic duct up to 7.5 mm with an associated cystic mass in the head of the pancreas, suggestive of main duct IPMN (). EUS was attempted, but was unable to be completed due to severe tortuosity of her esophagus. Positron emission tomography (PET) demonstrated heterogeneous metabolic activity within the pancreatic uncinate process and to a lesser degree within the body and tail. Additional workup included a paracentesis to evaluate the ascites, which was unremarkable and ultimately deemed secondary to poor nutritional status from her exocrine insufficiency. Laboratory results were within normal limits with the exception of tumor markers and a mildly low albumin (3.4 gm/dL). Carcinoembryonic antigen was elevated at 6.0 ng/mL, and CA 19-9 was elevated at 46.7 U/mL. She was placed on pancrelipase, which resolved her symptoms of exocrine insufficiency and helped improve her nutrition.
Due to the concern for main duct IPMN, she was referred for surgical resection. Again, it was unclear if the diffuse dilation of the pancreatic duct was secondary to involvement by main duct IPMN or due to proximal pancreatic duct obstruction. The patient was planned for a Whipple procedure with possible total pancreatectomy if high-grade dysplasia was noted

[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 2: A 20 year-old male was admitted to our hospital on 15th February 2005 with a history of intravenous injection of mercury taken by him and his friend as an aphrodisiac. The patient presented with fever, tachycardia, and swelling of the right hand (which was the primary site of injection) extending up to the forearm [Figures –]. The patient was haemodynamically stable. An attempt had been made for incision and drainage in the emergency room because it was diagnosed as a injection abscess. An X-ray of the hand revealed a radio-opaque shadow overlying the fourth metacarpal, third and fourth intermetacarpal space extending over the carpus, and the wrist joint up to about 1 cm over the distal end of the radius and ulna dorsal to the skeleton. A diagnosis of extravasation of injected mercury was made. After basic investigations, the patient was shifted to the operation theatre where a thorough debridement was performed under general anaesthesia and a large amount of mercury was removed physically from the dorsum of the hand. Some of the mercury could only be removed along with excision of the surrounding soft tissue; the removal of mercury was confirmed by radiography. The wound was left open so that any mercury left behind could find a passage to come out. On the following day, the patient went home against medical advice but came back on the 7th of March with a history of another subcutaneous injection of elemental mercury over the precordium. Once again, an attempt had been made to drain an abscess in another hospital. The patient refused any further surgical procedures although the radiograph showed the deposition of mercury in the subcutaneous plane in the chest wall. The patient turned up in October 2005, with a swelling over the precordium with surrounding inflammation []. This time, he was willing for surgery and the mercury was removed along with surrounding tissue en masse and the wound healed uneventfully.
On both occasions, the patient was not willing t

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man presented with dyspnea on exertion and leg swelling for four months. He had undergone surgical repair of ruptured right SVA by direct closure at age of 19, and remained asymptomatic after the operation. On physical examination, a grade 3/6 continuous murmur was heard at his right lower sternal border, with increasing intensity while he was leaning forward. Electrocardiogram (ECG) showed atrial flutter with 2:1 atrioventricular conduction (ventricular rate around 100 beats per minute) and complete right bundle branch block. Chest X ray revealed enlargement of right atrium and ventricle, but no pulmonary congestion. Transthoracic echocardiography revealed bicuspid aortic valve and a large cystic structure protruding from right sinus of Valsalva to the right atrium. The wall of the cystic structure was relatively thick and hyperechoic, which was distinct from the congenital form of SVA (Figure a, b). Color duplex showed a continuous shunt from the aorta to the right atrium through a small defect at the posterior aspect of the aneurysm (Figure c, d, e and Additional file : Movie 1). Gradual bulging of the previous patch sutured at the SVA 38 years ago with recurrent rupture was impressed. Multidetector computed tomography also demonstrated a large SVA with a defect connecting to a dilated right atrium (Figure ).Surgical exploration from both right atrial side and aortic side confirmed the communication between SVA and the right atrium (Figures and ). The defect was located at a weak point of suture between the previous patch and the sinus of Valsalva. Double patch method was performed with bovine pericardium patches. From the aortic side a patch was sutured from the aortic annulus to the inferior rim of the right coronary artery; and from the right atrial side the redundant sac of the SVA was resected and the defect was repaired with another patch. The patient was discharged uneventfully two weeks after surgery.

[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 23-year-old female patient reported to the Department of Oral Medicine and Radiology, with a chief complaint of a swelling in the right side of the lower jaw, of six months duration. History revealed that the swelling had gradually increased in size since its onset. The swelling was not associated with pain, discharge or paraesthesia. The patient had noticed mobility of her lower right back teeth since 15 days.
On extra oral examination, a solitary, diffuse swelling was evident on the right mandibular body that was roughly oval; measuring 2.5 cm × 2 cm, and the surface appeared smooth. The skin was intact with no secondary changes. The swelling was nontender and hard.
Intraoral examination revealed a diffuse swelling in the mandibular right buccal vestibule, extending from the canine up to the first molar, measuring 2.5 × 1 cm in size. [] The surface appeared smooth and the surrounding area normal. Lingual displacement of the first and second premolars was evident. On palpation, bicortical expansion was evident with an area of decortication at the region of the first molar on the buccal side. The swelling was hard except at the region of decortication. Grade II mobility of the premolars and first molar was evident. Aspiration of the lesion yielded scanty amount of frank blood.
The differential diagnosis for the lesion included odontogenic keratocyst, ameloblastoma, pindborg tumor, and nonodontogenic lesions such as central hemangioma, and central giant cell granuloma, as well as central malignancy such as an osteosarcoma.
Intra oral periapical radiograph showed a well-defined radiolucency extending from the distal margin of the first premolar root up to the mesial margin of the mesial root of first molar tooth, having a uniform internal density, with a sclerotic lining in the superior aspect. External root resorption and displacement of the first and second premolars and the first molar teeth was appreciated. Cross sectional occlusal radiograph showed bicortical e

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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 49-year-old female had a history of fever and repeated vomiting for 3 days followed by numbness of hands and feet at the time she admitted to the hospital and positive PCR of nasopharyngeal swabs and bilateral GGO of CT chest were recorded; 1 day later, the patient developed rapid progressive symmetrical weakness of both lower and upper limbs, proximal more than distal, and within 2 days, she became bedridden (rapidly evolving). On examination, the patient was fully conscious, with intact cranial nerves. Motor examination showed hypotonia of both upper and lower limbs, reduced muscle strength (MRC grades were 3 for proximal and 4a for distal muscles of both upper limbs; 0 for proximal and 1 for distal muscles of both lower limbs), with four limbs. Sensory examination revealed a glove and stocking hypoesthesia. Three days after admission, the patient developed deviation of the angle of the mouth to the right side and was unable to close her left eye, dysphagia, hoarseness of voice, and an impaired cough reflex. On examination, there was a left lower motor neuron facial palsy and true bulbar palsy with reduced gag reflex. The EGRIS was 5 and the MRC sum score was 24. Details of laboratory findings are in . ABG showed low PaCO2. Otherwise, PT, PC, INR, liver, and renal functions were normal. All electrolytes were normal (Na+, K+, and Ca2+).
A neurophysiological study provided evidence of a mixed axonal and demyelinating variant of GBS. Detailed data are given in .
Ten days after admission, the patient received the first session of plasmapheresis, during which she showed a hypersensitivity reaction with respiratory failure. She was admitted to the ICU with an oxygen mask and 40% ventilation. Nasopharyngeal swabs were repeated three times on a weekly basis (firstly at admission) and were positive for COVID-19; the fourth swab was negative. Four weeks later, the patient received 5 days of

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old woman presented to our hospital with low back pain. Trauma history was vague except for falling 40 cm from a bed a month earlier. She had a past history of eosinophilic granulomatosis with polyangiitis and was treated with prednisolone (40 mg/day) 3 months before presenting at our hospital. Her bone mineral density in the hip had a T-score of −4.7, and bisphosphonate and vitamin D were initiated to treat osteoporosis. She underwent computed tomography (CT) and was diagnosed as having a left vertical sacral fracture and treated conservatively. Three weeks after her initial diagnosis of sacral fracture, her low back pain worsened and she started to have radiating left posterior thigh pain with symptoms of stress urinary incontinence, constipation, and loss of anal sensation.
On examination, she had weakness of dorsiflexion of her left ankle and flexion of both great toes, in which the muscular power was grade 3/5 and 4/5, respectively, as measured with manual muscle testing (MMT). Sensation to pinprick on her S2 receptive field was impaired. Lumbosacral magnetic resonance imaging using a short inversion time inversion recovery (STIR) sequence revealed an H-shaped fracture in the sacrum, but there were no abnormal findings such as spinal stenosis in her lumbar spine potentially explaining for her neurological symptoms (). Repeated CT demonstrated slightly aggravated displacement of the sacral fracture compared with previous CT ().
We consulted a urologist, and the patient was diagnosed as having stress incontinence because of poor function of pelvic floor muscles or the sphincter. However, we speculate that both the weakness of dorsiflexion of the ankle and great toes and loss of anal sensation could be attributed to SIF and recommended that she undergo surgery. She underwent lumbopelvic fixation from L3 to the ilium using a minimally invasive technique with a percutaneous pedicle screw system () []. Her radiating leg pain, motor weakness in her ankles, a

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


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

[User]
RADIOLOGY NOTE:
A 92-year-old man with osteoarthritis and a remote history of right total hip replacement and bilateral total knee replacements presented with a two-day history of severe right hip pain accompanied by nausea, chills, and fatigue. He was unable to bear weight due to pain, and range of motion in his right hip was severely limited. He denied recent trauma or pain in other joints but had undergone routine dental cleaning one week prior to presentation. He had received 2 gm of amoxicillin immediately prior to his dental procedure. He presented afebrile, mildly hypotensive, and was noted to have exquisite tenderness with passive movement of the right leg and reduced range of motion secondary to pain. He had full range of motion and strength distally. He had a leukocytosis of 15,600 WBC per milliliter. Aspiration of right hip joint revealed cloudy fluid with WBC 68,000 cells per milliliter. The patient was resuscitated with IV fluids and started on vancomycin and piperacillin-tazobactam. On the third hospital day, he underwent prosthetic joint drainage and washout with retention of liners. Joint aspirate culture grew Gram-positive cocci in chains, which we subsequently identified by matrix-assisted desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) as S. salivarius. We narrowed antibiotic therapy to ceftriaxone to complete six total weeks of intravenous therapy, after which he was treated with amoxicillin for additional six weeks. At this point, the patient discontinued his oral antibiotics rather than complete a full three months of oral therapy or remain on long-term suppression.
Five months after completion of the above therapy, the patient presented to the ED with hip and back pain following a mechanical fall at home. He was found to have a fracture of L4 and was admitted. On hospital day 5, he was found to have an occult superior dislocation of the R femoral head on CT and an ESR of 71 and CRP of 12.3. He was

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


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

[User]
RADIOLOGY NOTE:
The case is based on a 17-year-old boy with neck pain that had lasted for more than 1 month, with numbness in both upper extremities that started 1 week earlier. He complained that symptoms were aggravated after playing computer games for a longer time than normal. This was accompanied by slight dizziness, nausea, diplopia, paresthesia, and an unsteady gait in supplementary inquiries. In addition, his gastroscopic examination showed gastric ulcer and bile regurgitation in previous medical records. The positive signs of vigilance revealed a stiff neck, limited abduction of left eye, and a positive Romberg test in the patient's physical examination with no other abnormal symptoms.
A plain film radiograph of cervical vertebrae revealed nonspecific curve and intervertebral space and foramen. In consideration of medical history and alerted signs, the patient was immediately arranged for a craniocerebral magnetic resonance imaging (MRI) examination on the second day of admission. MRI showed huge CPA tumor that extended to the front medulla oblongata (Fig. A–C). The patient was referred for neurosurgical intervention. In surgery, the tumor was presented in the lower left CPA and left side of the medulla oblongata. There was ample blood supply and it had a mass size of 3 × 4 × 3 cm3. The fourth ventricle and left foramen of Luschka were compressed by the tumor that was adhesive to the lower cranial nerves and closely adjacent to accessory nerve and the anterior inferior cerebellar artery (AICA). The large neoplasm was subtotally resected and the tissue adhesive to brain stem was not forcibly removed (Fig. E,F). The pathological diagnosis was CPP (CPP, WHO I) (Fig. D). The clinical symptoms of the patient gradually alleviated after surgery and subsequent radiotherapy treatment. Unfortunately, in a follow-up 2 years later, the tumor was recurrent. Considering his overall health and tumor condition, the young man could not receive another intracranial surgery nor was he able

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old man with no history of eye surgery underwent 25G+ pars plana vitrectomy for proliferative diabetic retinopathy. After retrobulbar anesthesia, a vision system was used to view the surgical field, and an inferotemporal sclerotomy was created using a 25G+ trocar. The trocar obliquely punctured the bulbar conjunctiva and sclera at an angle of 45° (sclerotomy), approximately 4 mm from the limbus and parallel to it. The trocar was twisted into the eyeball, and its orientation was gradually changed perpendicular to the limbus. After confirming that the cannula was inside the eye, we pulled out the trocar and inserted an infusion cannula into the port. Two more sclerotomies were created in the superotemporal and superonasal quadrants. However, when we pulled out the superonasal trocar, the collar of the cannula fell off and the cannula tube was missing (Fig. a). Therefore, a bulbar conjunctival incision was placed to search for the missing cannula. No cannula was found in the subconjunctival space. We used a scleral depressor to look for the missing cannula tube along the peripheral retina and found the broken cannula tip in the ciliary body corresponding to the superonasal sclerotomy site. We created a new sclerotomy 2 mm above the original incision and 4 mm from the limbus and subsequently performed vitrectomy around the broken cannula to mobilize it for extraction. The new scleral incision was extended to 3 mm parallel to the limbus and allowed entry of a foreign body forceps (Fig. b). The broken tip of the cannula was brought into view by indenting the sclera adjacent to the original sclerotomy. We used the foreign body forceps to clamp and pull the fractured cannula toward the central vitreous body (Fig. c). With the help of the light probe, the longitudinal length of the cannula was aligned with the foreign body forceps and retrieved through the enlarged incision (Fig. d).

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old woman was admitted to our endocrine department with a diagnosis of Cushing’s syndrome (CS) presumably caused by a cortisol-secreting adrenal carcinoma with pulmonary metastases. The patient reported a progressive course of central obesity, moon-shaped face, muscle atrophy and weakness, asthenia and emotional disturbance over the last six years. During this period she had developed arterial hypertension, which was poorly controlled despite five antihypertensive drugs. Five years ago abdominal magnetic resonance (MR) imaging had been performed in the local hospital for further evaluation of a suspected liver hemangioma, and revealed an incidental finding of a 2.5 cm lesion in the right adrenal. No endocrinological evaluation was performed. Three years before admission she underwent abdominal computed tomography (CT) imaging for evaluation of recurrent hypertensive crises. No change of the adrenal tumor size was found. Screening for pheochromocytoma and primary hyperaldosteronism was negative. In the weeks before presentation at our department the patient complained of polyuria and exertional dyspnoe. The family physician diagnosed diabetes mellitus, which was treated with dietary measures. Furthermore, abdominal CT imaging was repeated, which showed an increase of the adrenal tumor size to 3.3 cm. The patient was subsequently admitted to the local hospital for further endocrinological investigation.
Laboratory tests performed at the local hospital showed failure to suppress cortisol levels after 1 mg dexamethasone and elevated 24-hour urine cortisol secretion. Plasma adrenocorticotropin (ACTH) levels were suppressed indicating an adrenal origin of the hypercortisolism (Table ). A pulmonary nodule was suspected in the abdominal CT imaging and an additional chest CT revealed multiple bilateral pulmonary nodules which were not described in a CT imaging of the chest performed 5 years earlier. A fluorodeoxyglucose positron emission tomography (FDG-PET) was pe

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


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

[User]
RADIOLOGY NOTE:
In May 2016, a 67-year-old woman came primarily to our hospital for a consultation about painless mass of the left lower gingiva. Intra-oral examination showed a 46 × 25-mm tumor with induration on the left lower gingiva (Fig. ). A submucosal mass, independent of the gingival tumor, was palpable in the left buccal region. Several cervical lymph nodes on the left side were also palpable. Pathological examination of a biopsy sample taken from the gingival tumor revealed a well-differentiated squamous cell carcinoma.
A computed tomography (CT) scan with contrast showed a large gingival tumor, with destruction of the adjacent mandibular bone, and four metastatic left-cervical lymph nodes that were markedly enlarged, non-homogeneously enhanced, and partially necrotic. These lymph nodes included two left submandibular and two left upper jugular nodes. CT imaging showed no metastases to the lungs. Magnetic resonance imaging (MRI) showed a large primary tumor on the left side, with its epicenter located in the lower gingiva. The tumor appeared to extend into the sublingual space medially and into the buccinator muscle laterally. A non-homogeneously enhanced mass was identified in the buccinator space along the facial vessels, anterior to the anterior edge of the masseter muscle, and lateral to the buccinator muscle (Fig. ). This mass lay on the cranial side of the primary tumor. The mandibular ramus and pterygoid region that are on the cranial side of BN were not invaded by primary tumor (Fig. ). Moreover, T1-weighted MRI showed a thin layer with high signal, indicative of fatty tissue, between this mass and the primary tumor, indicating that the mass was independent of the primary tumor. Based on its anatomic location, the mass appeared to be metastatic disease to BN. Greyscale sonogram showed some metastatic cervical lymph nodes on the left, and metastatic BN. These cervical lymph nodes were markedly enlarged, round in shape, heterogenous hypoechoic, and without

[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 previously healthy 35-year-old African American male presented with a one-month history of worsening lower back and bilateral lower extremity pain, intermittent night sweats, and 32 kg unintentional weight loss over the course of a year. He did not have saddle anesthesia or urinary or fecal incontinence. He was initially seen in a primary care clinic and was diagnosed with sciatica. As symptoms continued to worsen, he underwent a computed tomography (CT) scan of the lumbar scan as an outpatient that was concerning osseous spinal metastasis. He was started on prednisone 10 mg daily and was referred to the oncology clinic at our center. Prednisone gave him minimal symptomatic relief. While waiting to be seen in the oncology clinic, the patient had an episode of leg weakness with near-fall prompting him to present to the emergency department of our hospital and was admitted for further evaluation. His vital signs were stable. He had no palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Neurological exam was normal with intact strength and sensation in both lower extremities.
His complete blood count and serum electrolytes were normal including a normal serum calcium level at 8.1 mg/dL. He tested negative for human immunodeficiency virus 1 and 2 antibodies. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine showed several enhancing lesions in T11, T12, L3, L4 vertebral bodies, right sacrum, and ilium that were concerning metastatic disease. There was effacement of the right lateral recess and right neural foramen at the L3-L4 and effacement of the left lateral recess and left neural foramen at the L4-L5 due to tumor retropulsion (Figures –). In addition, a small epidural tumor was noted at the T5 vertebral level without significant spinal canal stenosis or cord compression. Imaging was also concerning osseous metastasis involving the sternum and multiple ribs. Incidentally, narrowing of the neural foramen at

[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 man presented to the emergency department with a 1-month history of intermittent nausea, chills, and jaundice. Preoperative laboratories revealed an elevated total bilirubin and alkaline phosphatase. Serum tumor marker analysis revealed a normal carcinoembryonic antigen (CEA) but an elevated CA 19-9. The patient underwent a magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography that revealed thickening of the proximal common bile duct with proximal biliary dilatation and an absence of distant disease. Incidentally noted on the MRI was that the third portion of the duodenum did not cross to the left of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), and the majority of the small intestine lies in the patient's right abdomen, whereas the large intestine lies in the left. Also, the SMA lies to the right of the SMV consistent with gastrointestinal malrotation (). The patient underwent endoscopic retrograde cholangiography with biliary endoprosthesis placement for decompression. Upon surgical exploration, a mass was identified in the proximal common bile duct (with no evidence of disseminated disease) and gastrointestinal malrotation was confirmed. Oncological resection of the extrahepatic biliary tree was performed from the level of the bifurcation of the right and left hepatic ducts to the intrapancreatic portion of the bile duct, along with a portal lymphadenectomy. A biliary enteric reconstruction was created with a Roux-en-Y hepaticojejunostomy. To compensate for the malrotation, the proximal jejunum was divided 50 cm distal to where the duodenum exited the retroperitoneum and the 50 cm Roux limb was brought up in a right paracolic position rather easily, as the hepatic flexure of the colon was absent, such that it simply rested over the top of the duodenum. An end-to-side hepaticojejunostomy was formed in a single layer, and the Roux limb was tacked down to the retroperitoneum to prevent intestinal hernia

[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 nine-year-old female was referred to our department for a mass arising in the left hard palate () that had been reportedly growing for the past several weeks and was associated with discomfort with mastication and teeth brushing, as well as minor bleeding. Examination showed an ulcerated firm mass of the left hard palate. The ulcer was not opposing the inferior dentition. CT scan showed a 2.2 × 1.3 × 2.6 cm heterogeneously enhancing expansile mass of the left lateral hard palate with bone destruction, extending into the alveolar recess and maxillary antrum. There was no evidence of orbital extension ().
A first biopsy was performed at an outside center and reviewed at out institution. The biopsy consisted of a small fragment of ulcerated squamous mucosa with a submucosal bland spindle cell proliferation. Due to the limited biopsy and lack of material to perform further immunohistochemical analysis, it was not possible to establish the nature of the tumor. Consequently, an open biopsy was performed and showed that the spindle cells were characterized by elongated cigar-shaped nuclei, eosinophilic cytoplasm with indistinct borders, and a storiform to fascicular growth pattern. Significant nuclear pleomorphism, increased mitotic activity, and necrosis were absent. The spindle cells showed variable immunoreactivity for muscle specific and smooth muscle actin and had a low Ki67 proliferation index (<5%); they were negative for desmin, S100 protein, cytokeratin (AE1/AE3), and nuclear beta-catenin. The overall findings supported the diagnosis of a myofibroma.
The patient was brought back to the operating room for resection which involved a left partial maxillectomy and reconstruction with a buccal advancement flap (Figures and ). The tumor was macroscopically completely resected despite a positive deep margin. The bone of the remaining tumor bed was drilled over the entire surface, which ensured elimination of the microscopically positive deep margin. Postoperatively, th

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old female patient reported severe dyspnea and showed tachypnea. She was diagnosed as a pulmonary thromboembolism and immediate anticoagulation with warfarin was started. In the morning two days after anticoagulation, she felt heaviness in both legs and progressive paraparesis. A neurologist evaluated her and requested a lumbosacral magnetic resonance imaging (MRI) of the lumbar spine. While waiting for the MRI, her paraparesis progressively increased and ascended; eventually she became quadriplegic and respiratory distress developed. After checking whole spine MRI, an emergent endotracheal intubation was performed and neurosurgical consultation was taken. On examination, she was alert and no focal cranial nerve sign was observed. However, grade 0 quadriplegia was noticed and tendon reflex was not elicited. An acute epidural hematoma was noted on the high cervical cord (). After informed consent, an emergent decompression of the cervical cord was performed. Unfortunately, her quadriplegia did not improve after surgery. Moreover, self-respiration was not elicited. Thereafter, she was maintained with artificial ventilation during the following three months in the intensive care unit. During the follow-up, no spontaneous, voluntary respiration was observed and the MRI checked at postoperative 3 months showed a myelomalacia at the C2 level suggesting high cervical cord injury (). A standard apnea test did not elicit voluntary respiratory effort. After 3 months of artificial ventilation, we decided to perform a trial of diaphragm pacing, and informed consent was taken. An electromyographic examination of the diaphragm was performed for the verification of contraction of the diaphragm.
A stimulation lead implantation was performed in right neck under general anesthesia with the head rotated to the left side. Muscle relaxant was not used to monitor intraoperative contraction of the diaphragm. A linear horizontal skin incision about 4 cm was made at 4 cm rostral t

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