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

[User]
RADIOLOGY NOTE:
A 38-year-old woman, gravida 5 para 4 presented at 32 weeks pregnancy. She first presented to her primary general practitioner with a small vulvar lesion that she had first noticed one year prior. The lesion was suspected to be benign Bartholin’s cyst and treated with broad-spectrum antibiotics. The patient noticed no improvement and had many other consultations with different clinics when she was advised to the same diagnosis and treatment. Initially, the swelling was constant in size, however, it started to enlarge rapidly. A significant increase in size was noticed during pregnancy and causing a restless feeling. The patient was thus referred to our hospital. She had no significant gynecological past history, prior gynecological malignancies, or condyloma acuminatum. Her pregnancy course was uneventful. The medical, surgical, and family histories were noncontributory. No medications had been taken before or during the pregnancy.
Physical examination revealed a healthy woman with normal vital signs. Abdominal examination reveals a gravid abdomen with a fetus of appropriate size for the gestational age in cephalic presentation. Pelvic examination revealed a vulvar mass at the left side involving left labia majora and minora. The mass was painless, rounded, firm in consistency, freely mobile with an intact overlying skin measuring 15.0 x 10.0 cm diameter (Figure ).
No palpable lymph node was detected. Pelvic Magnetic Resonance Imaging (MRI) with heterogeneous signal intensity on T2-weighted images showed a solid mass with no cystic signal intensity measuring 4.8 x 7.2 x 10 cm. The radiological impression was labial leiomyoma.
At 34 weeks of pregnancy, the patient was admitted for tumor resection. A baseline fetal cardiotocography and obstetrics ultrasound were normal. Under spinal analgesia, the tumor was completely resected with minimal blood loss (Figures , ). No frozen section samples were taken. The patient and her fetus tolerated the procedure well. The histopa

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.
The patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male not known to have any chronic medical illness, presented complaining of epigastric and left upper quadrant pain for 1 month, associated with intermittent nausea and vomiting, and aggravated by fatty meals, with no other associated symptoms. He had frequent visits to the emergency department where he was managed with analgesia and antacids with mild symptomatic improvement. Clinical examination was unremarkable with no evidence of jaundice or abdominal tenderness. His blood test results showed a normal complete blood count, kidney function, and liver function. Chest X Ray revealed dextrocardia with stomach fundic gas shadow on Right side (). Abdominal ultrasonography revealed transpositioning of the solid organs with a left sided liver and gallbladder with a solitary stone and mild wall thickening. We elected to perform a Magnetic Resonance Cholangiopancreatography to delineate the anatomy and to rule out any anomalies within the biliary tree. It confirmed the previously noted findings, showed no evident anomaly within the biliary tree, and confirmed the diagnosis of situs inversus totalis (, ). The patient was Scheduled for an elective laparoscopic cholecystectomy.
The Operating room equipment arrangement was adjusted as Mirror Image of Routine Laparoscopic cholecystectomy (). The Monitor was placed on left side of the patient. The surgeon with the camera assistant were on right side of the patient and the first assistant was on left side of the patient. The abdomen was scrubbed and draped in the standard aseptic technique. The first infraumbilical 11 mm trocar introduced and pneumoperitoneum induced using the open technique. Three 5 mm trocars were placed, at the xiphisternum which was used for the surgeon’s left hand, at the left midclavicular line 2 cm below the costal margin which was used as working port for the surgeon’s right hand and at left anterior axillary line 5 cm from the costal margin which was used for retraction of the

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


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

[User]
RADIOLOGY NOTE:
The patient is a 4-year-old boy, weighing 17.5 kg, with no relevant medical or surgical history and no documented allergy or medication intake, scheduled for circumcision. His preoperative vital signs were a heart rate 98 beats/min, blood pressure 100/56 mmHg, temperature 36.6°C, and a respiratory rate of 20/min. Chest was clear to auscultation and no cardiac murmur was identified. The anesthetic plan was explained to the parents and included general anesthesia and a penile block for postoperative pain management.
Anesthesia was induced in the presence of the parents with oxygen/nitrous oxide and sevoflurane administered through a face mask, with the patient breathing spontaneously. Propofol 40 mg and fentanyl 25 μg were administered after intravenous access. Anesthesia was maintained with sevoflurane at an end tidal concentration of 3.5% in a 1 L equal mixture of oxygen and air after securing the airway. The heart rate was noticed to be in the range of 80 beats/min, dropping to 60 beats/min. Ringer's lactate solution was administered at 10 mL/kg/h. A close observation of the electrocardiogram (ECG) tracing revealed a complete dissociation of P wave and QRS complex []. Blood pressure was normal and the patient was normothermic. The surgeon was notified, and resuscitation equipment was brought to the room. A trial of switching from sevoflurane to desflurane did not produce any change in the heart rate and was equally tolerated by the patient. Inhalation agents were discontinued and propofol infusion started at 300 μg/kg/min for the remaining 25 min of the procedure. There was no change in hemodynamics or in the ECG tracing. Atropine 250 μg was administered intravenously for a heart rate below 60 beats/min with a transient effect of increasing the heart rate to 80 beats/min. A penile block, with 10 mL of 0.25% bupivacaine was performed at the end of surgery. The patient was transferred awake to the recovery room

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


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

[User]
RADIOLOGY NOTE:
Patient 1 was a 69 year old Caucasian male with a BMI of 17.7 and a history of GERD, asthma, hypertension, emphysema, recurrent SBO and bilateral inguinal hernias. His surgical history included SBO surgery at birth, childhood appendectomy, 3 laparoscopically repaired hernias from 2008–2010 with a surgical mesh inserted, Nissen fundoplication and partial thyroidectomy in 2010, laparotomy for SBO secondary to extensive adhesions in July 2010 and January 2011. Immediately after surgery in 2011, Patient 1 underwent a small bowel radiographic series that showed an incomplete SBO at the junction of the proximal mid ileum, and dilation throughout the small bowel, likely due to adhesions per the radiologist (A). He was still experiencing symptoms of SBO (bloating, nausea, inability to eat normally) three months following the 2011 laparotomy, and reported a significant impact on his quality of life, focused on the changes to his diet that occurred after the SBO. He also reported abdominal tightness and significant intermittent pain (10/10 on a pain scale).
Patient 1 received no further medical interventions after his 2011 radiography prior to receiving this manual physical therapy treatment. Upon initial physical therapy evaluation, he presented with pain; visible scarring superficial to tissues that felt like deep palpable adhesions (consistent with his physician’s 2011 diagnosis of abdominal scarring), decreased visceral mobility (decreased ability for organs to glide normally), and tightness throughout the abdomen; myofascial, osseous and visceral hypomobility; and decreased quality of life due to SBO. He also presented with decreased strength and range of motion in both hips and trunk, and in his cervical, thoracic, and lumbar spine at the initiation of his physical therapy regimen.
In 2011, Patient 1 underwent 20 h of intensive manual physical therapy over the course of five days with a focus on improving range of motion, and decreasing scar tissue, adhesions, and soft

[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 healthy 21-year-old man was admitted to our hospital after being referred from another medical institution because of worsening left eye (LE) uveitis. He was treated 3 weeks earlier with oral acyclovir and topical steroids because of suspected LE herpetic anterior uveitis as serological tests revealed positive immunoglobulin M to herpes simplex virus-1. Initially he responded to treatment but 2 weeks later, his vision declined from 6/9 to counting fingers (CF), resulting in his referral to our center.
The patient denied any relevant past medical history. However, he mentioned that a month earlier he was examined for LE discomfort and diagnosed with allergic conjunctivitis following minor blunt trauma from a tree branch.
On examination, visual acuity (VA) was 6/6 in the right eye (RE) and CF at 1 meter in the LE. Intraocular pressure was 14 mmHg in both eyes. RE anterior and posterior segments were normal. There was a remarkable LE anterior chamber reaction with dust-like keratic precipitates, cells (4+), flare (2+), and some iris nodules. Fundus assessment was not possible because of dense vitritis. B-scan and high-frequency ultrasound did not reveal any intraocular foreign body. Aqueous tap was performed and the sample was sent for culture and polymerase chain reaction analysis. It was negative for all herpes viruses and for 16S rDNA. Meanwhile, with oral steroids and valacyclovir, the patient showed signs of improvement and LE VA improved to 6/15. Despite the remarkable improvement, it was insufficient as the patient continued to have marked anterior uveitis and vitritis. A white shadow was noted in the peripheral temporal retina of the LE which again could not be assessed properly due to vitreous opacities (). The patient eventually underwent pars plana vitrectomy and laser retinopexy was performed around the white peripheral temporal lesion, which was later believed to be the site of penetrating injury by a thorn on the tree branch from the previous trauma des

[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 26-year-old Saudi man presented with a six-month duration of right cheek swelling and left upper eyelid swelling. Physical examination revealed right cheek erythematous mass of size 3 × 3 cm and a similar erythematous mass over left upper eyelid of size 1 × 2 cm (); however, clinical examination revealed no lymphadenopathy or any visceromegaly. Hematology, electrolytes, serology for Lyme disease, systemic lupus erythematous, thyroid function tests, blood cultures for mycobacteria, and angiotensin-converting enzyme were all within normal limits.
Incisional biopsy from left eyelid mass and excisional biopsy from right cheek mass were taken, which showed a nodular inflammatory infiltrate within the dermis consisting of histiocytes with plasma cells and lymphocytes aggregates. Large histiocytes were found with vesicular nuclei and emperipolesis. Immunohistochemistry demonstrated the positivity for S-100, CD68, and CD45 and negativity for CD1a, which confirmed the diagnosis of extra-nodal RDD (). Patient was started on oral prednisone 30 mg per day for 3 weeks and then tapered over the subsequent 2 weeks, which showed a minimal response of left eyelid mass.
After discussing the case in multidisciplinary meeting, patient was given 30 Gy in 15 fractions radiation therapy with 6 MV photons to left eyelid mass (). Magnetic resonance imaging (MRI) of head and neck showed more than 90% of reduction in size of eyelid lesion. After 3 months of radiation therapy, MRI of head and neck revealed the reappearance of masses in left eyelid and right cheek (). Patient was started on Rituximab, cyclophosphamide, vincristine, and prednisolone (RCVP) based chemotherapy 8 cycles with partial response, and he was reirradiated to left eyelid mass with 6 MeV electron 10 Gy in 10 fractions with complete response. Patient remained disease-free for one year and without any late radiation induced sequelae. After one year again, there was reappearance of right cheek mass, and at the time of repor

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male presented to us with complaints of painful swelling of his right knee joint with inability to bear weight. He had undergone surgery (done elsewhere) for GCT of lateral condyle of femur 22 months ago in the form of curettage and bone grafting from iliac crest (: Pre-operative and : 3-month post-operative radiograph). The patient did not relieve his pain in knee joint (which he had before surgery) throughout the course of the treatment. He consulted the primary surgeon for the same and advised active range of motion exercises. The pain kept on increasing, especially in last 6 months, and on examination, he had tenderness over lateral and posterior aspect of knee joint with diffuse swelling and limited range of motion (10—°) when presented to us. Investigation in the form of radiograph () depicted diffuse osteolysis and cortical destruction in lateral femoral condyle. Magnetic resonance imagingMRI of the lesion illustrated the heterogeneous decreased signals on T1 sequences and areas of hyperintensities on T2 sequences with overall picture suggestive of recurrence ( and ). Complete surgical excision of the tumor and articular surface reconstruction was planned as described by D’ Aubigne []. A 15-cm long vertical incision was made over anterolateral aspect of distal thigh and right knee and quadriceps tendon, patella and patellar tendon exposed. A 3-cm wide, musculovascular pedicle separated at inferior border of vastus lateralis muscle, approximately 10-cm proximal from lateral border of patella. Patella was then enucleated from rest of its attachments, releasing quadriceps tendon all around except the pedicle, leaving a rim of 4-mm soft tissue to spare vascular supply. Lateral condyle of femur was exposed and excised en bloc with whole tumor mass with the help of saw and osteotome. The deep articular surface and medial aspect of patella were freshened. The anterior surface which was to be used as articular surface was rotated inferiorly, brought 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 46-year-old asymptomatic man presented to our hospital for follow-up of an abnormal cardiac shadow found on chest X-ray during a medical check-up. He was found to have a benign tumor in the parapharyngeal space 6 years ago. The tumor had gradually grown in size and he felt pain around the back of his teeth and had difficulty in swallowing associated with mass pressing symptom; he had the tumor resected 4 months ago. On histopathology exam, the tumor was identified as a schwannoma. The patient had no medical or family history of cancer, including intradermal carcinomas. There were no abnormal findings in his eyegrounds, such as juvenile cataract, and his audiometry results were normal. Computed tomography (CT) showed three masses measuring 16 × 14 mm in the posterior mediastinum, 15 × 13 mm in the left pulmonary hilar area, and 12 × 10 mm in the right pulmonary apex area (Fig. ). The patient had undergone CT exam at another institute 6 years ago prior to the CT scan performed at our institute. Retrospective evaluation of the previous CT scan revealed that the posterior mediastinum tumor was 13 mm in size at that time. Chest magnetic resonance imaging (MRI) revealed that these masses had low intensity on T1-weighted sequences and high intensity on T2-weighted sequences. Cranial high-quality MRI showed no evidence of bilateral vestibular schwannoma. The thoracic surgeons at our institute initially diagnosed multiple mediastinal tumors.
Resection of the right apex area lesion had the associated risk of causing recurrent nerve deficit symptom; hence, removal of the two other tumors was planned initially; the posterior mediastinum tumor by right thoracotomy and the left pulmonary hilar area tumor by left thoracotomy in a single operation. During right thoracotomy, a small pericardial incision was made and they noticed the posterior mediastinal tumor to be at the cardiac chamber; surgery was suspended immediately. Following surgery, the patient underwent transesophageal

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Caucasian woman presented for evaluation after a 2-year history of left hip and knee pain. On physical examination, the left knee presented with a mild effusion, tenderness and with stiffness and decreased mobility. The hip showed a true capsular pattern of limitation and pain with internal rotation of the hip. Radiographically, the left knee showed degenerative osteophytic changes and osteophytes in all compartments of knees and mild to moderate narrowing of the joint space. In case of the left hip, radiographic evaluation showed also advanced osteoarthritic changes.
Since the physical examination and radiographic findings were compatible with the diagnosis of an end-stage hip osteoarthritis and knee osteoarthritis, the patient was first listed for a cementless total hip arthroplasty (THA) (Fig. ), followed by a cemented total knee arthroplasty (TKA) (Fig. ).
During surgical dissection it was noticed that the articular capsule and the cartilage of the femoral head were black (Figs and ). Histological sections of bone and soft tissue demonstrated classic findings of ochronosis, including multiple pigmented areas by deposition of ochre-coloured granules, reactive giant cells, hyaline cartilage degeneration and a thickened and inflamed synovium. The case was discussed intraoperatively with the Senior Surgeon: the macroscopic evaluation of bone quality seemed reasonable and the OA diagnostic was the most consensual between the team. We maintained our initial plan and finished the cementless THA.
After surgery she confirmed that was never diagnosed with alkaptonuria in her past. She was re-examined and we found black ochronotic pigmentation in sclera and ear cartilage (Fig. ), as well as dark urine. A high level of HA was also found in the urine. She was evaluated by a senior rheumatologist and progressed favourably without any complications.
Eight months later she was treated for her left end-stage knee osteoarthritis and we noticed again the presence of

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman with a past medical history of Grave’s disease presented to the hospital complaining of sudden onset of facial and bilateral arm swelling, as well as "bruising" in her neck, abdomen, and arms, all of which she developed over a few days. Further, the patient reported fatigue, neck tightness, and dyspnea on exertion. She denied any other symptoms and the remainder of the full review of systems, including weight loss, was negative. Social history was significant for 40 years of smoking. The patient was hemodynamically stable with good oxygenation on 2 L of oxygen by nasal cannula. Physical exam revealed swelling of the face, neck, and both arms, superficial varicosities on the neck, chest, back, and arms, as well as mild inspiratory stridor. Computed tomography angiography (CTA) of the thorax and neck showed a large central mediastinal mass occluding the pulmonary artery and extending into the right atrium, encasing the superior vena cava (SVC), abutting the trachea but not causing tracheal narrowing (A), as well as pulmonary emboli at the right lower lobe (B). Given the tobacco abuse history, lung cancer leading to SVC syndrome was suspected, although other malignancies such as lymphoma were in the differential. The patient was started on a heparin drip and the Pulmonary and Hematology-Oncology services were consulted, both of which agreed for the need for tissue diagnosis of the likely malignancy and rapid initiation of treatment.
A complicating factor in this patient’s care was her adamant belief that the swelling was an allergic reaction to one of the many over-the-counter herbal and homeopathic medications that she was taking to try to rid her body of the “flukes” which she claimed to have seen in her nasal secretions and stool. The patient soon moved on to express the belief that her mediastinal mass was caused by her parasites and demanded treatment for them rather than for

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


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

[User]
RADIOLOGY NOTE:
A 7-month-old girl was referred to our institution in December 2009 with a right femoral lesion, with concerns of neoplasm or osteomyelitis. Her parents noticed that she had shown a decrease in the use of her right lower extremity especially at about 3 months of life when the patient would not bear weight on her right lower extremity when held up in an upright position. The patient’s ability to sit upright was also somewhat limited because she preferred to have her right hip and knee extended. At age 7 months, her pediatrician obtained a roentgenogram that showed a lytic lesion in the right proximal femur. The past medical history was unremarkable. Clinical examination showed an afebrile infant who moved her right lower extremity much less than the left and preferred keeping her right hip and right knee extended with external rotation. There was no erythema, warmth or mass in the right lower extremity. The results of routine laboratory studies were normal.
Roentgenograms of the right femur showed an osteolytic area in the intertrochanteric region, surrounded by a sclerotic rim and lamellar periosteal reaction (Fig. ). A magnetic resonance imaging (MRI) study showed a focal, 1.1 × 0.9 × 1.2 cm, high T2 signal lesion centered in the intertrochanteric region of the proximal right femur. There was marked lamellar periosteal reaction involving the proximal right femoral metaphysis extending to the mid diaphysis, with extensive, ill-defined intra- and extraosseous edema (Fig. ). The differential diagnosis included chronic osteomyelitis with a Brodie’s abscess, eosinophilic granuloma, osteoid osteoma, and small round blue cell tumor such as Ewing sarcoma or metastatic neuroblastoma.
A CT-guided core needle biopsy of the lesion was performed. The axial CT scan at the time of biopsy showed a 1-cm lucent lesion eccentrically located within the medial aspect of the proximal femur with marked periosteal new bone formation (Fig. ). Cultures of

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old right hand dominant male presented with a chief complaint of a soft tissue mass on the volar surface of his left forearm. He first noted the mass around age 11. The mass grew slowly between the ages of 11 and 13 before stabilizing in size two years prior to presentation. Initially the mass expressed a thick whitish fluid when squeezed, but at the time of presentation the fluid was thin and the drainage minimal. The mass was not painful and he reported no paresthesias in the hand. He denied any similar masses elsewhere on the body and had no history of malignancy. There was no family history of similar masses. He did not have a history of urinary tract malformation.
On physical examination, the patient was a well-appearing 15-year-old male in no acute distress. On the volar surface of the left mid forearm, there was a 2.0 × 1.5 cm pedunculated mass with a pinpoint central sinus (Figures and ). The mass was well-circumscribed, soft, and mobile. There was no surrounding erythema or warmth. A scant amount of thin, white fluid could be expressed from the central sinus. He had normal strength and sensation in the left elbow, wrist, and hand and had a palpable radial pulse. The remainder of his physical exam was remarkable for an accessory nipple on the left chest wall along the vertical “milk line” ().
Given the prior growth and bothersome appearance, surgical excision of the mass was planned. Prior to surgery, consent for photography was obtained from both the patient and his father. An elliptical longitudinal incision was used to excise the mass and the underlying tissue. The mass was firm and well-circumscribed and had the appearance and texture of breast tissue (). The skin was closed using absorbable sutures. A soft dressing was applied and the patient recovered uneventfully.
The soft tissue specimen with an

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old unmarried woman was admitted to the Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China because of severe unresponsiveness and twitching in October 2019. Subsequent computed tomography of the skull showed low-density shadows of the left temporal lobe and bilateral frontal lobe. Magnetic resonance imaging (MRI) of the skull and intracranial blood vessels showed direct enhancement of the cranial veins and brain. Diffusion imaging of the brain showed multiple filling defects, abnormal enhancement and diffuse signals at the distal end and branch of the superior sagittal sinus, the left transverse sinus-sigmoid sinus-internal jugular vein and the right transverse sinus. The patient’s prothrombin time was 13.4 s, prothrombin activity was 77% and D-dimer was 0.88 μg/ml. The patient was considered to have CVST with brain parenchymal damage (cerebral oedema and venous infarction). Therefore, the patient underwent whole cerebral angiography via femoral artery catheterization and catheterization thrombolysis. After the operation, the patient was given comprehensive treatments, such as thrombolysis, sedation and lowering of intracranial pressure.
The patient’s bone marrow aspiration result was verified to be normal. To identify the cause of CVST in such a young woman, a thorough medical history was taken and the patient reported a history of increased menstrual flow for 6 months, increased vaginal discharge and a peculiar smell for 1 month. Prior routine examination of leucorrhoea in the local hospital showed inflammatory changes. After taking oral anti-inflammatory drugs for 1 month, the condition did not improve. Then, the patient was given an urgent examination with uterine accessory ultrasound to prompt the following question: is this condition uterine disease? MRI of the pelvic cavity demonstrated an enlarged cervix with an irregular shape. The neurologist asked the gynaecologist for two consultations

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old female patient came to the department with a blackish discoloration in the right upper front tooth region for 1 month (). Her previous dental history showed that she had undergone trauma when she was 8 years old. She suffered tooth avulsion wrt to right and left upper central incisors. Her previous records depict she was treated with rigid arch fixation and was following up for apexification procedure. However, currently patient started noticing reddish turned black discoloration in the right front tooth for the past 1 month. There was no history of pain or tenderness. On clinical examination, there was grade II mobility with discoloration at the cervical margin of 11. However, 21, appeared to be clinically stable and lacking any signs of inflammation. On radiographic examination, there appeared to be marked oval-shaped radiolucency involving radicular pulp space and coronal third as well (). Following which a diagnosis of inflammatory perforating internal resorption wrt 11 and replacement resorption wrt 21 was made. Consecutively, a treatment plan for surgical intervention wrt 11 was made.
The treatment objective was:
To halt the process of root resorption wrt 11.
To provide stability for 11 and preserve alveolar bone wrt 11 to later receive implant prosthesis.
The procedure was started by administering an infraorbital and nasopalatine nerve block along with local infiltration to provide for profound anesthesia. Now using a 15 no. BP Blade vertical incision was given on the labial aspect of the 11 and 12 region and an envelope flap was raised. The site was thoroughly irrigated with normal saline. Upon inspection, the labial cortex of the maxilla and the labial root surface of the right maxillary central incisor had undergone serve root resorption (). A 90% aqueous solution of trichloroacetic acid was applied over the resorptive lesion for 1 to 2 minutes using a cotton pellet. Following this, curettage of the resorbed cavity was done to remove any devi

[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 referred to our facility for the management of abnormal computed tomography of the chest identified during investigation for atypical chest pain. His past medical history was significant for chronic hepatitis C complicated by liver cirrhosis and hepatocellular carcinoma (HCC). He underwent chemoembolization and radiofrequency ablation of the liver as bridging therapies prior to uneventful orthotopic liver transplantation (OLT), a curative treatment for HCC. The explanted liver was cirrhotic and contained two 4.5 cm extensively necrotic lesions consistent with poorly differentiated HCC on pathological examination. There was an extensive intravascular invasion, and tumor was presented within an intracaval thrombus, which was removed during surgery. After the OLT, he was maintained on immunosuppressive therapy with tacrolimus and prednisone. Unfortunately, he was diagnosed with prostate cancer a few months later and underwent prostatectomy as curative treatment. At this time, his immunosuppressant was changed from tacrolimus to sirolimus, which had shown to delay HCC recurrence when compared to regimens that use tacrolimus in retrospective study.
Physical examination of his chest revealed normal breath sounds. Cardiovascular examination was unremarkable for abnormal heart sounds or murmurs. The rest of his physical examination was normal. Cardiac workup was negative for myocardial injury. Computed tomography of his chest images is shown in . The patient subsequently underwent endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) of right paratracheal lymph node station 4R ().
Pathological examination revealed highly cellular and clusters of large, loosely cohesive sheets of tumor with thin-walled traversing blood vessels. The tumor cells had a moderate amount of granular cytoplasm containing occasional hyaline globules. Nuclei were round to oval in shape and moderately pleomorphic, with prominent nucleoli and scattered intranuclea

[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 38-year-old North African man, with no past medical history, consulted our out-patient clinic for a painless left scrotal mass. There was no history of previous orchitis or scrotal contusion. He noted the mass a month ago. A physical examination found a 2 cm palpable mass in the upper pole of his left testis. There were no signs of scrotal inflammation. The mass had a firm consistency and regular margins. Palpation of his right testis and the lower pole of his left testis were normal. Routine blood tests were normal. As a testicular tumor was strongly suspected, a bioassay of testicular tumor markers was ordered. Alpha-fetoprotein, human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) were in the normal ranges. There was no bacterial growth in urine analysis, including Mycobacterium tuberculosis screening. A scrotal ultrasound showed a homogeneous testicular parenchyma, with a conserved vascularization on Doppler. An extratesticular mass was observed, attached to the upper pole of his testis. The mass was isoechoic to the testis parenchyma, and poorly vascularized Doppler (Fig. ).
He underwent a radical inguinal orchiectomy. We first performed a high ligation of the spermatic cord. The operative specimen included the testis and the tunica vaginalis in one piece (Fig. ). The macroscopic aspect of the supratesticular mass looks similar to splenic tissue (Fig. ). There were no macroscopic lesions of the testis and the spermatic cord. His postoperative course was uneventful. He was discharged on the second postoperative day.
Histological examination of the operative specimen confirmed the presence of regular splenic tissue in the suspect mass, without any signs of malignancy. The splenic proliferation had its proper and regular capsule, demarcating it from the testis. Testicular pulp, the albuginea and the tunica vaginalis had a preserved microscopic architecture (Fig. ). He was examined 3 weeks after orchiectomy and he was examined again 2 months after

[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 with edentulous maxilla was referred to the University Department of Oral and Maxillofacial Surgery of the “Evaggelismοs” general hospital due to a migrated implant into the right maxillary sinus. The patient suffered from chronic obstructive pulmonary disease and therefore he had quitted smoking. Five years ago he underwent dental rehabilitation with the placement of six implants in the maxilla and four in the mandible. In less than 2 months after initial placement, all implants had failed to osseointegrate. A year and a half later the patient underwent guided bone regeneration with bovine-derived xenograft and 7 months after this point, another 10 implants were inserted into both the maxilla and mandible. Two months later, all implants had once again failed to osseointegrate. During the attempt of removal by the dentist, one of the implants was displaced into the maxillary sinus, without the dentist being able to retrieve it. The patient then visited another dentist, who could not either remove the migrated implant.
Upon arrival to our clinic, a full medical and dental record was retrieved from the patient, and he was scheduled for surgical removal of the implant. Prior to operation, the patient underwent a radiographic examination with water’s X-ray (Fig. ), as well as CBCT examination (Fig. ) which confirmed implant migration and revealed its exact position inside the maxillary sinus.
Surgical procedure initiated with local anesthesia by injecting xylocaine 1% andepinephrine 1:100,000 solution in the soft tissues involving the right half of the maxilla. After a crestal incision, a full-thickness mucoperiosteal flap was raised, exposing the anterior-lateral wall of the maxilla in an area extending from canine to molar region. Using a high-speed rotary instrument under sterile saline solution irrigation, a rectangular window was created in the anterior-lateral maxillary wall. The implant was detected through the bony window and captured by a mos

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


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

[User]
RADIOLOGY NOTE:
A 6-month-old full-term female with a history of respiratory syncytial virus bronchiolitis at two weeks of age presented to our hospital via emergency medical services with the chief complaint of ALTE. As per the mother, the patient was noted to have an episode of perioral cyanosis, coughing, and increased work of breathing after being placed on her back immediately following a bottle-feed. When the mother noted these symptoms, she picked up the patient who was described as “pale” and “limp.” A bystander was able to forcefully pat the patient's back and formula was expressed from the mouth. By the time medical personnel arrived, the patient was back to her baseline behavior.
Upon further questioning, it became clear that the patient had a several month history of chronic cough, congestion, and feeding intolerance for which she had already undergone an extensive outpatient workup. This workup included testing for various immunodeficiencies, as well as a laryngoscopy by otolaryngology. Per report, these tests and the above procedure did not reveal any pathology. The mother reported that the primary care physician had seen the patient earlier in the week of presentation for increased coughing and prescribed nebulized albuterol treatments and a short course of steroids for presumed reactive airway disease. Neither intervention alleviated her symptoms. While this was the patient's first episode of cyanosis associated with cough, the mother reported a worsening of the patient's cough and shortness of breath upon lying flat and after feeding.
After admission to the floor, the team observed the patient feed which resulted in a choking-like episode and overt respiratory distress, only alleviated by positional maneuvers. Other pertinent positives on her physical exam were baseline audible breathing with occasional inspiratory stridor. Given the patient's increased symptomatology with feeding and her concerning baseline respiratory exam, she was deemed unsafe for oral feeds un

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


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

[User]
RADIOLOGY NOTE:
An 8-year-old girl presented with a 6-month history of slowly growing mass on the volar aspect of the right middle finger []. An incisional biopsy was done at a local hospital, but it was not conclusive and the specimen was not available for reexamination. Clinically, the mass was fixed to the dermis and the flexor sheath. However, there was no numbness and there was full range of motion of the finger joints. A magnetic resonance imaging showed an enhancing lesion that is adherent to the flexor sheath []. Excisional biopsy was done through a zigzag volar incision. Intraoperatively the tumor was found to have ill defined borders. It was adherent to the dermis, flexor sheath and both digital nerves. Part of the flexor sheath was resected and the tumor was shaved off from the dermis by sharp dissection. No skin excision was done and both digital nerves were preserved. The tumor size was 2 × 1.5 cm []. Postoperatively, a small area of the skin flap became necrotic and this was treated conservatively []. Histological examination showed all the classic features of EHE. The tumor consisted of numerous epithelioid cells which are arranged in clusters, trabeculae and cords in a myxoid background []. Another characteristic histological feature of this tumor is the presence of intracytoplasmic vacuoles []. The mitotic rate was 3/10 high power fields (HPF) with evidence of focal pleomorphism. The tumor cells were extended to all resection margins. A panel of immune histochemical stains was done and showed positive staining of tumor cells with CD34, CD31, and factor VIII []. Tumor cells were negative for other markers confirming the endothelial origin of the tumor. We considered the malignant potential of the tumor and the positive resection margins and we offered the patient further management in the form of wide resection of volar soft tissues and flap reconstruction. The family refused and elected for followup. The followup protocol was local examination and radiological work

[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 27-year-old male reported to the Department of Periodontics and Implantology, DJ College of Dental Sciences and Research (Uttar Pradesh) with a chief complaint of painful, bleeding swollen mass in his lower front teeth region []. Patient noticed these swelling 9 months ago in his lower jaw in front and right region, which was slowly increasing in size. Gingiva had a reddish pink appearance and bled on probing was present. Probing depth ranged from 7 mm to 9 mm with an attachment loss of 5-7 mm in the mandibular anterior teeth region. Grade 2 mobility was present around the mandibular central incisors and Grade 1 around the mandibular lateral incisors and canines and mandibular right first premolar. Patient had a poor oral hygiene and had left oral hygiene measures since 3 months due to pain while brushing. Patient had visited a physician 2 months ago and was under antibiotics, but that did not improve his condition. Patient was systemically healthy and did not report a positive drug history. After taking a detailed history, it was found that the patient used an herbal tooth powder since past 7 years. Radiographs showed a moderate amount of bone loss in the mandibular anterior region []. A blood specimen was obtained in order to rule out leukemia or other blood dyscrasias. Provisional diagnosis of the chronic generalized gingivitis with localized gingival enlargement was made.
Treatment and follow-up-initial periodontal therapy comprising of scaling and root planning and oral hygiene instructions were given. Patient was also instructed to rinse with 0.2% chlorhexidine twice daily. The patient was advised to discontinue the use of herbal toothpowder. The appearance of the gingiva improved after 10 days []. However, complete resolution of enlargement was not accomplished. Gingivectomy was performed [] and the excised mass [] was sent for biopsy. Postoperative follow-up after 3 months showed firm and resilient gingiva with no enlargement []. No

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old woman was admitted to the internal medicine ward with painful lesions on her lower left leg of recent onset. Her medical history included prosthetic aortic and mitral valves, chronic ischaemic stage 4 kidney disease, multifactorial anaemia (due to valvar leak, gastrointestinal loss and chronic kidney disease) and a recent diagnosis of oligoarthritis of unknown aetiology. She was under the care of cardiology, internal medicine and rheumatology clinicians.
The patient had been on warfarin for over a decade. She was also taking calcium carbonate supplements, receiving weekly intravenous iron supplements, and had been recently started on prednisolone 20 mg daily for the oligoarthritis.
The lesions were described as initially small violaceous nodules with diameter of 3 cm or less on the posterior side of the patient’s left leg. By the time of admission, they had progressed to typical stellate ulcers (). The initial differential diagnosis by a dermatologist was warfarin-related ulcers, vascular ulcers or calciphylaxis. Warfarin was suspended and replaced with low molecular weight heparin adjusted for renal function. A first skin biopsy was inconclusive.
Within 5 days the small nodules had developed into necrotic ulcers with eschars that covered the entire left calf. General surgery, palliative care and nutrition specialists were consulted. Pain control and wound management were essential as the necrotic bed was spreading and there was a risk of superimposed infection ( and ). Pain management was also challenging as the patient reacted with confusion and agitation to an opioid combination. Administration of a morphine bolus, transdermal fentanyl and oral gabapentin was effective.
Laboratory findings were non-specific and did not suggest calciphylaxis. The patient’s anaemia worsened and gradual acute-on-chronic renal failure was observed. Parathyroid hormone (PTH) levels were normal, as were calcium and phosphorous levels throughout the patient’s admission. Ho

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 40-year-old Asian man with complaints of bleeding and discomfort in his anus of 2 months’ duration. He was an employee with average income who did not smoke tobacco or drink alcohol. He had no weight loss or urinary symptoms, and no substantial family history. He denied any significant medical or surgical history. His abdomen was soft, non-tender, and non-distended, with normoactive bowel sounds. In examination, a mass could be touched by finger tips. The mass was large and bleeding. In subsequent examinations, blood was detected in a stool sample. His vital signs were: blood pressure, 130.77 mm Hg; respiratory rate, 18 breaths/minute; heart rate, 83 beats/minute; and temperature within normal limits. Oxygen saturation was 98% on room air on admission. In colonoscopy, a large lobular tumor was diagnosed at 4 cm above the dentate line, which was suspicious for malignancy. Various samples were taken from the tumor. The rest of his large intestine did not show a clear pathologic lesion in the colonoscopy.
High-grade adenocarcinoma was reported in pathological examinations. In subsequent diagnostic procedures, his carcinoembryonic antigen (CEA) level was normal. Computed tomography (CT) scans revealed that metastatic lesions were not detected in his liver, abdominal viscera, and chest. In CT scans with or without contrast, and magnetic resonance imaging (MRI) scanning, an ectopic kidney was detected incidentally on his right pelvis without any prior urinary symptoms. The left kidney was in its original location, and both kidneys were functional. Renal function tests provided normal results.
In subsequent investigations done by MRI scanning for staging the tumor, a pelvic rectum tumor was reported to be interfering with the T3 N1 mesorectal lymph nodes (Figs. , ). The case was discussed in a multidisciplinary cancer team; afterward, our patient was regarded as a candidate for neoadjuvant radiotherapy. He underwent 45 GY radiation in 25 fractions to the p

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


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

[User]
RADIOLOGY NOTE:
A Japanese 26-year-old man without any relevant medical history had progressive refractory massive ascites of unknown origin. He shortly developed hematemesis. An endoscopy revealed spurting bleeding from esophageal varices, and he was referred to and then admitted into our hospital. He underwent emergency endoscopic injection sclerotherapy (EIS). The laboratory data on admission showed severe liver dysfunction without any suggestion of chronic liver diseases, such as cirrhosis. The hepatitis viral markers, including hepatitis B and C, were all negative. Color Doppler ultrasonography (US) revealed a heterogeneous enlarged liver, shunt vessels between his middle and right hepatic veins (MHV and RHV, respectively), and retrograde flow in MHV. Computed tomography (CT) is a more sensitive modality for showing parenchymal abnormalities. In our case, enhanced CT revealed much clearer heterogeneity of the liver with decreased attenuation in the periphery. It also showed shunt vessels between MHV and RHV. The latter was markedly dilated, and it seemed to have some flow into the IVC, whereas his left hepatic vein was obstructed. Furthermore, sagittal CT images suggested severe stricture of his IVC at the level of the liver. Angiograms confirmed marked narrowing of his IVC at the level of the liver (Figure ). Magnetic resonance imaging (MRI) revealed findings similar to those of the CT. From these findings, and the rapid onset of the clinical manifestations, we diagnosed this patient as having acute BCS. Within one week, our patient developed massive hematemesis again. Subsequently, he showed manifestations of acute liver failure, possibly due to "shock liver". Since we could not find a donor for deceased liver donor transplantation (DLDT), we decided to perform PTA first. A balloon catheter was inserted into his right femoral vein, and the stricture of the IVC at the level of his liver was dilated using a 12 × 40 mm balloon catheter. After PTA, the pressure difference betwee

[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 with a 2-week story of dry cough and progressive dyspnoea. He had been submitted to an allogeneic hematopoietic cell transplant procedure for a refractory acute myeloid leukemia 4 months before hospital admission. The patient developed grade III graft-versus-host disease (GVHD). He was taking cyclosporine and prednisone 10 mg daily. He received prophylaxis with posaconazole oral solution (200 mg daily) in the first 15 days following transplantation (during the neutropenia phase, as per local protocol). A chest computed tomography revealed a bilateral interstitial infiltrate and multiple nodules with a maximum size of 1.3 cm, without halos (Fig. ). He was non-neutropenic at this time. Bronchoscopy was performed and BAL fluid analysis was negative for fungi (microscopy and culture). The BAL GM index was 0.9. An open lung biopsy revealed invasion by branched hyphae, suggestive of Aspergillus sp. Voriconazole was initiated at standard doses but the patient died 6 days later of respiratory failure and dysfunction of multiple organs and systems. Cultures of the lung specimen were negative.
This was a transplant recipient who had undergone posaconazole prophylaxis and who developed an IFD 3 months after the end of the 30-day prophylactic regimen. Posaconazole prophylaxis represents a safe and effective strategy against fungal infections in transplant patients [, ]. Although there is an ongoing debate regarding the optimal approach to the prevention of IFD in allogeneic stem cell transplant recipients, recent guidelines support the use of prophylactic antifungal agents in these patients, particularly in the context of GVHD [, ].
There are important differences between aspergillosis in neutropenic hosts and in non-neutropenic hosts []. In neutropenic hosts, angioinvasion is a hallmark of the disease and this is associated with a high frequency of dissemination to other organs. In this scenario, classic radiologic findings such as pulmonary nodules

[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 29-year-old male, warehouse worker, presented with a noticeable mass in the left side of his abdomen and weight loss of three and half stones over a four-month period. His past medical history and family history were unremarkable. Physical examination revealed a large, nontender, and fixed left-sided abdominal mass and a normal neurovascular examination except an isolated reduction in light touch sensation in the L2-L3 dermatomes of his left leg only.
An abdominal and pelvic magnetic resonance imaging (MRI) and computed tomography (CT) demonstrated a large, 19 × 16 × 11 cm mass arising from the anterolateral aspect of the L3 pedicle with peripheral calcification, completely obliterating the distal psoas muscle and causing a considerable mass effect to surrounding structures, with displacement of the left kidney. Distally, the tumour extended to the level of the pelvic inlet but not into the spinal canal (Figures and ).
CT guided biopsy of the left abdominal mass confirmed the diagnosis of a low-grade chondrosarcoma arising from an osteochondroma from the lateral body of the L3 vertebrae. The difficult anatomical location and the large size of the lesion greatly increased the complexity and risks of any surgical approach. In order to improve the chances of surgical success and reduce and prepare for possible risks and complication such as catastrophic haemorrhage, spinal instability, and paralysis/neurological deficit, a two-stage surgical procedure and a multidisciplinary team approach to a curative en bloc tumour resection were utilized.
In the first stage, a posterior midline incision to expose the lumbar spine was performed. Bilateral pedicle screws were placed at the levels of L2 and L4, with rods fixated at the end of the procedure for spinal stabilisation. Bilateral laminectomies and facetectomies were performed leading to exposure of the nerve roots, of which the left L3 nerve root was identified and ligated. A partial osteotomy was carried out at the level

[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 otherwise healthy 33-year-old woman, gravida 3, para 2, from a Sephardic Jewish origin, was initially referred to our institution at 30.6 weeks of gestation due to a large neck mass found on prenatal ultrasonography (US). Her previous two pregnancies were uncomplicated. The fetal sonogram showed a 10 by 8 cm mass on the right side of the neck, which was not present in detailed scans taken at 14 and 22 weeks. The mass was composed of a cystic portion and a solid portion containing blood vessels and was growing rapidly in subsequent ultrasound studies. A significant polyhydramnios with amniotic fluid index (AFI) of 50 suggested an upper gastrointestinal obstruction and a highly possible airway obstruction as well. Findings were confirmed by fetal magnetic resonance imaging (MRI). In anticipation of the difficulty in establishing a secured airway at birth and the potential complicated resection of the giant tumor after birth, the mother was referred to our hospital for consultation.
The parents were in consultation with the maternal fetal team, neonatologist, anesthesiologist, pediatric surgeon, and otolaryngologist. The parents were presented with a guarded prognosis but insisted that the pregnancy continue with maximal efforts during delivery and during the neonatal period.
Therefore, a planned EXIT procedure, which provides the best chance to establish a patent airway, was offered to our patient, presenting the risks []. Specifically, we informed the parents about the risks for the mother, including significant hemorrhage from the uterus due to the uterine relaxation necessary to avoid placental separation, with a possible uterine resection in the case of a life-threatening hemorrhage.
Knowing the risk of an unplanned preterm delivery due to polyhydramnios and uterine contractions, we scheduled our patient for a planned cesarean delivery at 34 weeks organizing and preparing a multidisciplinary team ready to perform the EXIT procedure.
A multidisciplinary team inc

[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 woman presented to her ophthalmologist complaining of protrusion of her right eye in August 2005. She had exophthalmos of left eye 20 years ago and she was diagnosed as Graves’ disease which resolved without any treatment or intervention. She was without complaint for 20 years until presenting to her ophthalmologist who felt that her exophthalmos was due to Graves’ disease but she was found to be borderline hypothyroid. Six months later, she developed redness, dryness, and pain in the right eye with worsening exophthalmos. She also complained of double vision and headaches. She was started on thyroid replacement for borderline hypothyroidism but had no relief in proptosis. Antibiotics were prescribed for suspected bacterial infection of the right eye without resolution of her symptoms. She was then started on prednisone 80 mg daily for possible autoimmune/inflammatory etiology and her symptoms improved significantly. At this time, her visual acuity was noted to be 20/25 in the affected eye. Fundoscopic exam was normal. Hertel exophthalmometry, ocular tension, and biomicroscopy were not documented. An MRI of brain and orbit revealed an enhancing soft tissue mass behind the right globe (). The biopsy of the soft tissue mass revealed transmural inflammation with fibrinoid necrosis consistent with necrotizing vasculitis as well as also evidence of lymphocytic infiltration in the fatty tissue consistent with Graves’ disease (). ANA, ANCA, ACE, anti-SSA and anti-SSB antibodies were negative though the patient was found to have an equivocal MPO-ANCA of 6. A diagnosis of limited WG was made. Patient was started on oral cyclophosphamide at 2 mg/kg/day in August 2006 and prednisone was continued. A repeat MRI of the orbit in November 2006 showed decreased enhancement and infiltration of fat adjacent to right optic nerve. In April 2007, cyclophosphamide was discontinued because of leucopenia and methotrexate was started. The prednisone has been discontinued. She

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 48 year old woman with a screen-detected left breast cancer. She was found to have an abnormal bilateral screening mammogram which demonstrated a suspicious area of architectural distortion in the right breast and an obscured nodule in the left breast. This prompted further imaging with diagnostic mammogram and ultrasound. This was especially concerning for a solid microlobulated nodule in the left breast measuring 7 mm in size at 3:00 and a persistent suspicious area of architectural distortion in the right breast with two adjacent simple cysts. Bilateral breast biopsy was performed. Ultrasound guided core biopsy of the suspicious right breast lesion was consistent with sclerosing adenosis with usual ductal hyperplasia. No atypia or malignancy was noted. Ultrasound guided core biopsy of the left breast lesion was consistent with grade 2 invasive ductal carcinoma, ER 10%, PR 0%, Her2/neu negative (1+), Ki 67 1%. Bilateral breast MRI was performed which showed no suspicious lesions in the right breast and a 2–3 mm ovoid rapidly enhancing nodule with plateau kinetics reflecting a portion of the originally biopsied cancer. No other suspicious lesions were noted within the left breast, left axilla, or internal mammary chain. Her case was reviewed, and the multi-disciplinary decision was to proceed with breast conservative surgery first. She was taken for right partial mastectomy and left partial mastectomy with sentinel node biopsy. Final pathology of the right breast did not show any evidence of malignancy. Initial pathology of the left breast was initially concerning for a biologically unfavorable invasive ductal carcinoma, NOS type. However, further pathologic review revealed that the patient had a grade 2, 8 mm secretory carcinoma. The diagnosis of secretory carcinoma was suspected based on histologic findings which included a microcystic and tubular growth pattern with luminal secretions. The tumor cells were polygonal with eosinophilic to foamy cy

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old Hispanic man presented to the emergency department complaining of right groin pain for one week. He described the pain as aching (6–8/10) in severity, localized to the right groin, precipitated by walking, and relieved by resting for approximately 10 minutes. The pain had progressively worsened over the previous week, and causing a painful limp at the time of presentation, he denied any morning joint stiffness, muscle aches, other joint pain, rash, fever, or back pain. He had taken a few tablets of nonsteroidal anti-inflammatory drugs every day for the last week, with minimal pain relief.
Upon review of other organ systems the patient described that he had been feeling subtle weakness in the left upper and lower extremities which started three years earlier and became slowly progressive. He stated that the weakness was not causing any limitation of activity or falls and denied any history of urinary or bowel incontinence, numbness, or pain in the extremities other than the presenting complaint.
When evaluated for the weakness two years earlier an MRI of the brain was ordered and reviewed by his primary care physician with reportedly normal results.
On physical examination, no erythema or swelling around the right hip or groin area, and no inguinal lymphadenopathy were noted. The passive range of motion of the right hip was limited and painful, especially forced internal rotation. Passive internal and external rotation of the extended leg “log roll test” and straight-leg raise test elicited pain. Bilateral hyperpigmentation from the knees to the toes was noted, with mild bilateral lower extremity pitting edema, and normal peripheral pulses.
Cranial nerves examination revealed a left spinal accessory nerve lesion as the patient was unable to shrug his left shoulder. Tongue fasciculation was noted with a slight deviation of the tongue to the left on protrusion, suggesting a left hypoglossal nerve lesion. The remainder of cranial nerves examination was nor

[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 male with a history of left testicular cancer treated with chemotherapy (Bleomycin, Etoposide, Cisplatin; BEP), radiotherapy, retroperitoneal lymph node dissection, and partial left nephrectomy in 1992 presented to hospital with complaints of left lower abdominal mass for 3–5 years, associated with ulceration and active drainage. He was asymptomatic with β-hCG and alpha-fetoprotein (AFP) levels within reference ranges (<2.39 and 1.4, respectively). On examination, inspection of abdomen revealed well-healed midline scar with bilateral incisional hernias and a 10 × 8 cm mass in the left lower quadrant () firm and fixed to the abdominal wall. An open lesion characterized by yellow, non-purulent drainage was noted in the left lower quadrant. CT imaging of abdomen and pelvis with contrast revealed a multiloculated large cystic mass in the left inguinal canal measuring 11 × 7 × 7.7 cm () along with a similar soft tissue nodule in the right inguinal area. A right retroperitoneal soft tissue mass in the mid abdomen was also identified, measuring 3.3 × 4.2 × 5.7 cm (). Changes of prior left nephrectomy and orchiectomy consistent with treatment of previous left-sided testicular cancer were also noted.
Biopsy of right retroperitoneal mass revealed squamous cell-lined cystic lesion followed by left lower quadrantabdominal mass excision and complex wound closure. An elliptical incision was made in the left groin incorporating the lesion, and subcutaneous flaps were created. Dissection was carried down to fascia where the mass extended into inguinal ring and the lower edge of the external oblique aponeurosis, extending into the abdomen. The mass was excised and noted to be multi-loculated and heterogeneous in consistency. The fascia and peritoneum that was adhered to the mass were then resected. A superficial inguinal lymph node was excised and sent to pathology as a separate specimen, and no other inguinal or femoral enlarged lymph nodes were found. Final pathology

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old male was an unrestrained passenger in an automobile travelling between 60 and 70 mph. This car was the involved in a road traffic collision at an oblique angle with another vehicle. The patient in question was a rear seat, nearside passenger.
At the scene of the collision, the passenger-side front seat trapped the patient for approximately 1½ h. Once released the patient was then transferred by helicopter to a local trauma center.
Upon arrival, the patient was stable despite tachydcardia with Glascow coma scale of 15/15. Primary and secondary surveys were performed, and trauma team noted open wounds in both right forearm and left thigh. There were bruises and patient was complaining of pain and difficulty in using his jaw. The abdomen was soft and normal oxygen saturations were maintained. The extremities were neurovascularly intact distally, and the patient was complaining of pain in the right leg.
He had been administered opiate analgesia, oxygen and tranexamic acid. Once stabilized the patient was transferred for an urgent computer aided tomography (CT) scan, which revealed the following injuries: Subcondylar fracture of the mandible, open fracture of the right ulna and radius, open fracture of the left femur, inferior dislocation of the right hip joint, small splenic laceration, and contusion of left pulmonary base.
The same day as admission the patient was taken to the operating theater for reduction under general anesthesia of the inferior dislocation of the right hip joint. With hip abduction traction, external rotation and flexion of the hip joint multiple attempts were made to reduce the hip joint, but unsuccessfully. It was therefore considered necessary to attempt an open reduction of the inferior dislocation. An anterior approach was used and the hip capsule opened anteriorly. The acetabulum was empty and the ligamentum teres ruptured. The femoral head was stuck within the obturator region; inferior to the transverse acetabular

[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 51-year-old female with a recent diagnosis of acute lymphocytic leukemia was admitted to our hospital due to persistent fever and left-sided perioral dysesthesia following initiation of chemotherapy. Clinical examination revealed ulcerous lesions in the patient’s palate. Further laboratory tests were notable for pancytopenia and elevated CRP and ESR. Cultures of tissue samples taken from the oral lesions revealed multidrug-resistant Pseudomonas aeruginosa and Pseudomonas fluorescens and intermediate antibiotic sensitivity Acinetobacter baumannii. Chemotherapy was discontinued and the already instituted empiric antibiotic coverage was adjusted according to antibiograms. Head and facial computed tomography (CT) revealed extensive bone erosion of the maxilla around the dental alveoli without signs of inflammation of the paranasal sinuses. Anatomic variation was the bony dehiscence of the superolateral wall of the left sphenoid sinus [], with concomitant carotid artery protrusion into the sinus and separated by the sinus cavity by only dura and mucosa.[,] One and a half month later, there was sudden-onset epistaxis that was managed successfully by tamponade by ENT surgeons. Postcontrast head and facial CT imaging revealed inflammation of the left nasal cavity and paranasal sinuses –especially the left sphenoid sinus – without any gross vascular abnormalities. Further episodes of intermittent epistaxis were noted although clinical and laboratory signs of infection remitted during the following fortnight. A repeat head-facial contrast CT scan was performed at that time. It showed containment of the infection but revealed a large enhancing lesion protruding into the left sphenoid sinus, which on further CT angiography (CTA) and digital subtraction angiography (DSA) were determined to be a 0.9 × 2 cm infectious irregular multilobulated pseudoaneurysm of the cavernous ICA [ and ]. The patient underwent emergent complete selective endovascular occlusion of the pseudoaneurys

[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 29-year-old male was transported to the emergency department after a traumatic near total amputation of the right distal tibia due to a motorcycle accident; the patient's leg was run over by a truck. The distal portion of the leg was severely crushed and the only remaining portions were the anterior and posterior tibial nerves, the tibialis anterior tendon, and some soft tissue connections, with no viable blood flow to the distal stump (). The amputation site was critically contaminated, with circumferential degloving tissue loss of approximately 15 cm in length at the distal portion of the lower leg ().
A comminuted fracture of the tibia and fibula was observed at the distal portions with damage to the ankle joint. Despite the severity of the damage to the amputated region, the general condition of the patient remained fairly stable. The total ischemia time was more than 10 hours of warm ischemia.
After an external fixator was applied to the open tibial fracture and internal fixation was performed for the fibula, wound exploration was performed (). Thrombosis of the anterior tibial artery and a 20-cm-long segment of the artery's crushed intimal structure were observed, along with a similarly damaged vein. The posterior tibial vessels showed an arterial gap of 10 cm, with one accompanying vein ruptured and the other vein crushed with a venous gap of 7 cm (). The posterior tibial vessels appeared more promising for a successful repair. A lesser saphenous vein graft was harvested from the contralateral leg in a 12 cm segment for the arterial reconstruction (). After blood flow resumed, 400 mL of blood was drained before the vein was repaired.
The ruptured vein was repaired primarily, and the vein with a 7 cm gap was repaired with an 8 cm strip of arterial graft from a non-thrombosed segment at the middle portion of the thrombosed anterior tibial artery ().
The healthy vein graft was considered more reliable for the arterial reconstruction than the arterial graft fro

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male patient presented to emergency department after an assault with an incise wound in the external canthus of the left eye and severe alcohol intoxication, which prevented history taking. The physical exam of the ocular globe was not possible due to the large hematoma that hindered opening the eyelid. The exploration of right eye was normal. Therefore, the skin wound was initially sutured with a polypropylene 5/0 interrupted suture and an orbital computed tomography (CT scan) and skull X-ray were performed. An intraorbital foreign body with triangular shape of 4.6 cm x 2 cm was seen in the left orbit, passing through the orbit and the ocular globe, fracturing the superomedial wall of the orbit, with a probable associated fracture of the ethmoidal cells, and reaching the anterior cranial fossa, causing pneumocephalus (Figures and ). The patient did not present any neurological symptoms beyond his alcohol intoxication nor did he develop rhinorrhea at any time, and the Glasgow Coma Scale/Score was normal (15/15). He remained under observation and was treated with intravenous antibiotic (ciprofloxacin 200 mg twice daily, for five days, selected due to its broad spectrum for gram negative and positive) and corticosteroids (methylprednisolone 80 mg per day for 3 days). Surgical extraction was performed. The foreign body turned out to be a fragment of a dagger. The extraction was done locating the end of the foreign body after removing the suture of the wound and disinserting the lower eyelid to have a wider surgical field. The foreign boy was carefully extracted without exerting force. It was then possible to see a corneoscleral wound 2 cm long affecting the upper cornea 7 mm and the sclera 8 mm located from 9 to 2 o'clock positions. It was closed with nylon 10/0 suture and polyglactin 910 7/0 suture. The entrance area in the orbit was revised, with special attention to the upper nasal quadrant,

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


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

[User]
RADIOLOGY NOTE:
We report on a 63-year-old female patient who presented in January 2016 with the following symptoms: complaint of cold sensation affecting the upper arms on both sides (left > right), weakness and arm claudication, with an increasing inability to perform work on the computer, and symptoms of a fatigue syndrome. The patient was unable to perform her employment as a hospital secretary. Clinically, pulselessness of the brachial and radial artery on both sides was noted. Bruits were discovered in the left and right subclavian artery. A blood test revealed increased levels of the inflammatory markers C-reactive protein (CRP 47.9 mg/dL) and an increased Erythrocyte Sedimentation Rate (ESR 74 mm/h). The patient had a history of hypertension, hyperlipoproteinemia, and osteoporosis; she was a former smoker and reported moderate daily alcohol consumption.
A neurological examination, an MRI of the cervical spine, and myocardial scintigraphy were without pathological findings. Duplex ultrasound of the carotid artery and upper extremities revealed noticeable intima-media thickening. For suspected large-vessel vasculitis, a diagnostic angiography was carried out, which revealed bilateral stenosis of the axillary artery at the transition to the brachial artery and, on the left side only, an additional stenosis in the proximal segment of the brachial artery. TA was diagnosed based on the American College of Rheumatology criteria, with four out of six criteria met.
The patient was admitted to a rheumatological specialist clinic in March 2016. Treatment with prednisolone 20 mg daily was started, but there was no improvement of the arm claudication. Therefore, the patient received cyclophosphamide 15 mg/kg body weight × 0.75 (=600 mg) plus prednisolone (75 mg/d initially, reduced in stages to 30 mg/d at the time of hospital discharge). Six cycles of cyclophosphamide at 3-week interval were planned, at the end of which treatment with methotrexate 15 mg subcutaneously once a week accomp

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old male patient visited our hospital with complaints of limitation of ROM in the left knee and inability to walk for 9-months. Nine months prior, he visited a local hospital after a motorcycle traffic accident and was diagnosed with an open fracture of the left femur shaft and an intra-articular fracture of the proximal tibia. He underwent an operation using the Ilizarov external fixator at the femur and tibia. Two months after the first surgery, the Ilizarov fixator was removed and changed into a monoaxial external fixator for the left femur and converted to internal fixation with a screw for the left tibia. One month later, he underwent an operation for conversion to internal fixation with intramedullary nailing of the left femur. At that time, he underwent manipulation of the knee joint for ankylosis. On physical examination at the initial visit to our hospital, he had tenderness and dimpling in the superior aspect of the patella and markedly decreased mobility of the patella (including mediolateral and superoinferior translation). He had quadriceps atrophy (a 3-cm decrease in mid-thigh circumference as compared to the contralateral limb). His left knee ROM was between flexion contracture of 30° and further flexion of 90°. On plain radiographs, nonunion of the left proximal tibial fracture and femur shaft fracture were shown. The lateral radiograph revealed a fracture in the superior pole of the patella and patella infera (). The ultrasound showed discontinuity of the quadriceps muscle fiber and hypoechoic hematoma ().
Under the presumptive diagnosis of a chronic quadriceps rupture with a patellar superior pole avulsion fracture of the left knee and nonunion of the left proximal tibia fracture, we performed quadriceps reconstruction using tibialis anterior allograft tendon and additional screw fixation. Initially, after removal of the fibrotic nonunion site, 2 cannulated screws were used to fix the nonunion fragment of the proximal tibia at full flexio

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old woman visited our outpatient clinic with an erosive nodule on the scalp. She had been treated for juvenile dermatomyositis and had been administered immunosuppressive agents such as cyclosporine and prednisolone since she was 1 year old. On her initial visit, physical examination revealed a dome-shaped, easy-to-bleed nodule on her parietal scalp (Fig. ). In addition, a wide-spreading scarring alopecia-like lesion was observed on the whole scalp. The size of the nodule was approximately 32 mm in diameter. Skin biopsy from the nodule revealed a dermal infiltration composed of atypical keratinocytes with dyskeratotic cytoplasm (Fig. ). Around the tumor mass, a dense infiltration of lymphocytes was observed. We diagnosed this patient as having a moderately differentiated SCC on the parietal scalp and excised the tumor with a 10-mm margin. Four years after the initial excision, another red nodule developed in the left temporal region (Fig. ). Since the histological findings of the second tumor were similar to those of the first cutaneous SCC (Fig. ), we excised the tumor with a 10-mm margin. Eleven months after the second surgical treatment, a keratotic lesion was apparent around the grafted area (Fig. ), and again we excised it with a 10-mm margin. The histological findings of the third tumor were similar to those of the first cutaneous SCC, which was a widely spread SCC in situ (Fig. ). Additionally, we performed a random biopsy on the patient's scalp, and there were no atypical cells – only homogenization of the collagen bundle with carcinosis.
Since recurrent multi-focal lesions were detected in this case, and since a previous report suggested that IL-17 plays a key role in cutaneous SCC carcinogenesis, we employed immunohistochemical staining for IL-17 as well as IL-17R in the lesional skin of each of the cutaneous SCC in our case. Immunohistochemical staining revealed that these atypical keratinocytes strongly expressed IL-17R (F

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male was admitted to our hospital with a 5-day history of severe dizziness, mild chest pain and dyspnea. On admission, he had a pulse rate of 115 bpm, a blood pressure of 80/60 mmHg, and a respiratory rate of 24. He had a history of hypertension and no diabetes mellitus. On physical examination, there were no pathological signs for heart sounds, but some wet rales were detected in the lower lung region. There was minimal bilateral leg edema. Cardiac troponin T levels were clearly normal. The electrocardiogram (ECG) did not show any new myocardial infarction (MI) sign. When checking patient history, we discovered that he had suffered STEMI four weeks prior. In the coronary angiography performed, an occlusive lesion was detected in the distal circumflex artery and he was discharged with medical treatment (). There was a right type of coronary dominance. Transthoracic echocardiography showed a 3-cm wide wall defect on the posterior side of the left ventricle, a 57-mm pericardial effusion and the left ventricular ejection fraction (LVEF) was 40% (). The operation was performed immediately via standard median sternotomy. Adherence of the pericardium was at an advanced level. The anterior part of the pericardium was dissected carefully for cannulation. We used cold potassium-based cardioplegia (Plegisol®, Baxter, Chicago, USA) for cardiac arrest and continued with cold blood cardioplegia. After a standard cardiopulmonary bypass (CPB) procedure, we separated the entire pericardium from the heart. On the posterior region we detected a formation like pseudo-aneurysm which was a 2-mm thick membrane formed by adhesion. It was almost completely covered the posterior face of the left ventricle. After opening this membrane, the myocardial defect was seen (). We considered that it was a subacute situation because of the non-existence of fragile necrotic tissue. The defect was sutured with eight separated and teflon felt supported 3-0 prolene sutures ( and ).

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old male with no significant past medical history presented to our facility with a history of worsening pain and swelling in the medial aspect of his proximal left lower extremity over the past several years. Anteroposterior (AP) and “frog leg” lateral radiographs of the left lower extremity revealed a dense lesion consistent with dense matrix, adjacent to the medial aspect of the femur (). An MRI of the left lower extremity revealed that the lesion was of extraskeletal origin, arising from the adductor magnus, without any involvement of the femur (, ). The solid heterogeneous mass was located in the posterior compartment of the proximal-to-mid thigh and measured 9.6 × 7.3 × 13 cm in the transverse, AP and vertical dimensions, respectively. Multiple tiny hypointense foci, which corresponded to the calcific density noted on the prior plain radiographical studies, were noted centrally. The mass was otherwise of intermediate soft-tissue intensity on T
1 weighted images and moderately hyperintense to muscle on T
2 weighted images. Following intravenous administration of gadolinium, moderate enhancement of the mass, excluding the central portion, was observed. Superiorly and inferiorly, the margins of the mass were indefinite, and the mass demonstrated peripheral vasculature, which was most prominent at the cephalad and caudad margins. The mass was centred within the adductor magnus muscle fibres that were displaced around the mass. Anterolaterally, the mass was very closely approximated to the posterior cortex of the femur and the fascial margins that separated the quadriceps and the posterior compartments (Supplementary videos). No obvious signal abnormality was noted within the femur to indicate invasion or primary osseous origin. Post-excision pathology confirmed the presence of mesenchymal chondrosarcoma.
In the interval, surveillance imaging for metastatic disease with CT scan of the chest, abdomen and pelvis was performed. At 18 months, multiple bilatera

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.
To obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.
The right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ult

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old Native American female presented to the ER with a bladder infection, and a urine culture grew E. coli. She was treated with trimethoprim/sulfamethoxazole and developed a diffuse rash including the palms and soles. There was no lymphadenopathy present upon physical exam. One month later, she presented to the clinic with a month of severe pounding headaches, blurry vision in the right eye, and pain over the temporal area on the right side. Her ESR was elevated with a normal CRP. The suspected diagnosis was giant cell arteritis, and she was started on 60 mg of oral prednisone daily that helped the headaches. A temporal artery biopsy was done and showed no evidence of vasculitis. The patient was tapered from the steroid and started having progressive blurry vision and floaters. Three months later, the patient presented to the emergency department and was admitted to the hospital due to the blurry vision and floaters at which time she had a positive fluorescent treponemal antibody absorption test. She was HIV negative. The patient had a Venereal Disease Research Laboratory test of the cerebral spinal fluid done which came back negative. Her cerebral spinal fluid cell count was 178 nucleated cells with 164 lymphocytes, and protein was 53 mg/dl. She had a serum rapid plasma reagin titer of 1 : 1024. She was diagnosed with secondary and early neurosyphilis for which she was started on 24 million units per day of IV penicillin G, and severe uveitits for which she was started on 60 mg of oral prednisone and 1% prednisolone acetate eye drops. The uveitis was likely secondary to the syphilis infection. A CT scan of the head showed four osseous lesions (Figures –). An immunohistochemical stain of a skull biopsy was done which came back positive for Treponema pallidum, thus confirming syphilis as the cause of the bone lesions. An echocardiogram was performed which did not show any significant cardiac defect. The patient completed 14 days of 24 million units

[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.