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

[User]
RADIOLOGY NOTE:
A five-year-old typically developing female was referred by her primary care provider for evaluation of a rash reported to be sensitive to sunlight and had been reoccurring for the last 4 years. Cutaneous exam revealed fine scale on her trunk and extremities as well as small pink flat papules on lower left leg. She was diagnosed with ichthyosis vulgaris and provided with a treatment plan. She was subsequently referred to gastroenterology for decreased appetite. Two weeks later the child presented to the Emergency Department for right knee pain. Her mother reported her daughter had experienced bilateral lower extremity pain and had been limping. During the evaluation she was able to walk for the physician without reporting pain and no tenderness was reported with palpation. The mother reported her daughter was bitten by a tick about 1 year ago and that no workup or treatment was conducted. Radiographic scans of the right knee and leg showed no abnormalities. Laboratory testing for Lyme disease was conducted and found to be negative. She was discharged with the diagnosis of tenosynovitis. The child presented again to the Emergency Department the following week for left knee and ankle pain. She reported pain in her left calcaneus when asked to bear weight. Migratory arthralgia was noted and further laboratory testing, including a vitamin C level, was ordered. Her vitamin C level was found to be < 5 umol/L (reference range: 23 to 114 umol/L). Her prealbumin level was also low, 14 mg/dl (reference range: 17–36 mg/dl) as was both her ferritin 3.9 ng/ml (reference range: 6.2–137.0 ng/ml) and her iron saturation 15% (reference range: 20–55%). Both vitamin A and vitamin D were found to be within the normal reference range. With the diagnosis of the vitamin C deficiency, the child was started on ascorbic acid and referred to the feeding program.
The participant was the youngest of six

[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 fifty-nine year old male presented with a 4 × 2 cm lump in the right neck at level II. He had noticed the swelling for less than one week but reported a three year history of sore throat, fatigue, reduced exercise tolerance and shortness of breath. He had never smoked and consumed 18 international units of alcohol per week. There was no other lymphadenopathy and no intra-oral abnormality. Fine needle aspiration cytology was inconclusive and the patient underwent a diagnostic lymph node excision for histological evaluation, which showed metastatic squamous cell carcinoma. Computed tomography (CT) and 15fluoro-deoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) were undertaken to identify the primary site and revealed a 2 cm mass involving the right tonsil with a right sided level II lymph node mass extending into the deep lobe of the right parotid gland. He was treated with radical chemoradiation comprising image-guided intensity modulated radiotherapy (IMRT) delivering 65Gy in 30 fractions to the oropharynx and right neck level II with 54Gy in 30 fractions to right neck levels III to V and left neck levels II to V. Concomitant cisplatin 100 mg/m2 was given on days 1 and 29 of radiotherapy. A FDG-PET/CT scan performed at 3 months post-treatment confirmed a complete metabolic response. The patient remains disease free after 15 months.
Histological evaluation of the excised lymph showed complete effacement by carcinoma comprising two clearly demarcated and morphologically distinct subpopulations of cells. In most areas, the two subpopulations were separated by fibrous tissue bands. Where the two phenotypes were not separated by fibrous tissue, there was abrupt delineation of the subpopulations without any intermediate transition. One component was composed of broad interconnecting strands of tumour cells with obvious squamous maturation but with minimal keratinisation typical of conventional HPV-associated OpSCC, designated the ‘differentiated’

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old Chinese man sustained severe knife trauma and was referred to a local hospital. An exploratory laparotomy showed traumatic rupture of his left external iliac vein with massive intraperitoneal bleeding, but his iliac artery was intact. To rescue him, the proximal and distal parts of his injured external iliac vein were ligated (there was no vascular surgeon in the local hospital); however, his left leg quickly became severely swollen, cyanotic and pulseless. Two hours after the first operation, he was transferred to the emergency department of our university hospital with endotracheal tube intubation. On physical examination, he was tachycardic (142 beats per minute), hypotensive (86/50mmHg). His left lower extremity was markedly edematous, cyanotic, mottled (Figure
a) and had no palpable pulse, but his right lower extremity was normal. He was diagnosed with posttraumatic PCD. Considering the high risk of pulmonary embolism during the next surgical procedure, an OptEase® retrievable vena cava filter (Cordis Corp., New Brunswick, NJ, USA) was placed in his inferior vena cava via his right femoral vein under digital subtraction angiography (Figure
). His abdomen was immediately reopened while his left leg was also prepared for treatment.During the second emergent laparotomy, there was less blood in his pelvic cavity. No active bleeding was identified. His left iliac vein and artery were exposed and his entire iliac artery appeared normal and without rupture. His external iliac vein was ligated but not transected, connected only by the posterior wall, and the caudal part of his iliac vein was significantly dilated. By replacing the vascular clamp in the proximal and distal parts of the rupture, the ligations on both sides of the venous rupture were resolved. A wedge-shaped rupture was revealed, approximately 4cm in length, on the anterolateral side of his left external iliac vein. The edges of the venous rupture were smooth as a result of the kn

[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 53-year-old woman presented to our department with signs and symptoms of multinodular goiter (MNG). Bulky hypertrophy of the thyroid gland at the anterior neck was determined by inspection. Larger nodules with regular margins were palpated in both lobes by physical examination. Serum thyroid-stimulating hormone and free thyroxine levels were normal by biochemical analysis. Thyroid ultrasound revealed multiple nodules in both lobes. Bigger nodules were a 50 x 36 x 40 mm hypoechoic solid nodule in the right lobe and a 33 x 25 x 37 mm isoechoic solid nodule in the left lobe. Fine needle aspiration from dominant nodules revealed benign cytology. The diagnosis was MNG. Total thyroidectomy under the guidance of IONM was planned as the surgical treatment. Informed consent was obtained from the patient.
The right thyroid lobe was partially mobilized after ligation of the middle thyroid vein. The carotid sheath was incised, and the right vagus nerve (VN) was located behind the carotid artery and the jugular vein. Direct stimulation of the VN with the stimulator probe at a standard distal point did not create a sound signal. The absence of a distal V1 (d-V1) signal revealed the early proximal separation of the inferior laryngeal nerve and eventual presence of the non-RLN. The carotid sheath incision was extended toward the cephalic direction. The right VN was proximally followed under the guidance of IONM with serial electrophysiological stimulation to identify the separation point of the inferior laryngeal nerve. A positive signal from a proximal point of stimulation (p-V1 = 648 µV) helped us to locate the separation point of the right inferior laryngeal nerve. Stimulation of the inferior nerve when first identified at the separation point posterior to the carotid artery created a positive sound signal and wave amplitude (R1 = 661 µV). Both lower and upper poles of the right lobe were carefully dissected, and the lobe was mobilized medially. The right non-RLN arising

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old male, working as a shopkeeper, presented to our emergency department with complaints of pain and loss of movement in bilateral shoulder, following fall from the standing height. This incident was associated with an epileptic episode while he was doing routine work in his shop. On detailed history, we discovered that he was a diagnosed case of generalized tonic clonic seizure for 9 years with the past episode 3 years back and was off medication for 2 years. There was no history of diabetes, hypertension, alcohol, and smoking. A history of oral tobacco intake for the past 20 years was present. He had suffered 4 episodes of right shoulder dislocation, the most recent episode being 2 months ago.
On examination, diffuse tenderness and swelling were present over bilateral shoulder with bony crepitus. No distal neurovascular deficit was noted. No other injuries were noted during the examination. Immobilization and analgesics were given in an emergency. Plain radiographs followed by computed tomography scans revealed bilateral Neer [] IV part fracture with anterior shoulder dislocation (Figs. , ). The patient was prepared for operative intervention and necessary investigations were done. Both the shoulders were operated in a single sitting. The same deltopectoral approach was used bilaterally and open reduction with Proximal Humerus Interlocking Osteosynthesis (PHILOS) plating was done (). The right side was operated first for no particular reason, taking approximately 3 h followed by the left side in the next 2 h. Re-draping was done and a shot of an intravenous antibiotic was given before starting the left side. Intraoperatively, a bony Bankart lesion in the right shoulder was noticed which led to persistent instability even after fixation of the proximal humerus. Henceforth, a Latarjet procedure was done for the same.
Postoperatively, the right shoulder was immobilized for 2 weeks. Pendular exercises were started on the 1st post-operative day on the left si

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman was admitted to our hospital in March 2018 with a lump in her left breast. On a physical examination in the outpatient service, we found a lesion that was approximately 8 × 7 cm in size in the upper outer quadrant of the left breast with occasional bloody nipple discharge. Some abnormally enlarged lymph nodes were observed in the left axilla ().
A biopsy specimen of the left nodule showed invasive ductal carcinoma and scirrhous type cancer of the breast (cT3NxM0). Estrogen and progesterone receptors were positive, but human epidermal growth factor receptor 2 (HER2) was negative in immunohistochemical staining. The Ki-67 labeling index was 60%. At the same time, ultrasound imaging showed a 20 × 22 ×27-mm hypoechoic nodule of Thyroid Imaging Reporting and Data System category 4 in the left thyroid. Fine needle aspiration biopsy of a thyroid nodule showed papillary thyroid carcinoma (cT2NxM0, stage I) ().
During routine examinations, transvaginal ultrasound showed a hypoechoic area in the muscle layer of her uterus (). She was diagnosed with uterine fibroids. Her history of disease included adenomyosis and dysfunctional uterine bleeding. She had continuous androgen, estrogen, and progesterone treatment for her gynecological diseases for longer than 5 years. She did not have any family history of papillary thyroid or breast cancer. The patient did not receive external beam radiation to the neck region. She did not know whether she had thyroiditis because she had not been examined before admission. She was not diagnosed with thyroiditis during preoperative laboratory tests in this hospitalization. She underwent endometrial scraping surgery 30 years previously because of uterine functional bleeding and adenomyosis.
The patient was diagnosed with breast cancer and thyroid cancer. Her breast cancer was in the advanced stage and luminal B type. She was treated with neoadjuvant chemotherapy of epirubicin 100 mg/m2 and cyclophosphamide 600 mg/m2, followed b

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


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

[User]
RADIOLOGY NOTE:
A 45 year old single woman with a non regressing congenital vascular malformation of the right arm and upper chest, presented with a 3 day history of high fever, chills, dysuria, hematuria and right loin discomfort. Her urine output was normal and she had no spontaneous bleeding manifestations or features of uremia. A marked drop in her platelet counts compared to recent baseline levels had been detected by her primary care physician following the onset of symptoms.
Her past medical history was significant for persistent low baseline platelet counts in the region of 100,000/mm3 with episodic reduction to values as low as 30,000/mm3 following infections. She had been extensively and repeatedly investigated from the time the low baselines platelet counts were detected at the age of 28, however no definite cause was identified. On direct questioning she denied spontaneous mucocutaneous bleeding in the past. However her past medical history was significant for an abandoned plastic surgical procedure after developing a haematoma surrounding the preoperative intravenous cannulation site with a corresponding platelet count of 47,000/mm3. She had also been managed conservatively for uterine adenomyosis with depot provera from the age of 45 due to concerns of high risk of perioperative bleeding.
Detailed evaluation was negative for symptoms attributable to anemia, connective tissue disease and liver disease. History of medications was negative for agents associated with thrombocytopenia.
Examination revealed an ill looking lady with a temperature of 100.4 degrees Fahrenheit. She had a giant hemagioma involving the entire right arm, right lateral aspect of the neck and both the anterior and posterior aspect of the chest extending up to the 4th intercostal space (Figure
). The hemangioma had small areas which were ulcerated and inflamed as well as healed scars. A soft bruit was appreciated on auscultation over the hemangioma. She had no petichiae or ecchymoses and her conjunc

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old primiparous woman was seen at our hospital for preterm contractions for seven days with reduced fetal movements at 27 weeks and 4 days of gestation. A threatened premature labor was diagnosed. Ultrasound showed a female fetus with normal development and amniotic fluid volume. Small bowel appeared mildly dilated (14 mm) with thickened and hyperechogenic intestinal wall. There was a typical whirlpool configuration of the bowel (). First and second trimester ultrasounds were unremarkable. Screening for infectious diseases was negative. A molecular genetic testing of CFTR was realized in the parents who were tested for the 32 main mutations of CFTR during a genetic counseling. This testing was negative in both of the parents. So, the fetus was not screened for cystic fibrosis. The patient received atosiban for tocolysis and steroids for fetal lung maturation. Ultrasound follow-up one week later and every two weeks showed absence of significant modification in small bowel dilatation and normal fetal development and amniotic fluid volume up to 33 weeks and 1 day of gestation when a peritoneal calcification appeared leading to the suspicion of meconium peritonitis. Fetal biometry measures including the abdominal circumference and amniotic fluid volume were normal throughout the follow-up in antepartum period. Ultrasound follow-up at 36 weeks and 4 days of gestation revealed a significant aggravation of intestinal dilatation (30 mm) appearing more extensively with persistent intestinal peristalsis, and some parietal calcifications appeared with a meconium pseudocyst but there were no ascites (). Fetal vitality was good with a satisfying Manning's score; there were neither ascites nor significant increasing in abdominal circumference nor abnormality in fetal heart rate and the amniotic fluid volume was normal. So, the patient was hospitalized for close monitoring of fetal heart rate. After consultation with members of pediatric surgery team, induction of labor

[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 presented to urology clinic with the chief complaint of persistent feelings of impending orgasm. He reported a sensation similar, but not identical, to sexual arousal that did not occur in the setting of sexual thoughts or desire. During these episodes his penis would be extremely sensitive. With manual stimulation he would achieve orgasm, which alleviated the arousal for only a short time after which the symptoms would return. This had become quite bothersome to him.
The onset of symptoms was sudden. This was associated with a change of bowel habits with a sensation of fecal urgency and inability to have a bowel movement without straining. He also complained of an ache in the area of his coccyx. The need to strain resolved with fiber supplementation and did not return, but the fecal urgency persisted. His arousal symptoms persisted as well. He denied any urinary frequency, hesitancy, or urgency. The patient reported normal erections and ejaculation.
His past medical history was significant intermittent neck pain and chronic back pain from a herniated disk at L5-S1, for male pattern baldness, for which he was taking Propecia, and Peyronie's Disease for which he had seen an urologist in the past, but had declined treatment because he was not sexually active. Past surgical history was significant for appendectomy.
Genitourinary exam revealed a circumcised phallus with a 1.5 cm plaque on the dorsum of the penis at the base, otherwise the penile and perineal exam were normal. There was a grade 3 varicocele on the left. No inguinal hernias were present. Digital rectal exam revealed good sphincter tone and a small, smooth, nontender prostate.
The patient was referred to an orthopedic spine surgeon and MRI of the brain and cervical, thoracic, and lumbosacral spinal cord was obtained. The MRI showed the previously diagnosed L5-S1 herniation which was stable and a synovial cyst

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

[User]
RADIOLOGY NOTE:
A 40-year old male patient presented to the Emergency Department of our hospital complaining of malaise, fatigue, night sweats and fever during the last month. The patient had been tested positive for HIV 7 years ago and had been followed on a regular basis in our Infectious Diseases Unit, until two years ago, when he had insistently denied initiation of HAART and was lost to follow up.
On admission, the patient was in a good clinical condition. Clinical examination was remarkable for a mild splenomegaly and a small focus of Kaposi sarcoma in the ankle. Apart from moderate normocytic anemia and elevated ESR, other blood tests and biochemistry panel were normal (). His CD4 cell count was 17 cells/uL and HIV viral load 105,000 copies/mL.
Blood cultures for common bacteria and mycobacteria were negative. Serum Cryptococcus neoformans antigen and Wright reaction were negative. PCR amplification for CMV genome was undetectable, while for EBV genome 3.4×103 copies/mL were detected. Bone marrow aspiration and biopsy were performed and cultures were drawn. PCR amplification for Leishmania infantum was positive in the bone marrow and the serum. However, Giemsa stain of the bone marrow was negative for the parasite and antibodies against K39 antigen in the serum were also negative. In view of the above findings, HAART with abacavir, lamivudine and dolutegravir was initiated in the 6th hospital day (day 0 from that point) and the patient was subsequently treated with liposomal amphotericin, while continuing the diagnostic workup.
Whole body CT scan performed early in the course of the fever had revealed mild lymphadenopathy in the mesenteric region, as well as mild splenomegaly. A PET-18-FDG scan had then been performed, which had raised suspicion of lymphoma in the above lymph nodes. In the meantime, there was a transient amelioration of the patient’s fever spikes and transfusion needs and laparoscopic biopsy of the lymph nodes was postponed.
On day

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old female was admitted to our hospital complaining of numbness in the left limb for one week. Past medical history was notable for the diagnosis of NMO and intracranial hemorrhage. The patient was diagnosed with NMO ten years ago due to repeated episodes of blurred vision and numbness and weakness in the limbs. Brain and spinal magnetic resonance imaging (MRI) at that time indicated lesions in the brain white matter as well as spinal cord involving cervical and thoracic regions. AQP4 antibody test was not performed. Considering the potential diagnosis of demyelinating disease, steroid pulse therapy was initiated and the patient improved after the treatment. After discharge, corticosteroid was gradually tapered and the patient was maintained at a low-dose corticosteroid and azathioprine in the long term. The patient was also diagnosed with left basal ganglia hemorrhage three years ago, presenting as right-sided hemiplegia and confusion. Brain angiography was not performed at that time, and the patient recovered after symptomatic treatment. Family members exhibited no sign of the case pathology. Upon examination, the patient appeared lethargic and sluggish, with normal vital signs. Visual acuity was impaired in the right eye with a score of 20/200 on testing. Pupils were 3 mm bilaterally, round and reactive. Regarding motor function, muscle strength was decreased in the left extremities (Medical Research Council strength score, grade 3). Hypoesthesia of the left side was also observed. Babinski sign was present bilaterally. Further investigations revealed a positive AQP4 antibody in the serum, with an elevated titer of 1:32. An initial diagnosis of NMOSD was made considering her medical history and radiological findings. Other tests including complete blood count, basic metabolic panel, serum glucose, and anti-nuclear antibodies were all normal. Brain MRI after admission indicated lesions with restricted diffusion in the right thalamus and hemosiderin depos

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old man was admitted to our Department on May 2013 as emergency case because of gastrointestinal bleeding and anaemia. The patient's medical history was significant for hypertension, noninsulin-dependent diabetes mellitus and iron-deficiency anaemia.
Anamnesis is also characterized by a diagnosis of skin melanoma in the abdominal region on April 2011; however, the patient gave us such information only at the end of our surgical treatment. At that time a diagnostic excisional biopsy of the lesion was performed and the histological report confirmed: “III Clark level, Breslow thickness 0.55 mm malignant melanoma with the prevalence of superficial diffusion and without regression or vascular infiltration”. Consequently a wide skin removal was performed, because a melanoma was found on the skin near to the previous excision. However the patient did not have sentinel lymph node biopsy procedure or any follow-up control because he did not accept them.
At the beginning of 2013 the patient had several episodes of melena and, with the aim to discover the source of bleeding, we performed a colonoscopy with biopsy (the histological diagnosis was hyperplasic adenomatosus polyp) and a gastroscopy which solely showed an antral gastritis and an inflammatory stomach polyp. Moreover the patient underwent abdominal US and MRI and a total body CT scan that showed right axillary lymphadenopaty, a nodular lesion in the medial lobe of the right lung and a big mass (7 cm of diameter) in the IV–VIII segment of the liver of which an US-guided biopsy was carried out. In addition we founded an increase in the tumour markers (TPA, NSE, S100B). For a more accurate diagnosis, the patient underwent capsule endoscopy which showed a subtotal stenosing vegetating ulcerating neoplasm of the upper jejunum (just below the Treitz's ligament); because of this, it was impossible to end the examination.
While we were waiting for the histological response of the hepatic biopsy, the patient had a se

[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 propositus is a 3-year-old right-hand dominant girl who presented to a multidisciplinary neurodevelopment clinic with a question of developmental delay and hypotonia. Early spotting in the third week complicated the pregnancy however, no subsequent difficulties occurred. She was born at 41 weeks of gestation by vaginal vertex delivery. Apgar scores were 8 at 1 min and 9 at 5 min. The birth weight was 3935 grams. She had a stable neonatal course and was breastfed for the first 7 months of life. She presented with early emesis but with no history of reflux or aspiration. She did have a history of chronic respiratory congestion since early infancy and was subsequently diagnosed with asthma; which was treated with Flovent and Ventolin. She had a history of recurrent middle-ear infections requiring myringotomy tubes. Serial neuro-opthalmologic assessments were performed for mild intermittent exotropia, which had been improving. An MRI of her brain at 1 year of age showed normal brain structures with no evidence of agenesis of the corpus callosum.
Early in her second year of life, her parents were concerned when her walking milestone was delayed. She walked at the age of 23 months, but continued to have difficulties with balance and coordination and was quite a cautious child. Her first words were around the age of 8 months. Slow progress was made and by her assessment at 31 months of age she had approximately 30 single words and was not combining words into phrases. She had difficulties with pronunciation and remained unintelligible to unfamiliar people. In her fine motor skills, she was found to be severely delayed in both manipulation and skills required for self-care. She was not toilet trained. A decrease in pain sensation was also reported. She was very social, had a happy temperament and enjoyed a variety of play activities although at a younger developmental level than her chronological age. There was no regression and no signs of autism.

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

[User]
RADIOLOGY NOTE:
A 28-year-old Caucasian woman, gravida 4, para 1, was referred to our high-risk obstetric unit at 24 weeks' gestation for fetal ascites detected during a routine ultrasound examination. Her personal and family history did not reveal any pathology of note. Her first pregnancy ended with an intra-uterine death at 23 weeks' gestation caused by chorioamnionitis. In the second pregnancy, a live baby girl was delivered at 40 weeks' gestation. Four years later our patient had a spontaneous miscarriage. Our patient denied any fever, rash, cold symptoms, or joint pain before and during pregnancy. She did not refer to any vaginal bleeding. Laboratory tests for Toxoplasma and rubeola showed negative immunoglobulin M (IgM). An ultrasound examination performed during the consultation confirmed the presence of abdominal ascites (Figure ). A borderline monolateral dilation of the cerebral ventricle was also seen. Biometry of the fetal limbs was below the mean in relation to gestational age, while cephalic measurements were normal. No other fetal anomalies were observed. Amniotic fluid was present in adequate quantity, but fetal movements were poor. For these reasons, the woman was admitted to our institution for close pregnancy monitoring. During hospitalization, her blood pressure and heart frequency were measured several times during the day, while cardiotocography was performed twice a day. Maternal blood pressure was normal, and there was no proteinuria. Investigation about the etiology of the fetal ascites were carried out, and a fetal paracentesis was also performed. Both parents had normal mean corpuscular erythrocyte volume with no sign of microcythemia and they both had positive blood group Rh without any pathologic antibodies. A routine blood laboratory assessment did not show any kind of abnormalities. Viral serology markers (cytomegalovirus IgG and IgM, parvovirus IgG and IgM) were negative in the maternal blood, and no viral genome was isolated in her amniotic fluid o

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


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

[User]
RADIOLOGY NOTE:
The patient is a 15-day-old dizygotic twin girl born via uncomplicated vaginal delivery. She was referred to our institution as a result of findings of ventriculomegaly noted on prenatal screening ultrasonography. The cause of the hydrocephalus was unknown at that time. On examination, the patient had a soft but full anterior fontanelle, along with dilated scalp veins. The head circumference was greater than the 97th percentile for gestational age. No focal neurologic deficits were appreciated on examination. Postnatal cranial ultrasonography revealed progressive hydrocephalus as well as a midline echogenic mass in the posterior fossa with mass effect on the cerebellum. Magnetic resonance imaging (MRI) was obtained, which revealed a very large dural-based extraaxial mass along the dorsal aspect of the posterior fossa []. The mass was well-circumscribed and heterogeneous, but mostly T1 isointense and T2 hypointense with flow voids and evidence of previous hemorrhage within it. Avid contrast enhancement was seen. There was marked mass effect on the cerebellum, fourth ventricle, and brainstem with resultant obstructive hydrocephalus and evidence of transependymal flow. The differential diagnoses of an intracranial vascular lesion in this 15-day-old infant included hemangioma, hemangioblastoma, vascular malformation, and other neonatal tumor types, such as soft-tissue sarcoma.[] In addition, meningioma could not initially be definitively excluded because of the dural attachment.
Owing to the compressive nature of the lesion and the progressive hydrocephalus, the infant was taken to the operating room for resection of the posterior fossa lesion. Prior to the resection, an external ventricular drain (EVD) was placed in the occipital horn of the right lateral ventricle with care to avoid the egress of cerebral spinal fluid until the tumor was resected. A suboccipital craniectomy and C1 laminectomy were performed. The lesion appeared extremely vascular and clearly emanated

[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 presented to our emergency department due to acute onset chest pain. He originally presented three days earlier with similar symptoms but was released from the emergency department when the cardiovascular workup was negative. His current chest pains were localized to the midsubsternal area. Morphine and nitrate treatment were not effective in relieving his pain.
The patient has a history of seizure disorder, high blood pressure, reflux disease, gastritis, hiatal hernia, osteoporosis, and osteoarthritis. He had encephalitis at approximately 18 months of age and a subsequent head injury. At 3 years old, the patient had a large benign brain tumor which was removed. These early incidents resulted in developmental and physical disabilities.
On admission his troponin I level was minimally elevated, and D-dimer was elevated. The patient was anemic and an upper endoscopy was scheduled to rule out a gastrointestinal bleed.
The endoscopy findings showed evidence of Grade IV esophagitis. The ulcerations extended in the esophagus from 25 cm to 32 cm. A 15 mm linear ulcer was also seen on a hiatal hernia (). The stomach and duodenum appeared normal.
The biopsy results of the esophagus showed esophageal squamous mucosa with marked acute and chronic inflammation, granulation tissue, and overlying necroinflammatory exudate. In addition, there were abundant sheets of plasma cells, seen in all biopsy fragments (). The atypical plasma cells demonstrated abundant cytoplasm with eccentrically placed nuclei, some with prominent nucleoli ().
Immunohistochemical analysis revealed that the plasma cells expressed CD138 and MUM1 and were IgG kappa restricted ().
A whole body PET/CT scan was subsequently performed. The findings showed a focal area of increased metabolic activity in the midesophagus which may correspond to the biopsy site. An enlarged and abnormally metabolically active lymph node was identified in the left paratracheal position measuring 1.3 cm. There was als

[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 otherwise healthy woman presented with three to four months of mechanical right groin pain radiating to the right buttock. She had a history of a benign soft-tissue mass in the right thigh that had been biopsied 10 years earlier, and the patient was told it was a myxoma. No other workup was done at the time, and no other lesions were clinically detectable. She had been very active and played tennis regularly. She was assessed with a hip ultrasound for her right groin pain and was prescribed physiotherapy. During physiotherapy, she felt a snap in her right groin and was no longer able to ambulate without a walker. Initial radiographs demonstrated a lucent intramedullary lesion within the subtrochanteric region—further characterized by a focally aggressive appearance with cortical destruction and lytic expansion of the lesser trochanter (Figures and ). A ground-glass appearance, typical of fibrous dysplasia, was also noted in the mid-femoral shaft ().
Further workup included a Computed Tomography (CT) scan of the chest, abdomen, and pelvis which showed multiple hepatic and renal cysts but no evidence of a primary carcinoma or lung metastases. Bloodwork including serum protein electrophoresis was normal. A Total Body Bone Scan (TBBS) revealed increased uptake in the right proximal femur and two areas of relatively mild uptake in the mid femur. Fat-suppressed T2 Magnetic Resonance Imaging (MRI) displayed an intermediate to high signal lesion within the medullary cavity of the proximal and mid right femoral shaft (). In line with the initial radiographs in which two benign sites of fibrous dysplasia were noted, in the third proximal lesion, there was cortical destruction with an extraosseous soft-tissue mass in the region of the lesser trochanter. Additionally, in keeping with the known myxoma, a soft-tissue T2 hyperintense mass within the medial distal thigh was also present (). On further review of the MRI images, five other myxomas were seen

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


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

[User]
RADIOLOGY NOTE:
A 41 years old South Asian female of Indian descent, a homemaker by occupation, presented to the Otorhinolaryngology outpatient department with bilateral hearing loss for one month. The hearing loss was sudden and occurred within two days. The hearing loss was preceded by an episode of upper respiratory tract infection. There was no history of diabetes mellitus, hypertension or tuberculosis. She was taking hormone supplementation for hypothyroidism. There was no relevant family history. On examination of the ear, the tympanic membrane was retracted bilaterally. An audiogram revealed moderate to profound sloping mixed hearing loss on the right and moderate to severe sloping mixed hearing loss on the left with bilateral “B” type tympanogram ).
Her routine blood investigations were unremarkable except for an erythrocyte sedimentation rate of 42 mm. Ultra-sonogram of the neck showed bulky thyroid gland with nodules in the right lobe. She was treated with systemic steroids (Prednisolone 1mg/kg body weight) for 10 days, which was tapered over 16 days. At the time of discharge, her hearing had dramatically improved ().
Two weeks later, she again presented with decreased hearing in both ears. An audiogram revealed mild to moderately severe mixed hearing loss with bilateral “C” type of tympanogram. On myringotomy, thin serous fluid was present in both middle ears and grommets were inserted bilaterally. Diagnostic nasal endoscopy and blind biopsy of the fossa of Rosenmuller on both sides was also done. Histopathology was reported as normal with no evidence of malignancy.
After 10 days she presented with facial weakness on the right side and difficulties in speech and swallowing in addition to hearing loss, tinnitus and vertigo. Vertigo was mild, rotatory and brought about by sudden changes in posture. It was not associated with vomiting or sweating. Tinnitus was bilateral, continuous and resembled a whistling tone. Audiology revealed moderate to severe mixed hearing loss on t

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


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

[User]
RADIOLOGY NOTE:
A 34 year old female patient reported to Department of Oral Medicine and Radiology, with a chief complaint of swelling of the lower jaw since six years. She stated that a small swelling on the left side of jaw was noticed six years ago, measuring about 1cm in diameter, which gradually increased to the present size, involving both sides of the face. There were no subjective symptoms, except for difficulty in chewing food.
Gross facial asymmetry was noticed due to a swelling involving the middle and lower one third region of the face []. Bilaterally fullness of the cheeks and lower lip with obliteration of the mentolabial sulcus and nasolabial fold was noticed. A well demarcated swelling was noticed over the left cheek region and a diffuse swelling over the right side, which extended from the left ramus of the mandible to the right body of the mandible with obliteration of inferior border of the mandible. Swelling on the left side was roughly ovoid in shape, measuring about 8 × 6 × 5 cm[]. Skin over the swelling was stretched. On palpation the swelling is hard in consistency, lobulated and nontender; with no accompanying cervical lymphadenopathy.
On intraoral examination [], a diffuse swelling was seen extending from the left to right retromolar region. Bilaterally, vestibular obliteration was noticed due to buccal labial and lingual cortical plate expansion with normal appearing mucosa. Swelling was hard, lobulated and nontender. Correlating the history and clinical findings, a provisional diagnosis of benign fibro-osseous lesion of mandible was given and differential diagnosis of fibrous dysplasia, ossifying/cementifying fibroma and central giant cell granuloma (non- aggressive lesion) was given. Patient was further subjected to hematological, radiological and histopathological investigations. Routine hematological examination, serum protein, calcium, phosphorus and alkaline phophatase levels were estimated and the values obtained were within the normal range.
Panor

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


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

[User]
RADIOLOGY NOTE:
In 2008, a 13-year-old boy was referred to Department of Oral Pathology, Government Dental College and Hospital, Aurangabad, Maharashtra, with a complain of progressive deformity of left side of face since 5 to 6 years. During the physical examination, it was noted that this patient presented a facial asymmetry with marked hypoplasia of the left side of the face, deviation of lips and nose toward left side, and enophthalmy in left eye region [Figures and ]. A big linear dark scar (coup de sabre) was present in the left side of mandibular mentum region passing upward to involve lips and left ala of nose producing obvious depression []. The notching of the upper and lower lip leads to exposure of anterior teeth on left side. Alopecia was noticed in the region of left eyebrow toward medial side []. Patches of hyperpigmentation were seen on the skin of affected area. In addition, ear on left side was slightly smaller than that of right side.
Intraorally, the most relevant alteration was the unilateral atrophy of tongue papillae of left side []. There was over-retained maxillary left deciduous canine with palatally erupted permanent canine leading to crowded left maxillary arch. The occlusion was disturbed with midline shifted to the left side. Also, there was hypoplasia of maxillary anterior teeth [].
Radiographically, an abnormal root development was seen with maxillary left premolars. The over-retained root pieces of deciduous mandibular second molar of left side were seen on mesial and distal side of roots of second premolar. The overall eruption pattern of teeth on left side was retarded as compared to that of right side. The mandible showed decreased vertical height of ramus along with loss of gonial angle prominence on the affected side [].
The patient presented with good general health condition without any history of obvious past illness that would explain the cause of facial asymmetry.
With these clinical 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 61-year-old woman fell over a barrier curb while walking and bruised her right shoulder. A local clinic examined the patient and diagnosed her with anterior dislocation of the shoulder with a glenoid rim fracture (). The right shoulder had been immobilized with a sling for a month after immediate reduction (). However, the active range of motion for the shoulder remained limited. An MRI scan two months after injury revealed rupturing of the supraspinatus tendon. The patient was referred to our hospital for further management. Clinical examination found stiffness in the right shoulder with muscular weakness. Respective ranges for active and passive right shoulder flexion were 30 degrees and 120 degrees. There was sensory disturbance over the lateral aspect of the shoulder. Radiographs and CT scanning revealed a large anteroinferior glenoid rim fracture, a type IA fracture under the Ideberg classification [, ]. The articular surface was displaced by 2.5 mm, and the width of the bony fragment was 30% of the glenoid length. Upon initial presentation at our hospital, the fracture had already achieved partial union (); therefore, we treated the glenoid rim fracture conservatively. An MRI scan showed a large tear approximately 3 cm long in the supraspinatus tendon, with atrophy and fatty degeneration of the supraspinatus muscle (). Electromyography and nerve conduction studies showed an incomplete lesion of the axillary nerve; therefore, we diagnosed axillary nerve palsy in addition to glenoid rim fracture and rotator cuff tear. The axillary nerve palsy was incomplete and recovering. Following improvement in manual muscle testing (MMT) of the deltoid from grade 4/5 to 5/5 and the disappearance of the sensory disturbance three months after injury, we performed an arthroscopic rotator cuff repair using a suture bridge technique (). Shoulder function recovered satisfactorily with approximately full ranges of motion one year after surgery. Constant score recovered from 38 po

[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:
After falling off a mountain bike down an incline into some brush, a 49-year-old male mountain biker presented to an outside ED with normal vitals, severe vertigo, nausea, intractable vomiting, profound hearing loss, and tinnitus. A CT was performed, which showed opacification of the ear canal, but did not comment on any abnormalities of the inner ear. The patient was transferred to our facility for further management. On examination, there was a spontaneous right-beating nystagmus and the facial nerve was intact. A tree twig was embedded in the left external auditory canal, obscuring visualization of the tympanic membrane.
Temporal bone CT demonstrated a linear foreign body projecting from the external auditory canal to the oval window, and an additional, separate small foreign body projecting into the vestibule. Presence of extensive intralabyrinthine air was detected radiographically (). On axial view, air bubbles were seen in the vestibule, posterior semicircular canal, and the scala vestibuli compartment of the cochlear basal turn, as well as in the lateral and superior semicircular canals (). Preoperative audiogram conducted at bedside revealed normal hearing on the right side and moderate-to-severe mixed hearing loss on the left.
The patient was diagnosed with a traumatic PLF with extensive pneumolabyrinth due to penetrating temporal bone injury and was taken urgently to the operating room less than one day after his inciting injury. A three- centimeter tree twig was lodged in the ear canal and found to be penetrating the tympanic membrane. Postauricular approach included mastoidectomy and intraoperative assessment of the middle ear ossicles and extent of injury. The long process of the incus was dislocated but still attached to the malleus, the stapes was deeply embedded into the vestibule, and the oval window was completely open but covered by blood clot. All penetrating foreign bodies were extracted. Temporalis fascia was used to seal the oval window and a

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


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

[User]
RADIOLOGY NOTE:
An 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 61-year-old woman was referred to our center for urgent coronary angiography due to failed thrombolysis and ongoing chest pain. She had been previously admitted to a hospital in another city far away from our center due to acute inferoposterior myocardial infarction (MI). She had no known atherosclerotic risk factors, but laboratory examination revealed dyslipidemia with high serum triglyceride (230 mg/dl) and low high-density lipoprotein cholesterol (36 mg/dl). On admission, hemodynamics was stable and chest pain had subsided. On electrocardiography, there were low-voltage limb leads with small q waves in the inferior leads and a pattern of incomplete right bundle branch blockage with an R/S ratio greater than 1 in lead V3 in the precordial leads, altogether indicating a recent inferoposterior MI. Echocardiography revealed inferoposterior wall akinesis with a left ventricular ejection fraction of 40%.
The patient subsequently underwent coronary angiography. The left circumflex artery (LCx) was cut off after the first obtuse marginal. The LAD had severe long stenosis (up to 90%) at midportion. An anomalous vessel was seen originating from the midportion of the LAD (shortly after the second septal perforator within the diseased segment), which followed the course of the RCA (). In this case, the anomalous RCA traveled along the free wall of the right ventricle into the atrioventricular groove and gave rise to a posterior descending artery (). Interestingly, there was also a separate small artery originating from the right coronary sinus that was most probably a right atrial branch (). Aortic root injection confirmed the absence of the RCA stump or any other vessel except for the small right atrial branch in the coronary sinuses as well as the ascending aorta ().
A decision was made to predilate the LCx lesion using a 1.5 × 15 mm balloon in order to visualize the distal bed. There were 2 more large obtuse marginal branches at distal (). Stenting was not performed du

[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 19-year-old Caucasian female with no past medical or surgical history. She presented to the orthopedic oncology clinic three months after a sudden onset of a traumatic left ankle swelling. An outside provider placed her in a CAM walking boot for a presumed ankle sprain; her swelling eventually subsided. After removing the boot and returning to unrestricted activity, the swelling returned. An MRI was done, which showed a large distal fibular mass with characteristics consistent for Ewing Sarcoma (). She underwent a CT guided biopsy on the same day of the initial consultation, which demonstrated a small round blue cell lesion that was CD99 positive, FLI 1 positive, and FISH positive for EWSR 1, confirming the diagnosis of Ewing Sarcoma (). The Hematology/Oncology service promptly saw her, and staging studies were negative for distant metastasis (). Pre-chemotherapy echocardiogram demonstrated an ejection fraction of 62 %. She was started on a neoadjuvant regimen of vincristine, doxorubicin, and cyclophosphamide. She also underwent a pre-operative radiation therapy regimen at a total dose of 4500 cGy broken up into 25 fractions. After completing her neoadjuvant chemotherapy and radiation treatment, a repeat MRI scan showed a significant decrease in the distal fibular lesion and soft tissue component (). She continued to be followed with surveillance MRI scans for local recurrence until a decision was made between the patient, family, and treating specialties to proceed with surgical treatment.
Just over one year from the initial presentation, she underwent en bloc resection of the distal left fibula, neurolysis of branches of both the superficial peroneal and deep peroneal nerves, local flaps, and reconstruction of the lateral ankle ligaments using the peroneus brevis (). She was immobilized in the immediate postoperative period with a three-sided short leg splint and was instructed to be non-weight bearing.
She did very well ten months postoperative without evidence

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old female patient presented to our department with complaint of pain and mild swelling on the right side of the face since the last 2 months. She gave a history that pain is aggravated while opening the mouth, chewing and on application of pressure on that area and was not relieved by NSAIDs. Her past medical history revealed history of typhoid fever 3 months back for which she had taken complete course of treatment.
On extraoral examination, maximal mouth opening was reduced to around 28 mm and a diffuse swelling around 1 × 1 cms in diameter was also observed in the right temporalis muscle which was soft to firm in consistency and was tender on palpation (). Examination of the TMJ and other muscles of mastication revealed normal findings. On intraoral examination edentulous spaces were present involving the right and left mandibular posterior teeth.
On the basis of the history and examination findings, a clinical provisional diagnosis of myofascial pain was made and the patient was put on the treatment of muscle relaxants Tab Myospaz forte two times a day and topical application of voveran emuigel along with hot fomentation, soft diet, and bilateral chewing. The patient reported to us after 3 days but she did not have relief whatsoever. Reevaluation of the case was done and she was advised of blood investigations along with ultrasonogram (USG) and MRI involving the right side of the face. The findings of the blood investigations were normal. USG showed the presence of a well-defined anechoic lesion around 1.2 × 1 × 0.9 cms involving the right temporalis muscle with its long axis parallel to its fibres and 14 × 12 mm echogenic nidus was also seen within it (). MRI revealed the presence of a rounded iso to mildly hyperintense lesion in the right temporalis muscle with an identifiable hypointense nidus on T1 and T2 and Fiesta-C images (). The lesion also

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 7-year-old girl with metastatic medulloblastoma (T3b M1 according to the Chang staging system) diagnosed as a result of an epileptic seizure after 3 months of headache. Brain MRI in July 2000 revealed a mass in the posterior fossa, in the midline cerebellum next to the fourth ventricle and vermis, causing hydrocephalus and an initial herniation of the cerebellar tonsils. At the end of July, she underwent a macroscopically complete resection of a 3 × 3 cm nodule filling the fourth ventricle and attached to its lateral recesses. The final histologic diagnosis was classic medulloblastoma.
A postoperative cerebral and spinal MRI in August 2000 revealed an ambiguous neoplastic residue close to the surgical cavity, jutting out into the fourth ventricle, and malignant neoplastic cells were found in the cerebrospinal fluid.
From August 2000 to March 2001, the girl was treated according to our institutional protocol for metastatic medulloblastoma/PNET in children over 3 years of age, which included sequential high-dose chemotherapy, radiotherapy, and myeloblative-dose chemotherapy with autologous hemopoietic stem cell rescue []. The protocol was partially modified omitting two scheduled vincristine administrations due to intestinal toxicity after the first course.
Hyperfractionated accelerated radiotherapy was administered from November to December 2000, scheduled in two daily 1.3 Gy fractions 6 hours apart, 5 days a week for a total dose of 31.2 Gy to the craniospinal axis plus a boost to the posterior fossa using a 1.5 Gy fractionation twice a day to give a total dose of 59.7 Gy.
Diagnostic lumbar puncture before radiotherapy still documented malignant neoplastic cells, while lumbar puncture and MRI after radiotherapy and between the two myeloablative courses were both negative, with the latter showing only surgical sequelae.
In June 2001, our patient started the follow-up program with routine MRI and outpatient visits. In September 2001, MRI showed

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old female patient had come to the Department of Orthodontics, with the chief complaint of forwardly placed upper front teeth. Her medical history was found to be noncontributory.
On extraoral examination, facial asymmetry was evident for which patient was unaware. There was no history of trauma. The patient did not have any difficulty in opening of mouth. Inspection showed elongation of left side lower half of face as compared to the right side. The left side of the face appeared flattened as the prominence of the chin appeared shifted to the right side [].
On intraoral examination, her molar relationship was found to be Angles Class II on right side and end on the relationship on the left side. The lower midline was shifted 3 mm to the right side with respect to maxillary midline [].
Radiographic investigations were also carried out. Panoramic view of girl revealed symmetrical condylar enlargement of the left side in comparison to the right side and condylar neck along with the elongation of the left side of ramus [].
PA cephalogram of the girl showed a shift of dental midlines due to the asymmetry of the mandible [].
Her mother who was 44 years old had accompanied her and asymmetry in her face was also noticed. She was unaware of it and gave consent to be examined. On examination, she did not have any difficulty in opening her mouth. The chin was deviated to the right side as left side of her face was elongated. The left side of face appeared flattened [].
Intraorally, her oral mucosa was normal with permanent dentition and a total of 24 teeth. Her oral hygiene was poor and no previous history of trauma. Medical and family history was noncontributory. There were root stumps and carious teeth present. Maxillary right first molar had already been extracted. Clinically, she showed a lower midline shift to the right side, chin deviation and misalignment [].
PA cephalogram

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old man without any symptoms was referred to Hino Municipal Hospital, because of a faint infiltrative shadow observed in the left lower lung field on routine chest radiography (). The patient did not complain of chest wall swelling; however, the physical examination revealed a subcutaneous soft tumor on the left anterolateral chest wall without tenderness or a skin surface abnormality. The transcutaneous oxygen saturation of peripheral artery was 94% under the room air inhalation at the diagnosis. He had never smoked previously and was taking medication for hypertension and asymptomatic cerebral infarction. Contrast medium-enhanced chest computed tomography (CT) revealed an enhancing tumor (58 × 33 mm in size) on the left anterolateral chest wall with destructive changes in the 6th rib bone (), corresponding to the abnormal shadow on the chest radiograph. In addition, a massive filling defect of the right proximal pulmonary artery was detected with pulmonary nodules in the right lung (Figures and ). Importantly, the “mass” in the pulmonary artery was, unlike in CPTE, weakly enhanced with contrast medium. Pulmonary nodules existed only on the ipsilateral side of the pulmonary artery mass and formed a mold-like shape in the peripheral pulmonary arteries. Further examination did not identify another site of suggestive malignancy, except for prostate cancer using body CT and head magnetic response imaging (MRI). A laboratory test did not show any significant abnormalities, including those of D-dimer and tumor markers. These findings implied a possible diagnosis of primary sarcoma of the pulmonary artery with metastases to the lungs and chest wall.
The patient was referred to Keio University Hospital for further examinations. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a positive uptake of FDG to the pulmonary artery tumor (standardized uptake value, SUVmax 5.32), the chest wall tumor (SUVmax 9.56), and lung nodules (highest SUVmax 3.50)

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old male with no history of trauma or prior neurological disease presented with 3 days of intermittent dizziness and vomiting. On the second day, the patient was examined by a head computed tomography (CT) scan, and no abnormal changes were found. Five days later, the patient had a sudden onset of weakness in his right limbs, followed by an episode of focal seizure without impaired awareness. The patient had symptomatic deep venous thrombosis (DVT) in the left lower limb 4 years ago, which was treated with warfarin for 3 months. No secondary prophylaxis was subsequently applied, and as a result he experienced multiple recurrences of lower limb DVT. The patient also had a 5-year history of hypertension without antihypertensive therapy. He also had a 2-year history of Raynaud’s phenomenon in his hands, as well as a 30-year history of smoking (10 cigarettes per day) and alcohol intake (50 g per day). The patient’s parents had died of ICH. Additionally, the patient’s three sisters were diagnosed with hypertension, and one brother had a history of occlusion of the distal artery in the right leg at the age of 55 years. The patient’s son had their first symptomatic lower limb DVT at the age of 25 years, for which he underwent inferior vena caval filter placement.
Upon examination after admission, the patient had a blood pressure of 164/92 mmHg. Skin color, temperature, and peripheral pulses were normal. No varicose veins or swelling of the limbs were found, and the lung and heart examinations were normal. The patient was fully alert and oriented, with no signs of cognitive impairment, thus neurocognitive tests were not performed. Results of the cranial nerve and sensory examinations were normal. Motor examination revealed spastic tone and moderate pyramidal weakness in the right arm and leg (4/5), with a total NIHSS score of 2. Repeated head CT plain scans (Fig. a) and brain magnetic resonance imaging (MRI)

[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 Greek male patient underwent a radical nephrectomy for a stage 2, grade 3, renal cell carcinoma in September 2001. Five years later, he presented with left hip pain and he was eventually diagnosed with biopsy proven relapsed disease. Imaging with CT scans and bone scan revealed a prominent bulky metastatic lesion extending from the acetabulum of the left iliac bone into the iliosacral joint, a metastatic lesion of the second left rib, as well as several metastatic pulmonary nodules (,). He was started on anti-angiogenetic TKI agent sorafenib and biphosphonates.
After a year of treatment, in October 2007, a necrotic ulceration appeared on the left flank area, proven by CT to be an extension of the increasing metastatic left iliac focus, which measured 8 cm in maximum diameter, associated with increasing pain. The lesion was considered too large to be controlled with irradiation. The patient underwent an arterial embolization of the metastasis using a femoral artery approach (). One week later, the same mass was treated by radiofrequency ablation (RFA) (). The procedure was well tolerated overall and led to significant pain reduction (). However, the ulceration rapidly enlarged and evolved into a crater-like deficit of the skin and subcutaneous tissue 5 cm deep and of 5 cm diameter (). It was decided to be managed conservatively with frequent local wound care. Antiangiogenic treatment was suspended for a period of a month to allow for wound healing. However, during this time the pain recurred and a follow up CT showed evidence of extension of the large lesion medially towards the spinal canal; the bulk of the lesion was necrotic and a large tissue deficit was documented. The patient received external beam irradiation with symptomatic control (4750 cGy in 19 sessions) followed by initiation of sunitinib and biphosphonates. The patient continued improving, regained ambulation, and his disease elsewhere remained stable for over 16 months. His necrotic ulcer

[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 43-year-old premenopausal woman with Gravida 3 and Para 3 came to gynecology outpatient unit with complaints of irregular vaginal bleeding and lower abdomen pain since 6 months. There was no significant medical history. On clinical examination, vital signs were normal, and abdomen was soft with no palpable mass. Abdominal and pelvic ultrasonography (USG) was performed and revealed heterogeneous echogenic mass each in uterine corpus (3.5 cm × 2.5 cm × 2.5 cm) and cervix (1.2 cm × 0.8 cm). A diagnosis of leiomyoma in uterine corpus and cervix with degenerative change was made. Surgical specimen of hysterectomy was received for histopathological examination. Specimen showed a well-circumscribed gray-white to yellow tumor mass (3 cm × 2.5 cm) at upper pole of uterine corpus and yellow tumor mass (1 cm × 1 cm) in cervix [].
Histopathology examination of the tumor from uterine corpus showed a tumor composed of lobules of mature adipocytes separated by fibrous septae. At places, thin bundles of smooth muscle cells were seen. Small sized normal blood vessels were seen in . There was no nuclear atypia or increased mitotic figures. A diagnosis of lipoleiomyoma was made. Histopathology of tumor from cervix showed a tumor tissue composed of lobules of mature adipocytes, thick fibrous septae [], and few entrapped mucosal glands []. A diagnosis of pure lipoma was made.
Immunohistochemical (IHC) stains such as smooth muscle actin (SMA) and vimentin were done in sections of both the tumors to confirm the nature of cells. Smooth muscle cells, endothelial cells from the tumor of uterine corpus showed immunoreactivity with SMA and adipocytes were negative [] Vimentin staining showed immunoreactivity with smooth muscle, endothelial cells and mature adipocytes, fibrous septae were negative [].
In sections of cervical lipoma, only endothelial cells of blood vessels showed immunoreactivity with SMA, and fibrous septae and mature adipocytes were negative []. Mature adipocytes

[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 69-year-old man was referred for surgical assessment after the findings of an abdominal wall and left atrial (LA) mass. He had mild obstructive lung disease and a 30-pack-year smoking history. He sought medical attention after experiencing abdominal discomfort and had noted a 30 lb weight loss over the last few months, apparently related to dieting. There were no other constitutional symptoms. His symptoms persisted despite a course of antibiotics, for presumed diverticulitis. Physical examination was unremarkable. Laboratory investigations revealed a hemoglobin of 131 g/L (normal: 140–180), with all other values within normal limits. Emergency computed tomographic (CT) scan revealed a 5 × 4 cm heterogenous mass in the left anterior abdominal wall and an intracardiac mass. CT head, chest, and abdomen did not show any other masses.
Two biopsies of the abdominal wall mass were examined, and most of the tissue was necrotic. The conclusion was that a definitive diagnosis was not possible (in spite of the immunohistochemistry) and that the definitive diagnosis was best accomplished following cardiac and abdominal mass resection.
Transesophageal echocardiogram (TEE) revealed a 4.4 × 3.5 cm mass attached to the posterolateral wall of the left atrium, above the mitral annulus. Mean and peak gradients across the mitral inflow were 4 and 12 mmHg, respectively (). Cardiac CT and MRI corroborated the TEE findings ().
Coronary angiography showed a 90% right coronary artery (RCA) lesion. The patient underwent extensive resection of the LA mass and repair of the left atrium, left ventricle, left ventricular outflow tract, as well as mitral valve replacement and saphenous vein graft to RCA. The postoperative course was complicated by acute renal failure requiring dialysis and reintubation for volume overload. Ten days postoperatively, he became acutely hypotensive, developed multiorgan failure, and succumbed to his illness.
Macroscopic examination of the cardiac specimen revealed

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male patient was admitted to our hospital's gastroenterology department. The patient had no specific medical history, except for dyslipidemia, and complained of rectal tenesmus, lasting for 1 month, and anal pain, which had progressively worsened for 10 days. At the time of arrival, stool occult blood test was negative and no relevant findings in other laboratory results were identified. An 8-mm polyp in the ascending colon was detected during colonoscopy, and hyperemic mucosal swelling with nodularity was noted at 4–17 cm from the anal verge (Fig. ). Biopsies performed for each lesion indicated adenoma and chronic colitis, respectively. Diffuse swelling throughout the rectum was seen on CT, and engorgement of the superior rectal veins with early draining was also observed (Fig. ). AVM-related venous hypertension was suspected as the cause of symptoms, and angiography was requested. On angiography performed 3 days later, rectal AVM was identified at the inferior mesenteric artery just before the beginning of the superior rectal arteries and was drained via fine feeders into the inferior mesenteric vein with a large venous aneurysm (Fig. ). Venous regurgitation by venous hypertension was also clearly observed through the retrograde flow of the superior rectal veins (Fig. ). After an in-depth discussion with the patient about the options for surgery or other endovascular embolization, transarterial sclerotherapy using ethanol was decided. After selection to the far distal feeding artery using a microcatheter, sclerotherapy was performed several times using a total of 5 mL of 80% ethanol (Fig. ), while shunt was gradually reduced in serial follow-up angiography. To prevent venous thrombosis, 2,000 units of heparin were intravenously administered during the procedure. The early arteriovenous shunt was completely lost in completion angiography, and a little spasm was observed in the distal branch of the superior rectal arteries (Fig. ). The spasm improved a

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


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

[User]
RADIOLOGY NOTE:
A 56 year old previously healthy Caucasian woman and non-smoker, presented to the outpatient chest department with symptoms of episodic bouts of dry cough associated with an occasional wheeze for 12 months and upper thoracic back pain for 3 months. She had no history of chest trauma. On examination, she was not breathless or wheezy and she had a normal temperature. The chest radiograph revealed an area of gas-filled tissue in the upper right mediastinum (fig. ) and a Computer Tomography (CT) scan confirmed a loculated air-filled collection predominantly anterior to the trachea and extending below the carina with no evidence of fluid within the locules. There was no air tracking into the neck or the abdomen. (fig. ). The patient had no recollection of having the cyst diagnosed in the past. The patient was stable and a wait and watch approach was taken, and the patient was to be reviewed in 3 months.
She was readmitted 2 months later with severe chest pain. On examination she was breathless with an expiratory wheeze and was febrile (37.5°C). The patient was not in shock. A repeat chest radiograph (fig ) and CT scan (figs. and ) demonstrated a 9 × 5 cm loculated mass containing fluid and gas, encasing the lower trachea and the main proximal bronchi and extending from the innominate vein to the left atrium consistent with a mediastinal abscess. Bilateral pleural effusions were also present. The lungs were normal. The patient was treated with broad spectrum antibiotics and then had an open thoracotomy three days later with complete resection of the mass. The air-fluid level seen on the CT scans would suggest a tracheobronchial communication but no such communication was found during the operation. Histopathological examination of the mass revealed a collapsed thick walled cyst about 55 mm in diameter. The cyst wall consisted of fibrous and granulation tissue with heavy, chronic active inflammation. There were fragmented seromucinous glands on the inner surface of the cys

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old female with significant past medical history of recurrent pancreatitis presented to the emergency department with abdominal pain that was radiating to the back, to the left inferior angle of the scapula. She described it as sharp, stabbing pain of 8/10 on severity scale. She mentioned that she has experienced this type of pain before, but it has been three years since her last episode. She was unable to consume solid foods without “debilitating” nausea, but denied vomiting. The patient mentioned that her first episode of pancreatitis was at the age of seven when she underwent surgery for pancreatic cyst drainage. Family history was also unremarkable. She has an 11 pack year smoking history but denied alcohol intake. Her vitals were as follow: blood pressure of 132/80 mmHg, heart rate of 81 bpm, 94% oxygen saturation, and a temperature of 98.6 F. Patient weighed 247 lbs with a BMI of 36.49. Abdominal examination revealed a large scar in the center of the abdomen with bowel sounds present in all quadrants. Her abdomen was soft, and non-distended but presented with guarding and tenderness, which was especially tender in the left and right upper quadrants radiating to the umbilicus. She had a negative Murphy sign. Her labs were consistent with elevated lipase and amylase. Computed tomography examination conducted in 2010 and 2017 showed evidence of pancreatitis. In the CT study performed in 2017, there was a 10-mm calcification discovered in the head of the pancreas that was not seen in the 2010 study. We suggested magnetic resonance cholangiopancreatography (MRCP) radiological analysis for the patient which displayed a dilated pancreatic head with a maximal diameter of 6-mm. The MRCP findings demonstrated a small amount of fluid between the pancreatic head and proximal descending duodenum, as well as the posterior border of the liver and diaphragm consistent with pancreatitis. The MRCP also showed evidence of a small remnant

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old man, with extensive cardiac history and an AICD located within the radiotherapeutic field, was successfully treated for stage IIIB NSCLC with definitive dose of thoracic chemoradiation. With a history of type II diabetes mellitus and transient ischemic attacks, the patient was initially evaluated at our institution for cardiac disease. He was found to have triple vessel coronary artery disease and congestive heart failure requiring coronary artery bypass grafting (CABG) and placement of a prophylactic AICD (St. Jude Medical Fortify Assura VR 1257-40Q ICD). During preoperative assessment for CABG, an incidental left apical lung mass appeared on chest radiograph. The decision was made to follow the mass without intervention at that time.
Two months after surgery, he returned to the hospital for a fall during a hypoglycemic episode, at which point a chest radiograph revealed a persistent 3.0 by 2.2 cm mass in the left upper lobe as well as left hilar and supraclavicular lymphadenopathy, this time prompting evaluation for malignancy. Biopsy and staging studies confirmed T1bN3M0, stage IIIB poorly differentiated adenocarcinoma of the lung. Due to the complexities involved in radiation therapy (RT) to patients with AICDs, the final treatment plan included interdisciplinary input from radiation oncology, medical oncology, and cardiology.
The radiation oncology team hesitated to deliver RT to the patient with an AICD located within the field of radiation due to the risk of AICD malfunction. Multiple discussions were held with cardiology, St. Jude Medical, and with the physicians and radiation oncology physics teams about the patient. However, repositioning of the AICD was not possible in this patient's case. Fortunately, our patient was not AICD-dependent, as he had the device prophylactically implanted after CABG and had since experienced a single remote episode of ventricular tachycardia []. After thorough consultation and discussion among the physicians 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 37-year-old man visited a private ophthalmic clinic because of diplopia that was aggravated during his upward gazing. No significant abnormalities were found upon ophthalmologic examination except for a mild conjugation problem occurring during his upward gazing. He was referred to the department of neurosurgery of our institute and he underwent a brain CT. The brain CT showed acute hemorrhage in the third ventricle and there were also spots of calcification (). This hemorrhage showed mixed signals that indicated different ages of the pathology, but there was no hemosiderin rim on the T1- and T2-weighted MR (). The clinical differential diagnosis was primarily split between intratumoral hemorrhages originating from a pineal germ cell tumor, specifically choriocarcinoma vs. hemorrhage from a pineal cyst. The presence of a cavernous malformation was considered to be a less likely diagnostic possibility. We were easily able to rule out the possibility of vascular malformations because MR angiography revealed no such abnormalities (). Two weeks later, he experienced an improvement in the diplopia, but the headache that he had been experiencing became progressively more severe. Brain CTs, performed weekly after the first attack of symptoms, revealed a resolving hemorrhage and the progressively enlarging ventricles (). We performed VP shunting using the HAKIM programmable valve without the prechamber Shunt System, and it was adjusted to an opening pressure of 120 mm CSF. Two days after the shunting, he complained of a sudden aggravation of his diplopia. The follow-up brain CT revealed rebleeding from the previous lesion (). The patient underwent an emergency operation consisting of an occipital-transtentorial approach to the pineal region, and this resulted in the complete excision of a discovered tumor and the removal of the hematoma. The lesion mass was composed of acute and subacute hematomas and it was well encapsulated. These surgical findings corresponded to a cav

[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 healthy Caucasian woman presented with a metal ceramic restoration on the left maxillary central incisor, that did not satisfy her esthetic demands anymore. In addition, the patient was feeling a dull pain in the area. The patient did not smoke and was healthy. The radiographic examination showed an oversized cast post and core, which occupied three quarters of the root's length (). The clinical examination revealed that the metal ceramic restoration was fractured at the buccal marginal area, it had a surface texture that did not match that of the adjacent natural teeth, it was rather opaque, and its margins were placed on the underlying cast post and core instead of on sound tooth structure (). Soft tissue inflammation was evident around the crown's marginal area. An 8 mm pocket depth was found at the distal area of the tooth. The examination also demonstrated a discrepancy of the soft tissue contours between the two central incisors, sufficient width of keratinized tissue in the maxillary anterior area and a scalloped thin periodontium [–].
Treatment options were presented to the patient after assessment of all clinical and radiographic data. The patient wished to restore the failing tooth with an implant-supported restoration.
Prior to implant surgery, preliminary impressions were obtained by using irreversible hydrocolloid impression material. Diagnostic casts for both the maxillary and mandibular arches were fabricated with type III dental stone and they were mounted in maximal intercuspal position on a semiadjustable articulator. A diagnostic waxing was made and the maxillary cast was duplicated. A surgical stent was then fabricated with clear autopolymerizing polymethyl-methacrylate resin. The tooth's cingulum area was marked and an access channel was opened with a 261E-023 laboratory carbide bur (Brasseler, USA). A provisional restoration was also fabricated by using autopolymerizing acrylic resin (GC Unifast III, GC Tokyo, Japan). Two acrylic

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old male patient suffering from severe back and both legs radiating pain was transferred to our hospital. The magnetic resonance imaging (MRI) taken at the previous hospital showed an epidural mass at L1-2. Besides, there was a spinal stenosis at L4-5 and a spondylolytic spondylolisthesis at L5 (). The patient had suffered from neurogenic claudication for the last 10 years and had received epidural steroid injections from time to time. Eleven days before his transfer he was troubled due to multiple tryouts of an epidural injection. Severe back pain and both legs radiating pain were developed after that night. MRI was done the next day and SEH compressing the cauda equina was found at L1-2. The conservative treatment failed to ameliorate the symptoms. Thus, he was transferred to our hospital. On neurological examination, there was a diffuse sensory decrease in the left lower extremity, the motor power was intact. On laboratory findings, platelet count, bleeding time, clotting time, and prothrombin time were within normal limits. Activated partial thromboplastin time was slightly extended with 36.4 seconds (). As the patient had neither a past history of abnormal bleeding nor any medication of anti-platelet agents and there was nothing specific in his laboratory findings, we couldn't consider any bleeding disorder. His SEH was suspected to be related to the unsuccessful epidural injections. Carelessly, we did not give attention to the fact that the location of the hematoma was different from the site of epidural injections. We performed the hematoma evacuation and the surgery for L4-5-S1 simultaneously. All surgical procedures were uneventful. The symptoms had improved after the operation. However, the pain in the right leg re-developed after 6 hours. So, the MRI was retaken. During the MRI, his blood pressure dropped to 90/60 mm Hg and a complete paraplegia developed. The MRI showed large hematomas at L1-2 and L4-S1 comp

[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 85-year-old male was referred to GI clinic by his primary care physician for evaluation of anemia, weight loss, and positive stool occult blood. On obtaining a detailed history he admitted to having early satiety for the past three months and nonbilious vomiting and colicky epigastric abdominal pain for the past three weeks. His physical examination was pertinent for pallor and his abdomen was soft and nontender with no apparent swelling or hepatosplenomegaly. An esophagogastroduodenoscopy () was performed which showed a large mass in the gastric antrum obstructing the gastric outlet with a nonbleeding but friable ulcer on top []. Biopsies were sent due to the concern for Gastrointestinal Stromal Tumor (GIST), gastric lymphoma, or adenocarcinoma stomach. A Computerized Tomography (CT) abdomen was ordered to further look into the etiology of the mass and determine the size and presence of lesions elsewhere. The CT abdomen [] revealed a homogeneous submucosal mass of 5 cm x 2.5 cm size. The lesion was in the gastric antrum, homogeneous, and well contained within the gastric wall. There were no lymphadenopathy or remote lesions in the abdomen. This together with endoscopic features of the mass was suggestive of benign gastric lipoma. Surgical referral was done for possible surgical removal; however, it was advised to try to endoscopically resect or at least debulk the mass for palliation of his symptoms before attempting a surgical removal because of patient's debility and comorbidities.
After the failure of initial attempts to do a complete resection, partial piecemeal resection was made with the aim of debulking the lesion to relieve symptomatic gastric outlet obstruction. To limit bleeding, endoloops were deployed at the base of the lesion prior to the start of resection. Because of the location and size of the lesion, only 2 cm by 2 cm of the mass was resected. At the end of the procedure, one of the endoloops remained deployed tightly at 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 66 year-old male presented to the emergency department (ED) with a one-week history of progressive pruritic erythematous rash, dry cough and two days of episodic high fevers. He had suffered a fall 12 weeks prior that had resulted in a pelvic fracture requiring an open-reduction internal fixation, which subsequently became infected with methicillin-resistant Staphylococcus aureus (MRSA) and treatment with intravenous vancomycin was initiated. After four weeks of vancomycin therapy he developed a rash. This was initially thought to be due to a red-man syndrome variant. Infusion rates were slowed, and premedication with diphenhydramine was initiated, but the rash worsened, with the subsequent development of episodic daily fevers, documented to be as high as 40°C.
His past medical history was significant for heterozygous hemochromatosis, a remote splenectomy secondary to traumatic rupture, and non-anaphylactic adverse reactions to penicillin and sulfa antibiotics. He had no history of reactive airway disease and had no travel history, living in an Ontario city.
In the ED he was hemodynamically stable with a normal mental status. He had a severe erythematous macular rash involving his face and trunk (see Figure ), and some facial edema. He had no mucous membrane involvement. He had palpable bilateral cervical and left axillary lymphadenopathy. Cardiorespiratory examination was normal, and his abdominal exam revealed central obesity and a scar from his remote splenectomy. Initial laboratory investigations are shown in Table . A computed tomography (CT) scan of his pelvis showed no abscess formation. A skin biopsy of the initial rash showed a mild perivascular lymphocytic infiltrate, consistent with a drug reaction.
Our initial working diagnosis was Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) secondary to vancomycin, which was immediately discontinued. Initially, his liver enzymes and eosinophilia appeared to improve spontaneously, thus management was

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