[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 67-year-old female patient of the present study had previously been diagnosed with transitional cell cancer of the urothelium (non-invasive, pT1N0M0), which had been treated with total cystectomy, ileal conduit diversion and urostomy at the age of 63. The patient had smoked 10 cigarettes a day between the ages of 30 and 60 and had then quit. The patient had no documented hypertension or diabetes mellitus. Subsequent to the finding of an abnormal shadow in the right upper lung, based on X-rays taken during the follow-up post-operative testing in April 2012, the patient visited the Department of Respiratory and Infection Control (Tokai University Hachioji Hospital, Tokyo, Japan) for a detailed examination. No such shadow had been detected in the lung during testing the previous year.
The patient’s blood pressure was 156/93, the heart rate was 79 bpm and regular, percutaneous oxygen saturation was 95% (room air) and there were no cardiopulmonary symptoms such as coughs and sputum. The patient had previously undergone a urostomy in the right lower abdomen. The blood tests, including those for tumor markers, were normal except for a slightly elevated white blood cell count. The aspergillus antigen and antibody were not present, and the β-D glucan level was also normal. The sputum culture detected no fungus or mycobacterial colonies throughout an 8-week incubation period. The chest CT showed a cavitary lesion that was 3.5 cm in diameter, with fungus ball-like shadows and air crescent signs next to the pleura in the right upper lung (). No nodular density was noted in the other lung fields. No pleural effusion or enlargement of the mediastinal lymph node was found. Based on the clinical and imaging findings, the patient was temporarily diagnosed with aspergilloma with a cavitary lesion and fungus ball-like shadows in the right upper lung.
The primary treatment of aspergilloma is surgical removal, and the differentiation

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


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

[User]
RADIOLOGY NOTE:
An 11-year-old boy presented with complaints of frequent cough and fever since the age of 5 years. The child was initially investigated elsewhere and diagnosed as a case of pulmonary tuberculosis. He had received antitubercular treatment for 1 year. After temporary relief, his symptoms recurred and the sputum showed presence of acid fast bacilli. The child was restarted on antitubercular treatment, which was administered for 2 years. Radiological investigations revealed the presence of a left intrathoracic mass. The child underwent thoracotomy and biopsy elsewhere. The biopsy was suggestive of inflammatory myofibroblastic tumor of the lung. The child was started on prednisolone but remained symptomatic. Subsequently, the child was referred to our institution for definitive treatment. His general condition was good and there was no evidence of respiratory distress. On examination, the movements of the chest wall were diminished on the left side. The left hemithorax was dull on percussion and the air entry was absent. The right side was normal. Chest radiograph showed the presence of a homogenous opacity in the left hemithorax with large areas of calcification in the hilar region. A contrast enhanced CT scan of the chest revealed a large soft tissue mass in the left lung with dense calcification and collapse of the lung. The child underwent thoracotomy; there was a soft tissue mass arising from the left lung and densely adherent to the pericardium, aorta, and thymus. Large mediastinal lymph nodes were present and the left pulmonary vein and artery were encased by the mass. Complete excision of the mass along with the involved pericardium and left pneumonectomy was performed. The child suffered a cardiac arrest during surgery but was revived immediately. Postoperatively, the child required ventilator support for 7 days. The child was subsequently discharged in a stable condition with no neurological deficit. The histopathological examination confirmed the diagnosis of

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old previously healthy girl presented 2 weeks after an uncomplicated laparoscopic appendectomy for non-perforated acute appendicitis in a regional hospital. The girl complained of gradually reducing urinary frequency to twice per day and prolonged hesitancy. The micturition stream was initially weak and slow before becoming interrupted. Straining did not produce stronger urinary stream. She had never suffered from urinary tract infections (UTIs) or constipation and opened her bowels daily.
Following an episode of acute cystitis 2 months later, she completely lost her ability to void. She was put on indwelling Foley urinary catheter, and her cystitis was successfully treated with antibiotics. After every attempt to remove the urinary catheter, she had to be catheterized again with 300 to 1200 mL of urine volume registered. She noted loss of urge to urinate and felt only dull pain in suprapubic region and right iliac fossa on extreme bladder distention. The girl was kept on indwelling urethral urinary catheter and referred to a tertiary center to determine the etiology of her urinary retention.
She was examined with normal clinical findings and no obvious pathology on abdominal and pelvic ultrasound scan (USS). A pediatric neurologist found nothing abnormal, and magnetic resonance imaging (MRI) of the brain and spine, electromyography (EMG) of the lower extremity, somatosensory-evoked potentials (SEP) of tibial nerve, electroencephalogram (EEG), and lumbar puncture were with no pathology. On USS, the gynecologist described multiple follicular cysts on ovaries bilaterally and found no pathology explaining her urinary retention.
Our pediatric urologist performed an examination under general anesthesia including a free calibration of the urethra up to 26F followed by normal findings on cystoscopy. Videourodynamic study (VUDS) showed an asensitive and hypotonic bladder. The bladder filling had to be stopped at 360 mL due to the patient's discomfort. Maximum intr

[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 gentleman with end-stage kidney disease due to hepatitis C with focal segmental glomerulosclerosis, on hemodialysis for seven years, underwent deceased donor renal transplantation. The donor kidney had a KDPI of 60%. There was a 4 antigen HLA mismatch with Class II panel reactive assay (PRA) of 62.31%. Class I PRA was 0%. His donor specific antibody testing was positive for an antibody to DQ7. The donor had died as a result of anoxic brain injury following cardiopulmonary arrest resulting from anaphylactic shock. The cold ischemic time was 12 hours, 7 minutes and the warm ischemic time was 51 minutes. Basilixumab was used for immunosuppression induction and the patient underwent early steroid withdrawal. His maintenance immunosuppression was tacrolimus (targeting trough levels 5-8) and mycophenolate sodium 720 mg BID.
The patient's postoperative course was complicated by delayed graft function, necessitating continuation of renal replacement therapy. He was hemodynamically stable throughout his hospital course. A renal allograft ultrasound showed good blood flow to the entire kidney with a resistive index of 0.64. A repeat flow crossmatch was negative, but he remained positive for a persistent low-level donor specific antibody to DQ7 (1000 MFI). He underwent a renal transplant biopsy on his 4th day postoperatively. This showed extensive acute tubular necrosis with associated peritubular capillaritis and interstitial nephritis (). Oxalate crystals were seen in several tubules. One large caliber artery showed active endothelialitis, but no tubulitis or glomerulitis seen. C4d staining was negative in the peritubular capillaries. Electron microscopy revealed minimal effacement of podocyte foot processes. The patient received methylprednisolone 500 mg x 3 doses to treat moderate acute cellular rejection. His tacrolimus dose was also optimized as his trough levels had been running low at between 3.5 and 6. He continued to take mycophenolate sodium at a dose

[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 four-year-old febrile healthy male child presented with a lump in the right parotid region. On examination, the swelling was about 6 × 5 cm in size, nontender, irregular, and firm to hard in consistency with obvious proptosis. Swelling extended superiorly up to zygomatic region, inferiorly up to mandible, anteriorly up to maxillary region, and posteriorly up to retromandibular space. Radiological examination showed a large solid ill-defined lesion along the ramus of the mandible extending into masseteric space and until skull base of the right side. Involvement of nasopharynx, posterior ethmoid, and sphenoid sinus with sinus wall remodelling was suggestive of neoplastic mass (). Clinical differential diagnosis of rhabdomyosarcoma, lymphoma, and primitive neuroectodermal tumour was suggested. Routine investigations were all within normal limits, and evaluation of complete blood count was normal except for anaemia. On microscopic examination of the processed biopsy, tissue sections showed mainly tumour tissue infiltrating into normal parotid gland (). Tumour cells seen were mostly round to oval with high N/C ratio and hyperchromatic with irregular nuclear membrane and at some places with angulated nuclei also (). Increased number of eosonophilic precursors were also noted along with few neutrophils and lymphoid cells. No evidence of acinous formation or lymphoglandular bodies was found which helped in ruling out carcinoma of parotid gland or lymphoma. Histopathological diagnosis of Langerhans cell histiocytosis (LCH) versus granulocytic sarcoma was considered. To confirm the histologic diagnosis and to rule out clinical diagnosis, immunohistochemistry was performed, and a panel of markers were used as described in and . Peripheral blood smear showed increased number of blast cells, morphologically mostly monoblast and myeloblast in myeloperoxidase staining (MPO). The bone marrow smear taken showed increased number of blast cells (more than 20%) which were myeloperox

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old female with a past medical history of morbid obesity [body mass index (BMI) of 58.4 with a height of 1.6 m and weight of 149.5 kg] presented with right-sided abdominal pain. The abdominal pain had been present and consistent for several weeks but had increased acutely over the last few hours. She denied fevers, chills, chest pain, palpitations, shortness of breath, cough, nausea, and vomiting. Her past medical history was significant for multiple cardiopulmonary comorbidities including heart failure with preserved ejection fraction, chronic obstructive pulmonary disease requiring 3 L of oxygen per minute at baseline, myocardial infarction, and type 2 diabetes mellitus. Her surgical history was significant for a remote history of a hernia repair, but the patient was unclear of when it occurred.
At the emergency department (ED), her respiratory rate was 32 breaths/minute with an oxygen saturation of 88% on 3 L of oxygen. The rest of her vitals were unremarkable. There were no significant abnormalities on the cardiac exam. She had decreased breath sounds in the lower lung lobes bilaterally with mild diffuse wheezing throughout all lung fields. An abdominal exam revealed moderate tenderness to palpation in the right upper and lower quadrants. A hernia was palpated in the right lower abdomen.
Pertinent lab values included a white blood cell count of 12,400 cells per microliter with negative blood and urine cultures. Basic metabolic panel and lactic acid were unremarkable. Liver tests were within normal limits (Table ). Chest X-ray was inconclusive because of poor penetration due to the patient’s body habitus.
CT of the abdomen and pelvis with contrast showed distension and thickening of the gallbladder wall, pericholecystic stranding, and a fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe (Figure ). The gallbladder was located in the right lower quadrant of the abdomen due to the mass effect from

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


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

[User]
RADIOLOGY NOTE:
A 2.5-year-old boy was referred to the pediatrics clinic with severe self-mutilating injuries to his hands, feet, tongue and oral mucosa caused by unconscious biting ().
He is the second child of cousin parents and the product of a term, normal vaginal delivery with a birth weight of 3300 gr.
At two-months of age, he was admitted to the hospital as a result of fever and convulsion. The patient continued to have fever throughout his hospital stay and evaluation for the etiology of prolonged fever was done and abnormal results were not seen in any of the diagnostic tests including blood culture, CSF analysis and culture, urine analysis and culture, echocardiography, blood smear, bone marrow aspiration and culture, Wright and Vidal test, abdominal sonography and brain CT scan. Finally, he was discharged from the hospital on phenobarbital medication, but episodes of hyperthermia and unexplained fever recurred.
His parents found him never sweating after birth and he did not tolerate warm weather or sun exposure and he was irritable and cried with appropriate tearing in such situations. The parents also complained that the child showed no response to any kind of injury including pinpricking, burning, hitting and cutting. The boy had never complained of painful sensation and his hands or feet were burned by heater flame or hot water repeatedly.
He had a right third metatarsal fracture without reason when he was 2.5 years old that was managed on an outpatient basis and caused edema and deformity in his right foot.
Teething had started at seven months of age, but because of biting and ulcerative lesions in the gums, his teeth had started to shed at 1.5 years of age.
On examination, he had 12 kilograms weight (10th percentile), 92 centimeter height (75th percentile) and 48 centimeter head circumference (10th percentile) and a normal blood pressure without orthostatic hypotension. Ulcerative lesions were seen in his fingers

[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 male had a history of road traffic accident 18 months back with severe head injury and pelvic fracture. He remained in the referring hospital for three months. After discharge he remained reasonably well except for occasional episodes of anterior chest pain and dyspnea on moderate exertion.
Recently he was admitted again through the emergency department with complain of severe chest pain along with shortness of breath. CT chest with intravenous contrast showed large aneurysm of the descending thoracic aorta distal to the origin of left subclavian artery causing compression on the origin of the left main bronchus, and on the right and left pulmonary arteries with no evidence of dissecting or contrast leak; however, the patient referred to the vascular surgical unit in our institute for further management.
After admission he complained of mild shortness of breath. His vital signs and his routine blood investigation were within normal limits. His chest radiograph showed normal bilateral lung fields.
He underwent endoluminal thoracic aortic stenting under general anesthesia. Postoperatively the patient started to complain of severe dyspnea and was desaturating. His immediate post-procedure routine chest X-ray revealed complete collapse of the left lung []. An urgent CT chest with intravenous contrast showed endovascular stent in place, but the aneurysmal sac was completely occluding the left main bronchus with complete collapse of the left lung but with adequate perfusion. The aneurysmal sac also had a mass compression on the adjacent right main pulmonary artery, which was compressed and stretched maximum at its proximal portion [].
Patient was stable hemodynamically and with relatively acceptable arterial blood gases.
He was monitored closely for possible emergency intervention with an endobronchial stent.
Although placement of an endobronchial stent in the left main bronchus can open the collapsed left lung, at the same time it may increase the pressure

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old woman was transferred to our emergency department following a road traffic accident. The patient was a restrained passenger of a car, the driver lost the control of the vehicle and the car fell into a ditch at the side of the road. The patient lost consciousness at the impact but was found alert and oriented at the time of the arrival of the ambulance. Patient observations were stable and there were no signs of other bone injuries. Patient had no neurological deficits and cranial nerves were intact. Past medical history of the patient included acute glaucoma and visual impairment.
A routine trauma series CT-scan was performed and showed a type II odontoid fracture with anterior displacement (Figure ). Patient was referred to our spinal unit and, after appropriate counselling, elected a non-operative treatment. Cervical spine was stabilized with a Philadelphia collar and patient was discharged home 3 d after the injury. The first outpatient clinic appointment was booked at 2 wk after discharge and patient was seen at regular intervals thereafter. Six months following the injury the patient was still complaining of significant axial neck pain requiring regular pain killer. An interval computed tomography (CT) scan at 6 mo after the injury revealed a non-union at the fracture site, distance between fracture fragments was 4 mm and there was evidence of sclerotic bone margins at the level of the fracture (Figure ). Surgical options were discussed with the patient at this stage, but she again refused any surgical intervention.
Patient was maintained in rigid collar and was offered off-label therapy with daily subcutaneous injections of Teriparatide (rhPTH1-34) 20 μg/d which she accepted. This is the same regime used for treatment of osteoporosis in post-menopausal women. The anabolic treatment with Teraparatide was monitored through periodic examinations and regular measurements of serum levels of calcium, phosphorus, vitamin D, parathyroid hormone and alkal

[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 white English male was presented to the vascular outpatient clinic with history of a lump behind his right ankle on inner aspect over a year. Apart from the presence of a lump, he denied any other complaints including any violent or repeated trauma. He also suffered from diet controlled Type II diabetes mallitus and gout and had tonsillectomy and manipulation of colles’ fracture in childhood. He was not taking any antiplatelet or anti-coagulation medications and denied any use of tobacco. On examination, there was 3 × 3 cm size lump just behind the right medial malleous which was non-tender and non-pulsatile. The peripheral pulses were easily palpable on either side. There was no evidence of aneurysm anywhere else in the body on clinical examination. He underwent Doppler ultrasound which confirmed 1.4 cm size aneurysm of posterior tibial artery with presence of mural thrombus. The distal and proximal parts of posterior tibial artery, anterior tibial artery and popliteal artery were reported normal. He underwent an elective operation in the form of excision of aneurysm (Figure ) followed by reversed vein graft from the same leg (Figure ). Histology confirmed the true aneurysm of posterior tibial artery with mural thrombus attached to the intima of the vessel with normal arterial wall pattern without any evidence of connective tissue disorders, arteritis, necrotizing vasculitis, infection or inflammation (Figures , , and ). The bacteriology examination neither revealed any organisms nor grown any organisms in the culture media. He recovered well postoperatively and was discharged the next day. At follow up at one year, he did not develop any complications and colour Doppler revealed patent posterior tibial artery.
False aneurysms are more common in comparison to the true aneurysms of infrapatellar blood vessels. There have been only very few case reports of true aneurysms of posterior tibial artery published [,]. The precise aetiological factors are not

[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 83 year old female patient presented with a two week history of a self detected lump in the upper outer quadrant of the left breast. Clinically there was a 15 mm suspicious lump in the left breast, mammography did not reveal any abnormality (R1) and ultrasound scan findings were consistent with the diagnosis of breast cancer (U5). Clinical and ultrasound examination of the axilla was unremarkable. Core biopsy of the lesion confirmed the diagnosis of invasive ductal carcinoma.
During review of her past medical history, it was noted that in 1996 she had a cardiac PM inserted for persistent sinus bradycardia. In 2003 this was replaced with a St. Jude Medical dual chamber PM (St. Jude Medical Inc., St. Paul, MN, USA). The pacemaker was programmed to VVIR 70 bpm, hysterises 60 bpm in single chamber mode due to an atrial lead failure. The dominant rhythm was atrial fibrillation with intermittent ventricular pacing. The patient’s heart rate varied between 60–107 bpm. The patient had been self caring and a recent transthoracic echocardiogram showed a normal ejection fraction and left ventricular size. Anatomically, the PM was located in a subcutaneous tissue pocket in the upper pole of the left breast 9 cm away from the primary tumour (Figure , Figure ).
After discussion at the multidisciplinary meeting, we recommended wide local excision and sentinel node biopsy. In view of the size of the tumour and presence of the PM, it was also decided to offer the patient intraoperative radiotherapy using the TARGIT technique.
Prior to surgery, the details of the PM were obtained from the implanting hospital and the distance from the tumour to the device was measured at an assessment session. During surgery, after harvesting the sentinel node and wide local excision, intraoperative radiotherapy was performed using the Intrabeam™ device (50 kV, Carl Zeiss Surgical, Oberkochen, Germany). A 3 cm diameter applicator was used, delivering approximately

[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 presented with a 2-month history of intermittent epigastric pain. At the time of presentation, the patient had hypertension that was controlled with medication, and he had no other remarkable past medical history. The physical examination and laboratory tests were unremarkable.
After admission, the patient underwent an upper gastroduodenal endoscopy examination and the result was normal. We then performed ultrasonography (US) and computed tomography (CT) examinations to further evaluate the abdominal pain. Based on the US findings, a large well-defined anechoic mass was identified and it was located in the posterior aspect of the splenic vein. The lesion was seen with posterior acoustic enhancement that suggested the presence of a cystic or necrotic mass (). Helical CT was performed using a multidetector-row CT (MDCT) scanner (LightSpeed VCT; GE Healthcare; Milwaukee, WI) with 64 detectors. The abdominal CT axial and coronal images () showed an approximately 5 cm sized, well-defined, necrotic mass with an even peripheral wall in the retroperitoneal area. The mass was located between the left renal vein and the splenic vein and the mass compressed the adjacent pancreas without evidence of direct invasion. There was no calcification detected in the mass. Several abnormal enlarged lymph nodes in the left gastric area were also noted. Based on these imaging findings, metastatic lymph nodes, tuberculosis lymphadenitis and an unusual form of Castleman's disease were considered in the differential diagnosis. The main necrotic mass and abnormal enlarged lymph nodes were removed by surgical excision. On a gross specimen, the mass showed extensive internal necrosis that correlated to the image findings seen on US (). Spindle to ovoid cells that made up fascicles were identified on a light microscopic examination of the resected mass and lymph nodes. The tumor cells had slightly eosinophilic plump cytoplasm with an indistinct cell border and small nuclei ().

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old gentleman was admitted to the emergency room for unstable angina. He underwent coronary artery bypass grafting 6 years prior to current admission and also had persistent atrial fibrillation on rate control and anticoagulation. His ejection fraction was 65%. Coronary angiogram showed occlusion of all vein grafts but patent left internal mammary graft to left anterior descending artery with severe native multivessel disease. There was severe stenosis of the native left circumflex artery (); the proximal right coronary artery was completely occluded, and it was supplied distally by bridging collaterals and collaterals from the left circumflex artery. After extensive discussion with the patient, decision was made for percutaneous coronary intervention (PCI) of the native left circumflex artery. Serial balloon dilation to the mid circumflex artery was performed: first with a 2.5 mm × 15 mm balloon but a waist was noted (), followed by a noncompliant 2.5 mm × 12 mm balloon but a residual waist was still observed, and finally with a 2.5 mm × 10 mm scoring balloon (AngioSculpt, Spectranetics, Milwaukee, Wisconsin, USA) inflating up to 20 atmospheres (). The stenosis gave way, and repeat angiogram noted Ellis Class III perforation ().
The operators immediately inflated a 3.0 mm balloon to 8 atmospheres at the site of perforation followed by deployment of a 2.5 × 24 mm covered stent. However, repeat angiography still showed extravasation from perforation site and a second 2.5 × 12 mm covered stent was deployed, but there was continued extravasation. Protamine sulfate was given, and prolonged balloon inflation was then performed. Subsequent angiography showed that the circumflex artery was thrombosed.
Immediate bedside transthoracic echocardiogram showed very small 4 mm pericardial effusion. Pericardiocentesis was attempted but was unsuccessful. The ejection fraction was normal, and there were no other echocardiographic features of cardiac tamponade.
The patient

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old female patient, known to have arterial hypertension and coronary artery disease and on aspirin therapy, was admitted to the hospital for elective total thyroidectomy with a symptomatic non-toxic multinodular euthyroid goiter.
Physical examination revealed palpable neck swelling. The neck ultrasound showed an enlarged thyroid gland with multiple nodules on both sides; the thyroid volume was 22 ml. The preoperative thyroid function test, parathyroid hormone and serum calcitonin were within normal ranges.
The patient underwent a total thyroidectomy. The parathyroid glands and recurrent nerves were recognized and preserved. After meticulous haemostasis and an intraoperative Valsalva manoeuvre, the wound was closed. No drain was placed. The patient was sent to the recovery room and then to the normal ward.
The neck circumference was regularly measured at different intervals as follows: the preoperative measurement was 37 cm; immediately postoperative, 38 cm; 30 min, 38 cm; 60 min, 38 cm; 90 min, 39 cm; 120 min, 39 cm, 4 h, 39 cm; 6 h, 40 cm; and 8 h, 41 cm. At this point, the patient experienced a pressure sensation and tightness in her neck but no respiratory distress or hypoxia.
The patient was transferred immediately to the OR. No difficulties in intubation were reported by our anaesthesiologist. After surgical draping, the wound was opened and cervical exploration was carried out, which revealed a haematoma deep to the strap muscles. Blood clots were removed, the surgical bed was irrigated and bleeding was identified from the small venous branch of the middle thyroid vein. After ligation of the bleeder and meticulous haemostasis, drains were placed in the thyroid bed. The patient was extubated and shifted to the recovery room and later to the surgical ward. The postoperative course was uneventful. Oral intake was gradually increased as tolerated. The drains were removed on postoperative Day 2. Histopathology returned benign. The patient was discharged o

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old female Arab, a known asthmatic, presented to the emergency department of our hospital with complaints of chest pain and a nonproductive cough of 1-hour duration. She was conscious and well-oriented to the surroundings but had mild dyspnea. There was no history of receiving assisted mechanical ventilation. There was no previous history of pulmonary tuberculosis, recent trauma, surgery, or other intervention.
Vital parameters were stable, and body temperature was normal. There was subcutaneous emphysema involving the right side of the neck. Auscultation of the chest did not reveal any significant abnormality. A chest radiograph was obtained, which revealed surgical emphysema along the upper part of the right lateral chest wall and the right side of the neck. Minimal pneumomediastinum was also noted with air within the superior mediastinum on the right. A loss of volume of the right lung was noted with a shift of mediastinum to the right and elevated right diaphragmatic dome (). No lung consolidation, pneumothorax, or pleural collection was noted. The patient collapsed immediately after the chest radiograph was obtained. She was intubated and given intravenous fluids and vasopressors to control the hypotension. Her condition stabilized after 2 hours. The portable bedside chest radiograph revealed increased severity of pneumomediastinum, surgical emphysema, right lung collapse, and mediastinal shift to the right ().
Computed tomography (CT) imaging of the thorax was also performed, which confirmed the dissection of air into the mediastinal and subcutaneous spaces (). A CT scan also revealed air within the posterior spinal extradural space in the thoracic spine ( and ), minimal pneumothorax on the right, and obstruction of the segmental right upper lobe bronchus by mucus plugs ().
She was hospitalized and treated with antibiotics, bronchodilators, oxygen inhalation, and other conservative measures. A bronchoscopic removal of mucus plugs and thick secretion

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 41-year old, right-handed male patient presented in the emergency room after a motorcycle accident. The patient collided with a car while grasping the handlebars with both of his hands but could not remember the exact mechanism of injury. After excluding any life threatening organ injuries the patient was referred to the Department of Plastic Surgery for further evaluation of the left hand. The clinical examination revealed severe swelling and tenderness of the left hand. Tenderness was reported especially over the snuffbox, proximal to the base of the second metacarpal bone and distally to the distal radio-ulnar joint with a skin laceration and superficial abrasions on the dorsum of the hand. Additionally, a skin laceration with a diameter of approximately two centimeters was located at the area above the lunate on the dorsum of the wrist. The perfusion and sensibility were without any pathological finding.
X-ray showed a dorsal dislocation of the lunate with no clear signs of fracture or dislocation of other bony structures ().
Since lunate dislocations often come along with additional carpal bone injuries and pain over trapezoid persisted, a computed tomography (CT) of the left hand and wrist was carried out immediately. It confirmed a dorsal dislocation of the lunate and interestingly also a compound sagittal fracture of the trapezoid ( and ). Furthermore, air pockets in the dorsal wrist indicated an open trauma.
Under general anesthesia, a closed reduction of the lunate was performed by pushing the lunate to proximopalmar direction while applying longitudinal traction to the fingers with the wrist fixed in a neutral position. The intraoperative x-ray confirmed anatomical reduction of the lunate. Since no tendency of lunate re-dislocation, neither in neutral nor in hyper-flexed or extended wrist position was seen on x-ray image intensifier dynamic screening, no open ligament reconstruction was carried out. Due to slight carpal instability without confirmed by

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old female presented with history of sudden onset weakness of right upper and lower limb for 1 day with deviation of angle of mouth to the left side. There was no history of headache, vomiting, seizures, or previous history of stroke or transient ischemic attacks. Also there was no history of chest pain, palpitations, or any cardiac disease. She is not a diabetic or hypertensive and there was no other comorbid illness. Her general examination revealed a pulse rate of 180/ min, regular, low volume, and blood pressure of 130/80 mmHg. The central nervous system examination showed normal higher mental functions, right upper motor neuron facial nerve palsy, and muscle power of 3/5 in upper limbs, 2/5 in lower in lower limbs with right extensor plantar response. The examination of other systems was normal. The laboratory investigations revealed normal liver and renal function tests. The serum calcium, magnesium, and potassium levels were normal. The serum troponin T and creatine phosphokinase levels were normal. The CT brain revealed left middle cerebral artery territory infarct measuring around 2×3 cm.
Our patient presented to the emergency medical services department within 8 h of acute stroke. Her ECG showed regular narrow QRS complex long RP tachycardia at a rate of 186 beats per minute (bpm) with inverted p waves in lead III []. She had a normal study on echocardiography without structural changes or thrombus. On intravenous injection of 6 mg of adenosine, the patient transiently developed complete atrioventricular block but the atrial rate was persisting at the same 186 bpm with regular p waves separated by isoelectric baseline [] which reverted back to AT within a minute []. A diagnosis of atrial tachycardia was made and she was started on verapamil 40 mg three times daily orally. Following one dose of verapamil she developed sinus bradycardia (50 bpm). So verapamil was withheld and she was monitored in intensive care unit. In the following 1 week, she di

[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 71-year-old woman was referred for evaluation of back pain and worsening left lower extremity pain, which included neurogenic claudication. She gave a history of a fall from standing height, with onset of low back pain. Around a month later, her left leg pain became a prominent feature, with a symptom duration of approximately five months at the time of injury. She did not experience lumbar epidural or intrathecal injections. She reported no history of fever and no difficulty passing urine. Significant medical history included mild hypertension, of note, and there was no history of malignancy and no history of use of anticoagulant drugs. Both platelet count and prothrombin time were in the normal range. On examination, there was full power and symmetrical reflexes in both lower extremities. Patchy reduction in sensation to the left lower limb was noted. She was given a left L5 nerve root block which was only effective for 3 days. The patient and/or her families were informed that data from the case would be submitted for publication and gave their consent.
A lumbar MRI without gadolinium (Gd) had been performed prior to evaluation (4 months after symptom onset) in a previous hospital (). The MRI showed a posterior mass at L4/5. On T1-weighted images (), the mass was isointense, with a few hyperintense areas within. On T2-weighted images, the mass was hyperintense in the center and hypointense in the periphery (). We suspected the spinal tumour and carried out a 2nd MRI with Gd. On the 2nd MRI of the same area (Figures –), after a 2-week interval, a newly isointense mass was present within the anterior part of the previously identified lesion on T1-weighted image () and the hyperintense area in the lesion was a little extended on T2-weighted imaging (). There was no significant enhancement with Gd-based contrast (Figures and ). Her symptoms were not changed between 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 13-month-old female presented to the emergency department for urinary retention. She was born at 35 weeks gestation in Mexico with an unknown postnatal hospital course. She was known to have mild gross motor developmental delay diagnosed several months before; caregivers stated that she pulled to stand but did not cruise or walk and babbled but did not have any words. She had no additional past medical history or previous surgeries and no known previous trauma. Upon presentation, the adoptive parents with whom she has lived since very early in her life provided the history. Adoptive parents reported about 2 weeks of fussiness and decreased ability to bear weight on her lower extremities. Parents denied any known trauma at that time. Her weight was <3rd percentile with a Z score of −3.36. She was thin appearing but without signs of dehydration or malnourishment. Examination was notable for 0/5 strength, hypotonia, and areflexia in the bilateral lower extremities as well as hypotonia of the trunk. In addition, she was found to have significant head lag and very severe thoracic kyphosis or gibbus deformity. The patient was first evaluated by outpatient urology after referral from the primary care office for urinary retention. A renal ultrasound was performed and was notable for bilateral moderate hydronephrosis and bladder distension. She was sent to the emergency department for further workup. Laboratory studies in the emergency department yielded normal creatinine for age at 0.3 mg/dl, and urine culture obtained by in and out bladder catheterization grew >100,000 CFU/mL of Enterococcus faecalis. Complete blood count and basic metabolic panel were unremarkable, and thyroid stimulating hormone was within normal range. The patient's creatinine kinase was >1200 U/L, six times the upper limit of normal. Spinal CT demonstrated complete retrospondylolisthesis of T12 vertebra (). MRI was also performed and showed marked compression of the spinal cord resulting in inability

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male with a chief complaint of pain during chewing and swallowing was referred to our department He mentioned a history of trauma to his right mandibular angle during an assault four months previously. The patient did not have any neurosurgical signs, loss of consciousness (LOC), dizziness or vomiting. The Glasgow coma scale (GCS) of the patient was 15 when he was referred to our department.
The main complaints of the patient were pain on the right side of the neck and lower jaw during chewing and swallowing. Although the patient experienced pain during mandibular movements and yawning, no limitation of jaw movements was observed. The nature of the pain was sharp and intermittent and lasted a few seconds every time the patient turned his head or upon chewing. The maximum mouth opening (MMO) was about 46 millimeters and there was no deviation in mandibular movements. On clinical examination, there was neither extra-oral swelling nor tenderness of temporomandibular joint (TMJ) or masticatory muscles. Intra-oral examination did not show any occlusal problems or premature contact. The patient did not mention any surgical history or tonsillectomy. He did not complain of symptoms mimicking glossopharyngeal neuralgia.
A panoramic radiograph was obtained from the patient (). The radiographic view of the jaws showed elongated SP in the left side whereas the right SP was normal in size but displaced. The right displaced SP on panoramic view suggested fracture of this process without mandibular condyle fracture. Computed tomography (CT) was obtained for more evaluation and to detect other possible fractures. The CT views confirmed right SP fracture ().
The treatment plan for the patient was conservative treatment and follow-up. He was instructed to restrict neck movements. An anti-inflammatory (Naproxen 500 mg for every 8 hours for two weeks) and muscle relaxant (Tizanidine 2 mg twice a day for two weeks) drugs were prescribed to reduce the pain during the mastic

[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 71-year old man was referred to our clinic for the sudden onset back pain with weakness in both legs and sensory change. The pain was located at mid thoracic area, and was positively related to motion. It started 5 days prior to the visit and the neurologic changes occurred the following day. Neurologic examination revealed grade IV motor power on both legs and hypoesthesia was present below the level of the xiphoid process. The patient was able to walk with the aid of a cane. He had been taking anti-arrhythmic medications for a year, and had no other past medical history.
Plain radiographs and magnetic resonance imaging (MRI) taken from the other hospital revealed a T8 acute compression fracture with cord compression (). Under an impression of the T8 pathologic fracture, we ran a series of tests to find the primary origin of the spinal metastasis. All laboratory tests including tumor markers were within normal limits. Chest and abdominal computed tomography scans did not show any mass lesions in solid organs. We discussed the plan for diagnosis with oncologists. Since the patient presented with neurologic symptoms in both lower extremities, we came to an agreement that planning an early spine surgery of T8 decompression and stabilization and making the pathologic diagnosis through tumor tissue removed during the surgery would be reasonable. Further systemic work ups such as whole body positron emission tomography was planned after confirmation of the pathologic diagnosis. No steroid therapy was performed during the preoperative period.
A spinal embolization was performed prior to the operation. As a small size of the ASA was visualized on the left T8 segmental artery angiography (), only the right T8 segmental artery was embolized. On the following day, we carried out a total laminectomy of T8 and pedicle screw fixation from T6 to T10. Tumors located at the ventral side of the dura sac were partially removed to achieve circumferential decompression of the spinal

[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:
Chest X-ray findings during a medical checkup of a 70-year-old man showed an abnormal shadow. Chest computed tomography (CT) revealed a nodule on the side of the left lower lobe or posterior mediastinum (A). The patient's medical history showed that he had multiple rib fractures and traumatic left hemopneumothorax due to falls 17 months before the first visit to our hospital. In addition, he had undergone chest tube insertion at another hospital. Three days after insertion of that tube, there was no leakage, and the amount of daily drainage was decreasing. Chest X-ray revealed improvement in the left hemothorax and the chest tube was removed. At this point, he had evidence of left lower pulmonary lobe contusion; however, no nodule was identified.
Contrast-enhanced chest CT of our hospital revealed a nodule in the left lower lobe (S10). The nodule was 27 × 18 × 16 mm in size and was elliptical with well-defined margins. It showed no contrast effect (B). Furthermore, 18F-fluorodexyglucose positron emission tomography/CT (FDG-PET/CT) revealed a little uptake (the maximum standardized uptake value = 1.66) in the lesion (). Chest CT performed 4 months after the first visit showed that nodule size had not changed. The patient had no history of malignancy, making a metastatic tumor unlikely. Taking the shape of the nodule and his history together, we suggested that the differential diagnosis was a benign lung tumor, a neurogenic tumor in the posterior mediastinum, a low-grade malignant tumor such as a pulmonary carcinoid. The resection surgery for diagnostic treatment was planned to rule out a malignant tumor.
Partial resection of the left lower lobe was performed by thoracoscopic surgery. Intrathoracically, the white pleural change was at the left lower lobe. This pleural change was considered as the nodule that was visualized in the image, and a partial resection was performed (). The intraoperative pathological diagnosis was not a malignant finding, 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:
The patient, a 76-year-old woman with both multiple myeloma (MM) and myelodysplastic syndrome (MDS), was seen in the haematological outpatient clinic for a planned blood transfusion. The patient had no history of GI disease apart from minor GI bleedings, and no implants or history of alloplastic surgery. The most recent surgery the patient had undergone was an operation for a rotator cuff lesion 7 years previously. Six days earlier she had received two red blood cell transfusions and one transfusion of pooled platelets. The patient was diagnosed with light-chain MM 7 years ago. During the following years she received several lines of treatment with alkylating chemotherapy, glucocorticoids, immunomodulatory drugs and radiation therapy. Two years ago, she developed transfusion-dependent anaemia and thrombocytopenia and a new bone marrow biopsy and cytogenetic karyotyping revealed therapy-related MDS. Treatment with 5-azacytidine and recombinant erythropoietin or thrombopoietin was ineffective. Subsequently the patient was put on supportive treatment with oral 12.5 mg prednisolone daily and supportive transfusion therapy. She was in partial remission for her MM at the time of infection. Due to severe thrombocytopenia and prednisolone treatment the patient had had several prior episodes with minor GI bleedings before the time of the infection. The patient had also previously been examined for infections several times before the time of infection. Sixteen days before the positive blood culture with was drawn, the patient was discharged from the hospital after an admission because of suspected tonsillitis. Blood cultures were negative, and the patient was found to be negative for influenza virus A and B and respiratory syncytial virus. No other microbiological tests were performed. The patient was treated empirically with intravenous piperacillin/tazobactam and was discharged with oral penicillin and pivmecillinam. Two months before the present case story the patient had

[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 right-handed male presented to the emergency department with right wrist pain and decreased range of motion of the forearm following a friendly grappling match. On history, he was mildly intoxicated by alcohol at the time of the injury. His friend had performed an arm-bar holding the patient's right arm between his legs while pulling on the forearm with his hands. The patient tried to escape the maneuver by forcefully pulling and pronating his forearm. He immediately felt pain in his right forearm and was unable to use it afterwards. His past medical history was significant for alcohol, tobacco, and cocaine use. He was not known to be suffering any other medical conditions and had never suffered any injury to his right wrist or forearm in the past. On physical examination, the forearm was locked in supination, with no passive or active pronation elicited. There was loss of the dorsal ulnar prominence, and a palpable and tender solid mass was felt on the volar aspect of the wrist, which was presumed to be a volarly dislocated ulnar head (). The skin was intact, and the neurovascular status of the hand was normal. Radiographic examination of bilateral forearms confirmed our suspicions, displaying overlap between the radius and ulna on the anteroposterior view and volar displacement of the ulnar head relative to the distal radius on the lateral view. A CT scan was performed, completing the clinical picture by revealing impaction of the ulnar head on the distal radius ().
After obtaining informed consent, closed reduction was planned under procedural sedation. The reduction was first attempted by pronating the forearm while applying a posteriorly directed force to the ulnar head. After an unsuccessful first attempt, a second attempt was performed with an assistant applying pressure on the interosseous membrane (IOM) of the forearm using the palm of both of his hands, in an effort to free the impacted ulnar head from the distal radius (). With the ulnar hea

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old female patient presented to our orthopedic outpatient department with a rapidly enlarging ulcerated right upper arm swelling which was growing gradually over the past six months. She recalled that it had been a pea-sized lesion and had remained the same size over the past 30 years. No history of preceding episodes of trauma or local irritation was found. The initially asymptomatic lesion had recently become painful and pruritic with slight bleeding. On examination, a large nodulo-ulcerative plaque was noted on the right upper arm, measuring approximately 12 cm × 6 cm in size (). Magnetic resonance imaging (MRI) revealed a mass measuring 12 cm × 6 cm × 1.5 cm, invading the deltoid and triceps brachii muscles (). Examination of the needle biopsy specimen demonstrated the proliferation of spindle cells in a storiform arrangement in the dermis. Results of tests for CD34 and factor VIII were negative, suggesting the possibility of a benign tumor. However, the clinical findings, which included muscle invasion, large tumor size, and rapid enlargement, suggested the possibility of malignancy, prompting the need for wide resection and myocutaneous flap-plasty. Intraoperatively, the tumor was found to have invaded the deltoid and triceps brachii muscles, as well as the cutaneous and subcutaneous tissue. Wide resection was achieved with a 3 cm margin. A latissimus dorsi musculocutaneous flap was needed to close the skin defect. The postoperative period was uneventful. Histopathological examination following hematoxylin and eosin stain revealed spindle cell proliferation with a vague storiform growth pattern and basal cell hyperplasia in the overlying epidermal cells (). The tumor tested negative for CD 34 on immunohistochemical staining but tested positive for SMA, CD 68, and factor XIIIa (Figures –). Mitoses were inconspicuous in the lesion, and the Ki 67 labeling index was also low, at 1 to 2%. These findings were consistent with a diagnosis of dermatofibroma.

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male presented to the Cardiology department due to edema of the legs, erythema, pain, abdominal swelling, and was hospitalized with pulmonary hypertension, right heart failure, atrial fibrillation, chronic obstructive pulmonary disease, and cellulitis. The patient had a history of appendectomy when he was 20 years old and had been stabbed in the abdomen when he was 35 years old. He had been stabbed twice, and 1 h after the stabbing, he had been successfully treated by general surgery. The patient had been discharged 1 week postoperatively. The patient also had a 4-year history of smoking during his adolescent period. Five years earlier, the patient (age 45 years) had presented to the Cardiology outpatient service and was diagnosed with New York Heart Association (NYHA) Class II shortness of breath. On echocardiography (echo), his right heart cavity dimensions were mildly increased and pulmonary artery systolic pressure was found to be 45 mmHg. After treatment, his complaints regressed completely. Three years earlier (age 47 years), he had been admitted to the Pulmonology department with abdominal and bilateral leg swelling, and shortness of breath (NYHA Class III) complaints. CT thorax was performed and he was diagnosed with right heart failure. But dilated IVC was missed or might have been accepted as secondary dilatation to pulmonary hypertension and right heart failure. Intravenous diuretics, steroids, teophylline, and inhaled bronchodilator treatment had been administered. Subsequently, his complaints regressed. His echo findings at that period of time were as follows: Left ventricular ejection fraction 65%, Grade I diastolic dysfunction, normal left heart cavities, significantly enlarged right heart cavities, pulmonary artery systolic pressure 70 mmHg, and Grade 2–3 tricuspid failure. He was being closely monitored by the pulmonologist for pulmonary hypertension. One year earlier (age 49 years), he had been admitted to the Pulmonology department d

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


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

[User]
RADIOLOGY NOTE:
In April 1996 this 78-year-old woman was diagnosed with a poorly differentiated lobular carcinoma in the upper outer part of the left breast. Clinically it measured 15 mm. She was treated with conservative breast surgery and level III axillary node clearance. Tumor margins were clear and all lymph nodes were negative. Tamoxifen was commenced at 20 mg OD.
A course of postoperative radiotherapy was arranged due to breast conservation surgery. She received 46 Gy in 23 fractions over 35 days using paired glancing megavoltage fields. This treatment was completed in July 1996 and was followed by a boost to the site of excision of a further 12 Gy in 4 fractions over 7 days using 9MEV electrons. Chemotherapy was discussed but the patient did not want to pursue this option.
She remained in regular follow up with no evidence of local or regional recurrence. In June 2005 during a routine follow up appointment she reported a 2 cm area of purple skin lesion at the lower inner quadrant of the left breast (figure ), with a history of it being there for about 3 months. It was associated with peau d'orange and soft tissue thickening extending from the lower inner quadrant across the midline. Mammography was not performed, as she was too tender. Ultrasound showed no evidence of a lesion deep to the abnormality. Freehand core biopsies were taken of the area. Pathology demonstrated the presence of malignancy in keeping with high-grade angiosarcoma.
Staging investigations including CT chest and abdomen, CXR and bone scan none showed any evidence of metastasis. She had wide surgical excision and reconstruction with a Vertical Rectus Abdominus Myocutaneous flap (VRAM flap). She has completed her first year follow up without any recurrence.
Histological examination following routine processing and staining with haemotoxylin and eosin shows malignant tumor (figure ). Although this tumor is predominantly solid, comprising highly pleomorphic cells (figure ) and areas with spindle cell morphol

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


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

[User]
RADIOLOGY NOTE:
A 2-year-old male child presented to the outpatient clinic with a painless swelling and deformity over the left scapular region which was insidious in onset and gradually progressing over the past 3 months. The child was first born, with no siblings and there was no history of a similar condition in any of the family members. The child had developmental milestones appropriate for his age. There was no history of trauma and no swelling elsewhere in the body. There was no history of fever or weight loss.
On clinical examination, the left scapula looked asymmetrical as compared to the right, with the medial border of the left scapula seeming prominent and elevated from the thoracic cage (). A swelling was palpable 5 × 4 × 4 cm in size which was non-tender, immobile, arising from underlying bone and non-adherent to the overlying skin. It was non-fluctuant and non-compressible. Skin overlying the scapula was intact. Range of motion of shoulder and cervical spine was normal and unrestricted. On neurological examination, the sensory, motor, and reflex testing of bilateral upper limbs were within normal limits. There was no sign of compression of nerves, vessels, or lymphatic system.
Plain radiographs and computed tomography (CT) scan (, , ) were done. The radiograph showed a bony lesion and the CT scan demonstrated a well-corticated bony excrescence arising from ventral surface of the left lower part of body of the scapula, 3 cm proximal to inferior angle and no associated fracture of the bony stalk.
In this case, we had a skeletally immature 2-year-old male child who was asymptomatic apart from a painless mass over the scapula with no associated complications, and hence, was planned to be managed conservatively and followed up regularly at 6 monthly intervals till skeletal maturity. This was planned keeping in mind the fact that a benign ventral scapular osteochondroma ceases to grow after the

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


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

[User]
RADIOLOGY NOTE:
The patient is a 40-year-old man who presented to the Mycetoma Research Centre (MRC) in Khartoum, Sudan with a painful left shoulder mass lesion and multiple sinuses discharging purulent discharge and black grains. He experienced increasing pain and loss of shoulder function over 3–4 months, alongside nausea, vomiting, and anorexia.
Fourteen years earlier, the patient recalled a laceration to the left shoulder during a traditional sword dance. This penetrating trauma may well relate to the current infection. The clinical course of the laceration infection lasted six years. He presented to his local rural medical centre six times, undergoing two surgical incisions and curettage procedures with subsequent physiotherapy. These achieved good functional restoration, but a definitive diagnosis was not achieved. The swelling recurred sometime later. At his fifth local consultation, four months before presenting to the MRC, a differential diagnosis of mycetoma was raised and he was started on oral itraconazole. Two months later he returned for his sixth consultation at his local health centre when it was noted the swelling had increased in size, accompanied with pain, discharging sinuses, and the systemic features noted above. He was admitted to the local health facility for 11 days and treated with intravenous benzyl penicillin, cefuroxime, and analgesia. Blood test at this time showed raised erythrocyte sedimentation rate (ESR) (110/hour). No surgical biopsy or cytology smears were taken from the lesion, but, following discharge, he was referred to the MRC to be seen one month later with subsequently admission to Soba University Hospital.
He had an appendicectomy one year prior to presentation, keloid scars over the xiphisternum following cautery, traditional treatment for back pain, a snake bite resulting in fixed flexion of the right fourth finger, and childhood abdominal surgery to evacuate traumatic haematomas. There was no family history of mycetoma. The patient was

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male patient with no specific medical history was admitted to University Hospital for paraparesis and sensory disturbances in both lower extremities, caused by a fall 3 months prior to admission. He was diagnosed with CES, due to a L3 burst facture and spinal canal compression. Thus, posterior lumbar interbody fusion was performed (). After surgery, paraparesis improved progressively and no specific symptoms were reported, except neuropathic pain. The patient was transferred to a rehabilitation hospital for conservative treatment of the neurogenic pain and gait training; no specific complication was found during treatment.
The patient was transferred to our emergency department with fever and general weakness for 7 days. A complete blood count indicated leukocytosis, and Klebsiella pneumoniae was isolated from blood and urine culture tests. By abdominal ultrasonography, edema was observed in the bilateral renal parenchyma with hyperechogenicity, indicating renal failure, caused by acute pyelonephritis. No local lesion in the renal parenchyma, decreased blood perfusion, or extension of the renal pelvis or renal calyx was observed. After diagnosing sepsis, caused by acute pyelonephritis, meropenem was administered intravenously. After antibiotic treatment for 13 days, vital signs were stable and laboratory findings returned to normal. Antibiotics were stopped on the 15th day.
The patient was transferred to the rehabilitation medicine department for comprehensive management of his CES on the 16th day of hospitalization. In the Medical Research Council Manual Muscle Test, muscular weakness was observed in both lower limbs, with hip flexor 4/4 (right/left), knee extensor 3/3, ankle dorsiflexor 3/3, hallucis extensor 3/3, and ankle plantar flexor 2/2 grades. The patient complained of tingling sensations, allodynia, hyperalgesia, and decreased sensations below the third lumbar segment.
Sitting and standing up could be performed independently according to 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 64-year-old male presented with a two month history of difficulty urinating and was found to have a fungating penile mass involving 50% of his penis. The mass was hard and fixed and extended from the glans proximally up the shaft. He also had bilateral palpable inguinal lymphadenopathy. There were no associated constitutional symptoms. Given there was a high suspicion for malignancy, the patient underwent partial penectomy within a month of presentation. Biopsy results confirmed a pT2 tumor with invasive keratinizing squamous cell carcinoma, poorly differentiated, and tumor size of 5 × 4 × 2.5 cm, with corpus spongiosum and lymphovascular involvements.
Following the procedure, the patient had PET-CT for staging, and imaging revealed enlarged hypermetabolic bilateral axillary lymph nodes concerning for metastatic disease. In addition, there was a large centrally necrotic lymph node conglomerate in his left groin that had increased FDG avidity. The patient had left inguinal and bilateral pelvic lymph node dissections revealing metastatic squamous cell carcinoma in multiple lymph nodes. The left inguinal mass was also found to be metastatic well-differentiated SCC. His diagnosis was staged at T2N3M0.
After his surgical procedures, patient was started on adjuvant chemotherapy. He began first line chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP). He underwent 4 cycles of TIP but eventually developed disease progression on repeat imaging. At this point, the patient was started on cetuximab given EGFR amplification on tumor analysis with the FoundationOne testing platform. However, the patient had an allergic reaction to cetuximab, so his treatment was changed to panitumumab. The patient had stable disease and a progression-free survival of 6 months with anti-EGFR treatment, which is clinically significant given that this treatment was given in the second-line setting for an aggressive tumor type that other than chemotherapy there is no other approved drug 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:
Mr. B.C. is a 35-year-old male patient who presented with a six-month history of right lower quadrant pain and weight loss of 20 pounds. He also complained of constipation with a decrease in bowel motion frequency from once per day to two per week.
On examination, B.C. was noted to be cachexic. Palpation of the abdomen revealed tenderness in the right iliac fossa; however, no signs of peritonitis were elicited. Complete blood count and renal and liver function tests were normal.
Computed tomography (CT) of the abdomen and pelvis with intravenous contrast showed a thick-walled (6.3 mm) caecum with fat stranding and a small volume of adjacent free fluid (see ). These findings were reported as being consistent with inflammatory bowel disease.
The patient subsequently had a colonoscopy which showed a mass at the caecal pole with edematous, inflamed tissue and pus (see ). Random biopsies were obtained from the inflamed colonic mucosa. Attempts at intubation of the ileocecal valve were unsuccessful. The rest of the colon appeared normal. Histology of the biopsy showed a marked increase in the number of chronic inflammatory cells dominated by tissue eosinophilia, consistent with a diagnosis of eosinophilic colitis. The specimen revealed no evidence of malignancy.
Considering the CT and histology findings, the patient's age, and the absence of a family history of malignancy, the findings at colonoscopy were interpreted as an inflammatory mass secondary to eosinophilic colitis. Stool microscopy showed no ova, cysts, and parasites. In conjunction with a gastroenterologist, the patient was started on an empiric course of albendazole and mesalamine.
One month after his first presentation, Mr. B.C. represented reporting no improvement in symptoms, further weight loss of 10 pounds, and intractable abdominal pain. At this time, the patient was tender in the right lower quadrant of the abdomen with guarding. Repeat CT scan showed a fluid collection surrounding the ca

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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 62-year-old hypertensive, obese, diabetic, male patient with short neck presented with episodic falls, difficulty in walking, and brief loss of consciousness to our hospital. Weakness of both hands and progressive weakness of all four limbs were present since 1 week. The patient was diagnosed as complex partial seizures clinically. There was no history of trauma at the presentation or in the past. The patient had a history of subarachnoid haemorrhage 6 months back for which conservative management was done elsewhere. Magnetic resonance (MR) imaging of the brain showed mild effacement of the sulcal spaces on T1 weighted images (T1WI) and T2 weighted images (T2WI) (Figures and ). There was a positive phase shift and blooming along the sulcal spaces on phase contrast and maximum intensity projection (MIP) susceptibility weighted images (arrow heads in Figures and ) suggestive of superficial siderosis. There was no evidence to suggest the possible source of haemorrhage in the MR images of the brain. The remainder of general physical and systemic clinical examination was also unremarkable. Screening of the spine was done to locate the possible source of the bleeding leading to superficial siderosis.
Cervical spinal magnetic resonance imaging (MRI) revealed an intradural extramedullary mass occupying the anterior intradural space which displayed hypointense signal on T2WI and hyperintense signal on T1WI (Figures , , , and ). Contrast enhancement of the mass was not evidently revealed by visual assessment on postcontrast fat saturated T1 weighted images () due to strong T1 hyperintensity of the mass on unenhanced images. Mild peripheral heterogeneous enhancement of the tumor was verified by the subtracted images (). The lesion was compressing and displacing the spinal cord posteriorly (arrow in Figures , , and ). The PET CT images showed moderately FDG avid extramedullary intradural mass (arrow in ) and no other foci of FDG avidity were noted elsewhere in the body

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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 35-year-old female, not known to have any chronic illnesses, presented to the urology department after the patient developed sudden hematuria six hours after a lower abdominal cesarean section. Her medical history was insignificant with one previous child who was delivered by CS and no allergies or medications confirmed. Meanwhile, social history was negative for tobacco, alcohol, or any illicit drug use. Upon examination, the patient was afebrile, vitally and hemodynamically stable, while systemic review was unremarkable. Moreover, local examination showed a full flank with mild abdominal distention and mild generalized tenderness without any signs of peritonitis. Regarding her investigations, complete blood count was within normal limits while Renal Function Test (RFT) showed elevated creatinine (3.42 mg/dl) (Table ). A non-contrasted Computed Tomography (CT) was ordered and a finding of a large amount of intraperitoneal fluid accumulations was reported (Figure ). After normalization of serum creatinine and glomerular filtration rate (GFR), which was achieved by a foley catheter drainage, a CT cystogram showed a defect in the dome of the urinary bladder with extravasation of contrast to intraperitoneal space (Figure ).
The choice of taking a non-invasive approach was determined after the patient's refusal for any further surgical interventions to be done. Afterwards, tapping off the intraperitoneal fluid was done with an abdominal fluid drain insertion which was inserted under local anesthesia and under the guidance of ultrasound and complete aseptic conditions rather than the standard surgical approach for the removal of the intraperitoneal fluid collection. Moreover, a 6.5 French pigtail catheter was inserted for 14 days to allow for maximum fluid drainage with a plan for surgery in case there is further deterioration. Fluid chemistry showed high creatinine levels (377 mmol/L), indicating the presence of urine in the abdominal area within less than 24 hours. T

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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 20-year-old gentleman reported with inability to lift his right upper lid following the development of a painless swelling in the right brow region of two weeks' duration. There was no history of any diplopia, or visual disturbances and nor was there any concurrent dental, ear, nose, throat (ENT) or significant systemic illness. The patient had sustained deep lacerations of the scalp and forehead due to a road traffic accident a year earlier. There was no history of loss of consciousness, bleeding ENT or any visual disturbances at the time of injury. He had been treated elsewhere with wound suturing and antibiotics novoclox and metrogyll for five days, following which he recovered well and had remained symptom-free till the present illness.
Clinical examination revealed a firm, non-tender, finely nodular swelling 2 cm × 4 cm in size, in the superotemporal region of the right upper lid, with an accompanying moderate grade mechanical ptosis. Skin over the swelling was normal and the mass seemed to be continuous with the supero-temporal orbital rim but not with the lacrimal gland []. The frontalis muscle was acting normally. Both eyes were normal with a visual acuity of 20/20 in each eye. Exophthalmometric readings were normal. Dental, ENT and systemic examinations were also normal.
Orbital X-rays revealed a soft tissue shadow anterior to the orbital margin. There were no bony abnormalities seen. Magnetic resonance imaging (MRI) revealed an ill-defined extraconal lesion at the superior and lateral aspect of the right orbit which seemed to involve the lacrimal gland. The radiologist's report suggested the presence of a pseudotumor orbit or lymphoma [Figs. and ]. Consequently, tissue samples from three different areas of the mass were obtained by fine needle aspiration cytology (FNAC), through both skin and conjunctival approaches. The FNAC was reported as organizing infected hematoma, although the infective organism was not identified. As treatment with intravenous ce

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old man presented to our institution with a 3-year history of pain in the left throat and trismus caused by pain. Magnetic resonance imaging in the Department of Neurology revealed an abnormal shadow above the hyoid bone. The patient was referred to the Department of Otorhinolaryngology, where no abnormal signs other than trismus were found. Computed tomography (CT) revealed that the left styloid process was connected to the hyoid bone, had a total length of 70 mm, and was approximately 10 mm thick along almost its entire length (Figures and ). Five years earlier, the patient had been transferred to our emergency clinic with a facial injury, and cervical CT images taken also revealed elongation of the styloid process. At that time, the styloid process had been approximately 5–7 mm thick, and its enlargement in the subsequent 5 years was evident ().
The patient was diagnosed with Eagle syndrome and treated initially with analgesics. However, the treatment with analgesics had not improved his pain, so he underwent transcervical resection of the styloid process under general anesthesia. A horizontal skin incision was made in the upper part of the neck, and the submandibular gland was removed to ensure a wide surgical field (). The styloid process was firmly connected to the hyoid bone on the dorsal side of the hypoglossal nerve, and a 40 mm portion was resected from the attachment to the hyoid bone. No invasion of the surrounding tissue was found intraoperatively, and it was easy to separate and resect the bone. Pathologic examination revealed that the lesion consisted of bony tissue with a bone marrow component and a cartilaginous component in contact with the trabecular bone. There were no signs of active inflammation or malignancy. The symptoms such as pain and trismus disappeared completely. Preoperatively, the patient scored pain on opening his mouth and pain on swallowing as 8 on a visual analog scale, and both scores improved to 0 postoperatively. The

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old man with spastic tetraplesia diagnosed with CLS at age 3 was referred to our hospital. One year before admission, the patient's parents noticed that he could not walk long distances and had a spastic gait. His gait disturbance became worse over time. One month before admission, the patient could not walk even several meters and had decreased upper extremity locomotor activity, such as an inability to elevate his arms. At the time of admission, he could not get up and could only make slight movements of the distal potions of his extremities.
The patient's appearance was consistent with previous descriptions of patients with CLS. He had a prominent forehead, coarse faces, broad nose, thick septum, wide mouth, and tapering fingers (Fig. ). He could emit a groan but could not have a conversation. We were unable to perform assess sensory function on physical examination. He could move his neck but not his trunk or extremities. Spastic weakness and very brisk muscle stretch reflexes were observed in all 4 extremities, and Babinski sign was observed. A balloon-catheter was placed because of dysuria. We suspected his symptoms were caused by cervical spinal cord damage, and performed imaging studies.
Computed tomography (CT) showed hypoplasia of the posterior arch of the C1 vertebra, and continuous calcification of the YL from C2 to T3 (Fig. ). Magnetic resonance imaging (MRI) revealed that the cervical spinal cord from C1 to T1 was compressed by the calcification (Fig. ). Image quality for MRI was low because the patient reacted poorly to anesthesia and moved during the examination. Although diagnostic information was limited, we diagnosed acute exacerbation of cervical myelopathy, and performed emergency surgery.
Under general anesthesia in the prone position, the C1 to C7 laminae were exposed. Twenty millimeters of the width of the C2 to C7 laminae were removed using a high-speed drill. Adhesion

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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 58-year-old female presented with a chief complaint of left hip pain of 5 months’ duration. The patient had been seen approximately 10 months prior to presentation, shortly after experiencing a “clunk” in her right hip. She reported that her pain was stable and had not increased since that episode. Relevant history included a left primary THA approximately 25 years ago. The patient also reported a right primary THA at the age of 33 years, followed by a head and liner exchange 10 years later due to poly wear and broken tine. A right total knee arthroplasty procedure was performed approximately 1 year ago. Comorbid conditions reported included degenerative joint disease, thrombocytopenia, cirrhosis of the liver, lumbar spondylosis and anemia. The patient had been managing any ongoing hip pain with anti-inflammatories and routine monitoring of poly wear with annual radiographs.
On physical examination, a pain-free range of motion (ROM) of the affected hip was noted, although the patient demonstrated hesitation at the extremes of motion. Slightly reduced ROM was noted with internal and external rotation when compared with the right hip. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. Radiographs were obtained and revealed severe polyethylene wear and asymmetry in the left hip (). Some acetabular and proximal femoral lysis was noted, although there was no change in the acetabulofemoral component interface.
The pre-operative plan for this patient was to exchange the polyethylene liner only; however, during surgery, it was observed that the locking mechanism on the poly component was incompetent. Furthermore, intraoperative measurement with the navigation system indicated anteversion of 5° (radiographic definition), revealing a cup component significantly more retroverted than the 18° indicated by the pre-operative radiograph (). A decision was made to exchange both the liner and the cup component ().
Surgery was successful, and post-operat

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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 three year-old girl presented with abdominal pain and jaundice of one month duration. The pain was epigastric in origin, and worsened after eating. Her history was unremarkable except for blunt trauma following a car accident. The child was sitting on her father’s lap while he was driving whenthe accident occurred.After trauma the child was visited by a physician because of vomiting. When ultrasound and physical examination of the child was normal she was discharged and given metoclopramide drops. Over the next three days, she had nonbiliary vomiting which stopped thereafter. The child complained of occasional abdominal pain which was finally complicated by icterus. She appeared healthy and tolerated feeding well, although occasionally complaining of postprandial abdominal pain. She did not have a fever and her vital signs were normal. The physical examination showed a soft abdomen with no tenderness but revealed jaundice. The laboratory data results wereas follows: WBC = 12600 mm3, Hb = 12 g/dL, ESR = 25 mm/h, total bilirubin = 8.4 mg/dL, conjugated bilirubin = 6.9 mg/dL, aspartate aminotransferase (AST) = 559 IU/L, alanine aminotransferase (ALT) = 475 IU/L and alkaline phosphatase = 938 IU/L. A new ultrasound examination showed remarkable dilatation of the common bile duct to 8 mm with a terminal stricture. Barium meal showed a normal stomach and an open duodenum. Magnetic resonance cholangiopancreaticography (MRCP) demonstrated severe dilatation of the both intrahepatic and extrahepatic bile ducts ().
The patient was operated with a diagnosis of obstruction of the end of the common bile duct. The severe dilatation was obvious upon operation. The common bile duct was explored. A small catheter was passed with difficulty which pointed to severe stricture and fibrosis,not amenable to dilatation. The patient underwent choleducoduodenostomy. On the third day postoperatively, the patient started oral feeding. On the fifth day postoperatively, the serum bilirubin decr

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

[User]
RADIOLOGY NOTE:
A 7-year-old girl was referred to the Oncology Section of the Endocrine Unit of the University Hospital of Pisa, Italy, for suspected MTC based on the presence of both thyroid nodules and elevated serum levels of calcitonin (Ct).
The medical history of the child showed that she was born after a caesarean section at 38 weeks with a weight of 2400 g as well as with newborn jaundice and biliary vomiting. Because of the failure to pass meconium, congenital intestinal dysganglionoses or cystic fibrosis was hypothesized, but at that time, both were ruled out by a rectal biopsy and sweat test, respectively. The patient continued to experience biliary vomiting and failure to thrive; for this reason, she was fed using a nasogastric tube for a long period of time. When she was 2 years old, pyloric stenosis was suspected, and the girl underwent digestive system scintigraphy that demonstrated slowed gastric emptying. On the basis of this test, the patient underwent dilatation of the pylorus but did not achieve any clinical benefit. During gastroscopy, an irregular and small duodenum associated with esophagitis was documented. Magnetic resonance imaging (MRI) demonstrated an abdominal solid massive and expansive lesion (14 cm at the largest diameter) that extended down to the pubic region and surrounded the urethra and the bladder, without any cleavage plans, thus causing mild hydronephrosis. She underwent laparotomy with debulking of the lesion since it was unresectable. The histology described a ganglioneuroma. Over the years, she developed vesicoureteral reflux and recurrent pyelonephritis due to an increasing pressure of the pelvic mass on the bladder that forced her to practice intermittent catheterizations. At 6 years of age, urological control demonstrated high-grade (grade III) vesicoureteral reflux with markedly decreased excretive functioning bilaterally.
At 7 years of age, a serum calcium level of 11.3 mg/dl with a serum parathyroid hormone (PTH) level of 49 pg/ml was

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

[User]
RADIOLOGY NOTE:
A 58-year-old man with liver cirrhosis and ulcer of the stomach in his medical history was found to have a T3N1M0 squamous cell carcinoma in the floor of the mouth between teeth 33-43. The tumor was surgically resected, and the patient was reconstructed with a free anterior lateral thigh (ALT) flap. At the same procedure, a neck dissection region 1-5 right side and region 1 left side was carried through since fine needle aspiration cytology had confirmed a regional metastasis in region 1, right side. The patient received antibiotics the same day as the surgery and regularly the days after surgery. However, the patient developed a redness on the neck and on the flap donor site 5 days after surgery, and pus started to leak from the neck wound.
Three years previously, the patient had been diagnosed with left-sided tonsil cancer and ipsilateral metastases on the neck. He then received full-dose (68Gy) radiotherapy. At the 3 months follow-up, a CT scan was routinely done and showed remaining lymph nodes with suspicious appearance. A neck dissection of the ipsilateral side regions 1-5 was carried out. Three days after surgery, a redness and suspected infection on the neck was found and clindamycin was ordinated. The patient was dismissed from the hospital but returned 13 days after surgery since the neck did not improve (Figure ). The neck showed alarming redness and the surgical wound was purulent. The patient was put into the ward and ordinated intravenous cefotaxime and later, cloxacillin, since a swab showed s aureus. Despite adequate antibiotics, a flap necrosis developed, and the neck was closed a month after the neck dissection with a transposition flap. The flap area got red after surgery, and a local swab showed presence of enterococcus and coagulase-negative staphylococcus. The patient was treated with several courses of antibiotics, and the flap eventually healed without necrosis about a month after the flap surgery (Figure ).
After

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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.