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

[User]
RADIOLOGY NOTE:
A 27-year-old right-hand-dominant and otherwise healthy female student presented with a pain in the right upper scapular region that increased with shoulder motion and resting in the supine position. She reported that a painless snap in her back had occurred during sports activity 11 years previously and had disappeared 2 years later after discontinuing sports activity. The pain in the right upper scapular region had appeared 3 months earlier during continuous inputting to her personal computer and had rapidly worsened. She presented at a nearby hospital because the pain was generated during activities of daily life and prevented her from sleeping in the supine position. A physician suspected a malignant bone tumor based on radiographic and magnetic resonance imaging (MRI) findings and referred the patient to our hospital.
The patient had no relevant family or medical history. The right shoulder was slightly lower than the contralateral shoulder. There were no neurological deficits in the right shoulder or arm. There was winging of the right scapula with the arm at the side. An upper interval between the spine and the medial scapular border was widened by 70%, but the lower one was not (). There was no atrophy of the back muscle, and contraction of the trapezius was normal. The muscle bellies of the short rotators and rotator cuff were not tender and were without defects. The limitations of the active ranges of motion were 10° for total elevation, 15° for external rotation, and two vertebrae for internal rotation. Horizontal adduction was not limited with moderate pain beyond 100°. The empty can test generated upper scapular pain. No deformity or osseous tumor was palpable in the large joints, pelvis, or ribcage. Radiographs revealed a bone mass extruding from the ventral side of the superomedial scapular angle; no abnormality was depicted in the large joints. Computed tomography showed a mushroom-shaped osseous tumor composed of a cortex continuous with the scapula

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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:
The patient was a 32-year-old otherwise healthy female who was admitted to a tertiary care center with unexplained hypoglycemia and altered mental status. She was in her usual state of health until one month prior to hospitalization when she presented with morning drowsiness and loss of appetite. Due to the gradual worsening of symptoms, she was brought to the Emergency Department for further evaluation.
Upon admission, the patient was found to have a glucose level of 35 mg/dL. She had recurrent episodes of hypoglycemia despite numerous intravenous glucose infusions which led to a work up for a possible pancreatic tumor. An ultrasound of the abdomen was performed showing several liver nodules along with a large pancreatic mass measuring up to 10.7 cm in the largest diameter (not shown). Computerized tomography (CT) scan of the abdomen was performed confirming the sonographic findings. The patient underwent a liver biopsy. Histopathology and immunohistochemistry results were consistent with low-grade neuroendocrine neoplasia (positive stain for chromogranin A) (). Insulin and C-peptide levels are depicted in .
The patient received continuous intravenous glucose because of recurrent episodes of hypoglycemia throughout the hospital stay (). Glucagon and hydrochlorothiazide failed to elevate glucose levels.
Octreoscan was performed showing a high uptake in focal areas of the liver, left lower quadrant of the abdomen, and cervicothoracic area ().
Sandostatin LAR 30 mg IM was started on hospital stay day 43 on an every 28 days basis. The patient received 2 infusions of radiolabeled somatostatin analog lutetium (177LU) 8 weeks apart beginning on hospital day 56. By the second administration of the radiopharmaceutical, Octreoscan SPECT/CT had already shown objective metabolic and radiologic response to treatment (Figures and ). Serum glucose levels started to rise by hospital stay day 60 (). Intravenous glucose infusion was titrated progressively down onwards. The patient w

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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 79-year-old Indian male patient presented to a tertiary centre in Melbourne with 3 months of progressive dysphagia, which significantly worsened over the 3 weeks prior to admission. He was admitted under the upper gastrointestinal surgical unit for further evaluation and consideration of an elective Heller myotomy.
The patient presented with the primary complaint of dysphagia; unable to tolerate any solids or liquids without regurgitating it back up. The vomit contained undigested food with no apparent features of haematemesis such as coffee ground appearance. The patient did however complain of mild epigastric pain while vomiting. This dysphagia was accompanied by substantial weight loss of 5 kg over the preceding 2 weeks. He denied any associated fever, cough or other coryzal symptoms. He also denied symptoms of bowel obstruction such as new constipation or significant abdominal distension.
The patient had a recent presentation to another large metropolitan hospital due to aspiration pneumonia in October 2017. During that admission, he was investigated for dysphagia. A barium swallow test revealed the following features: ‘bird beak’ appearance, marked distal oesophageal dilation with abnormal peristalsis and tertiary peristaltic waves; however, subsequent oesophageal manometry (lower oesophageal sphincter basal pressure: 8.9 mm Hg, residual pressure: 9.3 mm Hg, upper oesophageal sphincter basal pressure: 48.9 mm Hg, residual pressure: 7.5 mm Hg) was not typical of achalasia. He consequently underwent a gastroscopy, which showed oesophageal dilation and gastritis. The patient was given the diagnosis of achalasia and managed conservatively at that stage and was referred to the upper gastrointestinal surgical unit at Monash Medical Centre for surgical management of achalasia.
His medical history includes a previous Heller myotomy at the age of 17 and neurofibromatosis. The indication for the Heller myotomy remains unclear as it was completed overseas with no record

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


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

[User]
RADIOLOGY NOTE:
A healthy 54-year-old woman presented with a 1-year history of a large smooth plaque on the scalp with associated alopecia (Fig. ). The lesion was tender, had slowly increased in size and had not been treated prior to the visit. She had no other symptoms, organomegaly or lymphadenopathy. Excisional biopsy was performed, which revealed a lobular infiltrate of atypical lymphocytes (Fig. ) predominantly expressing CD8 and displaying rimming of adipocytes (Fig. ). The immunoperoxidase workup also showed moderately dense dermal and subcutaneous lymphocytes expressing CD4, a minority of lymphocytes expressing CD56 and an elevated Ki-67 labeling rate with rimming around adipocytes. There were associated necrosis and sclerosis of fatty lobules and increased dermal and subcutaneous mucin. Bacterial and fungal cultures and stains were negative. There also was superficial perivascular and perifollicular mixed lymphocytic infiltrate with vacuolar alteration of the basal layer of the epidermis and follicular epithelium. A diagnosis of SPTCL was made by the dermatopathology unit at a large, academic medical center, based upon the clinical, histologic and immunohistochemical studies. T-cell gene rearrangement studies were not performed on the original biopsy, and the tissue was no longer available for subsequent testing. Some of the histologic features described might also have suggested lupus profundus. The patient was referred to the oncologist and treated with radiotherapy with complete resolution of the lesion and hair regrowth.
Four years later the patient returned to her original dermatology clinic with new multiple firm, tender and enlarging subcutaneous nodules on the upper back, left shoulder, left forearm and both shins (Fig. ). Based on the patient's prior history and the clinical appearance of the lesions, the differential diagnosis included recurrent SPTCL, as well as traumatic panniculitis, lupus profundus and erythema nodosum. Punch biopsies of the two lesions were

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


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

[User]
RADIOLOGY NOTE:
This patient was a generally healthy 62-year-old male with a left lobe complex nodule within a nontoxic multinodular goiter that had been enlarging for approximately 3 years. In 2015, the patient had a FNAB reported as benign, BC II. Because of continued growth, he had a second FNA biopsy approximately six months later reported as a Hürthle cell neoplasm or suspicious for a Hürthle cell neoplasm, BC IV with Oncocytic / Hürthle cells dispersed mostly singly and in small fragments in a background of lysed blood. CKAE1/AE3, TTF-1, and thyroglobulin immunostains were positive (). Molecular testing with ThyroSeq® v2 revealed an absence of gene mutations or fusions but overexpression of the MET gene with an uncertain increased risk of malignancy. After repeat ultrasound imaging, the nodule had grown from 4.9 to 6.0 cm over the course of 1 year. He was euthyroid with negative anti-thyroid antibodies. There was no family history of thyroid cancer or known radiation exposures in his youth. He had no obstructive symptoms despite the size of the mass and denied shortness of breath, dysphagia, neck pain, neck pressure, or recent voice changes. His weight had been stable and appetite good. His past medical history was significant for a retinal detachment, hypertension, and inguinal hernia with a surgical history limited to eye surgery and hernia repair. He denied tobacco or alcohol use. On exam, the patient had an enlarged, firm thyroid gland with the left thyroid lobe causing significant tracheal deviation to the right. A neck CT scan demonstrated a markedly enlarged left thyroid lobe (7.2 cm in sagittal height) causing significant rightward tracheal deviation, minimal tracheal compression, and slight early substernal extension (). He had multiple opinions from both endocrinologists and surgeons with various recommendations from left thyroid lobectomy to total thyroidectomy. The patient had initially contemplated a hemithyroidectomy due to concerns for voice impairment that cou

[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 58-year-old man presented to the general surgical team with a one-week history of constant right iliac fossa pain radiating to his back. He did not report any other concerning symptoms - weight loss or change in bowel habit. Previous clinic letters indicated he had intermittent colicky right iliac fossa pain 6 years prior, which was investigated with a CT abdomen and no abnormality was detected. His past medical history included hypertension and human immunodeficiency virus (HIV) stage 3, which is the most severe stage of HIV infection where individuals are most immunocompromised []. He was taking antiviral medication for his HIV with a good CD4 count. His past surgical history included bilateral inguinal hernia repair. He denied any family history of malignancies.
The bed-side abdominal examination demonstrated a soft abdomen with tenderness and guarding in the right iliac fossa, and no masses were palpable. Biochemistry revealed an elevated white cell count of 10.02 × 109/L and a C-reactive protein of 133.7 mg/dL, and the remainder of his blood results were unremarkable.
CT abdomen and pelvis with contrast revealed an appendiceal abscess (Figure ). This finding was discussed at the local X-ray multidisciplinary team (MDT) meeting, where a decision was made to manage it conservatively with broad-spectrum antibiotics and CT-guided drainage. This improved his symptoms substantially and was discharged two days later with a drain in-situ which was to be reviewed as an outpatient. Cytology from the drainage did not reveal any malignant cells.
Following his discharge, he was further investigated with an outpatient colonoscopy, which revealed a caecal lesion and biopsy showed a high-grade dysplasia. A repeat CT scan still demonstrated a para appendiceal collection, which had improved.
In view of these findings he was referred to Basingstoke Hospital, a tertiary centre. He was reviewed at Basingstoke and a decision was made for him to undergo cytoreductive surgery. Subse

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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:
The patient is a 54-year-old Caucasian male with a past medical history significant for chronic lower back pain for 15 years and basal cell carcinoma, who initially presented with a left sided inguinal mass associated with mild discomfort (). The patient was diagnosed with an indirect inguinal hernia which was repaired robotically using Progrip mesh at an outside community hospital. Intraoperatively, the surgeon noted what appeared to be a large cord “lipoma,” as well as hematoma that was attributed to attempted reduction, and incarcerated sigmoid colon through the defect. The mass was not sent for pathology and was assumed to be a simple lipoma. At 4.5 months postoperatively, the patient returned with a left sided groin fluid collection ().
Ascribing this to postoperative seroma, a 15 French Blake drain was placed with removal of 1 L of serosanguinous fluid without evidence of infection. This fluid was not sent to pathology. Drain placement was complicated by cellulitis 1 week later which resolved with IV antibiotics. Two weeks following drain placement it was removed as the fluid had resolved. At 7 months postoperatively, the patient again noted recurrent fluid collection in the left inguinal site. A follow up CT scan of the abdomen/pelvis with contrast demonstrated a large left sided retroperitoneal seroma with fluid that extended into the left inguinal canal in addition to a new retroperitoneal fluid collection ( and ()). Additionally, a new right sided retroperitoneal fluid collection was noted well away from the original postoperative bed. Bilateral drains were again placed with evacuation of 1140 mL of hematoma. Cytology of the fluid revealed mononuclear mesothelial, monocytic, and histiocytic cells and culture was negative for microbial organisms.
The treating medical team felt that the patient’s symptoms were most consistent with mesh complications, and the patient underwent explantation of the mesh. Intraoperatively, fluid was noted to extend below the mes

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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 56-year-old male, 168 cm tall and weighing 71 kg, with a traumatic right rotator cuff injury, was scheduled for arthroscopic reconstruction surgery under general anesthesia. This patient had a history of diabetes mellitus and was taking oral hypoglycemic agents and insulin. For several years, he experienced recurrent episodes of severe left ocular pain and increased IOP, which later resolved. On close ophthalmic examination, he was diagnosed with Posner-Schlossman syndrome. There was mild epithelial edema of the cornea with a few keratic precipitates, and his cup/disc ratio was 0.5 with no visual field change. During the acute crisis period, the measured IOP in his left eye was above 30 mmHg and the IOP in his right eye was 13 mmHg. His symptoms were relieved after applying eye drops containing dorzolamide, a carbonic anhydrase inhibitor, and prednisolone acetate, but frequently recurred. Three weeks before his scheduled surgery, the IOP in his left eye rose again and he became extremely anxious about the operation. After consultation with an ophthalmologist, we decided to measure the patient's IOP intraoperatively using portable tonometry, and obtained informed consent from the patient for this perioperative risk.
Preoperative laboratory findings, including hemoglobin concentration, liver function and coagulation tests, and arterial blood gas analysis, were normal, as were chest X-rays. The patient had a left axis deviation and an incomplete right fascicular block on electrocardiography and a mild restrictive pattern on pulmonary function test without any significant symptoms. In the morning of the day of surgery, the patient received 7.5 mg of midazolam per os. Before entering the operating room, his vital signs were stable, with a blood pressure of 133/75 mmHg, a heart rate of 82 beats per min, and an oxygen saturation of 99%. Two drops of 0.5% proparacaine hydrochloride were applied to each eye, and IOP was measured by portable tonometry (Tono-Pen Avia, Ametek

[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 woman presented with acute and progressive weakness of the right-hand extensors with painless swelling in the proximal part of the right forearm. Interestingly, she noticed that weakness after a fall on the outstretched left hand leading to fracture of left distal radius. She was treated conservatively in a cast. Six weeks later, and during routine follow-up, she mentioned that she noticed her right-hand weakness only when she started to use it excessively. She denied any injury to her right-hand or elbow. Examination revealed a swelling 3 × 3 cm in the antero-lateral aspect of the right forearm in the region of supinator muscle. The swelling was soft in consistency and decreased in size on flexion with supination of the forearm indicating that the lump was deep to the brachioradialis muscle. Extension of the metacarpophalangeal joints of all fingers in her right-hand was weakened. Also, there was slight weakness in the wrist joint extension. There was no sensory deficit in any of the dermatomes of the hand or the forearm.
Radiographs of the right elbow showed soft-tissue density closely related to the proximal radius with normal bone appearance. Electromyography of the posterior interosseous nerve and muscles demonstrated active denervation, but nevertheless there were 1 or 2 recruited motor units confirming continuity of these motor fibres. Magnetic resonance imaging (MRI) of the right forearm revealed a multilobulated mass with hypointensity signal on a T1-weighted sequence which is pathognomonic of a lipoma. The precise anatomical location was in the lateral and anterior aspects of the right radius neck and extending distally for about 3 cm as shown in Figures and . The lesion was explored through anterior approach under general anaesthesia. The radial nerve and its two branches were identified. PIN was traced distally to the level of the proximal margin of volar supinator muscle (arcade of Frohse). There was focal

[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:
This 18-year-old, right-hand dominant male college freshman was referred to our clinic for evaluation of recurrent right shoulder dislocations. He had no history of connective tissue disorder and was otherwise healthy. His first dislocation event occurred 2 years prior while rock climbing and simply reaching forward and laterally to his right. No significant causative trauma was reported in association. He sought no medical treatment as the shoulder was reduced on sight. The patient reported that the dislocations were becoming more frequent and the most recent event occurred while practicing Jiu Jitsu, again while simply reaching without significant forces. Dislocations continued to occur despite rehabilitation exercises. On physical exam, he was noted to have no significant muscle atrophy or scapular dyskinesis. Notable on examination, he was found to have anterior apprehension, a positive inferior sulcus sign (compared to the uninvolved limb), and a mild posterior instability to load shift testing. On observation, the patient also showed signs of a minimal right upper extremity hemimelia despite the fact that this was his dominant arm and that he was a recreational athlete. Most apparent, his right hand was minimally, although noticeably, smaller than left, a finding not previously reported in unilateral congenital absence of the LHB tendon. His preoperative DASH score was 29.55. Magnetic Resonance Imaging (MRI) without contrast of the affected shoulder indicated an anterior Bankart type labral lesion, small nonengaging Hill-Sachs lesion, and most atypically nonvisualization of the biceps tendon () and absence of the bicipital groove ().
Arthroscopic shoulder stabilization was recommended and an anterior and posterior capsular shift with anterior Bankart repair were performed (). The posterior capsular shift was added to the stabilization procedure due to assessment of subtle multidirectional type instability. The rotator interval was not closed as this was felt t

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.
The patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.
On examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular regio

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

[User]
RADIOLOGY NOTE:
A 69-year-old woman with a chief complaint of hematochezia and anorexia that had been present for one month was admitted to the hospital. Physical examination and blood test results revealed nothing of note except for an elevated carcinoembryonic antigen of 24.7 ng/mL. Colonoscopy revealed that a type 1 tumor, i.e., a polypoid-type tumor, was located in the sigmoid colon, and an elevated lesion with redness was located in the appendiceal orifice (). The tumor was biopsied and diagnosed with well-differentiated tubular adenocarcinoma, which was suspicious of primary sigmoid colon cancer. The elevated lesion in the appendiceal orifice had redness on its top surface, but biopsy was not performed there because it was not suspected to be malignant due to the apparently normal mucosa. A computed tomography (CT) scan showed, however, an appendiceal mass that involved the sigmoid colon () and was located adjacent to the right ureter, suggesting an appendiceal cancer invading the sigmoid colon. The preoperative diagnosis was appendiceal cancer with a clinical stage of T4bN0M0, stage IIC, according to the TNM classification, the Union for International Cancer Control (UICC) 8th edition.
Ileocecal resection with extended lymphadenectomy and en bloc resection of the sigmoid colon was performed through a lower abdominal midline incision after the insertion of a ureteral stent. The appendiceal tumor involved the sigmoid colon and the terminal ileum. The ileocecal part was mobilized from the retroperitoneum, keeping the right ureter intact. The ileum was divided proximal to the involved part with a linear stapler. The ileocolic vessels were ligated at their origins, and the extended D3 lymph node dissection was performed. The ascending colon and then the sigmoid colon proximal to the invaded part were divided with a linear stapler. The ileocecal part which included the tumor and the involved sigmoid colon was resected in total after the rectum was divided. The pericolic lymph node

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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:
We present a case of a 65-year-old female patient admitted to the Cardiac Surgery Department in Wroclaw in January 2018 with severe mitral regurgitation (MR) and the history of ischemic heart disease, after elective percutaneous coronary intervention of the circumflex branch of left coronary artery with two drug-eluting stents (DES) implantation 4 years earlier. Furthermore, the patient diagnosed with many chronic conditions, such as metabolic syndrome, obesity with BMI 33 and gastroesophageal reflux disease. Currently, with an exercise dyspnoea for about 2 years, intensifying in recent weeks, she was hospitalized in the Cardiology Department for further diagnostics. The transthoracic echocardiography (TTE) revealed non dilated left ventricle with a normal systolic ejection fraction of 60%, and no evidence of segmental wall motion abnormalities, severe MR with the prolapse of the A2 segment and systolic restriction of the posterior leaflet. Colour Doppler showed a highly distinctive eccentric turbulent jet directed towards the lateral wall and the base of the left atrium with ERO 0.6cm2 and regurgitant volume of 60 ml. Additionally, in the performed coronary angiography, hemodynamically significant narrowing was found in the area of the previously implanted DES. The patient was then consulted by the cardiac surgeon and qualified for surgery. After admission to the Cardiac Surgery Department, as part of the pre-operative preparation, TTE was again performed, in which the severe MR was confirmed and no pathological structures in the right atrium were described. Due to the unclear image in the right pulmonary field, described by the radiologist in the chest X-ray (Fig. ), diagnostics was extended by performing a computed tomography of the chest, which excluded the presence of pathological shadow in the lung parenchyma. There was no referral to the atrial septum in the CT report. The patient was scheduled for mitral valve repair surgery and coronary artery bypass grafti

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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 60-year-old woman underwent transurethral resection of bladder tumor (TURBT) at our institute in 2004; her pathological diagnosis was a high-grade UC with adenocarcinomatous differentiation (pT2a, G2>G3). Radical cystectomy was conducted. Only carcinoma in situ (CIS) was found in the surgical specimen, and the surgical margin was negative. There was no cancer cell infiltration in the resected uterus or anterior wall of the vagina, and no lymph node involvement was detected. The patient developed continuous pain and bleeding from the residual vagina in 2010, and a tumor was found in the residual vagina; magnetic resonance imaging (MRI) showed it to be located on the anterior wall (). A biopsy of the tumor revealed a pathological diagnosis of adenocarcinoma (). Computed tomography (CT) and bone scintigraphy revealed no metastasis. Based on a preoperative diagnosis of a primary adenocarcinoma occurring on the residual vagina, tumor resection was performed (). The sigmoid colon was partially resected as it was strongly adherent to the tumor. On pathological examination, adenocarcinoma and SCC were detected (); on immunohistochemistry, sections of the tumor were positive for the SCC markers CD56, chromogranin A, and synaptophysin and were negative for the urothelial carcinoma markers GATA-3, p63, uroplakin, thrombomodulin, and 34βE12. We then reexamined the original TURBT specimen and confirmed the presence of SCC (). Adenocarcinoma and SCC were mostly present in the superficial layer of the TURBT specimen, while high-grade UC was found in the deeper layers where muscle invasion was present. Based on these findings, the tumor was diagnosed as a recurring bladder tumor. Local recurrence and pelvic bone metastasis were detected via MRI 3 months after the patient underwent surgical resection of the vaginal recurrence, whereupon she underwent radiation therapy (52 Gy, 26 fractions). She developed ileus in January 2011 and underwent release surgery. Subsequently, multiple l

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman (G4,P2), at the 15th gestational week of twin-pregnancy following IVF-embryo transfer, was found to have a solid adrenal mass on a regular checkup. MRI revealed a 11×7.5 cm right suprarenal hypervascular mass with mixed signal intensity in T2-weighted images (). The diagnosis of PC was confirmed by laboratory analysis (). The patient had no genetic testing and her family history was not indicative of any hereditary disease. She had two previous vaginal deliveries (14 and 11 years ago) and a history of one abortus at 10-week gestation two years earlier. The patient confirmed that she had no symptoms relating to PC in her previous deliveries. She had no genetic testing and her family history was not indicative of hereditary disease. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. She was asymptomatic and normotensive and had no hemodynamic instability during pregnancy. Perinatological ultrasonography revealed normal morphology of dichorionic and diamniotic male and female fetuses.
A multidisciplinary team consisting of urologists, anesthesiologists, endocrinologist, and obstetricians focused on the therapeutic approach. The patient did not receive any medical treatment for alpha or beta blockade preoperatively. She underwent laparotomy with a subcostal incision and transperitoneal tumor resection at 17 weeks of gestation (). During surgery blood pressure (BP) was stabilized with phentolamine and esmolol, with occasional bouts of brief hypertensive periods up to 240 mm Hg systolic pressure. A hypervascular mass with fragile large veins was dissected free of the upper pole of the right kidney, between the vena cava and the lower border of the liver. The estimated blood loss was 1100 ml. The patient was transfused with 3 units of erythrocyte suspensions. The postoperative period was uneventful and she remained hemodynamically stable. Histopathological examinations were in accordance with a PC.
She had a norma

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man presented with the complaint of painful swelling in the right lower limb for 5 months. Also, he noted a serous discharge from the scar of the previous surgery, over the last 5 months. His medical history included an internal fixation with a metal rod implant for femoral fracture treatment (). Roughly two months after the initial symptoms, the implant was removed (). The computed tomography (CT) detected a huge right proximal thigh lesion as well as multiple soft tissue lesions. These soft tissue lesions included the subcutaneous tissue of the face and abdominal wall, left perinephric and posterior pararenal space, left gluteal region, right second rib, and the right iliac bone. The Magnetic resonance imaging (MRI) scan of the right thigh showed an ill-defined, lobulated, expansile, intramedullary lytic lesion, which involved the metaphyseal and diaphyseal region of the femur. It also showed thickening and multi-focal breach of the cortex with associated extraosseous soft tissue component involving the skeletal muscle tissue. The positron emission tomography (PET) showed increased FDG avid uptake in the right thigh, nodal and extranodal tissue, intramuscular and subcutaneous region, renal, bowel, skeletal, omental, and peritoneal region, indicating the possibility of a disseminated malignancy ().
A biopsy of the femoral lytic region was performed, and the patient underwent a prophylactic internal fixation of the right femur with nails.
The biopsy’s histology revealed large, atypical cells in solid sheets with a round to oval irregular nuclei and nuclear indentations (). The chromatin was coarse to vesicular with prominent nucleoli and moderate basophilic to eosinophilic cytoplasm. Amidst these large cells, the characteristic hallmark cells with kidney-shaped nuclei were also present. Mitotic activity was brisk. These neoplastic cells were invading and replacing the surrounding bone trabeculae, indicated by dead bony fragments, collection of giant os

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


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

[User]
RADIOLOGY NOTE:
We describe a case of a 40-year-old female nurse who presented in May 2003 with an 18-month history of pain in the left thumb. Clinical examination showed soft-tissue swelling around the left thumb metacarpal. Radiographs showed an expansile lesion occupying most of the metacarpal with periosteal reaction and cortical destruction. MR scan () showed extensive destruction with expansion of the shaft of the first metacarpal of the left hand, associated with a soft-tissue mass and an extraosseous component, primarily on the dorsal aspect. On T
1 weighted images, the lesion was of low signal; on fluid-sensitive sequences, the lesion showed high signal with a thin and irregular septae. Following contrast medium administration, inhomogeneous, multilobulated, peripheral enhancement of the lesion was noted but also areas of non-enhancement predominated centrally, consistent with a cartilaginous lesion.
The CT scan () demonstrated a lytic lesion involving virtually the entire shaft of the first metacarpal of the left hand and reaching the subchondral bone plate at both ends. The lesion demonstrated a significant expansion of the bone with small areas of punctuate calcification, significant thinning of the cortex circumferentially and a breach in the cortex with some new bone formation on the dorsal aspect. Some soft-tissue swelling was also seen. There was no evidence of pulmonary metastases on the CT scan () at initial diagnosis.
An open biopsy was performed in June 2003, the histology of which revealed a grade II chondrosarcoma with evidence of spread beyond the cortex into the periosteum. Vascular invasion was not identified. 1 month later, under general anaesthesia, a first ray amputation was performed with disarticulation of the thumb at the trapezioscaphoid joint. A tourniquet was used at the time of the surgery to exsanguinate the limb. Macroscopic examination revealed an expansion of the metacarpal bone due to a chondroid tumour measuring 35 × 25 mm, which eroded thro

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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 five-year-old boy weighing 11 kg, was brought to a public tertiary care hospital in Karachi, Pakistan by his parents. His chief complaints were described as a diffuse rash over the body, swelling of the head and bulging of both eyes as well as swelling of the gums. These symptoms were progressive and relapsing, with the rash being present since the past 18 months and having extended to a breakout over the head, neck, back, chest and perineum over the last month and the swelling and bulging having progressed over the past year.
According to his mother, the child had been in absolute good health until the age of two years, when he developed a spontaneous fracture of his right clavicle. The family was counseled and told the fracture would heal without any intervention. At two-and-a-half-years of age, the family sought a dental consult for a spontaneously broken tooth which was described to them as a developmental problem of the mandible. Further on, at three years of age, the child developed an infected oral ulcer, a severe swelling of his gums and had two episodes of a yellowish ear discharge for which he underwent drainage. His bodily rash made its first appearance six months after that, at 3.5 years of age, presenting as yellow lesions with pus filled discharge over the head, palms, soles and genital area - albeit, healing afterwards. The swelling of the right side of the head and bulging of both eyes started at the age of four years, with the proptosis gradually progressing to its current state upon presentation and associated with dimness of vision in the right eye. The child had previously been misdiagnosed as a case of Papillon-Lefevre syndrome (rare ectodermal dysplasia characterized by palmoplantar keratoderma associated with early onset periodontitis) two years ago and prescribed fluconazole, but to no avail. He was the third offspring of a consanguineous marriage,

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

[User]
RADIOLOGY NOTE:
An 82-year-old female, with a BMI of 33.9, was transferred to our hospital from an outside facility with a diagnosis of a failed left hip prosthesis. The implant had fractured in the area of the femoral neck adjacent to the modular head ().
The patient had undergone left total hip arthroplasty twelve years prior to presentation for osteoarthritis. The femoral component was a cemented Exactech Opteon stem, size 2, with a 28 mm, +5 mm femoral head. The acetabular component was a 54 mm Duraloc cup with an Enduron polyethylene liner (DePuy Inc., Warsaw, IN). The patient had a total knee arthroplasty performed in the ipsilateral extremity three years prior to the total hip arthroplasty also for osteoarthritis. Three months after the total hip arthroplasty, the patient developed a Staphylococcus epidermidis periprosthetic infection in her knee and underwent exchange arthroplasty later that same year. Only the total knee implant had been affected and revised, whereas the total hip implant was unaffected. The patient subsequently underwent successful rehabilitation and had been an independent community ambulator thereafter.
Upon presentation, the patient denied shortness of breath, chest pain, fevers, chills, night sweats, or recent travel. Five month prior to presentation, the patient had dental work with appropriate antibiotic prophylaxis. The critical event most likely occurred several days prior to presentation when the patient slipped and fell in the bathroom. Plain radiographs revealed a fracture of the femoral component at the area of the femoral neck adjacent to the modular head (). The stem appeared well seated with no evidence of infection, loosening, malalignment, or periprosthetic fracture. Examination and imaging of the ipsilateral knee were unremarkable.
Surgery was subsequently planned for component retrieval and revision arthroplasty. Under general anesthesia, the patient was placed in the lateral decubitus position. The previous incision was opened, the sub

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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 36-year-old married male presented to our clinic with complaints of few confluent and mildly itchy blisters on the glans penis for one day. The blisters had appeared a day after having protected sexual intercourse with his wife. There was mild fever along with the specified symptoms. On further questioning the patient recalled that he had three similar episodes at the same site about one, two and four months ago. For these he did not seek medical attention since they healed spontaneously without any sequela. On further query, the patient correlated all four episodes of penile blistering with prior intake of an oral sex stimulant medication that he had procured over the counter (OTC).
On examination, skin colored blisters of different sizes were noted on the glans penis [] covering an area of 3 cm × 2 cm. The blisters stood on a slightly erythematous base and few of the blisters had coalesced to form larger ones. On palpation the lesion was non-indurated but mildly tender. Rest of the mucocutaneous examination was normal. There was no local or generalized lymphadenopathy. Systemic examination was non-contributory and tests for VDRL, herpes simplex (1 and 2) and human immunodeficiency virus (1 and 2) were negative. We advised a biopsy of the area which the patient declined. Based on the history and clinical findings, we made a diagnosis of fixed drug reaction. The patient furnished a sample of the suspected medicine and also brought his wife for history taking and examination. We prescribed a low potent topical steroid and told him to avoid using the medicine in future.
After one week, the lesions had healed without any residual pigmentation. We found that the medicine contained 10 mg of tadalafil along with herbal ingredients. Patch test over the healed area with the medicine (containing both the taldenafil as well as the herbal ingredients) was negative. The patient declined an oral challenge test. The Naran

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


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

[User]
RADIOLOGY NOTE:
A 14 year-old female presented with a year's history of painless enlargement of the right parotid gland and one week's history of facial asymmetry. Physical examination revealed a firm mass 2 × 3 cm in diameter in the region of the parotid gland as well as right facial nerve paralysis. The mass was fixed with palpation as was a palpable right cervical lymph node. She had a normal body temperature and normal complete blood count, erythrocyte sedimentation rate, and blood chemistry.
We investigated the possibility of other diseases that could cause a swelling in the parotid gland: granulomatous infections such as mycobacterial diseases and autoimmune disorders. The results were negative.
Magnetic resonance imaging (MRI) showed an enlargement of the right parotid gland with evidence of multiple cystic masses involving both the superficial and deep portions of the gland.
Fine-needle aspiration (FNA) biopsy was used for diagnosis. Cytopathological examination suggested ACC with the finding of large globules of the extracellular matrix, partially surrounded by basaloid tumour cells but lacking characteristic globules.
A radical parotidectomy and modified radical neck dissection with spinal accessory nerve preservation was planned under general anesthesia. A preauricular incision that curved under the ear lobule was made in extension with the neck dissection incision. A skin subcutaneous flap was raised over the parotid until the distal branches of the facial nerve were seen to exit the gland. The mandibular, buccal, and zygomatic branches were incised and tagged with fine silk sutures for later grafting []. As the main trunk was considered to be encased by the tumour, a mastoidectomy was performed, to identify the main trunk of the facial nerve, increase the length of the proximal nerve stump for grafting, and also to provide adequate surgical margin.[] Once the main trunk was identified, extensive resection was performed to remove the parotid neoplasm. Frozen sections fr

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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 13-year-old Italian girl was referred by her pediatrician because of a retained deciduous canine in her right mandible. During an earlier visit to the pediatrician, the doctor, considering the age of the patient, asked her about the exchange of deciduous teeth, and she reported that the tooth had not yet changed. She was not alarmed, neither was her mother, but the pediatrician insisted that the tooth would probably have already dropped. The pediatrician therefore encouraged her to contact her dentist.
The girl was in good health, and her dental and medical history was unremarkable with only the usual childhood maladies.
An extraoral clinical examination disclosed a symmetrical face with balanced vertical thirds.She shows a dental-skeletal class I with normal mandibular divergence, with no bad habits, and her cephalometric values are all normal; even her lower and upper incisors are normal-inclined. Her profile is standard for Italian people. An intraoral examination revealed that her dental midlines were concordant with each other and with her face, and no mandibular shift was detected on closure. Except for some lower incisor crowding the overall occlusion was fair with acceptable overjet and overbite. Her clinical periodontal parameters were normal. A radiographic examination revealed that the mandibular right canine was in an oblique position with its crown tip near the apex of the lower right first incisor root (Figure ). An occlusal radiograph confirmed that the crown of the impacted canine was vestibular (Figure ). The canine angulation to the midline was 55° (Figure ). This value suggested a very difficult problem, which might not be orthodontically treatable. After careful evaluation of this case, in view of the age of the patient, the clinical decision was to treat this impacted tooth orthodontically. Full mouth orthodontic treatment was suggested.
It was our goal to treat this case with a non-extraction orthodontic approach using upper and lower jaw app

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old male patient presented at our emergency room after a traffic accident and the brain computed tomography (CT) scan indicated an incidental arachnoid cyst on posterior fossa. At that time, the patient complained only of facial abrasions and the left knee pain, but not of headache or visual disturbance. In eight months, however, he revisited our Department of Ophthalmology to check the decreased visual acuity, visual field defect, and headache. On the ophthalmologic examination, bilateral papilledema (), decreased visual acuity, and visual field defect () were found. After the transfer to the Department of Neurosurgery, we rechecked brain CT scans (). The diameter of the patient's arachnoid cyst did not change compared to the previous CT scans; however, the slightly enlarged third ventricle was compressing the optic chiasm and the suprasellar area. Since visual complications were expected, we recommended an emergency operation. However, the patient refused the operation for personal reasons. One week later, he came back to the hospital with nearly complete visual loss. His right eye was completely blind, whereas his left eye recognized only light ().
On that day, he underwent an emergency operation. A conventional suboccipital craniectomy was performed on the patient lying on the operating table in the prone position. After the dural incision, the arachnoid cyst was exposed and cystic fluid was expelled. Arachnoid membrane was carefully dissected and the arachnoid cyst was fenestrated to cisterna magna for connecting with the cerebrospinal fluid (CSF) flows. Arachnoid membrane which covering the foramen of magendie was also fenestrated and the CSF flows was running properly (). Excluding the brain tumor, the collected membrane was sent to the pathologic laboratory. In high power field microscopy under the hematoxylin and eosin stain, the cystic membrane was composed by membranous fibrocollagenous tissues without tumor cells. Finally, the patient was diagn

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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:
In December 2011, a 69-year-old male patient was admitted to our institution for the evaluation of further therapeutic options of metastatic malignant melanoma. Previously, in March 2009, the diagnosis of an ulcerated nodular solid malignant melanoma of the left cheek (thickness 30 mm, Clark level 5) with infiltration of the left parotid gland had been made. The neoplastic cells carried wild-type B-RAF alleles, but an oncogenic mutation in exon 2 of the N-RAS gene was found. The past medical history was unremarkable except for hypertension, for which antihypertensive combination therapy was given. In March 2009, the patient underwent surgical excision and neck dissection, during which a total of 16 lymph nodes were removed, which histologically did not show any signs of tumor invasion at that time. Subsequently, however, in October 2009, a soft tissue metastasis developed at the base of the resection area, which was treated with local irradiation over a course of 2 months. In December 2010, another subcutaneous metastasis was found above the left base of the mandible, which was surgically resected. Histopathological analysis showed clear resection margins.
Adjuvant immunotherapy with 3 million units of interferon-α thrice weekly was initiated in January 2011 but terminated in May 2011, when increasing serum concentrations of the tumor marker S100 indicated disease progression under therapy. Moreover, by this time, the patient had developed numbness and weakness of the right arm and left leg. A CT scan revealed newly developed lung metastases and lymph node metastases in the right hilar region as well as below the carina, and an MRI scan showed 2 new brain metastases – one in the left frontal region and another one in the area of the head of the right caudate nucleus.
After a course of stereotactic irradiation (7 × 5 Gy, i.e. a cumulative dose of 35 Gy), another MRI scan performed in December 2011 showed regression of the left frontal brain metastasis and constant si

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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 twenty-five-year-old woman presented at our Institute with three months history of cough with scanty expectoration, progressive dyspnoea and chest pain. She migrated from Nepal to India along with her husband and was working as a part-time domestic helper. There was no history of diabetes, hypertension, or any other significant disease. She had weight loss by 4 kg over the last three months, presently weighing 40 kg. She had dyspnoea at rest, respiratory rate 28/min, and pulse rate 120/min. She had wide spread crackles over bilateral lung fields. No significant cardiovascular system or ECG finding was observed. No cause of chronic alveolar edema could be elicited. There was no clinical evidence of any gynecological involvement. No BCG scar was seen and she could not recall any BCG vaccination. Her complete blood count, routine biochemical tests including blood sugar and urinalysis were within normal limits. Her serum was non-reactive for HIV-antigens on two different occasions. Chest radiograph revealed bilateral diffuse alveolar opacities having irregular fluffy margins with a pattern of coalescence and presenting in butterfly distribution. The blunting of right CP angle was also seen []. The tuberculin test read at 48 h showed an induration of 28 mm. The microbiological evaluation of her sputum showed no pathogen. CT scan of thorax [] was also suggestive of alveolar opacities, showing the air-bronchogram within alveolar opacities and presence of right pleural effusion. Thoracentesis and the evaluation of pleural fluid showed exudative effusion but leading to no further differentiation. The various differential diagnoses considered [] were individually evaluated for by using fiberoptic bronchoscopy, detailed systemic history, thorough clinical examination and appropriate relevant investigations. The BAL specimen and brush specimen obtained through the fiberoptic bronchoscope were negative for any malignant cells and bacterial, mycobacterial or fungal infection us

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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 21-year-old male presented to the emergency room with complaints of central abdominal pain for the past eight to nine hours and multiple episodes of vomiting. The pain was cramping, located in the central abdominal area. The pain occurred every one to two hours and each episode lasted 15-20 minutes. The pain was associated with episodes of bilious vomiting that provided partial relief. His last bowel movement was two days ago. The patient had been experiencing multiple such episodes for the past two years. No history suggestive of tuberculosis was present. The patient had no previous abdominal surgery. The patient’s blood pressure was 114/82 mm of Hg. The patient’s pulse rate was 92 beats per minute. The systemic examination was unremarkable. The upper abdomen was distended. The abdomen was soft and no tenderness was present. No free fluid was present. Exaggerated bowel sounds were heard. Rectal examination was normal. Abdominal x-rays revealed dilated jejunal loops with abnormal air-fluid levels and no air in the colon.
The patient was admitted with a provisional diagnosis of acute intestinal obstruction and was managed with nasogastric decompression and fluids. The pain resolved the next day as did the distension. Patient moved bowels subsequently. The nasogastric output was 800 - 1,000 cc in 24 hours with bilious contents. The patient was allowed liquids gradually and started tolerating semisolids well. Urgent contrast-enhanced computed tomography (CECT) abdomen was done and revealed the duodenojejunal (DJ) flexure to be lying on the right side and not crossing over to the left, small bowel loops in the right half of the abdomen, lack of visualisation of the caecum in the right lower abdomen (Figure ), and reversed superior mesenteric artery and vein in relation with the vein lying to the left of the artery (Figure ). A barium contrast study was done and revealed the DJ flexure was limited 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 52-year-old female presented to our polyclinic with increasing pain in the left upper quadrant in the previous month. She had been treated for hypertension and had a hysterectomy 7 years ago due to a myoma. The patient had quit smoking 3 years earlier and was taking alprazolam 0.5 mg/day for an anxiety disorder. A physical examination revealed minimal sensitivity of the left upper quadrant upon deep palpation and an incision scar from the gynaecologic surgery. Nothing else of note was detected. The patient's body mass index was 32.5 kg/m2, and laboratory measurements were within the normal range. Endoscopy and a colonoscopy conducted to determine the cause of pain revealed no pathological findings. An ultrasonic evaluation revealed no evidence of an aneurysm. However, magnetic resonance imaging (MRI) was conducted due to the presence of a hyperechoic lesion (53 × 39 mm in size) in the right lobe of the subcapsular area of the liver. The MRI study revealed a 35 mm diameter hemangioma in the liver segment 8 and a 40 mm aneurysm with a thrombus in the splenic artery of the pancreas tail region (). Tortuosity of the splenic artery, which had a proximal diameter of 1 cm, was detected. In angiographic multislice computed tomography (CT), minimal aneurysmatic dilatation was detected in the celiac truncus in the midsegment of the splenic artery, in addition to saccular aneurysmal dilatation, 50% thrombosed and in the size of 45 × 40 × 39 mm adjacent to the pancreas. A long segment of the splenic artery transection extended from the distal aneurysm to the splenic hilus ().
Following a consultation with the interventional cardiovascular department, an endovascular intervention was planned for the treatment of the aneurysm. Endovascular interventions made from the femoral region were inconclusive because of extreme angulation of the truncus celiacus, aneurysmal dilatation of the trunk, and tortuosity of the splenic artery. The patient was informed about the surgical procedur

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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:
In December 1999, a 64-year-old man underwent a cemented left total knee arthroplasty using a sigma PFC posterior cruciate retaining total knee prosthesis (DePuy Orthopaedics, Warsaw, IN, USA) for degenerative changes in relation to osteoarthritis using a medial parapatellar approach in a different centre. The patient recovered uneventfully and was doing well. In July 2009, the patient presented to us with a history of sudden onset pain and locking of the left knee since the preceding three months. There was no history of trauma and since was mobilising with difficulty using crutches. The patient weighed 89 kgs and had no other medical comorbidities. Clinical examination revealed a severe antalgic gait and a significant amount of rocking with metal on metal noise in 20 degrees flexion. Passive movements ranged from 0 to 90 degrees. At that moment, the knee was quiescent. AP and lateral radiographs (Figures , , and ) of the left knee revealed a fracture of the posterior condyle of the femoral prosthesis with rotation and evidence of further loosening. Given the patients symptoms and the radiographic evidence, a decision to perform a revision of the total knee arthroplasty was made after a fully informed written consent.
Revision surgery was performed as an elective procedure in August 2009 revealing the broken prosthesis (Figures and ). A TC3 RP PFC revision prosthesis was used with a medial parapatellar approach. A size 4 tibial prosthesis with a 53 mm sleeve and 12∗75 mm stem and a size 4 femur with 31 mm sleeve and 14∗75 mm stem along with femoral metallic augments and a 12.5 mm RP insert were used. Intraoperative range of motion was from 0 to 120 degrees and the procedure was uneventful. The patient recovered well and was mobilised with touch weight bearing for 6 weeks. Checking the X-ray revealed a satisfactory prosthesis and the patient was discharged on the 8th postoperative day. Follow-up at 6-week and 6-month period revealed

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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 46-year-old Asian woman was referred to our department for a renal angiogram following 8 months of uncontrolled hypertension despite receiving medications. Initially, the patient presented with severe headache and fatigue. She had no history of smoking or drinking alcohol, was not diabetic, and had no history of diabetes in her family. She had no history of atherosclerosis. Apart from high blood pressure, the result of her physical examination was unremarkable; her general, cardiovascular system, respiratory system, and abdominal examinations were unremarkable. Neurological examination on admission showed that the patient was alert, attentive, and oriented. Her speech was clear and fluent with good repetition, comprehension, and naming. She recalled 3/3 objects at 5 min. All of her cranial nerves were intact. Motor examination revealed no pronator drift of outstretched arms. Her muscle bulk and tone were normal. Her strength was full bilaterally. Her reflexes and sensory were both intact. Her coordination and gait were normal. Laboratory investigations revealed normal complete blood count, serum cholesterol, lipid profile, and renal function (serum creatinine 119 μmol/L). Her left kidney size was normal with measurement of 9.6 cm by 4.8 cm. Renal Doppler ultrasound confirmed renal artery stenosis with renal resistive index of 0.58. The percentage of renal artery stenosis in the two branches of the left renal artery was 70% and 75%, respectively , before the first balloon angioplasty; after the first balloon angioplasty, these percentages remained the same. After the second ballooning and stenting procedure, revascularization was achieved. The patient had been attending a hypertension clinic and receiving antihypertensive drugs for the past 8 months on a regular basis under close observation. Despite this treatment and care, her blood pressure remained high at 175/110 mmHg, which the attending doctor concluded to be uncontrolled blood pressure. Initial imaging indi

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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 70-year-old female with a past medical history of stage IV NSCLC with metastatic disease to the bones and liver presented with lower extremity edema. She reported 2 weeks of swelling that initially began around her eyes and face that then progressed inferiorly to her abdomen and lower extremities. She had gained 12 pounds over a similar time frame and noted new, progressively worsening hematuria with frothy urine. She denied fever or recent illness, although she had endorse dyspnea with dry cough and orthopnea. She also had a new erythematous maculopapular rash on her face over her eyelids, cheeks, and nose. She had received her first cycle of ipilimumab for the treatment of her lung cancer 4 weeks prior.
She was diagnosed with NSCLC approximately 2 years prior and completed 6 cycles of carboplatin, pemetrexed, and pembrolizumab with good initial response to therapy, followed by maintenance therapy with pemetrexed and pembrolizumab and progression of disease. Her treatment course was complicated by primary adrenal insufficiency secondary to pembrolizumab use, for which she was initially treated with pulse steroids (1 year prior to current presentation) and remained on oral prednisone (5 mg by mouth daily). She had not received pembrolizumab for 3 months prior to her current presentation. Her other medical history included hypertension, gastroesophageal reflux disease, and osteoporosis. She continued to smoke approximately 1 pack of cigarettes per day.
On physical examination, her temperature was 37.1°C, blood pressure was 192/104 mm Hg, heart rate was 73 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 94% on room air. She appeared to be in no acute distress and did not have evidence of jugular venous distention, though did have faint rales at the bases of the lungs, bilaterally. Her cardiovascular exam was unremarkable. Her abdominal exam did not have a fluid wave. She had 1+

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

[User]
RADIOLOGY NOTE:
The publication of case information and materials was approved by the Institutional Review Board of The Gachon University Gil Medical Center (GAIRB2015-197).
A 31-year-old male patient visited our hospital with symptoms of recurrent rib fractures in the absence of physical trauma, increased body hair, and central obesity. His evaluation showed Cushing’s syndrome with bilateral adrenal cortical thickening, three calcified lesions on the left testis, and a pigmented skin lesion on the buttock. The patient and his sister had resection for familial cardiac myxomas 5 years ago, but did not have any other symptoms at that point; they were the subject of a previous case report []. The patient was diagnosed with Carney complex, and bilateral adrenalectomy and resection of the pigmented skin lesion were performed. A needle biopsy was done for the testicular tumor to preserve patient fertility.
The cardiac myxomas resected 5 years ago were located in both the right atrium and the ventricle, with sizes of 6.0 × 3.5 cm and 0.9 × 0.5 cm, respectively. The resected specimens were composed of hyperemic gelatinous soft tissue (). Histologically, they showed fusiform to stellate cells with a moderate amount of eosinophilic cytoplasm embedded within the myxoid stroma (). The patient was found to have a mutation in the protein kinase A type I-a regulatory subunit (PRKAR1A) gene when he had the resection of his cardiac myxoma [].
The bilateral adrenalectomy specimen showed multiple dark to light brown nodules measuring up to 1.2 × 1.2 cm throughout the cortex (). Histologically, the nodules were composed of cells resembling those of normal zona reticularis and contained dark brown pigments (). The histological features were consistent with those of PPNAD.
The resected skin showed dumbbell-shaped intradermal melanocytic proliferation with heavy pigmentation resembling blue nevus (), but with epithelioid melanocytes (). The cells were positive for S-100 protein () and human melanoma blac

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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 27-year-old male, with Crouzon syndrome phenotype, visited the emergency department of a tertiary referral center, reporting multiple episodes of epistaxis in the past few days. The patient also reported nasal obstruction and impaired nasal breathing for the previous several months. Rest of the medical history was free. On clinical examination, a polypoid lesion protruding from the right nostril was noted. In addition, asymmetry of the face and projection of the ipsilateral canine fossa were evident.
Computed tomography of the paranasal sinuses showed an inhomogeneous soft-tissue mass, which completely occupied the right nasal cavity, maxillary sinus, and anterior and posterior ethmoidal cells. The lesion produced extensive bone remodeling of the right maxillary sinus with complete absence of its anterior wall, as well as erosion of the posterior wall and entry of the lesion in the pterygopalatine fossa. There was also erosion of the ipsilateral lower as well as median orbital wall, and entry of the lesion in the orbital cavity. Despite its large size, the lesion seemed to be well defined without invasive characteristics (Figures –).
Routine laboratory tests were within normal range. Preoperative maxillofacial consultation excluded pathology of odontogenic origin. The patient underwent a biopsy under local anesthesia, and the findings showed nonspecific inflammation. Open surgery under general anesthesia was undertaken via lateral rhinotomy and medial maxillectomy (). The maxillary sinus mucosa was completely replaced by inflammatory tissue simulating a benign mass. This mass was readily mobilized and dissected free from surrounding tissues within the orbit and pterygopalatine fossa, as no macroscopic invasion of any neighboring structures was noted. Histopathological examination revealed typical nasal polyposis with mixed population of eosinophils, neutrophils, and macrophages, with no evidence of fungal invasion (Figures –). Antibiotic and corticosteroid treatme

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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 13-year-old Caucasian male sustained diaphyseal fractures of the left radius and ulna three months prior to the presentation in focus. The fractures were managed surgically with closed reduction and 3.0 mm intramedullary elastic nailing of the ulna and open reduction and internal fixation (ORIF) of the radius with a 3.5 mm dynamic compression plate (DCP). Follow-up at two months confirmed satisfactory progress and radiological evidence of the union. The patient was scheduled for elective removal of the elastic nail at three months.
One week prior to metalwork removal the patient tripped and fell onto his outstretched left hand. He presented with severe clinical deformity of the forearm and severe distal neurovascular deficit (Figure ). The hand was pale with an absent radial pulse, prolonged capillary refill time (CRT) and no digital signal on pulse oximetry. Furthermore, both sensory numbness and motor weakness in the distributions of both median and ulna nerves were noted.
Emergent closed reduction in the emergency department was only partially successful in restoring alignment, with restoration of the CRT but persistent neurological deficit. Post-reduction radiographs revealed persistent angular deformity of sixty degrees. Re-fracture of the ulna with plastic deformation of the flexible nail was again noted, as was a periprosthetic fracture at the distal margin of the radial plate (Figure ).
In view of the persisting neurological deficit, the patient was taken to the operating theater expediently. Further attempts at closed manipulation under general anesthesia were unsuccessful. The IM nail- though deformed- was intact allowing successful removal via the routine method from the proximal ulna entry point; however, satisfactory reduction could still not be gained. The radius was approached through the previous volar approach and re-plated, ensuring use of a longer 3.5 mm DCP to account for the previous screw holes. The ulna was then approached directly and inter

[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 68-year-old male presented to the oral oncology outpatient department with a swelling over the right side of the mandible of one month's duration. A comprehensive history was taken, and the patient revealed a history of extraction of multiple teeth on the same side, after which the swelling started insidiously. It was soon accompanied by intermittent episodes of pain, which was of a pricking nature and radiated upwards along the jaw and to the ear on the same side. The patient was prescribed analgesics and anti-inflammatory medications, which provided temporary pain relief but there was no decrease in the swelling. The patient also complained of excessive salivation for two weeks. The patient had a habit of smoking 10 - 15 cigarettes a day for more than 25 years with occasional alcohol consumption. There was a negative history of chewing tobacco in any form.
Clinical examination revealed a bony hard swelling of the right side of the mandible, approximately 5 x 4 cm in maximum dimension, extending from the angle of the mandible to 2 cm short of the midline. The swelling was tender on palpation, with defined edges, and was fixed over the bone. No crackling or crepitus was elicited and the overlying skin was unremarkable. However, paraesthesia of the skin over the ipsilateral chin and lower lip was elicited.
On intraoral examination, no abnormality of the oral mucosa was detected and the patient was edentulous. Tenderness was elicited on palpating the alveolar mucosa on the right side, up to the retromolar region. The neck was palpated; however, no significant cervical nodes were found. An orthopantomogram was taken which showed a large radiolucency with irregular borders extending from the lower right canine region to the right angle of the mandible (Figure ).
Clinical findings and previous biopsy reports were correlated and the diagnosis was inconclusive. The lesion was provisionally diagnosed as an intraosseous malignancy of the mandible. The oral pathologist sugg

[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 Caucasian man with a four-year history of left hand pain, dysesthesia and weakness that progressed over the subsequent year to involve the left upper extremity presented to our clinic. He was initially diagnosed with Raynaud’s disease and treated with nifedipine. His pain continued to worsen and later progressed to involve bilateral upper extremities all the way up to the elbows. Over the subsequent two to three years he developed progressive right upper extremity as well as bilateral lower extremity weakness. Neurologic examination revealed quadriparesis and impaired sensation to all modalities over bilateral upper extremities up to the elbows and bilateral lower extremities up to a few inches below the waistline.
He underwent a magnetic resonance imaging (MRI) of the brain and cervical spine which showed a 2.7 × 1.1 × 1.5cm avidly enhancing intramedullary lesion at C2-C4 with a cervical cord syrinx, marked cord edema and expansion, extending from the medulla through T3. He was taken to the operating room and an attempt at surgical resection was unsuccessful due to the lack of a defined surgical plane and the high vascularity of the tumor mass. A biopsy was performed which confirmed the diagnosis of hemangioblastoma. The syrinx was not entered or drained during this procedure. The patient refused testing for von Hippel-Lindau disease but no other hemangioblastomas were seen on whole neuraxis scanning and fundoscopic examination. Postoperatively he continued to deteriorate to the extent that he became wheelchair bound. Oral dexamethasone (16mg daily) was initiated approximately one week postoperatively because of increasing arm weakness and he showed minimal improvement. The improvement was short-lived and dexamethasone was subsequently tapered over the ensuing two to three weeks.
Bevacizumab was started after obtaining appropriate informed consent. The patient was given a 10mg/kg infusion every two weeks (initially for two cycles) and an MRI of the 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:
We present the case of a nineteen year old male with a motorcycle accident, admitted to the emergencies complaining about a mild pain at the base of the neck. No other serious injuries were present despite of the severity of the crash.
A free medical history was reported. Clinical examination confirmed patient's stable respiratory and hemodynamic condition, the lower cervical pain as well as the absence of any neurological deficit. X-ray examination demonstrated a small fracture at the anterior superior surface of the C7 vertebrae indicative of a combination of flexion-destruction forces applied during the accident.
Dynamic cervical spine x-rays were indicative of instability and CT-scan 3D analysis, performed to evaluate x-ray findings, confirmed the presence of the fracture and the anterior subluxation at the C6–C7 level.
Conservative treatment with Halo-vest, x-ray evaluation of the reduction and a new neurological examination were performed, figure . Patient was discharged from the hospital with instructions to visit the outpatients department according to treatment schedule.
Despite of our instructions, the patient neglected visiting regularly the outpatient department and presented three months later to the emergencies complaining of mild headaches and fatigue.
Clinical examination revealed mild redness and edema of the skin as well as pin loosening and irritation at the point of pin insertion. GCS was estimated at 15/15 and no neurological deficit was detected. Lateral and anteroposterior X-rays were normal. Blood count presented an increased amount of WBCs, mainly neutrophils. Pins were tightened and patient was instructed to visit the clinic the following day for new blood and radiologic exams.
The following day, the patient was admitted in our clinic. New blood counts and x-rays were performed and samples were taken from the area of pin insertion with minimal incision and were sent to the Microbiology Department. Due to the lack of definite diagnosis, furt

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


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

[User]
RADIOLOGY NOTE:
A 38-year old female presented to the surgical clinic with pain and swelling in the left gluteal region. The swelling had gradually increased in size over 4 months. The pain was radiating to the left lower limb and associated with numbness. The patient had been involved in a road traffic accident two years earlier and had suffered a left acetabular fracture, which had been treated conservatively.
Physical examination revealed a large tender swelling in the left gluteal area simulating an abscess. However, pulsation was observed over the swelling that raised the suspicion of a vascular lesion. Therefore, contrast enhanced computed tomography (CT) was done before trying any intervention. The scan demonstrated a large pseudoaneurysm originating from the left superior gluteal artery measuring 6.4 × 5.8 × 3.4 cm with a small intra-pelvic component and large extra-pelvic component in the gluteal area []. This lesion appeared as a contrast-filled structure in direct communication with the superior gluteal artery. Its two components were communicating in the region of greater sciatic notch.
Magnetic resonance imaging (MRI) was also performed for better assessment of this vascular swelling and any surrounding hematoma. The aneurysm demonstrated mixed signal intensities; with rounded central signal-void area representing the patent lumen, and a peripheral thick rim of high signal intensity on T1-weighted and low signal intensity on T2-weighted images denoting a thrombus/hematoma []. In addition, the signal void lumen showed some flow artifacts.
The patient was referred for endovascular treatment.Digital subtraction angiography (DSA) and transcatheter embolization were done in the same session. The aneurysm was approached by puncturing the right femoral artery and occluded by placing four coils and gelfoam in the feeding vessels [].
Repeated CT angiography after 1 week confirmed exclusion of the aneurysm with only a residual hematoma in the area [Figure and ]. Patient had an u

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


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

[User]
RADIOLOGY NOTE:
We present a case of a nine-year-old, previously healthy boy, presenting to the emergency department of a tertiary care hospital with complaints of severe frontal headache for the last two weeks but more for the last two days. Headache was associated with nausea, vomiting, photophobia, and pain in both eyes. There was no history of fever, jerking movements, or trauma. The child had no past medical or surgical history. He achieved all developmental milestones normally and was doing well at school. His examination revealed a fully conscious and oriented child with a heart rate of 77 per minute and blood pressure of 159/112 mm Hg. Power was 5/5 on both sides, all cranial nerves were intact, and no sensory loss was observed. There were no meningeal signs but there was right side papilledema. The rest of the exam was normal. His blood investigations, including blood glucose, full blood count, serum creatinine, and electrolytes, were normal. MRI of the brain was done, after initial symptomatic management. MRI showed left temporal, extra-axial collection measuring 5.40 × 4.10 cm of CSF-like intensity compatible with arachnoid cyst and bilateral frontoparietal subdural enlargement compatible with subdural hygroma ().
Within an hour of ED admission the child's frequency of vomiting increased along with mild drowsiness. At that point Cushing's reflex was positive with heart rate was 64/minute and blood pressure of 177/110 mm Hg. The child was referred to the neurosurgery team and the subdural hygromas were drained through bilateral frontal burr holes. Left temporal arachnoid cyst was partially drained through left temporal craniotomy. A left subdural-peritoneal shunt was placed for drainage of any future collection. Drained CSF was xanthochromic and negative for malignant cells. CSF culture showed no growth. Histopathology of cyst confirmed radiological diagnosis of arachnoid cyst. Final diagnosis of left temporal arachnoid cyst with spontaneous subdural hygroma was made as t

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch (Figure ). Tenderness was only noted involving the two masses on the left foot. Plain radiographs were negative. Conservative therapies were discussed and tried that included shoe gear and activity modification as well as analgesics. The patient declined injection therapy. An MRI was ordered that revealed two discrete soft tissue masses within the plantar fascia consistent with PF lesions without neurovascular encroachment (Figures , ). Surgery was proposed and she wished to proceed with surgery on her symptomatic left foot (Figure ). Risks and benefits were outlined for both complete fasciectomy and wide en bloc resection. The patient chose the latter technique and was advised to refrain from smoking that she did for several days both pre- and post-operatively. Surgery was completed without complications. Wound management included placement of a battery-powered ciNPT device (Prevena™) and light compression bandaging (Figure ). The device remained in place for one week and then was removed. No significant erythema or swelling was seen. Surgical pathology was consistent with two, benign PF lesions. Sutures remained in place for a total of three weeks and were then removed. At this time, the incision was found to be negligibly tender, flat and well coapted. She was non-weight bearing immediately post-operatively through suture removal at which time she was transitioned to a walking boot with instructions

[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:
Informed consent was obtained from the individual participant in the study.
A 35-year-old man (body weight: 100 kg) was admitted to our center complaining of headache and chest discomfort. Physical examination revealed high blood pressure (184/88 mm Hg) in the right arm and weak lower extremity and left arm pulses. Echocardiography and computed tomography (CT) angiography demonstrated an aortic arch coarctation with a minimal diameter of 5 mm. The coarctation was located between the left common carotid artery and the LSA, with a large collateral circulation and a large biloculated calcified aneurysm just distal to the coarctation. The LSA arose from the upper locule of the aneurysm with an upper-to-lower flow direction (Fig. A and B). Coronary angiography and CT cerebral angiography are unremarkable.
Anatomical surgical aortoplasty or percutaneous transluminal aortoplasty for the complex lesion between the aortic arch and descending aorta would be a difficult as well as high-risk procedure. Therefore, the team decided to treat the patient via a 2-stage hybrid approach, with extra-anatomic bypass grafting performed first, followed by subsequent transluminal occlusion of the aneurysmal orifice several months later.
The first-stage procedure was performed under general anesthesia via a left thoracotomy without cardiopulmonary bypass or deep hypothermic circulatory arrest. A bypass between the ascending aorta and the descending aorta was established using a 16-mm Gore-Tex tube. Arterial ligation was performed at the aorta just proximal to the coarctation, at the descending aorta distal to the aneurysm, and at the origin of the LSA. Postoperative recovery was uneventful, with a decreased blood pressure difference between the right arm and lower limbs (preoperative and postoperative systolic blood pressure difference is 46 and 8 mm Hg, respectively). The patient was discharged 8 days after the operation in good condition.
Six months later, the patient was readmitted for t

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


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

[User]
RADIOLOGY NOTE:
A 46 years old housewife presented with left knee pain of ten months’ duration without significant trauma. She had been treated elsewhere as septic arthritis of the left knee based on the radiological features of severe bone defect of the medical condyle of the left tibia. There was neither history nor clinical appearance suggestive of septic arthritis of the left knee. Results of investigations did not support the diagnosis of infection of her left knee. There was genu varus deformity of her left knee, and she walked with an antalgic gait, occasionally requiring a walking frame for long-distance walking. She had never been hospitalised before. She was given two trials of oral antibiotics empirically but to no avail. Due to the persistent pain that had not resolved with nonsteroidal anti-inflammatory therapy and antibiotics, she was referred to our orthopaedic department.
At our centre, we found there was muscular weakness in the lower extremities. Movement of the left knee was painful with limited range of movement of 0° to 90°. The skin in the affected knee was normal without signs of infection, vascular abnormalities or oedema. Peripheral pulses in the left lower limb were normal. The varus deformity of left knee was passively correctable. Radiograph of her left knee showed no progressive changes of the bone defect compared to the bone defect ten months previously. () Laboratory studies including haematological tests revealed no evidence of metabolic, neoplastic, immunological or infectious aetiology. She was then scheduled for total knee replacement for her left knee, six months later.
However, while awaiting elective surgery, three months after presenting to our centre, she returned with complaint of right hip pain of three weeks duration. The right lower limb was shorter by two centimetres compared to the left lower limb. There was no history of trauma or infection. Radiograph of the right hip revealed complete osteolysis of the femoral head, though a radiogra

[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 eight-year-old girl presented to the clinic suffering from tenderness and bleeding from a vast necrotic sacro-gluteal mass. She had small pigmentation at this region since birth but it was asymptomatic and diagnosed as a naevus. However, at the age of eight years, the lesion aggressively progressed and became painful and haemorrhagic. No family history was significant. The patient went to a dermatologist who prescribed local steroids without any benefits. The lesion continued to become larger and more painful. No signs of puberty were present at time of presentation and no trauma other than sitting for long periods during school was reported.
Currently, the lesion became around 12 cm at the longer diameter and 10 at the shorter one with irregular episodes of mild bleeding which prevented the patient from her normal life. Current physical examination found a murmur on auscultation over the mass and Doppler ultrasonography showed a fast and high-flow lesion which speculated to be AVM. Magnetic resonance imaging (MRI) showed non-capsulated superficial soft tissue mass in the sacro-gluteal region. The mass was large and measured approximately (12*10*4) cm. It consisted primarily within the skin and subcutaneous fat in the retro sacro-gluteal region and encased the coccyx. There was no extension to the pelvis or to the spinal canal. The mass was heterogeneous in signal intensity with numerous dark flow voids. Contrast enhanced images showed multiple enhancing abnormal blood vessels. It was consistent with an arteriovenous malformation (AVM). Otherwise, the pelvic structures were within normal limits (). Brain MRI was normal, and no medications were used to treat the lesion.
The patient had financial difficulties and the surgery and embolization was postponed for another six months. During the six months, the lesion grew rapidly and became necrotic with occasionally heavy haemorrhage. Haemoglobin (Hb) reached as low as (5 g/dl) and the mass reached (15*15*2 cm) in size

[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.