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

[User]
RADIOLOGY NOTE:
A 48-year-old gentleman presented as an emergency to our institute with left-sided hemiparesis and aphasia. He had no prior co-morbidities, and the family history was insignificant. On examination, he was found to have a power of 0/5 in all muscle groups, according to the medical research council (MRC) muscle grading system, on the left side along with complete aphasia. However, the function of cranial nerve XII was intact. However, the examination was the neck was unremarkable; there was no palpable mass or skin changes in the neck region. The carotid pulses were palpable bilaterally.
On initial workup, Magnetic resonance imaging with angiogram was done, which showed a right middle cerebral artery (MCA) territory infarct and a heterogenous lesion within the neck just above the level of the carotid bifurcation. Subsequently, post-contrast images from the head and neck region were also acquired (). The lesion's appearance and characteristics suggested a glomus tumor of the neck. Further evaluation with an ECG and cardiac echo was performed to rule out the cause of an infarct. ECG and cardiac echo were found to be normal. Computed tomography angiogram of the neck was done (), which showed a highly vascular mass, 2.8 x 3.4 x 6.0 cm in size, arising above the carotid bifurcation with its feeding vessel arising from the right external carotid artery. It was splaying the right internal carotid artery anteriorly and medially and extending up to the hypoglossal canal.
The radiologist suggested it as an atypical glomus tumor or a rare peripheral nerve sheath tumor. With consideration of the location, clinical presentation, and imaging features, a working diagnosis of glomus tumor of the neck was made.
Based on our working diagnosis of Glomus tumor, surgical excision was planned. In order to control hemorrhage intra-operatively, angioembolisation of the tumor was done before surgery, and approximately 90% embolization was achieved ().
Under

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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 71-year-old male with a history of alcoholism and radiation treatment (total dose of 57.6 Gy) for early-stage vocal cord cancer 16 months earlier was referred to us with radiographic detection of a pulmonary nodule in the right lower lobe. Endobronchial biopsy of the pulmonary nodule revealed the diagnosis of squamous cell carcinoma. Positron emission tomography/computed tomography (CT) revealed accumulation in the pulmonary nodule, but no other lesion was suggestive of metastasis. The tumor was diagnosed as a primary lung cancer, clinical stage IA1 (T1aN0M0), or metastatic pulmonary tumor, and video-assisted thoracoscopic right lower lobectomy with lymph node dissection was performed. Level 8 and 9 lymph nodes were not enlarged; therefore, lymph node dissection of these nodal station was not performed (Fig. a), while the level 7 lymph nodes were dissected. There was no direct injury of the esophagus, and no apparent esophageal damage was visualized on magnified video endoscopic images (Fig. b). The operation was uneventful. The patient was able to resume oral intake from the day after the surgery.
The patient tended to need to make a strong effort to cough, with swallowing and expectoration having become difficult, presumably due to the radiation therapy given to the larynx. Three days after the operation, the patient developed severe sudden pain in the right shoulder with high fever (39.6 °C). Findings of the chest X-ray obtained with a portable apparatus showed a few infiltrative shadows in the right lung field, and blood examination revealed no findings that were not compatible with the postoperative status of the patient. The patient was started on intravenous antibiotic administration. Absence of air leakage through the chest tube was confirmed, and the chest tube was removed 4 days after the operation. However, a plain chest X-ray revealed increased infiltrative opacities in the right lung field, and the patient developed a right pneumothorax 5 days after t

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

[User]
RADIOLOGY NOTE:
A 16-year-old previously healthy young man presented to the Pediatric Infectious Disease Clinic in September of 20151week after arriving in the United States from a refugee camp in Mozambique with a 3-month history of pain and swelling in the upper leg just below the knee. He had no fever noted, no erythema over the knee, and his symptoms had not changed appreciably since arrival in the United States. He had not received any antimicrobial therapy for this condition. His erythrocyte sedimentation rate (ESR) at presentation was 40 mm/h with a C-reactive protein (CRP) level of 0.9 g/dL and a leukocyte count of 6,900 cells/µL (50% polymorphonuclear cells, 37% lymphocytes, 11% monocytes, 1% eosinophils, and 1% basophils). On examination, his affected knee was slightly swollen with mild tenderness over the medial aspect. No discharge or erythema was noted. His range of motion for his knee was slightly decreased for flexion and extension, and an antalgic gait was present. At that time, a plain radiograph demonstrated concerns of chronic osteomyelitis of the right proximal tibia although tumor or subacute fracture was also considered (). Contrasted magnetic resonance imaging (MRI)demonstrated findings consistent with chronic osteomyelitis along the medial aspect of the proximal tibial epiphysis and metaphysis, however, with a cloaca extending from a cortical disruption of the posteromedial tibial metaphyseal cortex (). Given a desire to pursue potential debridement and obtain cultures simultaneously, he underwent surgical debridement of the area the following day, cultures from which were sterile. Given his recent exposure to a refugee camp in Africa, the resulting potential for infection with an unusual organism was also felt to justify the need for an open biopsy with cultures. A cortical window was not created although extensive debridement of the area was performed. The joint space was not entered during the surgery. No orthopedic hardware or antimicrobial-impregnated b

[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 male was admitted to a hospital in June 2016 because of right arm asthenia and dysarthria and was diagnosed as having cerebral infarction in the left middle cerebral artery area along with deep vein thrombosis. ECG demonstrated normal sinus rhythm and echocardiography revealed no intra-cardiac thrombus or vegetation. The patient was discharged from the hospital following administration of apixaban.
In August 2016, the patient was readmitted to the hospital because of recurrent right arm asthenia and dysarthria. MRI revealed multiple cerebral infarctions in not only the bilateral cerebral hemispheres but also the cerebellum. Trousseau’s syndrome was suspected at this time. Apixaban administration was stopped and an intravenous drip of heparin was started. Echocardiography revealed mild mitral regurgitation with vegetation on the mitral valve. Although the laboratory data suggested no evidence of infection, ceftriaxone and gentamicin were added as a precaution against infective endocarditis. The patient was then referred to our hospital for surgery.
A CT scan revealed a left renal infarction and multiple swollen lymph nodes around both the abdominal aorta and stomach with antral hypertrophy, suggesting an advanced gastric cancer or lymphoma. As the vegetation showed no change despite the heparin and antibiotics therapy, cardiac surgery was performed on day 5 after referral. Extracorporeal circulation was instituted employing aortic and bicaval cannulation. After aortic cross-clamping, the mitral valve was exposed via a left atriotomy. Both mitral leaflets had vegetation on the surface, and major vegetation 15 mm in width was evident on the anterior leaflet (Fig. ). These were resected in their entirety and replaced with a 25-mm Epic bioprosthesis (Abbott). Continuous intravenous heparin administration was resumed on the following day, aiming for an activated partial thromboplastin time of between 40 and 50 s. Histologic analysis revealed that the vegetat

[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 right master-handed gentleman presented approximately 20 hours after sustaining a crush injury to his left non-master hand in a log splitter at home. His past medical history was significant for hypertension.
The patient initially was seen at a neighboring institution for evaluation and treatment. The physical exam on transfer revealed bruising of the distal volar forearm just proximal to the wrist without skin laceration. Radial and ulnar pulses were lacking distal to the area of injury. Clinically, the hand was cool, slightly blue, and lacked digital pulp turgor. Plain X-ray revealed pisiform fracture and scapholunate dissociation. The patient underwent emergency angiogram, which revealed abrupt cutoff of radial and ulnar artery flow into the left hand at the level of the distal forearm just proximal to the wrist junction. There was no evidence of extravasation of dye (). Radiologic interpretation was felt to be consistent with ulnar and radial artery spasm. The patient was not felt to be a candidate for tissue plasminogen activator (tPA), given the nature of his injuries. Since the patient showed no improvement on IV Heparin and the hand remained mottled and cool, emergent surgical exploration was recommended and accepted.
Fasciotomies were performed on the volar forearm, the thenar eminence, and the inter-metacarpal regions in conjunction with a carpal tunnel release. Additionally, a Guyon’s canal release also was performed. The median and ulnar nerves were both intact. The ulnar artery was severely bruised and thrombosed over a length of 8 cm, extending from the ulnar aspect of the superficial palmar arch to 2 cm proximal to the volar wrist crease. At that level in the distal forearm, a total avulsion injury of the ulnar artery was evident with the proximal and distal components of the ulnar artery separated by 5 cm (). The intervening gap between the ends of the ulnar artery contained torn and stretched adventitial

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old boy presented with profound painless progressive diminution of vision of right eye since 3 months. Suddenly, in the left eye, he developed a painful red eye during the last 15 days. On ocular examination, best-corrected visual acuity in the right eye was hand movement close to face with an inaccurate projection of rays and in the left eye was 6/60. The right eye pupil was 8 mm in size, dilated, and nonreacting (), and the retina had exudative retinal detachment around the disc with macular edema (). The left eye was congested and the cornea was edematous. The anterior chamber was filled with fibrinous exudates and hyphema (). Hemorrhagic iris nodules were noted in the iris stroma without iris neovascularization. The pupil was 5 mm in size, irregular with multiple posterior synechiae, and sluggishly reacting and covered with fibrinous exudates. The lens appeared clear, but the details of vitreous and retina of the left eye could not be appreciated. An ultrasonography of right eye showed hyperechoic shadow in vitreous and areas of retinal detachment with subretinal fluid collection, but left eye ultrasonography was normal. Intraocular pressures in right and left eye were 12 and 31 mmHg.
The episode was preceded by high-grade fever with chills/rigor and multiple skin rashes involving the face and trunks for the past 4 months. It was also associated with painful subcutaneous nodules over the scalp, trunk, and arms followed by painless enlargement of axillary and cervical lymph nodes.
On systemic examination, there were multiple papulonodular rashes over the face () and trunk with a subcutaneous ulcerated nodule in the scalp, arm, and back of trunk (). The cervical and axillary lymph nodes were enlarged, firm, nontender, and not matted. Histopathological examination of skin and axillary lymph nodes revealed dense infiltrate of cells composed of histiocytes, lymphocytes, and occasional eosinophils. The histiocytes have scant

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female patient was referred to our department for laparoscopic excision of GIST in the stomach. Prior to our treatment she underwent an esophagogastroduodenoscopy due to epigastric pain and occasional vomiting. Endoscopy showed erosive gastritis, a hiatal hernia, and a submucosal tumour located along the lesser curvature on the posterior wall of the antrum (). The tumour had a central eroded depression but otherwise appeared to be covered with normal mucosa. Several biopsies of the tumour were taken using the bite-on-bite technique. Unfortunately, only scant samples of the submucosa were obtained, which precluded a histological diagnosis of the tumour.
Endoscopic ultrasonography confirmed a 22 × 13 mm submucosal well-defined solid tumour arising from the fourth, muscular, layer of the stomach (). The tumour appeared to be nodular, with slightly heterogeneous echogenicity. Endoscopic ultrasonography did not demonstrate a significant ulceration or ductal structures. In the diagnostic work-up of abdominal pain and vomiting the patient had undergone transabdominal ultrasonography, which showed no focal lesions in the liver. Before surgery, we performed another endoscopy where the lesion was tattooed proximally and distally.
Laparoscopy was performed, and on initial exploration of the abdominal cavity, we discovered a tattooed submucosal tumour on the greater curvature of the stomach. Laparoscopic excision was performed and the specimen was recovered in a retrieval bag. The abdominal cavity was irrigated with saline and the fluid aspirated. An abdominal drain was inserted beneath the stomach. The fascia and skin wounds were sutured. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day.
Resection samples were sent for histopathological analysis. The histopathologic analysis report about 6.6 × 3.5 cm excision gastric wall. The mucosa and serosa have normal appearance, muscularis propria and submucosa include a

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


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

[User]
RADIOLOGY NOTE:
A male patient aged 49 years reported to the Department of Periodontics, Sri Siddhartha Dental College and Hospital, Tumkur, with the chief complaint of deposits present on his teeth and he desired to get his teeth cleaned. Patient's medical history was not contributory. Patient had undergone extraction of upper right canine 2 years back, with uneventful healing.
On intraoral examination, stains and calculus were present along with generalized gingival inflammation and bleeding on probing []. Generalized periodontal pockets and attrition were present. Grade I mobility was present w.r.t. 12, 17, 25, 26, 35, and 36. Periodontal pocket measuring 7 mm was found w.r.t. 35 and 36, and no carious lesion was seen. The patient was advised orthopantomogram (OPG) which revealed presence of generalized bone loss along with a unilocular radiolucent area resembling a “tear drop shape” with a clear sclerotic lining, along with angular bone loss involving the mandibular left premolar and the mesial root of mandibular first molar [].
The vitality of the pulp was checked w.r.t. 35 and 36; it showed positive response as that of the contralateral side, and hence, endodontic involvement was ruled out. The patient was explained regarding the presence of lesion and a surgical excision of lesion was planned. The patient showed no symptoms, no history of swelling, discomfort, or pain, and was unaware of the presence of the lesion. Hematological investigation was done prior to surgery and was found to be normal. A comprehensive explanation was given to the patient regarding the intended surgical procedure to be done and an informed consent was taken before starting the procedure.
For surgical enucleation of the lesion, crevicular incision was given extending from canine till the first molar region [], with two vertical releasing incisions given, one on the mesial aspect of 33 and the other on the distal aspect of 36. A subperi

[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 54-year-old woman was admitted with fever and dull abdominal pain. She had been postmenopausal for 18 months and had no abnormal vaginal bleeding. A physical examination confirmed the presence of a cystic mass 10 cm in diameter on the right posterior of the uterus with clear boundaries, poor activity and no tenderness. The serum levels of CA125 and CA199 were 88.8 U/ml and 40.4 U/ml, respectively. Vaginal ultrasonography revealed a cystic mass full of fine spots that was located in the right ovarian area; the mass had clear boundaries, irregular low echo protrusions on the wall and no blood flow signals on CDFI. A solid mass with clear boundaries and a diameter of 7.3*5.9*6.5 cm was located below the former site of the cystic mass, and abundant arteriovenous blood flow signals could be seen inside and around the mass.
Her medical history included 30 years of dysmenorrhea and 18 years of endometriosis and adenomyosis.
We performed an exploratory laparotomy, and during the operation, a small amount of bloody ascites was observed. We observed that the size of the uterus was approximately equal to that at 6 weeks of pregnancy, and no obvious abnormality was seen in the left ovarian area. A cystic-solid mass with an approximate diameter of 10*15 cm was seen in the right ovarian area. After 600 ml of thin, chocolate-like intracapsular fluid was removed, we observed that the mass was densely adherent to the surrounding pelvic peritoneum and that the rectal pouch was completely closed. The source of the mass was found to be the left accessory ovary, and thus, the left adnexa was completely removed. After the mass was cut open, the contents appeared pale white, crisp and vortex-free and contained a chocolate-like liquid. The intraoperative rapid pathology report described a right ovarian spindle cell tumor with a large necrotic area, which was considered a sex cord-stromal tumor, but a malignant

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old left-handed man who works as a mechanic and firefighter presented to our institution with hand pain and cold intolerance for 3 months. He was referred by a local vascular surgeon who had made the diagnosis of hypothenar hammer syndrome (HHS) following an angiogram of the right upper extremity showing complete occlusion of the ulnar artery (). On initial examination, Doppler signals of the ulnar artery, superficial palmar arch, and ring/small digital arteries were absent in the right hand. Subsequently, the patient developed an ulcer on his right long fingertip after minor trauma that had not healed over a 4-week period. He suffered ischemic hand pain and severe cold intolerance. After conservative management failed, the decision was made for operative intervention. We proposed using an arterial graft versus a venous graft in order to improve long-term patency. Our plan was to utilize the descending branch of the lateral circumflex femoral artery (DLCFA) as an arterial graft.
Intraoperatively, Doppler ultrasound revealed a segmental thrombotic defect extending from the superficial palmar arch, across the Guyon canal, extending 10 cm proximally in the forearm. The ulnar artery was resected back to healthy bleeding pulsatile flow, resulting in a segmental defect of 12 cm. Final pathology of the submitted ulnar artery segment revealed organizing thromboembolus in the lumen, which at the time of resection was adherent to the lumen.
The DLCFA was harvested, with care taken to prevent injury to the lateral femoral cutaneous nerve. A 12-cm segment of the artery was circumferentially dissected, as well as approximately 2 cm of 2 branching vessels at the distal end of the segment that would be used to reconstruct the superficial palmar arch and common digital arteries with one graft. With the arterial graft completely dissected, it was ligated both distally and proximally.
The arterial graft and recipient vessels were examined under the operative microscope. The

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man presented with a 16×6 cm2 open wound with an accompanying tibiofibular fracture due to a traffic accident. Free flap coverage was planned, with a necessary pedicle length of 14 cm from the middle of the flap to the recipient vessel and 9 cm from the flap margin. A 20×6 cm2 ALT flap from the patient’s ipsilateral thigh was planned. The perforator that branched at the proximal descending branch of the lateral circumflex femoral artery was found intraoperatively (). The length of the branched perforator was 7 cm, and the available length of the descending branch on the proximal side was 2 cm, so the estimated pedicle length was 9 cm (). For pedicle length extension, dissection was performed on the distal aspect, which resulted in obtaining 7 cm of the distal descending branch. Thus, we were able to obtain a reverse ALT free flap with a total pedicle length of 14 cm in the distal direction. Before elevating the reverse ALT free flap, we clamped the proximal descending branch to check for flap circulation. We confirmed that flap congestion was present due to impaired retrograde flow through the valves of the vena comitans in the distal direction. To resolve flap congestion, one of the venae comitantes of the distal descending branch was isolated and connected to the proximal venous stump in an antegrade manner (). When connecting a 1.5-mm vena comitans of the distal descending branch with the 2-mm proximal venous stump, the diameter discrepancy of the venous anastomosis was not significant (). A modified ALT flap pedicle 15 cm in length was formed to prevent venous congestion and to ensure adequate length to reach the recipient vessel. As a result, the direction of the arterial flow to the flap was retrograde, and the venous flow was antegrade. To evaluate the flap condition after surgery, the flap color was checked and the pin-prick test and Doppler ultrasonography were performed. For 2 days after surgery, the flap status was maintained, with no findin

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


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

[User]
RADIOLOGY NOTE:
Case 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye "". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted "". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.
Cases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival

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


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

[User]
RADIOLOGY NOTE:
The patient, a 54-year-old female, is a known case of carcinoma of the head of the pancreas, which revealed being a periampullary pancreatic adenocarcinoma after histopathological examination. She underwent uneventful Whipple's procedure in September 2010 followed by adjuvant chemotherapy (carboplatin and methotrexate), with the last cycle being five years before her presentation. She has been on regular follow-up with oncology department without local or systemic recurrence.
In November 2015, she presented with a progressive painless swelling in the right parietal region of six-month duration. There was no history of trauma or previous head radiation. Before the presentation, patient overall health condition was stable with unremarkable history. Her social history was unremarkable and specifically negative for smoking.
Her physical exam and vital signs were within normal. Local examination revealed a hard mass of 5 × 6 cm in diameter with distinct edges, fixed to the skull.
The scalp over it was mobile and with no discoloration or discharges and no regional cervical lymphadenopathy. Neurological examination revealed a conscious, alert, and oriented patient without a focal neurological deficit.
Laboratory workup including CBC, renal, hematology, and hepatic profiles was within normal. Chest X-ray identified a small nodule in the left upper lobe.
Investigations also included CT brain, which demonstrated a lytic bony lesion with classic sunburst periosteal reaction measuring 4.3 × 3.1 × 5.4 cm (). The lesion was causing mild displacement of the adjunct cortex with no detected calcifications. There was no underlying vasogenic edema, and no other osseous skull lesions were detected. The cerebral and cerebellar parenchyma showed preserved gray-white matter differentiation, with no evidence of acute territorial infarction and no evidence of abnormally enhancing cerebral parenchyma or meninges. There was no midline shift, and ventricular system, basal cistern, and cortical

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


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

[User]
RADIOLOGY NOTE:
An 82-year-old woman sought evaluation of a mass in the anterior chest wall. A cardiac pacemaker was placed for bradycardia due to atrial fibrillation 3 years before. Twenty years prior an enlarged hilar lymph node was biopsied and the histologic evaluation revealed an adenocarcinoma that was thought to be a metastatic lung carcinoma, but the origin was not established.
A magnetic resonance image (MRI) and computed tomography (CT) showed the chest wall lesion on the surface of the sternum and the distal third rib. The tumor size was 4 x 5 cm, and the lesion extended to the subcutaneous tissue and intracoastal spaces between the second and third ribs (). The histologic evaluation of a biopsy specimen was characterized as proliferation of atypical spindle cells.
The tumor was resected along with the surrounding normal tissues of the overlying skin, the surrounding subcutaneous tissues, and the pectoralis major muscle. The anterior cortex of the sternum at the proximal and distal cut lines, as well as right lateral aspect of the cortex was cut with a high-speed burr. The left second-to-fourth ribs were cut along the resection line and an additional excision of ~5 mm was made at each second-to-fourth rib to confirm complete pleural reaction and handle the lesion for the next step.
Under fluoroscopy the left outline of the sternum was confirmed. As a tip, a 1.5-mm Kirschner wire was placed along the line of the sternum on the skin. A curved pelvis osteotomy chisel was used to cut the sternum from right-to-left, then the blade was used along the anterior surface of the posterior cortex of the sternum. Under fluoroscopy guidance, the blade was directed over the left outline of the sternum, which was marked with a Kirschner wire. Incomplete resection of the left outline of the sternum was cut with the curved chisel from the distal end. The remaining soft tissues, including the internal thoracic

[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 female presented with a 6 months history of progressively worsening pain over the right shoulder and chest wall, aggravated by movement and with associated right arm oedema and paraesthesia. She believed mild symptoms began 2 years prior to presentation.
On physical examination she had a tender mass over the 2nd–5th intercostals spaces with over lying visibly engorged veins. The blood pressure was BP 130/70 mmHg and pulse rate (PR) was 62 bpm and regular.
A chest xray showed a vague shadow over the 3rd intercostals space mid clavicular line, (Fig. ), a CT scan showed clearly a mass extending to a butting the pleural cavity pleura, see Fig. .
An echocardiogram and ECG were normal; cardiac enzymes panel was normal too.
The patient was consented for an exploration under general anesthesia, in supine position under general anaesthesia (GA), a 6–8 cm incision was made over the mass and a combination of blunt and sharp dissection the mass was wholly excised without opening into the pleura.
The patient was discharged on the 3rd post operation day, pain had significantly reduced and the limb oedema nearly resolved.
The histopathological examination revealed a benign lesion; a schwannoma with degenerative changes. The section revealed a benign nerve sheath tumor characterized by a proliferation of band spindle cells arranged in fascicles and variable cellularity and associated with dilated and think walled blood vessels. There was no evidence of malignancy.
Schwannoma is a benign neurogenic tumour and is usually founded as a solitary lesion. Chest wall schwannoma is rare and usually asymptomatic (Moon et al. ). In this patient it was symptomatic and mimicked a metastatic lesion even though no primary lesion was detected prior to the exploratory surgery. The lesion was completely excised under general anaesthesia and endotracheal intubation in supine position. The procedure lasted 45 min with minimal blood loss. The immediate post operative period was unremarkab

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old Caucasian British woman originally presented to her local hospital in 2002 with shortness of breath secondary to atrial fibrillation. During the admission, chest radiography revealed widespread pulmonary nodular infiltrates, and a subsequent computed tomography (CT) scan confirmed the presence of widespread pulmonary metastases, most marked in the lower lung fields (Figure ). The CT scan also demonstrated extensive retroperitoneal and para-aortic lymphadenopathy and hepatic abnormalities consistent with metastases, but no obvious primary site for the disease (Figure ).
Before admission, our patient had no symptoms of liver dysfunction and her medical history was otherwise unremarkable. She had no family history of malignancy. Routine haematology, clotting, serum biochemistry and liver function tests, hepatitis screen and tumour markers were all within normal limits. After the standard medical management for atrial fibrillation was completed, a CT-guided biopsy of the predominant hepatic lesion was performed.
Histological examination of the biopsy confirmed the presence of an infiltrating tumour with pleomorphic elongated cells that stained positively with the vascular markers Factor VIII, CD31, and CD34. These morphological and immunohistochemical features were consistent with the diagnosis of HEH. In the presence of disseminated disease, surgical management was not indicated, and our patient was referred to the oncology team for ongoing management.
In response to radiological evidence of disease progression, first-line therapy with interferon was commenced in accordance with the dosing recommendations published in an earlier case report []. A CT scan performed after three months therapy demonstrated stable disease; however, as our patient was experiencing significant interferon-related side effects, the treatment was discontinued. After a six-month break from therapy, there was evidence of disease progression within the spleen seen on an updated CT sc

[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 two-week-old female was brought in with an initial complaint of multiple masses that failed to regress since birth. She was born from a nonconsanguineous union and the mother’s pregnancy was uneventful. The baby was delivered vaginally at 37 weeks of gestation and multiples masses were found over the body. The treating physician advised follow-ups on discharge. However, the parents decided to seek more medical help for the child and she was admitted for more investigations.
On physical exam, the child was alert and active. She was not jaundiced and no pallor was noted on the extremities. Her vitals were all within the normal range and the birth weight and changes in weight corresponded properly. Two masses measuring 26 mm by 19 mm and 19 mm by 17 mm were observed on the forehead and the scalp (Figures -). One smaller mass was seen on the abdomen, measuring 11 mm by 10 mm (Figure ). All three masses were red and non-hemorrhagic. The parents reported that the size of the masses did not change since birth. No similar family history was found and both parents were healthy. Any hepatosplenomegaly was not observed on palpation nor were any other cutaneous lesions detected. She did not present with any other systemic abnormalities. An ultrasound was performed, and it revealed a normal liver, spleen, and kidneys with no masses or lesions. A Doppler examination also showed a fast-flow vascular lesion, as reported by many other articles []. The full blood count showed normal levels of white blood cells, platelets, hematocrit, and red blood cells.
The diagnosis of congenital hemangioma was confirmed and the family was properly educated about the condition as well as possible complications. A wait and watch approach was adopted and the child was scheduled for regular visits at three months. The family was asked to properly monitor the size of the masses and informed that appropriate surgical treatment would be provided if the masses fail to regress or if they continue to grow

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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 55-year-old man with the end-stage renal disease was assessed for decreased appetite, dysphagia, and nausea during the hemodialysis. He was on a routine hemodialysis program for 4 h, three times a week, for 7 years. In his history, he had essential hypertension for 15 years. The etiology of end-stage renal disease may be hypertension or systemic amyloidosis in our patient, but kidney biopsy had never been performed. He had been diagnosed with RA 20 years ago and had been taking leflunomide 20 mg/day regularly. His other medication was darbepoetin alfa 40 mcg/week, acetylsalicylic acid 100 mg/day, calcium acetate 700 mg three times a day, and lansoprazole 30 mg/day. On physical examination, the thyroid was diffusely enlarged (Grade 4) with multiple nodules. He had signs of long-standing RA in the form of joint deformities and rheumatoid nodules.
Laboratory findings of the patient can be seen in . Abdominal ultrasonography (USG) was performed, and it revealed normal findings. In addition, the fecal occult blood test was negative, and the patient did not have weight loss, so intraabdominal malignancy was not considered.
On thyroid USG, the parenchyma was homogeneous. Both of the thyroid lobes were enlarged. A large number of heterogeneous, hypoechoic solid and mixed nodules with cystic and calcified degeneration were found on both the lobes and isthmus, the largest one being on the right lobe (50 × 28 × 24 mm). Aspiration biopsy of the largest nodule showed a benign characteristic. As the patient had a large number of nodules, total thyroidectomy was performed.
According to macroscopic pathological examination, the right lobe was 12 × 7.5 × 7 cm, left lobe was 9.6 × 6 × 5 cm, and whole surface was encapsulated. In the right lobe section, a partially cystic nodule 4 × 3 cm in size separated by marked and regular borders from surrounding tissue was

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

[User]
RADIOLOGY NOTE:
A 65-year-old female with gallbladder carcinoma presented to our palliative care unit (PCU) with a history of pain abdomen and vomiting. Patient had pain in the right upper quadrant of abdomen, which had increased over the past 15 days. Pain was associated with vomiting for the past 3 days. The patient was taking tablet hyoscine butyl bromide 10 mg tds and tablet metoclopramide 10 mg tds without any improvement.
A contrast-enhanced computed tomography abdomen revealed gallbladder mass with liver and periportal nodal metastasis. An ultrasound-guided fine-needle aspiration cytology from gallbladder mass was suggestive of adenocarcinoma. Since patient had an Eastern Cooperative Oncology Group 4 status, she was deemed unsuitable for chemotherapy and referred to PCU.
In the PCU, she was started on morphine-based analgesic titration. After 3 mg bolus of injection morphine, an infusion of injection morphine 0.5 mg/h was started. She was started on injection metoclopramide 10 mg thrice a day for nausea and vomiting. Her abdominal pain was reduced in intensity, but nausea and vomiting persisted and was severe in nature. Considering liver metastasis, she was started on injection dexamethasone 8 mg twice a day.
Pain was settled but vomiting still uncontrolled. Addition of ondansetron also did not relieve the symptoms. Her vomiting persisted and adversely affected her quality of life (QOL). Hence, injection haloperidol 0.5 mg twice a day was added. Even with the use of a combination of different classes of antiemetics, her nausea and vomiting was not controlled.
A diagnosis of functional small bowel obstruction was made, and patient was kept on nasogastric tube decompression along with nil per oral for 24 h as per surgical oncology opinion. After 24 h of fasting, intermittent feeds were started with Ryle's tube clamping, but patient symptoms of nausea and vomiting persisted. We decided to start tablet olanzapine 2.5 mg once daily Ryle's tube. There was a dramatic response after

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


[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 32y old woman was referred to Yas hospital due to severe low abdominal pain and vomiting on May 2017. Ultrasonographic examination of her pelvis revealed bilateral ovarian cysts. During the 5 days before the admission, she had experienced severe right lower abdominal pain and vomiting especially after a meal. She had a long history of dysmenorrhea and, one cesarean delivery 3 years before. She was taking no medication. Her physical examination report included the temperature of 37°C, systolic blood pressure of 100 mmHg and heart rate of 120 beats per minute. The right lower quadrant of her abdomen was tender along with hypoactive bowel sounds. Laboratory data reported leukocytosis (16×109/L) with neutrophilia, C-reactive protein of 20 mg/dl and erythrocyte sedimentation rate of 60 mm/hr. Abdominal erect X-ray showed dilatation of small bowel segments. Colonoscopy was requested by gastroenterologist for finding the cause and excluding colon neoplasm. Diagnostic colonoscopy showed one small ulcer (8 mm) with the pressure effect of mass like lesion at cecum and scope couldn’t find the ileocecal valve. It was thought that a mass like lesion had caused the ileum obstruction. Colonoscopic biopsies were taken and histopathological examination revealed endometriosis. Afterwards, the patient was taken to the operating room for excision of the mass. At the exploration of the abdominal cavity, adequate exposure was attained by a vertical incision across the midline of the abdomen with a transverse extension to the right. The ileocecal part was covered by the omentum and was adherent to the abdominal wall. The ileocolic intussusception was seen without ischemic changes. Reduction of the intussusception was performed at first. After reduction, a firm mass was recognized at cecum, located close to the ileocecal valve. Then, the ileocecal resection was performed (). Pathological examination confirmed endometriosis.
The postoperative period was uneventful and she was discharged o

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old male patient sought the medical facility complaining of recent productive cough and dyspnea. His past medical history included pulmonary tuberculosis, which was treated few years before, and smoking of 15 packs/year. He had sought medical care several times during the prior 2 months, but was always treated with symptomatic medication until a plain chest radiography was taken, which showed mild mediastinal enlargement and a bulging on the right atrium contour (). This was the reason for the hospital admission and clinical investigation.
The initial physical examination revealed an afebrile patient, who presented normal hemodynamic parameters and no peripheral edema. Lung examination was normal, and cardiac auscultation revealed an ejection murmur. Raised jugular venous pressure and hepatomegaly were also observed. The remaining examination was normal and the initial laboratory workup was unremarkable.
The echodopplercardiogram showed pericardium thickening with mild effusion and a left ventricular ejection fraction of 60%. Thoracic computed tomography (CT) showed a mass with soft tissue attenuation infiltrating the pericardium and the anterior wall of the right atrium () and multiple, bilateral, scattered, solid pulmonary nodules measuring up to 2.6 cm.
The magnetic resonance imaging (MRI) also showed a mass with heterogeneous distinction diffusely involving the pericardium, with compression/invasion of the right ventricle’s outflow tract, pulmonary artery and superior vena cava ( and ).
The pericardium was biopsied, but the histological examination did not reveal evidence of malignancy. A pulmonary nodule was subsequently biopsied, which showed a mesenchymal malignancy represented by sinusoidal vascular channels filled with red blood cells and lined with atypical endothelial cells (). The immunohistochemical profile showed positivity for CD31, CD34 (), while Desmin and S100 Protein were negative, rendering the diagnosis of angiosarcoma. Adding the radi

[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 9-year-old boy was hospitalized in our cardiology department for repeated episodes of paroxysmal tachycardia at 180 bpm (Fig. ). Propranolol was ineffective to control arrhythmia. Because of frequent episodes of tachycardia the family accepted electrophysiological study and ablation.
The ECG during sinus rhythm showed no sign if pre-excitation. Echocardiography showed normal values for the age of 9 years (Fig. ).
During the electrophysiological study we mechanically induced PSVT. The coronary sinus catheter confirmed an orthodromic reentrant tachycardia using a left lateral accessory pathway (Fig. ). Our protocol is to perform electrophysiological study with zero or near-zero irradiation in children under 14. We used the NAVX Ensite Velocity system provided by Saint Jude medical (Fig. ). The impedance-based system permits introduction of catheters through the femoral or jugular veins and inside the heart chambers without the use of fluoroscopy. The system delivers a small amplitude electrical signal between surface electrode patches. A catheter that is introduced in the electrical field has a clear position and can be visualized inside the heart chamber. The 3D geometry of the cardiac structure can be thus created. Using the patch surface electrodes from the abdomen and thigh we first created the image of the right common femoral vein, than the right iliac vein, inferior and superior vena cava. Using the previously created contours we placed the catheters inside the right atrium, right ventricle and coronary sinus.
After catheter placement at the His level and right ventricular apex, we punctured the right femoral artery and introduced the ablation catheter retrogradely through the aortic valve at the level of the mitral ring. We reconstructed the descendant, ascendant aorta and the aortic arch and precisely localized the mitral annulus (Fig. ). During tachycardia we mapped the mitral ring and we found a spot where the ventricular and atrial electrograms were fuse

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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 52-year-old male patient was admitted for weakness and numbness involving the bilateral lower limbs for 18 mo, and disorder of defecation and erectile dysfunction for 6 mo. For the last 3 mo, these symptoms started to worsen.
The patient started to present disorders of bilateral lower limbs in January 2016, and defecation and erectile dysfunction in January 2017. Subsequently, he received magnetic resonance imaging examination at a local hospital, which suggested an intramedullary mass located at the level of T9-T10. However, he did not take any cure. In April 2017, the clinical symptoms began to worsen. Therefore, the patient was admitted to our department on July 13, 2017 for further treatment.
The patient underwent an appendectomy in 1984, and had suffered from diabetes for 7 years and hypertension for 2 years. He had been taking nimodipine, metformin, and gliclazide to control the blood pressure and blood glucose levels under the supervision of local doctors.
Neither he nor anyone in his family had a history of primary intramedullary melanocytoma.
Neurologic examination presented that the myodynamia of the right lower limb was grade 3 and left lower limb was grade 4. Besides, the superficial and deep sense in the right lower limb was clearly worse than that of the left lower limb and these dysfunctions in distal lower limbs were more severe than those of proximal lower limbs as well. Moreover, achilles tendon reflex and patellar tendon reflex were brisk with absence of ankle and patellar clonus. Babinski sign was positive in the right lower limb. Anal reflex revealed a mild decrease and the Romberg sign was positive.
Total protein was slightly low (63.2 g/L). Triglyceride (1.75 mmol/L) and low density lipoprotein (3.47 mmol/L) were a little high. Color doppler ultrasound of the stomach and pelvis indicated a single gallbladder polyp (3 mm × 3 mm) and gallstone (5

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male patient reported with a huge swelling in the left parotid gland region, slowly enlarging in size since 5 years. On inspection and palpation, swelling was non-tender, pyramidal in shape, 12 × 10 cm in size, nodular and firm in consistency; temperature over the swelling was normal with no fixation of the tumor to the underlying structures. The ear lobule appeared to be raised with no facial paralysis or restriction in jaw movements []. On the affected side, the lymph nodes were not palpable. The case was clinically diagnosed as benign salivary gland neoplasm involving left parotid gland.
Hematological investigations showed no significant alterations except increased eosinophilic count. Ultrasonography revealed hypoechoic lesion showing increased vascularity []. Lateral view and posteroanterior view of skull was normal without any underlying bone resorption [Figure and ]. Fine-needle aspirate showed atypical mononuclear cells suggestive of malignancy []. Patient was advised a complete surgical excision. The tumor was excised from superficial lobe of parotid gland. No intra-operative complications were reported. Postoperatively, patient showed signs of paresthesia with transient signs of Bell's palsy, which were taken care of. Then the specimen was sent for histopathological examination. On grossing, it showed a well-encapsulated mass, measuring 10 × 12 cm in size and was firm in consistency. The cut section showed white fibrous mass inside the capsule [].
Histopathologically, it showed islands of tumor cells separated by dense bands of hyalinized fibrous connective tissue. Islands were composed of small ducts lined by inner luminal cuboidal cells and outer clear myoepithelial cells representing the characteristic biphasic pattern. The cuboidal epithelium was surrounded by clear cells, which interfaced with a thickened hyaline basement membrane. Nests of atypical myoepithelial cells, some in acinar pattern and some scattered in the connective tissue s

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old woman presented with worsening dyspnea over the past 12 months. She had no medical or surgical history. Cardiovascular risk factors associated were arterial hypertension, hypercholesterolemia, former smoking history and obesity (body mass index 32.9 kg/m2). The physical examination was normal, except for a 3/6 systolic murmur audible at the apex and along the left sternal border. The electrocardiogram was also normal. Chest X-ray showed situs solitus, levocardia, mildly increased cardiothoracic index, and pulmonary plethora. TTE revealed severe mitral regurgitation (MR) due to a mitral valve structural abnormality. A linear structure was present in the left ventricle outflow tract (LVOT) connecting the basal interventricular septum with the tip of the anterior mitral leaflet, restricting the mitral valve motion and causing severe MR. There was no evidence of LVOT obstruction. Both LV volumes and ejection fraction were normal, with no wall motion abnormalities. An abnormal high velocity systolic jet was visualized in the RA ( and in the online-only Data Supplement) with a peak velocity of 5.2 m/s (). There were no indirect signs of pulmonary hypertension. Therefore, an abnormal communication between the LV and the RA was suspected. The TEE exam confirmed the LV to RA shunt above the septal leaflet of the tricuspid valve consistent with a Gerbode type defect ( and in the onlineonly Data Supplement). TEE also revealed a more detailed linear structure in the LVOT ( in the online-only Data Supplement) connecting the basal interventricular septum with the tip of the anterior mitral leaflet, restricting the mitral valve motion and causing severe MR ( and in the online-only Data Supplement).
The preoperative coronary angiography revealed normal coronary arteries. No opacification of the RA during left ventriculography was observed, and the absence of pulmonary hypertension was confirmed at right heart catheterization. The patient underwent successful mitral va

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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:
Our patient, a 58-year-old Caucasian male, presented to the emergency department with the acute onset of quadriplegia extending from C5 throughout the rest of the pan neuroaxis while awakening from bed the morning of presentation. Upon initial physical examination there were no signs of trauma noted that were significant to the presenting symptoms, additionally, patchy sensation was noted in the upper and lower extremities with clonus in the legs only and hyperreflexia in both arms and legs. Initially, our patient was administered one intravenous dose of methylprednisolone and allowed to enter a state of permissive hypertension which improved our patient's arm strength bilaterally to 2/5, but had no positive effects on the lower extremity paraplegia. As a result of minimal improvement, immediate imaging of the cervical spine was ordered and highlighted a severe cervical stenosis from C3 to C7, as seen in Figure , due to extra-axial posterior compressive spinal mass with cord signal change.
Additional imaging of the brain was completed as a precautionary measure and was normal. Upon obtaining full patient history and medical records from nearby hospitals, it was found that our patient was on a prolonged regimen of warfarin for many years due to a prior diagnosis of congestive heart failure without regulation and regular INR/prothrombin evaluation. Our patient also did not follow up with his primary care physician throughout the duration of the warfarin regimen. At presentation, our patient's INR was found to be 5.0 necessitating the prompt correction with intravenous injection of fresh frozen plasma (FFP) and vitamin K. Additional magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed large compressive acute epidural hematoma posteriorly compressing the thoracic spinal cord from T6 to T10, visualized in Figure , with cord signal change, as well as L4-S1 posterior acute epidural hematoma compressive of the cauda equine, visualized in Figure .
Upon

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


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

[User]
RADIOLOGY NOTE:
Patient 3: A 24-year-old gravida 6 para 4 female at 31 weeks of gestation presented to the emergency department as a belted passenger in a 45-mph motor vehicle collision. Her pregnancy had been complicated by anemia and obesity. Plain film radiography demonstrated a mildly comminuted and displaced right femoral shaft fracture with foreshortening (). Her obstetric history included four previous full-term spontaneous vaginal deliveries and one elective abortion. She had no other significant past medical history. Laboratory evaluation was remarkable for a white blood cell count of 20.7×103/μL and hemoglobin of 9.1 g/dL, with a normal calcium level of 8.6 mg/dL. She was transferred to labor and delivery where fetal monitoring was reassuring. Uterine tocometry showed contractions every 2–10 mins and the decision was made to give a 12 mg dose of intramuscular betamethasone for fetal lung maturity prior to surgical intervention.
On hospital day 1, the patient underwent an uncomplicated anterograde rod insertion of her right femur under general endotracheal anesthesia. Fetal monitoring before and during surgery was reassuring. Total preoperative and intraoperative radiation dosage was 135.2 mGy and a lead apron was used to shield the maternal abdomen during all images. The patient was started on 30 mg twice daily enoxaparin sodium for VTE prophylaxis, physical therapy as well as oral cholecalciferol and calcium acetate for daily supplementation. Throughout her postoperative course, the patient was not meeting ambulation goals necessary for discharge and on postoperative day 5, she was diagnosed with preterm premature rupture of membranes. Azithromycin and amoxicillin were started as latency antibiotics. On postoperative day 7, the patient complained of increasing pain and pressure, the cervix was found to be fully dilated, and she vaginally delivered a live born male fetus at 32 weeks and 1-day gestation from the breech presentation. The patient had an unremarkable postpart

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


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

[User]
RADIOLOGY NOTE:
In August of 2012 a 16-year-old male presented complaining of rest and activity pain worsening for the past year. He denied any history of trauma. The patient reported is worsening left knee pain and decreased range of motion were limiting his daily activities. Radiographs from an outside facility (not available for publication) showed a lobulated well-defined epiphyseal lesion with sclerotic margins and without stippled calcifications. Computerized tomography (CT) further defined a low-attenuation lesion in the medial femoral condyle measuring 13 mm by 16 mm with well-defined sclerotic margins and depression of the subchondral bone at the lesion border (). Differential diagnosis at this time included chondroblastoma, giant cell tumor, clear cell chondrosarcoma, and osteomyelitis. Given the patient's delayed presentation and our increased concern for metastatic disease we elected to proceed with a CT chest, in place of a routine screening chest radiograph. This CT showed no evidence of metastatic disease. Core needle biopsy () showed mononuclear neoplastic cells with intermixed multinucleated giant cells, tumor cells surrounded by dark blue “chicken wire” calcifications, and fibrochondroid islands all consistent with a chondroblastoma. At this point an MRI of the left knee was obtained to evaluate the extent of articular cartilage involvement and to determine reconstruction options after recommended intralesional curettage. MRI demonstrated a lytic lesion with sclerotic borders involving the posterior aspect of the medial femoral condyle and abutting the posterior articular surface with a 3 mm collapse of the subchondral bone and breach of the chondral surface (). Also the significant enhancing of marrow edema in the medial femoral condyle and adjacent soft tissue edema with associated joint effusion is well demonstrated on the T2 STIR images (). The imaging and pathology were reviewed at multidisciplinary tumor board and the surgical approach and reconstructive opt

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old primigravida with a singleton pregnancy was referred to our center because of the finding of an oral cyst diagnosed during a routine ultrasound at 26 weeks of gestation.
The medical history of the parents was unremarkable and they were nonconsanguineous.
The first and second trimester scans performed at 12 and 20 weeks of gestation in another center were normal.
Ultrasounds were performed using a GE Voluson 730 Expert.
The initial examination performed at 28 weeks of gestation showed a single male fetus with an oral cystic lesion of 18 × 10 mm, located under the tongue. The tumor appeared to be fluid and homogeneous, without solid components, with well-defined limits and it moved with the tongue movements. The most likely diagnosis with that ultrasound appearance was a congenital ranula or a thyroglossal duct cyst.
The fetal anatomic study found no other abnormalities, except a left renal pelvic dilatation of 7.3 mm; fetal biometric parameters and amniotic fluid index were normal ().
Follow-up ultrasound scans performed every 2 weeks always showed appropriate fetal growth (75–90 percentile) and a normal amniotic fluid index. There were no changes in the measurements of the oral cyst and the most striking finding was that the fetus kept his mouth open during all examinations ().
Fetal magnetic resonance imaging was performed at 31 weeks and revealed a moderate left renal pelvic dilatation and an orofacial lesion of 18 × 14 mm located before the free edge of the tongue and above the lower lip, with cystic characteristics and the same echogenicity as the amniotic liquid, without evidence of fat or signal diffusion restriction. That image could correspond with a cyst probably dependent on the salivary glands ().
At term, the oral tumor did not show any changes in measurements and characteristics, there was no evidence of polyhydramnios, and the stomach was visible; we also could see complete tongue movements and we occasionally observed that the fetus was

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male with no previous medical history experienced a transient loss of consciousness after two simultaneous head-to-head collisions during a high school football game. Upon regaining consciousness, the patient initially answered questions appropriately; however, he became combative and was intubated due to severe agitation and suspected seizure activity. The patient was transferred to an outside hospital and received computed tomography (CT) scans of the head and cervical spine, both of which reported no acute pathology. An attempt was made to extubate the patient; however, a neurological examination revealed 3/5 left-sided strength with spasticity. Sensation was intact bilaterally, and no carotid bruits were heard. Brain and cervical spine magnetic resonance imaging (MRI) revealed a right MCA infarct on the diffusion-weighted image and questionable right internal carotid artery (ICA) dissection (Figure ).
The patient was started on heparin and a CT angiography revealed mild irregularity along with segmental narrowing of the distal cavernous and supraclinoid segments of the right internal carotid artery.
Upon arrival to our institution, sedation was turned off and the patient was noted to have 1/5 left extremity strength on repeat neurological exam. Neurology and neurosurgery were consulted and the decision was made to perform a cerebral angiogram. The study showed multifocal irregularities of the right supraclinoid internal carotid artery and the M1 segment of the right MCA, highly suggestive of nonflow limiting vasospasm. Distal emboli were observed in the right MCA (Figures , , ).
An electroencephalogram (EEG) was performed and the presence of a mild encephalopathy with superimposed right temporal slowing was noted. No epileptiform activity was seen. The patient was started on hypertonic saline due to cerebral edema, valproic acid, and aspirin 325 mg. He was extubated one day after arrival at our facility. Serial head CT scans were performed and reve

[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 44-year-old female presented to the emergency room with sudden onset sharp right lower quadrant pain, nausea, and vomiting. On physical exam, she was positive for McBurney's, Rovsing's, psoas, and obturator signs. Her white blood cell count was elevated at 16.5. CT scan showed signs of appendicitis as well as suspicious intraabdominal soft tissue masses (). Five years earlier, she presented to a different hospital with diffuse abdominal pain, and CT scan identified a small bowel lesion; endoscopic biopsy showed GIST. She underwent SB resection without complications. No pathology was available, and according to the patient, no adjuvant chemotherapy was given; on her one-year follow-up CT scan, no evidence for tumor recurrence was found with no additional oncologic follow-up. She remained symptom-free for the next several years, until this episode.
Secondary to the CT findings suggestive for appendicitis, nonoperative management and further workup were contemplated. The RLQ masses were most concerning for recurrent GIST, and after discussion with the patient, indication for surgery was made. On diagnostic laparoscopy, the appendix wall was found thickened and acutely inflamed with nodular lesions. In addition, multiple up to 2 cm in diameter nodules on the terminal ileum and the parietal peritoneum of the anterior and lateral abdominal walls were visualized (). One larger nodule in the right pelvis could not be mobilized. The liver was found to be free of any lesions. Due to the volume of the separate masses and inability to mobilize the large right pelvic nodule out of the pelvis, the case was converted to laparotomy. A lower midline incision was made. The appendix was mobilized, the mesoappendix was secured using a stapler, and the appendix was resected at the base and handed off for pathology. All visible nodules were then removed from the peritoneum, and a partial resection of the terminal ileum was performed. When the small bowel was run from the terminal ileum

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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 male athlete presented to the emergency department with an injured left tibia. The patient reported a left knee forced hyperflexion during a football match, which caused the injury. The described mechanism of injury was violent contraction of the quadriceps muscle against a fixed tibia.
The left knee was held in 100° of flexion with complete inability to extend the knee or bear weight. On examination, there was obvious swelling over the proximal tibia and on palpation there was tenderness on the anterolateral part of the proximal end of the tibia. No neurovascular impairment was identified. The patient was able to actively move his ankle, as well as his toes, and both posterior tibialis artery and dorsalis pedis artery were palpable.
From the plain radiographs, a displaced flexion type Salter-Harris type II fracture of the proximal tibia epiphysis was identified ().
Few hours after admission, the patient was led to the theatre and, under general anesthesia, a closed reduction of the fracture was performed by extending the knee and putting strong pressure over the tibial tubercle. Reduction was confirmed using image intensifier () and stability of the fracture was verified, as there was no displacement at 80° of knee flexion. After reduction, the dorsalis pedis artery and the posterior tibial artery were palpable. Since there was no displacement with that degree of flexion, percutaneous pinning of the fracture was not performed and only a circumferential cast with the knee in full extension was applied.
Patient was hospitalized in the Orthopaedic Department under close observation of limb neurovascular status. On the same night after reduction, the patient developed severe pain, which subsided after splitting the cast. The next few days, the patient developed severe swelling over the anterior tibia compartment, but there were no clinical signs of compartment syndrome. Posterior tibialis remained easily palpable, whereas the dorsalis pedis became weak bu

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


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

[User]
RADIOLOGY NOTE:
A 67-year old male patient presented to the otolaryngology clinic with a swelling on the left side of his jaw which had been present for 12 years but had enlarged recently. His medical history included an operation for a swelling on the right side of his jaw at another centre, 17 years previously. However, there was no medical record of that operation. His recent medical treatment included doxazosin for hypertension and inhaler bronchodilator for chronic obstructive pulmonary disease. Pathology examination of the biopsy materials of the swelling excluded malignancy and the patient was scheduled for a parotidectomy operation with a diagnosis of benign Whartin tumor. He was a smoker for 55 years and an ex-coal mine worker and rhonchi were present in his physical examination. Therefore, chest radiography and magnetic resonance imaging (MRI) were performed. In these examinations, a 40 mm ARSA aneurysm was observed posterior of the trachea ( ). Thorax CT angiography with contrast was then performed to determine the relation of the aneurysm to adjacent organs ( ).
Although an endovascular intervention had been planned initially, because of the patient’s comorbidities, the anatomical measurements of the ARSA were inappropriate for placement of an endovascular stent so we decided to perform open surgery. We planned surgical resection of the Kommerell diverticulum through left thoracotomy and repair of the descending aorta with primary sutures or patching of the descending aorta with polytetrafluoroethylene (PTFE) graft. We were also going to implant the left subclavian artery into the left common carotid artery with fine running polypropylene sutures.
Written informed consent was obtained from the patient and he was operated under general anesthesia. The chest cavity was accessed through the 4th intercostal space after left lateral thoracotomy. Sudden abundant bleeding from the posterior wall of the aneurysm occurred during surgical exploration of the aortic arch. The patie

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


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

[User]
RADIOLOGY NOTE:
The patient involved was a healthy 28-year-old G1 at 18 weeks of gestation who consented for pregnancy termination via preparatory laminaria dilators and subsequent operative dilatation and evacuation for a confirmed, lethal diagnosis of Trisomy 18. Aside from an ultrasound-diagnosed lower uterine fibroid, her antenatal course was unremarkable and she had had a normal pelvic examination just prior to conceiving.
On preparation of the cervix for dilatation, a speculum exam revealed an obstructing 5-6cm fibroid protruding through the cervix into the vagina. The cervix itself was not visualized due to the size of the fibroid and its protrusion into the vagina. On bimanual exam, the internal os was closed around the fibroid, which appeared to arise from the level of the internal os of the cervix. In order to prepare the cervix for dilation, osmotic dilators were tucked around the fibroid within the cervix. After three hours, the internal os was a finger tip dilated with further ripening required. Rather than a sequential set of dilators which would be challenging to place and maintain around the fibroid due to angulation, a cervical Foley catheter was employed to ripen the cervix further. The intent was to allow proper placement of a dilator without increasing the risk of false passage creation.
Given the obstructive fibroid, the patient consented for a myomectomy prior to the evacuation, with the added, increased risk of hemorrhage. The possibility of an operative hysteroscopy was explained, as it would allow for removal of the stalk of the fibroid in its entirety, as well as cauterization of the base itself should it be required. Prior ultrasound had indicated that the fibroid was within the lower uterine segment, and the location of the base could not yet be identified.
The following day with the Foley having fallen out and under general anesthetic, examination revealed a sufficiently 3-4cm dilated cervix with the prolapsed fib

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old gentleman presented with a two-month history of bleeding per rectum and altered bowel habits. There was no history of tenesmus but sensation of incomplete evacuation following defecation as well as a feeling of a lump in the anal canal was present. His appetite and weight had been stable.
Clinically he looked well and abdominal examination revealed no abnormality. Per rectal examination revealed a mass in the posterior wall of the rectum with intact mucosa, which had significantly narrowed the lumen. Colonoscopy revealed the presence of a mass in the posterolateral wall of the rectum extending from 4 to 14 cm from the anal verge, with normal overlying mucosa. In addition, there was also a large sessile polyp in the descending colon and an ulceroproliferative growth at the splenic flexure; histopathology confirmed adenomatous polyp and adenocarcinoma respectively.
Computerised tomography (CT) of the pelvis showed thickening of the distal rectum with an obvious low density poorly enhancing lesion with possible calcification in its wall. Tissue plane between this lesion and prostate was not clearly seen but there was no infiltration of the ischiorectal fat (Figure ). Magnetic resonance imaging (MRI) showed a very large well-defined mass in the left presacral / ischio-anal fossa contiguous with rectal wall and thus almost certainly arising from one of the elements of the rectal wall (Figure ). Barium enema showed an apple core lesion in the splenic flexure (Figure ) as well as narrowing of the distal rectal lumen (Figure ).
The case was fully discussed at the colorectal multidisciplinary team meeting and all the surgical options including left hemicolectomy combined with rectosigmoidectomy plus transverse colostomy were fully evaluated. However, the consensus was that the additional presence of an adenocarcinoma as well as an adenoma higher up in the colon combined with the size of rectal schwannoma (12 cms) made panproctocolectomy with permanent ileostomy

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.
Computed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).
After physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.
On the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.
The examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of eme

[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 woman was referred from a primary clinical to the Department of General Surgery at Asan Medical Center (Seoul, Korea) for an inguinal hernia. She had noticed reducible swellings on both inguinal areas for 10 years but did nothing until the swellings became problematic. These swellings had increased 7 months earlier, accompanied by pain. Ultrasound examination showed a well-defined cyst in the right inguinal area, and a mass with cystic and solid portions in the left inguinal area. Computed tomography showed a 7.4 cm round homogeneously enhanced mass in the left inguinal canal with an enlarged lymph node in the left para-aortic area ().
The mass excised from the left inguinal area was well-defined and firm, measuring 7×7×6 cm in size. The cut surface was homogenously creamy white and vaguely lobulated with focal hemorrhage (). The mass in the right inguinal canal was heterogeneously golden yellow to pinkish gray and encapsulated (). Microscopically, the mass of left inguinal area consisted of large uniform cells growing in broad sheet divided by thin septa which infiltrated by lymphocytes. The nuclei of the tumor cells were centrally located and round to polygonal with finely granular chromatin and prominent nucleoli. The cytoplasm was eosinophilic to clear and had distinct cell border (). These features were consistent with seminoma of classic type. Adjacent to the mass was soft tissue composed of atrophic hyalinized seminiferous tubules and interspersed Leydig cell nests in between, compatible with testicular tissue (). The mass from right inguinal canal also had testicular tissue with atrophic hyalinized seminiferous tubules, but the leydig cell nests were larger and more abundant, consistent with leydig cell hyperplasia (). This mass was removed surgically, as was the reducible mass in the right inguinal canal, followed by herniorrhaphy.
Postoperatively, the surgeon in charge requested a detailed examination of this patient by a gynecologist for fur

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


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

[User]
RADIOLOGY NOTE:
A fifty seven-year-old lady who was previously very active and a keen golfer sustained a closed, comminuted proximal humerus fracture/dislocation of the shoulder of her non-dominant upper limb whilst skiing. This was treated with plate and screw internal fixation the day after her injury. Unfortunately, this was complicated by early infection and within six weeks, she presented with a draining sinus from the wound. She was started on oral Clarithromycin and a subsequent drainage and washout failed to isolate causative organisms.
Ongoing pain and stiffness was attributed to a screw protruding through the humeral articular surface (confirmed on shoulder arthroscopy). However, four months after the injury, at surgery to remove this screw the metalwork was found to be bathed in pus, loosening and with a large cavity in the proximal humerus. The metalwork was removed and the affected area curetted and washed out. She was started on intravenous Vancomycin for two weeks followed by a further four weeks of oral Cephradine. Again no organisms were cultured from operative samples. Blood tests revealed a normal white cell count (WCC), an Erythrocyte Sedimentation Rate (ESR) of 21 mm/h and a C-reactive protein (CRP) level of 5 mg/L. She was referred to our unit at this point.
At initial assessment, she had no systemic symptoms of infection and the skin defect had healed. She had a poor residual range of shoulder movement with both flexion and extension limited to thirty degrees, abduction to twenty degrees, with no internal or external rotation. All movements were painful. She had no neurovascular deficit. Radiographs confirmed destruction of the joint surface, an un-united fracture with some collapse and mal-rotation (Figure ). MRI scans revealed a cavity in the proximal humerus with marked surrounding oedema in the bone and soft tissues (Figure ).
Clinical assessment revealed that she had almost no glenohumeral movement but had reasonable sc

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman with a past medical history of hypertension, scoliosis and depression presented with 1 week of flu-like symptoms (diffuse body aches, fatigue, and chills) and generalized weakness that rapidly progressed over several days in June 2018. Her social history is significant for living in a trailer in a wooded area in Florida, living in areas close to a mix of salt and river water, and exposure to mold, rats, and bat droppings near her home. On initial neurological examination, the patient was lethargic but oriented to person, place and time. She had impaired concentration and required occasional tactile or auditory stimulus to maintain attention. There were no cranial nerve deficits. Strength was 4/5 in the bilateral upper extremities and 3/5 in the bilateral lower extremities. There were no pathologic reflexes and sensation to light touch was intact in all extremities. The patient then had a rapid deterioration requiring intubation and mechanical ventilation. Serum laboratory results and serology testing throughout the hospital course are presented in –. Ceftriaxone, acyclovir, vancomycin, and ampicillin were started due to suspicion of meningitis based on the initial clinical presentation and serum testing. Computed Tomography (CT) angiogram of the head was unremarkable. Initial MRI Brain without contrast (hospital day 1) showed abnormally increased T2 FLAIR signal in the deep gray nuclei bilaterally, most prominent in the striatum (). Blood cultures were negative throughout her hospitalization. Cerebrospinal fluid (CSF) analysis was suggestive of meningitis and is presented in . Her CSF arboviral antibody panel is shown in and was initially unremarkable except for California encephalitis IgG 1:256.
Electroencephalogram (EEG) showed diffuse background slowing and rare left temporal sharp waves. On hospital day 4, neurological exam in the setting of pharmacologic sedation and mechanical ventilation was significant for a comatose state with absent bra

[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 75-year-old male whom initially presented to our service with a mass on his right upper back. The patient's medical history included coronary artery disease and hyperlipidemia. Further history revealed he had received (2) stents in the past and undergone multiple heart catheterizations (up to seven) approximately seven years prior at an outside facility. During his last catheterization and stent procedure, which took over 4 hours (approx. 33 mSv), he developed a radiation-induced injury to his right back around the T10 dermatome (). During the following years, the burn was closely followed at an outside facility, and the area developed a chronic nonhealing ulcer which continued to evolve over time eventually growing outward from his back and developing a foul odor on his presentation to our facility in 2017. He reported increasing pain at the periphery of the tumor margin. Up to a year prior to presentation, the area was flat and biopsies revealed no evidence of malignancy. Upon presentation to us, however, the physical exam demonstrated a fungating mass approximately 5 × 9 cm with central purulent necrosis and induration surrounding the periphery (Figures –). No additional nodularity or adenopathy was found on physical exam initially. At this time, punch biopsies demonstrated undifferentiated pleomorphic sarcoma along with frankly necrotic debris.
Initial staging showed only localized disease by MRI with no evidence of metastasis by CT scan (Figures and ). Approximately one month following diagnosis, the patient underwent a radical excision with a 20 × 9 cm elliptical excision of the site. In this case, the patient chose human dermal matrix reconstruction, as primary closure was not possible due to the size of the site. Our patient did not want an additional wound of autologous skin procurement.
Pathology of histologic sections revealed a highly cellular spindle cell neoplasm. Focal areas of necrosis comprised less than 50% of sampled tissu

[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 87-year-old woman with an intractable pain radiating over the left chest, suggestive of intercostal neuralgia, was referred to our spine center for further evaluation and management. Five weeks earlier, she experienced a ground-level fall, causing severe back pain. According to the initial evaluation conducted elsewhere, she was diagnosed as having OVF of the T10 vertebral body and managed conservatively with a brace and pain medication for one month. Her chief complaint gradually changed from bilateral back pain to an aching pain extending to the left thorax before her first visit to our hospital. What is noteworthy about the history of this case is that 8 years previously, she had had a painful OVF of the T12 vertebral body at the age of 79 years, which was treated with vertebroplasty using hydroxyapatite (HA) blocks and posterior pedicle screw instrumentation followed by iliac bone graft fusion from T11 to L1 at another hospital [].
On clinical examination at our hospital, the patient had no neurologic deficits, complaining of nothing but reporting a position-dependent severe chest pain on the left side, which intensified when sitting up from a supine position. Imaging studies revealed neither rib fractures nor abnormal findings of the chest cavity as a possible cause of the chest pain.
On the plain radiographs of the thoracic spine (), the anteroposterior (AP) views and the lateral views taken in the supine position showed the IVC within the T10 collapsed vertebral body as a gas-like radiolucent area, which disappeared on the lateral view obtained in the sitting position (i.e., the opening-closing phenomenon) most likely indicating an OVF of nonneoplastic and noninfectious origin [, ]. The lateral radiograph in the sitting position also demonstrated that the fracture line extended through the posterior fusion mass bone, grafted 8 years ago, indicating a potentially unstable flexion-distraction injury. Close observation of the AP radiograph obtained in the sup

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old male presented to our clinic with pain, mechanical limitation, and swelling in the right elbow, that had become increasingly severe over the previous 3 years. In physical examination, there was limitation in extension by 30° and in flexion by 20° when compared to the contralateral elbow. It was detected that there was a palpable, painful, rigid, immobile mass at the anterior and posterior aspects of the elbow joint.
In radiological evaluation, it was seen that there was narrowing in the joint space and cortical irregularity in the anterior region (). On computerized tomography (CT) scan, it was seen that there was soft tissue swelling at the right elbow joint, and cortical erosive changes in the distal humerus (). On magnetic resonance (MR) imaging, hyperintense, well-defined, nodular mass lesions were seen in fat suppression sequences ().
Surgery was scheduled for the patient with an initial diagnosis of SC. First, olecranon fossa was exposed through the lateral and medial tricep muscles following a midline incision at the posterior aspect of the elbow. Numerous chondral loose bodies, which resulted in limitation of extension of the elbow and filled the olecranon fossa leading to enlargement of the joint capsule, were removed after capsulotomy. A second incision was made at the anterior aspect of the elbow for lesion in the anterior region of the elbow. The anterior capsule was exposed by preserving the vascular and neural components. Again, numerous rigid, free chondral loose bodies, which extended to the radius head and a process inside the joint, were removed following capsulotomy (). Both anterior and posterior synovial excisions were made. After excision, the range of motion was assessed intraoperatively. It was noted that preoperative flexion and extension limitations were relieved.
In the histopathological evaluation of the chondral loose bodies that were removed, SC was confirmed by observation of well-defined chondrocytes and mature cartilage

[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.