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

[User]
RADIOLOGY NOTE:
A 19-year-old black female presented with painful lower lip swelling of 2 weeks duration. She was initially seen by a physician whom she claimed had given her anti-allergic medication and painkillers in the form of tablets for 1 week, but the situation worsened and the swelling and pain increased. She was then prescribed intravenous penicillin for another week with no improvement, after which she presented to our hospital for assessment and further management. There was lower lip swelling with discharge from the exfoliated crusted lower lip surface. The condition had started as a small pimple on her chin just below the lower lip on the left side which was painful and increasing in size. She attempted to open it and did not use any antibiotic. After 48 h she became febrile and her lower lip became swollen. She went first to a physician, then presented to our dental hospital. The patient’s medical and family history was non-contributory, and there was no history of trauma, hospitalization or current medication except those prescribed by the physician. She was lactating and had a 6 month old boy.
The patient’s oral cavity was examined carefully and good oral hygiene was noted. There were no obvious odontogenic causes or lip paraesthesia. Panoramic radiograph was done to exclude odontogenic causes and was insignificant. A thorough facial examination followed and a small crusted pimple was noticed on the left side of the chin. There was extensive swelling involving the whole lower lip and extending to involve the chin and submental area (Fig. ) with pus discharging from the left side of the chin just beneath the site of the pimple (Fig. ). The patient’s blood investigations were negative for HIV and hepatitis, with a TWBC of (25.8×), random blood glucose of 190 mg/dl and a creatinine of 0.7 mg/dl. She was anemic (10 g/dl), mildly hyponatremic (134 mmol/l

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

[User]
RADIOLOGY NOTE:
A 40 year old woman presented at our clinic with severe mitral valve rheumatic stenosis. Intraoperative findings showed a typical rheumatic disease with commissural fusion and thickened valve leaflets, but a relatively preserved mitral valve apparatus.
We performed a mitral valve repair consisting of bilateral commissurotomy papillary muscle splitting and placement of a rigid anuloplasty ring (SEGUIN, St. Jude Medical) N. 30. Intraoperative echocardiography showed a good performance of the valve. No stenosis and regurgitation were detected. The postoperative period was uneventful and the patient was discharged on the 7th postoperative day in good conditions. No signs of pericardial effusion were noted on echocardiography.
The patient was readmitted at our institution a week after on an emergency basis with clinical signs of cardiac tamponade. After confirmation by echocardiography of the presence of massive pericardial effusion, a central venous 18 F catheter was placed in the pericardial space. An amount of 1300 milky fluid was drained gradually and the patient get better. The pericardial fluid laboratory analysis showed chylomicrons and elevated triglycerides. Lymphocytes were seen on microscopy. The diagnosis of chy lopericardium was obvious. Microbiology studies were negative. Parenteral nutrition was initiated and oral nutrition was stopped. Somatostatin 0,6 mg three times a day and antibiotic prophylaxis was constituted. The patient was treated conservatively for 30 days.
The average daily drainage was 75 ml but it did not decrease and stop during this period. Under these circumstances and taking in consideration the prevention of other complications we decided to reexplore the patient in sternotomy in an attempt to find the place of the leakage and close it. The patient was given to eat fat 12 hours before surgery and on the operating room by gastric tube. No place leakage was observed. We ligated and sutured thymus gland remnants and the pericardial edges wi

[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 47-year-old female had a car accident and sustained fracture of both tibial bones. She underwent internal fixation of the fractured tibial bones under general anaesthesia. One week later she developed generalized muscle weakness and acute respiratory distress. She was transferred to the ICU where mechanical ventilatory support was given after intubation. Clinically she had bilateral lower motor neuron facial palsy and quadriparesis. The upper limb power was 3/5 bilaterally and lower limbs were 0/5 proximally and 2/5 distally. She had total areflexia of all four limbs and the plantar responses were mute. She was assessed by a neurologist and a diagnosis of acute GBS was suspected. Nerve conduction study (NCS) showed prolonged distal latencies, absent H reflex and reduced conduction velocities suggestive of acute demyelinating polyradiculoneuropathy. The blink reflex was abnormal with prolonged motor latency of both facial nerves. The patient refused lumbar puncture, hence cerebrospinal fluid examination was not done; as she complained of back pain. Other investigations including full blood count, blood biochemistry, autoimmune screen, protein electrophoresis, and porphyria screening were negative. Serological tests for Mycoplasma pneumonia, Epstein-Barr virus and hepatitis virus were negative. The clinical picture and electrophysiological findings were consistent with GBS. She was treated with intravenous immunoglobulin (IVIG; 0.4 g/kg for 5 days). While in the ICU she developed severe bulbar weakness. After the first course of IVIG, she started to improve slowly. The facial weakness and motor power in her limbs improved slowly. However, weaning from the ventilator was delayed due to bulbar weakness and inter-current respiratory tract infection. A second course of IVIG was given after 2 weeks. Chest infection was treated with piperacillin and tazobactam along with chest physiotherapy. Subsequently she recovered and after 3 weeks of ICU care, she was extubated. This

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old Korean male patient presented with an ill-defined erythematous indurated patch on the umbilicus (). The patient had not received any treatment for 1 year as the lesion was asymptomatic. Recently, the patient was referred to our center after an incisional biopsy. The tumor was cleared after three stages of MMS. We received the patient's consent form about publishing all photographic materials.
Histopathologic examination revealed basaloid tumor cells forming nests and cords in the dermis and subcutaneous tissue (). The tumor showed cribriform or tubular structure without connection to the epidermis. Abundant mucin was observed inside the tubular structure (). Tumor cells had hyperchromatic nuclei but did not demonstrate distinct cellular atypia (). Immunohistochemical study against receptor tyrosine kinase (cKIT) and epithelial membrane antigen (EMA) showed strong positive for tumor cells. The tumor was diagnosed as ACC upon histopathologic examination and immunohistochemical study. Physical examination and whole-body positron emission tomography fused with computed tomography (PET/CT) performed to exclude the possibility of metastasis from other original lesion showed no evidence of additional lesion. Finally, the patient was diagnosed as PCACC.
In the process of removing the tumor, the umbilicus was completely eliminated with an asymmetrical defect that extended into the left upper quadrant, which required elaborate reconstruction. The size of the postoperative defect was 2.0×1.8 cm (). An elliptical repair was done at the left side of the defect to close the paramedian defect as well as to remove the dogear. To close the remaining central defect and to recreate the concavity of the umbilicus, about 0.5 cm of the soft tissue was removed from the surgical margin, deeper layered purse string sutures were placed to adjust the size of the umbilicus, and the superficial purse string suture involving the dermal layer was tacked at 3 areas at 12, 4, and 8 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:
We present the history of an 82-year-old man with chronic lymphatic leukemia (B-CLL), diagnosed in 2004 who received rituximab, fludarabine and cyclophosphamide for four cycles between May 2010 and October 2010 as first-line therapy. The past medical history showed arterial hypertension and prostate cancer treated with radical prostatectomy in 2005.
In July 2014, an SCC of the skin located in the scalp was diagnosed and completely resected without any signs of metastases. At that time, there was no sign of progressive B-CLL. In January 2015, the patient presented with progressive lymphadenopathy, night sweats, fever and weight loss and a worsening of peripheral blood count with a decrease in hemoglobin (from 11 to 9 g/dl) and a reduction of thrombocytes (from 60 to 20 × 109/l). Further examinations revealed a progression of the B-CLL with generalized lymphadenopathy and an increase in monoclonal B-CLL population (up to 65%) in peripheral blood detected by FACS. Therefore, salvage therapy with ibrutinib was started in January 2015.
After an initially very good response to ibrutinib with fast significant lymph node regression and improvement of the peripheral blood count, in February 2015, he presented with progressive painful cervical swelling and numbness of the right side of his face. At that time, the B-CLL was in stable remission, and therapy with ibrutinib was stopped immediately. An MRI scan revealed a progressive cervical tumor. A lymph node biopsy showed an infiltration of a keratinizing, moderately differentiated squamous cell cancer of the skin due to a metastatic manifestation of the squamous cell cancer of the scalp diagnosed in July 2014. In February, first-line treatment with primary radiochemotherapy (cisplatin 20 mg/m2 days 1–5 and radiation with 60 Gy) was initiated. He received a total of three cycles until April 2015. There were no signs of metastases at the end of therapy. However, the primary tumor, located retroauricular, was not resectable

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old man, who had experienced sudden weakness and numbness in the left lower extremity for 4 weeks, visited our emergency department for evaluation and treatment. Over several days, his gait disturbance gradually worsened and the numbness had extended to the left upper chest region. There was no evident traumatic episode before admission. A physical examination conducted at presentation revealed gait disturbance with spasticity. He was able to stand by himself, but needed a crutch for walking. A neurological examination showed motor weakness of left lower extremity (Grade IV). In addition, sensory disturbances of vibration and positional sensation were present on the left side below the T4 dermatome. Impaired perception of pain and temperature stimuli were also noted on the right side below the T4 dermatome. Brown-Séquard syndrome of the cervicothoracic or thoracic spine was then suspected. Plain radiographs of the cervical spine showed multiple degenerative changes. Accordingly, magnetic resonance imaging (MRI) of the whole spine was performed. Sagittal T2-weighted MR images revealed a left-sided cystic extradural lesion at the C7-T1 junction (), and axial images showed that the extradural cystic lesion markedly compressed the spinal cord (). The lesion appeared homogenously isointense on T1 weighted images and exhibited heterogeneous high signal intensity on T2 weighted images. Under a presumptive diagnosis of a cystic lesion in the lower cervical spine, emergent surgery was performed. Because there were additional osteophytes causing cord compression at C4-5 and C5-6, modified expansive laminoplasty of C5-6 and a laminectomy of C7 followed by complete removal of the extradural cyst were performed. The lesion was homogeneous, bright yellow in color, firm in consistency, and slightly adherent to dura mater, and contained a small amount of serous fluid. Pathological examination showed the cyst to be composed of fibrous connective tissue and to have a distin

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old male, a seasoned cyclist with no past medical history, presents to the emergency department with complaints of lightheadedness and diaphoresis after a bicycle fall. Patient was participating in a bicycle race when another rider ahead of him fell causing the patient to swerve to avoid him. Patient states that he fell on his left side and hit a tree with his right leg. Patient was wearing a helmet and did not suffer any chest or head trauma. After the fall, he felt lightheaded and diaphoretic and complained of mid back pain. Patient denied any chest pains or shortness of breath. Patient was subsequently brought to the hospital directly following the accident by ambulance.
In the emergency department, patient was noted to be in no acute distress; initial blood pressure was 128/69 mmHg with pulse of 65 beats per minute. He was afebrile, not tachypneic, and well appearing with marked right thigh swelling and tenderness to his medial thigh. Given the dizziness and diaphoresis initially, patient had an ECG performed which showed lateral ST segment elevation () and had a subsequent troponin I that was positive, 0.49ng/mL, with a Creatine Phosphokinase (CPK) of 617 U/L.
There was initial concern for a possible cardiac contusion, although the patient had no chest wall trauma and thus was admitted for further evaluation. As an inpatient, an echocardiogram was performed demonstrating normal right and left ventricular function and trace pericardial effusion while the patients troponin continued to trend upwards towards a maximum of 21ng/mL. He was loaded with Aspirin and Clopidogrel as well as initiation of a heparin infusion, Lisinopril, and a Beta Blocker. Coronary angiography was subsequently performed demonstrating a spontaneous coronary artery dissection of left anterior descending coronary artery. No further diagnostic study was performed at that time. Further history revealed that he took multiple caffeine Jello shots and drank 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:
Case 2. The patient was a 40-year-old female without history of smoking and with a history of exposure to birds. She had a history of childhood asthma and a family history of breast cancer. She was diagnosed at 37 years with bilateral invasive ductal carcinoma with axillary lymph node metastasis during pregnancy. She received neoadjuvant chemotherapy before surgery with Adriamycin and cyclophosphamide followed by docetaxel. She underwent bilateral mastectomy with dissection of axillary lymph nodes and received adjuvant chemotherapy with 4 cycles of cyclophosphamide, methotrexate, and fluorouracil with concomitant radiotherapy afterwards. The initial chest radiography after the diagnosis of breast cancer was normal. However, in the follow-up chest radiographs, a progressive loss of lung volume at the expense of the upper lobes was noticed, which manifested by superior shrinkage and distortion of the pulmonary hila, and the appearance of coarse irregular linear opacities at higher fields and biapical pleural thickening with linear opacities of scar appearance in the neighboring lung parenchyma (see ). 15 months after radiotherapy, the patient presented with acute dyspnea and chest pain. She was diagnosed with right spontaneous pneumothorax that required thorax drainage.
Subsequently, she presented exertional dyspnea with ordinary physical activity (New York Heart Association Functional Class II) and dry cough, for which she was referred to our consult for further study.
On physical examination, she had a low BMI of 19, no acropachy, and diminished global vesicular breath sound. The chest X-ray showed worsening compared to the previous one, with apical pleural thickening, hilar retraction, and flattened thorax on the lateral projection ().
The first HRCT performed to this patient 16 months after diagnosis of breast cancer showed only discrete linear opacities of fibrotic appearance in both lung apices.
However, the second HRCT, performed during the period in which the

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


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

[User]
RADIOLOGY NOTE:
A 26-day-old-male baby, born at 35 weeks gestational age with 2 kg birth weight was referred for ROP screening. During the early neonatal period, there was a history of multiple systemic problems like shock, seizures, anemia, and respiratory distress syndrome requiring ventilator support for four days. The child was diagnosed to have stage 3 zone 2 posterior ROP with flat neovascularization, multiple vascular loops with intraretinal shunts in zone 2 posterior avascular retina, and plus disease in both eyes. In view of anticipated rapid progression, laser photocoagulation by Indirect ophthalmoscope laser delivery (LIO) was planned. Detailed history regarding COVID symptoms and travel from containment zone, elicited from parents, was negative. COVID-19 status of the parents and child was unknown. After obtaining informed consent from parents, the baby was taken up for LIO under topical anesthesia.
Laser treatment in a crying baby can be a significant aerosol-generating procedure.[] To avoid this, an ACB was used. ACB has six sides, named A-F, described in detail later. The baby was dressed up in OR (operating room) dress and covered with a small blanket, adequate to prevent hypothermia. Trained OR assistants handled the baby under the supervision of the anesthetist and the surgeon. The baby was placed inside the ACB and removed via the open side B after lifting the plastic sheet. For easy access by the surgeon, the baby was placed over two pillows covered with blankets inside the ACB. ECG chest leads, and pulse oximeter probe were connected and, heart rate and oxygen saturation were monitored by an anesthetist throughout the laser procedure. The suction machine attached to a suction tube passed through Side A aperture was switched on. The baby was held by an assistant through side B, while the surgeon did laser by passing the hands through the holes in sides C, D, and E []. The laser was performed

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


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

[User]
RADIOLOGY NOTE:
The patient is a 29-year-old pregnant female, who originally presented with a small nodule on the tip of her right nipple, at approximately 28 weeks of gestation. The lesion increased in size over the next few weeks and showed no improvement with a 2-week course of antibiotic treatment (Keflex). Due to the progressive increase in the size of the lesion, the patient was referred to a general surgeon and underwent an incisional biopsy. As seen in Figures and , the biopsy showed fragments of squamous epithelium with hyperkeratosis, keratotic plugging, and filiform acanthosis. These features were interpreted as consistent with a squamous papilloma. On review at our institution, we agreed with the originating pathologist's description of the lesion. However, due to the patient's clinical history and the degree of hyperkeratosis and keratotic plugging, in our opinion, findings were more consistent with hyperkeratosis of the nipple.
The patient delivered a healthy infant but was unable to nurse on the right side due to sloughing of the nipple skin and pain. In addition, the lesion continued to increase in size. On physical examination at our institution, a soft, exophytic mass of the right nipple was noted. The areola was uninvolved. No other abnormalities in either breast and no axillary lymphadenopathy were detected. A mammogram was performed and revealed no masses, calcifications, or sites of architectural distortion within the breast parenchyma. The radiologist noted that, due to the heterogeneously dense breast composition, small masses could be obscured and a targeted ultrasound was performed. The ultrasound revealed an enlarged right nipple, approximately 1.7 cm in diameter with a hypervascular nipple mass. The subareolar ducts were normal in size, without evidence of an intraductal mass. Although the previous sample had been interpreted as benign, the biopsy was superficial, and, given the progressive increase in size, excision of the lesion was recommended. The pa

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old gentleman with hypertension, cholelithiasis, and previous left ureteric calculus had an episode of syncope and lower abdominal pain. On examination, he was tachycardic at 137 beats per minute and hypotensive at 68/53 mmHg. The patient was given intravenous 0.5 mg of adrenaline and started on a noradrenaline infusion during resuscitation. Ultrasound scan done in the Accident and Emergency Department showed a large amount of intra-abdominal free fluid.
A CT mesenteric angiogram showed a large volume hemoperitoneum and active contrast extravasation in the region of the greater omentum (Figures and ). The source of the haemorrhage was initially not discernible. However, after careful comparison with a previous CT scan done 3 years earlier, a long aberrant omental artery demonstrating a cockscrew pattern arising from the left gastro-epiploic artery was noted terminating in a large fat containing structure within the lower right abdomen.
A catheter angiogram was performed with a view to identify and embolize the bleeding vessel. Angiogram performed from the splenic artery confirmed the presence of an active haemorrhage from an aberrant artery which extended from the splenic hilum down to the right iliac fossa (). The artery terminated in a small cluster of abnormal cockscrew shaped vessels. Successful embolization of the artery was performed using coils and N-Butyl cyanoacrylate (glue). The patient remained haemodynamically stable and recovered well.
The CT scans were reviewed again in view of the abnormal vasculature in the right iliac fossa. It was noted that there actually was a large lipomatous lesion in the right iliac fossa. It had grown slightly in between the CT scans and was causing displacement of the small bowel loops. A MRI confirmed the presence of a fatty lesion with several abnormal internal vessels.
Image guided biopsy of the lesion was performed. Pathological specimen of the fat-containing mass demonstrated lipomatous tissue with focal fibro

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old female patient visited the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital, with a complaint of severe difficulty in eating due to limitation of jaw function and trismus. The patient had a history of multiple TMJ surgeries for reduction of condyle fracture of both sides and arthroplasty/coronoidectomy due to trismus. Clinically, the patient exhibited the maximum mouth opening of 8 mm and relapse of severe trismus (Fig. ). After CT scan was taken, type IV TMJ ankylosis on both sides was confirmed (Fig. ). Since the glenoid fossa and condyle of both sides were completely fused, the anatomic structures were indistinguishable. Gap arthroplasty or interpositional arthroplasty could not be applied to this patient because bony TMJ ankylosis in both sides was complete and recurrent. Therefore, we decided to use the 3D virtual surgical planning, CAD/CAM-fabricated surgical guide, and stock TMJ prosthesis system (Biomet, Jacksonville, FL, USA) for total joint reconstruction.
The 3D virtual surgery was performed with a specific navigation surgery software (FACEGIDE, MegaGen implant, Daegu, South Korea). As the first step, both condyles and their surrounding hyperplastic bone were removed, while making it sure to avoid the mandibular foramen. The second step was virtual placement of the condyle and fossa components of the stock TMJ prosthesis. After placement of the fossa and condylar components, any areas of interference were investigated by virtually opening the jaw.
After confirmation of the position of the fossa and condyle components, the surgical guides were fabricated by using the CAD/CAM technology. The surgical guides consist of the upper and lower parts. The upper part is designed to be adapted onto the root of the zygoma, which guides the location of upper margin for resection of the root of the zygoma and the position of the fossa component of the stock TMJ prosthesis. The lower part is designed to

[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 man was admitted to our hospital with a two month history of general weakness, intermittent left lower quadrant abdominal pain, weight loss, constipation and signs of partial bowel obstruction. Physical examination revealed a palpable tender mass in the left abdomen. There was no history of melena or mucus. The overlying skin and subcutaneous tissue were unremarkable. A barium enema showed narrowing of the distal sigmoid colon. Colonoscopy revealed inflammatory changes of the sigmoid colon – the mucosa was erythematous and edematous, but there were no colonoscopic features of Crohn's colitis or ulcerative colitis. Computed tomography was negative except for a small amount of free fluid present in the abdomen. Laboratory findings were normal. The pre-operative impression was of a possible cancer of the sigmoid colon although the pre-operative investigations were not conclusive, particularly because no mucosal mass was identified. Laparotomy was performed through a midline incision. The mesentery of the sigmoid colon was markedly thickened, constricted and puckered. The color varied from yellow to red-brown suggestive of fat necrosis. The normal architecture of the adipose tissue was lost and was replaced with an irregular nodular mass involving appendices epiploicae of the colon. There was a moderate amount of serous effusion in the peritoneal cavity. No enlarged lymph nodes were identified. On macroscopic pathological evaluation the mesenteric mass was composed of areas of pale yellow and reddish-brown color with focal hemorrhage. The blood vessel walls were thickened and congested. The bowel wall adjacent to the mesenteric mass was thickened, edematous and markedly congested (figure ).
Microscopic pathologic sections from the involved mesentery demonstrated a chronic reactive inflammatory process with exuberant proliferation of fibroblasts, fibrocytes and fibrosis (figure ). Scattered areas of steatonecrosis and lipid-laden macrophages, lymphocytes an

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female presented to our department with a seven-year-history of involuntary movements of the abdominal wall. The movements were initially intermittent. However, they gradually evolved over time to occur more frequently. There was no pain but some discomfort was accompanying the movements. The movements were not voluntarily suppressible and disappeared during sleep. The rate and the amplitude of the involuntary movements were increased by stress. Five years prior to presentation, she underwent cholecystectomy, hysterectomy, and oophorectomy. One year later she was diagnosed with depression and irritable bowel syndrome. She was treated with lorazepam, fluoxetine, chlorodiazepoxide, and clidinium bromide. The patient is a chronic smoker with chronic obstructive pulmonary disease. She had no family history of movement disorders.
Her neurological examination was unremarkable. Semirhythmic writhing wavy movements involving abdominal wall and paravertebral muscles producing displacement of umbilicus were observed. These movements occurred exclusively in the sitting and standing positions, and abolished on lying on her sides and significantly decreased when lying supine (Additional file 1: video, segment 2). The movements did not show any variation in intensity or frequency during respiration.
Laboratory, radiological, and fluoroscopic investigations were normal similarly to case I. Abdominal ultrasound depicted fatty liver. A diagnosis of belly dancer’s dyskinesia was made and she was started on trihexylphenydil and clonazepam, but without noticeable benefit.
Utilizing the same aseptic technique and under ultrasound guidance, a total of 240 units of BTX was injected into the rectus abdominus muscles bilaterally, in which 40 units/site in a total of 6 sites were administered. The patient reported marked improvement and she was able to sit on the chair and walk independently 3 weeks after the injections with no side effects. She has been on regular follow ups e

[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 Chinese man presented to our hospital for further management of a laterally spreading tumor (LST)-like lesion in the proximal rectum accidently discovered on colonoscopy over 1 mo prior.
The biopsy results indicated an inflammatory hyperplastic polyp. The patient had no obvious symptoms and received screening endoscopy as part of a routine health examination. Gastroscopy showed chronic atrophic gastritis and inflammation of the cardia.
The patient had a history of diabetes mellitus for more than 6 mo and was administered metformin and other drugs to control his blood sugar. He also had a history of hypertension for more than 1 mo without medication.
He had a long smoking history of over 30 years, with an average of 20 cigarettes per day. He also had a drinking history for more than 30 years, with half a catty of liquor per day.
Physical examination upon admission showed that the patient was 1.82 m in height and 94 kg in weight. He had a blood pressure of 139/84 mmHg with a heart rate of 68 beat/min. He had clear lungs and normal heart sounds with no murmurs or gallops on auscultation. There were no obvious pathognomonic signs during physical examination of the abdomen.
No significant abnormal laboratory results were recorded in this patient.
Colonoscopy in our hospital also revealed a 25 mm × 20 mm, LST-like slightly elevated lesion in the proximal rectum with a red color (Figure ). To observe the microstructure and capillaries of the lesion, magnifying endoscopy with narrow-band imaging (NBI) was carried out. It showed enlarged and dilated branch-like vessels on the surface of the tumor similar to those of gastric MALT lymphoma (Figure ). The margin of the lesion became clearer, and a type II pit pattern was observed on magnifying endoscopy after indigo carmine staining (Figure and ). Gastroscopy revealed atrophic gastritis and cardia mucosa erosion with irregular microstructure and capillaries on

[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 18-year-old male patient was referred to our outpatient clinic because of masslike lesion in his left calf. He had a history of car accident and left isolated and closed tibia fracture 30 months ago that was treated by open reduction and internal fixation with 4.5mm broad DCP plate (, ). The surgical approach was through 1 cm lateral to tibial crest and plate was in lateral aspect of tibia. In this period, the patient was fully asymptomatic and had no complaint in routine follow-up. The patient had no significant past medical history. After 2 years, union was obvious in AP and lateral radiographs, and removal of tibial plate was decided. The plate had been removed 7 months ago on patient’s request. At the time of surgery, we used the previous incision and found that the bone was completely united. Plate and screw removal was done without any complication (eg, plate or screw break down).
After the operation, the bone in radiograph was completely united and the patient was discharged when we find near 50-100 cc collection in the drain at the second day post operation.(). Examination at this time showed he was intact in neurovascular examination.
At the first post operation visit, he was asymptomatic and progressive partial weight bearing had been described. About 4 weeks after plate removal, he came back with mild paresthesia in the left foot at the plantar surface. Also, he had firm, pulse less and non-tender swelling with unclear border on the posterior aspect of the leg which gradually increased over time. Position of ankle was plantigrade.
In vascular examination, we found the dorsalis pedis and the posterior tibialis pulses were equal to the opposite leg. We followed this patient without further investigation.
At about 3 months after plate removal, paresthesia became persistant. We prescribe EMG/NCV for the patient. This assessment showed tibial nerve axonal injury pattern. Thus, we thought that paresthesia was due to iatrogenic tibial

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


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

[User]
RADIOLOGY NOTE:
An eight-year-old girl presented to us with complaints of diffuse swelling of the right thigh and skin rash. Her parents denied history of fever, swelling anywhere else, any systemic complaints, bleeding from any site, or trauma. On local examination, her right thigh was diffusely swollen and tender to touch. There were no signs of inflammation. No abnormal mobility was found in the underlying femur. General physical examination revealed scaly, erythematous, brown to red papular lesions over the scalp, abdomen, inguinal region, and palms (). There was no pallor, icterus, lymphadenopathy, clubbing, edema, or swelling anywhere else. Rest of the general as well as systemic examination was unremarkable. X-ray of the limb showed a well-defined lytic expansile lesion in the diaphysis of femur with surrounding periosteal reaction (). Rest of her investigations including complete hemogram, liver function tests, coagulation profile, skeletal survey, and chest radiograph were unyielding. Patient was treated conservatively by us with a functional brace while being investigated for the cause. The skin lesion biopsy revealed inflammatory lesion with numerous uni-, bi-, and multinucleated histiocytes in the background of numerous eosinophils and lymphocytes. The patient was subjected to bone biopsy which showed similar findings consistent with Langerhans' cell histiocytosis. The follow-up radiograph of femur at two weeks showed signs of healing of the lesion. However, two weeks after presentation, the child developed alteration of sensorium and started having recurrent seizures associated with symptoms of raised intracranial pressure. There was no associated fever, signs of meningeal irritation, or focal neurological deficit. She succumbed to her illness within 72 hours. MRI head could not be done due to very sick general condition of child and CSF study was not done because of raised intracranial pressure and suspected space occupying lesion. Postmortem lumbar puncture as well 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 35-year-old woman was referred to the Department of Gastrointestinal Surgery of The University of Tokyo Hospital for evaluation of a gastric lesion in August 2005. During esophagogastroduodenoscopy, a 30-mm flat and depressed lesion was identified at the anterior wall of the upper gastric body and was diagnosed as Type 0-IIc gastric cancer (Fig. ). A pathological analysis of the biopsy specimen determined a moderately differentiated tubular adenocarcinoma (tub2). The patient underwent laparoscopic-assisted total gastrectomy (LATG) with Roux en-Y reconstruction and lymph node dissection (D1 + No. 7) in accordance with the Japanese Gastric Cancer Treatment Guidelines []. A pathological analysis of the specimen revealed the depth of the lesion remaining in mucosal layer, without any lymph node metastasis. The patient showed good progress after the operation and did not receive any further treatment including chemotherapy. She was only instructed to continue oral iron supplementation for postoperative chronic anemia after discharge. She became pregnant 1 year and 8 months after the operation. After her pregnancy, radiographic examinations were excluded during the follow-up period while oral iron supplements were continued. In addition, 500 μg of methylcobalamin (MeCbl), an active form of vitamin B12, was intramuscularly injected once a month for a potential vitamin B12 deficiency, although her serum vitamin B12 level was within normal range. No pregnancy-associated discomfort or illness was observed including hyperemesis gravidarum during her pregnancy while the fetus was developing normally. In May 2008, the baby was born by vaginal delivery at 41 weeks of gestation. Delivery time was 4 h and 20 min, and the baby was delivered as a healthy normal child weighing 3076 g. The mother’s weight change and the uterus height change of the fetus are shown in Fig. a–c.
After delivery, she continued to take oral iron supplements and vitamin B12 intramuscular injection and had k

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

[User]
RADIOLOGY NOTE:
A 60-year-old South Indian female presented with a swelling on the left zygomatic region of the face since a year with a history of the swelling initially appearing small in size which subsided. It later recurred a month before visiting the clinic. The swelling was associated with fever with no other associated history of epistaxis or headache.
On clinical examination, extraoral inspection revealed slight fullness in the left maxillary region. There was a firm, nontender mass palpable in the floor of left orbit just below the inferior orbital margin. The swelling measured about 4 cm in diameter with the surface appearing normal []. Visual acuity, visual field, and eyeball movements were normal. There was no regional lymphadenopathy. A small nasal polyp was noted on the left nasal cavity. Palpation revealed it to be tender and soft.
The intraoral inspection revealed her oral hygiene to be poor. Malaligned dentition with calculus debris and mobility was seen. There was an intraoral swelling seen at the palatal region measuring about 5 cm in diameter extending from 24 to maxillary tuberosity region. On palpation, it revealed to be tender and hard to firm [].
Occlusal radiograph and orthopantomogram revealed the presence of minute radiopaque structures resembling calcifications in an ill-defined hazy radiopacity in the left maxillary sinus suggestive of the residues of the eroded bone [Figures , and ]. Cone-beam computed tomography (CBCT) revealed soft tissue opacity in the left maxillary sinus with the extension of the mass into the left nasal cavity almost invading the nasal septum along with prominence in the calcification seen in the center of the sinus cavity as well []. Bony erosions were seen involving the left floor of the orbit, nasal wall, and nasal septum. The sinus cavity appeared expanding as an expression of the pressure due to the growing mass [].
The patient was further sent to the Department of Oral Pathology for a biopsy which conferred to be schwannom

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Japanese man with a history of distal partial gastrectomy for gastric cancer 10 years earlier was admitted for surgical treatment of intrathoracic esophageal cancer (T3, N2, M0, stage III). He underwent subtotal esophagectomy with three-field lymph node dissection and removal of the remnant stomach with the abdominal lymph nodes. The alimentary continuity was reconstructed with a pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. Anastomosis of the esophagus and jejunum was carried out instrumentally with a circular stapler. A postoperative enteral contrast examination showed smooth passage and no deformity of the reconstructed jejunum. The patient was discharged about 4 weeks postoperatively. About 6 months after the esophagectomy, the patient was readmitted to our hospital because of abdominal discomfort and vomiting. His vital signs were stable and unremarkable. He was thin, with a body mass index of 18.6 kg/m2. Physical examination revealed that the pedicled jejunum through the antethoracic space was markedly dilated and the abdomen was soft and flat (Fig. ). Laboratory data showed only leukocytosis with no other remarkable findings. A chest roentgenogram revealed an increased cardiothoracic ratio of 70%, and an enteral contrast study showed a bird’s beak deformity. The swallowed barium remained static in the reconstructed jejunum. Computed tomography of the thoracoabdominal region showed the reconstructed jejunum within the pericardium anterior to the heart (Fig. ). We diagnosed the patient with IPDH after esophagectomy and performed an emergency laparotomy. Upon opening the abdominal cavity, we found that the reconstructed jejunum had herniated into the pericardium through an approximately 4-cm-diameter diaphragmatic defect without a hernia sac (Fig. ). The herniation was easily reduced, and t

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male patient reported with the complaint of a scar and hollowing on the right side of forehead, following road traffic accident 3 months back. He had received conservative treatment only. On examination, there was a “S-” shaped concavity present at the junction of lateral one-third and medial two-third of right eyebrow extending upward, approximately of about 6 cm × 4 cm in size, in the right lateral forehead [Figure ��]. Computed tomography scan revealed comminuted frontal bone fracture in the right side without any dural tear [Figure –]. Thus, a cosmetic correction of the defect was planned.
A stereolithographic model of the defect area of the skull was reconstructed. The undercuts were blocked with modeling clay. An impression of addition silicone impression material in light body consistency was made and poured in Type III dental stone. A wax pattern was fabricated with base plate wax so as to provide proper bony contour of the depressed defective area alongside covering the gaping bony defect [Figure and ]. Care was taken to match the external bony contour of the affected region with that of the unaffected contralateral side. The wax pattern was then acrylized with double heat-cured medical grade PMMA of the colorless variety. Due to its less residual monomer, it is supposed to cause least tissue irritation [Figure and ].
Care was taken to gradually blend the margins of the acrylic fabrication with the edges of the defect. Holes were drilled around the edges of the acrylic fabrication and on the surface with a number 8 round bur which would be helpful to secure the prosthesis with screws to the underlying bone. Once satisfactory fit was achieved, the prosthesis was finished and polished and made ready for surgical placement.
Oroendotracheal intubation was done. Coronal flap was elevated. Dissection was done to the pericranium. Disposable Raney clips aid in hemostasis.

[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 with hepatorenal polycystic disease and end-stage renal failure who was on chronic hemodialysis was admitted to our center because of a recent history of dyspnea and palpitations.
Physical examination revealed wide splitting of the first heart sound and an enlarged liver and left kidney. Bilateral mild edema of the calves was observed. A 12-lead electrocardiogram (ECG) showed paroxysmal atrial fibrillation. Blood tests revealed high creatinine and blood urea nitrogen levels due to severe chronic kidney failure (serum creatinine=10.4 mg/dL).
Transthoracic echocardiography showed a large, polylobulated, echogenic, highly mobile mass that occupied most of the right atrium and extended from the inferior vena cava (IVC) and prolapsed into the right ventricle through the tricuspid valve during diastole ( and angiographic run in , ).
Cardiac magnetic resonance imaging (MRI) failed to reveal if the observed mass represented thrombus or the terminal part of an intravascular tumor ().
CT angiography (angio CT) showed an extensive, serpiginous, highly vascularized mass originating in the right internal iliac vein, which extended to IVC up to the right cardiac chambers. Massive linear calcifications were seen along IVC and above the renal veins (confirmed by angiography run in Video. 2). Cystic transformation of the liver and kidneys was extensive. The right kidney was ectopic and occupied most of the pelvis (). No pulmonary artery embolus was noticed.
Coronary angiography showed calcified coronary atherosclerosis, but no significant obstructive coronary artery disease.
The terminal mobile segment of the tumor was considered to carry an increased pulmonary embolic risk, although at the time of diagnosis no signs of pulmonary embolism were noted. Therefore, surgical excision of the tumor was considered. The high calcific burden and the out of shape aspect of IVC led to the decision of a two-stage procedure.
To ensure an appropriate access and to facilitate th

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


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

[User]
RADIOLOGY NOTE:
A 30-year old male was involved in a motor vehicle accident and suffered from multitrauma including fractures of the processus spinosi of the cervical vertebra 7 and thoracic vertebrae 1 and 2, fracture of the processus transversi of the thoracic vertebrae 8 to 11, fractures of the right olecranon, the left clavicle and a third-degree open right tibial fracture with severe soft tissue defect exposing the tibial fracture zone (Schatzker C). At first entry to the combined center of traumatology and reconstructive surgery an external fixation was performed combined with a plate osteosynthesis (LCP proximal tibial plate 3,5/6, Johnson&Johnson Synthes) to ensure limb salvage. In a second procedure the osteosynthesis was planed to be replaced by a coated tibial nail (e.g. PROtect expert tibial nail, Johnson&Johnson) after the coverage of the vacuum sealed soft tissue defect and a 6-week antibiotic therapy to avoid chronic infection with subsequent osteomyelitis. Prior to the subsequently discussed operation, an attempt to cover the defect was made by performing a free ALT flap with end-to-end anastomosis to the posterior tibial artery, but ended with flap necrosis due to arterial embolism triggered by the massive intima damage in spite of temporary therapeutic anticoagulation. The decision to make an end-to-end anastomosis within the primary injury zone is debatable, even though a preoperative CT angiography showed sufficient flow of the posterior tibial artery. The clotted posterior artery was ligated after removal of the ALT flap.
Negative wound pressure therapy (NPWT) was used for coverage and preconditioning of the 8 x 18 cm soft tissue defect (Figure 1 ). Preceding the free LD flap an AV loop system (AV loop marked * in Figure 2 ) was constructed by the vascular surgery department on the popliteal P3 segment. The patient was thus ready to have the defect covered by means of a free LD flap with microvascular connection to the

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man suffering from the bilateral knee and ankle arthralgia for several months was transported emergently to our hospital owing to acute respiratory distress and hemoptysis. Upon arrival, he was in a shock state. Chest roentgenography revealed severe pulmonary congestion; cardiac echogram revealed a large mass in the LA that incarcerated into the mitral valve. Additionally, chest computed tomography (CT) revealed a tumor in the LA; thus, he was diagnosed with acute left heart failure caused by the mass that obstructed cardiac blood flow (Fig. ).
An emergency surgery was performed under cardiac arrest with extracorporeal circulation, which was established in the usual manner with bicaval direct cannulation. Because of the dimensions of the tumor and its pedicle attachment, we could approach through both the wall incisions on the right-side LA from the right upper pulmonary vein and atrioseptostomy from the right atrium. The tumor pedicle widely and irregularly originated from the right upper and posterior LA wall and extended to the lateral LA wall, which included the right upper pulmonary vein. The tumor was visibly extirpated and invaded the LA wall (Fig. ). The shape and function of the mitral valve were intact, and the large defect in the LA wall was reconstructed using a bovine pericardial patch. It was 159 min under extracorporeal circulation, and the aortic cross-clamping time was 123 min.
Extracorporeal circulation weaning and post-operative course were uneventful, and arthralgia in both lower limbs disappeared immediately after surgery. The pathological diagnosis was UPS with clear resection margins (R0 resection), which invaded the atrial muscular layer (Fig. ). Subsequently, as imaging studies soon and 3 months after surgery did not reveal tumor presence, we decided to adopt a more suitable treatment strategy without involving adjuvant therapy after surgery if UPS relapse or metastasis occurred. Specifically, we planned to perform re-surgical

[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 one-day-old male Nigerian neonate of Igbo ethnicity was referred from a private hospital with complaints of bleeding from the mouth and vomiting of blood shortly after delivery. Frank bleeding started about an hour after delivery. There was no bleeding from any other site. He had vomited nine times on the first day of life and three times on the day of presentation.
He had received some antibiotic injections from the referring clinic but bleeding had persisted. A diagnosis of neonatal sepsis with disseminated intravascular coagulopathy was made and he was referred to our hospital.
The pregnancy had been supervised in a maternity home and had been uneventful. Delivery was at term by a traditional birth attendant (TBA). Further history revealed that the lingual frenulum had been clipped by the TBA about an hour after birth, after which bleeding had commenced. The indication for frenotomy could not be ascertained.
The baby was the last of five children, four girls and a boy. All the other children had undergone the same procedure, performed by the same TBA, within the first few hours of birth, with minimal complications. The family was of a low socioeconomic background.
On examination, our patient was in respiratory distress, severely pale and had cool extremities. He was noted to have a bleeding severed frenulum. His peripheral pulses were weak and thready and his systolic blood pressure was unrecordable. His heart rate was 180 beats per minute with normal heart sounds. His respiratory rate was 94 cycles per minute and breath sounds were vesicular. His abdomen was flat and soft with no palpable organs. He was conscious but lethargic, with a depressed anterior fontanelle. His primitive reflexes were depressed but he had normal tone in the limbs. A review of his systems showed that he was very weak, had poor suck and had not passed urine in the last eight hours.
A diagnosis was made of severe anemia and hypovolemic shock secondary to acute blood loss, occurring after

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


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

[User]
RADIOLOGY NOTE:
Thirty-two and 5/7 week twin males were born to a 23-year-old woman who initiated prenatal care at 28 weeks. The mother had a history of illicit substance use, including marijuana and cocaine, and had been incarcerated early in her pregnancy. Additionally, she had a history of appropriately treated gonococcal infection. Prenatal serologies demonstrated that she was not infected with HIV, Treponema pallidum, or hepatitis B virus, and she was immune to Rubella. An uneventful Cesarean delivery was performed because of premature and prolonged rupture of membranes, and the infants required only blow by oxygen during resuscitation. APGAR scores were 7 and 8 for twin A and 8 and 9 for twin B at 1 and 5 minutes, respectively. Both infants were small for gestational age and were tachypneic with mild retractions. The physical exams were otherwise unremarkable, and the infants were transferred to the neonatal intensive care unit for further evaluation and management where they were started on continuous positive pressure ventilation. On the day following delivery, the patients’ mother was noted to have an ulcerated vaginal lesion suspicious for HSV. The mother denied a history of herpetic outbreaks, and primary genital herpes was subsequently confirmed by a positive viral culture for HSV-1 but negative IgM and IgG serologies.
The infants were started empirically on intravenous acyclovir at 60 mg/kg/day administered every 8 hours. Initial workup of the infants for neonatal herpesvirus infection included surface viral cultures; lumbar puncture with cell counts, glucose, protein, and polymerase chain reaction (PCR) analysis for HSV DNA; complete metabolic panel; and a complete blood count. All laboratory values for both infants were within normal limits for gestational age, and the HSV PCR and surface viral cultures were subsequently reported as negative. Because of the high-risk clinical scenario, however, routine EEG was conducted on day of life 7 to evaluate for signs of encep

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

[User]
RADIOLOGY NOTE:
An 8-years-old boy was admitted in our tertiary care hospital with painful swollen and stiff left knee joint for last 15 days. He sustained trivial injury and did not inform about the incident to his parents and carried his daily activities for 7 days after which he developed fever with painful swelling of the left knee. His anxious parents took the kid to local general practitioner who prescribed oral drugs for 3 days. The kid does not show a response to the oral drugs and the fever and swelling increases gradually.
Later the kid was brought to our center, on examination in the emergency room; the kid was febrile and anxious. His left knee examination shows swollen erythematous, warmth, and tender joint with fullness in suprapatellar region. Range of movements was painful and restricted. There was effusion in the joint which was clinically confirmed by positive patellar tap test. There was no evidence of any external injury to knee. Retrospective questioning following surgery he narrated an incident of thorn prick to his left knee while playing with his friends 15 days ago and he removed the broken twig of the thorn on the spot itself.
Routine blood examination was done, and the result was elevated total count (16.1×103), differential count (polymorphs - 73%, lymphocytes - 20%, and basophile - 07%). Erythrocyte sedimentation rate was - 28 mm/h and C-reactive protein positive. Hemoglobin was - 10.3 g/dl. Plain radiography of the left knee joint shows no obvious bony injury except for soft tissue swelling (). Magnetic resonance imaging (MRI) of the left knee joint was advised which was reported as extensive synovitis with effusion and thickened suprapatellar plica and multiple enlarged inguinal and popliteal lymph nodes with larges measuring 1.5 cm × 1.0 cm.
The suspicion of septic arthritis was raised. Knee arthrocentesis was done under sterile precautions, seropurulent fluid was

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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 61-year-old Caucasian male had previously seen a urologist for recurrent low-grade bladder cancer, which required multiple resections. Unfortunately, he was lost to follow-up and presented to his family physician several years later with abdominal discomfort and weight loss. An abdominal CT scan was ordered, which found a 10 cm cystic mass in the superior pole of the left kidney, concerning for malignancy with suspected splenic hilar invasion. A full metastatic workup was undertaken. No evidence of metastatic disease was identified ().
The patient underwent a radical left nephrectomy, splenectomy, distal pancreatectomy, completion nephroureterectomy, and RPLND. In anticipation of a difficult resection, the thoracoabdominal approach was selected to maximize surgical exposure. Intraoperatively, the tumour was found to involve the distal pancreas, which was resected with assistance from the general surgery team. During the kidney dissection, an incidental left upper ureteric mass was identified. Given the patient's history of recurrent bladder cancer, urothelial malignancy was suspected, and a completion nephroureterectomy was performed. A 28 Fr chest tube was placed prior to the closure of the thoracic cavity and connected to low suction. No complications were encountered during the procedure and EBL was 4000cc. Three units of packed red blood cells and 1 L of fresh frozen plasma were administered intraoperatively.
The patient's postoperative course was slow, but uneventful. The epidural and chest tube were discontinued on postoperative day 5, and he was discharged on postoperative day 9, once deemed physically fit for independent living by physiotherapy and occupational therapy.
Final pathological analysis confirmed high-grade transitional cell carcinoma (TCC) with extensive tumour necrosis. Tumour was found to be invading peripelvic fat, renal parenchyma, perinephric fat, and the tail of the pancreas. The resection margins, including the pancreatic margin and the

[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:
An 87-year-old Caucasian British woman presented to our emergency department with a three-day history of shortness of breath, pyrexia and non-productive cough. Her only significant past medical history was well controlled hypertension. She was independent in her daily activities, did not smoke cigarettes and reported a good cardiorespiratory reserve prior to the onset of symptoms. The diagnosis of community-acquired multilobar pneumonia was made with a CURB-65 score of three. She was admitted to the high dependency unit with type 1 respiratory failure and a high alveolar-arterial oxygen gradient. She received intravenous antibiotics (piperacillin/tazobactam and erythromycin) and non-invasive high-flow continuous positive airway pressure (CPAP). By the fourth day, our patient had deteriorated, with a chest radiograph showing bilateral alveolar and interstitial infiltrates and a ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) of < 26.6 kPa, which required invasive ventilation. The criteria for ARDS were met and the cause was thought to be a combination of the direct pneumonic pulmonary injury and extrapulmonary severe sepsis. With protective lung ventilation, low dose methylprednisolone, antibiotic therapy and a negative fluid balance, gradual improvement was made; over the following five days respiratory parameters weaned sufficiently to allow an uncomplicated percutaneous tracheostomy to be performed. On day 10, a period of desaturation required recruitment maneuvers with a Mapleson C circuit that resulted in notable surgical emphysema. The cause was thought to be a tracheal injury sustained at the time of tracheostomy insertion. An adjustable flange tube was positioned under bronchscopic guidance just proximal to the carina in an attempt to limit any further tracking of air through the potential tracheal defect. Despite these measures, a high alveolar-arterial oxygen gradient and peak airway pressures persisted. A chest r

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old female presented to neurology department with a history of severe pain in the right side posterior aspect of the head for 2 months’ duration. The pain was gradually increasing is intensity. She also complained of slurring of speech. She was a known case of diabetes mellitus on treatment for the past 10 years. On examination, there was slight deviation of the tongue to the left side with fasciculations. There was also a neck swelling which moved with deglutition. Fine-needle aspiration cytology of the neck swelling showed colloid goiter.
She was advised magnetic resonance imaging (MRI) of the brain for evaluation of headache. MRI showed altered signal intensity with a lytic lesion in the right condyle of the occipital bone. Neoplastic etiology was suspected, and the patient was subjected to a whole body fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT).
FDG PET-CT [] showed a metabolically active lytic lesion with minimal soft tissue (21 mm × 16 mm) in the right condyle of the occipital bone. In addition, there was a metabolically active hypoenhancing soft-tissue lesion in the left lobe of thyroid gland measuring (21 mm × 27 mm). No other metabolically active lesion was noted in rest of the organs.
The patient underwent total thyroidectomy subsequently which confirmed the presence of 3.5 cm × 3.3 cm sized follicular variant of papillary thyroid cancer. The patient was referred for radioiodine ablation of the metastases. In view of significant pain in the head, radiotherapy to the metastatic site was planned before radioiodine therapy, and she received 30 Gy in ten fractions.
Whole body iodine scan [] performed as per routine protocol, after 15 days of external beam radiotherapy, showed thyroid remnant with an iodine-avid osseous lesion in the occipital bone. No other distant metastases were made out. Her preablative stimulated thyroglobulin level was 203.33 ng/ml. She received 193 mCi of iodine-131. She, presently

[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 previously healthy 42 years old male presented to our institute with history of gradually progressive and painless swelling over left calf since two months. He was a non-smoker, laborer by occupation. The patient noticed a firm swelling in calf region of left leg 5 years ago. No history of trauma or infection prior to the appearance of the mass was reported. No family history of any such swelling in the past. Patient was operated for swelling over calf region 20 years back but no records were available. There was a history of gradual increase in deformity of left foot since 3 years and the patient had started walking on toes on left side with no dorsiflexion at ankle joint.
On examination, there was a single, non-tender, hyperpigmented scar of size 8×3 cm over mid-calf region fixed to underlying structures. A large, well defined non-tender, firm, swelling was palpable in posterior aspect of left leg measuring about 28×8 cm extending from tendoachilles region up to 5 cm distal to popliteal fossa and medially and laterally up to border of tibia and fibula respectively. The overlying skin was normal with no discoloration and local raise of temperature. Movement of knee joint was normal. There was fixed equinus deformity of left foot (). No inflammatory signs, skin changes or adenopathies were present. No bruits were heard on auscultation. Neurovascular examination of left leg and foot was normal. Laboratory findings were within normal limits. Radiological examination revealed large soft tissue mass with linear and streak-like ossification around the left tibia. MR Angiography () showed arteriovenous malformation in left calf with multiple feeding arteries arising from popliteal, peroneal and anterior tibial artery and large draining veins draining deep into venous system of leg. The tibia and fibula marrow showed normal signal intensity.
Because of patient symptoms and with clinical diagnosis of a vascular malformation, a wide surgical excision of the lesion was done

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old man with a history of infiltrative vesical carcinoma treated with intravesical immunotherapy 13 years previously was referred for recent-onset pain in the pelvic girdle. Pain was assessed by a visual analog scale (VAS) at 8/10 and was much increased with walking, which was limited to a short distance and required the use of a crutch. CT revealed extensive osteolytic metastasis involving almost all the right iliac wing and acetabulum together with the right sacral wing (
). Bone scintigraphy and 18F-FDG PET/CT revealed multiple other skeletal lesions. Biopsy of the pelvic bone revealed an epidermoid carcinoma. A vesical biopsy gave negative results, but because the prostate was clinically enlarged and the prostate-specific antigen level was increased (5 ng/mL), a prostate biopsy was performed and revealed epidermoid urothelial tumoral infiltration. The patient received a first course of systemic chemotherapy with carboplatine (AUC 5) and paclitaxel (80 mg/m2), a first infusion of bisphosphonates (4 mg acid zoledronic), and analgesics.
Given the pending risk of fracture and severe pain, the decision was taken in a multidisciplinary consultation to stabilize the pelvis before continuing systemic treatment and to attempt percutaneous osteosynthesis rather than open surgery because of the comorbidities and risk of complications with extensive surgery. Extension of the bone destruction to the sacral wing and anterior acetabulum precluded the use of the locked and perforated nail recently described to reinforce the arcuateiliac line []. Therefore, a combination of double screwing and cementoplasty was planned to restore weight-bearing force transmission from the spine to the hip.
The first step of the procedure consisted of percutaneous double osteosynthesis with two perpendicular screws. The optimal position and dimensions of the screws were determined from 3D CT-scan reformations of the pelvis. The percutaneous osteosynthesis procedure was performed under C

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male presented with a history of left-sided chest pain for a few years that had been progressively worsening over the last 3 months. The pain was characterized as vague and intermittent, although there were some fluctuations in intensity. He had a gunshot wound to the left upper abdomen resulting in diaphragmatic and splenic rupture 30 years ago. He stated that his spleen had been removed at that time. Other medical history included chronic hepatitis C and a 30 pack-year history of smoking. His physical examination revealed several abdominal scars, but was otherwise unremarkable. Routine blood work demonstrated no significant laboratory abnormalities. A peripheral smear was not obtained. On presentation, his chest X-ray showed a large, ill-defined, clearly marginated mass along the left heart border on the posteroanterior view. In comparison, the chest radiograph obtained 1 year previously was reviewed, and the lesion was noted, in retrospect, to have been present at that time; it had obviously grown over the 12-month period between the two examinations (Figures A and B). Computed tomography (CT) of the chest with intravenous contrast showed a large, homogeneously enhanced mass of 13 × 3 × 8 cm extending from the level of the aortic arch inferiorly along the mediastinal contour into the left upper quadrant, corresponding to the lesion seen on the chest radiograph (Figure C). Technecium-99 m (99mTc) sulfur colloid scintigraphy was performed based on a high index of suspicion for splenosis given the patient’s trauma history and subsequent splenectomy. Thick linear uptake was present in the medial left hemithorax, corresponding to the mass on the chest CT, and was consistent with splenic tissue (Figure ). Although the diagnosis of intrathoracic splenosis was established, the patient was referred to the thoracic surgery service because of symptoms refractory to pain control with analgesia as well as the interval growth of the mass. Video-assisted thoracosc

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


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

[User]
RADIOLOGY NOTE:
A 33 yrs old female presented to us with knee pain after history of fall with minimal swelling. Anterior and lateral knee radiograph showed features suggestive of Giant cell tumor and intercondylar fracture. A CT scan further strengthed the suspicion of GCT ( & ). Surgical decision of arthroscope assisted fixation of the fracture and intralesional curettage of the GCT was contemplated considering the age and proximity to the joint. With knee in 90deg flexion standard antero-lateral portal was taken at the soft spot above the joint line 2cm lateral to the patellar tendon. Hematoma was drained, antero-medial portal was established with outside in technique. The joint was copiously irrigated. The reduction of the fracture was confirmed under vision with the help of the arthroscope. A guide wire was passed from the lateral femoral condyle, 6.5 mm drill bit was used and with a 70mm 6.5mm CC screw with washer fracture was fixed. The portals were closed with 3.0 ethilone. A lateral longitudinal incision was taken on the distal femur extending upto the screw. The fascia was incised to expose the lateral femoral condyle. A cortical window of 2x2cm was made with an intact perisosteal hinge 2cms above the screw head (). the cortical window. After introduction of the scope the light source cable was rotated to have a 360 deg visualization of the tumor cavity. The surrounding structures of the cortical window were covered with sterile mop to avoid spillage of the tumor cells coming out along with the irrigation fluid in the surrounding tissue. The irrigation fluid was started. A small curette, 4.5 mm shaver tip and a high speed burr were used to curette the GCT cavity. The end point of curettage was visualization of the normal cortical bone through the arthroscope. During the curettage copious normal saline was used for irrigation of the cavity. After curettage dry visualization of

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old male basic military trainee reported chronic, intermittent bilateral hip and groin pain since childhood, which acutely worsened over the past two weeks related to increased physical training. He reported mild discomfort associated with long periods of walking which increased with running, left greater than right. Pain decreased but persisted at rest. The patient’s pain resulted in walking with a limp. Physical examination was notable for joint pain in both hips with active and passive motion, which worsened with weightbearing. The patient appeared younger than his stated age. Bilateral hip radiographs were obtained with frog leg views (Figure ). Findings were concerning for left SCFE, possible right SCFE, and abnormal delayed skeletal maturation without significant closure of the femoral physes or apophyses.
The radiologist recommended orthopedic referral and obtaining a bone age assessment to estimate the amount of delay in skeletal maturation. He was subsequently admitted by the orthopedic department for treatment with bilateral surgical pinning. Magnetic resonance imaging (MRI) of the bilateral hips was ordered prior to surgery, which further supported findings consistent with left SCFE (Figure ).
Subsequent clinical follow-up initiated by his primary provider and the referred endocrinologist were notable for an elevated thyroid-stimulating hormone above 160 mcIU/mL, a low level of free thyroxine, and an elevated serum thyroperoxidase antibody level of 765 IU/mL, findings consistent with hypothyroidism likely secondary to Hashimoto thyroiditis. Further history obtained from the endocrinologist revealed symptoms consistent with hypothyroidism: fatigue, constipation, increased sleep, and problems with losing weight but without cold intolerance. A bone age study demonstrated a markedly delayed bone age, consistent with Greulich and Pyle male standard for 13 years and 6 months, incongruent with the patient’s chronologic age of 19 years and 2 months (Fig

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old African-American woman presented to her primary care physician for evaluation of a palpable right breast mass in the upper outer quadrant that she had identified several days prior to presentation. Bilateral mammography demonstrated a spiculated mass with pleomorphic calcifications in the axillary tail of the right breast at the 10:00 position, which corresponded with a palpable 4 cm mass on physical examination (Figure ). A second, less distinct mass in the upper inner left breast was also visualized. An ultrasound of the right breast demonstrated an irregular hypoechoic and vascular mass measuring 3.3 × 2.1 × 1.9 cm in diameter that abutted the underlying pectoralis major muscle at the 10:00 position in zone 3, 13 cm from the nipple. No abnormalities were identified in the upper inner left breast on subsequent imaging. Taken together, these findings were assigned a BI-RADS 5 classification. The patient was referred to the breast surgery team at the Stefanie Spielman Comprehensive Breast Center at The Ohio State University Wexner Medical Center for further management.
On establishment of care, the patient revealed a family history of breast cancer involving her maternal cousin, who was diagnosed with left breast cancer at age 27 and right breast cancer at 33 years of age. Of note, her cousin was positive for the T37K variant of uncertain significance in BRCA1, an allele suspicious for deleterious effects. The family history was also significant for a maternal aunt diagnosed with ovarian cancer at 58 years, and a maternal grandmother who developed breast and ovarian cancer during the 7th and 8th decades of life, respectively. On physical examination, the patient had a palpable, firm 3-4 cm mass within the upper outer quadrant of the right breast. No other masses or nodules were identified in the left or right breast. The nipples appeared normal bilaterally. There was no evidence of cervical, supraclavicular, or axillary lymphadenopathy. These findings

[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:
A59-year-old male reported with a chief complaint of a growth on the left side of upper lip. The lesion had been present for the last 6 months with gradual increase in size. Previously, the patient had undergone surgical excision of the lesion twice in the same area from an outside clinic only to notice it regrow again. He had the habit of smoking cigarettes for the past 25 years, around 20 cigarettes per day. The patient also gave a history of anemia for the past 1 month and was taking folic acid medication regularly. No other signs and symptoms were present.
On close clinical examination, an exophytic growth was seen on the left corner of upper lip. The growth was about 1.5 cm in length and was brown. On palpation, the growth was firm to hard in consistency and was slightly tender. Intraoral examination revealed a grayish-white patch on the left commissural mucosa and the dorsum of tongue measuring about 3 cm × 1 cm in dimension. Both the white patches were nontender and nonscrapable in nature. Hard tissue examination revealed several missing teeth (15, 16, 17, 25, 26, 27 and 46) and Grade II mobility with respect to teeth (11, 21, 22, 23, 31, 41, 42 and 47). Generalized gingival recession and attrition were also seen in .
Excision of the lesion on the lip along with its adjacent grayish-white patch was done using CO2 laser. Satisfactory healing was observed after a week. The gross specimen received measured about 28 mm × 7 mm × 4 mm. One end of the specimen was soft in consistency, and the other end was firm which represents the horn [].
The histological sections revealed hyperkeratotic stratified squamous epithelium with underlying connective tissue. The epithelium exhibited acanthosis, spongiosis, hyperkeratosis and broad rete pegs with pushing margins along with parakeratinized keratin plugging. The underlying connective tissue exhibited mild

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Hispanic woman presented to the emergency department with a 1-week history of intermittent fever. She was seen by an emergency room doctor at that time and was sent home after being diagnosed with pneumonia after a chest radiograph was performed showing a questionable left lung base infiltrate and discharged with levofloxacin and ibuprofen. The patient returned to the emergency department 3 days later because of worsening symptoms described as weakness and inability to walk coupled with fever of 101 degrees Fahrenheit. As per the family, the patient was unusually confused, had difficulty with comprehension, and articulating her needs. In addition to these symptoms, the patient denied any other constitutional symptoms, sick contact, recent travel, or interaction with pets or animals. A thorough physical examination revealed crackles in the right middle and lower lungs; therefore, another chest radiograph was performed showing increased patchy density at the left lung base as compared with prior exam. She was started on 1 gram of ceftriaxone daily and 500 mg of azithromycin daily for treatment of the pneumonia at this time. A series of neurological examinations initially revealed a mildly confused elderly woman who was, nonetheless, oriented to person, time, and place. The patient stated she felt weak but was able to move her legs. She could move her arms but could not raise them more than approximately 10 inches. Consequently, the neurologist ordered the first CT scan which had unremarkable findings. On day 2 of admission, the patient was awake, alert, but oriented only to person. She denied headache but had a rigid neck with her speech becoming increasingly incomprehensible although she was able to follow few simple commands. Neurological exam was significant for asymmetric facial droop and left arm dropping fast than right and drop arm test. Stroke notification was called, and another noncontrast CT of the head was performed which was unremarkable.
La

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old male presented with the left cervical and submaxillary lymph node enlargement with size of 30 mm × 30 mm. The following lymph node biopsy was completed and the pathological evaluation showed reactive lymphoid hyperplasia characterized by vascular, atrophic germinal lesions with surrounding concentric “onion skin” layers of lymphocytes (Fig. ), defined as the hyaline vascular variant of CD. He denied weight loss, lymphadenopathy, tuberculosis, diabetes mellitus and hypertension. He gave no history of bone pain and drug abuse. The bone marrow (BM) cytology indicated no clonal plasma cell infiltration. Thereafter the patient was treated with irradiation dose of 30 Gy in 10 fractions with clinical response. The clinical evaluation remained stable in annual follow-up visits. In the 4th visit, the patient was diagnosed in an outside hospital with 2-diabetic mellitus on basis of increased blood glucose, C peptide release test and oral glucose tolerance test (OGTT). The blood glucose was well-controlled by the hypoglycemic and diet therapy for three years when he presented to the previous hospital with progressive hand-foot numbness spreading from the proximal extremes to distal ends. The electromyography test confirmed the hampered nerve conduction velocity of bilateral ulnar, median and peroneal nerves. The cerebrospinal fluid (CSF) biochemistry from lumbar puncture indicated the slightly elevated protein (1.1 g/L, normal, 0.1~ 0.4 g/L) with normal cell count. The blood monoclonal protein level and bone marrow cytology was normal. Based on the resultant diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP), the patient was treated with daily intravenous pulse methylprednisolone therapy of 1.0 g for three consecutive days. Due to the minor clinical response, the diabetic peripheral neuropathy was suspected with following insulin injection and oral mecobalamin therapy. However, the manifestation of hand-foot numbness remained constant. One and

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old man presented to our hospital due to sustained headache and uncontrolled hypertension. The patient had a history of hypertension diagnosed approximately 10 years previously. His hypertension was poorly controlled despite a combination of three different antihypertensive agents (candesartan 16 mg DP, amlodipine 5 mg DP and hydrochlorothiazide 12.5 mg DP).
Physical examination showed a blood pressure of 140/80 mm Hg in both arms, a heart rate of 69 beats/minute and no audible murmur. There was no significant pathologic finding in the chest radiography. His echocardiogram showed enlarged sinus portion of ascending aorta with moderate aortic regurgitation (grade 3), suspicious of aortic aneurysm, but left ventricular systolic function was well preserved. Due to the significantly enlarged sinus portion of ascending aorta, the patient underwent multislice spiral computed tomography (CT) angiography for evaluation of aorta anatomy. CT angiography showed focal significant stenosis of the descending aorta, just below the left main pulmonary artery level with vigorous collateral blood flow (). Invasive aortography was then performed, which showed severe aortic coarctation distal to the origin of subclavian artery (). According to the quantitative aortography measurements, the coarctation segment was a minimum of 8 mm in diameter and 40 mm in length. The diameters of the thoracic aorta above and below the coarctation segment were 19 and 22 mm, respectively. The patient was then planned for elective percutaneous balloon dilatation with subsequent stent implantation.
Under the local anesthesia, bilateral retrograde femoral artery approach was carried out. A 7 Fr arterial sheath was inserted into the right femoral artery and then in sequence a 5 Fr arterial sheath was also inserted into the left femoral artery. After this, a 5 Fr pigtail catheter was placed at the coarctation segment following successful wiring with a 0.035 inch Terumo guidewire (Terumo, Tokyo, Japa

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


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

[User]
RADIOLOGY NOTE:
A 65-yr-old male presented to the emergency department with acute mental changes after a traffic accident on September 16, 2006. He was hit by a car while riding a motorcycle. On physical examination, he exhibited a stuporous mental state. There were positive light reflexes on both sides, but no spontaneous nystagmus. He had bilateral ear bleeding and multiple contusions on his body. An otologic examination revealed a bilateral hemotympanum. The function of the other cranial nerves was impossible to check due to his stuporous mental state.
An emergency brain CT scan revealed a hemorrhage in the left temporal subarachnoid space with a pneumocephalus. A high resolution CT scan of the temporal bone revealed bilateral transverse temporal bone fractures involving the otic capsules with evidence of a bilateral pneumolabyrinth (). The fracture line extended to the internal auditory canal on the left side and was associated with a pneumocephalus in the internal auditory canal.
He was admitted to the neurosurgical department for conservative treatment. Two days after the trauma, he exhibited an alert mental state with a complete bilateral hearing loss. No facial asymmetry or weakness was observed.
Audiometry was performed 25 days after the trauma. There was no reliable response to the application of a pure tone or speech stimuli at the maximum limits of the audiometer. Immitance audiometry revealed a type A tympanometry on both sides. Vestibular function testing revealed the absence of any caloric responses bilaterally with ice water.
The patient was offered a cochlear implant soon after the trauma. However, he accepted the fact that his deafness was permanent near three months after the trauma and decided to get an operation of cochlear implantation. Follow-up audiometry revealed similar to the previous one, except residual hearing response at 500, 1,000, and 2,000 Hz on the right side. A repeated high-resolution CT scan of the temporal bones was obtained which showed no ev

[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 10 year-old Hispanic male presented with a fluctuant mass in the right maxilla. Computed tomography (CT) scan revealed a 3.3 cm soft tissue lesion with destruction of the adjacent maxillary bone and sinus, and displacement of several teeth. Biopsy demonstrated OGCC. Preoperative staging five weeks later revealed size progression and metastatic disease. The mass now measured 5.3 cm. A right submandibular node and several enlarged right cervical lymph nodes were noted corresponding to FDG avidity on PET. Right-sided modified radical maxillectomy and palatectomy, and right-sided modified radical neck dissection was performed one week later. Significant involvement of the buccal mucosa and submandibular gland were noted. After multiple attempts, final surgical margins were negative. Pathology confirmed OGCC (). Seven of thirty-eight Level I and II lymph nodes were positive for metastases. The tumor was positive for EGF receptor indicating cellular expression of EGFR protein. One week after surgery, maxillary packing was removed in the operating room. No tumor recurrence was appreciated. Adjuvant therapy was recommended given the rapid pre-surgery growth, positive lymph nodes, and concern for microscopic residual disease. A lesion in the right buccal space was noted at the time of radiation simulation (19 days after surgery). Given these findings and prior history of rapid growth, this was presumed recurrent tumor. An intensity modulated radiation therapy (IMRT) plan was designed for the entire rightsided postoperative bed and bilateral neck. The patient received 44 Gray in 22 fractions (6 mega-Volt photons) prior to receiving a break for treatment-related toxicities. Imaging obtained then showed a 4.9 cm soft tissue mass in the right cheek and a 1.7 cm left gingivolabial soft tissue mass (). Biopsy confirmed OGCC. Radiation volumes were expanded to include the new disease.
In summary, the postoperative bed received 60 Gray in 30 fractions over two plans (44 Gray in 22

[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.