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

[User]
RADIOLOGY NOTE:
A 37-year-old woman patient who is a homemaker was accepted to our hospital with the complaint of a 10-day pain in her right upper limb. She mentioned that the pain first involved the elbow and then the forearm, particularly the medial part of it. Nearly 10 days before, while she was cleaning and shaking the rug, she developed a discomforting pain in her right elbow. She explained that the pain in her elbow had become worse and in 24 hours spread through her whole forearm. She added that, previously, the pain had been partially responding to NSAI drugs, but subsequently, it continued to progressively increase.
There was a pain in her medial forearm and elbow. She felt abnormal when she was palpated on her medial forearm. During her examination, she was able to describe the point where her pain started in the proximal part of her elbow. On detailed neurological examination, a region of dysesthesia which extends from the elbow to the medial forearm was detected (Figure ). The patient had no history of polyneuropathy, chronic systemic disease, injection or surgical intervention at the elbow. Range of motion, motor, and reflex examinations of both upper extremities were normal. Cervical spine examination was normal. Varus-valgus stress test for the elbow was normal. Medial epicondylitis test and tinel test for the ulnar nerve were negative.
X-ray views of the elbow, including oblique views, appeared normal. Electromyography showed normal findings in the right biceps, triceps, flexor digitorum sublimis, pronator quadratus, interosseous and abductor pollicis brevis muscles, and nerve conduction studies in both upper limbs except for the right MACN were found normal. The MACN is stimulated antidromically at the lateral border of the biceps brachii tendon in the cubital fossa. An active surface recording electrode is placed on the anteromedial surface of the forearm 14 cm from the active stimulating electrode.

[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 man presented to his general practitioner with symptoms of cough and progressive shortness of breath. He was previously well other than longstanding treated hypertension and he had no significant family history. On further questioning he also described night sweats and unexplained weight loss.
He was referred to the local chest clinic where salient findings on examination included oedema of the extremities, dilated chest wall veins and palpable cervical lymphadenopathy. Examination of the cardiovascular, respiratory and abdominal systems was otherwise unremarkable. Blood tests performed recently had shown elevated ferritin and C reactive protein with otherwise normal haematology and biochemistry results.
A chest x-ray performed one month previously at the onset of symptoms was normal. A repeat chest x-ray now showed bilateral pleural effusions and extensive reticulonodular shadowing [Figure ]. Urgent ultrasound guided biopsy of the neck masses was performed along with CT of the chest, abdomen and pelvis.
Ultrasound examination of the neck confirmed bilateral enlarged lymph nodes in the supraclavicular, and lower and midjugular regions with thrombosis of the right internal jugular vein. Needle biopsy of the lymph nodes was performed.
CT demonstrated lymphadenopathy affecting the cervical, mediastinal and hilar regions and thrombosis of both jugular veins with extensive collateral circulation. Throughout both lungs there was extensive septal thickening typical of lymphangitis carcinomatosa as well as nodular areas suggestive of pulmonary metastases and moderate bilateral pleural effusions [Figure ]. Within the abdomen, a 9 × 13 cm mass containing central necrosis was present arising from the lower pole of the right kidney and associated with extensive retroperitoneal lymphadenopathy [Figure ].
Appearances were those of a renal cell carcinoma (Clinical TNM Stage T3N2M1) with lymphangitis carcinomatosa as part of extensive lymphatic spread. The initial nee

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.
At age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.
Six months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.
A clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.
She was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.
Magnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial

[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 six years old female child weighing 12 kg, admitted with history of gradual abdominal distension that was noticed by the mother for the last 2 years but did not seek any medical advice as there were no other associated complaints. With an increase of abdominal girth and vague abdominal pain, parents took the child to a nearby general practitioner who advised ultrasound and referred the child to our facility. On examination child appeared comfortable with abdominal fullness. Abdominal examination did not reveal a distinct mass though vague fullness was present oriented more in vertical direction. There was a definite feel of fluid thrill on palpation.
Ultrasound done previously showed cystic mass in abdomen. With female gender a differential diagnosis included ovarian cyst in addition to mesenteric and omental cyst. CT scan abdomen was advised. This showed a large cystic mass occupying almost whole of the abdomen and located under anterior abdominal wall with viscera pushed posteriorly (Fig. 1,2). A diagnosis of omental cyst was made at this stage.
Laparotomy was performed. On opening peritoneum a huge lymphatic cyst was found (Fig. 3). It was delivered out with difficulty and that too after partially evacuating it. More than 1500 ml of milky fluid was drained out. The anatomy was then identified more clearly. It was found between leaves of transverse colon mesentery and extending into its root (Fig. 4). The redundant leaves of mesentery were excised without jeopardizing blood supply of colon and left open so as to prevent re-accumulation of fluid. Drain was kept and wound closed.
Post-operative course was uneventful and patient discharged on 4th day. Biopsy was reported as consistent with mesenteric cyst. Parents were counseled again as to possible recurrence of the lesion and a regular follow up was planned. At three months follow up child is well. On ultrasound a small hypoechoic area of 4cm x 4cm was noted in mid abdomen. A repeat ultrasound after a month is ad

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


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

[User]
RADIOLOGY NOTE:
In a 19-year-old, mentally disabled male, chest radiography was done because of a sudden episode of cough. Metallic, hook-shaped foreign bodies were identified in both the main bronchi.
The right-sided FB was removed by fiber-optic bronchoscopy in the regional hospital, whilst the left-sided extraction failed with the left-sided FB persisting in the left main bronchus ().
Upon urgent admission in a tertiary institution, extraction was attempted by rigid bronchoscope under general anesthesia. Bronchoscopic extraction failed, associated with some bleeding and subcutaneous emphysema immediately after the intervention. The increasing mediastinal and subcutaneous emphysema raised suspicion about an iatrogenic airway lesion, so surgery was indicated. Esophageal injury was previously ruled out by esophagoscopy, revealing many metallic FBs in the stomach. At thoracotomy, a significant mediastinal emphysema (), together with diffuse adhesions, was noticed. After the lung liberation, a proximal 0.5 cm of the noncurved part of the metallic hook was found to protrude through the perforated membranous wall of the left main bronchus, 1 cm away from the descending aorta (, arrow). The part of the FB protruding outside the bronchus was grasped by the clamp and, by following the curved shape of the FB, gentle maneuvers were applied by pulling the sharp end (hook) of the FB in the direction outside the bronchus. The FB was removed from the bronchus (insert on ) without the need for additional bronchotomy. The remaining 10 × 1 mm defect in the bronchial wall, caused both by manipulations during a bronchoscopic extraction attempt and subsequent surgical extraction, was sutured by interrupted PDS 3-0 stitches, and the lung fully inflated. No air leaks appeared during the water test. Having in mind the dimensions of the defect and tensionless suture, no suture-line protection was performed.
After the thoracotomy closure, laparotomy was done and several sharp metallic pieces of different

[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 was a 33-year-old Caucasian man without any specific personal or familial history. He was an active smoker without alcoholic intoxication. In 2009, he presented a lesion of the lower lip. He underwent resection of this lesion, and the first pathological analysis revealed a salivary ductal ecstasy.
One year later, he developed a peripheral facial paralysis associated with left trigeminal neuralgia. MRI showed perineural invasion of the trigeminal nerve within the temporal fossa (fig. ). Surgical biopsies performed in July 2010 identified secondary lesions from a well-differentiated SCC localized around the V and VII nerve sheaths. According to this diagnosis, a new pathological analysis of the previous resection of the lip was performed in a cancer reference center and diagnosis of SCC of the lip was made. The patient started radio-chemotherapy in September 2010. He received 70 Gy in 35 fractions, and five courses of an association of 5-fluorouracil and cisplatinum. First radiological assessments, 4 months after the end of radio-chemotherapy showed no residual disease.
However, in November 2011, the patient presented with new neurological symptoms: paraparesis and back pain. MRI showed medullary myelitis without meningeal enhancement. Lumbar puncture revealed inflammatory cells without atypical cells within the cerebrospinal fluid (CSF). Cerebral MRI and positron emission tomography scan were normal with no evidence of visceral metastasis. Multiple sclerosis was suspected and the patient received several corticosteroid flashes who led to partial improvement of symptoms. Nevertheless, other explorations were negative, and it was not possible to certify the diagnosis of multiple sclerosis. In early 2012, the patient relapsed and developed paraparesis once again. Sequential lumbar punctures found no abnormal cells. He was given a symptomatic treatment combining corticosteroid and plasma depletion. In March 2012, CSF analysis showed intrathecal immunoglobulin

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old female reported to the department of oral pathology with the chief complaint of pain in the left side of the face for the past 1 month. History of presenting illness revealed a swelling which was initially small and gradually progressed 1 week before to the current state. Pain was sudden in onset, intermittent in nature, which aggravated on mastication and did not subside over medication (the patient was advised Combiflam tablet for 5 days, twice daily and intramuscular injection of cefixime for 3 days by physician whom she visited earlier). The patient revealed a past medical history of regular treatment for progressive SSc/lupus overlap syndrome, secondary Sjogren's with interstitial lung disease and PAH for the past 10 years. The patient was hospitalized for left lower limb cellulitis 8 years back and was discharged after complete observation and medication. Vitamin D insufficiency was suspected and corrected by calcirol granules.
The patient also had a complaint of difficulty in swallowing and spasm-type pain which was diagnosed as esophageal dysmotility and reflux disorder and was advised on prokinetic agents, low-fat diet and to avoid cold exposure to extremities. The patient also revealed a history of whitish skin lesion on both her legs and foot 20 years before these lesions have not progressed. The patient revealed no history of autoimmune disease in the family. The patient had undergone multiple uneventful extractions and complete prosthetic denture treatment. The patient also revealed a history of impaired taste sensation. On general examination, patient's vital signs were normal, and left submandibular lymph node was palpable, roughly oval, firm in consistency, tender and mobile.
On extraoral examination, facial asymmetry was seen in the left side of the face as a solitary diffuse swelling. The swelling extends from the middle third of the body of the mandible anteriorly to 1 cm behind the auricle posteriorly and superiorly at the level 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:
The male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms (Fig. a) showed hemorrhage in the left temporal lobe, and the patient was admitted in our department with a clinically confirmed diagnosis of ��hemorrhage in the left temporal lobe”. The patient had a previous history of hypertension for more than 10 years, and was under medication to control and maintain the blood pressure to be around 130/80 mmHg. The patient denied the history of diabetes and had no bad habits, such as smoking and drinking alcohol. Physical examination at admission revealed that his body temperature was 36.2 °C and blood pressure was 196/119 mmHg. The patient was conscious and suffered from incomplete aphemia. Bilateral pupils were of the size and round, the diameter of pupils was 3 mm, and pupils were sensitive to light reflexes. Muscular strength of the limbs was about grade 4. Bilateral pathological signs were negative, and there was no significant abnormality noticed during nervous system examination. Head MRI conducted the next day after admission indicated no significant vascular malformations (Fig. b). General consultation evaluated that bleeding sites of the patient were slightly different from hypertensive intracerebral hemorrhage. The hematoma sites were close to the middle cerebral artery and the walking areas of its branches, mainly in the temporal lobes. Therefore, cerebral vascular hemorrhage and other causes could not be excluded, and head CTA was further suggested. Head CTA performed on 17th May 2017 showed that the patient suffered from intracerebral hematoma caused by aneurysm rupture at the M1 bifurcation of the left middle cerebral artery, without any significant subarachnoid hemo

[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 woman and her 30-year-old husband presented with history of primary infertility over a period of 4 years. Although she did not report a history of pelvic inflammatory disease or sexually transmitted infection in the past, she had ultrasound confirmed bilateral hydrosalpinges, and both of her fallopian tubes had been removed laparoscopically. Thereafter, she required fertility assistance by in vitro fertilization (IVF).
After confirmation of a pregnancy in the 1st attempt of IVF in February 2005 she was admitted to the local hospital with abdominal pain during the first trimester. Following an ultrasound suspicion of an interstitial pregnancy, she underwent a laparoscopy, which confirmed a right cornual ectopic pregnancy. The operation was then graduated to a laparotomy, and the cornual ectopic was removed by a longitudinal incision on the right cornu. After evacuating the products, the bleeding was minimised by diathermy coagulation. Postoperatively, she received supplementary treatment with intramuscular methotrexate to resolve any remnant trophoblastic tissue. Trophoblastic tissue, however, remained viable for up to 3 months after the first dose of methotrexate, and serum hCG was detectable albeit at low concentrations (27–45 iu/L). She opted for a conservative management as opposed to a repeat dose of methotrexate, and it was finally 8 months before all evidence of trophoblastic activity disappeared completely.
She conceived again after the 2nd attempt of IVF performed in February 2006. This time she presented with an acute abdomen at 6-week gestation at her local hospital and underwent an emergency laparoscopy. She was then found to have 1200 mL of haemoperitoneum. Active bleeding at the right cornu was seen, but trophoblastic tissue attached to the uterine cornu was not seen. Subsequently tissue found amongst the blood clots was histologically confirmed to be the “product of conception.” Due to this very early rupture, the exact location of this p

[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 23-year-old man, who had been injured during a wrestling competition, was referred to our hospital with an abdominal pain. He had no significant past medical history. On physical examination, he was a thin young patient with stable vital signs. He had pain and mild tenderness in left upper quadrant region. Laboratory tests including complete blood counts, liver function test (LFT) and blood chemistry were normal. Anti-hydatic cyst antibody test was negative. Erythrocyte sedimentation rate (ESR) was high (62 mm/h) and culture for enterococcus was positive. Abdominal computed tomography scan revealed a complicated cystic lesion with dimensions of 118 x 130 mm between spleen and the left kidney and a compression effect into the kidney. The mass had septa and calcification in its inferior part. Using contrast enhancement, no abnormal vessel or enhancement was noted (). Thus the patient underwent a semi-elective operation. During the operation, a huge cystic structure was discovered filled with thick, brownish secretions in retroperitoneal area. The cyst was about 20 x 20 x 20 cm in diameter and adjacent to spleen, adrenal gland and kidney. Postoperative course was uneventful; the patient was discharged on day 3, and had remained asymptomatic during the follow-up period of 4 years.
On gross examination, the specimen consisted of an opened creamy brown ovoid cystic lesion, measuring 10 x 8 x 7 cm with irregular surface. On opening internal surface was brownish and irregular, wall thickness from 0.2 cm to 1.5 cm. The cyst was submitted for microscopic examination.
Histological sections showed fragments of cystic wall, lined by bronchial type pseudostratified cylindrical epithelium resting on fibrovascular connective tissue containing extensive foci of mononuclear inflammatory cells aggregates and presence of smooth muscle fascicles. There were foci of non-neoplastic adrenal tissue attached to external surface of the cystic lesion. A subsequent cytological examination wer

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old Japanese woman was admitted to our hospital because of visual field loss and unsteady gait. The patient spent time gardening as a hobby and was on infliximab and methotrexate therapy for rheumatoid arthritis. Two months before admission, her left visual field loss had steadily progressed, and she felt low-grade fever and general malaise. A high signal in the right occipital lobe and the left parietal lobe was detected in the MRI fluid-attenuated inversion recovery (FLAIR), and the lesions were enhanced by gadolinium (Fig. A–D). Brain biopsy of the right occipital lobe lesion demonstrated granulomatous inflammation, but no pathogenic micro-organisms were detected using either microscopic examination or culture. A diagnosis of neurosarcoidosis was made by the neurologists based on the brain biopsy findings.
The symptom of unsteady gait was temporarily relieved by intravenous methylprednisolone (IVMP); although, it worsened soon after discharge, followed by readmission to our department. At the time of readmission, there were no notable findings in the chest and abdomen and no uveitis was noted. A brown spot with a scab, about 10 millimeters in diameter, was observed inside the left upper arm. Neurologically, left lower visual field and mild weakness in the distal muscles of the upper limbs were observed. Deep tendon reflexes and muscle tonus in the upper and lower limbs were normal, and there was no ataxia or sensory impairment. Analysis of blood samples showed no abnormal findings in the blood cell count or the coagulation system. Serum angiotensin-converting enzyme II activity was 12.9 U/L and lysozyme level was 6.2 μg/mL. Antinuclear and antineutrophil cytoplasmic antibodies were negative. Specific antibodies for aquaporin 4 and myelin oligodendroglia were also negative. Tumor markers were not elevated. Antiparasitic antibodies and blood cultures were also negative. The CSF collected 1 week after brain biopsy was colorless and transparent, and the ini

[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 woman presents to the Emergency Room with palpebral edema as well as various erythematous plaques in supraciliary and malar areas that appeared and have gradually worsened a couple of days prior to presentation (). Initially the patient did not share having changed her daily facial hygiene, making any diet changes, getting any animal bites, or taking any new medication.
On exanimation, the patient had facial swelling, pain on palpation, and flushing.
A full blood count was performed with no alterations of the blood formula, neither leucocytes nor the eosinophils, and no inflammatory markers or IgE elevated.
Still suspecting an allergic reaction, she was given treatment with corticosteroids and antihistaminic medication, both intramuscularly and with a unique dose.
Four days later, the patient returned to the Primary Care consultation due to recurrence of her symptoms and was referred once again to the Emergency Room where she was clinically diagnosed with cellulitis and received antibiotic treatment (amoxicillin with clavulanic acid) along with corticosteroids and antihistaminic medication once again.
Although she referred a short period of improvement of the symptoms, the swelling and rash reappeared when the treatment was suspended along with another two nodules of hard consistency localized on the cheekbone of the right facial side ().
During the fourth Primary Care consultation, the patient was interrogated more thoroughly and only then she mentioned that she was visiting, for about four months, an Esthetic Private Clinic, where she was injected in various sessions with Metacrill, as a facial lift, for beauty purpose. Apparently no other patient suffered the same symptoms.
Due to suspecting an allergic reaction to the Metacrill and the failure of the initial treatments, she was referred to the dermatologist.
During the dermatology consultation, a biopsy of one of the granulomas was performed, being diagnosed as Chronic Edematous Panniculitis to a f

[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 22-year-old female patient with gravida 2, para 0, living 0 and abortion 1 with a history of 24 weeks of amenorrhea, presented to casualty with bleeding per vagina and loss of fetal movements since 2 days. She was from a low socioeconomic background. She had not undergone any antenatal checkups. She had a previous history of abortion. The patient had a history of second-degree consanguineous marriage. Past and personal histories were not significant.
On general physical examination, it was observed that the patient was a middle-aged female, moderately built, and nourished. Pallor was present. Per abdomen examination revealed that the uterus was relaxed and uterine height was of 24 weeks. Fetal heart rate was absent. Per vaginal examination revealed partially closed os, admitting only tip of finger, and effacement was absent. Routine biochemical investigations were within normal limits. Hemoglobin level was 7.2g/dL, hematocrit was 22%, and peripheral smear showed microcytic hypochromic and normocytic hypochromic red blood cells with normal white blood cells and platelets, giving a picture of dimorphic anemia. Coagulation profile was within normal limits.
Emergency antenatal ultrasound examination was carried out and it showed conjoint twins with loss of fetal cardiac activity. After obtaining informed consent from the patient and attenders, induction of labor was initiated with prostaglandins and the pregnancy was terminated by vaginal delivery. Dead male baby weighing 1800g was delivered. After obtaining consent, the fetus was sent to pathology department for histopathological examination.
External examination revealed male fetus with head circumference of 30cm (both the heads), chest circumference of 15cm, abdominal circumference of 20cm, and foot length of 7cm. The fetus had complete duplication of cranial structure with three eyes. One eye of both the duplicated head was fused in the center. Two nose, two ears, two mouths, of which one lip showed cleft lip 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 16-year-old boy with no urological or medical history presented to his general practitioner with a six-month history of strangury, poor flow, suprapubic discomfort, urinary frequency and urgency. He had also noticed one recent episode of visible haematuria. There was no family history or congenital abnormality noted. Blood tests revealed a normal renal function. An ultrasound of his urinary tract had been ordered in the community, which had shown two large polypoidal masses arising from the right and left lateral walls of the bladder, measuring up to 2.1 cm and 2.5 cm, respectively. The remainder of the urinary tract was unremarkable, and there was no significant post-void residual volume ().
The patient was referred urgently to be seen by the urology team. Following further discussion in clinic with the patient and his parents, a decision was made to proceed directly to cystoscopy under general anaesthetic for further evaluation and possible resection of these lesions. A urine cytology was sent which showed a few inflammatory cells but no overtly malignant cells to be present. Serial urine cultures had revealed no growth and he had no history of previous urinary tract infections. On cystoscopic examination, following dilatation of a tight urethral meatus from 14Ch, the two large polypoid lesions were identified on either side of the bladder neck that they were partially obstructing, resembling malignancy in some areas and inflammatory masses in others (). The remainder of the urethra was normal. Neither ureteric orifice was visualised. Both lesions were resected using a 17Ch resectoscope, and a small red area on the posterior wall was biopsied. A decision was made to remove the majority of the lesions from around the bladder neck, leaving as much normal or non-polypoid tissue as possible to reduce the risk of bladder neck stenosis. The patient was kept overnight for bladder irrigation, and the catheter was removed the following day with no postoperative complicat

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


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

[User]
RADIOLOGY NOTE:
This 11-year-old girl presented with headache for 3 weeks, weakness of all the four limbs for 2 weeks, and rapidly progressive vision loss for 10 days. At 16 months of age (10 years back), she underwent fenestration of posterior fossa arachnoid cyst with ventriculoperitoneal (VP) shunt insertion when she had become lethargic and lost motor milestones. She improved and returned to baseline and was doing fine.
Three weeks before presentation to our center, she developed persistent frontal headache and vomiting which progressively increasing. On the 7th day of illness, she was evaluated elsewhere by an ophthalmologist. Visual acuity was reportedly normal. There was no papilledema. Magnetic resonance imaging (MRI) was done, which showed a posterior fossa arachnoid cyst with VP shunt in situ and normal-sized ventricles []. Cerebrospinal fluid (CSF) examination revealed acellular CSF with normal biochemistry, but opening pressure was not measured. She also had aching over the limbs. Headache decreased after the CSF drainage (25 mL).
During hospitalization, she developed symmetrical proximal as well as distal weakness of all the four limbs without sensory loss. She also developed difficulty in chewing and jaw drop without facial sensory loss. There was left-sided facial, palatal, tongue, and neck weakness. Eleven days after the onset of headache, she developed horizontal binocular diplopia. Then, she started having diminution of vision in both the eyes, which progressed over 5 days to complete blindness with worsening of headache. There were no seizures, ataxia, fever, and loss of weight or appetite. There were no other systemic complaints. She received pulse methylprednisolone with no improvement. At presentation at our center (3 weeks after onset of illness), she was conscious, drowsy, and had a normal general physical examination and hemodynamically stable without any features of Cushing's triad but had neck stiffness.
Examination revealed absent perception of light bil

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


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

[User]
RADIOLOGY NOTE:
An 11-year-old female patient reported with a painless swelling over the right lateral border of the tongue for the past 4 months. There was no history of trauma in that region. There was complaint of slight dysphagia and globus sensation. Medical history and general physical examination were unremarkable. There was no regional lymphadenopathy.
On physical examination, there was a single 2 cm × 2 cm soft, well-delineated, nontender mass occupying the right lateral aspect of the tongue.
The swelling was sessile, submucosal, and firm in consistency with a smooth surface. Overlying mucosa was normal in appearance and not fixed. Tongue movements and speech were normal. The magnetic resonance imaging (MRI) showed a medium-sized hyperintense lesion arising from the anterior two-third of the right half of the tongue along the lateral border on T2-weighted images measuring 1.9 cm × 1.3 cm × 1.9 cm []. Heterogenous enhancement of the lesion on intravenous administration of Gd-DTPA was observed. The MRI was suggestive of involvement of the intrinsic muscles of the tongue on the right side with no involvement of the lingual neurovascular bundle or the base of the tongue. Level IB and II lymph nodes were enlarged bilaterally.
An incisional biopsy was done for the patient under local anesthesia and was submitted for histopathological examination. The lesion was suggestive of AR. The mass was explored under general anesthesia with an intraoral approach. The tumor mass was marked with methylene blue. An elliptical incision was marked around the tumor mass and it was excised from the surrounding musculature of the tongue []. Care was taken to preserve all the adjacent vital structures; a two-layer primary closure was done with 3-0 vicryl. No postoperative complications were noted. There was no recurrence noted up to 2 years of follow-up.
Histopathological examination of the excised specimen revealed large polygonal vacuolated cells with a granular cytoplasm and abundant glycogen 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 71-year-old male patient was referred to the Department of Otolaryngology-Head and Neck Surgery, Kobe University Hospital, for the evaluation of a 6-month-old, large neck mass that had gradually increased in size. Written informed consent was obtained for surgery including neck dissection. Upon examination, the mass presented as a swelling of approximately 4×5 cm in size, located in the left posterolateral side of the lower neck. It was non-tender, hard, and attached to deep neck structures. A contrast enhanced computed tomography scan revealed a large soft tissue mass in the left posterior neck that involved both the anterior and medius scalene muscles (, ). Magnetic resonance imaging (MRI) revealed an iso-intense mass on the T1 weighted image and a low-intensity mass on the T2 weighted image (). On the anterior side, the mass extended up to the sternocleidomastoid muscle (SCM), with splaying of the left internal jugular vein. No pathological finding was detected in the upper aerodigestive tract by endoscopic examination. After an inconclusive fine needle aspiration, surgical extirpation of the tumor was performed. We did not perform preoperative incisional biopsy because incisional biopsy of neck masses before radical treatment is associated with poor prognosis. The negative influence of preoperative incisional biopsy on prognosis is possibly because of tumor cell dissemination or changes in lymph flow. We were ready to perform a neck dissection procedure if the tumor was malignant. A preoperative incisional biopsy was performed at the beginning of the surgery. The pathological diagnosis of the biopsy was fibromatosis. In response to the clinical findings, a wide excision of the tumor was performed. We encountered difficulty because of local infiltration of the surrounding tissues. Parts of the scalenus medius and SCM were also resected because of tumor invasion. The carotid artery, internal jugular vein, the remainder of the SCM, lower cranial nerves, phrenic n

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 60-year-old woman of West African descent, with no history of asbestos exposure, who originally presented 24 years ago to another institution with acute abdominal pain. At that time, she underwent an exploratory laparotomy and was found to have nodules diffusely covering the peritoneum. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed for suspected ovarian carcinoma, and biopsies were taken of the peritoneal nodules. The pathology from this original surgery was interpreted as low-grade papillary mesothelioma. She then received six adjuvant cycles of intravenous cyclophosphamide, doxorubicin and cisplatin. She underwent a second-look laparotomy six months later, and still had gross disease visible in the peritoneum. Post-operatively she received three additional cycles of intraperitoneal cisplatin and intravenous sodium thiosulfate. She subsequently received maintenance therapy with alternating courses of tamoxifen and megace alternating every two weeks.
She presented four years later with obstructive gastrointestinal symptoms and was again found on laparotomy to have diffuse peritoneal studding. Pathology from this surgery was interpreted again to be papillary mesothelioma. As a result, she began six cycles of carboplatin and cyclophosphamide chemotherapy for suspected progressive disease. Several months later, she presented with complaints of shortness of breath, orthopnea, and worsening lower extremity edema. A multi-gated acquisition scan (MUGA) revealed an ejection fraction of 14% and enlarged cardiac silhouette on chest X-ray, and she was clinically diagnosed as having anthracycline-induced cardiomyopathy. Medical therapy was initiated at that time for congestive heart failure.
Two years later, she was found on a computed topography (CT) scan to have an interval increase in loculated subhepatic fluid collection and a lobular soft tissue mass in the right subphrenic region. She then received three cycles 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:
Our patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.
She reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.
During her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.
The oncology team became involved at this time. Her CLL was the suspected etiology of the neck mass and lymphadenopathy, and intravenous fluids and allopurinol were started to prevent tumor lysis syndrome. Further laboratory workup showed the predominantly lymphocytic, elevated WBC count as before and a normocytic anemia, hemoglobin 10.6 g/dL. Smudge cells were present on the peripheral blood smear. Iron studies, B12, and folate were normal. Flow cytometry

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old female with cancer in the right breast underwent a modified radical mastectomy in December 2001. At that time, the patient was diagnosed with breast cancer in stage T2N1M0. The tumor was positive for estrogen and progesterone receptors on immunohistochemical staining, and negative for HER2 overexpression by fluorescence in situ hybridization. Postoperatively, the patient was treated with adjuvant chemotherapy of cyclophosphamide, doxorubicin, and 5-FU every 3 weeks, for 6 cycles duration from December 2001 until May 2002, and hormonal therapy (toremifene citrate) from May 2002 until April 2006.
In April 2006, a follow-up bone scan revealed metastasis to the left scapula (), for which the patient was treated with doxorubicin and docetaxel every 3 weeks for 3 cycles. A follow-up bone scan revealed exacerbation of the metastasis, and in March 2007 (). At that time, the patient received intravenous (IV) zoledronic acid (4 mg) to prevent skeletal complications.
In October 2010, the patient accidentally tripped while walking and subsequently, felt pain in her right hip. Because she had no problems walking, she did not receive any specific treatment. A follow-up bone scan 1 month later demonstrated a focus of increased tracer uptake; however, the patient had no complaints of hip pain (). The finding was thought to be a bone metastasis, and zoledronic acid was administered on an ongoing basis.
In March 2011, the patient underwent X-ray evaluation at a local clinic because of intermittent right hip pain that was negative for fracture (). The following April, she developed pain in her right hip while jogging and had problems walking. Subsequent X-rays showed a right subtrochanteric fracture () and she underwent an open reduction with internal fixation (using compression hip screw & autogenous iliac bone graft) (). A bone biopsy of the fracture site demonstrated acute and chronic inflammation.
In addition, the left femur was observed to have cortical thickening a

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old man with history of grade 1 follicular lymphoma since 2013 with no indication for therapy being followed by oncology for clinical surveillance presented with worsening shortness of breath and hemoptysis. Physical exam was unremarkable, and lab workup showed chronic anemia. Computerized tomography (CT) imaging of the chest showed an enlarging 2.0 cm density in the posterior right upper lobe of lung (RUL) as well as scattered pulmonary nodules in the RUL. With his extensive history of smoking, he underwent bronchoscopy with endobronchial ultrasound-guided biopsy (EBUS) of mediastinal lymphadenopathy. Bronchoscopy revealed lung mass with endobronchial lesions and mediastinal lymphadenopathy. Although clinically on bronchoscopy it appeared to be cancer, biopsy was negative. He subsequently was sent to interventional radiology for biopsy of an RUL spiculated mass, which again was negative for cancer. Needle biopsy sections of lungs were suggestive of organizing pneumonia.
With clinically suspected cancer and two separate negative biopsies, we decided to proceed with positron emission tomography (PET) scan to reassess approaches for tissue biopsy. Meanwhile patient was started on antibiotics with which he had significant improvement clinically and his shortness of breath and mucus production got better. Patient had PET scan that showed extensive mediastinal lymphadenopathy throughout the right mediastinum and LA which could probably correspond to patient’s known lymphoma ( and ) as his biopsied right spiculated lung mass did not appear to be growing and had less impressive uptake. Patient was recommended to have repeat EBUS; however, he refused to undergo any further procedures or biopsies.
Three months later, patient underwent repeat chest CT with contrast that showed right hilar and mediastinal mass measuring 7 cm in size with involvement of right and left brachiocephalic veins, SVC and a large tumor thrombus in the LA (). He had transthoracic echocardiog

[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 23-year-old Hindu female, married for 5 years, living with her husband, a 4-year-old son, and a 20-weeks-old daughter, and in-laws in a joint family, belonging to the middle socioeconomic strata, came to psychiatry OPD with complaints of having thoughts which were extremely distressing to her. The thoughts were of her performing sexual acts with Lord Hanuman and also of her children sharing incestuous relations. The thoughts first began 2–3 days after delivery of her daughter, 5 months ago. They would initially occur only when she would happen to view her newborn daughter's genitals, whereas bathing her or cleaning her, when she would happen to see Lord Hanuman's image on her daughter's genitals. This persisted for around a month. After that, she began having thoughts of her son having sexual relations with her daughter. This would earlier occur only when her two children were sitting or playing together but eventually began occupying her thoughts throughout the day. Alongside, the thoughts of her performing sexual acts with gods also began increasing. The thoughts were also associated with vivid visualization of the act as if occurring in front of her eyes and continuing to be seen by her even when she would shut her eyes in an attempt to stop the images. She would try her best to suppress such thoughts by diverting her mind to other thoughts or by keeping herself occupied with work, which, albeit effective in the beginning, was not helping her. These thoughts grossly violated her moral and religious ethics and were causing her immense distress. She took cognizance that the thoughts were her own, and that they were unreal and impossible. She would feel apprehensive with palpitations, tightness in chest, and restlessness. She also began reporting no interest in the world around her and her daily activities. She completely stopped breastfeeding her daughter, and vehemently refused

[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 female patient from a less-developed region was first seen at our institution almost seven years ago for evaluation of mBC. This patient had been diagnosed a few months earlier at another institution with infiltrating ductal carcinoma (mucinous type). Both ER and progesterone (PR) receptors were positive in 90% and 60% of the cells, respectively, while Human Epidermal Growth Factor Receptor (HER/neu) was negative on immunohistochemical staining. Her pathology results were reviewed and confirmed at our institution.
Staging at the time of diagnosis and at presentation to our institution showed a tumor in the left breast and left axillary lymph node involvement, in addition to right hilar lymph node involvement and a right lung mass (Figure ).
She was treated with four cycles of adriamycin and cyclophosphamide; however, there was no significant response. She was then switched to docetaxel and four cycles were administered, again with no response. Given the lack of response, both hilar lymph nodes and the lung mass were biopsied and pathology test results confirmed the original diagnosis of invasive mucinous carcinoma (Figure ). Again, both ER and PR were strongly positive while HER2/new was negative.
Given the stable nature of her disease, the absence of a visceral crisis, and because of the patient’s social issues and the limited availability of appropriate medication in her home region, she was started on tamoxifen along with ovarian ablation using gonadotropin-releasing hormone (GnRH) agonists (goserelin, 3.6 mg subcutaneously, every four weeks). Follow-up imaging studies showed a significant disease response three and six months later. Our patient continued on the same treatment, with no major side effects. Follow-up CT scans at nine months showed a continued response in the breast mass and complete resolution of the right lung mass and the right hilar lymph nodes. Moreover, tumors in the left axillary lymph nodes had completely disappeared (Figure ).

[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 presented to an outside facility with the complaint of increasing low back pain over the past month that radiated bilaterally to the level of his ankles. The pain was accompanied by progressive lower extremity weakness to the point where ambulation became impossible 3 days prior. He also complained of bilateral calf and anterior thigh numbness with paresthesias. He denied changes in normal bowel and bladder function. He had been evaluated 3 weeks prior at the same facility with similar but less severe complaints and diagnosed with bilateral sciatica. Workup during the more recent visit revealed an L2 mass invading the spinal canal for which the patient was transferred to our facility for neurosurgical evaluation [].
The patient had noted a left testicular mass 3 years ago and stated that it had been enlarging in size and was painful to touch. He denied having ever brought this complaint to the attention of a physician. He also admitted to poor appetite and significant weight loss over the prior month amounting to 25 pounds and attributed this to his major depression. He denied fevers, vision changes, night sweats, or any other palpable lesions or rashes.
The patient was a pale, anxious-appearing male who was alert and cooperative, tachycardic, and hypertensive. He exhibited tenderness to palpation in the midline lumbar spine. Upper extremity strength was normal. Right hip flexion, knee extension, dorsiflexion, and plantar flexion were grade 4/5. The same motor groups were only at anti-gravity strength (3/5) on the left side. Rectal sphincter function was normal. On sensory exam, saddle anesthesia was noted as was decreased sensation to light touch in a distribution that approximated the bilateral L2 and L3 dermatomes. His reflexes were grade 2+ throughout and no long-track signs were observed. His left testicle was enlarged and a mass was palpable that was non-tender at the time.
A magnetic

[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 23-year-old Chinese female patient presented to our clinic complaining about a 1-year history of a growing lump at the medial third of her right clavicle, associated with recurrent and aggravated pain. Limited range of motion of the right shoulder was reported as well. The patient experienced no compression and difficulty in breathing. Physical examination indicated the right shoulder had limitations in adduction, abduction, back extension, and elevation. A hard lump with a diameter of 7cm × 5 cm lump at the medial third of right clavicle was palpated with pain and slightly swelling. No redness and skin lesion around the lump; no muscular atrophy and weakness; no dislocation or deformity of the shoulder joint and no thoracic varicosity were observed.
The X-ray film and computed tomography (CT) scan showed the sclerotic bone remodeling of the medial third of the right clavicle (Fig. ). After admitted to the ward, a percutaneous bone biopsy was performed, revealing a suppurative inflammation with bone destruction, without the signs of malignancy (Fig. ). A diagnosis of clavicle osteomyelitis was suggested. Thus, conservative treatments with antibiotic (based on drug sensitivity, clindamycin was given 1.2 g/d for 2 weeks) and non-steroidal anti-inflammatory drugs were given. The patient was discharged after the pain was relieved.
In the next 7 months, the symptom of pain gradually worsened and radiated to her right arm. Despite the intake of non-steroidal anti-inflammatory drugs and treatment with antibiotic, the pain was still obvious. Meanwhile, she started complaining of muscle weakness and limited mobility of the right shoulder. The lump of right clavicle was bigger than before and developing to her right neck. After admitted to the ward, X-ray film and 3D reconstruction of CT scan were carried out. Despite the conservative treatments were given, the pain and swelling of the right clavicle were still not relieved, seriously affecting the patient�

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old woman was referred to our neurosurgery department from gynecology and general surgery due to paresthesia and pain in perianal area. By then, her symptoms had persisted for 2 months. Previously, she had been examined in general surgery and in gynecology. After the gynecologist confirmed an abnormal mass in the retrorectal space by pelvic MRI and CT, she was admitted to our department for surgery. There were no abnormal findings by digital rectal examination or on perianal skin. Pelvic CT showed a bony defect on the lower sacral bone near the cyst (). Pelvic MRI with gadolinium enhancement showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image. The size of the mass was about 6 cm, of which was a multilobulated mass on the sacrococcygeal area. The uterus was enlarged and heterogeneously enhanced (). Surgery was performed with the patient in prone position under general anesthesia. After making a 10-cm long midline skin incision, 3 cm distant from the anus, we exposed the lamina by dissecting the soft tissue. The bony defect was palpable above the cyst wall. The additional laminectomy was performed to take the large mass out. While performing a careful cyst dissection, we realized that the demarcation of the cyst was good, and there was no evidence of cyst rupture. The cyst contained soft suctionable yellowish material of creamy consistency. A small incision was made on the cyst wall, and the cystic contents were aspirated with a syringe. After the cyst wall was sutured, marginal cyst dissection was performed although part of the cyst wall was stuck to other tissue. The contents were removed with no significant spillage into the retropelvic cavity. Complete excision of the retro-rectal tumor (which was fixed to the apex of the coccyx) using posterior midline approach was performed (). Histopathology exam of the retropelvic cyst revealed a multiloculated

[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 female patient, 39 years old, is complaining of diffuse abdominal pain, more prominent in the flank and left hypochondrium, initially bearable and with response to simple analgesics, but with progressive and significant worsening in the last 24 h. The patient reported bilious vomiting and denied fever or other similar episodes in the past. She was admitted in good general condition, moderately dehydrated and discolored. On abdominal palpation, there was evidence of diffuse pain without peritonitis. The patient was given IV hydration with crystalloids and underwent an abdominal/pelvic CT scan, which identified a voluminous expansive formation in the pancreatic tail, with compression, but without direct invasion of the splenic vein (Figure ). Laboratory tests showed CA 19–9 serum concentration greater than 1,000,000 U/mL, with no other changes.
Upper gastrointestinal (UGI) endoscopy did not show any extrinsic compression or gastric/duodenal wall invasion.
An MRI of the upper abdomen was performed in order to better characterize the lesion, with evidence from projection imaging of a mass in the pancreatic tail, predominantly with cystic aspect, multiloculated, with thick septations and regular margins, showing heterogeneous contrast enhancement and areas of T1 signal hyperintensity, possibly corresponding to hematic content. Its size was 63 × 60 × 61 mm (Figure ).
No endoscopic ultrasound was indicated, since the main diagnostic hypothesis was a mucinous lesion with malignant transformation, and its treatment included surgery, provided that no metastatic disease was found.
Clinical stabilization and preoperative evaluation was performed, with no additional significant findings. The patient was the taken to the operating room. At first, she underwent a diagnostic laparoscopy, with no signs of peritoneal and liver metastasis. Laparotomy was then performed, and a distal pancreatectomy with splenectomy was conducted. The patient had an uneventful postoperative outcome 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 49-year-old woman with a past medical history of hypertension, preeclampsia, anxiety, and bipolar disorder on buspirone, presented to the emergency department with triage complaint of “multiple complaints”. Her history of present illness revealed a persistent headache that initially started one week prior to arrival. The patient recalled onset in the evening associated with nausea and vomiting. She went to an urgent care the next day and received medications, after which she felt better for about two days. When her symptoms recurred, she went to an outside hospital where she had a computed tomography scan of the head and lumbar puncture, both of which were negative. The patient was admitted for an elevated troponin level and received a cardiac catheterization without intervention, findings significant for 60% blockage of a single vessel. The patient presented to us one day post discharge due to persistent headache. She described the headache as similar to her prior preeclampsia headache, feeling "like a grip around" her entire head.
Her initial vital signs were as follows: blood pressure 172/92 mmHg, pulse 81, respiratory rate 18, and oxygen saturation 99% on room air. A physical exam revealed a woman in pain but nontoxic appearing. Her heart and lung sounds were normal. Her neurological exam was unremarkable with no focal numbness, weakness, or abnormalities with coordination, gait, or cranial nerves. The chest plain film, initial lab, and electrocardiogram results were normal.
The patient received one liter intravenous fluids, metoclopramide intravenous, and ketorolac intravenous with minimal improvement and still appeared uncomfortable on multiple reassessments. The patient was placed in the observation unit and a magnetic resonance imaging (MRI) of the brain was ordered.
The magnetic resonance imaging (MRI) of the brain showed three punctate regions of focal restricted diffusion in the left middle frontal gyrus, right parietal lobe, and left temporal lobe that

[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 80-year-old man was diagnosed with a massive tumor having a central ulceration in the transverse colon after undergoing screening colonoscopy (Fig. ). Computed tomography (CT) revealed that the patient was suffering from multiple metastases in the right hepatic lobe. Biopsy specimens obtained by colonoscopy showed only necrotic debris. Although confirmative diagnosis was not made, our clinical diagnosis was colonic carcinoma associated with multiple liver metastases. After obtaining the patient’s informed consent, we planned surgical resection of both primary colonic tumor and metastatic liver tumors.
Laparotomy revealed many whitish deposits that were widely distributed in the peritoneal cavity. One of the disseminated deposits was sent for pathological examination. A diagnosis of metastasis of sarcomatoid tumors was made on the basis of histological examination using intraoperative frozen section analysis. The patient underwent only partial resection of the transverse colon to confirm the histological diagnosis of the tumor. The small bowel was not involved in the colonic tumor. In addition, no other tumors were found in the gastrointestinal tract. The postoperative course was uneventful. The patient was discharged on postoperative day (POD) 12.
The colonic tumor measured 8.0 × 6.0 × 4.0 cm and appeared as an exophytic growth with a deep central ulceration that opened the colonic lumen (Fig. ). Microscopically, the tumor consisted of solid sheets of spindle tumor cells with moderate atypia (Fig. a). Immunohistochemical analysis revealed that the tumor cells were positive for KIT (Fig. b) as well as CD34, and negative for alpha-smooth muscle actin and S-100 protein expression. Based on these histological and immunohistochemical findings, the tumor was diagnosed as a GIST of the transverse colon. The tumor showed markedly high mitotic index, counting 11 in 10 high-power fields. The Ki-67 labeling index was 40 % (Fig. c). Lymph node metastasis was also seen in a p

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 67-year-old female who was recently treated with a decompression and 10th thoracic to second lumbar fusion secondary to formation of an epidural hematoma from a 12th thoracic vertebra fracture (type unknown). While in a physical therapy session the patient suffered a fall forward, trying to break her fall with her arms outstretched above her head. After the fall the patient’s arms were stuck in full abduction and pronation and she was in significant pain. The patient’s presenting position is displayed in . She arrived in the emergency department where X-rays were taken and demonstrated bilateral inferior shoulder dislocations, LEH ().
Orthopedics was consulted to evaluate and treat. Upon evaluation, the patient was distally neurovascularly intact with 2/4 radial pulses bilaterally, sensation intact to light touch about the fifth cervical to first thoracic dermatomes, and motor function was intact in all peripheral motor groups of the upper extremities. The emergency physician provided sedation with closed reduction performed by the orthopedic service. The right shoulder was reduced using traction through the humerus through a flexed elbow to control the limb, and the opposite hand was used to place superior pressure on the humeral head through the axilla to guide the head into the glenoid. Slight external rotation and adduction was added as the head cleared the glenoid. Attention was then turned to the left shoulder, which was reduced, in a similar fashion; however, this shoulder was converted from an inferior to anterior dislocation using pressure in the axilla and slight external rotation.
Following this, traction through the humerus external rotation, and lateral pressure on the humeral head yielded a successful relocation of the glenohumeral joint. After reduction the patient remained neurovascularly intact bilaterally. The patient was placed into bilateral shoulder slings, advised to avoid active shoulder range of motion, and admitted 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:
Our patient is a 5-year-old female who was referred for evaluation and management of recurrent episodes of cellulitis in the left scapular region. A small cystic lesion had first been noted at the age of 2 years. While this had initially been an asymptomatic, small lump that grew in size over time, it first became symptomatic when the patient was 4 years old. The lesion developed surrounding induration and erythema, as well as purulent drainage and tenderness. Over the next 1-year period, she went on to develop 3 such episodes of cellulitis. This was treated with a 10-day course of cephalexin by the patient's family physician, and it was due to these recurrent episodes of infection that we saw the patient in consultation.
Physical examination revealed a playful and well-appearing 5-year-old female, weighing 24.8 kg and measuring 114.5 cm in height. Review of systems and cardiorespiratory examinations were unremarkable. On inspection of the left scapular region, approximately 7 × 5 cm area of cellulitis was noted, with a small opening and associated purulent drainage. The surrounding skin was tender to palpation, but there was no appreciable fluctuance. Thus, the initial working diagnosis was infected epidermoid cyst. An ultrasound of the affected area showed a complex cystic mass measuring 3.9 × 2.9 × 3.7 cm within the subcutaneous fat (). Deeper margins of the mass were poorly demarcated due to the degree of inflammation, and the lesion appeared to abut the underlying musculature. Since these findings were nonspecific, an MRI was obtained to further characterize the lesion. The MRI revealed the presence of a subcutaneous cystic lesion just superior to the scapula measuring 1.6 × 3.5 × 2.8 cm. While the mass abutted underlying muscular fascia, there was no extension into the underlying trapezius muscle itself (Figures and ). Thus, the decision was made to pursue surgical excision of the lesion. This 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:
A 53-year-old man was admitted for mobility of tooth. The dentist suggested the presence of a mass located at the tooth root by physical examination. Computed tomography revealed a well-demarcated radicular cyst of 4 cm in diameter at the tooth base. Carcinomatous infiltration of squamous cell carcinoma was observed in the excisional biopsy of the lesion. In microscopic evaluation, tumoral infiltration revealed features of moderately differentiated squamous cell carcinoma. Malignant cells infiltrated the underlying connective tissue stroma in solid groups and sheets. Numerous neutrophils were present within the cytoplasm of the malignant cells as well as in the surrounding stroma. The internalized neutrophils were intact (). Desmosomal connections were observed between the tumor cells in some areas. The tumor cells showed moderate cellular pleomorphism. The diffuse immunoreactivities of P63 and CK5/6 were determined in the malignant cells by immunohistochemical staining. Additionally, perineural invasion was found, whereas vascular invasion was not observed. Because surgical margin was positive for tumor cells, partial maxillectomy and bilateral neck dissection was performed. Bone infiltration was present. Furthermore, diffuse neutrophilic emperipolesis was observed in cancer cells by microscopic evaluation. Some of the neutrophils in the tumor cells revealed degenerative changes by high-power field (×1000) microscopic evaluation (Figures –), while some neutrophils included apoptotic bodies. Nearly one year later, local relapse developed and additional therapeutic manipulations including surgery, radiotherapy, and chemotherapy (cisplatin) were done. Tumor recurrence occurred in the periparotid and right neck lymph nodes after six months (). Chemotherapy (cisplatin) and radiotherapy were performed for the recurrence. Two more relapses developed in the right neck, left submandibular lymph nodes and in the superficial and deep soft tissues of the neck three months apar

[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 female with a history of diabetes mellitus type 1 who presented to the clinic for evaluation of recurrent symptoms of sinusitis and a persistent nasopharyngeal mass. Her symptoms first started at the age of 12 with chronic nasal congestion, repetitive sinus infections and chronic cough. Her tonsils and adenoids were removed at the time, but her symptoms persisted. Between the ages of 13 to 15 she was found to have a recurrent adenoid mass and tonsillar regrowth. She underwent another adenoidectomy and tonsillectomy. Microscopic description of the specimen showed overall preservation of the architecture with follicular hyperplasia and mildly expanded paracortex with scattered immunoblasts. The follicles show polarized germinal centers and contain numerous tangible body macrophages. Immunohistochemistry showed that the interfollicular paracortical cells are positive for CD3, CD5, CD10, CD43, BCL-2, CD1a, CD7, CD4, CD8, and TdT. The tumor was also negative for clonally rearranged immunoglobulin heavy chain gene and negative for clonal T-cell receptor gamma chain gene rearrangement. Additionally, the patient was noted to have an enlarged right cervical lymph node. Due to concerns about malignancy she was hospitalized for a bone marrow biopsy that was deemed negative.
Over the following years the patient developed progressively worsening severe thick nasal drainage, rhinorrhea, frontal pressure and headaches, for which she presented to the clinic again at the age of 25. Her neck and sinus CT scan revealed maxillary sinus disease and significant lymphoid hyperplasia in the adenoid and tongue base region as well as a right cervical lymph node. She underwent a revision endoscopic sinus surgery and an adenoidectomy. Biopsy of the right-sided inflammatory process demonstrated an atypical T-cell lymphoid infiltrate, with a Ki-67 of 50–60%. She was then given a month of methylprednisolone (2 mg) taper and her cervical adenopathy diminished in size f

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old female presented with swelling in the frontal region of the skull since 2 years and another swelling in parieto-occipital region since 4 months. Both the swellings over skull have been painless and gradually progressive in size, thus the delay in presentation. No significant past medical history. On examination, swelling in frontal region measured 18 cm in sagital and 13 cm in coronal directions and 7 cm in vertical dimension. The veins over swelling were distended and it was pulsatile in nature, firm in consistency and fixed to skull. The skin over the swelling was stretched but otherwise normal. Left orbit appeared distorted by the swelling but vision was normal []. The second swelling was located in parieto-occipital region right side and measured 3×4 cm pulsatile in nature and firm in consistency []. Incidentally a thyroid swelling was noted involving mainly right lobe around 3×2 cm, firm and not associated with any pressure symptoms []. Patient did not have any neurological deficit or psychological illness. The patient was clinically euthyroid with normal general physical, systemic, and neurological examination. Routine blood tests and thyroid function tests were normal. Ultrasound study of neck revealed 2 × 1.5 cm neoplastic solid nodule in right lobe of thyroid. Rest of the thyroid gland and neck was normal. X-ray of skull showed lytic lesion in frontal and occipital region of skull. Contrast enhanced computed tomography (CT) demonstrated a 13 × 18 cm size expansile osteolytic lesion in the fronto-parietal region on both right and left side of anterior half of skull. The lesion was extending intracranialy and causing compression of the underlying fronto-parietal lobes on both sides. Similar expansile osteolytic lesion of smaller size are seen in the occipital region on both sides largest measuring 4×3 cm on right side. On postcontrast study, these lesions showed significant enhancement suggesting increased vascularity and also areas of necrosis

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


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

[User]
RADIOLOGY NOTE:
A 58-yr-old woman with a nasal radix mass visited our clinic. Thirty years earlier at a local clinic, she had undergone augmentation rhinoplasty with a material presumed to be silicone. She had had no complication afterwards. However, 5 yr previously, a nasal mass developed that had increased gradually. Physical examination showed a 3.5×2.5 cm round, soft, painless mass on the midline of nasal radix (). The nasal dorsum and the tip were firm on palpation and a small cruciate incision scar was found at the infratip lobule, which was supposed to be the entry of the augmentation material. On computed tomography (CT) scan, a heterogeneous cystic mass was observed at the radix and the cyst was continuous with a homogenous density at the nasal dorsum, which was first thought to be a silicone implant ().
A presurgical diagnosis of nasal radix cyst associated with previous augmentation rhinoplasty was made, and a direct, open approach was chosen to remove the cyst. After a skin incision on the center of the cyst, it was dissected down to the nasal bone. The cyst was connected to the dorsal mass, which were removed together in en-bloc fashion (). For safe removal of the graft material over the tip area and effective tip-plasty, the tip was exposed with an open approach.
Grossly, the removed cystic mass had a thick, fibrous wall with dirty cheesy material inside. The cystic wall was composed of dense fibrous tissue containing dispersed, microsized amorphous foreign materials (). Foreign materials were surrounded by foreign body type multinucleated giant cells and induced granulomatous reactions. Infiltration of chronic inflammatory cells was also observed.
A scanning electron microscopy (SEM) showed a fragment of foreign body () and energy dispersive radiography spectroscopy (EDX) showed presence of silicone (Si) in the removed specimen (). The lesion was diagnosed as a foreign-body type cyst associated with silicone material used for 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 70-year-old man presented with a 1-month history of lower back pain. Three days before admission he had developed cyanotic changes in his left lower extremity, which gradually worsened. Eighteen months previously the patient had been diagnosed with superficial bladder cancer and had undergone transurethral resection of the bladder tumor (TUR-B), followed by intravesical BCG therapy (Onco Tice strain BCG; 12.5 mg BCG injected through a catheter into the bladder every week for 6 weeks). Three months later, another TUR-B was performed because atypical cells were observed in his urine. Histological examination revealed transitional cell carcinoma in situ and he underwent another 3 cycles of intravesicular BCG therapy (13 months, 10 months, and 1 month prior to presentation).
The patient's temperature was 37.5℃ and his other vital signs were stable. Computed tomography of the abdomen revealed an aortic aneurysm involving the abdominal aortic bifurcation and left proximal common iliac artery, with inflammatory soft tissue infiltration in the pre-vertebral space and focal pseudoaneurysm; these had not been seen on a scan performed 17 months earlier (). Magnetic resonance imaging of the lumbar spine revealed minor cortical erosion of the L4 vertebral body and paravertebral phlegmonous and abscess-like soft tissue lesions around the L4 vertebral body ().
Excision of the aneurysm, wide debridement of the psoas abscess, and an in situ aorto-biiliac interposition graft with a rifampicin-soaked Dacron graft were performed. The graft was fully covered with omentum. Surgical exploration confirmed a 3×3 cm cystic lesion in the anterior of the psoas muscle, with a hole leading to the site of suspected spondylitis. Pathologic examination revealed chronic granulomatous inflammation of the vascular wall, but microscopy did not reveal any microorganism. A polymerase chain reaction (PCR) was positive for M. tuberculosis complex, and 10 colonies of this complex were isolated after 31 da

[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 72 years old woman proceeded to the Emergency Department complaining of acute lower right abdominal pain, mild fever, mild weight loss and constipation. The past medical history of the patient was free.
The patient was presented with severe lower right abdominal pain, with signs of local peritonitis and a palpable mass in the same region. The body temperature was 37.2–37.4°C, while arterial blood pressure and cardiac rate 150/90 mmHg and 90/min respectively. The signs of local peritonitis combined with the palpable mass of the lower right abdominal area suggested perforation of the appendix and abscess formation. The laboratory examinations of the patient showed leucocytosis with white blood cell count (WBC) 19000 (with macrophage prevalence: 89%). Colonoscopy revealed obstruction of the right colon. Biopsies were not acquired because the colon lumen was obstructed and the endoscope could not approach the lesion. Computerized tomography (CT) scans of the abdomen (Figure ) revealed a soft lobular mass, measuring 5 × 5 cm, attached to the ascending colon and cecum, compatible with a tumor. The most possible diagnosis was that of a perforated colonic tumor. The patient underwent explorative laparotomy and right hemicolectomy with an end-to-end ileocolonic anastomosis. Thorough exploration of the abdominal cavity revealed no other pathologic findings.
The surgical specimen consisted of a 10 cm length of the terminal ileum and the whole of the right colon. The serosa was very heavily covered by suppurative exudates and fibrotic tissue.
Microscopic examination of the surgical specimen revealed thickening of the ascending colon wall with neutrophilic infiltration. Numerous polymorphonuclear leukocytes within the muscularis and a fibro-purulent reaction over the serosa with actinomycotic "sulfur granules" in it, were found in high power magnification (Figure ).
Upon receiving the pathology report, systemic intravenous penicillin treatment was initiated. Therapy continued

[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 84-year-old man was transported via emergency medical services to the emergency department (ED) following a motor vehicle collision. The patient was the restrained driver and was rear-ended while slowing down to make a turn. There was moderate damage to the rear of the patient's vehicle. The car was an old model vehicle and was not equipped with airbags. The patient was ambulatory at the scene but as a precaution he was transported via emergency medical services to the ED on a backboard and wearing a cervical collar.
On presentation, the patient was in no apparent distress and his vital signs were blood pressure of 157/78, pulse of 82 with a respiratory rate of 18 (unlabored), and pulse oximetry of 97% in room air. The patient initially complained of neck pain, bilateral upper extremity and shoulder pain, and numbness in both hands. A friend who accompanied the patient to the ED noted the patient's voice was raspy sounding. The patient's past medical history was significant for atrial fibrillation for which he took coumadin. He also had an automated implantable cardioverter defibrillator. The patient noted that his implanted defibrillator had not discharged today and he was in his normal state of health prior to the accident.
His physical exam was significant for midline cervical spine tenderness and his anterior neck exam was normal without tracheal deviation, jugular venous distention, or appreciable masses. The patient exhibited no neurological deficits except a complaint of bilateral hand numbness but his motor function was preserved and had full range of motion in all extremities. The patient had multiple abrasions over the anterior portion of both legs and over his right elbow. Laboratory studies revealed the patient had an INR of 3.5.
A chest X-ray and plain film images of the patients shoulders were both normal without evidence of osseous injuries. An extended focused assessment with sonography for trauma was negative for pneumothorax and abdominal, pelvi

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


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

[User]
RADIOLOGY NOTE:
This case report describes a 25-year-old female patient presenting to the Department of Orthodontics at the Centre of Dentistry, Oral and Maxillofacial Surgery at the University Hospital Tübingen due to acute pain in the right TMJ and mouth opening disorders in 2019. There were no general diseases or allergies in her medical history. The patient stated that she did not consume alcohol or nicotine; she was taking contraceptives. Over a period of 5 years the patient’s distal bite was treated with removable and fixed orthodontic appliances. The initial examination showed fixed retainers in both the upper and lower jaws (Fig. a + b). Despite orthodontic treatment, there was still a slight asymmetric distal occlusion on both sides (Fig. c + d). This was slightly more pronounced on the left due to slight mandibular tilt to the left (Fig. e). The mouth opening disorder severely restricted the patient in her everyday life. Previously, craniomandibular dysfunction was assumed due to multiple grinding facets on the teeth and bruxism. Therefore, a bruxism splint was already worn at night. The initial panoramic radiograph is shown in Fig. .
Three months later, the patient reported that she woke up with severe pain in her right TMJ after sleeping and was not able to close her mouth. When repositioning the lower jaw by herself a very loud cracking sound at the right TMJ occurred. After that, she had a mouth opening disorder and constant pain. The patient gave this constant pain a score of 7 on the verbal numeric rating scale (VNRS) (0–10). She was prescribed muscle relaxant therapy with methocarbamol twice a day. Although the pharmaceutical treatment with methocarbamol resulted in some slight pain relief, it also had some general medical side effects such as circulatory weakness and dizziness. The patient was also referred to the Department of Orthodontics. Due to severe pain a functional analysis of 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 12-year-old female patient reported with a chief complaint of swelling and pain on the right lower 3rd region of the face []. The patient was moderately built. No significant medical and family history. On extraoral examination, a diffuse swelling was present on right lower 3rd of the face, measuring approximately 3 * 4 cm, extending anteroposteriorly from right commissure to right angle of mandible and superioinferiorly from 1 cm below the right alatragal line to right inferior border of mandible which on palpation was firm in consistency and tender with slight rise in temperature. Intraoral soft tissue inspection revealed a diffuse swelling measuring approximately 2 * 3 cm on right buccal mucosa obliterating the buccal vestibule extending from the distal aspect of 45 to the mesial aspect of 48. On palpation, there was buccal and lingual cortex expansion; the swelling was firm to hard in consistency and tender without pus or blood discharge when palpated apico-coronally. Intraoral hard tissue examination revealed root stumps in relation to 46. The provisional diagnosis of the radicular cyst was made and differential diagnosis as dentigerous cyst and ameloblastoma. OPG [] revealed a welldefined large unilocular radiolucency, measuring approximately 4 × 5 cm in size on the right body region of the mandible surrounded by a well defined sclerotic border, sparing 2 mm of the inferior border of the mandible. The lesion was extending mediolaterally from the distal aspect of 45 up to the mesial aspect of 48 and there was root resorption of 46 and 47. CBCT [] revealed the measurement of the lesion in all three dimensions, that is, anteroposteriorly (AP), mediolaterally (ML) and superioinferiorly (SI) as about 32.1 mm, 18.2 mm and 19.1 mm respectively. It revealed bicortical expansion with a displacement of inferior alveolar nerve. Radiographic diagnosis of the radicular cyst and differential diagnosis as unicystic ameloblastoma was given.

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman with dyspnea, and recent aggravation of the condition 10 days prior, was referred to our institution for further evaluation of the tracheal mass. The woman had no outstanding medical history; however, upon a physical examination, a stridor and wheezing sound was examined by auscultation.
A digital chest radiograph showed a well demarcated mass with round opacity located in the mid level of the trachea (). A non-contrast enhanced chest CT scan was performed at a local clinic and revealed a well defined, intraluminal mass with homogeneous soft tissue attenuation in the trachea (). The mass was round in shape with a diameter of 1.5 cm. Next, a contrast-enhanced chest CT (Somatom Sensation 64, Siemens Medical Solutions, Erlangen, Germany) scan revealed a heterogeneous enhancement pattern representing a strong nodular enhancement in the peripheral portion of the mass, accompanied with a central area of low attenuation on the axial images (). Further, a photomicrograph helped determine that the round submucosal mass was primarily composed of hypercellular areas with some collagen-rich areas. In addition, various sized blood vessels were noted along the periphery of the mass, along with dilated and branched vessels in the central portion of the mass ().
The oblique sagittal reconstruction images clearly demonstrated the orientation of the mass and length of the tumor (). In addition, no evidence of tracheal wall invasion was observed. The volume-rendered and virtual bronchoscopic images clearly depict a round intraluminal mass arising from the anterior tracheal wall (). Furthermore, a conventional bronchoscopy revealed the round mass with prominent of small blood vessels on its smooth surface. Although the bronchial mucosa was intact, a bronchoscopic biopsy was not performed with the possibility of massive bleeding. Consequently, the surgical excision of the mass was performed via a segmental resection of the trachea and an end-to-end anastomosis.
A his

[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 12-year-old boy presented to the Cornea Clinic of our hospital with a conjunctival mass lesion on his left eye, which had developed over the course of a few weeks. During a slit lamp examination, the lesion was found to be lobulated with corkscrew vessels that infiltrated the temporal, nasal, inferior and superior bulbar, and forniceal conjunctiva (Figures and ). He had a positive history of recurrent herpetic keratitis on the same eye and had undergone penetrating keratoplasty six years earlier. However, his corneal graft had failed with total opacity and vascularization due to recurrent herpes simplex keratitis (HSK) in the corneal graft. The right eye was normal.
His history revealed that he had suffered from eczematous skin lesions, recurrent skin bursts, and sinopulmonary infections since early childhood and recurrent generalized HSV infection. He had been diagnosed with HIES at the age of three based on elevated serum IgE levels and other clinical features. He did not have a positive family history of HIES or any other immunodeficiency.
At the onset of the lesion discussed here, a differential diagnosis of a conjunctival lymphoid tumor, conjunctival papilloma, and ocular surface squamous neoplasia was given. Because the patient was prone to recurrent HSK, recurrent herpetic lesions were not considered in the differential diagnosis because the patient presented a papillomatous mass lesion of the conjunctiva. Thus, the pathogenesis was suspected to be HPV because the dendritic lesion and stromal infiltration had not be seen in the failed graft. For a specific diagnosis, an incisional biopsy was obtained from the conjunctival lesion, and sections were prepared and stained with hematoxylin and eosin using the periodic acid-Schiff technique to observe the sections under light microscopy (Olympus BX43, Tokyo, Japan). Microscopic examination revealed conjunctival tissue with dense, diffuse, acute, and chronic inflammatory cells that infiltrated the lamina propria 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.