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

[User]
RADIOLOGY NOTE:
A 68-year-old man with previous posterior MI, persistent atrial fibrillation, hypertension, and moderately depressed left ventricular function (EF = 0,44) was admitted with life-style limiting CCS class III angina. Diagnostic coronary angiography and possible PCI was planned using radial access. He underwent cardiac catheterization from the right radial using a 16 cm 6F hydrophilic introducer sheath (Terumo Interventional Systems, Japan). The radial artery had an anomalous origin from the mid-segment of brachial artery. Coronary stenoses were identified in the right coronary artery (RCA) and PCI was planned as a second stage in 2–3 weeks. At the time of diagnostic examination patient was on warfarin therapy and additional clopidogrel was prescribed for the forthcoming PCI procedure. The International Normalized Ratio (INR) at the time of angiography was 1.09. The sheath was removed and hemostasis was achieved using TR band (Terumo Interventional Systems, Japan). Patient was discharged 6 hr after diagnostic procedure and a small hematoma was noted after removal of hemostatic device without any signs of bleeding.
The patient was readmitted 1 month later with painful 6 X 4 cm pulsatile mass over the volar aspect of the right wrist just proximal to the previous radial puncture site (Fig. ). This swelling appeared 48 hr following discharge after lifting a heavy object with the right hand. A systolic bruit was audible over the mass and duplex ultrasonography demonstrated an oval-shape dual chamber pseudoaneurysm measuring 49 X 38 mm, partially filled with thrombus. Pseudoaneurysm sac was connected to the radial artery lumen through a long (6 mm) and narrow (2 mm in diameter) neck (Fig. ). Radial artery was patent and INR at the time of repeat hospitalization was 1.57.
At this point we contemplated a combined strategy of PCI of RCA and repair of RAP.
We decided to use the affected radial artery as the access site for PCI, because ultrasonography indicated presence of suffi

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man presented to our institution. He previously underwent laparoscopic intersphincteric resection of the rectum with diverting loop ileostomy for lower rectal cancer at the age of 56. The immediate postoperative course was uneventful. A pathological examination revealed that the patient had T1, N1a, M0, Stage IIIA rectal adenocarcinoma. He did not receive adjuvant chemotherapy, and there was no recurrence of cancer during the follow-up period. However, soon after surgery, he developed an anastomotic stenosis requiring repeated endoscopic balloon dilatation.
His loop stoma was not reversed because these treatments were unsuccessful. Therefore, the surgeon proposed surgical resection of the anastomosis, but the patient did not agree to undergo permanent colostomy. Consequently, he had lived with loop ileostomy since undergoing surgery.
Twelve years postoperatively, he felt swelling and pain in the scrotum. He was seen by a local physician and diagnosed with a perineal abscess. He was referred to a urologist at our hospital for treatment. Computed tomography (CT) scans revealed a low-density area and air-fluid level in the perianal region (Fig. ), which was consistent with the signs of a perianal abscess. Drainage was performed, and the abscess was resolved. The urologist was concerned about the cause of the perineal abscess, and anastomotic complications were considered to be associated with the abscess. The patient was then referred to the department of surgery for further evaluation and treatment.
During examinations, we found that the patient did not have a significant medical history, including inflammatory bowel disease. He denied having any allergies. He had undergone surgery for an inguinal hernia and duodenal ulcer. He quit smoking after undergoing rectal cancer surgery. He took oral antibiotics after the perineal abscess was drained; otherwise, he denied taking any routine medications.
He was 161 cm in height and 50 kg in weight, and his body ma

[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 76-year-old woman presented to our hospital with a mass occurring on the skin of her right chest wall. She had been diagnosed with right breast cancer (T1N0M0, stage I) 9 years previously and had received breast-conserving surgery, sentinel lymph node biopsy, and adjuvant chemotherapy and radiation therapy for the residual whole right breast at a previous hospital. She then developed pigmented skin on her right breast 6 years after surgery, and this lesion was diagnosed as an angiosarcoma. The patient underwent a breast mastectomy to treat for RAAS. Following this, however, the angiosarcoma on her chest wall recurred three times within 2 years. The angiosarcoma was resected each time, and she received radiation therapy to her chest wall after the third operation. Four years after the first occurrence of RAAS, we observed light pigmentation and a dark red tumor (gross diameter of 5 mm) on her right chest wall (Fig. ). Clinically, recurrence of RAAS was suspected, and recurrence of angiosarcoma was diagnosed by biopsy. We considered that it was necessary to remove the irradiated skin as much as possible in order to cure the RAAS. After extensive resection of the irradiated skin and tumor, new skin collected from her right thigh was grafted to the site (Fig. ). Pathologically, the tumor size was 6 mm and the surgical margin was negative. Histologically, there were many spindle cells and dilated vascular channels. Immunostaining showed that the tumor was CD31-positive and mildly positive for CD34 (Fig. ). Ki-67 index was also high. It was revealed that there is no inconsistency as recurrence of RAAS is pathological. After the operation, the patient was hospitalized for 30 days and did not experience any complications. Although some reports suggest chemotherapy can be used to treat RAAS, we considered that this option would offer little benefit in this case, because the patient was elderly and had a history of cerebral infarction. Indeed, the patient has remained angi

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female with medical history of hypertension, diabetes mellitus type 2, and chronic kidney disease stage V was transferred to our institution from an outside hospital for further evaluation and definitive management of a migrated intracardiac stent.
She initially presented to the outside facility with progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema. She was initially diagnosed with acute heart failure and pneumonia and treated with diuretics and antibiotics. Subsequently, a transthoracic echocardiogram was performed, which revealed a foreign body within the right ventricle. On transfer to our facility, a transesophageal echocardiogram revealed a long stent straddling the tricuspid valve from the right atrium with the other end lodged in the trabeculation of the right ventricle with severe tricuspid regurgitation ().
On further investigation, we learned that the patient had undergone peripheral endovascular intervention for May-Thurner syndrome with placement of a self-expanding Nitinol Protege (14 mm × 60 mm) stent to the left iliac vein 6 months prior to presentation.
A percutaneous endovascular approach with a 35- mm Medtronic-Covidien Amplatzer Gooseneck Snare was initially attempted to retrieve the migrated stent. However, the snared proximal segment fractured, leaving behind 2 stent fragments. After ensuring there was no myocardial perforation or pericardial effusion with intracardiac ultrasound, the patient was referred for surgical extraction via median sternotomy with use of cardiopulmonary bypass.
During the operative procedure, the stent was found to be densely adherent to the tricuspid leaflets and the subvalvular apparatus, with majority of the primary chords to the anterior and posterior leaflets ruptured (). After successful extraction of the stent and native tricuspid valve, she underwent valve replacement with a 29-mm Carpentier-Edwards bioprosthetic valve. Her postoperative course was complicated by hemop

[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 obese woman with no medical history presented to our emergency department (ED) complaining of 3 h of right flank pain radiating to her groin. On arrival, the patient was hemodynamically stable but in acute distress, writhing in pain from presumed renal colic. Three hours after arrival to the ED, the patient was noted to be lethargic with systolic blood pressure (SBP) in the 60 s. She was transferred to the trauma bay and administered 2 L of normal saline with SBP up to the 100 s. Emergent computed tomography of her abdomen/pelvis revealed a ruptured 9.2 cm suprarenal AAA with active extravasation. The alpha TTA, the highest level of activation at our institution, was initiated by the emergency medicine attending which mobilized the operating room (OR) supervisor to halt scheduled cases to hold one OR open, the blood bank to activate the massive transfusion protocol (MTP), and the in-house acute care surgeon and anesthesiologist to the trauma bay. The attending surgeon coordinated resuscitation efforts with the MTP as the OR staff set up the room. Within 38 min of the alpha activation, the patient was in the OR with the on-call vascular surgeon for open repair of her ruptured AAA.
Emergent open AAA repair was performed with the left renal and inferior mesenteric artery sacrificed. Her abdomen was packed and an ABThera™ (KCI, San Antonio, TX, USA) open abdomen negative pressure device was placed with plans for a second look operation as the patient was severely acidotic, coagulopathic, and hypothermic. An hour after transfer to the surgical Intensive Care Unit, the patient was noted with bright red blood per rectum with associated hypotension. Bedside colonoscopy revealed ischemic pancolitis. The patient returned to the OR with the on-call acute care and vascular surgeons for exploration, subtotal colectomy, and ABThera™ replacement. Her remaining hospital course was complicated by acute kidney

[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 May 2016, a 67-year-old woman came primarily to our hospital for a consultation about painless mass of the left lower gingiva. Intra-oral examination showed a 46 × 25-mm tumor with induration on the left lower gingiva (Fig. ). A submucosal mass, independent of the gingival tumor, was palpable in the left buccal region. Several cervical lymph nodes on the left side were also palpable. Pathological examination of a biopsy sample taken from the gingival tumor revealed a well-differentiated squamous cell carcinoma.
A computed tomography (CT) scan with contrast showed a large gingival tumor, with destruction of the adjacent mandibular bone, and four metastatic left-cervical lymph nodes that were markedly enlarged, non-homogeneously enhanced, and partially necrotic. These lymph nodes included two left submandibular and two left upper jugular nodes. CT imaging showed no metastases to the lungs. Magnetic resonance imaging (MRI) showed a large primary tumor on the left side, with its epicenter located in the lower gingiva. The tumor appeared to extend into the sublingual space medially and into the buccinator muscle laterally. A non-homogeneously enhanced mass was identified in the buccinator space along the facial vessels, anterior to the anterior edge of the masseter muscle, and lateral to the buccinator muscle (Fig. ). This mass lay on the cranial side of the primary tumor. The mandibular ramus and pterygoid region that are on the cranial side of BN were not invaded by primary tumor (Fig. ). Moreover, T1-weighted MRI showed a thin layer with high signal, indicative of fatty tissue, between this mass and the primary tumor, indicating that the mass was independent of the primary tumor. Based on its anatomic location, the mass appeared to be metastatic disease to BN. Greyscale sonogram showed some metastatic cervical lymph nodes on the left, and metastatic BN. These cervical lymph nodes were markedly enlarged, round in shape, heterogenous hypoechoic, and without

[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 41-year-old Iranian man who has been in good health except mild diarrhea until 36 months ago, when he was suddenly afflicted with severe generalized abdominal pain and rebound in abdominal physical examination. He was attended by surgeon and was operated on. Surgical diagnosis was perforated duodenal ulcer. After discharge, he was prescribed omeprazole for four weeks without any investigation for H. pylori infection. He hasnot had any past medical or drug history before operation but he mentioned mild watery diarrhea and decreased appetite without weight loss since a few months ago. One month after termination of omeprazole course, acute upper GI bleeding as melena occurred and he was again admitted in another hospital. Endoscopy was done. A small bulbar ulcer was the cause. Rapid urease test (RUT) was positive. Triple anti-H. pylori therapy was completed, and omeprazole was continued for another one month. Twenty days after termination of second course of omeprazole therapy urease breath test was done which was negative for active H. pylori infection. No further medication was administered. Approximately ten days later, another bout of upper GI bleeding in the form of melena occurred. He was admitted again in the hospital. Endoscopy revealed duodenal ulcer. RUT was negative. Regarding the history and unusual accumulation of peptic ulcer complications in spite of usual management, hypersecretory states such as gastrinoma were suspected. The result of serologic tests at that time is shown in .
Abdominal computed tomography (CT) scan revealed a 10 × 8 mm lesion in head of pancreas with peripheral enhancement (in favor of an islet cell tumor) and three superficially located enhancing lesions in both hepatic lobes, in favor of hypervascular metastasis (). CT-guided biopsy of pancreatic lesion was done. Pathologic result was as follows: section reveals fragments of tissue including pancreas with a benign neoplasm composed of monotonous cells looking like

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man presented after referral by his general dental practitioner with painless swelling in the anterior region of the mandible since 1 year. Swelling was small initially and had increased to the present size.
On further elicitation, the patient gave a history of swelling in the lower anterior region after he had hurt himself with a pin while cleaning his teeth 9 years ago. Patient visited a hospital where incisional biopsy was performed and patient was prescribed medications. Swelling subsided after the biopsy and so patient did not get any treatment done for 3.5 years. Patient reported to our department with a painless swelling in the anterior region of the mandible since 1 year.
Clinical examination [Figure and ] showed a painless swelling measuring 4 cm × 3.5 cm in size in the left anterior mandibular region lateral to the symphysis. Generalized mobility in all the mandibular teeth was noted. Splinting was noted in 31 and 41 teeth []. Extraoral palpation of the mandible showed expansion of the bone with no associated lymphadenopathy.
Erythrocyte sedimentation rate, white cell count and flocculation test were within reference ranges and chest radiograph and gamma globulins were within normal limits, which ruled out systemic involvement.
Radiographs [] Orthopantomograph showed extensive bony destruction with radiolucencies involving the anterior part of mandible where the involved teeth had lost their supporting tissue and appeared to be floating in radiolucent lesion. The lesion had invaded the cortical rim giving a scooped out appearance, typical of single system LCH.[] Differential diagnosis of Ewing sarcoma, lymphoma, leukemia, metastatic disease and osteomyelitis were also considered. We decided to further diagnose the condition by taking an incisional biopsy and examining the tissue histologically.
Hematoxylin and eosin stained sections of the lesion revealed marked chronic inflammation with aggregates of histiocytes that showed features of Lange

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old obese woman presented to an outside hospital in August of 2005 with significant abdominal pain and diarrhea. Computed tomography (CT) revealed a 17 × 13 cm mass in the left upper quadrant that appeared to arise from the body and tail of the pancreas. The patient was taken to the operating room at an outside institution, but the mass was deemed unresectable due to reported involvement of the SMA, stomach, and colon. Wedge biopsy of the mass was consistent with pancreatic VIPoma. Over the next 2 years, the patient was treated with long-acting somatostatin with some improvement in her symptoms. The patient, however, developed repeat episodes of upper and lower gastrointestinal bleeding with associated anemia and ongoing transfusion requirements. Repeat CT scan revealed thrombosis of the splenic vein with numerous large splenic and gastric varices consistent with sinistral portal hypertension. In the summer of 2007, the patient underwent a failed transjugular intrahepatic portosystemic shunt (TIPS) procedure at an outside institution. The patient was therefore referred to the Johns Hopkins Department of Interventional Radiology for variceal embolization.
The patient's case was reviewed at the Johns Hopkins multi-disciplinary pancreas tumor board. A repeat three-dimensional (3-D) pancreas protocol CT scan revealed an 18 × 12 cm mass abutting the liver, stomach, spleen, left adrenal, colon and invading the distal duodenum – proximal jejunum at the ligament of Treitz. The splenic vein was occluded. Large collateral vessels surrounded the mass and were associated with extensive gastric collaterals (Figure ). The mass displaced the SMA and SMV, but these vessels were patent and uninvolved (Figure ). As such, there were no obvious contraindications to resection and surgery was recommended.
Given the size of the mass and the associated extensive varices, the patient underwent preoperative proximal splenic artery embolization (Figure ). Twenty-four hours following

[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 case of a 16 year old female patient who suffered from first grade open multi-fragment fracture of the tibia (AO42-C2) due to a complicated horseback riding accident is presented in this case report.
On admission the patient had extensive soft tissue swelling and a first grade open fracture was detected. Initial radiological assessment showed a multi-fragmentary tibia shaft fracture (AO42-C2) with a long intermediate segment (). We decided in favor of temporary external fracture fixation concept due to the extensive soft tissue swelling. Intraoperative we encountered some difficulties achieving a satisfactory alignment of the bone due to a hypermobility of the intermediate segment, however because of the extensive soft tissue swelling internal fixation was not feasible. In the end a satisfactory alignment and reduction could be achieved by an extended position of the lower limp and application of longitudinal traction. Postoperative the patient was treated with strict confinement to bed and additional physical treatments like RICE (rest, ice, compression, elevation) in order to prevent further soft tissue swelling. There was no evidence of a compartment syndrome.
It is inherent to the system that external fixation of the hypermobile intermediate fragment is difficult and despite complete immobilization the postoperative radiological assessment showed a secondary dislocation of the hypermobile fragment (). Coherently we encountered insufficient detumescence; therefore we decided to an early change of procedure. In respect of the difficulties encountered during the first surgery we decided in favor of intramedullary nailing of the tibia, to minimize the risk of malunion or deformity in our female patient we utilized the suprapatellar approach.
The patient was positioned supine on the radiolucent table. First the external fixator was removed while maintaining axial tension on the injured leg. Hereafter the knee was positioned in an extended position on a sterile pill

[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 Caucasian male came to our department complaining of the appearance of an asymptomatic left submandibular neoformation progressively increasing in size over 3 months. Medical, family, and psychosocial history were negative for relevant information; also, no previous surgical treatments were reported.
On clinical examination the mass measured 8 × 5 cm arising from level Ib (submandibular region) and extended into levels III and IV. Such mass appeared adherent to the underlying structures with soft texture. No pain or other symptoms were present. Right cervical region, oropharynx, thyroid, and upper respiratory airways showed no involvement.
Ultrasound evaluation of the mass revealed a mixed tissue consistency of cystic and solid areas separated by high flow vascular fibrous septa in level Ib.
Contrast-enhanced magnetic resonance imaging (MRI) of the head and neck () showed a 5 × 4 × 3 cm multilobed neoformation originating from the left submandibular gland. A fluid component and solid areas were inside visible. No distant metastases were detected.
To integrate MRI data, subsequent head and neck computed tomography (CT) was performed. This examination indicated colliquate areas delimited by a thick pathological peripheral tissue within the mass context.
First, fine-needle aspiration cytology specimen was performed to determine the nature of the disease. It showed malignant cells without distinctive features failing to identify the type of primary lesion. A new US-FNAC was subsequently executed; however, also in this case the primary type of lesion was not identified.
We opted for surgical treatment, completely removing the mass by means of ipsilateral neck dissection of Ib, IIa, III, and IV levels.
Histological examination showed a neoplastic proliferation characterized by two cellular components, substantially distinct from each other. No fusion of the different cell types could be seen. The first cellular component consisted of medium size elements wit

[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 male presented with high-grade fever for which he was treated empirically. After the fever subsided, he was discharged. Eleven days later the patient developed headache, vomiting, and giddiness, not associated with convulsion, unconsciousness or any ear discharge. Neurologically and hemodynamically, the patient remained stable and routine blood investigations were within normal limits. There were no visual abnormalities and fundus examination was normal. A contrast magnetic resonance imaging (MRI) [] showed evidence of well-defined altered signal intensity lesion involving foramen of Monro of which appeared hyperintense on T1-weight images, T2-weigth images and short tau inversion recovery images. The lesion did not show restriction of on diffusion weighted imaging. There was mild perilesional edema seen on fluid attenuation inversion recovery images. The lesion caused obstruction of the foramen of Monro bilaterally resulting in hydrocephalus. Postcontrast study revealed peripheral rim enhancement of the lesion. A differential diagnosis of either Colloid cyst or NCC was made.
After preanesthetic evaluation, the patient was planned for endoscopic excision of the lesion. Through a precoronal right frontal burr hole, an endoscope was introduced to assist excision of the lesion. The whole degenerative lesion was excised except small islands of the capsule that was strongly adherent to the ventricular wall []. The lesion was pale, fluffy, avascular and was blocking both foramen of Monro. Considering that ventricular cysticerci may induce a local inflammatory reaction, and fluffy part of the lesion may migrate toward the third ventricle leading to aqueduct blockage, endoscopic third ventriculostomy was done in the same setting. On the 5th postoperative day, patient developed signs of raised intracranial hypertension as well as deterioration in level of consciousness which was treated with emergency ventriculostomy followed by endoscopic visualization of fora

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 62-year-old woman, admitted to a local hospital following a short episode of loss of consciousness related to physical effort, with subsequent generalized tonic-clonic seizures. The patient had features of Hunt and Hess Grade III SAH which was confirmed by CT scan and was referred to the Bagdasar Arseni Emergency Hospital for further management. An angio-CT scan [] and a four-vessel DSA [] were performed, which showed a ruptured ophthalmic artery aneurysm.
During the diagnostic angiography, the interventional radiologist also attempted endovascular treatment, but embolization had to be aborted due to the anatomic particularities of the case. In addition to the multilobulated aspect of the left ophthalmic artery aneurysm, the left ICA was intensely atheromatous, and the right ICA was hypoplastic. These findings related a high thrombo-embolic risk and rendered the endovascular treatment impossible.
Given this particular anatomical setting, we decided to perform an early surgical intervention, hoping to offer the patient the best chance of avoiding subsequent vasospasm. The intervention proved challenging, as the aneurysm size and location provided a very narrow working space. The surgical procedure was performed in a classic fashion, beginning with a left pterional flap. The proximal sylvian fissure was dissected after brain relaxation was obtained by having inserted an external ventricular drain into the frontal horn of the lateral ventricle. The ICA was then followed from the bifurcation to the emergence from the cavernous sinus, and additional CSF leakage provided further brain relaxation. We did not need to use a temporal clip, as the proximal ICA was adequately exposed. The base of the left anterior clinoid process was subsequently drilled and the aneurysm was dissected from its adherences. A 10 mm Yasargil titanium clip was applied on the neck of the aneurysm, parallel to the ophthalmic artery. Previously, the artery had been carefully d

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


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

[User]
RADIOLOGY NOTE:
This patient was a 57-year-old right-handed traffic policeman with a history of diabetes mellitus and hypertension. He was first admitted to a local hospital due to urgent hematochezia and upper abdominal discomfort. Emergency gastroscopy proved duodenal ulcer bleeding. After blood transfusion, he presented paraphasia, walking instability, and loss of bimanual coordination, characterized by the left hand performing opposite movements to the right hand. He also complained that his left hand did not belong to him but to someone else. More importantly, the patient showed loss of coordination as well as mirror movements between the lower limbs. For instance, he had difficulty going to the toilet by himself, because when his right leg moved forward, his left leg moved back at the same time. This phenomenon disappeared gradually and then mirror movements appeared. Sometime when his right leg moved forward, his left leg did the same action. Two weeks later, he was admitted to our hospital because he suffered from anesthesia of the left side of his body.
On examination, the patient was alert and oriented. There was only mildly dysarthric speech. Hypesthesia of his left side of body and face was observed. His motor strength and tone were both normal. But deep-tendon reflexes in all extremities reduced symmetrically and frontal lobe releasing signs such as reflexive grasping were absent. Other general physical examinations were all within normal limits. The brain magnetic resonance imaging (MRI) showed a few regions with low signal intensity in the genu, body, and splenium of the right corpus callosum on the T1-weighted image and high signal intensity in the same area on diffusion-weighted images (DWI), T2-weighted, and fluid attenuated inversion recovery (FLAIR) images (Fig. ). Computed tomographic angiography of the cerebral vessels did not show any obvious stenosis in cerebral arteries. Our patient got 23 and 12 scores in the Mini-mental State Examination and Montreal Cogn

[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 proband is a 14-year-old previously healthy female born to nonconsanguineous healthy parents who was admitted for having fever, fatigue, lower quadrant abdominal pain, and vomiting. Abdominal computerized tomography (CT) revealed significant hydronephrosis consistent with a right ureteropelvic junction (UPJ) obstruction, for which she underwent ureteral stent placement on hospital day 2. Her postoperative course was complicated by continued abdominal pain and fever, as well as an episode of rectal prolapse. Of note, she also endorsed an episode of rectal prolapse months prior to presentation which was manually reduced at home. On hospital day 6, due to continued fevers, abdominal and pelvic MRI was obtained. This study revealed a pelvic fluid collection concerning abscess; CT guided transgluteal drainage performed by Interventional Radiology resulted in 150ml cloudy yellow fluid. The etiology was believed to be an infected urinoma caused by instrumentation during stent placement and she was treated with ceftriaxone and metronidazole. The patient's fevers and pain continued, prompting an abdominal and pelvic CT on hospital day 10. The imaging was notable for diffuse ascites, bowel wall thickening, and organizing fluid collections within the pelvis. She ultimately went for exploratory laparotomy and washout with intraoperative findings of multiple pockets of turbid fluid. The entire bowel was evaluated and there was no evidence of perforations, fistulas, or other causes of gastrointestinal leakage. Peritoneal fluid cultures grew polymicrobial organisms, however, suggestive of gut flora. She was transitioned to meropenem and fevers eventually resolved prior to discharge.
Two months following discharge the patient underwent outpatient elective appendectomy, right pyeloplasty, and ureterotomy with stent placement due to persistent hydronephrosis. Pathology revealed normal appendix tissue. Ureter pathology was significant only for acute and chronic inflammation, with

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male presents with complaints of ill-defined right periorbital pain associated with intermittent photosensitivity. His symptoms progressed to involve discomfort in the right upper neck. He had no focal neurological deficits on detailed cranial nerve testing. A formal ophthalmology evaluation was negative for papilledema and visual disturbances. He noted symptomatic relief from applying pressure on the lateral aspect of his right neck at the level of the hyoid bone, and he was noted to “readjust” his neck constantly for symptomatic relief during the clinical visit. The symptoms were refractory to medical therapy. Staring at a computer screen had become increasingly uncomfortable, interfering with his daily occupation. He recalled falling face down while playing soccer several weeks prior to symptom onset. MRI of the brain was normal. MRI of the cervical spine revealed age-appropriate mild degenerative changes and diminutive venous caliber in the neck. A computed tomography venogram (CTV) demonstrated enlarged paravertebral and suboccipital plexus, right worse than left, and dynamic compression of the ipsilateral extracranial IJV by a hypertrophic hyoid bone and thyroid cartilage, worsened with leftward head turn in the presence of contralateral IJV compression in the upper neck (Figure ). The focus of IJV compression, as well as hypertrophy of the paravertebral venous plexus is well illustrated on 3D reconstructions (Figure ).
After extensive counseling and exclusion of alternative possible explanations of his disabling symptoms, it was decided to proceed with decompression of the right IJV via an anterior approach. After induction of anesthesia, a transverse right-sided incision was made following a natural skin crease to expose the posterior half of the greater horn of the hyoid, which was then bisected, and the posterior free portion was disconnected from the thyrohyoid ligament and excised. The superior horn of the thyroid cartilage was also resecte

[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 50-year-old man underwent left anatomical hemispherectomy at the age of 5 years because of infantile hemiplegia and intractable seizure disorders. Three months after the operation, the bone flap was removed because of osteitis and substituted by an acrylic cranioplasty in 1971 that is 2 years after the primary operation. The seizures were controlled and the child showed a satisfactory motor and cognitive development, with improvement of the right hemiparesis and good academic results. In 1984, the patient fell off a bicycle with severe head trauma. He developed an epidural hematoma on the right side, bleeding into the left hemispherectomy cavity, and decompensation of a previously documented arrested hydrocephalus []. The patient underwent an emergency right craniotomy to remove the epidural hematoma at the Ancona University Hospital and remained for 3 months in the intensive care in a comatous state, with a new left-sided hemiparesis and reoccurrence of seizure disorders. The patient was then referred to San Camillo Hospital in Rome where he underwent further surgical procedures by one of the authors (SV). A temporary external shunt of the right ventricle was applied to wash and clean the hemorrhagic CSF. A fractured acrylic resin cranioplasty was removed. A naturally “reparative” process closing the left foramen of Monroe was respected. A gel-like chronic subdural hematoma of the cavity was removed. A reduction duraplasty, with a Lyodura patch, was performed to reduce the volume of the subdural hemispherectomy cavity and to substitute a thick hemorrhagic dura. A permanent V-P shunt was applied. Subsequently, an intracranial Silastic breast prosthesis was apposed on the Lyodura patch and maintained in place using an overlying metallic mesh with flattened curvature to further reduce the hemicranium (Fig. ). The rationale for these procedures was previously described in detail in this journal [].
The patient’s clinical condition progressively improved with recov

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old male presented with a history of trivial fall from a ladder (5 Ft) and landing on the right heel. He complained of pain and swelling. On examination, he had swelling over the medial aspect of right heel (). The skin over the swelling was stretched and it was soft in consistency and tender. No relevant history and family history in view of bone cyst and malignancy. No evidence of any risk factors.
Radiograph of right ankle revealed an eccentric, expansile, and cystic lesion of the calcaneum with thin septae traversing the cystic cavity giving it a blown out or soap bubble appearance. There was a cortical breach suggesting fracture (). In our case, we avoided computed tomography/magnetic resonance imaging (CT/MRI) due to the expense, and we proceeded with biopsy and histopathological examinations, which is more informative.
The patient underwent two staged procedure: First for biopsy followed by second procedure after confirmation by histopathological examination.
Under strict aseptic precautions, biopsy was done under anesthesia. The specimen was sent for histopathological examination and it was diagnosed by a pathologist as aneurysmal bone cyst.
A differential diagnosis of aneurysmal bone cyst or giant cell tumor with pathological fracture was made. Under spinal anesthesia and strict aseptic precautions, the lesion was curetted and the cavity was filled with iliac bone grafts ( and ). The curetted specimen was sent again for histopathological examination, and the diagnosis was confirmed (). The wound was closed, dressed, and below knee posterior plaster slab was applied.
Postoperatively, a nonweight bearing crutch walking was allowed for 6 weeks followed by partial weight bearing for further 4 weeks. Follow-up was done on 3rd and 6th month of post-operative ( and ). The patient returned to his activities at the end of 6 months, and we are still continuing the follow-up because the recurrence usually happens within 1 year.

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

[User]
RADIOLOGY NOTE:
A 34-year-old man presented with a 6-month history of pain and swelling in his left knee. His medical history included prior presentation with a similar complaint for 5 years, involving left knee pain and difficulty walking. A mass had been detected in the center of his left distal femur, with a soft tissue component. The mass had increased in size and had become painful. There was no history of trauma.
Physical examination revealed a fixed, hard, painless, and palpable mass measuring 7-8 cm in diameter and locating on the patient's left distal femur. The patient had no neurovascular problems and no palpable lymphadenopathy. Standard laboratory test results were within normal limits. A roentgenographic study showed destruction of the distal femur and a corresponding dense soft tissue mass (). An MRI examination revealed a mass with focal cortical bone destruction in the distal metadiaphyseal region of the femur. On MRI, this lesion was mainly located in the subcutaneous tissue but extended through the fascia and into the muscle and bone. Osseous involvement was detected on radiographs as subtle bone erosion of the distal femur anterior cortex. The associated soft tissue was isointense to muscle on the T1-weighted image and was intermediately hyperintense to muscle on the T2-weighted image and showed intense enhancement after contrast medium administration (). No evidence of regional or distant metastasis was found in the patient. Biopsies of the neoplastic lesion contained elevated numbers of inflammatory cells.
In February 2011, the patient underwent distal femoral tumor resection and reconstruction with a modular prosthesis. During surgery, the tumor appeared encapsulated and consisted of multiple poorly circumscribed nodules, and the cortex appeared excavated from the outside. The excised lesion was 16 cm × 12 cm × 8.5 cm in size, with a capsule-like structure, and demonstrated a beige cut surface. The tumor had infiltrated the bone tissue as well as the soft tis

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old previously healthy Sri Lankan female presented with fever and cough for three days to our Emergency Treatment Unit. Her rapid antigen test and polymerase chain reaction (PCR) for COVID-19 were positive and she was managed as moderately severe covid infection at ICU with noninvasive ventilation and high flow nasal oxygen (HFNO); however, invasive ventilation was not needed. On day 20, her COVID-19 exit PCR was negative and she was transferred to the general medical ward for the continuation of treatment.
While recovering from moderate to severe covid infection, she developed excessive fatigue and shortness of breathing. She had severe pallor and tachycardia on examination. She was oxygen-independent and there were no signs of hypoxia in her arterial blood gas. Her ECG showed normal sinus rhythm and the troponin I was negative. Initial blood investigations revealed an acute drop of hemoglobin to 5.1 g/dl from her baseline of 11 g/dl. White blood cell count and the platelet counts were within normal limits. There was no other evidence of any cardiac or respiratory disease. Transthoracic echocardiogram showed normal left ventricular function with no evidence of pulmonary embolism and the D-dimers were within normal limits. Her high-resolution computer tomography of the chest revealed only resolving consolidation. Her thyroid status was also found to be euthyroid.
On further history taking, there was no evidence of any internal or external bleeding. There is no family or past history of hematological malignancy or connective tissue disorders. In summary, she was a relatively healthy female with no risk factors for AIHA until she developed COVID-19.
Her initial blood tests showed evidence of hemolysis with high reticulocyte count, lactate dehydrogenase (LDH), and indirect hyperbilirubinemia. A blood smear confirmed the presence of severe hemolytic anemia. The direct antiglobulin test was positive. Her Coombs profile confirmed warm-type autoimmune hemolytic a

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old Asian male presented to the gastroenterology office for a follow-up of a previously found duodenal lesion. He had an EGD at an outside facility 2 years earlier for evaluation of abdominal pain which showed a 1.2 cm duodenal polypoid lesion in the second portion of the duodenum. Pathology of the polyp revealed heterotopic gastric mucosa with benign lobules of gastric glands. He also was found to have chronically active H. pylori gastritis with numerous Helicobacter organisms and atrophic gastritis with patchy areas of intestinal metaplasia. At that time, he was instructed to follow up for a repeat endoscopy for surveillance in two years. As recommended, two years later he presented to our office for surveillance of his duodenal lesion. Due to his history of atrophic gastritis and a large duodenal lesion, we performed an upper endoscopy that showed atrophic gastritis, duodenitis, and a single 10 mm polyp in the second portion of the duodenum. The duodenal polyp was biopsied. Pathology revealed polypoid gastric metaplastic mucosa with focal epithelial atypia including nuclear enlargement, stratification, nucleoli, and few mitoses. The patient was referred for endoscopic ultrasound to further characterize the lesion and complete resection. Several weeks later he underwent an endoscopic ultrasound that revealed a 13-mm pedunculated and sessile polyp on the lateral wall opposite to the major papilla in the second portion of the duodenum (). The polyp was removed en bloc using a hot snare following a 4-mL saline lift. Two endoclips were placed for hemostasis. Pathology revealed a pyloric gland adenoma (Figures , , and ) with predominantly low grade dysplasia (Figures and ) and some small areas of focal high grade dysplasia. The slides were read by the in-house pathologist and were also reviewed by a GI expert pathologist at the University of Michigan. The patient was recommended to follow up for surveillance upper endoscopy in 6 months due to the areas of hig

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 36 year-old pre-menopausal Asian woman previously in excellent health, presented with a three-month history of a progressively worsening tender right breast lump, with associated ulceration, induration, and erythema, draining serosanguinous fluid. She denied systemic symptoms, as well as any known recent fungal or tuberculosis exposure. The patient is a G2 P2002 who nursed her children without difficulty. She has had no history of breast disease, and her past medical and surgical histories are otherwise unremarkable. She denied tobacco use, any family history of breast diseases, use of any medications including oral contraceptives, or any known drug allergies. Physical examination was otherwise unremarkable with no palpable lymphadenopathy.
During initial presentation to an outside hospital, mammography and breast ultrasound revealed an increased density and ductal dilatation of the right breast with associated edematous changes. All laboratory and other radiological studies were otherwise normal. Although malignancy had not been excluded, the patient received a presumptive diagnosis of mastitis and was treated with a 7-day course of amoxicillin and cefadroxil without improvement. This was followed by a course of cefdinir and gatifloxacin, which was complicated by an antibiotic-induced erythema nodosum. As a result, antibiotics were discontinued and the patient was scheduled for an open breast biopsy. Interestingly, the patient's symptoms spontaneously resolved before tissue sampling was performed.
Two months after her initial presentation, a second similar lump appeared in the right breast (Figure ). A repeat ultrasound of this area again demonstrated dilated ducts and debris. Bilateral breast magnetic resonance imaging (MRI) revealed regionally dilated ducts with prominent regional ductal and parenchymal plateau enhancement. Given these findings were not typical for mastitis, and clinical and radiological data could not exclude breast carcinoma, tissue sampling

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male with past medical history of congestive heart failure with ejection fraction of 30%, chronic kidney disease, atrial fibrillation, and alcohol abuse, presented with sudden onset of severe abdominal pain. Admission vitals were stable with the significant except oxygen saturation of 70% on room air. Labs on admission were significant for lactic acid of 5.3 mmol/L (), Acute Kidney Injury (AKI), and subtherapeutic INR of 1.5 on Coumadin. Urine toxicology screen was positive for cocaine use. CT scan of the abdomen was initially unremarkable. The patient was subsequently admitted to the ICU for severe acute hypoxic respiratory failure with potential for decompensation and clinical suspicion of mesenteric ischemia given his subtherapeutic INR in the setting of atrial fibrillation along with sudden onset of abdominal pain and elevated lactic acid without a clear cause. Cocaine abuse may have also been a contributing factor to sudden ischemia. A later repeat CT scan revealed nonspecific bowel wall thickening, and a transesophageal echocardiogram performed revealed an active left atrial thrombus, making mesenteric ischemia a higher differential. Due to the added possibility of sepsis and worsening renal function, there was no clear opportunity for surgical intervention, and conservative management was initiated through heparin drip and BiPAP showing initial clinical improvement. By hospital day 3, however, he suddenly became unresponsive. At that time, his labs revealed blood sugar of less than 10 mg/dl and worsening renal failure. The patient was aggressively managed and given multiple ampules of Dextrose 50% and infusion of Dextrose 5% was started (). Because of further decompensation of renal function, he was started on Continuous Renal Replacement Therapy (CRRT) as well. Despite these measures, his blood sugar continued to have multiple episodes reaching 40 mg/dl. His IV fluids were switched to Dextrose 10% drip and eventually to Dextrose 20% drip becaus

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


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

[User]
RADIOLOGY NOTE:
A 65 year-old male presented to the hospital with a two week history of diarrhoea and vomiting. He had no abdominal pain and no symptoms or signs of gastro-intestinal blood loss. He was initially thought to have gastroenteritis, stool samples were sent and he was treated conservatively. He was noted to be mildly anaemic with a haemoglobin level of 10.7. A flexible sigmoidoscopy (FS) was performed to begin investigation of his diarrhoea. This showed a small polyp which was benign on histology and no other abnormality. He settled and was then discharged home. Barium enema (BE) was booked as an outpatient investigation to assess the rest of the colon, and if negative, oesophageogastroduodenoscopy (OGD) would then be performed to investigate his anaemia. The waiting list for colonoscopy was too lengthy at that time, and the combination of BE and FS routinely replaced colonoscopy.
The patient was readmitted three weeks later in hypovolaemic shock with a blood pressure of 88/56, pulse 110. During this admission, he was noted to be cachetic, weighing just over 55 kilograms (Body mass index = 16.2). On further questioning he had lost over 12 kilograms in weight since the onset of his vomiting several weeks before. His admission haemoglobin level on this admission was 7.5.
In view of the worsening anaemia on this admission and a past history of duodenal ulcer in 1996, in-patient OGD and BE were requested. Meanwhile, the patient continued to receive intravenous fluid, blood and acid suppressing agents. OGD revealed an opening in the second part of the duodenum, which was biopsied. Histology showed poorly differentiated adenocarcinoma and one piece of normal colonic mucosa. BE clearly demonstrated a fistula between the hepatic flexure and second part of duodenum (figure ), and the patient vomited the barium following his enema.
Subsequent isotope bone scan and liver ultrasound did not show any signs of metastasis. Computed

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old male presented with complaints of pain in his left hip following an anterior approach for a THA, which was performed 8 months earlier at an outside institution. Per the operative report, there were no complications encountered with the surgery, including no femoral cortex perforation during reaming. He had undergone appropriate rehabilitation following the index procedure, but his symptoms remained refractory to analgesics and physical therapy. Upon arriving to our practice, a workup was begun for septic loosening of the femoral and/or acetabular component. Initial radiographs at our practice show well-aligned femoral and acetabular component without obvious evidence of loosening and with no periprosthetic fracture (Figures and ). Appropriate laboratory tests, including hip aspiration arthrogram, excluded infection as the etiology of his symptoms. A bone scan demonstrated hyperemia in the left thigh and increased uptake surrounding the femoral prosthesis. A subsequent X-ray arthrogram showed mild extravasation of contrast to the proximal aspect of the femoral component (), suggestive of aseptic loosening of the femoral stem.
The patient underwent revision of the femoral stem for THA without immediate complication. A standard, posterior approach was performed and blunt, Hohmann retractors were placed anteriorly and medially around the proximal femur for exposure of the femoral canal for reaming and cement removal. There were no complications encountered intraoperatively. Postoperative radiographs show the femoral and acetabular components in good positioning without periprosthetic fracture or femoral cortex perforation (Figures and ). He was discharged in stable condition on the third postoperative day to a skilled nursing facility.
10 days postoperatively he presented to the emergency room for tachycardia. Workup in the ER included INR (3.6), basic labs, and a CT of his left lower extremity. CT showed concern for possible underlying hematoma in the ope

[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 years old boy had a sudden onset of swelling in his left lower extremity along with pain which were worsening gradually for past 1 month duration. He had no history of fever, headache, cough, chest tightness, chest pain, abdominal pain and diarrhea. His CD4+ T lymphocyte cell count was 522 cells/μL and plasma VL was 943 copies/mL with a blood pressure around 97/69 mmHg at that time. Initially, topical ointment was applied for 1 month which were ineffective in reducing pain and swelling. Instead, the symptoms were aggravated and suddenly spread to the proximal thigh, accompanied by dyskinesia of left lower leg. The child was a known case of HIV positive since the age of two and was believed to be infected through mother to fetus transmission. He has been taking first-line regimen of ART (AZT + 3TC + NVP) since last 4 years when his CD4+ T lymphocyte cell count had reached 346 cells/μL at that time. The plasma HIV RNA was undetectable after half a year of ART.
His mother was HIV seropositive person. The child had no personal and/or family history of thrombotic diseases. There was no history of any prior surgery, trauma, prolonged bed rest, obesity, smoking and any other common risk factors of thromboembolic events.
On physical examination during hospital admission, the maximum circumference of his left thigh was 38 cm and the right thigh was 34 cm. The maximum circumference of his left calf was 27 cm and the right calf was 24 cm. His left lower thigh was inflamed and swollen, accompanied by tenderness and presence of varicose veins.
On hematological tests, his white blood cell (WBC) count was 3.28 × 109/L with a CD4+ T lymphocyte cell count of 430 cells/μL, hemoglobin (Hb) was 126 g/L and platelets was decreased to 66 × 109/L. On virology test, HIV RNA was found to be 580 copies/

[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 76-year old woman with a bioprosthetic aortic valve replacement three months prior and well-controlled diabetes was referred to the ED by her optometrist with one day of right eye pain and decreased visual acuity. She denied having fevers, night sweats, dyspnea or chest discomfort, and did not report a history of chemical exposure or trauma to the eye. On exam, she was afebrile, HR 60 and BP 120/59. Her right eye had diffuse conjunctival injection, corneal opacification and a dense vitreous with loss of red reflex. Visual acuity in the right eye was intact only to hand waving. Extraocular movements were full and there was no periorbital erythema or swelling. Left eye exam was normal with clear conjunctiva and 20/20 visual acuity. Ophthalmology evaluated the patient emergently and vitreous aspiration was performed. Empiric intravitreal vancomycin and ceftazidime were administered for a diagnosis of acute endophthalmitis. The patient was admitted due to concern for a systemic source of infection. Her cardiac exam was benign, without murmurs or pathologic heart sounds. Lungs were clear. There were no stigmata of endocarditis. Initial labs showed no leukocytosis and normal kidney function. An EKG was unchanged from prior. Gram stain from the vitreous aspiration was negative and cultures had no immediate growth. Blood cultures were also negative. A TTE revealed thickening of the posterior aspect of the aortic root but was otherwise unremarkable. Further evaluation with CT angiography (CTA) of the chest was performed and revealed a 3.4x2.25 cm pseudoaneurysm of the ascending aorta with extensive thrombus extending to the mid-descending thoracic aorta ( and 2).
The patient was taken for emergent surgery, which revealed disruption of the aortotomy suture line with a large thrombus both outside and within the aorta. The aortic valve was unaffected and there was no evidence of suppurative infection, therefore a Dacron patch was used to close the opening. Three days post

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old man had already been diagnosed stage V chronic kidney disease for 2 years but did not receive renal replacement therapy. Otherwise, he had no history of foreign travel and familial problems. This time, he visited our emergency room due to high fever and chills for a day. Abdominal fullness, anorexia, and weight loss had also developed for 3 months before this visit. The physical examinations revealed a tachycardia of 114 beats per minute, fever of 38.4°C, and diffuse abdominal tenderness. The blood sampling showed leukocytosis, azotemia, and increased serum procalcitonin level (Table ). The urine analysis revealed the pyuria, suggesting the complicated urinary tract infection. The abdominal plain film showed mixed osteoblastic and osteolytic changes: cortical thickening, sclerosis with coarsened trabeculae, and flame-shaped lucent lesion in the pelvic bone with right site predominantly (Fig. ).
Considering the image results and other clinical symptoms such as anorexia and weight loss, the differential diagnosed of the bone lesion is crucial for the patient. The blood chemistry results on the second day, showed only mild elevation in alkaline phosphatase (ALP) and inorganic phosphorus, while highly elevated parathyroid hormone but decreased corrected calcium was noted, favor secondary hyperparathyroidism due to chronic renal function insufficiency (Table ). On the third day after admission, we check the serum tumor markers of leading causes for bone metastasis in the male patients, such as carcinoembryonic antigen and squamous cell carcinoma antigen for lung cancer and prostate-specific antigen for prostate cancer, and all of 3 markers showed normal or mild elevation (Table ). Monoclonal globulin elevation was not identified in serum screening as well (Table ).
Otherwise the abdominal plain film, the skull X-ray plain film was performed on the second day after admission and demonstrated no osteolytic lesions (Fig. ). We arranged gallium-67 tumor scan a

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old man was diagnosed with bilateral Fuchs’ endothelial dystrophy, endothelial decompensation after cataract surgery with IOL implantation in his right eye, and an initial cataract in his left eye. An uneventful DSAEK was performed on his right eye. After donor graft insertion, an air bubble was injected into the anterior chamber for graft apposition and kept for 5 min at the pressure between 20 and 30 mmHg, followed by exchanging air with a balanced salt solution. At the end of the procedure, a residual air bubble filling 50% of the anterior chamber volume was left. On the second postoperative day, the graft was partially detached, so it was decided to re-bubble the anterior chamber with air. After re-bubbling, the graft remained well centered and completely attached. Postoperative standard medications included fluoroquinolones eye drops four times a day for 2 weeks and prednisolone acetate eye drops 1% four times daily for a month, then to be tapered accordingly. After the initial visual improvement, at five months post-operatively, the patient began complaining about worsening of visual acuity. At that time, the cornea was slightly edematous with no sign of postoperative anterior chamber inflammation. However, ten months following DSAEK, the corneal graft became cloudy and corneal decompensation was diagnosed. Upon slit-lamp examination, in addition to corneal decompensation, central IOL opacification confined to the pupillary zone of the anterior IOL surface was found. The patient subsequently underwent penetrating keratoplasty (PKP) with IOL exchange. During the surgery, the opacified IOL was explanted from the bag and a new IOL was implanted in the ciliary sulcus because of suspected damage to the capsular zonules.
The explanted IOL was then imaged by optical microscopy, atomic force microscopy, photoelectron spectroscopy, and mass spectroscopy to investigate the morphology of the surface opacification and its chemical composition. The patient was op

[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 work-up of a 40-year-old female with a history of low back pain, a routine MRI of the lumbar spine identified an incidental lesion. The axial T
1 weighted image showed a 21-mm round, homogeneous lesion of low signal intensity interforaminally in the left S2 segment of the sacrum. The axial short tau inversion-recovery image showed a well-defined lesion with an inhomogeneous signal intensity throughout the lesion with high peripheral rim intensity. The axial T
1 image with fat saturation after contrast media injection showed moderate enhancement throughout the lesion and in the peripheral rim (). A radiograph of the pelvis was performed to further characterize the lesion. On clinical examination, the sacral area was not painful to palpation. Owing to the atypical appearance of the lesion and the non-specific nature of the MRI signal pattern, a bone scan was performed that showed a solitary lesion on the left side of the sacrum with increased metabolic activity. For further characterization, and in the search of a potential primary tumour, positron emission tomography (PET)-CT was performed, which showed a well-defined sclerotic lesion with mild fludeoxyglucose (FDG) avidity (average standardized value 2.5) in the S2 segment and no other abnormalities (). Owing to the metabolic activity of the lesion, the patient was referred to the orthopedic oncology department for image-guided biopsy of the lesion. The biopsy specimen consisted of a few small fragments of bone marrow, some skeletal muscle, fibroadipose tissue and blood clots. Infiltration of the otherwise normal bone marrow with scattered small groups of big foamy cells was identified (). The foamy cells had vacuolated cytoplasm and small centrally located nuclei. The cells were negative for cytokeratin AE1/AE3, CD68, barchyury, Melan A, HMB 45, desmin and smooth muscle actin but positive for S100 protein (). The cells contained multiple lipid droplets and numerous large mitochondria; the existence 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:
The present case report is about a 25-year-old female patient who reported to the Department of Oral and Maxillofacial surgery with swelling in the right lower third of face below the lower border of mandible since 6 months []. Recently, the swelling had suddenly increased in size with severe pain from the past 3 days. On examination, it was associated with infected molar, which was assumed to be the etiology of the swelling, for which extraction was carried out. After extraction, the pain subsided, however, the swelling was persistent and had not completely resolved even after a month. During the follow-up visit, the lesion was soft, non-tender and compressible and it measured 5 × 4 cm in size approximately. The skin over the swelling had normal texture and consistency. No bruits were heard on auscultation. The patient informed us that the swelling intermittently increased and decreased in size and has reached the present size. The growth although painless was cosmetically disfiguring.
On investigation, needle aspiration yielded a blood-tinged clear fluid which resembled lymphatic fluid, which was examined in light microscopy. After a routine blood investigations, the patient was advised an orthopantomograph which failed to reveal any bony changes. Later on, the patient was advised to undergo an ultrasonographic scan which revealed a multicystic lesion with internal septations. A computed tomography (CT) scan with contrast was carried out, which revealed a multicystic, homogeneous, non-invasive lesion with low attenuation.
The lesion was provisionally diagnosed as a lymphatic malformation and incisional biopsy was planned. A 5-cm extraoral incision was placed in the first cervical crease. Blunt and sharp dissection was carried out to free the lesion from the overlying platysma muscle. Once the lesion was identified, aspiration of some content of the cyst was carried out to reduce the size of the lesion. Blunt dissection was carried out to protect vital structures 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 67-year-old male with a history of hypertension, type 2 diabetes, and hyperlipidemia, who went through the Inova Movement Disorders Program due to a history of fluctuating, progressing uncontrollable movements of the left side of his body. He reports these movements had been present for around 10 years, worsening over time.
At baseline, he always felt that his left arm and leg were moving, at times exhibiting large amplitude movements which could knock things down or affect his walking, making him fall. He described it as abnormal, uncontrollable movements that made his arm ‘reach around or fling out’ His leg was also described to ‘dance on its own.’ While at baseline, these were present but minimal stress or anxiety would exacerbate the movements. There were no movement issues on his right side, nor any facial movements noted.
His exam showed episodic, mild with some interspersed moderate-amplitude quick movements of the left hand, forearm, proximal arm muscles, as well as movement of the left leg. These were not suppressible, brought out more by distraction or with anxiety, such as discussing an MRI scan as he was claustrophobic. He also demonstrated some lateralizing movements of the head to the left, but no facial or tongue movements. His right side showed no such signs, and his neurological exam was otherwise unremarkable.
He was sent for a CT scan of the head initially due to a fear of MRI scanners, and was found to have asymmetric calcification of the right caudate nucleus and anterior putamen (Figure ). The calcification spared the anterior limb of the internal capsule. Laboratory work for parenchymal calcification was then sent and was normal. The MRI of the brain with contrast demonstrated both hypointense gradient echo (GRE) signal in the right caudate nucleus and putamen, as well as an underlying DVA (Figures -).
Given the lateralizing of his

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


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

[User]
RADIOLOGY NOTE:
A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.
The examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.
The blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old male with a past medical history of coronary artery disease status post coronary artery bypass grafting, hypertension, chronic obstructive pulmonary disease, diabetes mellitus type 2, and cerebrovascular accident presented to a local hospital with acute abdominal pain and bloating. A computed tomography (CT) scan of the patient's abdomen and pelvis was performed and showed intraabdominal bleed and multifocal liver lesions. Initial complete blood count (CBC) revealed a hemoglobin of 7 g/dL and he was transfused one unit of packed red blood cells prior to transfer to our institution. On arrival, CT angiogram of the abdomen and pelvis showed multiple dense, heterogeneous masses throughout the liver with associated perihepatic and intraperitoneal hemorrhage and areas of tumor blush were noted but no extravasation was seen to suggest active hemorrhage. There was also multiple enlarged periportal and upper mesenteric lymph nodes, likely representing metastatic adenopathy. There were no lesions present on the pancreas. CT chest was obtained and showed no evidence of intrathoracic metastatic disease. Initial blood work revealed normal liver function tests, appropriate response in hemoglobin to transfusion and negative viral hepatitis panel. Tumor markers revealed AFP elevation to 8705 ng/mL, normal Carcinoembryonic Antigen and Cancer Antigen 19-9. Magnetic Resonance Imaging (MRI) of the abdomen and pelvis showed multiple lesions throughout the liver with targetoid appearance. There was no evidence of cirrhosis and these lesions did not have imaging characteristics of typical HCC (Figure ). It was suspected the multifocal liver lesions were HCC given the elevated AFP. However, the MRI was not consistent with HCC and a liver biopsy was obtained. Pathology results were consistent with poorly differentiated, large cell-type neuroendocrine carcinoma with metastatic disease to the liver (Figure ). The patient had an unremarkable colonoscopy and esophagogastroduodeno

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old female was diagnosed with SLE at 12 years of age. At around 27 years of age, she experienced several instances of seizures and began taking antiepileptic drugs. On brain magnetic resonance imaging (MRI), diffuse cortical atrophic changes and an old infarct lesion in the left superior parietal cortex were detected. Three years later, she had fever, clonic seizure and loss of consciousness. On T2-fluid attenuation inversion recovery (FLAIR) imaging, a high-intensity signal change was detected in the left temporal and frontal lobes, both occipital lobes, and the midbrain (). She was also diagnosed with antiphospholipid syndrome. After 15 days of treatment, which included intravenous methylprednisolone, immunoglobulin and anti-epileptic drugs, she regained consciousness and her motor weakness was improved. Follow-up brain MRI showed improvement of the previous lesions, which were suggestive of posterior reversible encephalopathy syndrome (PRES) (). As she had fever and a urinary tract infection (UTI), the infectious condition following immunosuppressant therapy with cyclosporine was thought to be the cause of PRES. At her first admission to the Department of Rehabilitation Medicine, consistently with the dramatic neurological recovery commonly observed in patients with PRES, she showed mild functional and cognitive impairment. One week after the start of rehabilitation, weakness of the left extremities and fever were noted. Brain MRI showed acute infarction in the right basal ganglia (). Acute cerebral infarction was considered related to SLE activation due to UTI. One month after treatment in the Department of Rheumatology, she was returned to the Department of Rehabilitation Medicine. We performed an electrodiagnostic study and whole spinal cord MRI to rule out other superimposed diseases, such as neuropathy, transverse myelitis, and myelopathy. The cross-sectional area of the spinal cord from the cervical through the conus medullaris was markedly thin o

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


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

[User]
RADIOLOGY NOTE:
An otherwise healthy 12-year-old boy had left-sided abdominal pain after being beaten in the area. He then experienced temporal symptom improvements, but his symptoms recurred, prompting visit to a nearby hospital. The abdominal roentgenogram could not show abnormal findings []. A mass was detected on contrast-enhanced computed tomography (CT), and he was referred to our hospital forfurther investigation and treatment. Physical examination revealed tenderness on the left abdomen. C-reactive protein was 3.6 mg/dl, and other laboratory tests were normal.
Contrast-enhanced CT showed an oval mass in the upper left abdomen adjacent to the pancreatic tail, clearly separated from the spleen, the left kidney, and the left adrenal gland []. The mass, located below the spleen, was less dense than the spleen. A tubular low density structure connected to the normal spleen was detected above the mass; thus, it was considered as twisting of the vascular pedicle of the accessory spleen.
US revealed an inhomogeneous oval mass, measuring 4 cm in diameter below the spleen []. The mass was mainly hyperechoic, similar to the spleen, and the central part showed irregular low echoes. A small amount of ascites was detected in the pelvis. The following day, there was a notable decrease in the internal echo of the mass with linear hyperechoic spots noted in the hypoechoic areas []. Four days later, the expansion of the internal hypoechoic areas was noted, and the linear hyperechoic spots became more prominent []. A tubular structure from the upper edge of the mass to the spleen was detected [Figure and ], and there was no blood flow signal in the mass []. This tubular structure was considered to be a vascular pedicle of the accessory spleen; thus, accessory spleen torsion was diagnosed.
Twenty-five days after the injury, laparoscopic resection was performed [], and the accessory spleen was found adhered to the omentum and colon, twisted four times around its axis.

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old Caucasian man, with a 4-week history of right upper quadrant and right flank pain radiating to his right testicle, presented to his general practitioner. There was no preceding trauma, haematuria or any other systemic symptoms. The past medical history included osteoid osteoma in the left upper femur, which was removed in 2007. He also had L4/5 microdiscectomy. There was no positive family history of medical problems or cancer. He was a non-smoker, had no allergies and was not taking any regular medications. The general practitioner organized an ultrasound, which revealed a large subcapsular haematoma measuring 7 × 5 × 7 cm in the right kidney compressing the renal cortex. Further investigation with computed tomography (CT) scan of the abdomen with intravenous contrast revealed enlarged right kidney with subcapsular haematoma and a mass lesion within the right lower pole measuring up to 7.4 × 7.5 × 9.2 cm with associated paracaval lymphadenopathy producing compression of the right renal vein and inferior vena cava (). The patient was then referred to an urologist for further management.
Physical examination revealed that the right kidney area was filled, with minimal tenderness. The haemoglobin concentration was 140 g/L. There was a mild elevation of creatinine (116 µmol/L), and the estimated glomerular filtration rate was 66 ml/min. CT staging showed a large right renal tumour and significant paracaval lymphadenopathy producing compression of the right renal vein and inferior vena cava. The size of the tumour was substantially increased in size to 11.5 × 11.6 × 11.5 cm when compared with that in the previous CT scan.
A preliminary diagnosis of renal cell carcinoma was made based on the clinical findings and investigations. The patient underwent open radical right nephrectomy, retroperitoneal lymph node dissection and partial excision, and reconstruction of vena cava. The renal samples were sent for histopathology. The right kidney specimen (with fibro

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


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

[User]
RADIOLOGY NOTE:
A 6-hour-old female neonate born from a 22-year-old Para 1 mother after term pregnancy. The newborn had protrusion of mass per vagina since birth; she also has a defect at the lower back with no discharge since the time of birth. Additionally the mother has noticed deformity on both legs and feet which barely move. The baby was active since the time of delivery and is sucking well and she passed meconium. The mother had two ANC visits and was vaccinated according to the national schedule and she reported the whole course of the pregnancy as uneventful. She did not have any known medical illness and has never taken any medication during the entire course of the index pregnancy except iron folate which was prescribed during the ANC visit.
She had spontaneous onset of labor and the membrane was ruptured spontaneously intrapartum. She gave birth to a 2330-gram female neonate after 5 hours of labor at a local health center. Baby had good APGAR score. Health care providers at the health center noticed defect at the back of the baby and referred her to Hawassa University Comprehensive Specialized Hospital (HUCSH) with the diagnosis of spinal bifida.
During the initial evaluation at HUCSH the baby was active, vital signs were in the normal limits, and all neonatal reflexes were intact. There was 4x4 cm pink mass protruding through the introitus, cervical os is noted at the tip of the mass, the external genitalia appears normal, no discharge or bleeding from the mass, and the mass was reducible digitally and increases in size when the baby cries (see ). There was also 4x4 cm defect at the lumbosacral region the major portion of which is covered with skin while the lower edge is open, no discharge from the mass (see ). Additionally the newborn had bilateral club foot deformity (see ).
On investigation, the complete blood count was normal, creatinine level was 0.4mg/dl, and transf

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old caucasian female was diagnosed with thyroid papillary carcinoma after total thyroidectomy in 2001. Diagnosed with postsurgical hypothyroidism under treatment with levothyroxine, 100 micrograms per day. There was no other previous medical history of interest. The patient did not consume tobacco or alcohol.
In 2008, a computerized tomography scan (CT) showed locoregional relapse and surgery was performed with resection of locoregional recurrence and left cervical lymphadenectomy. In November 2011, pulmonary relapse was treated with I-131 since November 2011 until March 2012 (total accumulated dose: 850 mCi). In October 2016, a CT scan showed a progression of the disease with cervical and pulmonary progression. The patient started sorafenib, 400 mg twice a day. Stable disease was maintained during 20 months. In June 2018, patient presented an episode of abrupt instability and cervical pain. The magnetic resonance imaging (MRI) (Fig. ) showed a new metastatic lesion in the skull base with destruction of bony structures of the left occipital-petrous region. At this point, a molecular study of the cervical node was performed and a mutation in BRAF was found.
Due to the lack of alternative therapeutic options, treatment with vemurafenib–trametinib was requested as a compassionate use. In August 2018, patient was started on the combination of dabrafenib 150 mg twice a day and trametinib 2 mg once a day. MRI in October 2018 showed a slight decrease of the metastatic lesion in the skull base (Fig. ). In addition, the patient showed evident clinical improvement with decreased initial headache and cervicalgia.
A follow-up PET–CT scan was performed in January 2019. Tumor was on radiological partial response. In addition, there was intestinal pneumatosis with mild sign of pneumoperitoneum (Fig. ). Patient had no digestive symptoms and the abdominal medical examination was completely normal. Also normal neurological examination was verified. Routine physical examinat

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old gravida 4 para 1 female was presented to our hospital with 7 weeks of amenorrhea and positive for pregnancy test. After menarche at the age of 14 years, her menstrual cycles were regular and occurred approximately every 30 days with menstrual periods lasting 5 days. Her body mass index was 30.7 kg/m2. Transvaginal ultrasonography (TVUS) revealed a gestational sac and fetus in uterus and a solid mass of approximately 5 cm in diameter in the right ovary. The primary clinical course of her pregnancy was good, and magnetic resonance imaging (MRI) was performed at 12 weeks of gestation to assess the solid mass. MRI revealed diffuse enlargement of the right ovary with iso-intensity-to-low intensity on T1-weighted images, heterogeneous relatively high intensity on T2-weighted images, high-intensity signals on diffusion-weighted imaging (DWI), and a low apparent diffusion coefficient (ADC) value [Figure –]. The laboratory values were within normal limits, including those of tumor markers (e.g., carbohydrate antigen 125, carbohydrate antigen 19–9, and carcinoembryonic antigen). Based on these findings, a stromal tumor with a low possibility of malignancy was suspected, and the patient was followed up with TVUS and observation during pregnancy. There was no change in size or characteristics of the tumor with TVUS throughout her pregnancy.
At 40 weeks and 1 days of pregnancy, the patient was admitted to our hospital due to premature rupture of membranes and spontaneously delivered a male baby vaginally. The baby's birth weight was 2885 g, and his Apgar score was 8 at 1 min and 9 at 5 min. The postpartum clinical course for the mother and baby were unremarkable.
A month after delivery, TVUS was performed in the outpatient clinic for follow-up of the ovarian mass and revealed a solid mass in the right ovary measuring approximately 5 cm in diameter. MRI was performed repeatedly at 2 months after delivery MRI revealed that the diameter of the

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old male patient resident of Nagpur reported at a private E.N.T clinic with a chief complaint of a mass in the right nasal cavity since 3 years. The patient also gave history of right nasal blockage and nasal discharge since 3 years. It was a slow growing growth since onset. The patient gave similar history of right sided nasal mass 5 years back, for which he was operated upon in a private clinic and the mass was removed. The histopathological examination was not performed at that time. He remained alright for 2 years postoperatively. After few months, patient started experiencing intermittent nasal obstruction and nasal discharge in the absence of upper respiratory tract infection. However, as the time passed by these symptoms aggravated and he started experiencing some nasal mass inside right nasal cavity. On anterior rhinoscopy, a solitary, pinkish, pedunculated, irregular, firm mass was located in right nasal cavity. On probing, mass was attached to lateral wall of right nasal cavity and mass did not bleed on touch. Computed tomography (CT) scan was advised and it revealed that the tumor was arising from middle meatus of right nasal cavity and there was widening of osteomeatal complex of right side. On contrast, there was mild to moderate enhancement seen. This mass was quite large and measured approximately 7 cm × 6 cm. Based on the clinical features and radiographic findings, a provisional diagnosis of papilloma was given. The mass was surgically excised by lateral rhinotomy with medial maxillectomy [] and the excised tissue was sent to the Department of Oral Pathology and Microbiology for histopathological examination. Gross examination revealed a single bit of soft tissue specimen of size approximately 3 cm × 2 cm, pinkish-white in color, irregular in shape, firm in consistency with rough surface texture. On histological examination, the hematoxylin and eosin stained section showed polypoid tissue covered with pseudostratified columnar ciliated epi

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