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

[User]
RADIOLOGY NOTE:
A 66-year-old male visited our clinic complaining of right knee pain and restriction in ROM of the right knee, especially in flexion. He had undergone a patellectomy on the right knee for a gunshot injury 45 years ago, and knee pain and limitation of ROM worsened gradually since 10 years ago. He did not respond to conservative treatment, had progressive reduction in the ambulatory capability and was barely able to climb a single flight of stairs at presentation to our clinic.
Clinical examination of the right knee revealed a transverse surgical scar with a varus knee alignment of 3°, 0° to 15° of active ROM, and severe ankylosis. There was no collateral ligament laxity and both the anterior drawer and Lachman tests were negative. There was no posterior sag and no extension lag. Plain radiographs showed severe bi-compartmental osteoarthritis ().
TKA was performed through an anterior midline longitudinal skin incision, which was perpendicular to the previous patellectomy scar. Arthrotomy was made medial to the scar tissue of the previously excised patella, and extensile rectus snip was performed for adequate exposure and knee joint flexion (). All other ligaments were normal. We performed intra-articular adhesiolysis and synovectomy for hypertrophied soft tissue, and added 2° more tibial posterior slope to achieve greater ROM. Upon achieving balanced gaps and neutral mechanical alignment, press fit condylar posterior stabilized total knee prosthesis (DePuy Mitek Inc., Raynham, MA, USA) was inserted. The tibial and femoral components were fixed with cement.
Quadriceps femoris strengthening exercises were initiated immediately after surgery. From the 2nd postoperative day, active ROM exercises of the knee joint were performed with passive ROM exercises using controlled passive motion devices to facilitate rapid ROM recovery. Weight-bearing ambulation was allowed after suture removal at 2 week after surgery. Postoperative recovery was good and he achieved satisfactory am

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old man presented with a 19-year history of bilateral, slowly progressive, painful swelling of the Achilles tendon and a 1-year history of hypesthesia over the right sole without any trauma. The patient had no history of cataract or epilepsy, although he did have chronic diarrhea and had attended a special school due to learning disabilities.
Physical examination found a huge ovoid mass in bilateral Achilles tendons (). The patient experienced no pain during rest or ankle motion. Muscle strength was normal, except for mild weakness in both ankles. A sensory test revealed that the patient had decreased sensation in both feet, especially to light touch. The deep tendon reflex was increased in both lower extremities. Babinski sign and ankle clonus were positive on both sides. Magnetic resonance imaging (MRI) of the ankle showed fusiform thickening of the Achilles tendon and an enlarged tibial nerve (). The patient was mentally alert and he scored 25 points in the Mini-Mental State Examination with a very low IQ of 52 points.
Ultrasonography showed diffusely enlarged peripheral nerves in the lower limbs, upper limbs, and C5–C7 nerve roots. We also performed ultrasonographic evaluation of the peripheral nerves in a normal male subject of similar age and anthropometry. Cross-sectional areas (CSA) of the peripheral nerves were measured as shown in . Significantly larger CSA values were found in the patient with CTX than in the normal subject, for the posterior tibial nerve behind the medial malleolus and for the median nerve at both the wrist and the elbow, like the other peripheral nerves ().
Nerve conduction studies showed decreased sensory conduction velocity of the ulnar nerve on both sides (right, 43.7 m/s; left, 46.0 m/s) and decreased motor conduction velocity of the peroneal nerve (right, 37 m/s; left, 38.2 m/s). The posterior tibial nerve somatosensory evoked potential test (SEP) showed no response, while the median nerve

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old male presented in our emergency department complaining sudden, severe dizziness and left ptosis of an hour's duration. On admission, his symptoms gradually worsened, showing left-side facial palsy, severe dysarthria, and left-limb ataxia. He was on oral anticoagulation with a daily aspirin since he had a mechanical aortic valve replaced more than a year previously. However, his international normalization ratio (INR) on admission turned out to be only 1.4.
Subsequent, acute stroke MR imaging showed occlusion of the basilar artery with a focal infarction in the left superior cerebellar artery territory (). Systemic tissue plasminogen activator (Actylase, Boehringer Ingelheim, Germany) was given at a dose of 0.6 mg/kg as the patient was still within the time window of intravenous thrombolytic therapy. Because the patient did not show any symptomatic improvement, our endovascular treatment team was called in per our institutional acute stroke bridging therapy protocol.
Right vertebral angiogram showed a typical pattern of BAO. The lesion showed antegrade flow directly after placement of the SFR (). However, the f irst retrieval was unsuccessful and only showed a slight change in the shape of the filling defect. The pattern repeated during several, following trials. Eventually, the clot migrated further distally into the left posterior cerebral artery ().
At the time of the final device retrieval, we obtained a control angiogram while the device was still in the midportion of the basilar trunk (). We were able to retract the filling defect proximally into the mid portion of the basilar trunk. However, it was attached at the distal tip of the device. Eventually we could pull down the device to the distal vertebral artery (VA) level proximal to the ipsilateral posterior inferior cerebellar artery (PICA) origin.
On the control angiogram we noted that half of the filling defect had migrated into the right PCA and half of it was still within the device mesh

[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 77-year-old man with no history of skin cancer presented to the outpatient dermatology clinic for a scalp lesion of three weeks duration. He reported rapid lesion growth, but no change in the overall appearance nor any associated symptoms. Examination revealed a mobile, round, exophytic nodule with overlying ulceration and hemorrhagic crust, approximately 1.5 cm in diameter (Figure ). Given a high clinical suspicion of malignancy, the lesion was excised three weeks following the initial visit using a fusiform (elliptical) incision with 1 cm margins. The lesion immediately prior to the procedure is seen in Figure .
A histopathologic examination of an excisional biopsy of the cutaneous lesion revealed a proliferation of spindle and pleomorphic tumor cells, which flattened the overlying epidermis (Figure ) and extended to the subcutaneous tissue (Figure ). The tumor cells were large and polygonal and contained eosinophilic cytoplasm. They expressed diffuse CD10 positivity (Figure ) and focal CD68 positivity. The tumor cells were negative for p40 and SOX10, excluding the possibility of sarcomatoid carcinoma and melanoma, respectively. The histopathologic findings were found to be consistent with invasive pleomorphic dermal sarcoma. The tumor measured 3.3 cm at the largest dimension, and tumor cells were found to be present at the surgical margin. There was no evidence of lymphovascular or perineural invasion.
A surgical, wide, local excision was planned. Preparatory computed tomography (CT) imaging revealed an approximately 3.9 cm focus of enhancement with central ulceration in the soft tissue of the posterior scalp and confirmed a lack of bony erosion in the underlying calvarium. No metastatic adenopathy was appreciated. Figure demonstrates the scalp vertex prior to surgery. A wide local excision was performed using a 2 cm margin around the remaining tumor for a 7.5 cm area of planned excision. The repair utilized a 7x3.5 cm full-thickness skin graft from the left up

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old female patient of Indian origin reported to the out-patient department with a chief complaint of a painful swelling in the right posterior mandible of 6 months duration. The swelling was insidious in onset and had progressed slowly to cause facial asymmetry along with mild parasthesia. On examination, there was a diffuse hard swelling on the right side of face with smooth margins extending anteroposteriorly from anterior border of the masseter muscle to the posterior border of the ramus and superoinferiorly from tragus to the inferior border of the mandible []. The skin overlying the swelling was normal in appearance with no rise in local temperature and there was no associated cervical lymphadenopathy. Intraorally there was bicortical expansion in the posterior region of the right mandible with a firm, tender soft-tissue mass posterior to the second molar. The mucosa overlying the lesion was erythematous and the third molar was clinically absent. There was no other apparent abnormality in the oral cavity except for missing maxillary third molar on the right side. The hematological parameters of the patient were within normal range. An orthopantomograph was advised and it revealed a large unilocular lesion in the ramus of the right mandible extending supero-inferiorly from the superior border of the ramus, involving the coronoid process, to the inferior border of the mandible, leaving a thin rim of bone inferiorly. Postero-anteriorly the lesion extended from posterior border of the ramus up to the body of the mandible distal to the second molar and involving the entire width and the anterior border of the ramus []. Based on the clinical and radiographic findings a provisional diagnosis of ameloblastoma was made with other benign/malignant odontogenic neoplasm, keratocystic odontogenic tumor, calcifying cystic odontogenic tumor or any other intraosseous neoplasm being kept as differential diagnosis. Fine needle aspiration (FNA) was performed, which yiel

[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 was referred from a primary care facility for the management of dentoalveolar fracture involving the left maxillary tuberosity during attempted extraction of maxillary left first molar. He had no known medical problems and no known allergies.
Upon examination, he presented with facial asymmetry with swelling occurring on his left face. The swelling was diffuse and slightly tender to palpation, involving the entire left buccal region from zygomatic arch to the border of the mandible. There was no limitation of mouth opening and no deviation of the mandible upon opening and closing of the mouth.
Intraorally, there was a mobile fracture segment seen on his left maxilla involving the left maxillary first, second, third molar and maxillary tuberosity. The segment was extremely mobile and extruded preventing full occlusion of his teeth. The maxillary left second premolar was firm. The maxillary left first molar had a large occlusal caries which extends subgingivally and was reported to be tender to percussion prior to the attempted extraction. There was a small laceration wound on the buccal gingiva adjacent to the upper left first molar measuring about 6 mm (Figure ).
As the diagnosis as well as the extent of the dentoalveolar fracture was able to be determined clinically, no radiographical examination was done for this patient.
As the patient was a young healthy male, and the maxillary second and third molar that was involved in the maxillary tuberosity fracture was sound, the authors decided on a conservative approach to reduce and stabilize the fractured segment followed by transalveolar extraction of the unrestorable maxillary first molar at a later date. As the patient was seen toward the end of the working day, the fracture was first stabilized using eyelet wiring and an appointment was set for the following day.
During his next appointment, closed reduction and fixation was achieved using upper and lower arch bars with intermaxillary fixation (I

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old asymptomatic female, G1P0, with a history of curettage, is presented to the Department of Gynecology and Obstetrics for termination of pregnancy. Her last menstrual period was 17 weeks and 2 days ago. Abdominal ultrasound revealed a clear gestational sac (GS), fetus with heartbeat and placenta previa. Abdominal ultrasound also showed the GS at a distance from the cavity, with a compressed myometrium between the two of them (). The patient received a MRI examination, showing an enlarged uterus of 13.0 cm ×11.7 cm × 7.9 cm, because of pieces of evidence. The MRI demonstrated a foetus with clear organs (), and compressed the lower uterine segment (). The GS was not connected with the uterine cavity and endometrium, but embedded into the myometrium in the right posterior wall of the uterine. A linear hypointensity of the junction zone was observed between the GS and the uterine cavity on T2weighted image ().
This result is likely to be placenta implantation as the myometrium cannot be separated from the placenta. The patient was at risk of the uterine rupture and life- threatening haemorrhage. Emergent management should be performed. Performing uterine artery embolization (UAE) and interventional therapy is inadvisable because of the obstructing myometrium between the cervix and placenta. Employing a surgical exploration of the abdomen was decided that was undertaken under temporary balloon occlusion of the abdominal aorta to reduce the loss of blood. The balloon was placed in the abdominal aorta between the opening of renal artery and iliac artery just before the operation. If the area of the focal damage was heavy, the subtotal hysterectomy or hysterectomy was needed. Otherwise, clinicians can perform excision by laparotomy and hysteroplasty. Given the age of patient, clinicians did their best to perform hysteroplasty instead of hysterectomy. The intramural ectopic GS in the second trimester was successfully excluded without life-threatening haemorrhage

[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 Caucasian, Greek man presented to the out-patient clinic of KAT hospital complaining of weakness and limited range of motion of his right shoulder. He had noticed, over the past two months, that abduction and elevation of the joint had gradually become limited while he was carrying his newborn child in a baby basket. He denied any neck or shoulder pain and could not recall a specific precipitating traumatic event or any recent episode of respiratory infection. However, he reported that his job was a heavy manual one, requiring lifting and carrying heavy objects on his shoulders. Our patient had no significant medical history.
Physical examination revealed a winged scapula and asymmetry of his shoulders, with right shoulder depression (Figure ). He was unable to abduct his right arm above 80° in the frontal or scapular plane while his forward elevation was slightly reduced. His passive range of motion was comparable to the normal left side. Scapular winging was marked during abduction and disappeared in forward elevation, while it was only slightly evident at rest (Figure ). Furthermore, there was a marked wasting of his right trapezius muscle with decreased shrugging of the affected shoulder. Both wasting and weakness were not observed in the ipsilateral sternocleidomastoid muscle, and a neurological examination did not reveal other cranial nerve deficits. No brachial plexus neurological signs were detected. Our patient's rotator cuff was judged to be intact.
Results of his complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum biochemistry were all normal. The initial X-rays of his right shoulder region were unremarkable. Computed tomography (CT) of the shoulder girdle of our patient revealed significant diffuse trapezius muscle wasting (Figure ). Magnetic resonance imaging (MRI) of his cervical spine, right shoulder joint and skull base identified no pathology except mild atrophy of his right sternocleidomasto

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old previously health boy initially presented with intermittent headache, fever, and cough for few months. He was seen by his pediatrician and symptoms were thought to be infectious in nature. His headaches and fevers persisted for several weeks despite supportive management with hydration and antipyretics. Two months after initial presentation, he was seen by a neurologist for his headaches. He was diagnosed with migraine like headaches and given a course of steroids with minimal improvement. Later, he developed neck lymph nodes swelling and nausea/vomiting. His mother noticed that he had lost weight (3 kg) and fatigue, and the neck lesions increased in size and number. Three months after initial presentation, he was admitted to the hospital and physical exam revealed multilevel neck lymphadenopathy (in range of 1-2 cm), significant splenomegaly, and swelling in both lower extremities. Labs demonstrated significant anemia with a hemoglobin of 6 g/dL. MRI of the abdomen showed significant, small bilateral pleural effusions, splenomegaly of 19 cm and multiple retroperitoneal nodes. A left cervical lymph node excisional biopsy was done.
A small cervical lymph node was received in pathology department, measuring 1.2 cm × 1.2 cm × 0.2 cm. A portion of the lymph node was sent for flow cytometric analysis as routine lymphoma protocol. A result of flow cytometry was noncontributory; no aberrant lymphoid population identified.
Histologic sections of the lymph node revealed entirely effaced nodal architecture with lymphoid infiltrated and focal sclerosis (Figure ). No residual germinal center meshwork was revealed by CD23 stain. There were scattered atypical large lymphoid cells in the background of small reactive lymphocytes and histiocytes. These neoplastic cells were medium to large size with pleomorphic morphologic features. Many of them showed moderate or abundant cytoplasm; some of them showed binucleate or multinucleate with prominent eosinophilic nucleoli t

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old male was referred to Emory Eye Center in June 2010 for herpetic stromal keratitis in the left eye. His past ocular history was notable for central retinal vein occlusion (CRVO) in the left eye 3 years earlier. He underwent multiple intravitreal injections of bevacizumab and triamcinolone for the treatment of CRVO-associated macular edema. He subsequently developed a suspected herpetic keratouveitis resulting in a dense central stromal scar and visual acuity of count fingers despite aggressive topical and oral antiviral therapy.
The patient underwent penetrating keratoplasty (PK) with extra-capsular cataract extraction and intraocular lens placement in July 2010. Pathologic examination of the corneal transplant showed microsporidial organisms. Visual acuity improved to 20/80 with use of rigid gas permeable contact lens, and the graft remained clear until March of 2013 when the patient presented with signs and symptoms of early graft rejection. Topical corticosteroids were utilized with no improvement, so repeat PK was performed in October 2014. Pathologic examination of the repeat PK specimen again showed microsporidia despite the absence of intraocular inflammation, hypopyon, or any other signs of clinical infection.
Five weeks post-operatively, the patient presented with new onset floaters that had been present for 2 weeks. Visual acuity was light perception, and intraocular pressure was 17 mmHg. Anterior segment examination showed trace haze at the cornea graft-host interface, 1+ anterior chamber cells, a normal iris with a round and reactive pupil, and a well-positioned posterior chamber intraocular lens. There was no view of the posterior pole. B-scan ultrasound showed a presumed vitreous hemorrhage. The patient was lost to follow-up and presented again on post-operative week 9. Examination showed keratic precipitates, trace anterior chamber cell, and neovascularization of the iris. There was no view of the posterior segment due to a dense yellow o

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


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

[User]
RADIOLOGY NOTE:
We present a case of 83-year-old male with previous cerebrovascular disease, coronary artery bypass surgery, and prostate cancer. He was diagnosed with smear positive pulmonary TB. He received anti-TB 4-drug combination (HREZ). After 2 months of treatment, the patient sputum was converted to negative smear, but he was suffering from progressive dyspnea on exertion with a Medical Research Council (MRC) Dyspnea Scale grade 5 []. On the physical examination, wheezing was demonstrated on chest auscultation and O2 saturation was 96% in room air. Methylprednisolone sodium succinate 80 mg/day for one week followed by oral prednisolone 40 mg/day was administered for relief of dyspnea, but they were not effective. Chest X-ray demonstrated narrowing of distal trachea and minimal infiltrations in left lower lobe. Chest CT revealed stenosis of distal trachea and left main bronchus; the stenotic part in distal trachea was 5 mm in diameter at the narrowest portion and 30 mm in length. Additionally, the stenosis in left main bronchus was 3 mm in diameter and 33 mm in length (). The pulmonary function test indicated a reduction in the percent predicted FEV1 (49.8%). He was referred to Nagoya Medical Center to perform pulmonary intervention. Under general anesthesia, rigid and flexible bronchoscopies were used to perform balloon dilatation under fluoroscopic guidance for both distal trachea and left main bronchus. Tracheobronchial stenosis was of fibrostenotic type. Through the instrument channel of flexible bronchoscope, a controlled radial expansion balloon (Boston Scientific, Boston, MA, USA) was inserted into distal trachea. The diameters used were calculated from the CT taken before the procedure and modified by the real situation at the site. It was inflated to size of 7 mm in diameter for 2 minutes (min) once, 8 mm for 2 min once, 10 mm for 2 min twice, and lastly 12 mm for 4 min twice. Then the balloon was inserted in the left main bronchus and infl

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old male presented to the outpatient department with a history of low backache for the past one year, associated with typical claudication symptoms, left-sided unilateral numbness, and paresthesia of the foot. He gave no history of radicular pain, but he complained of progressive reduction in claudication distance. He had experienced a sudden deterioration in gait along with urinary incontinence, following a trivial traumatic fall, one week before presentation. There was no history of constitutional features. On examination, he had a bilateral high-stepping gait due to foot drop. Symmetrical weakness of both the L4 and L5 roots (MRC grade 0/5) and partial weakness of the S1 root (MRC grade 3/5) was noted with nondermatomal sensory disturbances. Deep tendon reflexes of the lower limbs were absent bilaterally. Though anal tone was normal, saddle anesthesia was present. Postvoidal ultrasonogram of the urinary bladder revealed a residual urine volume of 250 ml, thus confirming a neurogenic bladder.
Plain radiography of the lumbar spine did not show any gross feature of instability and was inconclusive (). Magnetic resonance imaging (MRI) of the lumbar spine revealed a solitary intraspinal posterior epidural lesion of 1.8 × 1.5 × 0.5 cm at the L2-L3 level with heterogeneous signal intensities and adjacent epidural fatty hypertrophy contributing to severe canal stenosis (3 mm). The cauda equina was severely compressed and was almost not visible (). Owing to the heterogeneous signal intensities, computerized topography (CT) was performed which revealed the presence of an osseous lesion attached to the right L2 inferior articular process causing severe secondary canal stenosis (). Considering the recent-onset neurological deficit, the patient was advised surgical decompression and excision biopsy at the earliest. The patient was positioned prone on a Relton Hall frame under general anesthesia. A standard midline posterior approach was employed and L2 and L3 lamina

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old African American man was initially sent to our emergency room to evaluate a possible head trauma after a witnessed fall. He complained of frequent falls and leg weakness for 3–4 months. The weakness appeared to be progressive and persistent without episodic worsening. He had to use a cane to compensate but was still able to ambulate. His family members also endorsed cognitive defects over the past few months before admission. These impairments consisted mainly of apathy and withdrawal from social interactions; he used to be fully independent but now stayed at home most of the time. His medical history was only significant for alcohol abuse (three to four cans of beer and red wine daily for 2 years), and his family history was unremarkable.
Physical examinations showed an age-appropriate, alert, and oriented man. He was able to engage in conversations with a paucity of speech and flat affect; he also made eye contact and followed all commands during our evaluations.
There was bilateral weakness with spasticity in all lower extremity muscle groups. The deep tendon reflex was hypoactive with an upward response of the plantar reflex on the left side. He also had a wide-based unsteady gait and poor limb coordination. The remainder of the neurological examination and a general examination were unremarkable.
Initial brain computed tomography (CT) in our emergency room demonstrated a mass lesion occupying the left caudate and extending into his frontal lobe (Fig. ). A brain MRI showed bilateral and symmetric hyperintense signals in the corpus callosum, periventricular white matter, and internal capsule (Fig. ) with an axial fluid-attenuated inversion recovery (FLAIR) sequence with gadolinium enhancement (Fig. ). A cervical spine MRI was negative for cord compression and abnormal signals.
Routine blood tests, as well as human immunodeficiency virus (HIV), syphilis, and thyroid function tests, were unremarkable, and his serum vitamin B12 level was borderline (28

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old man presented to us with chronic, progressive midline low back pain associated with right lower extremity radiculopathy. The patient described the pain as radiating and achy. On the physical exam, the patient had decreased sensation in the lateral aspect of the right lower extremity. Radiological findings demonstrated multilevel central stenosis and neuroforaminal narrowing with a degenerative scoliotic deformity of the lumbar spine (Figures , ). A conservative trial for up to a year with physical therapy, chiropractic and interventional pain modalities provided partial and short-lasting relief. As the pain continued to progress, the patient decided to proceed with surgery.
Various surgical options were considered. Eventually the patient underwent an ALIF at the L3-S1 levels using a retroperitoneal approach followed by a T10-pelvis posterior spinal fusion and a right L4-L5 laminotomy and decompression in two stages (Figure ). The post-operative course was complicated by abdominal distention that occurred on post-operative day eight. Computed tomography (CT) scan of the abdomen and pelvis demonstrated a large collection of retroperitoneal fluid measuring 11 x 9 x 22 cm in the left pelvis and left flank area with mass effect on the left kidney and ureter causing hydronephrosis (Figure ). After a consult with the general surgery team and the approach surgeon, the patient underwent ultrasound-guided drainage of fluid with temporary drain placement.
The fluid was serosangionous in nature with a high output of greater than 1500 cc/day. Fluid gram stain showed no organisms and cultures also revealed no growth. He was discharged home with the drain in place for a total of 22 days after which the drain was discontinued upon clinic follow-up. The lymphocele recurred four days after the drain was removed, and the patient presented back to the emergency room with recurrence of abdominal distension. A new drain was placed again in the fluid collection, and was fina

[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 encountered a 69-year-old man who had localized right pleural metastases after undergoing nephrectomy in September 2017 for right RCC (8.0 × 7.0 × 7.0 cm), clinical stage 3, clear cell type histology, grade 2 (, A–2C). The tumor was histologically solid, with hemorrhage, necrosis, scarring, and pseudocapsule formation, and infiltrated into the renal parenchyma. The tumor spread to the right renal vein, but no infiltration into the inferior vena cava was observed. He didn't receive adjuvant chemotherapy following the nephrectomy. Postoperatively, he did not present with any symptoms and received regular follow-up with chest and abdominal computed tomography (CT) every three months. There were no confirmed recurrence and metastasis until March 2020, when he visited our hospital complaining of right chest pain and dyspnea. At this time, CT scan revealed right pleural effusion and multiple pleural masses (C and D). There were no abnormal radiologic findings in the other organs. He had no smoking history, no past medical history, and no asbestos exposure. We suspected the following possibilities: metastasis from RCC, malignant pleural mesothelioma, and synovial sarcoma. For investigation and diagnosis, we performed two pleural effusion tests before surgery, but both cytological results were class I. After one month, there were no new abnormal radiologic findings, but we confirmed that the tumors obviously grew on CT (E and F). Finally, we performed intrathoracic tumor resection under general anesthesia and diagnosed histologically as pleural metastasis from clear cell type RCC (D–F). Thoracoscopy showed multiple reddish, soft, bleeding encapsulated tumors (). The pleural fluid cytology had no malignant cells. A total of eight bleeding tumors were completely resected, with the largest measuring 5.0 × 3.8 × 2.2 cm. This case is currently being treated for pembrolizumab plus axitinib, which has been reported to be superior to sunitinib in overall survival and progression

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old female patient presented to our emergency department with complaints of shortness of breath and chest pain. Her medical history was unremarkable. On her physical examination, arterial blood pressure was 125/70 mmHg, heart rate was 86 beats per minute, and respiratory rate was 16 breaths per minute. Cardiac and pulmonary auscultation was normal. Cardiac enzymes, biochemical analysis, and complete blood count were normal except for eosinophilia. Posterior-anterior chest radiograph showed normal pulmonary appearance; however, a hyperdense mass with regular contours, measuring 5 cm in diameter, was detected in the apical aspect of the left ventricle. Electrocardiographic (ECG) findings were unremarkable. A transthoracic echocardiogram (TTE) showed a cystic mass lesion located in the pericardium adjacent to the left ventricle. Thoracic CT and MRI were performed for differential diagnosis of the cardiac mass. Her CT showed a 5 x 6 cm cystic lesion with well-defined borders in the pericardium adjacent to the left ventricle (). On MRI, a cystic lesion adjacent to the posterior aspect of the left ventricle was observed; the lesion was hyperintense on axial T2-weighted images, hypointense on axial and coronal T1-weighted images, and did not show contrast enhancement on postcontrast coronal T1-weighted images (). The diagnosis was verified by an indirect hemagglutination test performed to the patient who had been considered to have a cardiac hydatid cyst. Abdominal ultrasonographic evaluation revealed no other cystic lesion either in the liver or other abdominal organs. Under the light of these findings, the patient was scheduled for surgery with the diagnosis of cardiac hydatid cyst. The mediastinum was accessed through left anterolateral thoracotomy. Accessing to the left mediastinal area, a solitary cystic lesion with a well-defined border was visualized in the pericardium adjacent to the left ventricle. The lesion was aspirated via puncture. Because the cyst

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old man was transferred to our emergency department from a local orthopedic clinic due to abdominal pain and vomiting for 6 days. The patient had been admitted to a local clinic for 6 days following surgery for fracture of his wrist joint. Epigastric pain developed and the patient underwent esophagoduodenoscopy, which led to a diagnosis of acute peptic ulcer. Use of ulcer medication, including a proton pump inhibitor, did not result in symptom improvement, and so the patient was transferred. His vital signs were stable and he showed mild epigastric tenderness on physical examination. Laboratory parameters revealed electrolyte imbalance and dehydration with a potassium level of 2.9 mmol/l, chloride level of 87 mmol/l, blood urea nitrogen level of 46.9 mg/dl and creatinine level of 1.40 mg/dl. Chest X-ray () and computed tomography (CT) scan () showed herniation of the gastric body and antrum through the left diaphragm with organo-axial volvulus and obstruction at the pylorus level. To identify the cause of herniation, we rechecked his medical history and found that he had fallen a height of 5 m 15 months prior. The CT scan at that time () revealed a small defect of the left diaphragm without herniation, which we had missed. The patient’s symptoms improved after insertion of a nasogastric tube and hydration. The patient then underwent a laparoscopic examination (). The patient was placed supine in the reverse Trendelenburg position with the surgeon on the right side of the patient. A total of 4 ports were used: one 10 mm port at the umbilicus for the 30-degree rigid scope, one 12 mm and one 5 mm port at the right midcostal for working port and one 5 mm port at the left anterior axillary line for liver retraction. The gastric body and omentum were herniated through the defect in the left diaphragm. We reduced the herniated omentum and stomach using ultrasonic shear because a part

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old man was admitted to a local hospital for transient (10 min) left limb numbness when he rested on the sofa. Magnetic resonance angiography revealed that the right ICA was occluded from its origin to the intracranial segment. The patient reported taking aspirin, clopidogrel and atorvastatin, and was referred to the authors' center 2 weeks later. Physical examination revealed no obvious positive findings. Although a 2-month history of diabetes was recorded, there was no history of hypertension, hyperlipidemia, or smoking.
The initial CDFI was performed on day 1 of hospitalization, which revealed a patent right ICA with normal blood flow velocity (). However, CTA on day 2 indicated that the right ICA was occluded (). A repeat CDFI scan on day 4 of hospitalization revealed a hypoechoic mass [thickness 2.8 mm (suspected thrombus)] was attached to the anterior wall of the initial segment of the right ICA (). Magnetic resonance imaging (MRI) was performed on day 6; T1-weighted imaging showed that the intracranial segment of the right ICA was invisible, indicating that the right ICA was occluded (). However, digital subtraction angiography (DSA) performed on the same day revealed that the right ICA was normal, with no significant stenosis in any segment ().
CDFI findings were consistent with those of DSA, but nevertheless inconsistent with CTA and MRI. It was not advisable for clinicians to make a definitive diagnosis pertaining to the vascular lesions of the patient. Given the generally good condition of the patient and no significant discomfort, he continued taking aspirin 100 mg/day, clopidogrel 75 mg/day, and atorvastatin 20 mg/day after discharge. Follow-up CDFI 1 and 3 months after discharge did not detect the hypoechoic mass that was attached to the anterior wall of the initial segment of the right ICA, and complete patency and normal blood flow velocity were apparently restored.
Five months later, however, the patient was re-admitted to the authors'

[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 79-year-old male was referred to the surgical outpatient department with a 2-month history of altered bowel habit. Abdominal examination and digital rectal examination in the outpatient clinic were unremarkable.
The laboratory studies, full blood count and biochemistry were normal. A colonoscopy study identified four abnormal lesions, two of which were colonic subcentimetre polyps. More distally in the mid-rectum, at 15 cm from the anal verge, there was a sizeable, villous polypoidal lesion, which was proved on biopsy to be a tubulovillous adenoma (TVA) showing low-grade dysplasia. More proximally in the distal sigmoid colon at 25 cm there was a segment of a malignant-looking lesion associated with a stricture (). However, biopsy samples from this region showed hyperplastic colonic mucosa showing lamina propria fibrosis and mild chronic active inflammation with separate pieces of granulation tissue and ulcer slough but no evidence of malignancy.
As per local protocol for malignant-appearing lesions on endoscopy, a staging CT scan was arranged on the basis of the colonoscopy appearances to facilitate the cancer pathway. This demonstrated, at the site of the presumed malignancy in the distal sigmoid colon, a 7 cm segment of circumferential thickening on a background of diverticulosis (). This was associated with a few subcentimetre locoregional and inferior mesenteric lymph nodes. There was no suggestion of malignancy elsewhere; so the proposed CT staging was T2/3 N1 M0.
Although the 5 cm rectal TVA could explain the patient’s symptoms it was felt at the multidisciplinary team discussion that either lesion could be responsible for the patient’s symptoms. Despite the lack of malignant cells from the biopsy samples the surgical team were still concerned about a potential sigmoid colon malignancy from the endoscopy and CT appearances. It was felt that the colonoscopy sampling was not truly representative of the malignant appearing sigmoid colon lesion seen at colonosco

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old female presented to our clinic in July 1996 with progressively decreased visual acuity and pain in both eyes that had begun 12 years prior. Her visual acuity was counting fingers at a distance of 50 cm from the right eye, while that of the left eye was 0.06. Corneal stromal edema and Descemet's folds were found in both eyes (). Corneal opacity was involved in all layers of the cornea, and epithelial bullas were found in the center of the right cornea. Lens, vitreous, and fundus were normal. The patient had neither a personal medical history nor familial history of eye disease. We performed penetrating keratoplasty in the right eye without a precise diagnosis. Visual acuity was maintained at 0.2 during the first few months after surgery.
Visual acuity proceeded to decrease, and ocular pain recurred four years after the first surgery. Right eye visual acuity was hand motion, and slit-lamp biomicroscopy showed recurrence of epithelial edema and stromal opacity (). In July 2005, the patient underwent a second penetrating keratoplasty in the right eye due to recurrent corneal opacity and neovascularization in the cornea. Despite mild corneal opacity and corneal edema, visual acuity was maintained at 0.08 during the first two years after the second surgery.
A third penetrating keratoplasty was performed on the right eye in July 2008, due to worsened corneal opacity and visual acuity decrease to 0.02 (). Total serum protein level, which had remained at a normal level until 2008, was elevated to 10.4 g/dL after preoperative evaluation. Electrophoresis revealed elevated M protein in the serum (2.72 g/dL) and urine (29.3 mg/dL). Immunofixation electrophoresis showed elevated kappa light chains. Bone marrow smears depicted a plasma cell concentration of 2.4%, and there were no morphological abnormalities. The patient was diagnosed with type IgG-kappa MGUS and was transferred to the hemato-oncology department for further examination.
In the

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old right-hand dominant female presented to our orthopedic department with tolerable pain in upper back associated with “clunking” during active movements of right shoulder. The parents also had noticed an abnormal prominence in the right scapular region. She developed gradual symptoms over a 6 month period before her presentation with no antecedent history of trauma and constitutional symptoms. Other siblings and parents were normal.
Physical examination revealed a nontender palpable mass at superior border near medial angle of scapula. A grating sensation, both palpable and audible, was produced during active shoulder range of motion. Vertebral border of right scapula was more prominent than left (). The winging of scapula was noticed even at rest which did not increase as the patient did push against the wall. There were no signs of infection or inflammation. A bony mass was felt over the superomedial angle of the right scapula, which was minimally tender and corresponded to the area from where the crepitus arose. The upper extremity and shoulder girdle muscles were neurologically intact. Laboratory investigations were within normal limits.
Radiographs showed a large bony tumor arising from superior border close to angulus superior scapulae and directed toward the thorax (). Computed tomography scan images revealed a pedunculated bony mass measuring 5.3×3.0×1.5 cm attached to ventral surface of superior border of scapula by a small stalk (-). Magnetic resonance imaging revealed this mass was extending anteriorly against the ribs and had a characteristic mushroom-shaped appearance with no obvious soft tissue component. A diagnosis of ventral scapular exostosis is made and patient was offered for surgical treatment in view of her complaints and cosmetic concern. Wide, open excision is the treatment of choice; however, there are recent reports of arthroscopic excision [, , , , ].
The patient was treated with excision of osteochondroma in prone position und

[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 21-year-old healthy nulliparous female presented to a regional hospital in Australia in spontaneous labour at 39 weeks and 4 days of gestation. Her pregnancy was otherwise uncomplicated and she had no medical and surgical history of note.
The patient presented to the hospital with a cervical dilation of 4 cm. Her first stage of labour lasted 1 hr and 45 minutes and her second stage lasted 1 hr and 16 minutes, respectively. Analgesic treatment in the first stage included nitrogen oxide as required and 10 mg of intramuscular morphine. Analgesic used in the second stage was only nitrous oxide as required. An episiotomy was performed at delivery. She delivered a live born infant weighing 3690 g with APGAR scores of 9 and 10. The 3rd stage lasted 15 minutes with delivery of an intact placenta.
After delivery, she further requested nitrous oxide and had 10 mls of 1.0% lignocaine infiltrated into the perineum for an episiotomy repair.
Approximately 2 hours postpartum, the patient started complaining of sudden onset dyspnea and lower chest tightness. Her GCS was 15 at this time and her vital signs were oxygen saturation >95% on room air with a respiratory rate of 18 breaths per minute, pulse of 85 beats per minute, BP 130/78, and a temperature 37.2°C.
Physical examination at the time revealed swelling in the neck and jaw line and palpable crepitus in the anterior chest wall, neck, and jaw, consistent with subcutaneous emphysema.
Initial management included observation and pulse oximetry, as she was clinically stable and able to have a conversation without increase in chest pain or decrease in oxygen saturation.
Subsequently a chest X-ray (CXR) was obtained which demonstrated pneumomediastinum with air tracking superiorly into the pericardiac spaces (). Following telephone consultation with a cardiothoracic team at our major tertiary referral center, a computed tomography (CT) contrast study was ordered as recommended. CT

[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 28-year-old male patient presented to the skin out-patient department with history of a huge progressively increasing swelling over the back of the scalp [] and multiple black nodules at various parts of the body. According to patient same kind of lesions were present over the trunk at birth, which were surgically removed when he was 4-year-old. The lesion over the scalp started at the age of 6-7 years and the truncal lesions developed gradually since then. On examination, there was a single bosselated irregular non-tender skin colored swelling of 15 cm × 20 cm with deep folds over the occipital region extending toward the nape of the neck. There were certain areas of depigmentation [ along with blue streaks over the swelling. The surface of the skin was hairless, the skin over the swelling was non-pinchable and the swelling was immobile. There was no skin erosion, dermatitis, infection, odor or tenderness.
There were multiple hyperpigmented nodules distributed over different areas of the body such as mandible, flanks, abdomen [], front and back of both thighs, right knee joint, lower leg [], right sole and over volar aspect of first and second finger of the left hand []. The size of the nodules ranged from 0.5 cm × 1 cm to 1.5 cm × 2.5 cm. The nodules were blackish brown in color surface was smooth and hairless. They were asymptomatic and non-tender on palpation. Nails and mucous membrane examination were within normal limits. He had normal intelligence (the full-scale intelligence quotient was 97) and he had no psychiatric problem. Examination of the neurological, ophthalmological and other systems was normal. Laboratory results, including venereal disease research laboratory test, serology for human immunodeficiency virus, growth hormone and thyroid function, were all negative or normal. A punch biopsy from the scalp lesion and an excision biopsy from the nodule over the body was

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old woman presented with pain in her chest wall for two months, and had no significant medical history, such as trauma, infection, or tumor. The pain was located in the left lower chest in a band-like pattern overlapping the T10 dermatome. The pain was intermittent and occurred several times a day, continuing for 10–20 min each episode and alleviated when lying down. The pain was considered to be intercostal neuralgia.
To identify the cause of the neuralgia, we performed MRI, which revealed multiple cysts at the T9–T11 nerve roots bilaterally (Fig. ). No other causal abnormality for the chest wall pain was found other than the cysts. The interior of the cysts showed similar intensity to the CSF on imaging. The largest cyst was at the level of the left T10 vertebra and had a linear shadow that suggested the presence of nerve root fibers. Computed tomography (CT) with myelography was also performed to study CSF communication between the thecal sac and the cysts. After 10 mL of 240 mg I/mL iodinated contrast medium (Omnipaque 240, Daiichi Sankyo, Inc., Japan) was injected into the thecal sac at L4/5 in the lateral recumbent position, the first CT image was taken immediately (left and middle columns of Fig. ), and revealed multiple cysts from T6–L2, including small cysts. The cysts were enhanced by the contrast medium and most showed the same intensity as that of the thecal sac at the corresponding level; however, the largest cyst at left T10 and another at left T9 showed much higher concentrations of the contrast medium. Three hours after the injection, the intensities of the cysts and the thecal sac were equal on the second CT (right column of Fig. ). The next day, another CT examination showed no detectable contrast enhancement. Based on these findings, we suggested a diagnosis of multiple perineural cysts.
The patient was treated

[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 6 years old male child born by full term vaginal delivery with a birth weight of 2.25 kg, presented with a huge asymptomatic swelling over the left lateral chest wall since 6 years. Mother noticed a small asymptomatic lump on back of the left shoulder at 1 month of age, which gradually progressed to present size of around 20 cm × 20 cm × 17 cm. Child was asymptomatic and had grown well with a weight of 15.6 kg without any other swellings or syndromes. His systemic and general physical examination was normal. The giant ellipsoidal non tender well demarcated swelling, having soft to firm in consistency with slight mobility was located on the left lateral thoracoabdominal wall extending superiorly from the left axilla to left upper half of lateral abdominal wall inferiorly, posteriorly 2 cm off the spine and extending anteriorly to anterior axillary line ( and ()). Chest X-ray showed ground glass opacity over left thoracoabdominal wall (); ultrasonogrpahy showed ill defined heteroechoic mass in left lateral thoraco abdominal wall in the subcutaneous plane 21 cm × 18 cm × 16 cm without any internal vascularity, calcification or necrosis. Computer enhanced chest tomography revealed a well encapsulated giant lipoma with multiple septations without calcifications, necrosis or rib/intra pleural extension over the left lateral thoracoabdominal wall, having an average of 165.87 Hounsfield units (HU) with an area occupying an average area of 108.17 sqcm ( and (); ).
Radical excision of the mass was done under general anaesthesia without prior biopsy. Intra operatively the mass was located below the muscular plane, just above the rib cage not infiltrating into the ribs, intercostals muscles or pleura; could be easily excised along with its capsule intact uneventfully (). Muscles were closed after keeping a drain. Post operatively feeds were started same day and drain removed next day. Mass weighted 1.5 kg with histology showing mature

[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 first patient is a 7-year-old Palestinian girl from the Arab community in Israel; she was born to non-consanguineous parents after a full-term pregnancy by normal delivery with a normal birth weight of 3.1 kg. According to her parents she had normal development until the age of 1 year. At this age she was hospitalized because of a generalized tonic-clonic convulsion during febrile disease. She was discharged with the diagnosis of simple febrile convulsions. A few months later she had recurrent episodes of febrile convulsions. She underwent an EEG recording, which was normal. At the age of 2 years she had several attacks of non-febrile generalized tonic-clonic seizures; every attack lasted for 3 to 7 minutes followed by 10 to 15 minutes of a postictal state. Another interictal EEG after sleep deprivation and photic stimulation was normal. Furthermore, karyotype testing and brain magnetic resonance imaging (MRI) were carried out when she was 2-years old and found to be normal. She also underwent cerebrospinal fluid examination for protein, glucose, lactate levels and cell count, yielding normal results. Routine metabolic screening was normal. Ophthalmologic and hearing examinations were normal. She was further followed by our pediatric neurology and child development clinic. Her examination revealed no dysmorphic features and no visceral enlargement. She showed mild motor and cognitive delay but could stand and walk with support, and could speak up to 15 words with good communication abilities. Her neurologic examination revealed normal tone and normal tendon reflexes of her lower and upper limbs. Babinski sign was normal. Her cranial nerves, sensory perception and cerebellar function were normal. For the seizures she was treated with valproic acid and topiramate, with good response. She attended special education kindergarten, with speech therapy and occupational therapy. At the most recent examination, at the age of 7 years, she had normal intelligence and atten

[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 73 y/o man with no smoking history and a diagnosis of RA was referred to the pulmonary clinic for multiple pulmonary nodules in a peri-lymphatic pattern (). Patient was noted to have progressive pulmonary nodules that have been increasing in size ().
His rheumatologist planned to start him on TNF-alpha inhibitors for his RA and wanted to evaluate for infections and malignant causes prior to proceeding with the treatment. He was asymptomatic and denied any respiratory complaints. At the time of presentation, he was being treated with leflunomide, hydroxychloroquine and sulfasalazine. Pt is a Navy veteran with exposure to asbestos while he was in the Navy. Following his discharge from the Navy, he worked 10 years overseeing production of plastic and metal parts for guided radar systems. He then transitioned to working in residential construction, hanging, siding and replacing windows. He also worked on restoring brick on old houses by stripping off paint for about 5 years.
Pulmonary function test (PFT) revealed mild obstructive ventilator defect with FEV1/FVC 66%, FEV1 of 3.13L, 94% predicted. He underwent bronchoscopy with transbronchial biopsies of the right upper lobe nodules. Pathology revealed a necrotic tissue () with central silica crystals visualized under polarized light which was consistent with silico-anthracotic nodules. The biopsies were negative for malignancy. There was no evidence of infection on bronchoalveolar lavage. His AFB and fungal cultures were also negative.
Three years following his biopsy, the patient presented with lower extremity edema and dyspnea on exertion. He was found to have worsening renal failure with subsequent renal biopsy showing a mixture of minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). The staining was negative for amyloid and no silica deposits were identified. He also underwent right heart catheterization that showed mild pulmonary hypertension with mean PAP of 33. CT chest did not show worsen

[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 thirty-one-year-old male presented with a six-month history of right shoulder pain with insidious onset after repetitive work-related shoulder exercises and movements. The patient was a nonsmoker with a BMI of 28. He had a history of Hashimoto thyroiditis and a right shoulder rotator cuff tear repaired arthroscopically in 1997. Upon physical examination, the patient had full strength of FPL, FDP, and the intrinsic muscles of the hand and pain with resisted external rotation as well as tenderness with palpation over the bicep tendon. MRI revealed significant fluid collection in the bicipital groove surrounding the long head of the biceps tendon and a subchondral lesion in the greater tuberosity of the humerus suggestive of a cyst. The patient was diagnosed with biceps tenosynovitis and a superior labrum tear with shoulder impingement. Surgery was scheduled after the patient failed conservative treatment options including physical therapy and corticosteroid injections having no significant improvement in his symptoms. On the day of surgery, the patient was given a preoperative, ultrasound-guided, interscalene nerve block with 25 mL of 0.5% ropivacaine administered with a 21 gauge, 90 mm, echogenic short bevel needle. Next, the patient underwent induction of general endotracheal anesthesia. The patient was placed in the lateral decubitus position with the head in a neutral position, and a boom was used to apply 15 pounds of traction throughout the arthroscopic procedure. Glenohumeral debridement and a subacromial bursectomy were performed arthroscopically. The weighted traction was then released and an open subpectoral long head biceps tenodesis was performed. The total case time was exactly 2 hours.
The patient returned to clinic twelve days postoperatively with symptoms consistent with AIN palsy of the right hand along with median nerve involvement at the level of the wrist. He was unable to flex the MCP or IP joints of the thumb or index finger, but flexion of the

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old male underwent a tissue-matched renal allograft transplant for end-stage renal failure secondary to hypertension and primary antiphospholipid syndrome. Primary antiphospholipid syndrome was diagnosed 2 years prior to renal transplantation when he developed recurrent episodes of thrombosis of the arteriovenous fistula and neck veins, for which he was started on warfarin. Anticoagulation was optimized prior to surgery by withholding warfarin 5 days before surgery while bridging with heparin. During the early postoperative period (first postoperative week), he developed a peri-renal hematoma (ultrasonography 13 cm × 7 cm). Noncontrast computed tomography scan detected a homogenous fluid collection posterior to the transplanted kidney which extended superiorly up to the right subhepatic area and inferiorly into the pelvis, displacing the bladder to the left (Figure ). Anticoagulation was then withheld and he recovered over the next few days with normalization of serum creatinine and urine output. Prior to discharge, his urethral catheter and ureteric stent were removed and warfarin was restarted.
Three weeks after the surgery, he presented with reduced urine output and progressive abdominal distension associated with pain and fever. Ultrasound scan revealed a large perigraft collection. Resuscitation and urgent exploration revealed a viable graft with a large urinoma posterior to the kidney. A possible anastomotic leak was suspected and a passive external drain was placed to allow adequate drainage of urine and healing of the anastomotic site. However, the conservative approach failed and there was no reduction in the drain output. Therefore, surgical exploration and definitive reconstruction were planned.
Surgical exploration revealed an allograft vascular pedicle in the inferolateral aspect of the graft with a completely sloughed off allograft ureter (Figure ). Sloughed part of the allograft ureter was excised up to the pelviureteric junction where the g

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old man accidentally fell at home and was admitted to our hospital. The patient was hospitalized with several problems such as multiple metastases of prostate cancer, chronic heart failure, emphysema, impaired renal function, and biliary stent placement due to idiopathic biliary stenosis. While no fracture was identified, the patient complained of lower back pain and was unable to move. As a consequence, he was hospitalized for the purpose of pain management. On the third day of hospitalization, the patient developed a fever of 38.2°C, and his laboratory data showed high levels of WBC count and CRP. While the source of infection was not identified, a urinary tract infection was suspected because he had purulent urine from previous examination and no symptom of respiratory tract infection. The patient underwent treatment with CMZ 1 g every 12 hrs. Three days after therapy initiation, the fever declined and the laboratory data of the inflammatory response normalized. Although blood culture was negative, we decided to treat according to sepsis because he was frail. We, therefore, planned to administer CMZ for 14 days. During the treatment course, the patient did not develop fever and had a healthy appetite.
On the morning of the 14th day of hospitalization, the patient complained of a sudden difficulty in breathing. His peripheral artery oxygen saturation decreased to 74%. No fever, coughing, or sputum was identified. A chest computed tomography (CT) scan was performed, showing the presence of ground glass shadows bilaterally (). While the blood work demonstrated the absence of an inflammatory response, Hb decreased by 1.5 g/dL from the previous day. The BNP value was 103 pg/dL, similar to that at initial hospitalization. Because hemostasis of the blood sampling site was difficult, additional laboratory tests were performed. These showed a marked prolongation of PT-INR (). In the evening, his value of Hb dropped from 6.8 to 5.5 g/dl in six hours. We doubted

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old female presented to our outpatient department with low back pain that had persisted for few years. The patient experienced severe left lower extremity pain for several weeks with no history of trauma. The pain limited her walk to <10 m in a stretch. She had no history of previous spinal surgery. The patient was treated at a local hospital with oral analgesics. However, intermittent claudication and pain persisted. The motor examination did not reveal any weakness; however, there was hypoesthesia in the S1 dermatome. Plain radiographs revealed degenerative Meyerding Grade I spondylolisthesis at L5-S1 () []. Subsequent magnetic resonance imaging done revealed an associated prolapsed intervertebral disc and lumbar canal stenosis ( and ). She was given a trial of caudal epidural steroid injections for symptomatic relief. The patient did not improve, and hence, surgical intervention in the form of bilateral pedicle screw fixation with interbody cage was planned. The patient underwent posterior decompression through left- sided laminotomy followed by pedicle screw fixation on the right side. Screws were inserted in the pedicle of L5-S1. An optimal hold of the screw in the left pedicle of L5 could not be achieved due to the poor quality of bone; hence, intraoperatively, the plan was revised from bilateral to unilateral pedicle screw fixation. Further, a transforaminal interbody cage was inserted. Optimal placement of the implant and the reduction was confirmed intraoperatively under C-arm (). The patient was given a lumbosacral corset, and physiotherapy was initiated from the 2nd post-operative day. The patient’s leg pain decreased immediately after surgery, and ambulation was started 3 days later ( and ). The patient started complaining of severe pain on the 8th post-operative day, for which she was treated with oral analgesics. X-ray done on the next day revealed loosening of the rod from the L5 pedicle screw, with back out of the insert screw (). The patie

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 20-year-old Somalian man, who presented with an inversion injury of his ankle, sustained during a fall downstairs. He had subsequent pain in the foot and difficulty walking. The history on admission was limited due to language difficulties, but he felt otherwise generally well.
Examination demonstrated tenderness over the base of the 1st and 5th metatarsals, cuboid and navicular, with swelling of the dorsal lateral aspect of the right foot. Ankle movements were normal, although limited by pain. There was warmth of the overlying skin, but no rash was seen. No abnormalities were detected in other joints, and systemic examination was normal with no lymphadenopathy or fever and unremarkable respiratory, cardiovascular and abdominal examinations. He had a slightly raised CRP of 10, normal ESR of 10, and an x-ray of the right foot and ankle showed abnormal lucent lesions at the base of the 3rd, 4th and 5th metatarsals but no recent fracture ().
Further history was finally obtained through an interpreter. The patient had come to the UK 2 years previously, but had sustained trauma to his foot during a road traffic accident in Somalia about 4 years previously. Following this he had persistent foot pain and a non-healing wound. He had not sought medical attention until 2 years later when he had presented to an orthopaedic outpatient clinic. An x-ray performed on this occasion demonstrated deformities at the bases of the lateral four metatarsal bones and of the lateral cuneiform bone. These deformities were well corticated and attributed to old fractures. He reported no contacts with TB and on direct questioning had no respiratory symptoms, fevers, night sweats or weight loss, and no other past medical history. Although bloods revealed a concomitant hepatitis B infection, an HIV test was negative.
An MRI scan showed prominent bone marrow oedema with destruction of the navicular, medial and lateral and cuneiform bones ().

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

[User]
RADIOLOGY NOTE:
This 40-year-old man developed daily headaches and was referred to an ophthalmologist when these were complicated by visual blurring. Fundoscopic exam revealed papilledema, prompting imaging studies. Head CT and MRI scans demonstrated a 5-cm partially calcified, partially enhancing right frontoparietal mass with extension into the splenium of the corpus callosum. There was associated cerebral edema and mass effect with compression of the right lateral ventricle. On the day of the MRI, the patient developed left sided weakness and had a seizure. The patient subsequently underwent a craniotomy with resection of the contrast enhancing component and a portion of the non-enhancing component. Adjuvant therapy included 12 cycles of temozolomide chemotherapy, but this had to be discontinued after the 12th cycle due to severe rash. The last MRI scan performed 4.9 years after initial presentation showed stable disease with residual non-enhancing tumor and otherwise, the patient is doing well.
The pathologic findings in case 3 were nearly identical to those of case 2, except that there was a greater degree of intermingling between the two elements and the zones of infarct-like necrosis within the oligodendroglial component were larger. Synaptophysin staining revealed strong cytoplasmic and Golgi pattern positivity in dysmorphic ganglion cells, while only rare oligodendroglial cells showed cytoplasmic reactivity. There was extensive GFAP positivity with most positive cells showing morphologic features of gliofibrillary oligodendrocytes. However, irregular cells with elongate processes were also seen, suggesting a minor astrocytic component. Both components were Neu-N negative. The CD34 stain highlighted endothelial cells only; tumor cells were negative. The Ki-67 labeling index was low to moderate, focally reaching a maximal staining of 15% in the oligodendroglial component; it was <1% in GGLF. FISH analysis revealed chromosome 19q deletion in both components, while chromosome

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

[User]
RADIOLOGY NOTE:
A 61 year old Caucasian man presented to our Accident and Emergency unit with a day history of right iliac fossa pain associated with fever and rigors. The appetite was reduced but no nausea or vomiting. The pain was said to be constant and sharp in nature and exacerbated by movement and stretching. He denies any history of a recent altered bowel habit or urinary symptoms. The only significant past medical history were renal calculi and well controlled asthma.
Physical examination revealed mild dehydration and normal vital signs. His abdomen was full with tenderness in the right iliac fossa and associated with guarding and local peritonitis. Blood investigations showed haemoglobin level of 14.0 g/dl, total white blood cell count of 22.4 with neutrophilia of 20.0, platelet count of 326, C-reactive protein of 36 and normal electrolytes, urea, amylase and liver function tests.
The initial diagnosis of acute appendicitis was entertained and patient was prepared and consented for an open appendicectomy. The findings at operation included a 4 cm by 5 cm pericaecal abscess mass adjacent to the anterior tenia coli. Within the abscess mass was a perforated anterior caecal diverticulum with necrotic wall. There was a polypoid mass within the wall of the caecum. The appendix was macroscopically normal with no evidence of acute inflammation. There was a suspicion of a perforated caecal tumour. He then underwent a right hemicolectomy with an ileo-transverse anastomosis through a medial extension of the appendicectomy wound.
The histology of the right hemicolectomy specimen macroscopically showed an inflamed and perforated solitary caecal diverticulum with abscess formation and an isolated caecal pedunculated polyp. Microscopically no dysplasia or malignancy within the caecal diverticulum and the polyp was a tubulovillous adenoma with low grade dysplasia. The caecal diverticulum lacked mucularis propria and therefore was considered to be acquired [Figures and ].
His postoperative

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

[User]
RADIOLOGY NOTE:
A 67-year-old Caucasian male with a 10-year history of tophaceous gout in his knees bilaterally, treated with allopurinol, was admitted with a 3-week history of swelling, pain, and drainage from his left knee. His symptoms began after an acute traumatic injury to the left lateral knee, in which he suffered a small cut with a break in the skin. Before the injury, the patient was asymptomatic and denied any pain, bleeding, or skin breakdown to the bilateral knees. On physical examination, the patient had a large, tennis ball-sized mass over his left knee anterior to the patella and patellar tendon, with a second irregularly shaped firm mass inferior to this (). There were multiple areas of skin breakdown over the large mass overlying the patient’s left knee, which was draining purulent and sanguineous fluid that appeared to be gouty tophaceous material. There was no surrounding erythema. Over the right anterior knee, there were two large, firm masses (). The superior mass was tennis ball sized and the inferior mass was smaller and irregularly shaped. There was thinning of the overlying skin, which remained intact. He denied any pain to the right knee. The patient’s examination was also remarkable for a 3×3 cm, firm, mobile, non-tender, soft tissue mass over the proximal right olecranon. He denied any pain or limited range of motion or function secondary to this mass. His medical history consisted of gout, diabetes mellitus, and hypercholesterolemia. The patient reported a distant history of a similar mass being resected from his right knee. His surgical history also included removal of the left knee bursa and carpal tunnel release. He denied any smoking or illicit drug use but endorsed social alcohol use. He had an average build with a body mass index of 26.9. The patient was started on intravenous antibiotics and imaging studies were performed.
Plain radiographs of the bilateral knees revealed large soft

[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 78-year-old male patient with coronary artery disease status post coronary stent placement was found to have a lung nodule on the chest radiograph at that time. The patient underwent a computed tomography (CT) scan, and bronchoscopy, and was found to have a 9 mm fatty endobronchial lesion in the bronchus intermedius above the middle lobe with 2 cm extraluminal fatty lesion into the right hilum. An endobronchial ultrasound with biopsy of the mass was performed, which showed benign bronchial epithelial cells. Since endobronchial resection of the mass would lead to a large defect in the right bronchus intermedius, the decision was made to perform robotic-assisted resection of the lesion (Video ).
We used the Da Vinci Xi robot to perform resection of the endobronchial lesion and hilar mass with right lower lobe superior segmentectomy to remove the lesion. The patient had a “five on a dice” port placement for the operation [, ]. First, we performed the right lower lobe superior segmentectomy to obtain adequate exposure of the hilar mass. We mobilized the superior segmental branch of pulmonary artery and superior segmental branch of the right lower lobe going to the inferior pulmonary vein and divided them with the vascular robot stapler. We divided the superior segmental branch of right lower lobe bronchus with the robot blue load stapler. We used indocyanine green angiography to define the borders of the superior segment of the right lower lobe, which was divided using the robot blue load stapler. This provided access to the hilar fatty tumor, which allowed for removal of the hilar mass and subsequent resection of endobronchial lesion with scissors. The frozen section on both lesions was negative for malignancy. We confirmed complete resection with intraoperative bronchoscopy that also showed a large opening in the airway.
In order to reconstruct the airway, we placed two 3-0 vicryl stay sutures at the proximal and distal ends of the airway and placed the suture throu

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

[User]
RADIOLOGY NOTE:
A 65-year old woman was referred in January of 2009 to our pulmonary hypertension unit. She presented with a six-month history of dyspnea on major exertion without dizziness, syncope or chest pain. Her prior medical evaluation revealed PH and a PA aneurysm. At examination the patient was found to have a palpable systolic impulse within the second left anterior intercostal space, a grade 3/6 systolic murmur and a 2/6 diastolic murmur at the lower and upper left sternal border, respectively. Her chest radiography showed cardiomegaly and dilation of the main pulmonary artery and its branches (Figure ).
Secondary causes for PH were excluded according to the protocol described in the PH guidelines of the European Society of Cardiology []. A transthoracic echocardiography demonstrated a dilated right atrium and a dilated, hypertrophied right ventricle with severe systolic dysfunction (TAPSE 13), mild tricuspid regurgitation with PH (pulmonary artery systolic pressure, 80 mmHg), an aneurysmally dilated main PA (76 mm) and right (56 mm) and left (35 mm) PA branches and severe pulmonary regurgitation. The left sided-chambers were normal. A posterior and lateral moderate pericardium effusion could be seen. NT-proBNP was 1746 pg/mL.
A right cardiac catheterization showed a mean PA pressure of 61 mmHg with a cardiac output of 3.2 L/min. After vasoreactivity testing with intravenous epoprostenol, carried out on April of 2009, mean PA pressure dropped to 39 mmHg and concomitantly the cardiac output increased to 4.7 L/min. Calcium channel blockers were initiated, with excellent hemodynamic response and normalization of NT-proBNP values after five months of treatment.
The control right cardiac catheterization after 20 months of follow-up showed a mean PA pressure of 26 mmHg with a cardiac output of 5.54 L/min. Regardless of the near normalization of right cardiac pressures and the improvement of right ventricle function the patient maintained a severe pulmonary regurgitation (Figur

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old man presented to the Department of Periodontology, Government College of Dentistry, Indore, with the chief complaint of severe ulceration in the mouth, sore throat, and low-grade fever for 4 weeks and skin lesions on his hands and back.
Intraoral examination revealed the presence of chronic ulcerative lesion on the buccal mucosa, gingiva, corner of the mouth, and palatal mucosa with subsequent disruption and necrosis of buccal mucosa and advanced bone loss involving all teeth []. The lesions were indurated, painful to touch, and covered with gray pseudomembrane accompanied by bilateral submandibular lymphadenopathy. Multiple firm, dark pigmented papules (<1 cm) were present on the dorsal surface of hands, forearms, and back [].
The patient gave a history of sore throat and hoarseness in voice for 6 months and chronic low-grade fever for 4 weeks. The patient was tested HIV seronegative.
The initial lesions mimicked necrotizing ulcerative periodontitis, for which he was prescribed amoxicillin (500 mg) and metronidazole (400 mg) thrice daily for 7 days. Lesions were swabbed with cotton pellet dipped in H2O2 to remove pseudomembrane; oral hygiene instructions were reinforced, and the patient was recalled after 3 days [].
The patient presented a significant improvement, following which the patient underwent staged, nonsurgical, quadrant-wise scaling, and root planing over a 2-week period. There was an initial reduction in inflammation during the treatment phase, but the palatal soft tissues in relation to maxillary posterior teeth remained intensely inflamed with bilateral disruption of the buccal mucosa showing no significant improvement [].
An incisional biopsy of the affected area was done, which demonstrated the presence of epithelioid cell granulomas in the connective tissue with multiple histiocytes that formed multinucleated giant cells. The cytoplasm of histiocytes demonstrated small round, oval basophilic bodies surrounded by clear halo, which is c

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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:
58-year-old woman was referred by her General Practitioner to the Emergency Department with a one-week history of a moderately painful irreducible lump in her right groin, associated with nausea and vomiting. She did not have any urinary or bowel symptoms. She last opened her bowel earlier that day. She was known previously to have a spontaneously reducible lump in the right groin suggestive of a hernia.
The patient's medical history included hypercholesterolaemia treated with statins, menopausal symptoms treated with hormone replacement therapy, and pending investigation of a liver lesion. She had no known allergies.
On assessment the patient was in painful distress, she was tachycardic but otherwise her vital signs were stable. Her abdomen was soft and nontender; there was a palpable, nonerythematous lump in the right groin which was tender to touch and irreducible. The patient had marginally raised amylase of 57 iu/L and C-reactive protein (CRP) of 19 mg/L; her full blood count and renal and liver function tests were within normal limits.
The patient had an abdominal radiograph which was unremarkable. A groin ultrasound scan showed an approximately 5.2 × 2.7 cm cystic abnormality with a small communication with the abdominal cavity, suggestive of a femoral hernia.
Patient then had an abdominal CT scan with oral and intravenous contrast (). This was reported as a right sided femoral hernia and the caecum and the ileocaecal junction were in close proximity to the hernial orifice. A tubular structure was seen in the hernial sac which did not take up the oral contrast; this was reported as an appendix in a femoral hernia.
The patient was taken to the operating theatre for an emergency right sided exploration and hernia repair under general anaesthesia. An infrainguinal transverse incision was made over the lump and the hernial sac was dissected free. The sac was opened revealing a congested appendix and ca

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

[User]
RADIOLOGY NOTE:
The patient discussed herein is a 60-year-old male who presented to the surgical oncology clinic with a one-year history of intermittent abdominal pain. He was previously evaluated by gastroenterology at an outside institution and had undergone a CT scan and an endoscopic ultrasound (EUS). This imaging revealed an approximately 4.5 cm mass between the duodenal bulb and the head of the pancreas with both solid and cystic components. A biopsy was performed during the EUS, but a tissue diagnosis could not be made.
At the time of our initial interview, the patient reported persistence of his abdominal pain as well as 15 pounds of weight loss over the preceding three months. He was otherwise asymptomatic. He admitted to occasional smoking and alcohol use. His family history was negative for GI malignancy. On exam, he was noted to be anicteric and nonjaundiced. Abdominal exam was normal aside from a reducible nontender 3 cm umbilical hernia.
After the patient's office visit, an MRI was performed for better characterization of the previously identified mass. This showed a 4.4 cm predominantly solid mass in the bulb and second portion of the duodenum with extension into the pancreatoduodenal groove as well as fluid in the right pararenal and paraduodenal spaces (Figures and ). A repeat endoscopy with EUS was performed. Endoscopy showed a nodular, edematous, friable mass in the first portion of the duodenum causing mild stricture of the lumen (). EUS revealed a slightly nodular, ill-defined, hypoechoic and heterogeneous submucosal mass in the medial wall of the first portion of the duodenum extending into the duodenal sweep and causing mild stricture. The duodenal wall was thickened with loss of demarcation between layers (). Repeat biopsy and fine needle aspiration (FNA) of the mass taken at the time of EUS revealed only duodenal mucosa with dilated lymphatic channels and prominent lymphoid follicles.
Given the remaining diagnostic uncertainty, the patient was discussed in

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

[User]
RADIOLOGY NOTE:
The patient was a 32-year-old man who presented to the emergency department with a complaint of lower abdominal pain for one week. His pain was persistent throughout the day and was stabbing in nature. He scored the pain as 7 out of 10 in intensity. It was associated with fever, nausea, and vomiting. There was no history of change in bowel motions or urinary symptoms. His past medical history was remarkable for a peptic ulcer disease. He had not undergone any surgical procedure previously. He was a non-smoker and did not drink alcohol. The family history was non-contributory. Of note, the patient did not have a history of diabetes mellitus, chronic steroid therapy, or any immunodeficiency disorders.
On examination, the patient looked tired and his vital signs revealed a low-grade fever and tachycardia. Abdominal examination showed tenderness in the lower abdomen with evidence of suprapubic mass. No overlying skin changes were noted. The abdomen was soft and lax with no signs of guarding or rigidity. Laboratory investigation revealed a leukocyte count of 14,200/𝜇L and erythrocyte sedimentation rate of 23 mm/hr. Other biochemical investigations, including renal and liver function tests, were within normal limits.
An abdominal ultrasound examination of the patient revealed a spheric collection with poorly defined borders. Subsequently, an abdominal CT scan was performed, which demonstrated a soft tissue mass adjacent to the anterior abdominal wall with an upward track to the umbilicus (Figures , ). Based on the clinical and radiological features, he was diagnosed as having a urachal abscess. A cystourethrogram was performed and revealed no communication with the bladder.
The culture from the obtained specimen of the abscess revealed growth of Staphylococcus aureus. The patient was administered a broad-spectrum intravenous antibiotic therapy, which resulted in clinical improvement with the resolution of the fever. He was then prepared for laparotomy, which confirmed 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.