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

[User]
RADIOLOGY NOTE:
A 16-year-old male subject visited the Department of Periodontics, The Oxford Dental College and Hospital, Bangalore complaining of bleeding gums following brushing and painless swelling in the left posterior area of the hard palate since 6 months. His medical and family history was noncontributory and was in good physical condition. The extraoral examination was unremarkable. No other abnormality was found.
Oral hygiene status of the subject was satisfactory. Intraoral examination showed the presence of swelling in the left posterior area of the hard palate of approximately 2 cm × 1 cm in size and color similar to that of palatal mucosa with slight bluish hue in the center of the lesion with a presence of sinus opening []. On palpation, the lesion was nontender and firm in consistency around the borders and soft at the center of the lesion. There was purulent discharge through the sinus tract.
Electrical pulp vitality test results were positive. To track the sinus tract, intraoral periapical radiograph was taken with gutta-percha point placed through the sinus opening. The gutta-percha point extended till the apex of mesial root of a maxillary first molar. There were no signs of alveolar bone resorption in the panoramic, periapical, and occlusal radiographs. The floor of the maxillary sinus appeared intact. Complete hemogram showed all the parameters within the normal range. Computed tomography peripheral nerve sheath reported soft tissue density on the left side of palate causing smooth bony indentation [].
Initially, the differential diagnosis of the swelling was made as periodontal abscess, palatal region vascular malformations such as hemangioma, mucocele, sialometaplasia, pleomorphic adenoma, adenoid cystic carcinoma, MEC, and adenosquamous carcinoma.
Incisional biopsy was done to establish a definitive diagnosis, to assign a histological grade and prescribe adequate therapy. On histopathological examination, H and E staining showed three groups of cells, name

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


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

[User]
RADIOLOGY NOTE:
Case D (Insomnia): A 19-year-old female was asked to take EPI reading by her physician (who is associated with Life in Yoga Institute) because she was seriously overweight at 278 lbs with 5' 6' height (body mass index = 44.9) and in suboptimal health condition. Her chief complaint was inability to sleep at night – and even when she falls asleep, she never had sound sleep and barely slept for two hours each night.
EPI showed very low C in all organ systems and the lowest was the nervous system at 0.5. Consistent with the protocol, we have developed, the exercise for the weakest system – nervous system – was recommended. After 6 restrictive throat breaths for vagal stimulation she began to feel better and being new to the practice found it difficult to do more. There was much improvement in C for epiphysis (pineal gland and melatonin) and nervous System []. She continued doing this practice three times a day with around 20 breaths each time, with the last session every night before going to sleep, and thereafter, she has had no problem of insomnia and has experienced higher level of wellness.
The readings also showed substantial increase in Pituitary C, but she had no weight loss. The puzzle is resolved by looking at the 33% increased E (reduced coherence) for Pituitary.
comparing C (communication energy), IA (total energy), and E (entropy) for the two cases explains more than the weight loss phenomenon.
Endocrine versus nervous system drivers – Case C diabetic is narrowly endocrine-related to metabolic elements indicated by pituitary and pancreases activation – the drop in E is much larger than drop in IA while C is in normal zone ensuring increased coherent energy. However, Case D's problem of insomnia is primarily nervous system driven where C and IA increase and E drops ensuring increased coherence. Milder impact in coherence

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


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

[User]
RADIOLOGY NOTE:
This is a healthy 53-year-old male with an unremarkable medical or surgical history, who has a 6-month history of progressive neck pain that radiates to his right and left shoulders. The patients’ pain, which was alleviated by analgesia and physiotherapy, increased when he lay flat or on his left side. His neurological examination, including a cranial nerves exam, indicated normal findings. There was no history of trauma or sinus disease.
Imaging of the cervical spine and brain was performed. The brain magnetic resonance imaging (MRI) [] showed a well-defined mildly expansile bone lesion in the clivus with low T1 and high T2 signal intensity with nearly complete suppression of signal intensity on fluid attenuated inversion recovery. No contrast enhancement or solid tissue was identified. There is a mild posterior expansion of the clivus, which caused effacement of the prepontine cistern, mild collapse of the clivus, and relatively acute angulation of the clivus canal angle. Surgery was discussed to perform a biopsy and reach a diagnosis.
The patient underwent transnasal endoscopic resection of the clival lesion in collaboration with the ear, nose, and throat team using neuronavigation. The superior margin of the clival lesion was identified by neuronavigation, and then trepination of the anterior portion of the clivus was performed using a high-speed drill []. A gush of clear colorless fluid leaked under high-pressure. Direct communication was detected between the subarachnoid space and the cyst through a dural defect. The cyst wall was a direct continuation of the arachnoid membrane. Specimens were taken from the bone, cyst wall, and cavity and were sent for analysis. The intraoperative fresh frozen section was inconclusive. A fat graft was obtained from the thigh, placed in the cystic bony cavity and supported by a synthetic plate and septal flap. There were no intraoperative complications, and the patient was transferred to the recovery room in stable condition f

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old woman working as a clerical staff, requiring daily commuting by crowded trains, was suffering from left knee pain for last 6 years. Her difficulty in walking had worsened since last 6 months and did not respond to nonsurgical management. She was bedridden for 2 months before she presented to us. She also had a history of intermittent rectal bleeding.
On examination, there were cutaneous and soft tissue hemangiomas alongwith varicose veins throughout the affected left lower extremity from hip to toes, mainly on the gluteal region, posterior thigh, popliteal fossa, calf and foot [Figure -]. There were no visible salmon patches or portwine stains. Left lower extremity was not significantly enlarged compared to right lower extremity. There were no lesions over the anterior aspect of left knee. There was a 10° valgus alignment of the knee []. She had a flexion deformity of 20° with further flexion up to 40°. The movements were very painful in the available range of motion (ROM). The knee society pain score was 29 and her functional score was 0. There was no true leg length discrepancy. Dorsalis pedis and posterior tibial pulsations were palpable. The distal neurological status was normal. The right knee had full range of movements with no pain or deformity. There were no vascular lesions in right lower extremity. Bilateral hip examination was normal.
Radiographs [] showed severe degenerative tricompartmental arthritis in the left knee joint with bone loss from the lateral femoral condyle and the lateral tibial plateau. There was subchondral sclerosis and osteophyte formation. Phleboliths in the vascular malformations were noticed on the X-rays.
Magnetic resonance imaging and magnetic resonance venogram [] of the left lower limb with pelvis showed vascular malformation; mostly multifocal hemangiomas involving superficial and deep soft tissues of the entire left lower limb, pelvic region, rectum and left femur. There were no communications between the superfi

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old, white Caucasian man was presented to our hospital emergency department with one-month history of jaundice, pruritus, acholic feces, dark urine, unintentional weight loss, and worsening pain in the lumbar region. On the date of admission the urine was light yellow and the patient reported that feces were of normal color and consistence. He denied alcohol or illegal drug use and had no travel history within the last 10 years. He reported jaundice and pruritus progressing for one month prior to admission. He denied having pain, nausea, vomiting, or elevated temperature during the whole month. Pain in the lumbar region was progressing during the last 2 years, due to PCa metastasis. Patient had metastatic PCa and underwent palliative hormonal therapy in ambulatory settings; he also had moderate aortic stenosis found by echocardiography and angina pectoris of class II according to the classification system by Canadian Cardiovascular Society. In year 2016, metastatic process involving the lumbar spinal and thoracic region was diagnosed using skeletal scintigraphy. Starting from year 2016 he received androgen deprivation therapy in outpatient settings and testosterone level was controlled in conjugation with PSA. Testosterone remained at castrate level.
During physical examination, yellow skin, scratch marks on the back and thorax due to pruritus, and aortic murmur were revealed.
Blood tests indicated that the patient had cholestasis, elevated alanine aminotransferase, elevated aspartate transaminase, elevated gamma-glutamyl transferase, and elevated bilirubin (). Infectious disease such as hepatitis C and hepatitis B was excluded using testing for antibodies. Autoimmune causes were also excluded; anti-mitochondrial antibody, anti-glycoprotein antibody-210, and anti-sp100 antibodies, IgA and IgM, were all negative. Alpha-fetoprotein was also negative. Alkaline phosphatase (ALP) was significantly elevated; thus isoenzyme of bone origin ALP2 was determined to

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman (158 cm, 72 kg), at 37 + 1 weeks of gestational age was scheduled for caesarean delivery. The patient had previously received caesarean delivery because of preeclampsia. In this pregnancy, the patient had been diagnosed with pregnancy-induced hypertension and was prescribed aspirin 100 mg once a day for prevention of preeclampsia for 12 to 36 weeks. Blood pressure was not well controlled during the week leading up to surgery and was associated with overall discomfort. Therefore, the surgery was performed 2 weeks earlier than the planned date. A preoperative laboratory test, including Na+, K+, Ca2+, and Mg2+, and chest radiography were all within the normal range, and electrocardiography showed sinus tachycardia.
In the operating room, the patient was monitored with three-lead electrocardiography, pulse oximetry, and non-invasive blood pressure monitoring. The initial blood pressure and heart rate were 140/80 mmHg and 122 beats per minute (bpm), respectively. Peripheral oxygen saturation was 99%, with 2 L/minute of oxygen supplied via nasal prongs. Before induction of anaesthesia, the patient had rapid, shallow breaths and appeared to be extremely anxious. However, considering effects on the foetus, no anxiolytics were used, and only verbal comment was provided. Spinal anaesthesia was performed in the left lateral position at the third and fourth lumbar intervertebral space with a 25-gauge needle. After free flow of cerebrospinal fluid was identified, 11 mg of hyperbaric bupivacaine was slowly administered intrathecally.
The patient was then placed in the supine position, and initial sensory blockade was assessed by the perception of cold sensation using an alcohol-soaked sponge and by detecting pain. Before this could be completed, the patient presented with sudden onset of convulsions in the face and bilateral upper extremities for approximately 5 seconds. She also showed a slightly decreased mentality, but did not lose consciousness. At that ti

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman presented to a local hospital with a history of recurrent urinary urgency and dysuria and without macroscopic hematuria for 1 month. Urinalysis revealed leukocyturia (133/HP) and hematuria (25/HP). The patient was sexually active and was initially diagnosed with uncomplicated urinary infection. The patient received norfloxacin for 1 week. However, the symptoms remained unrelieved, and she was consulted for further examinations in the local hospital. As urinary ultrasound indicated thickening of the bladder anterior wall, further an abdominal contrast-enhanced computed tomography (CT) was carried out, through which more lesions were found, and malignant changes were highly suspicious (Fig. a). The cystoscopy from the primary hospital identified extensive basal mass in the bladder walls and the histological results of tissue biopsy revealed non-invasive urothelial carcinoma. Radical cystectomy was recommended by the provincial hospital owing to the extensive involvement of the bladder.
The patient considered the possibility of radical cystectomy to be devastating and presented at our hospital for consultation. A review of the patient's medical history revealed that the patient had undergone a Chinese IUD (Copper-bearing) placement 11 years ago after the birth of her first child. However, she became pregnant and underwent a painless induced abortion 3 months later, and the routine gynecological sonography revealed no IUD. After the following 2 accidental pregnancies, she underwent another IUD placement which worked well. Considering the above-mentioned history, our CT scanning revealed that a portion of one of the two implanted IUDs had migrated beyond the right uterus wall and was adjacent to the bladder (Fig. b). To verify the pathological diagnosis, diagnostic transurethral resection was performed (Fig. c, d), including the right, top, and trigone bladder wall, whereas histological examinations reported granuloma of the bladder right and top wall

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man who works in a rubber factory developed reddish-colored lesions over the inner aspect of the left forearm, left elbow and outer aspect of the left arm, which were raised above the surface of the skin and were nonitchy and painless and associated with diminution of sensation []. The patient was diagnosed leprosy and was on regular treatment for the past 3 months. Six days before admission, he developed paresthesia (pin and needle sensation) in the left hand followed by the right hand and subsequently in both the lower limbs within 1 day. On the 2nd day of illness, he needed support to stand from the sitting position and started dragging his left feet while walking. After 1 more day, he buckles his knee while walking and could walk only with support of one person and also developed weakness of the upper limb on the next day. He could not comb his hair and could not grip a glass of water. On presentation, he was unable to get up from lying to sitting position and unable to turn side to side in bed. There was no cranial nerve abnormality and no bladder or bowel complaints. There was no history of recent cough or loose stools before the illness. No new skin lesions have appeared, but there was development of inflammation in the existing skin lesion.
On examination, he had hypoesthetic patch on the above-mentioned sites with bilateral thickened and tender ulnar and common peroneal nerve. Cranial nerves were normal. Power in the upper limb was Medical Research Council (MRC) grade 3/5 both proximally and distally with a hand grip of 5%–10%. Power in the lower limb was MRC grade 2/5 proximally and 4/5 distally. Deep tendon reflexes were absent globally. Sensation was decreased (pain, touch, temperature) around 60% on the patch and vibration was impaired at toes bilaterally.
On investigations, he had hemoglobin of 14.23 g/dl,

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


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

[User]
RADIOLOGY NOTE:
An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15–30 min after every meal. The full blood count, serum biochemistry values, and C-reactive protein level were within normal ranges. Additionally, arterial gas analysis was normal. Abdominal plain radiography showed free air between the liver and diaphragm, and PI (Fig. ). Abdominal computed tomography showed severe calcification of the SMA origin; SMA peripheral flow was reserved (Fig. ). Computed tomography (CT) revealed bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum (Fig. ).
Since the patient did not have peritonitis, a conservative approach was performed. She was managed in the condition of intensive care unit, due to fears of the potential for acute mesenteric ischemia due to mesenteric artery occlusion or non-occlusive mesenteric ischemia. She was managed for bowel obstruction, which included fasting and intravenous fluid administration. She received heparin infusion to prevent SMA occlusion and maintain collateral flow. During admission, she reported abdominal pain relief. Seven days after admission, abdominal plain radiography showed improvement in PI and pneumoperitoneum; therefore, she was permitted to begin drinking fluids. There was no evidence of recurrent abdominal pain after the fluid consumption, so she was allowed to eat solid food.
Angiography was planned to relieve the postprandial abdominal pain. The findings showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery (Fig. , ). ET, namely stenting to the SMA and common hepatic artery, was performed. The SMA trunk was engaged with a 6F Parent Plus 60 guiding catheter (Medikit, Tokyo, Japan) from the left brachial artery. Initially, 8000 units of heparin was infused, and additional heparin was added to keep the activated whole blood clott

[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:
We present a case of 40-year-old male patient with a colloid cyst in the third ventricle. The patient was admitted at Clinic of Radiology, with symptoms of headache and episodes of vomit. In clinical examination patient had symptoms of brain tumor. He was treated for depression since 2017. A year ago he underwent a MRI head scan, where dilation of lateral ventricle was seen as sign of early hydrocephalus.
The MRI scan demonstrated a cyst in foramen of Monro region with typical signal intensities in the cystic formation that confirmed the diagnosis of colloid cyst (). In MRI images, they present as homogeneously to heterogeneously hypointense or hyperintense masses in T1 and T2 weighted acquisitions. The outstanding characteristic is a sharply outlined round or ovoid mass in the anterior and superior third ventricle, near or at the foramen of Monro region. Hydrocephalus is observed in most patients4. After diagnosis the patients was recommended to consult with a Neurosurgeon for intervention. The patient underwent surgical intervention and the cyst was removed. Similar findings were revealed also on histopathological examination (, Panels a, b, c, d, e and f). After the intervention the patient did post-operative MRI exam control as recommended where it was evidenced successful tumoral extraction while the histopathologic results described findings compatible with colloid cyst Fig2.
A colloid cyst can be removed with a craniotomy. A craniotomy is a surgery where an incision is made in the scalp, and part of the skull is removed for the duration of the surgery then the skull is put back in place.
On the T1-weighted images, the lesion showed a central signal intensity slightly higher than that of the surrounding brain with a mildly hypointense rim (, Panel a). On proton density–weighted images, the colloid cyst was of homogeneous signal intensity, and on T2-weighted images, it showed a central region of hypointensity surrounded by a rim of relative hyperintensity (simi

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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:
Presenting concerns
This is a case of a 22-year-old white female who presented at 34 weeks with preterm premature rupture of membranes. She had a history of two prior cesarean deliveries. A left ovarian tumor, not noted during the course of her current pregnancy, was noted on cesarean delivery.
Current pregnancy
When she presented with preterm premature rupture of membranes, repeat cesarean section was performed again. At the time of surgery, another 8 cm mass on her left ovary was diagnosed intraoperatively. This mass was not diagnosed prior to surgery. A second trimester ultrasound was performed that did not show any ovarian cyst. During the surgery, the mass appeared tan with punctate focal hemorrhage. The mass was unable to be separated from her left fallopian tube, so the mass, the left fallopian tube and part of the left ovary were all removed. We were able to leave a small amount of residual ovarian tissue. Pathologic description noted a multiloculated and cystic mass with clear mucinous fluid consistent with mature cystic teratoma (Figure ). Her postoperative course was uncomplicated.
Previous pregnancy
Her antecedent pregnancy was complicated by right ovarian torsion at 13 weeks secondary to an ovarian tumor. A right salpingo-oophorectomy was performed. The right ovary was sent to pathology and noted to be infarcted with no viable tissue from the mass to make a definitive diagnosis (Figure ). During that same surgery, an 8 cm, irregularly shaped mass with a focally hemorrhagic surface was noted on the left ovary. A left ovarian cystectomy was performed, and final pathology showed a benign mucinous cystadenoma (Figure ). At the time of cesarean in the same pregnancy, a metachronous mucinous cystadenoma was noted on her left ovary; cystectomy and partial left oophorectomy were performed.
Follow-up and outcomes
Following her third cesarean delivery, this patient was surprised to learn that she had developed another ovarian cyst in pregnancy necessitating remov

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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 17-year-old male presented with dull aching pain and gradually progressive swelling over the left scapular region since five months. Pain was aggravated on shoulder movement and on lying supine. He had no fever. Physical examination revealed a swelling of 3 X 3 cm which was located in the left supraspinous region. The swelling was warm and tender with soft cystic consistency. There was no discharging sinus. Terminal range of motion was restricted with pain especially during the last 15° of abduction.
His blood investigations were unremarkable with ESR of 15 mm/hr. Anteroposterior radiograph of left shoulder revealed a well defined, 4 X 3 cm osteolytic lesion at the superomedial aspect of body of scapula, with surrounding sclerosis []. The lateral radiograph showed increased soft tissue shadow in the superior aspect of scapula. His chest radiograph was normal. Since appearance was similar to a bone tumor, differentiation was important and work up on same lines was planned. Whole body bone scan showed abnormal increase in tracer uptake in the body of scapula with the rest of the skeleton being normal. Computer tomography (CT) showed erosions involving the supero-medial aspect of the body of scapula and along the base of the spinous process of scapula [ and ]. Magnetic resonance imaging (MRI) scan revealed a well- defined lobulated lesion []. It showed high signal on T2W and low signal on T1W images. Central T2W hypointensity was also seen. There was a soft tissue component extending posteriorly into the subcutaneous tissue. The left shoulder joint was normal. The differential diagnosis were chronic infection probably tuberculosis, Eosiniphilic granuloma or tumourous conditions. A CT guided biopsy was done Tissue and fluid were sent for cultures and histopathology. Biopsy revealed granulomas composed of epithelioid cells, lymphocytes and a few multinucleate giant cells suggestive of tuberculosis. Culture from Lowenstein Jensen medium showed acid fast bacilli after

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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 35-year-old African man presented with an 8-year history of left upper limb pain. The pain was so severe that he was unable to sleep at night. He complained of almost incessant pain and paresthesia from the left side of his neck, and along his entire left upper limb. Touching him anywhere on his limb and neck would elicit a burning pain that radiated along his entire upper extremity. There was no antecedent history of trauma, and he did not have any features of neurofibromatosis type 1.
On further probing, he reported that the pain had initially started from the tip of his left middle fingertip. Over time, the pain had grown worse, and extended to involve the entire limb.
The pain was aggravated by cold weather, lifting of heavy weights with his left hand and direct pressure or trauma to his left middle finger. It was relieved by rubber band tourniquet (self-applied) and by rubbing either side of his finger on a rough cloth or other rough surface. During the 8-year period, he was managed for multiple different diagnoses including neurogenic pain, neuroma, gout and thoracic outlet syndrome. He underwent multiple diagnostic tests including computed tomography (CT) scan and magnetic resonance imaging (MRI) imaging of his spine and brachial plexus. He had a total of 12 stellate ganglion blocks administered over the 8 years without a resolution of symptoms.
On examination, he had neck tenderness along the brachial plexus roots, and along his entire left upper limb. His left middle finger was visibly thickened and dry, with exquisite tenderness over the entire pulp, precluding further examination.
A diagnosis of chronic regional pain syndrome (CRPS), most likely secondary to a glomus tumor, was made. Previous MRI images were inconclusive, and we did not see the need to get new ones. We proposed an exploration of his left middle fingertip, and informed him that the finding and excision of a glomus tumor would

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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 77-year-old female sought for treatment in our hospital due to pain mass in the left parotid gland. The lesion was symptomatic and had been present about 6 months with a recent rapid increase in size. The patient reported no prior surgeries.
Upon examination, there was a 3.5 × 3.0 × 1.5 cm medium texture, unclear boundary, immobile, and pain mass, but the facial nerve function was intact. There was no palpable lymphadenopathy. The remaining oral cavity and head and neck examinations were normality.
A large mass sized 35 × 30 × 15 mm in the left parotid gland was identified on MRI (Fat suppressed T2-weighted images showed mild hyperintensity, T1-weighted images showed hyperintensity). The mass was heterogeneous and had an unclear margin, so MRI suggested the mass could be a malignant tumor.
At surgery, we remove the tumor to the biopsy, and then the lesion was considered as a malignant neoplasm. The tumor was not invaded to adjacent tissues, so the patient subsequently underwent extensive resection of the tumor with a safety margin of 1 cm under general anesthesia. Then the tumor was sent for histopathological and immunohistochemistry analysis to confirm the histogenetic origin of the lesion. There were 2 different components including typical EMC and high-grade carcinoma in the lesion. The EMC component includes the inner layer of duct consisted of cuboidal epithelial cells and the outer layer consisted of clear myoepithelial cells. They present various tumor cells, which arrange in trabecular, tubular, or islands. The high-grade transformation component was composing of intensive spindle cells with increased nuclear pleomorphism, mitotic activity, prominent nucleolus and acidophilic cytoplasm. The large amount of spindle cells arranged in fascicular clusters (Fig. ). Immunohistochemical examination indicated that the EMC component was diffusely positive to CK. The tumor cells of the EMC were only positive for CD117 in the duct, and the outer myoepithelial cells w

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


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

[User]
RADIOLOGY NOTE:
A 6-day-old full term female baby, delivered at a peripheral hospital, was brought with continuous frothing of saliva from the mouth, refusal of feeds and a progressive respiratory distress since birth. No records were available regarding the initial resuscitation of the baby and whether a nasogastric tube was passed at birth to assess esophageal patency. She was seen at three different hospitals where a diagnosis of esophageal atresia was made before she reached our center for further management.
On examination, the baby was a sick-looking full-term female neonate having severe tachypnea with persistent white froth in mouth. No chest wall retractions or central cyanosis was noted. Heart rate was 162 beats per minute and respiratory rate was 54 per minute. Auscultation of the chest revealed equal air entry on both sides with coarse crepitations. Insertion of a red rubber tube through the mouth revealed obstruction at 10cms from the mouth was noted. Chest roentgenogram with the red rubber tube in situ demonstrated the tube lying at the level of the third thoracic vertebrae with presence of air in the stomach. Echocardiographic examination was normal. A clinical diagnosis of esophageal atresia with distal tracheo-esophageal fistula (Vogt type III) was made. She was stabilized by low-pressure continuous upper pouch suction, oxygen, antibiotics and chest physiotherapy.
The patient was taken up for a right postero-lateral thoracotomy. On exploration, the esophagus was found to be in continuity with no evidence of esophageal atresia. Careful palpation of the esophagus revealed a hard mass in the upper esophagus. Longitudinal esophagotomy over the mass showed multiple foreign bodies (beetle nuts pieces) and they were meticulously removed (Fig. 1). After removal of beetle nut pieces, a nasogastric tube could easily be passed into the stomach from the mouth. Esophagus was repaired over the nasogastric tube and chest was closed after putting an intercostal drain. Post-operati

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old woman presented with a 2-week history of progressive lower limb weakness and bilateral numbness from her hips to her toes. Her primary care physician referred her for physical therapy, which did not improve her strength. Her symptoms continued to worsen until she became bed bound and presented to the hospital 2 months after the initial onset of symptoms. Her past medical history included stage IIIC ovarian adenocarcinoma 17 months prior to presentation. At that time, her Ca 125 level was 1612 units/mL. She received 6 cycles of neoadjuvant chemotherapy with carboplatin and Taxol, followed by exploratory laparotomy, bilateral salpingoopherectomy, splenectomy (due to concerning lesions in the spleen), and 3 cycles of chemotherapy. Two subsequent abdominal computed tomography (CT) scans showed no evidence of recurrence and Ca 125 levels had decreased to normal.
On exam she had left lower extremity weakness; 2/5 in both hip and knee flexion and extension, 4/5 in dorsiflexion and plantar flexion. Right lower extremity strength was 0/5 in both hip and knee flexion and extension, and 3/5 in dorsiflexion and plantar flexion. Ca 125 levels were normal. Cerebrospinal fluid analysis indicated nonspecific inflammatory changes and no sign of infection. Spinal magnetic resonance imaging (MRI) showed an intramedullary lesion at T11-T12 (). Positron emission tomography CT revealed focally increased FDG avidity at T11-T12. A laminectomy and biopsy of the lesion were performed; pathology indicated metastatic ovarian cancer ().
The patient received high-dose corticosteroid therapy for 1 week after her presentation. She was discharged to a rehabilitation facility and underwent outpatient radiation therapy with 30 Gy in 10 fractions of 300 cGy each, from T7 to L1. She tolerated the treatment well and gained slight improvement in sensation and weakness, but was unable to ambulate. She received a subsequent 6 cycles of chemotherapy with Taxol and carboplatin. On completion of

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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 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.
To obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.
The right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ult

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


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

[User]
RADIOLOGY NOTE:
The patient is a 68-year-old lady with a past medical history significant for hypertension, hyperlipidemia, and hypothyroidism who presented with complaints of lower abdominal pain, diarrhea, and bright red blood per rectum. She was a retired medical assistant who had quit smoking 3-4 weeks prior to presentation after having smoked half pack a day for 30 years. Her home medications included lisinopril, simvastatin, aspirin, levothyroxine, and calcium and vitamin D supplementation. Her review of systems was positive for mild intermittent dry cough for the past 1.5 months. She denied fever, chills, weight loss, productive cough, hemoptysis, night sweats, and changes in urinary habits. She had unlimited exercise tolerance. Her physical examination in the emergency department was unremarkable except for mild tenderness to palpation over the lower abdomen. A computed tomography (CT) scan of the abdomen showed sigmoid and distal ascending colon colitis and incidentally identified a right hilar mass. The mass was in the superior segment of the right lower lobe and extended throughout the lower lobe along the pulmonary vessels (). The central part of the mass was enhancing with hypodensity noted peripherally suggestive of necrosis. The dominant portion of the mass measured up to 6 cm transverse × 3.4 cm antero-posterior. The tracheobronchial tree was found to be patent. An additional irregular, pleural based mass in the superior segment of the right lower lobe was also identified which measured 3.9 cm transverse × 1.5 cm anteroposterior. An additional pleural nodularity was noted in the inferior portion of the right lower lobe. These findings were highly suggestive of a right lower lobe malignancy. There was no significant mediastinal, axillary, or hilar adenopathy noted except for a subcarinal (9 mm in short axis) and paratracheal lymph node (5 mm in short axis). She underwent bronchoscopy which showed a friable exophytic endobronchial mass in the right lower lobe at 1 cm

[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 52-year old female patient was admitted to our hospital with complaints of intermittent dysphagia and chest pain for 1 year. She had symptoms on the lower substernal area when swallowing a large amount of water, which were accompanied by chest pain. Chest pain was a sharp and non-radiating and was relieved by transports of swallowed water to the stomach. These symptoms only occurred when guzzling water and not by taking a sip of water or eating. The temperature of water did not show any correlation with her symptoms. Her past history was unremarkable. There was no family history of similar symptoms. She was of normal body weight and had no abnormalities on chest and abdominal physical examination.
Endoscopy of the upper digestive tract was performed in other hospitals, but there were no abnormal mucosal lesions. Then she was referred to our hospital for further investigation on dysphagia and chest pain. The barium esophagogram showed no abnormalities. 24 hour esophageal impedance-pH monitoring was performed and there were no pathologic regurgitation.
HRM was performed to access the esophageal motility (). On sitting position, 14 times of water swallowing in total was performed. The interval between each swallow was 30 seconds. The patient swallowed 5 mL of water from the first swallow to the seventh swallow, 10 mL from the eighth swallow to the 10th swallow, 15 mL on the 11th swallow, 20 mL on the 12th swallow and 50 mL on the 13th swallow. On the 14th swallow she tried to drink 100 mL water, but could swallow only 25 mL. She did not have symptoms from the first to the 10th swallow, but started to complain chest pain and dysphasia when swallowing more than 15 mL. The more water she swallowed, the worse her symptoms got. She complained the most severe symptoms when swallowing 50 mL of water. Rapid propagated pressurizations were observed at the second, fourth, sixth and seventh swallows, in which pressurization front velocity was measured as 19.

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man presented to his primary care physician’s office with haematuria of one-month duration. He also reported a 10–15 lb weight loss over the preceding 4–6 weeks. A review of symptoms was positive for anorexia and lower-back pain for the preceding two months. Urinalysis confirmed the presence of haematuria without evidence of any infectious process. A computed tomography (CT) scan of the abdomen and pelvis revealed a left renal mass (measuring 13 cm in diameter) with imaging characteristics suggestive of primary RCC (). The workup for metastatic diseases with magnetic resonance imaging (MRI) of the brain, CT of the chest, and a bone scan was negative. The patient was evaluated by urology and was scheduled for nephrectomy but had to return to the hospital a week sooner than scheduled because of symptoms of right-flank pain, worsening back pain, and progressive weakness of both legs. The lower-extremity weakness started a week prior to presentation and progressively got worse, resulting in the inability to walk. The weakness was associated with urinary incontinence. The rest of the review of symptoms was negative.
The past medical history was significant for hypertension. He denied any significant family history. His personal history was significant for a 15 to 20 pack per year history of smoking.
On physical examination, the patient had tenderness in the lower back and over the right costovertebral angle. Motor power was 5/5 in both upper extremities, 3/5 in the left lower extremity, and 2/5 in the right lower extremity, in both the proximal and distal muscle groups. The gait could not be tested because of the patient’s inability to stand up. There was decreased anal sphincter tone, and sensation was impaired in the perineal region. There was no evidence of meningimus, and the cranial nerve examination was normal.
MRI of the spine demonstrated nodular enhancement of the spinal cord with diffuse leptomeningeal involvement along

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


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

[User]
RADIOLOGY NOTE:
A 68 year-old-male patient was involved in a motorcycle accident. He presented to our emergency department with diffuse swelling and severe pain over the left knee and over the left ankle. No evidence of other skeletal injury was reported at the clinical examination. Both a radiographic examination and a CT scan revealed a left tibial fracture (Schatzker type VI) with a depression of the lateral-posterolateral side. A medial and posteromedial involvement of the tibial plateau was found, associated with a non-displaced fracture of the peroneal malleolus (, , , ). The fracture of the tibial plateau involved all columns (lateral, medial, posterior), as previously described by Luo. A long leg partial splint - was applied and limb elevation was recommended until surgery. A 3D reconstruction of the knee was done for a more accurate investigation of the fracture and an in-depth preoperative planning (, , ).
The fracture of the proximal tibia consisted in a split depressed lateral condyle with a posterior-lateral involvement. Medial plateau fracture was more complex, as the posterior-medial involvement was more extended in the medial side. The patient was operated seven days later to the admission, as a detailed cardiologic examination was requested by the anesthesiologist before surgery.
The patient was placed onto an orthopedic transparent bed in supine position to facilitate fluoroscopy and without using a pneumatic tourniquet. Cephazoline (2 gr iv bolus) was administered 30 minutes prior to skin incision as antibiotic prophylaxis.
The knee was externally rotated and flexed about 30 degrees and a posteromedial approach was firstly made. Incision was made posterior to the superficial medial collateral ligament. The fascia was identified and incised, the space between pes anserinus and the medial gastrocnemius was developed. Under direct visualization, the posterior fragment of the posterior medial column was reduced and stabilized in an anti-glide way with a 3.5 mm T-plat

[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 man without any underlying diseases had suffered from left side weakness and clonic–tonic seizures for 12 days. Computed tomography (CT) of the patient's head revealed a hypodensed mass with the size of 3 × 3 × 2.4 cm of the right temporal lobe. He was then admitted, and the magnetic resonance imaging (MRI) of his brain showed cystic astrocytoma in the right parietal lobe without midline shifting. A craniotomy was performed, and the pathology showed astrocytoma (World Health Organization (WHO) grade III). After operation, he received 2-dimensional conformal RT with a total dose of 45 Gy in 25 fractions to the whole brain. Mild skin erythematous change was noted after the completion of RT.
During a regular follow-up of 14 years after postoperative adjuvant RT, a small red nodule was noted at the patient's right scalp. The size of the nodule increased overtime and the color eventually turned to black within a year. This gray-colored skin papule with a diameter of 2.5 cm has an ulcerative center. He received skin tumor excision at the age of 42. The skin tumor was totally removed with an adequate margin. The pathology revealed BCC. The morphology of the tumor featured basaloid cells which extended into the dermis with elongated nuclei and little cytoplasm. The peripheral cell layer of the tumor masses showed a palisade arrangement of the nuclei (Fig. ). No skin tumor recurrence has been noted to date.
Two years later, the patient developed headache, left side weakness with unsteady gait at the age of 44. His brain MRI revealed a huge cystic lesion with fluid-fluid level in the patient's right frontal lobe. There were hemorrhage, perifocal edema, mass effect causing mild midline shift. Second craniotomy was performed, and there was presence of microvascular of festoons gliosis, microcalcification and tiny foci of necrosis in the specimen, which favored the diagnosis of glioblastoma (WHO grade IV).

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


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

[User]
RADIOLOGY NOTE:
The patient was a fifty-six-year-old man who initially complained of swelling in his left external ear canal. Over the previous year, he had gradually experienced severe left trigeminal neuralgia, which was occasionally accompanied by a sensation of ear fullness. On physical examination, the lesion was a solitary nodule, with a maximum diameter of 1.6 cm. The lesion was a tender, smooth, firm swelling nodule that was skin-colored with a wide base, and it had not ulcerated the left external auditory canal, which was covered with intact skin. The lesion occluded the ear canal and obstructed the view of the tympanic membrane. The patient’s hearing in this ear was slightly affected. There was no sign of regional or distant metastasis on examination before surgery. The remaining clinical imaging examinations, including head, neck and cranial nerve examinations, were normal. Routine laboratory test results, including those of liver function, kidney function, total electrolyte levels, coagulation function and complete blood counts, remained within normal limits. A high-resolution positron emission tomography (PET)-computed tomography (CT) scan of the whole body demonstrated the fluorodeoxyglucose (FDG)-avid mass described above (maximum standard uptake volume (SUVmax 2.6), while no involvement of the bony canal walls was identified (). The patient had a history of being physically fit and did not have a personal or family history of skin tumors. Taken together, the results demonstrated that the patient had no evidence of local positive lymph nodes or distant metastases, and the lesion was limited to the external auditory canal. The patient underwent wide excision of the lesion with clear margins under general anesthesia. The postoperative course was normal and uneventful. The patient was followed up over a period of 6 months, and no evidence of local recurrence or systemic metastasis was clinically observed. The patient was instructed to report for follow-up after another

[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-year-old Caucasian female patient was referred to our department for further work-up of painful cutaneous lesions (Fig. ) and several masses within her liver.
Eight weeks prior, she had observed an erythematous nodule on her right chest. Subsequently, similar cutaneous lesions had developed on her arms and legs, and later also on her buttocks and back. She did not report any abdominal complaints. Outpatient treatment with topical and systemic steroids based on a suspicion of erythema nodosum (EN) did not yield substantial effect.
Four weeks prior, several liver lesions had been detected by ultrasound and were interpreted as metastases of a previously treated breast cancer. Additional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) had been carried out (Fig. ) and confirmed the liver lesions.
As the nodules on her skin continued to spread and became increasingly painful, she was presented to the Department of Dermatology in our clinic. There, another attempt of steroids and an intensified local therapy resulted in no improvement of her clinical condition. Due to raising inflammatory parameters a work-up for possible infectious causes and an antibiotic therapy with piperacillin/tazobactam, and later with meropenem were initiated. A colonoscopy revealed two small polyps, which were completely removed. Pancreatic enzymes were markedly elevated. A punch biopsy of one of the skin lesions was obtained showing a lobular necrotizing panniculitis with “ghost cells” compatible with pancreatic panniculitis (Fig. ). CT, MRI and repeated ultrasound examinations (Fig. ) did not reveal any pathological findings in the pancreas. In contrast enhanced CT multiple sharply-bounded liver lesions were visualized in both liver lobes. Compared with the CT obtained during outpatient care, the lesions had progressed in size and measured from 1 cm to 6 cm. The perfusion pattern was non-hypervascular and the density was hypointense, partly comparable with the den

[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 was a 24-year-old African American female with past medical history of congenital Human Immunodeficiency Virus (HIV) infection, compliant with antiretroviral therapy (ART) with a CD4 count of 275, recently diagnosed endometriosis, and childhood asthma. She was admitted to the hospital for an elective dilatation and curettage procedure. She was seen postprocedure by pulmonary medicine for acute onset of shortness of breath. She was noted to be in mild respiratory distress with oxygen saturation of 96% on 4 liters of oxygen via nasal cannula but, otherwise, had a normal exam. She improved after receiving nebulized albuterol. Upon further questioning, the patient revealed that she was diagnosed with asthma as a child. She was treated with various inhaled and nebulized medications throughout her childhood. During early adolescence, she required home oxygen for about 1-2 years. She had multiple hospitalizations for presumed asthma exacerbation during her childhood and teenage years. She did not recall having a pulmonary function test or any imaging of the chest. She had never been placed on noninvasive or invasive mechanical ventilation. Over the last 5-6 years, she had no hospitalizations for shortness of breath. She did not use oxygen at home. She had a desk job as a receptionist in a doctor's office so was able to perform her duties without experiencing any respiratory distress. However, she did get short of breath after walking 3 blocks and after climbing 1 flight of stairs. She used an albuterol inhaler which she said brought only mild relief of her symptoms. She had never smoked cigarettes or any other illicit drugs. However, she was exposed to second-hand smoke as her grandmother and several of her friends smoked in her presence.
Her hemoglobin on presentation was 8.9 g/dL, stable as compared to previous levels. She had a normal white blood cell, platelet count, and renal function. A liver function test was normal except for a low albumin level 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:
An 11-year-old boy presented with complaints of pain and swelling over the right forearm since 4 months. Examination revealed a 10 cm × 5 cm bony hard mass arising from the diaphysis of the ulna. Elbow and wrist range of movements were normal, pronation and supination were restricted due to pain, no distal neurovascular deficiency was noted. The plain radiograph of the forearm in two perpendicular planes revealed a permeative destructive lesion with a wide zone of transition involving the middle and lower third ulna with periosteal reaction and cortical breach []. Magnetic resonance imaging (MRI) revealed the involvement of almost the entire ulna except for the proximal part sparing the olecranon and articular surface (T1-weighted images). It was associated with a large soft tissue component with the displacement of ulnar vessels (T2-weighted images) [ and ].
The clinico-radiological diagnosis of Ewings sarcoma was confirmed histopathologically with core needle biopsy. The patient was staged with computed tomography of the chest, a bone scan and multiple-site bone marrow aspiration, which did not reveal metastasis. The patient was evaluated in a multidisciplinary clinic and was started on multi-agent chemotherapy. He was reassessed after induction chemotherapy with plain radiography and an MRI of the forearm for planning local treatment []. The MRI revealed a substantial decrease in the soft tissue component of the disease. Local treatment options (limb salvage surgery with complex reconstruction vs definitive radiotherapy) were discussed with the patient and attendants, who opted for surgical treatment.
A limb salvage surgical procedure was planned with wide excision of the ulna except the proximal 2 cm, which includes partial articular surface as this was uninvolved by the disease. This ensured a narrow 1 cm tumor-free margin proximally. Reconstruction was planned with medialization of the radius with its proximal articular surface to this retained fragment creati

[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 14-year-old male patient had normal birth and developmental milestones. He has no family history of dystonia or other movement disorders. At the age of 7, the first symptom of dystonia appeared as clumsiness of the hands; when he started to attend elementary school, he experienced difficulty with schoolwork because of an abnormal handgrip during writing. He was also noted to have difficulty playing with small objects such as building blocks or certain musical instruments such as a flute or piano. At first, the condition progressed very slowly. At the age of 10, the patient’s father became aware that his son’s hand clumsiness was not correlated with his age and development, and sought medical help. The boy visited a rehabilitation clinic for the hand clumsiness and underwent a series of rehabilitation treatments without obvious improvement. He also visited a pediatric neurologist for evaluation, but the brain magnetic resonance imaging (MRI) examination revealed only a parapineal arachnoid cyst, and no specific diagnosis was made at that time. However, when the patient was 11 years old, scoliosis appeared that mainly involved the thoracic and lumbar regions of the spine and abnormal posture, which rapidly deteriorated in the following 6 months. His gait and stance became severely impeded due to the severity of the scoliosis. He visited orthopedic doctors at the local hospital and received various medications, botulinum toxin injection, a back brace, and different types of physical therapy based on an initial suspicion of adult idiopathic scoliosis. None of these treatments were effective for the scoliosis. Muscle biopsy was performed but the results were normal. He was finally referred to a pediatric neurologist (WTL) at our center. Levodopa was given as a trial but had no effect. Laboratory biochemical tests showed no abnormalities and medication-induced and acquired dystonia were excluded. Genetic testing with a dystonia panel by next-generation sequencing reve

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old man presented to our institute with an enlarging, painless, nodular mass in the right upper lid that began 4 months prior with rapid increase in size over the last 3 months. The mass became significantly prominent over the last month prior to presentation resulting in discomfort, ulceration, and bleeding on manipulation. Physical examination revealed a solitary mass in the middle third of the right upper eyelid, overhanging the lid margin that was 9 mm × 12 mm in size, pinkish, firm, fleshy with small-dilated blood vessels on the surface with central ulceration and crusting []. The mass was underlying the right upper lid skin extending beyond the lash line without invading the palpebral conjunctiva. It was firm to hard in consistency and tender to the touch and did not appear to extend to the deeper underlying tissues. There was no regional aurical, cervical, or submandibular lymphadenopathy. The remainder of the ocular and general physical examination including examinations of the liver and lungs was normal. Basal cell carcinoma or squamous cell carcinoma was suspected on the basis of the clinical examination. A biopsy was sent to the pathology service.
A complete, wide excision of the nodular mass with a 3 mm clear margin of healthy surrounding tissue was performed along with primary closure []. The pathology service identified malignant nodular hidradenoma, a rare eccrine sweat gland tumor (described below). At the last visit, 6 months after excision, there was no recurrence of the lesion. The patient was subsequently lost to follow up.
The specimen submitted to the pathology department comprised of a nodular mass 1.5 cm in diameter. The cut surface was yellowish with few cavities.
Histopathologic examination revealed a tumor in the dermis with surrounding fibrous capsule. Two types of tumor cells were noted with predominance of one cell-type which was polyhedral to round in configuration with round to oval nuclei and prominent nucleoli surrounded b

[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 woman of African descent with NF1 presented to our clinic complaining of chronic pain, depression, and anxiety. She was diagnosed with NF1 at puberty but had reported symptoms since childhood. She was unaware of a family history of similar conditions. She has Lisch nodules on her iris bilaterally and 10 café-au-lait patches across her body. The patient also has numerous subcutaneous neurofibromas on her face (plainly visible and causing some facial disfigurement) and in several regions of her body. These caused her chronic, intermittent, sharp pain of varying intensity but averaging 6/10 on the 10-point pain scale. She has tried many OTC pain medications with limited benefits. She has had over 20 surgical resections and multiple laser treatments for the neurofibromas with limited success as they often recurred after treatment. She reports pain from both the treatment and the tumors themselves. The neurofibroma tumors have also caused her cosmetic issues. She reports being withdrawn, stressed, and anxious, especially in social situations when she feels that people are staring at her. She reports low energy and had lost interest in most activities. Furthermore, she reports that her condition has interfered with finding employment and leading a normal life. She states that her mood is low, and she has frequent crying episodes. Her general practitioner (GP) has prescribed multiple antidepressants that were not tolerated due to the side effects. Consistent with NF1 common symptoms, she reports having migraine headaches. She averages around 15 episodes per month varying in intensity between 5/10 and 10/10. She has reportedly used OTC pain medications for the migraines unsuccessfully.
CBD oil has no established dosing guidelines or maximum doses, except in psychosis (800 mg) and seizure disorders (2,500 mg or 25 - 50 mg/kg) []. Dosing is highly individualized and relies to a great extent on titration. The general approach to initiation is to "st

[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 45-year-old African American female presented to the emergency department (ED) with a new onset of dizziness, difficulty walking, and low blood pressure. Her past medical history was significant for hypercholesterolemia, hypertension, and a recent urinary tract infection. She smoked tobacco but used neither alcohol nor illegal drugs. There was no history of asbestos exposure or recent viral illness. Physical examination was unremarkable. Lab work was performed and showed normal results, so the patient was released. The following day, she returned to the ED once again, and reported that her symptoms had escalated significantly. Soon thereafter the patient developed multiple organ failure with subsequent cardiac arrest, passing into pulseless electrical activity, and her death was pronounced. The initial significant autopsy finding was the discovery of approximately one liter of blood within the pericardial cavity. The pericardial sac was focally adhesed to the surface of the heart. The pericardial surface of the heart was markedly granular and thickened. An area on the pericardium of the anterior left ventricle was focally disrupted without frank tearing or laceration and blood was observed to ooze through this defect. Gross photographs were not taken due to the initial impression of classic pericarditis. The remainder of the postmortem examination was negative for grossly suspicious malignancy, including pleural, pulmonary and lymphoreticular involvement. No abdominal or pelvic pathology was identified. In particular, there was no omental or peritoneal caking, and no ovarian, renal, or hepatic masses were identified. Microscopic examination of tissue sections taken from the epicardium revealed dense lymphocytic infiltrates admixed with numerous neoplastic, polygonal cells with abundant cytoplasm and enlarged, irregular nuclei containing conspicuous nucleoli. Some of these tumor cell clusters formed gland-like formations and papillary structures (Figure ). Abundant

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old boy, grade 9 student, presented in neurosurgery clinic with complaints of backache and left leg numbness. According to the patient’s father, his symptoms started three months prior when he developed pain in the lower back. Symptoms were gradual in onset, continuous and progressively increasing in intensity from moderate to severe. The pain was worse at night and was relieved by taking paracetamol (acetaminophen). It was also associated with weakness in the lower limbs, with a left-sided predominance. A week prior to presentation, the patient developed urinary retention and constipation. His birth and family histories were insignificant. Vaccination and developmental milestones were up to date. General physical exam was unremarkable. Systemic examination revealed decreased power in the lower limbs, bilaterally positive straight leg response and absent plantar reflexes.
Considering the presenting complaints and examination findings, the patient was admitted for further workup. Magnetic resonance imaging (MRI) of the whole spine was performed which revealed an intramedullary lesion extending from T8 to L1 vertebrae involving the conus. The maximum dimension of the lesion was 138 mm (Figure ). A decompression laminectomy for excision of space occupying lesion was performed. The resected specimen was sent for histopathological review, where the diagnosis of glioblastoma multiforme was established (Figures , ).
Immediate post-operative MRI of thoracic and lumbar spine demonstrated post-surgical changes along with hemorrhage at the site of surgery with cord edema (Figure ). MRI brain showed no metastatic disease. Post-operatively, the patient had noticeably reduced sensation and power in the lower limbs, making him bedbound. Physical rehabilitation was then instituted which improved his condition slightly to the extent that he could be mobilized using a wheelchair.
The case was further discussed in site-specific multidisciplinary team meeting, where the conse

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old ex-smoker with type 2 diabetes (70 pack-years) man was transferred to the Otorhinolaryngology after being seen in the Pulmonology Department with a progressive gradual increase in hoarseness of voice for a duration of 6 months, shortness of breath exacerbated by exertion and when lying flat had choking attacks, which occurred with liquids only, weight loss and recent hemoptysis with no history of fever, dysphagia, pain, or tuberculosis exposure. Afterwards, pleural effusion drainage was done by the Pulmonology Department to relieve the symptoms and he was sent for cytology. Surprisingly, the lung computed tomography (CT) only showed a large left pleural effusion at the time with complete left lung collapse, no obstructive mass was present, and no signs of any lesion was reported (). Meanwhile, the pleural effusion cytology showed atypical cells, vacuolated cytoplasm, and prominent nucleoli in a background of macrophages, lymphocytes and blood with suspicion of malignancy. Six weeks later, another pleural tap for a recurrent pleural effusion was performed with the pleural fluid cytology being negative for tumor cells. After complete full body workup, the Pulmonary Department discovered a thyroid nodule and transferred the case to the Otorhinolaryngology with a provisional diagnosis of thyroid nodule due to the progressiveness of hoarseness of voice with lung metastasis.
On head and neck examination, the tongue was deviated to the right with no other abnormalities found and no lymphadenopathy. A laryngoscopy showed a mobile left vocal cord and an immobile right vocal cord in the paramedian position with excessive pooling of hypopharyngeal secretions, most extensively in the right pyriform fossa. Further investigation of the thyroid showed a normal thyroid function tests (TFT) while a neck CT showed a right vocal cord paralysis with a right thyroid nodule about 1.5 cm () and an upper mediastinal lymph node enlargement at the right tracheoesophageal groove

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old male with no known medical history developed sudden onset chest pain, dyspnea, and a sensation of fullness in his throat. He was transported to the emergency room where he was found to be hypotensive (82/54 mmHg), bradycardic (40 beats/min), and tachypneic (26 breaths/min). His oxygen saturation was normal, and he was awake and alert and exhibited no neurologic deficits. His electrocardiogram showed normal sinus rhythm without acute ST-T wave changes, and his troponin T was normal. Given the concern for pulmonary embolism, a computed tomography (CT) scan with contrast was obtained. The CT scan revealed acute type A dissection arising from the aortic root and extending to the left iliac system. The left coronary ostium, all three great vessels, the celiac trunk, superior mesenteric artery, and left renal artery appeared to be involved. He was scheduled for emergent aortic reconstruction with deep hypothermic circulatory arrest.
The patient underwent induction of general anesthesia with tracheal intubation. Transesophageal echocardiography (TOE) was subsequently performed, which confirmed the presence of a dissection flap in the ascending aorta []. The flap was observed to prolapse across the aortic valve into the LV outflow tract during diastole [ and Online ]. Remarkably, there was no aortic valve insufficiency [], the LV wall motion was normal, and there was no hemopericardium. Following sternotomy and opening of the pericardium, heavy bleeding through the aortic wall was encountered. Cardiopulmonary bypass (CPB) via femoral cannulation was initiated, and the patient was cooled to 18°C. During 37 min of circulatory arrest, the ascending aorta and inside curve of the aortic arch were excised and replaced with vascular graft (hemiarch). The aortic valve and root were replaced with a valved conduit, and the coronary buttons were implanted into the conduit. After the anastomosis of the valved conduit to the hemiarch graft, the patient was separated from C

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


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

[User]
RADIOLOGY NOTE:
An 81-year-old man with a major complaint of painful mass at the lower calf was referred to our institution. Pain and swelling in his left lower leg started to develop 2 weeks prior to his presentation to our clinic and progressively worsened, eventually rendering him unable to walk. While he denied any trauma to that leg, he had been taking aspirin 100 mg, amlodipine 5 mg, candesartan cilexetil 8 mg per day for 7 years to control his hypertension, and had a history of several times of injections in the left knee for 1 year because of osteoarthritis.
Physical examination showed severe calf swelling with tenderness; however, no local heat or redness was observed (). The patient's body temperature was 36.8℃, his dorsalis pedis artery and posterior tibial artery pulses were strong at the level of ankle and foot, and the neurological findings were normal. Knee joint line tenderness and 10° of flexion contracture were observed in the left knee. The left knee score was 51 points.
The patient's blood parameters were normal: white blood cell (WBC) was 8,450, C-reactive protein (CRP) was 0.49, and coagulation parameters and autoimmune parameters were normal. But platelet aggregation function assay was delayed. A plain X-ray of the left leg revealed Kellgren-Lawrence grade 4 osteoarthritis of the knee joint and increased soft tissue density along the medial aspect of the proximal lower leg (). Computed tomography angiography (CTA) showed a large mass along the subfascial layer in the medial aspect of the gastrocnemius, and no evidence of deep venous thrombosis. MRI revealed a large mass extending distally along the subfascia in the superficial aspect of the medial gastrocnemius with muscle compression. The mass measuring 13×5×3 cm showed a low-intermediate signal intensity on T1-weighted images and an intermediate-high signal intensity on T2-weighted images. These MRI findings suggested the presence of a hematoma and the inhomogeneity

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


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

[User]
RADIOLOGY NOTE:
In August 2010, a 29-year-old African American female who was 16 weeks pregnant presented to her primary care physician complaining of a fever of 103 degrees Fahrenheit, chills, pleuritic chest pain, shortness of breath and a non-productive cough for 2 days. Her pregnancy had been complicated by thyrotoxicosis and hyperemesis gravidarum requiring the placement of a peripherally inserted central venous catheter for total parenteral nutrition (TPN). The catheter had been placed approximately 11 days prior to the onset of her symptoms and she had received TPN since that time. The patient had no other significant medical history and was born in the United States with no recent travel or unusual food exposures. She did not smoke tobacco, drink alcohol or use illicit drugs. She was sexually active with a single male partner and had no history of sexually transmitted diseases. Her only sick contact was her father who had recently been treated for cellulitis. Her immunization history was unknown.
The patient was initially given a 5-day course of azithromycin. No laboratory studies or cultures were performed at the time. Three days later she returned to the emergency department of a community hospital complaining of persistent symptoms and mild vaginal spotting. She continued to have fevers, chills, pleuritic chest pain and dyspnea that had improved minimally with azithromycin.
A chest x-ray revealed diffuse, peripherally located reticulonodular infiltrates in both lung fields. Laboratory testing demonstrated an elevated white blood cell count (15,800 cells per cubic millimeter). The automated differential showed 90% neutrophils and 6% bands. A complete metabolic panel was within normal limits. Her albumin, a general marker of nutritional status, was within normal range. The patient was admitted to the hospital. Two sets of blood cultures, both peripheral and from her central venous catheter, were drawn at the time of admission. Both sets had bacterial growth (at 44 and 30 h

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


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

[User]
RADIOLOGY NOTE:
The proband was a 34 year-old right-handed man. From the age of 26 years, involuntary movements of the bilateral lower limbs, associated with dysarthria, grinding teeth and drooling, appeared and gradually worsened. At 31, he suffered from epileptic seizures, which were considered to be generalized tonic-clonic seizure, but antiepileptic drugs had never been administered. One year later, involuntary movements spread to his upper limbs and orofacial automatisms including abnormal tic-like facial movements, tongue protrusion and biting his lips appeared. Then he was treated with haloperidol (2 mg three times a day) and baclofen (10 mg three times a day) for 2 years for his choreic and dystonic problems, but he responded poorly to drug treatments. At age of 34, his involuntary movements gradually spread to his whole body and epileptic seizures increased in frequency. Since the disease onset, the patient had never suffer from psychiatric problems. Neurological examination revealed poor muscle tone and absent deep tendon reflexes in all limbs. Additionally, right positive babinski sign was elicited. Laboratory data revealed elevated creatine kinase level in the peripheral blood. Acanthocytes were found in 4% of cells on the peripheral blood smear test. Doppler ultrasound examination revealed splenomegaly. Brain magnetic resonance imaging (MRI) showed progressive, symmetrical, mild atrophy of the caudate heads (Figure ). His 24-h continuous electroencephalography (EEG) showed generalized asynchronous theta and epileptiform activity, which mostly originated from the right temporal lobe. A nerve conduction study showed a polyneuropathy, which revealed the right peroneal nerve, right median nerve and bilateral ulnar nerves were partly damaged. His score of Mini Mental Status Examination (MMSE) was 27. The father of the proband did not show any neurological abnormalities and died from pneumonia at 65 years old (Figure ). The mother of the proband (II-3), a 65-year-old woman,

[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 male with body mass index of 42 kg/m2 was referred for management of bilateral asymptomatic nephrolithiasis. His family history was significant for nephrolithiasis in his brother and sister. He had passed five calcium oxalate stones since the age of 30 years. He was a smoker with no other medical history.
The initial abdominal plain X-ray (kidney, ureter, and bladder radiograph [KUB]) showed a left lower pole calcification and a 1.5 cm calcification on the iliac crest (). A noncontrast CT of the abdomen and pelvis revealed a 1.8 cm right midureteral stone (1288 HU) with proximal hydroureteronephrosis, a thin right renal cortex, two right lower pole stones 5 mm each (). In addition, a dilated tubular structure measuring 9 × 4.3 cm connected to the cecum and containing a few dependent calcifications was described. This was thought to be an appendiceal mucocele compressing the right mid ureter below the midureteral stone (). On renal scintigraphy, the right kidney was obstructed and contributed to 32% of the global renal function. After a failed attempt of extracorporeal shockwave lithotripsy, right retrograde flexible ureteroscopy (URS) was performed, which revealed a tortuous right distal ureter up to the midureteral stone that was impacted on an inflammatory stricture. In the presence of the stricture and of a tortuous ureter, we thought it was not safe to proceed with laser lithotripsy because of increased risk of ureteral trauma. An indwelling ureteral stent was placed and the patient was brought back for second-look URS and laser lithotripsy. During the second URS 4 weeks later, the impacted midureteral stone was accessed with a semirigid ureteroscope, and the stone was fragmented with Holmium laser energy (1 J, 10 Hz) and the fragments were removed using a zero-tip basket. At this point, a mucous plug was found in the dilated tortuous proximal ureter. A ureteral access sheath was placed

[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 52-year-old male presented to the ambulatory surgery center for a scheduled right sided C6 - C7 interlaminar epidural steroid injection. The patient had been dealing with neck pain for the last few years, with decreased range of motion predominantly on extension, positive Spurling’s sign on the right side, decreased sensation to light touch in the C6 - C7 nerve distribution, and normal reflexes that were elicited on physical examination. He had minimal relief with medication, including NSAIDs and tramadol, and physical therapy. MRI of the cervical spine showed a posterior disc osteophyte complex that was causing mild to moderate spinal canal stenosis with severe right and moderate to severe left neural foraminal narrowing. The radiologic findings along with the positive physical exam findings were evidence that the patient could potentially benefit from a cervical epidural block.
After informed consent was obtained, the patient was placed on the fluoroscopy table in the prone position with the neck in the neutral position. The right C6 - C7 epidural space was identified using fluoroscopy and a 22-gauge, 3.5 inch Tuohy was advanced to the epidural space using loss of resistance technique. Isovue contrast was used for needle localization and after confirmation of the presence of the contrast in the epidural space (), 10 mg of dexamethasone and 2 mL of preservative free 1% lidocaine were injected.
The patient was then taken from the OR to the post anesthesia care unit (PACU) for observation. About five minutes after arrival into the PACU, the patient was noted to be anxious and hypertensive, with the systolic pressure running in the 180s mmHg and the diastolic pressure in the 100s mmHg. The patient was normotensive prior to the procedure with a blood pressure of 134/82 mmHg. In addition to the elevated blood pressure, the patient reported that he was unable to swallow and was having a subjective sensation of dizziness, and concurrent horizontal nystagmus. All other v

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old Caucasian man with severe chronic thromboembolic pulmonary hypertension and progressive decline to New York Heart Association (NYHA) functional class IV was admitted to our intensive care unit (ICU) because of respiratory failure and need for mechanical ventilation. His medical history included repeated episodes of deep vein thrombosis and two episodes of pulmonary embolism despite adequate anticoagulant therapy. Upon completion of the pulmonary hypertension investigation, his pulmonary thromboembolic disease was considered non-operable and was treated with bosentan and inhaled iloprost. Following the initiation of mechanical ventilation he was switched to intravenous iloprost and three months later our patient demonstrated a significant hemodynamic improvement, allowing him to undergo PEA. Details on his hemodynamic status and management are described elsewhere [].
During his hospitalization, our patient had two episodes of ICU-acquired microbial and fungal infections including a catheter related candidaemia due to Candida albicans and Staphylococcus epidermidis (isolated from the catheter tip of a left internal jugular central venous catheter, treated with caspofungin for 15 days and linezolid 600 mg twice a day for 14 days), and an episode of ventilator-associated pneumonia (VAP) due to Acinetobacter baumannii treated according to the detected antimicrobial susceptibilities with imipenem (1 g every six hours) and colistin (3 × 106U every eight hours).
Immediately prior to PEA, our patient was given 1 g of vancomycin as surgical prophylaxis with the induction of anesthesia. During the first post-operative week he was febrile without an apparent site of infection and received antibiotic treatment according to the surveillance cultures. On the eighth post-operative day an exudate drained automatically from the surgical wound; cultures grown in Sabouraud dextrose agar revealed a fast-growing isolate with cottony texture identified as Aspergillus spp. Mi

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old female patient presented to us with a 6-year-old history of pain in the right little fingertip. She took treatment at multiple places and only got transient relief before she was referred from the primary care center for further evaluation. The onset was insidious and there was no history of injury, smoking, diabetes, peripheral vascular, and cardiovascular disorder. There was no visible swelling but localized pain and tenderness over the volar aspect of distal phalanx of the little finger. The neurovascular status was intact in the affected upper extremity. There was also the history of pain increasing on cold temperature, when a fan or air conditioner is on and during winters, On palpation, pinpoint tenderness was noted when the volar pulp was given pressure with a blunt pin. The nails were normal without any pain or discoloration. The patient had normal radiographs and patient was referred for magnetic resonance imaging (MRI) of the finger. The MRI revealed a 14 × 3.5 mm altered signal intensity lesion in the soft tissue of the distal phalanx on the volar aspect best seen on sagittal T1-weighted images as T1 hyperintense lesion with heterogeneous hypointensity on fat suppression []. The lesion was closely abutting the distal phalanx cortex but without any cortical breach noted. The MRI was suggestive of glomus tumor and the excision biopsy was planned. The volar midline incision centered over the lesion was made under aseptic preparation and finger tourniquet, A glistening bluish-colored soft tissue lesion was found and that was removed en bloc with careful dissection []. Hemostasis was achieved and the wound closed after ensuring the excision of the lesion in its entirety so that to decrease chances of recurrence. The specimen was sent for biopsy and diagnosis of glomus tumor was concluded []. The postoperative period and the follow-up was uneventful and there was a marked improvement in clinical parameters with a marked reduction in the presurgery

[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 78-year-old nondiabetic male, presented with two chronic nonhealing ulcers of six months duration, one on the posterior part of left lower leg, measuring 3.3 × 1.8 cm with a fibrinous base and a second cutaneous ulcer on the anterior part of right leg, measuring 3.0 × 2.0 cm with a fibrinous base []. The patient reported a sensation of tightness in and around the ulcer sites with increasing severity. Both ulcers had thick nonhealing edges with a punched out appearance. The patient had been administered previously with various medications, including various types of antibiotics for six months with no improvement in the healing of the ulcers. He was on Tab. methotrexate 15 mg once-a-week for seronegative rheumatoid arthritis from past 10 years. He had no history of psoriasis at any time. He underwent complete blood investigations, which showed no pancytopenia or any other significant hematological abnormality. Culture and sensitivity tests from ulcer sites were repeatedly sterile for bacteria and fungi. Venous and arterial doppler studies of both lower limbs were done to exclude peripheral vascular disease and were normal. In view of underlying rheumatoid arthritis, a biopsy of both the ulcers was performed. There was no histopathological evidence of vasculitis or granulomatous lesions []. After extensively reviewing the clinical and investigational findings, it was found that the appearance and characteristics of the ulcers resembled those of methotrexate-induced ulcer previously reported in the literature. After a detailed discussion with the patient, methotrexate was stopped and the ulcerated lesion was closely monitored. Also, the patient was monitored for any exacerbation of rheumatoid arthritis. Two weeks after withdrawal of methotrexate, the ulcer showed definite signs of healing and by six weeks it was almost complete healed []. No other significant adjunctive wound healing measures were given. There was no exacerbation of symptoms of rheumatoid arthritis. S

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old man from the Indian Subcontinent experienced right sided, painless, sudden visual loss. He presented on the same day and his best-corrected visual acuity (BCVA) was 6/60 in the right eye and 6/6 in the left. His anterior segment examination was unremarkable and his intraocular pressure was 17 OD and 15 OS. On fundoscopy, we found a recent cilioretinal artery occlusion on the right and a normal left fundus. White retinal oedema was present along the artery course leading into the fovea. No thrombi were seen within the artery lumen. The optic discs were healthy bilaterally and there were no other peripheral retinal or vascular lesions. No signs of inflammation were found in the anterior or posterior chamber.
He had normal eye movements and a neurological examination did not reveal any other signs of stroke. The patient was otherwise well with no other medical history. He was not taking any regular medication and there was no significant family history. He admitted to smoking cannabis three times earlier in the day, before his vision loss. He denied the use of tobacco and informed us that this was his first use of Skunk cannabis. He also denied using any other illicit substance, most pertinently, cocaine.
On general examination, his blood pressure, heart rate, and ECG were within normal limits. His full blood count, kidney, liver, and thyroid function tests were normal. Furthermore, inflammatory markers, glycosylated haemoglobin, plasma homocysteine, lipid panel, coagulation screen, and serum protein electrophoresis were also normal. His blood tests did not reveal any signs of dehydration.
The fundus photograph of the right eye showed neuroretinal thickening along the route of the cilioretinal artery (), while the left eye showed normal retinal layers. An optical coherence tomography (OCT) scan confirmed neuroretinal thickening in the distribution of the cilioretinal artery of the right eye (). He was treated with topical beta-blockers (timolol), prostagl

[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.