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

[User]
RADIOLOGY NOTE:
A 66-year old gentleman in otherwise good general health was admitted to the neurosurgical department due to a skull deformation in the left frontoparietal region, which was growing progressively. He first noticed it approximately seven months ago and complained of dull headaches, located in the left half of the head that were noticed a few times weekly. No other complaints in connection with his health status were reported at the admission.
The neurological status during the clinical examination was normal. Locally, a skull tumour of 5 cm in diameter was felt. It was immobile and insensitive on palpation and the skin covering it was normal.
The computer tomography (CT) and magnetic resonance (MR) imaging revealed an intracranial expansive lesion of 8 cm in diameter, compressing the cortex and invading the skull bone and subcutaneous tissue ( and ). The CT angiography did not show any signs about sinus invasion. Surgery was indicated.
The operation was performed via midline incision. In the subcutis, the tumour mass growing through the bone was seen, infiltrating the periosteum and galea (). A round section of the skull bone was performed, encircling the tumour first. Then, the bone in the very vicinity of the tumour was drilled in such a way that two circular bone flaps were formed around the tumour as it was not possible to elevate the first bone flap due to the tumour adhesion to the bone without damaging the bridging veins and the dura. The tumour was then microsurgically removed, carefully dissected and elevated off the brain substance (). The tumour origin was in the dural convexity over the left motor and premotor cortex. The cortex was relatively spared, though severely compressed and the superior sagittal sinus was also compressed but otherwise intact. However, the bone was porotic and invaded by the tumour, which spread through the periosteum into the galea. The tumour was completely excised together with all infiltrated extracranial tissue.
Extensive defe

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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 21-year-old lady was referred to us for management of pain and paraesthesia involving the outer aspect of right ankle joint of approximately 18 months duration. Over the next few months she began to walk with a slight limp and the paraesthesia had extended to involve the whole of outer aspect of right leg. She consulted an orthopedician, who, noting nothing significantly wrong with her skeletal system prescribed analgesics and crepe bandage. Over the next few weeks she had difficulty in standing on toes while stacking some shelves at her house. Since the last 6 months she noticed that her pyjamas were becoming tighter at the right calf and within few weeks it started becoming tight at the level of thigh as well. Being medical personnel herself, she measured width of both calves and found the right calf to be 3.5 cm wider than the left. A magnetic resonance imaging (MRI) scan of the lower limbs was carried out at another hospital and was referred to us following muscle biopsy of the right calf. There was no other significant history.
She was moderately nourished lady with an antalgic gait, favoring the right leg. Motor examination revealed pseudo hypertrophy of right gastrocnemius and hamstring group of muscles with weakness of plantar flexion causing inability to walk on toes. Ankle dorsiflexor strength was within normal limits as was testing of the proximal lower extremity muscle groups. The Achilles reflex was not obtainable on the right side even with the Jendrassik maneuver. The left Achilles reflex was normal as were other stretch reflexes. The sensory examination revealed a deficit to pin prick in the S1 dermatomal distribution on the right and intact vibratory and position sense. The straight leg-raising test was negative on both sides. There were no neurocutaneous markers noted and the systemic examination was unremarkable. In summary, the patient had manifested with unilateral S1 radiculopathy.
Nerve conduction studies [] showed low amplitude

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

[User]
RADIOLOGY NOTE:
An abdominal CT scan was taken of a 57-year-old male patient who had sacral and right buttock and thigh pain, and revealed with a tumor-like lesion at the T12 vertebrae. Previously in 2007, the patient had been diagnosed with colon cancer, confirmed as adenocarcinoma by open biopsy. Targeting the cancer lesion, only endoscopic mucosal resection was executed at that time and was considered as a cure. After a period of 3 years, on a follow up large intestine endoscope, a recurred lesion was identified, thus abdominal low anterior tumor resection with colostomy was performed immediately. The patient was also diagnosed with liver cancer in 2009, which was confirmed as hepatocellular carcinoma. About this hepatic lesion, the patient was treated by radio-frequency ablation twice.
The T12 level tumor mass was first discovered in the abdominal CT which was taken to confirm the hepatic lesion, and in the follow-up abdominal CT executed 6 months later, the diameter of tumor mass was increased from 1.5 cm to 4 cm (, ). First, it was presumed that the lesion might be a metastatic lesion originated from the primary colon or liver cancer considering the previous cancer history of the patient. As a treatment for the vertebral lesion, total laminectomy, right hemi-vertebrectomy of T12 and tumor resection was performed, and pedicle screw fixation of T10, T11, L1, and L2 vertebral bodies were done. Observed intra-operatively, the tumor was found to be a brownish, hypervascular, and friable mass compressing the thecal sac on right side of T11-12 level, and additional erosion of the T12 lamina was also identified.
On the final pathologic report, however, it was confirmed as plasmacytoma (, ), which was completely different pathologically from previously diagnosed colon cancer or liver cancer. On additional immunostaining, the tumor cells also showed a monoclonality for lambda immunoglobulin in its light chain.
In conclusion, the patient was finally diagnosed to

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

[User]
RADIOLOGY NOTE:
A 64-year-old female patient presented to the emergency department after a train derailment. Upon arrival, she was nonresponsive, and Advance Trauma Life Support protocol was initiated. She was intubated, and on further workup, she was found to have a right upper extremity- (RUE-) comminuted displaced fracture of proximal radius and ulna Gustilo grade IIIc open fracture with large degloving injury and gross contamination. illustrates the large bony and subcutaneous tissue defect, and shows the X-ray of bony loss after application of an external fixator device while is the X-ray obtained in the trauma bay on initial arrival.
The patient was taken urgently to the operating room (OR) for right upper extremity washout, elbow-spanning external fixation, proximal ligation of the radial artery with angiogram secondary to substantial damage to the artery from the initial injury complex, right forearm fasciotomy, decompression of the carpal tunnel, and placement of wound VAC. Intraoperative angiogram demonstrated patent ulnar artery flow with an intact arch and backflow to the radial artery in the wrist. The soft tissue injury measured 15 cm × 10 cm, as seen in , which shows the original debridement soft tissue and bony defect. demonstrates the bony defect with antibiotic bead placement. On the first postoperative day, the patient was alert enough to undergo a neurovascular exam, where a posterior interosseous nerve (PIN) injury was noted.
The patient was taken back to the OR for multiple additional washouts and antibiotic bead exchange. On postoperative day (POD) 8, the patient had placement of ulnar intramedullary nail secondary to the only remaining skin bridge which was along the ulnar shaft and decision was taken to preserve the remaining skin bridge. Wound cultures from the initial surgery grew Citrobacter fruendii, Serratia marcescens, and Enterococcus faecalis, for which antibiotic regimen was adjusted based on susceptibilities, and the patient was treated for 6 week

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old male with past medical history of hypertension, coronary artery disease, chronic atrial fibrillation, and stroke (in 2011) presented to the hospital with complaints of slurred speech, dizziness, and gait imbalance in October 2014. He denied any other complaints. His blood pressure on admission was 180/102 mm Hg and heart rate was 77/minute. Physical examination was significant for left facial droop and irregularly irregular heart sounds. The rest of the physical examination was normal. Electrocardiogram showed atrial fibrillation with ventricular rate of 80 beats per minute. A noncontrast CT scan of the brain showed new lacunar infarct in right corona radiata and old right frontal lobe infarct. Subsequent MRI of the brain showed acute infarcts in right insular cortex, subinsular region, and right corona radiata along with an old right frontal lobe infarct. His laboratory tests were within normal limits. The patient was continued on dabigatran 150 mg twice daily, which he was taking at home. His other home medications included aspirin 81 mg, metoprolol succinate 100 mg, diltiazem sustained release 120 mg, and atorvastatin 40 mg daily. The patient had a regular follow-up with his cardiologist and was complianing with all his medications. He had a transesophageal echocardiogram done in August 2011, which did not reveal any smoke or clot in left atrium or left atrial appendage. He subsequently underwent electrical cardioversion for atrial fibrillation at that time but reverted back to atrial fibrillation shortly thereafter. He has been on dabigatran since then.
A transesophageal echocardiogram was done on this admission to evaluate a likely embolic source of acute stroke. Surprisingly, it revealed significant smoke and a mobile thrombus in the left atrium measuring about 0.6 cm × 0.3 cm (, Video 1 (see Video 1 in Supplementary Material available online at )). The left atrial appendage was free of thrombus. The patient was switched to warfarin anticoagulati

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

[User]
RADIOLOGY NOTE:
A 65-year-old male was referred to our center for treatment of severe coronary artery disease. The patient had a medical history significant for extensive tobacco use, diabetes, hypertension, and peripheral arterial disease requiring an aorto-bi-femoral bypass, lower extremity bypass, and left carotid endarterectomy. He reported having intermittent right upper extremity numbness for over 5 years without weakness. After completion of the preoperative cardiac surgery evaluation, the patient underwent coronary artery bypass using his left internal mammary artery in addition to a saphenous vein graft to re-perfuse his left anterior descending and obtuse marginal coronary arteries, respectively. Prior to his operation, a left radial artery cannula was placed by an experienced anesthesiology staff for close hemodynamic monitoring. A 10 cm 20-gauge arterial cannula was placed under ultrasound guidance after the first attempt. There were no intra-operative issues with the arterial cannula, and it remained in place when the patient was transferred to the intensive care unit for recovery. On postoperative day 1, arterial cannula was discontinued, by first disconnecting the IV from pressure bag followed by immediate removal of the cannula and non-occlusive digital pressure for 5 min. The patient immediately complained of left-hand numbness and weakness. On examination, he had loss of left radial artery pulse and poikilothermia. Noninvasive vascular studies showed occlusion of the left radial artery, proximal peak systolic velocity (PSV) of 10 cm/s, and no distal flow at the wrist with absence of digital pressures (). There was a patent ulnar artery feeding the palmar arch and no other clinically significant lesions in the subclavian, axillary, or brachial arteries. After obtaining surgical consent, an emergent cut-down and open thrombo-embolectomy under local anesthesia and sedation was performed within 2 hours of initial consultation. A 5 cm fresh thrombus was removed via an

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

[User]
RADIOLOGY NOTE:
A 66-year-old woman presented at a hospital with chest pain. Her history included diabetes, hypertension, and hyperlipidemia. On examination, the patient had a pulse of 100 beats/minute and blood pressure of 150/80 mmHg. Her electrocardiogram, echocardiogram, and blood test results were normal. Multislice computed tomography (CT) showed a saccular LMCA aneurysm and significant stenosis in the LAD artery (Fig. ). Coronary angiography revealed a saccular LMCA aneurysm measuring 9.8 × 7.5 mm with 75% stenosis in the proximal portion of the LAD artery. The operation was performed under general anesthesia. A median sternotomy was performed, and after a longitudinal pericardial opening was made, the heart was inspected. The LITA was removed from the inner chest wall in a skeletonized fashion using electric cautery. A distal segment of 1.5–2 cm was procured and reserved for use as a patch repair. Before aortic cannulation, the ascending aorta was dissected from the pulmonary artery. Under cardiopulmonary bypass, coronary artery bypasses of the left internal thoracic artery to the LAD artery were constructed in the beating heart. After aortic cross-clamping, the LMCA saccular aneurysm was exposed without main pulmonary artery transection. The saccular LMCA aneurysm was carefully dissected and completely excised. There was no thrombus in the lumen. Then, the LITA was longitudinally divided and trimmed to fit the incised LMCA. The small internal thoracic artery patch was sutured to the normal and firm lateral coronary arterial wall with a continuous 7–0 Polypropylene suture. Resection of the saccular aneurysm and closure using a small internal thoracic artery patch was then complete. The aortic cross-clamp time was 120 min, and the CPB time was 147 min. The patient had an uneventful hospitalization and was discharged on aspirin therapy. Follow-up multislice CT 10 days after the operation revealed the complete disappearance of the aneurysm and a successful repair with no lumin

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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 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.
She returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.
The patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper ext

[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 17-year-old female reported with the chief complaint of pain, swelling and ulceration on her upper and lower lip for past one week. History of presenting illness revealed that patient developed small fluid filled boils on her lips following the use of a lip balm one week back. These blisters reportedly ruptured soon, followed by ulcerations and crusting on her lips. Patient also complained of stiffness and drying of her lips with occasional bleeding and fluid discharge. She further complained of inability to open her mouth and discomfort while chewing and swallowing of food. Patient had visited a dermatologist for the same problem one week back and was diagnosed with herpes labialis. She was prescribed antibiotics for 5 days which further aggravated the condition.
Gross examination of the patient was unremarkable. Patient denied any history of prodromal symptoms or similar episodes of dermatological lesions or allergic reactions in the past. Family history, personal history or systemic manifestations of the patient was non-contributory. Patient gave no known history of food or drug allergy.
Clinical examination revealed swelling and eversion of lower lip with extensive ulceration and sloughing. Presence of yellowish areas with crusting and few brownish areas were also noted. On palpation, the lip was tender, rough with slight bleeding, pus and fluid discharge. Upper lip also revealed less extensive, but similar lesion in its vermillion border with multiple fissures which was tender, rough and stiff on palpation ().
Based on the history and clinical examination, a provisional diagnosis of stomatitis venenata (contact stomatitis) was made with herpes labialis, cheilitis granulomatosa, erythema multiformae and oral lichenoid drug eruption as differential diagnoses. The lip balm used by the patient was thought to be the source of allergy as no other history elicited from the patient was relevant to the condition. In order to confirm the source of allergy, a small amou

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man was accidently detected with a mass without tenderness on the right lobe of the thyroid. B-ultrasound showed that the morphology and echo of thyroid were abnormal though without nodules. Magnetic resonance imaging (MRI) showed significantly enlarged right lobe of the thyroid with a clear boundary and uneven density of mass, partly involving the isthmus of the thyroid, which was suspected as being thyroid adenoma (Fig. ). The thyroid function testing and emission computed tomography (ECT) scan were normal. Physical examination showed the following: right lobe of the thyroid showed no-fixed II degree swelling with no tender and obvious nodules. The liver and spleen were normal. Bone marrow biopsy was normal and the percentage of eosinophils in peripheral blood was 2.97% (normal range, 0.5%–5%). The patient had a history of hypertension for 7 years and hepatitis for 10 years. There was no family history of thyroid diseases and radiation ray contact. The patient underwent a right thyroid resection and dissection considered the possibility of thyroid adenoma. However, the pathology after surgery indicated LCH because immunohistochemistry staining confirmed CD1a (+), S100 (+), CD68 (+), Valentine (+), and thyroglobulin (+). The thyroid lesion gradually improved after the patient further received radiotherapy of 16 regimens combined with interleukin-2 therapy. The patient regularly monitored the function of thyroid and began to take 50 μg Euthyrox (levothyroxine) per day since being diagnosed with hypothyroidism 3 years after subtotal thyroidectomy. In 2007, the patient was again admitted to our hospital with the complaint of thirst and polyuria for several months. Urine osmolality was obviously lower than blood osmolality and urine specific gravity was less than 1.005. Further, fluid restriction test was positive and MRI of the pituitary revealed loss of the pituitary posterior lobe signal and the pituitary stalk was slightly thicker (Fig. ). We consider

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

[User]
RADIOLOGY NOTE:
A 44-year-old man was admitted to our clinic because of left knee pain. He had pulmonary tuberculosis at 6 years old. He presented pus-forming arthritis, which was presumably tuberculous arthritis, in the left knee after 2 years, with spontaneous remission after closure of the draining sinuses. Thereafter, no recurrent symptom of infection was observed. However, the deformity and growth disturbance progressed with the knee pain. He had limb lengthening and alignment correction for the leg length discrepancy and genu valgum. However, his left knee pain continued despite the deformity correction. Radiographs showed a fused knee with severe tricompartmental arthritis (Fig. ). Severe limitation in range of motion was observed on the left knee. We planned to perform one- or two-stage primary TKA depending on the presence of infection [].
Intraoperatively, a large subchondral abscess was found in the lateral femoral condyle and lateral tibial plateau after takedown of the fusion (Fig. d). On the basis of the necrotizing inflammation with granuloma in the frozen-section biopsy, active tuberculosis was suspected. Aggressive debridement and curettage of the infected and necrotic bone and soft tissues were performed.. After bone cuts and soft tissue balancing to prepare for TKA, articulating cement spacers (vancomycin 4 g and streptomycin 2 g per 1 batch) were made intraoperatively and applied to the tibial and femoral sides in sequence using intraoperative cement molds with a previously described technique [, ] (Fig. ). Relative medial and lateral stabilities were confirmed intraoperatively after inserting the articulating cement spacers. The diagnosis of tuberculosis infection was confirmed by isolating Mycobacterium tuberculosis from cultures. We decided to delay the TKA for at least 6 to 9 months to allow the administration of antituberculous drugs []. Evaluation at 1-year follow-up revealed no recurrent infection after sufficient antituberculous drug treatment. Therefore

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old male presented to the emergency department with complaints of diffuse abdominal pain, vomiting, and abdominal distension for five days. He reported not passing stools for two days. He had an elective laparotomy done 15 years back for peptic ulcer disease in our institute, the details of which were not known. On examination, he was conscious, oriented, and his vitals were stable. His abdomen was soft and distended with exaggerated bowel sounds. On digital rectal examination, the rectum was empty. Plain x-ray of the abdomen did not show any evidence of acute intestinal obstruction. An ultrasound of the abdomen was done which showed dilated hyper-peristaltic small bowel loops of maximum caliber 3.5 cm. There was no free-fluid in the peritoneal cavity and the gall bladder was normal. A clinical diagnosis of the adhesive intestinal obstruction was made, and the patient was managed conservatively with intravenous fluids and nasogastric drainage. Following 48 hours of conservative treatment, the patient had clinical improvement and was started on oral fluids. After two days of starting oral feeds, the patient again developed abdominal distension with bilious vomiting. A water-soluble contrast study was done which revealed dilated jejunal loops with multiple air-fluid levels and slow filling of the contrast till the ileum [Figure ].
In view of the persistent high nasogastric drainage of more than one litre a day and diffuse abdominal pain with guarding, the patient was planned for an exploratory laparotomy. Intraoperatively, there were no adhesions. A 6 × 5 cm well-defined firm intraluminal mass was palpable in the ileum about 45 cm proximal to the ileocaecal junction. The bowel loops proximal to the mass were dilated and the loops distal to it were collapsed [Figures -]. The mass, which was firm but mouldable with pressure, was found impacted at the transition area in the bowel. There was no structural abnormality identified in the bowel or the gall bladder.

[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 63-year-old male who presented to our clinic with left axillary pain and significant shoulder movement limitation. His symptoms started 15 years ago and did not subside despite using several pain killers. Initially, his pain was vague and sensed over the entire left shoulder. However, after 7 years, his pain changed in nature to a paroxysmal and lancinating one localized to the left axilla. He did not state any history of trauma. He had undergone radiologic and cardiologic work-ups several times without achieving a definite diagnosis. From 6 years ago, he noticed an axillary lump, assuming it to be an insignificant lesion unrelated to his chief complaint. According to the patient, the mass was sensitive to cold temperature and obliged him to wear warm clothes. As the mass size became larger and the pain was exacerbated, he became worried and came to our clinic for further evaluation.
Upon physical examination, his lump was revealed to be a fixed and painful mass located at the patient's left chest wall (in the mid-axillary line). No enlarged axillary lymph nodes were detected. His left shoulder's passive motion was in full range, but his active range of motion, especially active forward elevation, was limited.
The chest X-ray and shoulder X-ray of our patient were insignificant. His left shoulder magnetic resonance imaging (MRI) revealed a 5-cm (in the largest diameter) left axillary soft tissue mass at the mid-axillary line. The tumor was deep to the fascia and over the posterolateral chest wall extending from third to fifth ribs with no visible rib cage involvement [Fig. ].
Our differential diagnoses were schwannoma, hemangioma, glomus tumor, lipoma, and their malignant counterparts. Thus, we decided to perform an open biopsy. The histopathology report was in favor of a GT. At the next step, the excision of the mass was planned. We approached the tumor through the mid-axillary longitudinal

[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 presented with a swelling and pain on the left pre-auricular region initiated about two to three years ago. He also had pain increases during opening his mouth. He had botulinum toxin injected on the affected area three month ago, and the symptom was not relieved at all. There was no particular underlined systemic disease in his medical record.
A TMJ panoramic radiography, an imaging technique especially for assessing TMJ structure, was performed to evaluate if there is degenerative change of condyle and articulating eminence as well as relative position of condyle to articular fossa. The image revealed that joint space was slightly widened on left TMJ compared with the right side (). While, there was no restriction of both condyles during mouth opening (). No significant destruction or remodeling of bony structure was seen on joint components.
A computed tomography (CT) and magnetic resonance (MR) imaging, both without contrast-media, were also obtained to evaluate any minor degenerative change of condyle and disc problem of TMJ. On the CT images, round soft tissue attenuation was localized on the posterolateral aspects of left condyle head (). The lesion showed soft-tissue equivalent attenuation compared with the adjacent muscles. As it was shown in the TMJ panoramic radiography, there was no significant bony destruction; however, slight thinning and focal discontinuity of cortical bone was detected on the condyle head contacting with the lesion. Also, mild subchondral sclerosis was found on this site ().
On MR image of proton density and T1-weighted sequence, the lesion was well-encapsulated and showed heterogeneous signal indicating solid mass rather than cyst (). The left mandibular condyle showed anterior dislocation due to a mass on the posterior aspect. However, TMJ discs were in normal position during the mouth open and close conditions. Local T1 hyper-intensity was recognized as it indicated that there was hematogenous component

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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 man, assessed as American Society of Anesthesiologists (ASA) grade II, was admitted to our emergency department one hour after a car crash accident. On admission, the patient was conscious but amnestic for the event. His Glasgow Coma score was 15 and he complained only of pain in the mandible. Routine examinations, including cranial radiography and chest x-ray, were performed to exclude major thoracic and head injuries. A neurosurgeon confirmed cerebral concussion without neurological deficits and cervical injury. A dental x-ray revealed an open fracture of the mandible with distorted dental occlusion. Four hours after admission, the patient was scheduled for emergency fixation of the fractured mandible.
On the preoperative anesthesiologic evaluation, the patient reported to be allergic to dust and fasting for a minimum of 5 hours. He was obese (weight 100 kg; height 180 cm, body mass index 30.8 kgm-2), his dental caps were loose, but all routine laboratory findings were within normal range.
Anesthesia was induced with 2.5 mg of midazolam, 20 mg of etomidate, and 0.15 mg of fentanyl, followed by 100 mg of succinylcholine after 30 seconds to facilitate the intubation. When the patient was ready to be intubated, a nasal tube (size 7.5) was smoothly inserted through the right nostril into the trachea without using any force. The right position of the tube was confirmed by direct Macintosh laryngoscopy. However, once the tube was placed in the right position, manual ventilation was impossible to perform. The tube was immediately removed and the diagnosis made on-site: a nasal polyp completely obstructed the lumen of the tube and was still partly protruding from its tip. The second attempt of nasal intubation was successfully performed through the left nostril. The surgery was completed without complications. The patient was admitted to the intensive care unit (ICU) for observation and extubated. The following day, he was transferred from the ICU

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

[User]
RADIOLOGY NOTE:
A 23-year-old female patient was referred to our institution with a huge mass on the posterior scalp near the midline. The patient's parents gave the history that the mass on the posterior scalp was present since birth which gradually increased to the present size.
The swelling was painless and was gradually enlarging. On examination, there was a well-demarcated solitary pear-shaped sessile swelling in the occipital region near the midline measuring 7 cm × 6 cm in its greatest dimension []. On physical examination, no other swelling was noted elsewhere in the body.
The skin overlying the swelling was normal in color and texture but slightly stretched. The absence of hair on the surface of the swelling was noticed. There was no local rise in temperature associated with the swelling. The swelling was nontender, soft and putty in consistency, and mobile over the underlying structures. The surface of the swelling was lobular with smooth bumps. The swelling was fluctuant, compressible, and nonpulsatile. On radiographic examination, a soft tissue shadow of the cyst was seen at the occipital region without any bony erosion.
On the basis of the clinical examination, a provisional clinical diagnosis of lipoma was made.
Fine-needle aspiration cytologic (FNAC) was carried out to evaluate the nature of the contents of the cyst. Contents of the lesion were aspirated using a wide bore needle and was sent for microscopic examination. The section revealed the presence of numerous cells with empty cytoplasm and peripherally placed nucleus resembling adipocytes. Few keratin strands were also seen in the section. The FNAC diagnosis was given as lipoma.
Surgical excision of the cyst was then planned under general anesthesia. The specimen was sent for histopathological examination [].
Soft tissue was received in 10% formalin. The tissue was soft, putty, and fluctuant inconsistency. On cutting the mass, muddy paste got extravasated [], which resembled soggy keratin

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old female with a swelling over the right shoulder was referred to the Department of Orthopaedics. The swelling had been present for four years and was attributed to be the result of a fall. On examination, shoulder movements were restricted. Swelling was firm to hard, non-tender, associated with mild pain, with normal temperature, and diminished sensation. The patient had no history of diabetes mellitus or any other long standing disease. The patient had been treated with massage and manipulation of the shoulder by a local doctor in the village.
Radiograph done four years ago after the trauma revealed dislocation of the shoulder. The patient had no other X-rays with her. In the meanwhile, she had been treated with massage and physiotherapy continuously for a period of two years in her village, as advised by a local doctor. The symptoms got aggravated and she was referred to the medical college for further management. A repeat X-ray was done that showed destruction of the head of the right humerus leading to its typical blunt amputated appearance and increased joint space []. The proximal right humerus and glenoid cavity were sclerosed and the proximal humerus was subluxated superiorly. Multiple bony fragments were seen in the soft tissues around the right shoulder joint with displacement of adjacent fat planes.
Magnetic resonance imaging (MRI) showed destruction and lateral dislocation of the head of the humerus []. Residual humerus was subluxated superiorly with sharp margins. A large quantity of fluid collection was seen in and around the right shoulder joint. Bony fragments and debris were seen within the collection. Tear and atrophy of muscles around the shoulder joint, namely the supraspinatous, infraspinatous, and subsapularis muscles were seen. Glenoid cavity was shallow and showed destructive changes.
MRI of cervico-dorsal spine showed syrinx formation with herniation of cerebellar tonsils (6mm) into foramen of magnum leading to foraminal stenosis

[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 31-year-old woman from Columbia with medical history significant for Gestational Diabetes presented to the labor ward without prior prenatal care. She came to the United States eight months prior to presentation. She received cesarean section for fetal distress and gave birth to a healthy baby. Her medical history was negative for cough, shortness of breath, fever, night sweating or loss of appetite, incarceration or living in institution, and any contact with TB patient or chronically coughing person. She was never diagnosed with active or latent TB. At the time of presentation patient was not actively coughing. Patient did not remember if she received BCG vaccination as a child or not.
Physical examination revealed young healthy looking female patient without any cardiopulmonary distress. Examination was negative for lymphadenopathy; chest was symmetrical, resonant to percussion, clear to auscultation bilaterally. Examination of other systems was within normal limits. BCG vaccination scar was not noted on either of the both upper arms.
The patient's perioperative chest X-ray () showed a small irregular density in the right middle lung and there was a hazy increased density over the left upper lung, which was suspicious for infiltrates versus fibrotic changes. Lucency was also noted within the left upper lobe, which was suspicious for cavitary change and further evaluation with CT was recommended for possible pulmonary tuberculosis. Noncontrast CT () showed patchy and nodular opacity in the apical posterior segment of the left upper lobe and to a lesser extent in the superior segment of the right lower lobe and right lung base as well as a small axillary node. The differential diagnosis would include mycobacterial infection and pyogenic pneumonia. In light of positive chest X-ray and chest CT scan, TB quantiFERON gold test was requested. All other lab tests including tests for hepatitis B surface antigen, HCV, HIV, work-up for collagen vascular diseases, and sarc

[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 male presented with cough, mucopurulent expectoration, and dyspnea since 3 months. There was history of exacerbation of cough after swallowing. This finding of swallow–cough sequence has been referred to as Ono's sign.[] A chest radiograph revealed complete opacification of the right hemithorax with volume loss suggesting complete collapse of the right lung with mediastinal shift to the right []. A plain and intravenous contrast-enhanced CT study with oral contrast swallow was performed on a 128-slice MDCT scanner (Siemens Somatom Definition AS, Erlangen, Germany). The study revealed complete collapse of the right lung with irregular dilated ectatic bronchi in the right lower lobe []. There was stenosis and diffuse narrowing of the right mainstem bronchus with nodularity of the mucosa seen best on the virtual bronchoscopy []. The right main pulomanary artery (MPA) was narrow in caliber. There was a resultant significant shift of the mediastinum and heart to the right. An air-filled tract was noted extending from one of the right lower lobar bronchi toward the posterior mediastinum with ill-defined soft tissue around it. The possibility of an esophagobronchial fistula was suspected, and we did a CT oral contrast swallow study to detect it. Oral contrast swallow study performed with the patient in right decubitus position using diluted non-ionic iodinated contrast medium (1:20 dilution of iohexol with normal saline). It depicted the site and the fistula tract between the right lateral wall of the esophagus and one of the ectactic bronchi in the right lower lobe of the lung. Thick MIP images and VRT processing demonstrated the fistula site and tract [Figures and ]. Right adrenal gland calcification was also noted. These imaging findings led us to conclude that these changes were most likely the sequelae of chronic tuberculosis. The patient underwent an open right pneumonectomy with repair of the fistula. Histology of the lung specimen revealed distorted 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 55-year-old non-diabetic, non-hypertensive male with a history of recurrent colicky left lumbar pain presented with acute urinary retention. Catheterization was attempted; however, it was unsuccessful. Ultrasound revealed an overdistended urinary bladder with a normal-sized prostate and scarring and focal caliectasis in the left kidney (). The right kidney was normal and no calculi were seen on either side on ultrasound. Serum electrolyte, renal and liver functions were normal. The haemogram revealed neutrophilia. The prostate-specific antigen was within normal limits. A rigid urethroscopy was performed owing to suspicion of a left urethral calculus and a 11-mm size calculus was removed from the posterior urethra. The patient was discharged and had no difficulty with micturition for 2 weeks thereafter. The patient subsequently developed burning micturition with hesitancy and induration in the perineal region. The urine was turbid and microscopy revealed the presence of Escherichia coli. A perineal ultrasound revealed an abscess in the perineum, which extended to the proximal parts of the corpus spongiosum (). This abscess was drained under saddle block. The patient subsequently developed a discharging sinus at the operative site () leaking purulent fluid. A retrograde urography revealed periurethral extravasation of the injected contrast material with a lytic lesion in the left pubic ramus (). A repeat perineal ultrasound revealed a linear hypoechoic tract leading from the skin surface to the corpus spongiosum (). A retrograde CT urography was performed to look for the extent and ramifications of the abscess. On the non-contrast CT scan, a lytic lesion was seen involving the left inferior pubic ramus (). The pubic symphysis and bodies of both pubic bones were normal. A proximal femoral nail was noted in situ on the left side, which was inserted 10 years before for fracture of the proximal shaft of the femur owing to accidental trauma. On injecting iodinated contra

[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:
Two months before presentation, a 45-year-old female Chinese Han patient had experienced right upper abdominal distension and intense pain of unknown origin; the symptoms lasted several minutes and then resolved without treatment. An ultrasound B-mode scan showed a cystic mass in the right lobe of approximately 11.5 × 8.6 cm in size, which was possibly a hepatic cyst. Liver CT suggested a right-lobe mass of approximately 11 × 8 cm in size. Enhanced CT showed a cystic mass at the edge of the liver parenchyma, with uneven enhancement during the arterial phase; the density of the lesion was lower than that of the surrounding normal liver parenchyma during the portal and delayed phases, indicating possible hepatic cystadenoma (Fig. A and B). MRCP showed a mass of approximately 10 × 13 cm in size with high T1 and T2 signals and with multiple nodules on the wall of the right anterior lobe (Fig. C and D). Laboratory tests were largely normal, and liver function was rated Child grade A; thus, the lesion was operable. During the operation, a cystic lesion of approximately 12 × 12 cm in size was observed in liver segments 5 and 8, directly adjacent to the gallbladder. Thus, resection of liver segments 5 and 8 and the gallbladder was planned. During the operation, the hilum was blocked for 25 minutes. Blood loss was approximately 500 mL, 1500 mL of fluid was infused, and no blood transfusion was given. The cystic fluid was brown and turbid. According to the postoperative pathology report, gross examination showed that the cystic wall-like tissue was 13.2 × 7 cm in size and that the interior cystic wall (0.1- to 0.4-cm thick) was smooth. Additionally, the gallbladder was 8.1 × 4.2 cm in size, the gallbladder wall was 0.1 to 0.2 cm in thickness, and the mucosa was rough. Microscopic examination showed that the cystic wall was covered with a single layer

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old woman diagnosed with asymptomatic WM 3 years ago presented with gradual vision deterioration the past 3 months. Ophthalmologic examination revealed bilateral reduction in visual acuity (7/10) and bilateral optic disc swelling which was more prominent in the left eye. Clinical examination was otherwise unremarkable. The patient reported no weight loss or B-symptoms. At the time of initial WM diagnosis, the bone marrow biopsy showed 15% infiltration of M(κ)-clonal lymphoplasmacytic cells and the serum immunofixation was positive for monocloncal IgM, while serum IgM levels were 147 mg/dL. Laboratory examinations were within normal ranges with no signs of anemia or thrombocytopenia, whereas clinical and imaging assessment did not reveal any sites of lymphadenopathy or hepatosplenomegaly. Therefore, the patient was defined as asymptomatic and had been under follow-up every 4 months. Two years postinitial diagnosis a new diagnostic bone marrow biopsy revealed an increase in clonal infiltration up to 40% and genetic tests performed both in the bone marrow and in the serum cell-free DNA did not detect any MYD88 or CXCR4 mutations. The presence of mutations in the aforementioned genes was evaluated by allele-specific polymerase chain reaction and direct sequencing, as previously described.[ Serum IgM levels had been gradually increasing as well with no other concurrent symptomatology and reached at 723 mg/dL at the time of presentation with visual loss (serum M-peak = 0.61 g/dL) (Fig. A). Her medical history was also remarkable of right eye cataract surgery, thyroidectomy, and T4 hormone replacement therapy, but she had no history of migraine. She was also current smoker with mild hypercholesterolemia. Due to the presence of risk factors for cardiovascular disease, we performed initially an extensive workup including electrocardiogram, cardiac ultrasound, sonography of the carotid, and vertebral arteries that revealed no clinically significant abnormalities. Co

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old lady with acute necrotizing encephalitis involving thalamus and secondary cortical venous thrombosis underwent surgical tracheostomy for long-term ventilatory support. The patient had various medical problems including urinary tract infection and a past history of uncontrolled diabetes mellitus. The surgical tracheostomy was uneventful. Eight days later, she had sudden onset of slow bleed from the tracheostomy site. Local exploration with tube in situ was unremarkable. Heparin thromboprophylaxis was withheld temporarily and tracheal suctioning frequency was reduced. The following day, she developed an acute massive hemorrhage with spurting flow from the tracheostoma, with an estimated blood loss of >500 mL in few minutes. Tachycardia was noted, though the blood pressure remained stable.
Acute management was initiated by the neurointensivist with suction for airway clearance and inflation of the tracheostomy cuff to a pressure of 80 cm H2O. Fluid resuscitation was initiated along with transfusion of blood and blood products. Direct inspection of stoma by endorhinolaryngologists revealed frank arterial spurt. It was noted that the bleeding point was above the cuff; and for the next 5 minutes, the surgeons tried in vain to contain the bleeder. Immediately endovascular management was resorted to and the patient was transferred to cath lab to visualize and embolize the culprit vessel. Direct pressure was applied on the tracheal and paratracheal soft tissues, with which the bleeding was temporarily controlled.
The digital subtraction angiography undertaken within 15 minutes of bleeding revealed a pseudoaneurysm arising from the right innominate artery, in contact with the anterior wall of the tracheostomy tube, which was later confirmed by three-dimensional reconstruction of computed tomography (CT) angiogram (). An endovascular stent implantation was performed, traversing and occluding the mouth of the pseudoaneurysm (). In the process, the right subclavian

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old male presented to a hospital in Togo, West Africa, with a long-standing swelling on the left lower leg, which progressively increased in size over time. He had a wide local excision done following a confirmatory biopsy for dermatofibrosarcoma protuberans (DFSP). No adjuvant therapy was recommended on account of clear surgical margins and the absence of distant metastases. The lesion recurred after two years and re-excision was performed. A second recurrence occurred in a year, which involved the knee joint, necessitating a transfemoral amputation. The surgical margin was clear and there was no evidence of distance metastases. He was rehabilitated and started walking with a prosthetic limb.
Two years after the second recurrence, the disease recurred in the left lower limb stump. At this point, a re-biopsy was done and DFSP was confirmed (Figure ). There was no fibrosarcomatous transformation. Immunohistochemistry was positive for CD34 (Figure ), focally positive for actin, and negative for desmin and S100 protein. Metastatic workup, consisting of chest X-ray and abdominal ultrasound, was negative. He commenced imatinib mesylate at a recommended dose of 400 mg twice daily. The recurrent lesion on the left lower limb stump gradually progressed in size after five months of imatinib mesylate treatment, and he eventually developed multiple lesions on the posterior torso.
He was then referred to the National Radiotherapy Oncology and Nuclear Medicine Centre, Korle-Bu Teaching Hospital in Accra. Physical examination showed a 15 x 12 cm mobile mass on the left lower limb stump and two palpable, firm, and fixed lesions on the posterior torso; the largest measuring 9 x 7 cm in size. There was no other clinical or radiological evidence of distance metastases. The decision was made to treat him with palliative radiotherapy to relieve pain in the left lower limb stump and to enable him to use the prosthetic limb.
Six months after stopping imatinib mesylate, he recei

[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 14-year-old female patient was presented for orthodontic evaluation; her chief complaint was the absence of both lower canines. During the clinical assessment, it was noted that the deciduous lower canines were still present and a class I malocclusion with crowding, deep bite, and a straight profile was diagnosed (). Dental casts, intraoral and extraoral photographs, and panoramic and lateral cephalogram X-rays were taken. On the panoramic X-ray, it was determined that both mandibular canines were impacted and the left one was in a Mupparapu type 2 transmigration position. Another critical issue was that the crown of the right canine was above the contralateral one. In the lateral cephalogram X-ray, it is possible to see that both canines were towards the vestibular side; however, the right one was closer to the incisors' roots (). According to the Ricketts cephalometric analysis (), it was diagnosed that the lower incisors were retroclined, possibly because of the absence of the canines.
The objectives of the treatment were (a) to open the space for the impacted and transmigrated canines, (b) to traction both canines to a functional position within the dental arch, (c) to improve the buccolingual inclination of the lower incisors, and (d) to correct the deep bite.
After the analysis of the studies, the patient was presented with the following treatment options: (a) surgical exposure of the canines and orthodontic traction and (b) surgical removal and an orthodontic opening of the spaces for future restoration. The orthodontist explained to the patient's parents that the first option presented a risk of damaging the incisors roots, so the biomechanical design had to consider that. Also, the time of treatment could be longer than when choosing the second option. On the other hand, given her young age, the second option also had a disadvantage in that the patient would wear the restorations for a long time

[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 14-year-old Thai boy presented to the community hospital with a complaint of intermittent cough of two weeks duration. Four years previously, he had undergone a tracheostomy for laryngeal stenosis following prolonged intubation after a burr-hole craniotomy for subdural hematoma evacuation. A No. 5 stainless steel tracheostomy tube was put in place. The current tracheostomy tube had been used for one year.
Two months previously, the patient started coughing and during the daily cleaning session his parents found that the inner tube was missing. He was brought to the family physician immediately. The patient was diagnosed with acute bronchitis and a new tracheostomy tube of the same size was inserted. After discharge, the parents reported that their child still coughed off and on every week. He slept well during the night without any breathing difficulties and had no abnormal breath sounds.
One day prior to admission, the boy had more severe and persistent cough. He was sent to the community hospital again. The chest X-ray revealed a metallic density foreign body in his right main bronchus. Subsequently, he was referred to our university hospital for definite treatment.
On arrival, the patient had occasional cough with hyperpnea. His vital signs were: a body temperature of 38.0° Celsius; a pulse rate of 140 beats per minute; respiratory rate of 44 times per minute; and blood pressure of 120/80 mmHg. The chest auscultation revealed decreased breath sounds on the right side but no chest wall retraction. An X-ray of the chest was performed. Patchy infiltration of the right lower lung and a metallic foreign body in the right main bronchus were found. He was transferred to the operating room for bronchoscopic removal under general anesthesia. The foreign body (inner tube of the previous tracheostomy tube) was retrieved from the right main bronchus and removed through the tracheostomy stoma (Figure ). A fracture at the junction between the inner tube and connector was fou

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old female underwent abdominal computed tomography (CT) imaging at a private clinic due to mild right upper quadrant abdominal discomfort and back pain during the previous 2 weeks. She was referred to our hospital to evaluate the cause of IVC dilatation shown by abdominal CT (). The patient had no history of hypertension or diabetes mellitus and no family history of aortic, collagen, vascular or congenital heart disease. She had latent hepatitis B virus infection and her mother died of hepatocellular carcinoma. Ultrasonography of the liver showed hepatic vein dilatation without obstruction or thrombus in either the hepatic vein or IVC. The abdominal CT showed prominent dilatation of the IVC and hepatic vein with no evidence of liver disease such as cirrhosis, hepatocellular carcinoma or Budd-Chiari syndrome. Her vital signs included blood pressure of 107/64 mmHg, pulse of 60 beats per minute, respiration of 20 breaths per minute, and body temperature of 36.5℃. During the physical examination, cardiac auscultation revealed no definite murmurs and her electrocardiography demonstrated no apparent ST segment or T wave abnormalities. The blood chemistry analyses were within normal limits, including N-terminal pro-B natriuretic peptide, coagulation studies with fibrinogen, antinuclear antibody, complete blood cell count, and liver enzymes. Her heart size was normal on chest X-ray. Transthoracic echocardiography was performed to evaluate right side heart abnormalities. Dilated IVC with diminished inspiratory collapse was observed (expiration 24.3 mm, inspiration 21.4 mm) using a subxiphoid approach to view the IVC along the longitudinal axis (). Spontaneous echo contrast was present in the dilated IVC without flow obstruction including the entry from the RA. The hepatic vein was dilated mildly (13.2 mm), but the flow through the hepatic vein was normal (). Tricuspid regurgitation (TR) was mild and showed normal right ventricular (RV) systolic pressure (). Normal

[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 heavy smoker male patient was admitted for the first time to our urology department for hematuria and dysuria. His past medical history was unremarkable. He had a transurethral resection of the prostate 5 years ago. He did not have any familial history of urothelial or bladder cancer. Physical examination and blood tests were normal. In the emergency room, an abdominal and pelvic ultrasound showed a thickening of the right lateral wall of the bladder with mild right side hydronephrosis (). On cystoscopy, a large tumor was found on the anterior and right lateral walls of the bladder, with invasion of the bladder neck and the prostate. The anatomopathological study of the tumor showed a neoplastic proliferation of large malignant polygonal cells with dark, irregular nuclei and frequent mitosis. A second component made of cylindrical cells was also present. Muscular invasion was documented with multiple necrotic areas (). Immunohistochemistry showed high positivity for CD56 marker and synaptophysin, minor and heterogenic positivity for cytokeratin 7, and negativity for cytokeratin 20 and CDX2 (Figures –). Overall, the histopathological study corresponded to LCNC with minor adenocarcinomatous component. Disease extension was assessed using computed tomography (CT) scan of the thorax, abdomen, and pelvis. A 6 × 3.5 cm mass of the anterior and right lateral walls of the bladder was identified, with diffuse infiltration of the perivesical fat and multiple necrotic iliac lymph nodes bilaterally (). Neither visceral nor bone metastasis was identified. Initially, the patient refused the treatment and was lost to follow-up. Two months later, he was readmitted to the hospital for similar complaints and additional pelvic pain. Blood tests were normal. A new CT scan revealed an increase in the size of the tumor, occupying now the majority of the bladder lumen, a persistent right hydronephrosis, and no new secondary lesions. The tumor was resected again, until the ap

[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 1-month-old male child initially presented with complaints of irritability and continuous crying. The child subsequently developed fever and chest infection. A chest radiograph done for the same revealed dextrocardia, and further evaluation by 2D echocardiography was done to look for congenital heart disease. The 2D echo findings showed dextroposed heart with lack of normal four pulmonary veins draining into the left atrium. A suspicion of scimitar syndrome was raised and further evaluation by CT scan was advised to assess the arterial supply and venous drainage of the right lung. CT imaging was preferred over MR angiography as there was a need to exclude lung sequestration besides delineating the pulmonary venous drainage.
CT pulmonary angiography was performed on a 64 detector GE Lightspeed VCT scanner using non-ionic contrast media and bolus-tracking method. Contrast was injected through an intraven intervenues (IV) line placed in the right hand as lower limb venous access was small and would limit the flow rate. The study was performed under short acting general anesthesia wherein 1.5 cc/kg of contrast was injected through a dual head pressure injector with a flow rate of 0.4 cc/s. Images were acquired on 64-detector CT scanner without ECG gating, using a slice thickness of 0.7 mm and collimation 0.6 mm, followed by overlapping reconstruction. The acquired CT images were post-processed with focus on establishing the arterial supply to both lungs, the size and location of the main pulmonary artery (MPA), the right and left pulmonary arteries (RPA and LPA), and the venous drainage of both lungs. Volume-rendered (VR) reconstructions were done for depicting the pathology in 3D to aid understanding of the anomaly.
A scout topogram of the chest taken for planning of CT imaging showed the heart shadow in the right hemithorax []. Evaluation of CT images showed that the right lung was small in size with compensatory emphysema of the left lung []. There was associated

[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 man with a history of treated hypertension and diabetes mellitus presented to our hospital following a single seizure attack; he regained consciousness shortly before arrival. Two weeks before this, he had a head injury that resulted in some minor scalp abrasion and bleeding. No obvious neurological deficit was noted at that time, and he was discharged following a period of observation without imaging. However, on the day after the discharge, he experienced another seizure attack that lasted for 5–6 minutes with subsequent loss of consciousness. He was then admitted to our hospital.
Initially, the patient experienced generalized tonic-clonic seizures twice daily. Persistent right calf paresthesia was also noted; this presented as a focal seizure when aggravated and often progressed to a generalized tonic-clonic seizure. Under antiepileptic medications, focal seizures remained persistent but progression to secondary generalized seizures became rare.
On physical examination there were no clinical signs to suggest other organ involvement, in particular there was no glandular enlargement or orbital disease. Abdominal ultrasound showed a normal liver, gallbladder, pancreas and kidneys.
Magnetic resonance imaging showed thickening of the meninges with enhancement near the superior sagittal sinus; skull bone defect was also noted (Figure A-D). We initially suspected meningitis or skull metastasis with dura invasion. Subsequently, lumbar puncture was performed for cerebrospinal fluid (CSF) examination. Sugar level was within normal limit compared to peripheral blood sugar levels, and no visible leukocytes were noted. Hemogram did not reveal leukocytosis, and C-reactive protein level was also within the normal limit. Thus, infection seemed unlikely. CSF cytology revealed no malignant cells.
Left parietal skull and dural nodule excision were then performed for both pathological diagnosis and symptomatic relief (Figure A). Duroplasty was also performed with autol

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female reported with the chief complaint of swelling in the right side of the lower jaw for the previous 10 days. The patient's medical and dental history was unremarkable, and the patient did not seem to have any harmful habits.
On extraoral examination, there was a swelling in the right mandible with a normal color and texture of the overlying skin. Mouth opening was found to be normal. Paraesthesia was detected in the skin over the swelling. The right submandibular lymph node was of 2 cm in size, palpable, tender, and non-fixed.
Intraoral examination revealed a nodular swelling in the right mandible extending from the mandibular canine to the mandibular first molar. It measured approximately 3 cm×5 cm. The overlying mucosa was eyrthematous in appearance and the borders were well defined, with a consistency varying from firm to hard. Tenderness was present on palpation. The teeth near the swelling were not mobile ().
A panoramic radiograph revealed a periradicular widening of the periodontal ligament space and loss of lamina dura involving the right mandibular second premolar and the mesial and distal roots of the first molar with mild rarefaction of the inter-dental alveolar bone between the roots of the mandibular right first molar and second molar ().
An intraoral periapical radiograph revealed a loss of the lamina dura and periradicular bone loss involving the interdental bone between the mandibular right second premolar and first molar (). A shadow of the soft tissue mass on the right side and mild peripheral cortical bone reactive bone formation in the molar and premolar region were visible in the right mandibular lateral occlusal radiograph (). Correlating the clinical and radiographic features, a provisional diagnosis of osteosarcoma involving the jaw bone was made.
Incisional biopsy of the lesion was performed, and the hematoxylin-eosin stained section showed highly cellular connective tissue stroma, predominantly composed of neoplastic spin

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old Hispanic female presented for evaluation of nausea, vomiting, abdominal pain, and watery diarrhea of two-week duration. She reported fevers, generalized malaise, and weight loss. She had similar gastrointestinal complaints in the past without any visual loss, weight loss, claudication, or joint pains. Her history was significant for appendicitis in 2003 and a perineal abscess/fistula repair in 2000. She denied smoking, alcohol, or illicit drug use.
Physical examination revealed blood pressure of 126/73 mmHg in the right arm and 114/74 mmHg in the left arm. Her right radial pulse was not palpable and the left one was thready at 70 beats per minute. The femoral and dorsalis pedis pulses were difficult to appreciate bilaterally. An abdominal bruit was noted, as well as tenderness of the right lower quadrant. Musculoskeletal exam was normal except complaint of pain in both arms when raised above her head for more than 6 seconds. The shoulder exam was normal on both sides. Laboratory evaluation () was significant for anemia of chronic disease and elevated inflammatory markers. She underwent colonoscopy and the right colon biopsy showed benign colonic mucosa with cryptitis, ulceration, and mild-moderate architectural change, consistent with Crohn's disease. Due to her symptoms of shoulder/arm pain, unequal blood pressure, and pulses in both arms and an abdominal bruit, further imaging studies were pursued. A magnetic resonance angiogram of the chest and abdomen was done and showed severe irregularity and narrowing of the descending thoracic aorta which tapers down from 2 cm transversely at the level of the distal arch to 7.5 mm transversely at the narrowest point just beyond the aortic hiatus. The subclavian arteries were not visualized in their entirety bilaterally during the initial imaging. There was 50% narrowing of the origin of the celiac artery with poststenotic dilatation; renal arteries were normal (). At this point, the patient was diagnosed with T

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


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

[User]
RADIOLOGY NOTE:
The patient was a 63-year-old female with a past medical history of hypertension and ulcerative colitis who presented to the emergency department with worsening epigastric pain. The pain started four days prior with one episode of non-bloody emesis, nausea, and one episode of dark stool. She denied previous history of abdominal surgery or trauma. She was not on any anticoagulant. Vital signs were within normal limits. On examination, the patient was diffusely tender to palpation, especially in the epigastrium. Initial lab work was unremarkable except for a mild leukocytosis of 12.3 k/uL and hemoglobin of 11 g/dL. A CT scan of abdomen/pelvis with intravenous contrast showed a large amount of blood in the upper abdomen (Figure ) with high attenuation material adjacent to the greater curvature of the stomach (Figure ) and around the liver consistent with hemoperitoneum, although a mass could not be excluded.
Given the presence of hemoperitoneum and diffuse abdominal pain, the decision was made to undergo urgent diagnostic laparoscopy. Upon entering the abdomen, a large amount of blood was encountered around the upper abdominal viscera. The gastrocolic ligament was taken down to reveal an additional 800 mL of blood within the lesser sac as noted on preoperative imaging (Figure ). An adherent clot was discovered on the posterior aspect of the stomach with a small amount of active extravasation. At this point, the procedure was converted to an open approach via an upper midline incision to adequately expose and control the source of bleeding. The stomach was retracted cephalad to expose the posterior body where a necrotic, friable mass was found along the superior aspect of the greater curvature. A partial gastrectomy was performed with a linear cutting stapler to wedge out the mass with grossly negative margins; the mass was found to be 7 x 6 x 3 cm with areas of necrosis and hemorrhage. An intraoperative upper endoscopy was performed to inspect the gastric and duodenal

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old, Caucasian woman was referred to our tertiary women’s heart center for persistent chest pain, palpitations, and dyspnea. Her medical history included hypertension, dyslipidemia, chronic anxiety, and bilateral non-obstructive carotid atherosclerosis. She had no prior history of diabetes mellitus, tobacco smoking, alcohol or substance abuse, or adverse pregnancy outcomes. Her family history was significant for premature coronary artery disease. Her father had a history of hypertension and had a myocardial infarction (MI) and coronary artery bypass grafting at the age of 39. Her brother had a history of coronary artery disease and also had a MI at the age of 40. Her occupational history indicated that she had been working in the field of psychology and was still an employee in the same job at the time of the hospital visit and follow-up care.
Table summarizes the general symptoms and characteristic signs of our patient for the onset of CMD and her progression to HFpEF. She had undergone an exercise treadmill test which revealed ischemic ECG changes and dyspnea. Her initial echocardiogram demonstrated a LVEF of 67%, mild diastolic dysfunction, mild left ventricular (LV) hypertrophy, no significant valvular heart disease, and no pulmonary hypertension. Subsequent invasive left heart catheterization was performed and it showed normal epicardial coronary arteries without angiographic evidence of atherosclerotic plaque. She continued to have exertional symptoms and angina-like chest pain and was subsequently referred to our center for further evaluation of suspected INOCA. During her evaluation and treatment she continued to experience stable angina and exertional dyspnea despite initial management with atorvastatin 20 mg daily, lisinopril 20 mg daily, aspirin 81 mg daily, and sublingual nitroglycerin as needed. She had a poor clinical response to sublingual nitroglycerin. Due to her persistent symptoms and abnormal stress testing, she was referred for coronar

[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 74-year-old woman was admitted to the emergency department of our hospital after a closed injury of her left femur due to a fall. Plain X-rays showed a spiral shaft fracture of the proximal third of the femur. The radiographs of the pelvis and the patient's history as well revealed that she was also suffering from bilateral congenital hip disease (Figures and ). The form of dysplasia of the left hip was type B2-low dislocation according to Hartofilakidis classification or type III according to Crowe classification [–]. The right hip lesion was more severe, classified as type C2-high dislocation or type IV according to Hartofilakidis and Crowe classifications, respectively [–]. There was a leg length discrepancy of 3 cm, with the injured leg being the longer one. Before the fracture, the left hip was almost immovable, ankylosed in fixed external rotation. The right hip was free of pain with functional range of movement. The patient had never been treated for the CHD, and she was walking with the use of a cane. She was also able to do the usual activities of daily living without significant difficulty. According to her medical history, she was a smoker and was receiving medication for arterial hypertension and hypothyroidism.
Taking into consideration the “personality” of the fracture, the patient's needs, and the surgical options, we performed an open reduction and internal fixation (ORIF) using the NCB periprosthetic femur polyaxial locking plate system (Zimmer Biomet, Indiana, USA). The operation was performed two days after the fracture, under spinal anaesthesia. The patient was placed in the right lateral decubitus position, and the middle and proximal thirds of the femur were accessed through a lateral approach. The subtrochanteric area of the femur was exposed with anterior retraction of vastus lateralis after an L-shaped detachment of its origin. The fracture was anatomically reduced, and two lag screws were placed initially.

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old Caucasian woman underwent surgery with a Harrington intrumentation (T4-L3) due to idiopathic scoliosis 30 years ago. During the operation she received a blood transfusion and was infected with hepatits C. Today she has cirrhosis with liver failure (Child-Pugh classification C). Without any trauma she felt a sudden pain in her lower back with paraesthesis in both her legs but no other neurological symptoms. A computed tomography (CT) scan (Figure ) and X-ray (Figures , ) showed a bilateral pedicle fracture of L3. We first performed a dorsal instrumentation L1-5 and a posterolateral spondylodesis. She had massive intraoperative bleeding and a very bad quality of the bone. Due to the bad quality of the bone we were not able to place the pedicle screws in L1 bilaterally. She needed a perioperative mass transfusion of fresh-frozen plasma (FFP), PPSB and erythrocyte concentrates which is why we were not able to perform a ventral augmentation in one session as originally planed. Postoperatively the liver function decompensated and the patient needed to stay in the intensive care unit for ten days and had a notably extended rehabilitation. Although she was carefully mobilized with a corset she developed a progressive thoracolumbar kyphosis with a looming cutting-out of the pedicle screw in L1 (Figures , ). We needed to perform an additional ventral augmentation T11-L3 with the same problems that occurred during the first operation with another mass transfusion of blood products. After the second operation the patient developed a hepatorenal syndrome and needed to stay in the intensive care unit for 28 days and another month in the rehabilitation unit. In summary, both operations required a long postoperative stay in the intensive care unit and led to a decompensation of her liver function. After rehabilitation, at her 12-month follow up, she is free of complaints and her X-ray shows no further loss of correction (Figures

[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 woman was referred to the Vulvovaginal Disease Clinic with debilitating vulvar burning and itching over the right labium majus, also causing severely disturbed sleep. Vulvar pain had been persisting for 2 years and was considered intractable. Careful history taking revealed that she had two vaginal deliveries and was known to suffer from Crohn’s disease involving the right hemicolon, terminal ileum, and rectum, for which she was treated with azathioprine orally and rectally applied mesalazine. The patient also had a laparoscopic fallopian tube ligation. Finally, she had a history of atopy, and reported occasional seasonal allergic rhinitis symptoms.
The patient was initially followed at a regional hospital. A blind biopsy was taken from the right labial skin in a dermatology practice; it showed no epidermal or dermal anomalies. Several topical treatments were initiated empirically, including vaginal antibiotic and fungistatic agents and various corticoid ointments, without providing relief. During a surgical consult, a nodule was detected in the right labium majus and was the presumed cause of the chronic pain. It was removed under general anesthesia, and had histological features indicative of a ruptured hair follicle. As no diagnosis was obtained, the patient was also asked to discontinue all medications, including those for treatment of Crohn’s disease. The patient was eventually referred to our hospital, which is a tertiary referral center.
Careful examination of the vulva and vagina revealed neither visible anomalies nor any other findings indicative of vulvar inflammatory, infectious, or neoplastic mucocutaneous disease. During the clinical exam, the patient was asked to point out the pain area, showing the right labiocrural fold, the anterior surface of the right labium majus, and right medial upper thigh, though burning sensation of the right labium majus was the most prominent complaint and was initially mentioned by the patient as the only co

[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 male with a history of hypertension and smoking habit suffered from cerebral infarction of the right cerebrum due to ICA occlusion. He showed consciousness disturbance, left hemiparesis, and dysarthria. Angiography and magnetic resonance angiography (MRA) demonstrated the occlusion of the right ICA. The blood flow in the right ICA territory was supplied through the anterior communicating artery and PComA. The left PComA was thick, with a diameter of about 3.0 mm []. However, no aneurysmal protrusion was detected in the left ICA on either angiography or MRA []. Single-photon emission computed tomography (CT) revealed decreased cerebral blood flow in the right cerebrum. His symptoms were gradually improved by medication. He was discharged on the 16th day. Recanalization of the right ICA was confirmed on MRI obtained 5 months later, and no aneurysm was detected on the left ICA []. MRA after 8 months showed mild stenosis of the right ICA in the neck []. MRA after 9 months also showed no cerebral aneurysm on the left ICA []. MRA obtained 38 months after cerebral infarction showed a small protrusion on the left ICA at the origin of the PComA. The size of the protrusion was about 2 mm. The left PComA was thick, as observed on the initial radiological examinations []. For 46 months after the detection of a small aneurysm, radiological examinations to observe an aneurysm were not performed.
Seven years after cerebral infarction, at the age of 64 years old, he suddenly developed consciousness disturbance. CT revealed subarachnoid hemorrhage []. Angiography demonstrated a left IC-PComA aneurysm []. The aneurysm became larger than that observed on MRA 4 years ago, at 4.3 mm × 3 mm × 3 mm. Left frontotemporal craniotomy was performed, and the aneurysm was clipped. During the operation, the thick PComA was observed running toward the medial side []. The aneurysm tip was incised and pathologically examined, revealing that there were red

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old Chinese man, without particular previous medical history, had complained of a bilateral temporal headache for more than half a year. The pain was diffuse, dull, and paroxysmal, and could be alleviated by rest. He also presented with transient fever (maximum 39.2°C) for several times. He did not seek medical services until nausea and vomiting occasionally occurred especially in the morning 1 month after the onset. He underwent a head computed tomography scan at the local hospital, showing a 15 mm × 10 mm cyst in the pineal region (just a chance finding). No apparent changes were found in other intracranial structures including the sella turcica area. He was treated pharmacologically with analgesics. However, his condition did not improve. After 2 weeks, because of frequent nausea and vomiting, he came to our hospital. The patient was down in spirits with heavy complexion. In addition to the above symptoms, he also complained a mildly decreased bilateral visual acuity (VA) in recent weeks. He denied polyuria, polydipsia, and sexual hypoactivity, and had no symptoms of unconsciousness, convulsion, epilepsy, and cognitive disorder, and no special circumstances regarding his family history or personal history related to his presentation were identified. Neurological examination showed a normal function of both sensation and motor at 4 limbs. No apparent changes in superficial and deep tendon reflexes were observed. Both superficial and deep tendon reflexes were normal. Pathological signs and ataxia were absent. Upon rough ophthalmologic examination, his left palpebral fissure was relatively small with ptosis, and pupillary light reflex was insensitive on the right side. The left VA was 0.8 and the right 0.6. There was suspicious defect in right upper quadrant of his right eye. However, his VA declined sharply. Just within 3 days while waiting for his head MRI scanning, the patient complained he even could not see anything with his right eye, and his vision

[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-79-year old man presented to our tertiary oculoplastic and adnexal clinic with a five-month history of gradually increasing painless left proptosis associated with a reduction in visual acuity, double vision, swollen left cheek, and nasal congestion. The patient had no significant medical or family history.
Visual acuity (VA) was 6/6 in the right eye and 6/18 in the left eye. Ishihara colour plates test was full at 17/17 in the right eye, and diminished to 12/17 in the left eye. No pupillary defect was noted. Optic disc appeared normal on dilated fundoscopy. Exophthalmometry illustrated a 4 mm left-sided nonaxial proptosis. Diplopia was demonstrated in all positions of gaze, but was more pronounced on down gaze and adduction. Nasal endoscopy revealed normal mucosa; however his left nostril was obstructed by the medialisation of the medial antral. There was no apparent lymphadenopathy on palpation or areas of numbness on his face.
An urgent CT scan was performed showing a large maxillary mucocele eroding through the inferior orbital ridge and causing superolateral displacement of the globe. The medial antral wall was eroded with the mass projecting into the nasal cavity (). There was no enhancing soft tissue to suggest the presence of malignancy.
Functional endoscopic sinus surgery was performed to drain the maxillary mucocele and 50 mL of thick yellow mucus was expressed, which was sent to pathology. This intervention induced an orbital decompression and preservation of optic nerve function. The mucosa appeared healthy and histology confirmed no evidence of malignancy.
Within one month his left visual acuity and colour vision returned to normal with a VA of 6/6 bilaterally and 17/17 bilaterally with the ishihara colour test plates. He also had complete resolution of diplopia and proptosis. Postoperative CT scans show remodelling of the orbital floor () and therefore further reconstruction surgery to the orbital floor was not performed.
Two years later

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 64-year-old left-hand dominant male who was involved in a motorcycle collision and sustained a right valgus impacted four-part proximal humerus fracture (). He also sustained a left small finger distal phalanx fracture. The patient’s medical history was significant for coronary artery disease. His past surgical history included a right shoulder arthroscopic superior labral repair and biceps tenodesis multiple years prior, and his social history included a history of cigarette smoking and social alcohol use. He denied having any pain or decreased range of motion in the right shoulder before the injury. The patient underwent open reduction internal fixation of the closed right proximal humerus 2 days after his initial presentation without complication. The fixation consisted of a lateral locking plate, separate plate, and screw fixation of the lesser tuberosity, and sutures into the supraspinatus, infraspinatus, and subscapularis that were anchored to the locking plate (). Pre-operative antibiotics included both 2 g of cefazolin and 600 mg of clindamycin per protocol for open shoulder surgery in the senior author’s practice, and this was readjusted throughout the procedure and continued for 24 h postoperatively. The patient was continued on the same antibiotics for the 24 h after surgery. He had a drain placed after surgery, and this was discontinued on post-operative day 2. He was discharged on post-operative day 3, after adequate pain control had been achieved on oral pain medications. His post-operative therapy regimen included a five-pound weight-bearing restriction for the first 6 weeks. He was encouraged to use his hand for activities of daily living. The patient was sent to physical therapy to work on active and active assisted range of motion, beginning with pendulums and progressing to full activity. At 4 months postoperatively, the patient was reporting continued pain and decreased range of motion in the right shoulder. His wound was well he

[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 74-year-old man was referred to our hospital for surgical management of aortic root aneurysm found by echocardiography during a preoperative work-up for spinal surgery. He presented with intermittent left-sided chest pain. His vital signs and laboratory data were unremarkable on admission. His past medical history revealed hypertension requiring drug therapy and herniated nucleus pulposus at the lumbar area. Trans-thoracic echocardiography revealed an enlarged sinus of Valsalva 58 mm in diameter with mild aortic regurgitation (). The left ventricular ejection fraction was 60% without regional wall motion abnormality. A computed tomography (CT) scan identified severe aortic sinus dilatation and a coaptation defect in the aortic valve (). The maximal diameter of the aortic sinus and aortic tubular portion were 60 and 36 mm, respectively. A coronary angiography showed 80% stenosis of the proximal left anterior descending artery (LAD), and total occlusion of the distal left circumflex artery. Thallium single-photon emission computed tomography showed fixed medium-sized moderately decreased perfusion in the basal anterolateral and basal inferolateral wall. Consequently, the patient was scheduled for concomitant aortic root surgery and coronary artery bypass grafting (CABG).
At the beginning, the patient underwent off-pump CABG (from the in situ left internal mammary artery to the LAD and the saphenous venous graft to the obtuse marginal branch). After establishing cardiopulmonary bypass (CPB) and aortic clamping (cardioplegic solution was delivered via the coronary sinus in a retrograde manner and concomitant antegrade infusion via saphenous vein graft to the obtuse marginal graft), the ascending aorta was transected above the sinotubular junction and the aortic root was mobilized to the aortic annular level, and the origins of the coronary arteries were mobilized. After measuring the aortic annular size, a 30-mm vascular graft (Gelweave Valsalva; Terumo Inc., Tokyo, J

[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.