[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 diabetic 90 years old woman with cough and diffuse abdominal pain was admitted into our hospital with an initial diagnosis of sepsis. Blood sample investigation revealed mild leucocytosis with PRC augmentation and normal AST, ALT and bilirubin levels. Preoperative ultrasound revealed thickened gallbladder wall suggestive of acute cholecystitis. She has had previous sigmoid resection for diverticulitis and ERCP for choledocholithiasis without any mention of biliary abnormality. She was scheduled for a laparoscopic cholecystectomy during which the incidental intraoperative finding of a left sided gallbladder was made. Standard trocar positions were used (A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy []. Having seen the anatomical variation (B), a careful dissection of Calot’s triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (C). This manoeuvre allowed us to demonstrate a right sided positioning of the cystic duct. Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (D), and the gallbladder was extracted in an endobag. The postoperative course was complicated by an aggravation of diabetes and basal pneumonia which were controlled postoperatively in the intensive unit. The patient was discharged on postoperative day 16, in good condition. Retrospective analysis of the clinical case was done and a previous CT scan was reevaluated. Even with the knowledge of a left sided gallbladder, the CT scan was unable to demonstrate its attachment to the left side of the liver. This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (). A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver () wit

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old man with both upper limb disabilities admitted to our hospital for mandatory health screening before military service. He had no health complaints other than the skeletal disorder involving his upper limbs. In detailed questioning, he stated that he had four fingers in his left foot. He is the last of six children born to nonconsanguineous healthy parents. All of his brothers and sisters are completely healthy. There is no family history of any kind of congenital skeletal abnormalities in the extended family. His mother was at the age of 32 when she gave birth to our patient. There is no history of any drug, smoke, alcohol, or radiation exposure during pregnancy. Our patient was born uneventfully at full-term through normal vaginal delivery. No other significant health problem is present in the history of his childhood.
On physical examination, all skeletal elements beyond his left elbow and right wrist, and the fifth finger of his left foot were found to be absent (). He had oligodactyly of the left foot (). Anteroposterior radiograph of the right arm depicted the absence of the hand with well-developed radius and ulna. There was a rudimentary bone of about 1 cm in the medial neighborhood of the distal ulna (). Anteroposterior radiograph of the left arm demonstrated that the proximal forearm segment participating in the elbow joint structure was small but present, while the radius and ulna distal to this point were absent (). Anteroposterior, lateral oblique, and mediolateral radiographs of the left foot revealed absence of the fifth finger and the lateral cuneiform. The second to fourth fingers were short. The number, size, and joint relations of the other bones forming the foot were normal (). Magnified anteroposterior and lateral oblique radiographs of the left foot showed that the middle phalanges of the second and third fingers were shorter than the distal phalanges, and the middle phalanx of the fourth finger was absent ().
The patient was then

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old male patient presented to our outpatient clinic with complaints of fever and a painful submandibular swelling for the past two days, the pain is precipitated with food intake. Further history revealed that this is the third episode in the past two years. Previous episodes were resolved with a prescription of oral antibiotics and analgesics from a local clinic. He had no other underlying health issues. Physical examination revealed a submandibular swelling measuring 5 x 4 cm, the submandibular area appeared inflamed and was tender to touch. Upon intraoral examination, a solid mass was felt over the right floor of the mouth area, possibly representing the calculus, and purulent pus discharge was also noted at the right submandibular duct opening. Other systemic examinations were unremarkable. In addition, he had a fever with a recorded temperature of 38.5’C. Laboratory investigations revealed leukocytosis (white blood cells, 14.2x109/L) and C-reactive protein level at 30.2 mg/dL. Serum uric acid level, total serum calcium, and corrected calcium level were normal. The patient was started on empiric intravenous antibiotics and oral analgesics consisting of paracetamol and ibuprofen. Ultrasound of the neck was performed the next day revealing dilatation of the right submandibular duct, measuring 0.2 cm in diameter, with calculi measuring 0.4 x 1.2 cm lodged in the distal Wharton’s duct. Abdominal ultrasound was negative for calculus in the kidneys, gallbladder, and pancreas. Swelling and pain resolved after day 3 of intravenous antibiotics. He was discharged from the ward with oral antibiotics for a week.
On subsequent outpatient follow-up two weeks later, the patient reported that the passing of the sialolith had occurred one week after being discharged from inpatient care. The patient was seen during follow-up at our ENT outpatient clinic for two more visits over a six-month period in which he reportedly had another episode of submandibular swelling, with

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


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

[User]
RADIOLOGY NOTE:
In January 2018, a 70-year-old man residing in South Korea was admitted to Chosun University Hospital with reported consistent low back pain. At first, he had been admitted to a local hospital on 24 November 2017, a month before visiting Chosun University Hospital with a history of 5 days of chills and fever. In the local hospital, in view of the possibility of acute pyelonephritis, he was first treated with intravenous ceftriaxone at a dosage of 2 g daily. Two days after admission, back pain started. During antibiotic treatment, blood cultures taken on admission yielded Salmonella enterica. He remained on ceftriaxone (2 g daily) for 18 days including initial treatment to cover S. enterica. Upon follow-up blood culture, no bacteria were detected on the 8th and 25th days after starting treatment, and the patient no longer had fever; he was subsequently discharged from the local hospital on 19 December 2017. However, he consistently suffered from lower back pain, nausea, and vomiting; he was re-admitted to the same local hospital 9 days after his discharge. When he was re-admitted to the local hospital again on 30 December 2017, magnetic resonance imaging (MRI) was performed and L1 spondylitis was demonstrated. MRI revealed whole bone marrow oedema with endplate lytic changes in the L1 body and focal marrow oedema in the upper endplate of L2 bodies. Additionally, mild destruction of intervertebral disc at L1–2 was shown. These findings were considered to be indicative of pyogenic spondylitis (Fig. a, b, c). He was empirically treated with cefazolin (1 g, 3 times a day) for 10 days to cover the possibility of Staphylococcus aureus infection, which is a common cause of pyogenic spondylitis. Then, blood cultures were tested and yielded S. enterica again. Finally, he was transferred to Chosun University Hospital, and bone biopsy of L spine was performed on 3 January 2018. He had no fever, and the initial blood test was

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man was admitted with cough. Chest computed tomography (CT) showed an 11-cm mass in the right upper lobe that was suspected of invading the right side of the superior vena cava (SVC) almost from the proximal end of the right internal jugular vein to the right atrium inflow (Fig. a, b). The patient did not present with signs or symptoms of SVC obstruction. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) showed leiomyosarcoma of the lung (Fig. a). 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT showed the high accumulation of FDG in the pulmonary tumor with a maximal standardized uptake value of 16.83; the absence of any other accumulation allowed us to exclude metastasis from another site. We diagnosed the patient with primary pulmonary leiomyosarcoma.
We considered complete resection of the tumor to be very difficult because of the tumor invasion, particularly that to the right atrium inflow of the superior vena cava, so we performed chemotherapy (doxorubicin monotherapy) for five cycles. We discussed the regimen for neoadjuvant treatment in a conference with orthopedic surgeons and medical oncologists. The recommended regimen for advanced soft tissue sarcoma is doxorubicin monotherapy or the combination of doxorubicin and ifosfamide. However, given that the combination therapy results in bone marrow toxicity more frequently than monotherapy, we selected doxorubicin monotherapy for neoadjuvant treatment. After chemotherapy, the tumor size shrank to 5.6 cm, and the distance of suspected invasion to the superior vena cava was reduced, rendering the tumor resectable with a sufficient surgical margin between the inflow of the atrium and the tumor (Fig. c, d).
We performed right upper lobectomy with combined resection of the superior vena cava and reconstructed the blood flow by an artificial vascular graft between the left brachiocephalic vein and right atrial appendage. We were able to remove the dense adhes

[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 Indian woman presented to our outpatient department with complaints of a lump in her left breast noted four months prior to presentation. The lump gradually increased in size and was non-tender. There was no history of nipple discharge. The patient denied any hormonal therapy or family history of breast disease. A physical examination found our patient to be obese and in no acute distress. A breast examination showed her left breast to be pendulous with a 6 cm × 5 cm × 6 cm irregular, firm mass fixed to the overlying skin in the midline above her left nipple. There was no nipple discharge or skin dimpling. There were no palpable axillary lymph nodes. Her right breast and axilla were found to be normal. The remainder of the physical examination was noncontributory. A mammogram of her breast showed a well-defined mass measuring 5 cm with lobulated margins and areas of calcification closely resembling bone. In addition, fine egg shell calcification around the tumor was also noted. A core needle biopsy was taken from the breast lump which was reported as osteosarcoma of the breast. Computed tomography of the chest and abdomen, serum alkaline phosphatase and a bone scan were all within normal limits. Our patient was prepared for surgery and a simple mastectomy was performed. The histopathological examination revealed a tumor consisting of highly pleomorphic oval- to spindle-shaped cells arranged in sheets and bundles separated by fibrocollagenous tissue (Figure ). The tumor cells had hyperchromatic nuclei and some showed mitotic figures. The stroma showed lymphocytic infiltration and areas of osteoid formation (Figure ). Areas of hyaline matrix were intermingled, with vacuolated cells showing cartilaginous differentiation. The picture was suggestive of osteosarcoma of the breast in a pre-existing phyllodes tumor showing areas of chondroid differentiation. The immediate post-operative period was uneventful and our patient was discharged on the fifth post-ope

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old woman was brought to the emergency unit after a traffic accident. She suffered multiple traumatic injuries including liver laceration, left femoral shaft fracture, pelvic bone fractures, and multiple rib fractures. Roughly three weeks later, she developed dyspnea and swelling of the left upper extremity. A contrast-enhanced chest computed tomography (CT) revealed a pulmonary embolism in the right pulmonary artery and thrombosis in the left brachiocephalic vein (). On a lower extremity CT angiography and Doppler ultrasound taken after the diagnosis of pulmonary thromboembolism, a lower extremity DVT was not detected. A left upper extremity venogram revealed complete obstruction of the brachiocephalic vein with lack of collaterals, implying the development of acute upper extremity DVT ().
To prevent the recurrence of a pulmonary embolism from the left upper extremity venous thrombi, and to reduce her left arm swelling, removal of venous thrombi was necessary. Because anticoagulation and thrombolysis were contraindicated due to her recent major trauma history, we decided to perform a thrombus aspiration. To prevent a further possible pulmonary embolism during the procedure, we planned temporary filtration in SVC.
One day following the diagnosis of upper extremity DVT and pulmonary thromboembolism, the Tempofilter II was placed in the SVC percutaneously, via the right femoral vein. After a right femoral vein puncture, a guide wire was threaded through the IVC, right atrium, and up into the SVC. The subcutaneous puncture site was enlarged by about 10 mm with an incision and an approximately 20-mm-sized subcutaneous pocket was created by tissue dissection. Next, the introducer system (dilator and sheath) was inserted along the guide wire into the SVC under fluoroscopic guidance. After the dilator and guide wire were removed, iodinate contrast agent was injected to obtain a superior vena cavogram to clarify the exact location of the thrombus and to confirm th

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old Dutch Caucasian woman was referred to our clinic with signs of dissociation of the polyethylene liner of a metal-backed patellar component in the right knee. Six years previously, she underwent an uneventful primary LCS patellofemoral arthroplasty with an uncemented patellar component. The patient reported a recent minor fall with direct injury to the anterior side of the knee, and later complained of persistent pain and noise arising from the knee while rising from a chair and climbing stairs. Walking on a level surface was uncomfortable with pain on both medial and lateral sides of the knee. Clinical examination showed no evident wasting of the quadriceps muscle, likely due to considerable obesity. Physical examination showed moderate valgus malalignment of both knees. No restriction of movement was observed with 0 to 130 degrees of flexion; however, a typical metal-on-metal grinding sound was heard from the anterior knee compartment during flexion and extension of the knee. There was significant tenderness on both medial and lateral femorotibial joint lines. Radiographs showed a displaced polyethylene liner of the patella with moderate femorotibial osteoarthritis (). We advised a conversion to a total knee arthroplasty because of symptomatic femorotibial osteoarthritis. During surgery, the patellar button was found to be resting in synovial tissue in the suprapatellar pouch. No signs of infection were found, and no significant metallic synovitis was noted. Removal of the uncemented metal backing patellar component proved difficult with substantial loss of bone. After removal of the trochlear component, a NexGen (Zimmer, Warsaw, Indiana) total knee prosthesis was inserted with use of a cemented polyethylene patellar button. Postoperative rehabilitation is currently in progress. Cultures of synovial fluid were sterile.
The retrieved polyethylene patellar component showed a fracture radially extending from the center of the specimen to the markedly thi

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old male resident of a nursing home facility of Hispanic descent was brought to our emergency department (ED) for respiratory distress and altered mental status. He was intubated promptly on arrival to the ED. His past medical history was significant for intracranial aneurysm with bleeding following VP shunt placement, ischemic stroke with aphasia and paraplegia, and percutaneous endoscopic gastrostomy (PEG) tube placement. His vital signs and clinical laboratory results are presented in Table .
The clinical picture was suggestive of septic shock. We ordered a sepsis workup including two sets of blood cultures and urine culture. The patient was treated with aggressive intravenous fluid hydration and broad-spectrum antibiotics (vancomycin and meropenem).
A non-contrast computed tomography (CT) of the chest, abdomen, and pelvis revealed bibasilar pulmonary atelectasis without focal infiltrate and the presence of a right-sided VP shunt catheter traversing the right neck, the right chest, and the right abdominal wall; the tip of the catheter was located within the gastric lumen and had likely entered through the PEG tube insertion site (Figures -). The PEG tube was outside the gastric lumen, terminating in the abdominal wall that was evidenced in the repeat CT scan confirmed that patient had abdominal wall cellulitis and localized abscesses around the PEG tube insertion site (Figure ). Medical records from another facility confirmed previously normal positioning of the PEG tube and normal intraperitoneal positioning of VP shunt catheter one year prior.
Given the malposition of the VP shunt inside the gastric lumen, we suspected VP shunt infection or meningitis/encephalitis and subsequently lumbar puncture was performed; the results of the cerebrospinal fluid (CSF) analysis were unremarkable. Blood cultures and urine culture results were negative.
The wound culture was positive for Proteus mirabilis sensitive to carbapenems and piperacillin/tazobactam. We debr

[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 man with a history of metastatic prostate cancer (treated with docetaxel ~2 weeks prior to presentation), hypertension, hyperlipidemia, paroxysmal atrial fibrillation (on rivaroxaban) and right knee osteoarthritis (status post total knee replacement) presented to the emergency room with left sided neck pain and swelling. He first noted left sided neck pain 1 to 2 weeks prior to presentation. Initially, he noted some discomfort and a small nodule on his left neck. However, the nodule grew over time and the pain progressed to the point where he noted discomfort with swallowing and breathing. Accordingly, he presented to our medical center for care. On the day of admission, he was febrile (38.7°C), tachycardic (122), hypertensive (152/94). Fortunately, despite the tender neck swelling, there was no airway compromise.
The physical exam revealed a tender non-pulsatile mass on the left neck extending to the angle of the mandible. A computed tomography (CT) scan of the neck with contrast revealed a focal outpouching of the left carotid artery (). There also appeared to be a mass encircling the left carotid artery (4.3 cm × 2.5 cm × 3 cm) with lateral displacement and compression of the left jugular vein.
A vascular surgery consultation was obtained and given concern for a contained ruptured aneurysm, the patient was taken to the operating room (OR). During the surgery, an aneurysm with a posterior perforation and contained rupture was noted (). Pathological specimens from the surgical site were notable for significant atherosclerotic disease. Also, purulence was noted along with extravasated blood and cultures taken from intraoperative specimens revealed pan sensitive S. enterica ser Dublin. The affected and ulcerated portion of the carotid artery was excised and replaced via end-to-end anastomoses with a bovine mesenteric vein graft. Interestingly, all peripheral blood cultures were negative for bacterial growth. He was treated with ceftriaxone 2 grams IV da

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


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

[User]
RADIOLOGY NOTE:
The patient was a 23-year-old female who presented in 2010 with new headaches and underwent a surgical resection of a left posterior frontal paramedian PXA (WHO grade 2). When there was recurrence approximately 2 years later she underwent a reresection followed by radiation to 56 Gy. She underwent a third resection when there was rerecurrence approximately 2 years later. The tumor remained grade 2 and was found to harbor the V600E BRAF mutation as well as MGMT promoter methylation. Craniotomy was followed by nine cycles of temozolomide. Approximately 1 year later, she underwent a fourth craniotomy for progressive disease. At that time, the patient started a regimen of alternative therapies outside of our institutions. Within 6 months, there was further tumor progression. At that time, treatment with a BRAF inhibitor was discussed with the patient. Although the underlying rationale was explained, the patient and family declined due to concerns of side effects. However, she agreed to bevacizumab, and the tumor initially showed radiographic response. However, there was further tumor progression approximately 5 months after starting bevacizumab.
The patient agreed to treatment with BRAF inhibitor, and vemurafenib was started at a dose of 960 mg every 12 h. Due to the multiply recurrent nature of the tumor, per the patient and family's request, TTF was added to the regimen. The patient achieved a marked partial response with 70% reduction of enhancing tumor after 2 months on combination vemurafenib and TTF. Based on response to vemurafenib and thought that synergism could achieve prolonged efficacy, the MEK inhibitor, trametinib was added. The BRAF and MEK inhibiting combination proved intolerable for the patient, so all treatment was held for 1 month. Then, vemurafenib in conjunction with TTF were resumed. After 2 months on the above-described regimen there was additional partial response on the order of additional 70% reduction of enhancing tumor. The regimen was conti

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


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

[User]
RADIOLOGY NOTE:
A 30 years old male patient attended our hospital with complaints of difficulty in walking, deformity, inability to flex the left knee joint and shortening of the limb for one month. He had been assaulted by unknown persons one month earlier and had sustained direct impact injury on the knee joint. There were no injuries on the other parts of body. He was able to walk only with the help of a crutch. There was no history of diabetes, hypertension, coronary artery disease, epilepsy or chronic respiratory problems. On examination there was distortion of shape of the knee joint, wasting of thigh muscle and shiny appearance of the skin. On palpation there was diffuse tenderness of the knee joint, proximal end of tibia was protruding anteriorly and patellar movement was not normal. There was no antero-posterior or varus-valgus laxity of the joint. Range of movement of knee joint was 0 to 20 degree, and shortening of the limb was 2.5cm. The distal neurovascular status however was normal. Radiograph confirmed anterior dislocation of the knee joint. Because of financial problems the patient had not sought any medical treatment for one month after the dislocation. He was not able to pay for the MRI, so we tested the status of ligaments intra-operatively. Both anterior and posterior cruciate ligaments were completely torn but the medial collateral ligament, lateral collateral ligament, medial meniscus, and lateral meniscus were intact. The knee joint was opened through a medial para-patellar approach; fibrous adhesions around the knee joint were released, blunt tip Homan’s retractor was inserted on the undersurface of the inter-condylar notch and by levering the retractor on the tibia, the joint was gradually reduced. After reduction, the joint was stabilized with two intra-articular crossed Steinman pins passed through the medial and lateral surface of the tibia. The knee joint was stabilized with a posterior POP slab for six weeks. Steinman pins were removed after six

[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 42-year-old male patient, a known case of chronic kidney disease with end stage renal failure secondary to ADPKD, was on maintenance hemodialysis since 1997. Since he did not have suitable donor in the family he was registered for cadaver transplant. He poorly tolerated hemodialysis sessions because of recurrent intradialytic hypotension and anginal chest pain during each HD session. He underwent coronary angiography in 2003, which confirmed triple vessel disease. He underwent CABG in 2003. In postoperative period, he had a stormy course, complicated with delayed sternal wound healing and prolonged ICU stay.
This patient showed no improvement in his functional status and also no symptomatic relief post CABG. He experienced anginal recurrences during dialysis sessions. He was the only earning member and had lot of family responsibilities. He was called in for cadaver renal transplant on 11/11/2004. The donor was a 38-year-old female, brain dead due to head injury, admitted at another hospital. At the time of organ recovery, both donor kidneys were studded with several cysts, 4 - 12 mm in size and were approximately 12 cm in longitudinal axis. The Serum creatinine concentration of the donor was 1.0 mg/dl.
After serious consideration, we decided to go ahead with the transplantation. The recipient was fully informed about the marginal status of the kidney before giving consent to transplantation. Surgery was uncomplicated and the kidney functioned immediately after transplant. The recipient was treated with cyclosporine, prednisone and azathioprine. Serum creatinine on day 20 was 1.4 mg/dL. The other kidney was also transplanted at the retrieving centre but unfortunately suffered graft loss.
Three months later, he had high-grade fever and right lower lobe pneumonitis. His Serum creatinine went up to 2.5mg/dL. Though he recovered from sepsis, his renal function remained same. Two years later, in 2006, in view of creeping creatinine and polycystic pathology, cyclosporin

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


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

[User]
RADIOLOGY NOTE:
A 62-years-old male was presented to our clinic because of loss of consciousness. Five years ago a single chamber AAIR pacemaker was implanted due to sick sinus node syndrome. Since then patient was symptom free, until an episode of syncope occurred recently. Echocardiography revealed preserved left ventricular function (EF=58%) without structural heart disease. 24-hours ECG showed an appropriate atrial stimulation without ST-segment/T-wave changes during the exertion. Few episodes of intermittent 2:1 AV block during rest were observed (). Upgrade of pacing system form AAIR to DDDR was advised and the patient was sent to our clinic. Routine chest X-Ray revealed the permanent pacemaker with the pacing lead in right atrium and hypo dense (bowel density) mass in the left chest cavity with the collapse of the left lung and shift of the heart and big vessels towards the right, resulting in reduction of right lung volume (). Diaphragmatic hernia was assumed. Few published reports show an influence of pneumothorax on atrioventricular conduction by increasing the parasympathetic tone [,]. Significant increasing of vagal tone due to displacement/mechanical compression of the heart and the left lung collapse was suspected as a reason of intermittent AV block. Patient was referred to surgical department, where Bochdalek hernia was diagnosed. Back-up temporary pacemaker lead was implanted in the right ventricle and surgical correction was performed. Thoracotomy revealed defect of posterolateral diaphragmatic wall with herniated abdominal viscera into the thorax (). Additionally ectopic intrathoracic left kidney was found, which represents less than 5% of all renal ectopias []. Hernia was repaired. Post operative day one X-ray showed normal position of the chest organs (). Repeat 24-hours ECG monitoring after a day of operation and then 3 months later revealed the normal function of permanent pacemaker (AAIR mode) with proper atrial pacing and no sign of AV block. Stable pacing

[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:
Mr G, a 48-year-old Italian man, manager of a small firm, married and father of two children, was diagnosed with sarcoidosis 24 years ago. The diagnosis, based on radiological and histological findings, was made at Ospedale Maggiore in Bologna. Tuberculosis, cryptococcosis, histoplasmosis, and other infective diseases were excluded by the laboratory analysis. The disease concerned his skin and his lungs, with the characteristic noncaseous granulomas. The main symptoms were an erythema nodosum to the legs and dyspnoea. The disease did not affect the central nervous system or other organs.
The patient was treated with corticosteroids, with different dosages according to the clinical condition. The physician noticed a state of depression and thus requested an evaluation from a clinical psychologist.
During the clinical interview the patient showed an alexithymic communication style, with limited speech, a pessimistic approach to the future, and social withdrawal. He worried about appearing idle at work, and spending little time with his family, with whom he felt isolated and not respected. He criticized himself and felt mortified when going against his own limits in his professional activity. He felt helpless that he had failed to meet his own expectations and that he was unable to cope with his pressing problems. This evidenced a state of demoralization, particularly frequent in medically ill patients [].
Moreover, he suffered from dyspnea, and, every 3-4 months, the sarcoidosis nodule on his right leg worsened, as it had been doing for the last ten years. The sarcoidosis manifested itself six months after the patient started working and got married. These events coincided with the onset of the oncological disease of his father, who died three years later. At the time of his father's death, the patient had just started an entrepreneurial activity. The patient was therefore left without the important psychological support of his father. During this period the wife

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old female patient was referred to our department for laparoscopic excision of GIST in the stomach. Prior to our treatment she underwent an esophagogastroduodenoscopy due to epigastric pain and occasional vomiting. Endoscopy showed erosive gastritis, a hiatal hernia, and a submucosal tumour located along the lesser curvature on the posterior wall of the antrum (). The tumour had a central eroded depression but otherwise appeared to be covered with normal mucosa. Several biopsies of the tumour were taken using the bite-on-bite technique. Unfortunately, only scant samples of the submucosa were obtained, which precluded a histological diagnosis of the tumour.
Endoscopic ultrasonography confirmed a 22 × 13 mm submucosal well-defined solid tumour arising from the fourth, muscular, layer of the stomach (). The tumour appeared to be nodular, with slightly heterogeneous echogenicity. Endoscopic ultrasonography did not demonstrate a significant ulceration or ductal structures. In the diagnostic work-up of abdominal pain and vomiting the patient had undergone transabdominal ultrasonography, which showed no focal lesions in the liver. Before surgery, we performed another endoscopy where the lesion was tattooed proximally and distally.
Laparoscopy was performed, and on initial exploration of the abdominal cavity, we discovered a tattooed submucosal tumour on the greater curvature of the stomach. Laparoscopic excision was performed and the specimen was recovered in a retrieval bag. The abdominal cavity was irrigated with saline and the fluid aspirated. An abdominal drain was inserted beneath the stomach. The fascia and skin wounds were sutured. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day.
Resection samples were sent for histopathological analysis. The histopathologic analysis report about 6.6 × 3.5 cm excision gastric wall. The mucosa and serosa have normal appearance, muscularis propria and submucosa include a

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


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

[User]
RADIOLOGY NOTE:
We report a case of 93 year old British lady, moderately built, living in a residential home. She was admitted for a few times in the past with a diagnosis of Major Depressive episode, Severe with Psychotic symptoms. She had been treated and stabilized with Mirtazapine 30 mg per day. She never smoked or consumed alcohol. She had no past history of chronic obstructive pulmonary disease.
Recently, she was admitted to Functional Ward with a diagnosis of Major Depressive Disorder, Recurrent, Severe with Psychotic features (296.34). She presented to us with poor sleep, anergia, easy fatigability, poor concentration and low mood. She was noted to have psychomotor retardation with tear laden eyes and Veraguth's folds. She firmly believed that dead people were around her and trying to harm her. She also admitted hearing voices of dead people telling her to die. She appeared distressed and refused to accept food, drink and medications. She was apparently stable in her mood until a month prior to the current admission. She contracted lower respiratory tract infection a month ago, for which she was successfully treated with antibiotics. Despite this, her general condition deteriorated and she refused her medications, food and drink.
Her general physical condition deteriorated further due to poor hydration and self neglect. On admission, her neurological examination was unremarkable. Her CT Brain showed age related generalized atrophic changes. There was no evidence of space occupying lesion, focal areas of hemorrhage or infarction in the brain. Since there was no history of seizures, focal neurological deficits and CT Brain scan showing age related changes, EEG was not performed.
It was felt in Multidisciplinary team that she would improve with a short term course of eight ECTs. As she was unable to consent, second opinion was sought and she was posted for bipolar ECT twice a week for four weeks. Pre-ECT investigations, ECG, Chest X Ray, Blood sugar were normal. The

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


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

[User]
RADIOLOGY NOTE:
Patient is a 27 year-old right hand dominant female who presented initially following an assault where a car door was closed on her right arm. She was evaluated and treated at a local emergency department with a coaptation splint. She had sustained a closed injury and remained neurovascularly intact. Initial management consisted of conversion over to a fracture brace and close follow-up. However, six weeks from injury, the patient endorsed continued pain. Examination revealed tenderness and movement through the fracture site; radiographs revealed unacceptable angulation and minimal callus formation (Figure ). With persistent pain, movement through the fracture and minimal healing, the patient was indicated for operative fixation.
The patient was brought to the operating room and placed in the lateral decubitus position. Stress fluoroscopy exhibited gross motion at the fracture site (Figure ). Via the posterior approach to the humerus, the radial nerve was found approximately two fingerbreadths above the confluence of the triceps lateral head, long head and aponeurosis []. Once the main trunk of the radial nerve was found, the surrounding branches were carefully isolated and dissected. The inferior lateral cutaneous branch was found subcutaneously and traced back to its origin (Figure ). This origin was noted to be a very proximally branching variant of the inferior lateral cutaneous branch, which is typically found at the inferior/distal end of the spiral groove, near the metadiaphyseal junction of the distal third of the humerus []. Operative fixation concluded without complication and the wound was closed primarily. The patient healed without complication and at 1-year follow-up was noted to have near full range of motion of the elbow (10-135) and was without complaints (Figure A-B).
Iatrogenic nerve injuries are among the devastating complications in the treatment of humerus fractures. Recent studies showed the rate of iatrogenic nerve injury in operatively treat

[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 68-year-old male with history of living donor renal transplant presented to the ED with acute onset of profound weakness, fatigue, left upper quadrant abdominal pain, hypotension and lactic acidosis. On exam, he exhibited mild left upper quadrant and epigastric tenderness without evidence of peritonitis. CT imaging demonstrated splenomegaly with a large splenic hematoma measuring 15.7 × 9.2 × 12 cm and associated hemoperitoneum (Figs –). In addition, innumerable osseous lytic lesions were identified. Given these findings, emergent surgical consultation was obtained and his coagulopathy reversed. He remained hypotensive despite resuscitation, thus was taken for laparotomy. Upon abdominal entry, a large amount of old clot was evacuated. The abdomen was packed in all quadrants in the standard fashion. Upon removal of the left upper quadrant packs, active hemorrhage began to well from the region of the spleen which was mobilized and removed via splenectomy. Upon gross inspection, the spleen was hyperemic and abnormally indurated, with an avulsion type injury extending several centimeters across the inferior pole. There was no evidence of pseudoaneurysm or other gross pathology. Given the patient was mildly hypothermic and coagulopathic with continued oozing from the retroperitoneum, the decision was made to pack the splenic fossa and place a temporary wound vac. The patient was transported to the ICU for resuscitation and brought back to the OR the next morning for re-exploration and closure. Despite hemodynamic stabilization, he underwent a prolonged hospitalization complicated by atrial fibrillation, renal allograft failure, VAP, and ultimately PEA arrest progressing to asystole. He died 6 weeks following splenectomy. The pathology from the spleen revealed splenomegaly with parenchyma that was replaced with amorphous and acellular eosinophilic material. Histologic staining (Thioflavin-T) was positive for amyloidosis, AL-type. Oncology was consulted based on these fi

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

[User]
RADIOLOGY NOTE:
A 81-year old woman was referred to our department to evaluate a wound dehiscence on her left knee with hardware exposure. The patient did not have any relevant comorbidities and her general status was good. The patient underwent a total left hip arthroplasty at the age of seventy four due to severe osteoarthritis pain that hindered baseline activities. Eight years later, the patient presented to the orthopedics department with a progressive pain in the affected hip, particularly when walking, causing difficulties in deambulation.
An X ray examination revealed an extensive femoral bone loss with displacement of the femoral component, and an MRI showed a femoral pseudo-tumor (bone proliferation). With this finding, a revision total hip arthroplasty was performed with the insertion of a reconstruction ring with cemented dual mobility cups. Three weeks after this last surgery, the patient started with early symptoms of infection (high fever, suppuration, no wound healing and laboratory abnormalities); an attempt at conservative management with intravenous antibiotic, irrigation and suction drainages was unsuccessful and a replacement of the endoprosthesis femur in two stages was planned.
In the first stage, the previous prosthesis was removed with enlarged osteotomy of the anterior tuberosity and a cement spacer with antibiotic was placed. Two months later, the spacer was removed and a new coated silver total femoral prosthesis was placed. The patient was referred to our unit four weeks after the last surgery for the assessment of wound dehiscence to the lateral knee with hardware exposure. The patient was taken to the operating room for retention debridement and wound coverage with a flap. Our first decision was to cover the defect with a lateral gastrocnemius flap, however, the surrounding area was highly scarred, and the gastrocnemius muscle was found to be very atrophic and no suitable to fit the large defect. shows no other local flaps to be large enough to cover

[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 40-year-old perimenopausal woman, gravida 1, para 0, who presented with lower abdomen pain and a pelvic mass. Her menstruation was regular in the past but began to be irregular 1 year ago. Her dysmenorrhea became increasingly serious, with visual analog scale score varying from 3 to 9, and she had secondary infertility. On physical examination, she had a large uterus with size similar to that at 14 weeks of gestation, a palpable 7-cm solid mass on the left side of the pelvis, and tenderness upon palpation of the posterior cervix fornix. Transvaginal ultrasonography revealed the pelvic mass to be solid, measuring 6.8 × 4.7 cm, with abundant blood flow signal, and is located near the body of the uterus and left ovary; soft nodules, with the largest measuring 1.2 × 0.6 cm, were found on the peritoneum. Pelvic magnetic resonance imaging (MRI) also revealed a high volume of effusion in the pelvic cavity, an irregular occupying lesion on the surface of the fundus of the uterus, and multiple nodules around the lesion; hence, a malignant tumor was suspected (Fig. A and B). Preoperative laboratory studies revealed no abnormalities. Tumor marker cancer antigen (CA) 125 was 372.4 U/mL. With the impression of advanced-stage ovarian cancer with massive ascites, diagnostic laparoscopy was performed.
Diagnostic laparoscopy revealed a large mass of crunchy tissue and some soft nodules on the surface of the posterior wall of the uterus (Fig. A), some vesicular tissues on the surface of the bilateral ovaries and the right broad ligament, and 2000 mL of bloody ascitic fluid (Fig. B). A small part of the tissue on the uterine surface was removed and sent for frozen-section analysis, which indicated endometriosis. After biopsy, the surface of the mass began to bleed, which cannot be stopped by repeated bipolar electrocoagulation. The surgical procedure was promptly changed

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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 47-year-old man reported to the emergency department (ED) with the complaint of continuous abdominal pain in right upper quadrant (RUQ) radiated to right shoulder. The onset of pain was 24 hours prior to arrival at the ED. He had a history of 10 pack/year smoking but had no history of alcohol consumption. He also reported two episodes of similar abdominal pain in RUQ with a continuous pattern in the past year. He underwent supportive treatment with a sonography report of chronic cholecystitis. His past medical and drug history were unremarkable. In review of systems, there was no further complaint except abdominal pain. On initial evaluation he was afebrile (axillary temperature of 37.1°C) with blood pressure of 120/85 mmHg, pulse rate of 85 per minute, and respiratory rate of 10 per minute. There was no evidence of icterus. In abdominal examination, on light palpation there was moderate tenderness in RUQ and epigastric region. Murphy’s sign was negative. There was no evidence of organomegaly and no palpable mass was detected. Laboratory results showed white blood cell count of 5600/µL with 60% polymorphonuclear, amylase level of 63 U/L (normal range of below 100 U/L) and normal liver and renal function tests. The patient underwent ultrasonography with primary diagnosis of biliary colic. Sonographic findings included gallbladder with thick edematous wall, free fluid around and a number of stones inside and also bile ducts with normal diameter. According to these findings the patient was transferred to the operating room for laparoscopic cholecystectomy after hydration and initiation of intravenous antibiotic. Due to the inability to detect the gallbladder during laparoscopy, laparotomy with Kocher incision was done. The gallbladder was not detectable even after laparotomy and a mass was seen and palpated in right lobe of liver. The laparotomy was ended after lavage of abdominal cavity and placing a surgical drain without any further action. Afterward a gastroenter

[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 2-month-old female child was brought to Orthopaedic OPD with stiffness of elbow and congenital deformities of right hand. She was second child, born out of a non-consanguineous marriage by full-term normal vaginal delivery. There was no family history of congenital disorders, and antenatal period was uneventful. Examination revealed shortening of right upper limb with slight flexion at elbow and radial deviation of wrist (Fig. ). The hand had seven well-formed digits arranged symmetrically as mirror images on either side of a presumptive sagittal axis (Figs. , ). Passive movements at shoulder were normal; elbow had fixed flexion deformity of 20° with further flexion of 30°. Supination and pronation was grossly restricted at forearm; wrist movement was from 15° to 45° of palmar flexion. Child was able to flex and extend the fingers and occasionally grasped object between the fingers (although exact finger function could not be assessed as the child was too small). Function of opposite limb was essentially normal. Radiographs of affected limb show two ulnae, one following the other, with broadened distal end and absent radius (Fig. ). The hand bears seven triphalangeal digits with seven corresponding metacarpals all in one plane (Fig. ). We planned gentle manipulation at wrist and elbow, followed by serial corrective cast application at weekly intervals to correct as much deformity of wrist and elbow as possible. Correction of deformity can be maintained by suitable orthosis until the child reaches 1 year of age. After 1 year of age, staged surgeries can be planned because by that time the limb size becomes reasonably large for corrective and reconstructive surgeries and also the child can be trained well in use of hand and muscle training of pollicised finger. Our aim was to obtain useful elbow flexion, forearm rotation and reconstruction of thumb from the functional point of view. In the first stage, soft tissue distraction would be achieved by application of radi

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old Greek male patient, which had undergone transurethral resection of prostate 14 years ago, was followed up with contrast enhanced computed tomography (CECT), which revealed a 4.5 × 4 cm macrocystic lesion in the tail of the pancreas. The patient complained for vague postprandial abdominal pain. Physical examination was not contributory. Ultrasonography (US) revealed a 4.5 × 4 cm hypoechoic lesion in the tail of the pancreas as well as cholelithiasis. Magnetic resonance imaging (MRI) also revealed a 4.5 × 4 cm macrocystic lesion in the tail of the pancreas. In addition, computed tomography-angiography (CTA) showed that the tumor distorted and compressed the splenic vessels (). The level of serum CEA and CA19-9 were within the normal range. Preoperative evaluation led to the possible diagnosis of mucinous cystic neoplasm of the pancreas. The patient was subjected to laparoscopy. Intraoperatively a cystic mass of approximately 4.5 cm in diameter was found in the tail of the pancreas in addition to atrophy of the adjacent parenchyma. Laparoscopic cholecystectomy and distal splenopancreatectomy was performed. Postoperative recovery of the patient was uneventful, while the drainage was removed and the patient stepped out on the second and fourth postoperative day respectively.
Despite the preoperative diagnosis of mucinous cystadenoma the histology was consistent with a pancreatic pseudocyst, which was subsequenced to moderately differentiated ductal adenocarcinoma. Resection margins were negative, as well as perineural invasion was not present and no metastasis was found in eight peripancreatic resected lymph nodes.
Patient underwent adjuvant chemotherapy, with gemcitabine 1000 mg/m2 weekly for 3 weeks followed by a rest week, and for 6 cycles. He tolerated treatment well without side effects. The patient was followed up with US, abdominal CECT and chest X-ray after 6 months. The level of CA19-9 was determined one month after surgery and then every 3 months

[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 five-year-old boy weighing 11 kg, was brought to a public tertiary care hospital in Karachi, Pakistan by his parents. His chief complaints were described as a diffuse rash over the body, swelling of the head and bulging of both eyes as well as swelling of the gums. These symptoms were progressive and relapsing, with the rash being present since the past 18 months and having extended to a breakout over the head, neck, back, chest and perineum over the last month and the swelling and bulging having progressed over the past year.
According to his mother, the child had been in absolute good health until the age of two years, when he developed a spontaneous fracture of his right clavicle. The family was counseled and told the fracture would heal without any intervention. At two-and-a-half-years of age, the family sought a dental consult for a spontaneously broken tooth which was described to them as a developmental problem of the mandible. Further on, at three years of age, the child developed an infected oral ulcer, a severe swelling of his gums and had two episodes of a yellowish ear discharge for which he underwent drainage. His bodily rash made its first appearance six months after that, at 3.5 years of age, presenting as yellow lesions with pus filled discharge over the head, palms, soles and genital area - albeit, healing afterwards. The swelling of the right side of the head and bulging of both eyes started at the age of four years, with the proptosis gradually progressing to its current state upon presentation and associated with dimness of vision in the right eye. The child had previously been misdiagnosed as a case of Papillon-Lefevre syndrome (rare ectodermal dysplasia characterized by palmoplantar keratoderma associated with early onset periodontitis) two years ago and prescribed fluconazole, but to no avail. He was the third offspring of a consanguineous marriage,

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old man was diagnosed with T1a melanoma arising from the right shoulder in 2009. He underwent a wide excision and sentinel lymph node biopsy. Pathology review revealed a 1.64 mm melanoma, anatomic level deep III/early IV, no ulceration, 1 mitosis/mm2. Four right axillary sentinel lymph nodes were negative for involvement with melanoma. In September 2013, after experiencing hematuria, the patient underwent a cystoscopy followed by transurethral resection of a bladder tumor (TURBT), which revealed a low-grade urothelial carcinoma with no evidence of bladder invasion. He is a lifelong non-smoker. A staging computerized tomography (CT) scan revealed two right lower lobe lung nodules (2.7 cm and <1 cm), and a 6.3 cm tumor in the left kidney. A positron emission tomography computerized tomography (PET/CT) in November 2013 (Fig. ) showed enlarged mediastinal lymph nodes in addition to FDG uptake in the lung nodules and a complex left kidney mass. A mass in the thoracic spine (T3 vertebra) and a small focus of uptake in the right sacral ala were also noted (Fig. ). A biopsy of the T3 vertebral lesion was performed and pathologic review demonstrated RCC. A core needle biopsy of one of the right lower lobe lung nodules was also performed and unexpectedly revealed recurrent metastatic melanoma (Fig. ). In December 2013, a brain MRI showed a subcentimeter left temporal metastasis. The patient received radiation to the T3 vertebral metastasis and stereotactic radiosurgery to the brain metastasis.
While weighing the treatment options for these two cancers, although our initial thoughts were to focus on the more aggressive melanoma (BRAF and NRAS wild type), we were motivated to design a therapy regimen that could yield efficacious responses against both cancers. Bevacizumab, the anti-Vascular Endothelial Derived Growth Factor (VEGF) directed monoclonal antibody approved for use in renal cell carcinoma, has some efficacy in advanced melanoma and was found to be safe and

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old man presented with left facial dysfunction and went to a local hospital in 2016. Brain magnetic resonance imaging (MRI) at the local hospital revealed a mass in the saddle area. The tumor was 6.3 cm × 5.8 cm × 4.5 cm. The patient was referred to a tertiary hospital and was diagnosed with a hypophysoma. He received pharmacotherapy and his facial numbness went into mild remission. In 2017, his MRI showed that the tumor grew from 6.3 cm to 7 cm. He continued treatment with medicine. The patient felt that his eyesight diminished further, and in April of 2018, he was admitted to hospital. The patient had no history of trauma, no family history of any hereditary illness, and his neurological examinations were normal.
Preoperative computer tomography (CT) and MRI showed a huge tumor in the sellar area. A CT scan revealed a hyperintense mass with an indistinct boundary located in the saddle area, sphenoid sinus area, and left temporal lobe; the tumor demonstrated expansive growth ( and ). MRI showed a 7 cm × 6 cm × 5 cm giant irregular mass in the left side saddle, sphenoid sinus, and medial temporal lobe. The tumor presented as non-uniform hyperintense signal on T1-weighted images and uniform hyperdense signal on T2-weighted images ( and ). Based on preoperative imaging results, the provisional diagnosis was a malignant tumor of the sellar region. A neurosurgeon removed the tumor by transcranial endoscopy. During tumor removal, the surgeon found that the tumor tissue was soft and had a fish-like appearance, with a rich blood supply. The tumor was completely removed piece-by-piece under an endoscope. Postoperative CT imaging on the first day after surgery showed that the tumor was resected (–). The patient accepted radiation therapy at the local hospital 1 month later (total dose, 50 Gy; 2 Gy once a day for 4 weeks).

[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 woman was admitted to the obstetrics ward during the 25th week of gestation to adjust her anticoagulation regimen. She was gravida 2, with one previous miscarriage and had a metallic mitral valve prosthesis as a result of a childhood episode of rheumatic fever. Except for her cardiac disease, which was under control, she led a normal life and was employed as a social worker. This woman discovered that she was pregnant in the first trimester of gestation, and without consulting her physician, stopped using her anticoagulants. She was late in initiating antenatal care and consequently her referral to a specialized antenatal clinic was also delayed. When she was in the 25th week of gestation, she reached the third level of care and was admitted to the obstetrics ward where she was prescribed 10,000 units of unfractionated heparin twice a day. During her third night in the hospital, after receiving subcutaneous heparin for almost 72 hours (at that time the dose had been increased to 12,000 units twice a day), she developed headache, nausea, vomiting and mental confusion. At that time, physical examination revealed a stiff neck, but no focal neurological deficits were noted. The patient's pupils showed isocoria and were reactive to light, and she had a Glasgow coma score of 11. During this initial phase of hospitalization, her blood pressure and pulse remained within the normal range. APTT (Activated Partial Thromboplastin Time) was 57 seconds. A computerized tomography scan displayed an intraparenchymatous haematoma with bloody obliteration of the ventricles. The patient underwent neurosurgical drainage of this lesion and was admitted to the obstetrical intensive care unit, where postoperative care and ventilatory support was continued. During the following hours, her neurological status deteriorated progressively and on the following day, the patient appeared to have gone into a non-reactive coma with no sign of brainstem activity. Maternal brain death wa

[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 34-year-old woman with severe Crohn’s disease, grade IV endometriosis, and bilateral tubal obstruction, booked for antenatal care at 13 weeks gestation. This was her first pregnancy following four attempts of in vitro fertilization and embryo transfer (IVF). Routine antenatal blood investigations were unremarkable. Her blood group was A-negative. Pregnancy was uncomplicated until 17 weeks gestation when she presented with spontaneous PPROM. This was confirmed by the presence of a pool of clear liquor in the vagina and a positive nitrazine test. High vaginal swab cultures for bacteria were negative. Ultrasound scans confirmed a singleton pregnancy with oligohydramnios. There was complete anhydramnion at 19 weeks gestation, and this rendered assessment of foetal anatomy difficult.
The couple was counselled on the poor outcome and risks of infection to the mother and foetus but expressed the wish to continue with the pregnancy. The risks of significant perinatal mortality and neonatal morbidity associated with chronic anhydramnios and the poor outcome associated with extreme prematurity was fully discussed by the neonatal team. The risks were based on the risk of infection to both mother and the foetus, up to date evidence and the ultrasound findings.
She was commenced on erythromycin 250 mg eight hourly, and managed expectantly as an outpatient with twice daily temperature checks at home, as well as serial full blood counts (FBC), serum C-reactive protein (CRP) and weekly low vaginal swabs. Two weekly growth scan showed a normally growing foetus, with visible breathing movements, and chest circumference growing along the 50th centile. Abdominal circumference (AC) measurement in foetuses with oligohydramnios may be technically difficult and less reproducible as the abdominal profile may be significantly deformed due to compression, thus, it is probably more reproducible to use ratios based upon head circumference rather than AC as the fetal head is more rigid, even i

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


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

[User]
RADIOLOGY NOTE:
The patient was a 66-year-old Caucasian man, who presented for a neuropsychological evaluation performed at the Centre of Alzheimer’s Evaluation Unit (AEU), with a Mini-Mental State Examination (MMSE) value of 18/30. The neuropsychological final report, as authentically quoted and faithfully pursuant to the description of the AEU doctor, related the following: ‘The present condition offers a picture of poor collaboration on the part of the patient who shows attention loss while performing the test and needs to be reminded about the given indications. Remarkable language worsening with reduced capacity of expression and comprehension that limit his autonomy. Worsening of executive functions with difficulty in planning and performing even simple activities, difficulty in solving problems. This picture defines a significant loss in instrumental activities for which assistance is needed. Treatment with anticholinesterasics and antioxidants must be continued’ (Table ). For the evaluation of occlusal muscle activity, bilateral electromyography (EMG) of the masseter muscle was recorded using surface Ag/AgCl electrodes. In accordance with dental diagnostic protocols [,], a preliminary evaluation of the patient’s myoelectric activity in habitual dental occlusion was performed via electromyography of the muscles in order to assess their functional balance, as the patient showed a bilateral lack of all molars, second premolars and the right medial incisor. Registered values showed a remarkable functional asymmetry of the masseter muscles: 10 mV for the left masseter and 111 mV for the right masseter, respectively (Figure ). According to the expressed electromyographic values, muscular activity was symmetrized by applying a 15-min transcutaneous stimulation of the trigeminal motor branches at low frequency for the masseter muscles and at medium frequency for the submandibular antagonist muscles. This method allowed detection of the functional trajectory of the occlusal elevator

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 60-year-old Kenyan woman who was admitted 1 year ago to a hospital in western Kenya with complaints of epistaxis and right-sided chest pain for the preceding 3 days. She reported an 11-year history of recurrent spontaneous epistaxis that had worsened 3 days before admission. Apart from one episode of postpartum hemorrhage (PPH) in the past that had required blood transfusion, she had no other history of bleeding tendencies. Her right-sided chest pain was pricking in nature and radiated to her upper back. She had associated shortness of breath but no cough or platypnea. She also complained of severe headache that she described as global, persistent, and not worsened by light but associated with dizziness. She had never been on any medications for the epistaxis.
She had two previous admissions: one 17 years ago for PPH that required blood transfusion and another in early childhood for malaria. She is a widow, mother of five children, and a first-born in a family of seven. Two of her sisters had histories of mild recurrent epistaxis. She had a history of occasional alcohol use but had stopped 4 years before admission. She had no history of tobacco use.
Her physical examination revealed a middle-aged woman in fair general condition with severe pallor and a tinge of jaundice. She had no cyanosis or lymphadenopathy. Her vital signs were blood pressure of 95/60 mmHg, pulse rate of 100 beats/minute, respiratory rate of 22 breaths/minute, and axillary temperature of 37 °C. Her oxygen saturation by pulse oximetry was 95 % on room air, which dropped to 92 % 5 minutes after changing positions from supine to upright.
Her oral examination revealed multiple, guttate-like, erythematous blanching lesions with a tendency to coalesce on the edges of the tongue, as well as a few grouped erythematous, well-demarcated, blanching lesions on the hard

[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 male presented with persistent pain and swelling of the left jaw for the past two months following a left 1st molar tooth extraction. There was an associated history of prolonged pyrexia associated with chills and rigors. Patient was treated with a course of antibiotics as infection of the extraction site was suspected. Several weeks later, he presented to an oromaxillofacial surgeon as the symptoms progressed. Physical examination revealed an ill-defined hard swelling arising from the body of the mandible with an exuberant soft tissue growth anterior to the left last molar. Full blood count showed hemoglobin of 127 g/L, white blood cell 11.7 x 109 and platelets 397 x 109. The ESR was 48 mm/hour, which was mildly elevated. He was not known to be immunocompromised.
An orthopantomogram (OPG) () and a contrast enhanced computed tomography (CT) scan of the mandible showed lytic destruction in the body of the mandible, and anterior and lateral alveolar process associated with a soft tissue mass (). Numerous cervical and submental lymphadenopathy was noted. Excisional tissue biopsy and, culture and sensitivity of the soft tissue as well as the mandible showed a heavy growth of Streptococcus oralis, and Enterococcus within chronic granulation tissue. The impression at that time was of chronic osteomyelitis of the mandible. He subsequently developed pain in the occipital region and thoracic spine. However, plain radiographs of these sites were normal.
In view of the poor response to various courses of antibiotic treatment and progressive bone pain, radionuclide bone scintigraphy (99mTC MDP) was performed. This revealed intense radiotracer uptake in multiple sites in the mandible, manubrium sterni , the upper thoracic and the skull vault (). At this point, a differential diagnoses of multifocal metastases, Langerhans Histiocytosis and skeletal lymphoma was made. CT scan of the thorax and abdomen showed no internal organ involvement or abdominal lymphadenopathy.

[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 27-year old, obese Somali gentleman was admitted with a history of acute onset of hallucinations and delirious behaviour. He was found by his relatives with suspected olanzapine overdose and had been on the floor for more than two days. He had a past history of depression and psychosis for which he was on this medication. The patient also had a longstanding history of "Khat" abuse (a flowering plant with amphetamine-like effects). On admission, he was noted to be disorientated and confused. He was afebrile, tachycardic and had a blood pressure of 110/70. His oxygen saturations were normal. Cardiovascular, respiratory, abdominal and neurological examinations were unremarkable. There were no signs of meningism.
Blood tests revealed no significant abnormalities apart from elevated Creatine Kinase of 4,800 u/l, which was presumed to be due to rhabdomyolysis secondary to lying on the floor for a prolonged period. Arterial blood gases and chest X-RAY were normal, whilst his ECG showed sinus tachycardia. A CT scan of his brain did not reveal any abnormalities. Urine dipstick showed no evidence of a urinary tract infection. Serial ECGs showed the development of widespread flattened T waves and right axis deviation. A CT pulmonary angiogram was performed 48 hours after admission and revealed extensive pulmonary thrombo-embolic disease and right lower lobe consolidation.
• Cardiac event
• Drug-induced arrhythmia
• Pulmonary embolus
• Lower respiratory tract infection
He was started on intravenous antibiotics for possible aspiration pneumonia and anticoagulation for pulmonary embolism.
He was subsequently reviewed by the psychiatrists and admitted to storing 90 olanzapine tablets and taking these with a clear suicidal intent following a severe depressive episode. He denied having taken any other medications and no other empty packaging was found, apart from that of his olanzapine tablets. Following medical treatment for the pulmonary embolus and lower respiratory tract infec

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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 40-year-old lady with an underlying systemic lupus erythematosus and lupus nephritis since 2002 currently under control with oral prednisolone 10 mg once daily, oral azathioprine 50 mg once daily, and oral hydroxychloroquine 250 mg twice daily presented to the emergency department with a low-grade fever and multiple episodes of vomiting and watery diarrhea for the past 3 days. There was no joint pain, no alopecia, no rash, no oral ulcers, and no heart failure symptoms. On physical examinations, she was febrile with the temperature of 38.2°C and mildly dehydrated, but otherwise comfortable, not tachypneic, and not in distress. Her blood pressure was 128/86 mmHg, and her pulse rate was 110 beats per minute. Her abdomen was soft, not tender, and no palpable organomegaly. Examination of the cardiorespiratory and neurological system was also revealed no abnormal finding. Initial blood investigation was done (as shown in Table ). Her white blood cells and C-reactive protein (CRP) were elevated, and there was mild hypoalbuminemia, acute kidney injury, and minimal proteinuria. She was treated as infective acute gastroenteritis with mild degree of acute kidney injury secondary to dehydration and was started on intravenous (IV) ceftriaxone 2 gm once daily. She was also given four pints of IV 0.9% saline over 24 h. In view of the presence of proteinuria, early reactivation of lupus nephritis was suspected. She was given IV hydrocortisone 200 mg three times a day (total dose of 600 mg per day). The oral prednisolone was withheld, while her oral azathioprine and oral hydroxychloroquine were continued. Shortly after the first dose of IV hydrocortisone, she developed severe sinus bradycardia with the heart rate of 30–40 beats per minute. Her blood pressure was 140/70 mmHg. Electrocardiogram (ECG) which was done immediately showed sinus bradycardia with the heart rate of 30 beats per minute, partial right bundle branch blocked, and no evidence of coronary ischemia (as shown in

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

[User]
RADIOLOGY NOTE:
A 32-year-old female was referred to our center with acute visual deterioration in the right eye following right-sided frontal headache and retrobulbar pain. Physical examination as well as family and personal history were normal, except for a single episode of iridocyclitis well treated with corticosteroids 5 years earlier. There was no history of trauma or drug intake, and she was a nonalcoholic and a nonsmoker. The visual loss was nonprogressive and there was no history of color desaturation; neither did she have pain with ocular movements.
Complete blood work, sedimentation rate, and urinalysis were performed, and all results were normal. Best corrected visual acuity at the first visit in the right eye was 6/10. No afferent pupillary defect was present. Extraocular muscle movements were full in both eyes. At slit lamp examination the anterior segment was normal and the intraocular pressure was 16 mm Hg. At fundus examination the patient presented a unilateral swollen optic disc in the right eye (Fig. ).
A standard automated perimetry (Humphrey 24-2) was performed which showed no field defect in both eyes. We suggested computed tomography (CT) without contrast of the paranasal sinuses to identify the cause of pressure on the right optic nerve. It showed enlarged and inflamed sinuses as well as an anatomical peculiarity: in the axial and coronal CT scans (Fig. ) we found the optic nerve to run through the inflamed sphenoidal sinus rather than simply adjacent to it, a condition associated with partial dehiscence of the optic nerve, which translates into a greater exposure to inflammation of the nerve. The patient was started on systemic steroids therapy for 1 week (aerosol therapy with N-acetylcysteine and budesonide). At 1-month follow-up her vision had improved from 6/10 to 9/10, contrast and color sensibility were normal, the pupils were equal and reacting to light, and ocular movements were normal as well. However, fundus examination was still abnormal,

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old female presented to the oral and maxillofacial department with gradual onset of right cheek swelling around the right gingival and a painful mass for about 1 month. Physical examination showed hard cheek swelling () and epiphora of the right eye, but the patient's eye movement was normal and she did not have any double vision. The skin around the right eyelids was regular and not reddish, whereas the right posterior alveolar gingival was ulceration (2 × 2) cm, irregular, and reddish in areas (). No history of nasal bleed, nasal congestion, and pus from ears. Clinically the patient had an enlarged right submandibular lymph node measuring approximately 3 cm in diameter. The patient was admitted, and imaging studies were performed.
Computed tomography (CT) scan of head showed a large mass measuring approximately 6 cm in diameter in the right maxillary sinus invading the right orbit, ethmoid sinus, and the skin of the cheek (Figures and ). Histologic examination of biopsy sample stained sections showed mucosal tissue bits with features suggestive of poorly differentiated squamous cell carcinoma/neuro-endocrine carcinoma and immunohistochemistry was advised for further evaluation. Immunohistochemical staining was performed on the formalin-fixed, paraffin-embedded tissue sections. The tumor cells were positive for synaptophysin and cytokeratin and negative for neuron specific enolase. These histologic () and immunophenotypic features were characteristic of SNEC, and clinical findings supported the diagnosis of small cell undifferentiated neuroendocrine carcinoma of right maxillary sinus. An extensive search for a primary lesion elsewhere was performed; however, findings from whole body CT imaging, urinary amine secretions, and sputum cytology were unremarkable.
This case was discussed with consulting medical and radiation oncologists and planned for combination of chemotherapy followed by radiotherapy. The patient was treated with 3 cycles of induction chemo

[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 66-year-old African American female with a past medical history of refractory immunoglobulin G (IgG) lambda MM, essential hypertension, and chronic kidney disease presented to the emergency department with five days of right upper quadrant pain.
Her MM was diagnosed one year prior when she presented with altered mental status, uremia, hypercalcemia, hypoalbuminemia, and paraproteinemia. A skeletal survey at that time revealed multiple thoracic spinal lytic lesions and an eroding soft tissue mass at the level of T10. Further evaluation revealed a very high IgG level, elevated M protein band, and a kappa/lambda ratio <0.01 (normal 0.26-1.65). A biopsy from the soft tissue mass revealed a plasmacytoma. Radiation therapy was initiated for 10 days. She received three cycles of bortezomib and dexamethasone followed by two cycles of bortezomib, dexamethasone, and lenalidomide. Her disease progressed, and a subsequent bone marrow biopsy revealed hypercellular bone marrow with 70% atypical plasma cells. The patient subsequently received seven cycles of carfilzomib, lenalidomide, and dexamethasone. She was not a candidate for bone marrow transplantation given the high plasma cell burden.
On her current presentation, the pain was sudden in onset, intermittent, worse with eating, and without radiation. The pain was associated with nausea and anorexia, but she was without any change in bowel habits. She denied any previous similar episodes. Upon physical exam, the patient was in distress but remained alert and oriented. Her vital signs were all stable. She exhibited right upper quadrant abdominal tenderness without rebound or guarding. Her initial labs are presented in Table . The patient was admitted to the hospital for further evaluation of her abnormal labs and supportive treatment.
The patient was started on intravenous hydration and was made nil per os. An abdominal ultrasound revealed a distended GB with sludge (Figure ). The GB wall was thickened up to 9.5 mm, and the s

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old male was referred to an otolaryngology at a general hospital in August 2003, because he became aware of a painless mass in the dorsal tongue before two weeks ago. The mass was a hard, smooth and 7 mm diameter, and was resected with narrow safety margin as diagnosis of a benign mesenchymal tumor. The histological diagnosis was chondromyxoid tumor, which is unusual, but that was not finally confirmed. After 4 years, he noticed a painless, mass gradually increasing in the same part, and consulted our oral and maxillofacial surgery clinic in January 2007.
The patient was healthy, with no family history of similar symptoms. The mobile pedunclated mass located at the center of the dorsum of tongue. The mass about 20 mm in diameter was firm in consistency, and had reddish and lobulated surface (Figure A). Ultrasonographic findings revealed a soft tissue mass in the tongue, which was 20 × 18 × 10 mm in size (Figure B). An incisional biopsy was performed based on the initial clinical diagnosis of soft tissue tumor of the tongue, and histological findings suggested a benign mesenchymal tumor as a possible diagnosis.
Under general anesthesia, the tumor was extirpated with a safety margin of about 3 mm. Macroscopically, the tumor was solid and lobular with a grayish white cut surface, and measured 20 mm at the greatest diameter (Figure C). Histologically, the tumor was located in subepithelial connective tissue and proliferated in a multinodular fashion (Figure A). The mass was relatively well circumscribed but not encapsulated. It was composed of solid and lobular proliferation of uniform short spindle or ovoid cells with vesicular nuclei and indistinct small amounts of eosinophilic or vacuolated cytoplasm (Figure B). In most areas, the tumor cells were closely packed and showed high cellularity. In some small areas, they were arranged in a diffuse haphazard or sheet-like fashion with an alc

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


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

[User]
RADIOLOGY NOTE:
An 8-month-old female infant had coronary reimplantation at age 3 months for ALCAPA. Postsurgical ejection fraction showed early improvement with subsequent deterioration. A diagnostic left heart catheterization performed as part of a heart transplant evaluation revealed severe ostial stenosis of the LMCA. She was referred for PCI of the left main coronary artery to relieve her heart failure and preempt transplant. Her physical exam was significant for congestive heart failure and failure to thrive. The patient's echocardiogram showed markedly depressed left ventricular function. A cardiac computed tomography angiography (CTA) and initial diagnostic nonselective root aortogram demonstrated stenosis of the LMCA at the site of ALCAPA reimplantation. Selective left coronary angiogram revealed severe kinking of the reimplanted LMCA at the ostium ().
The procedure was performed in the Pediatric Cardiology interventional suite after extensive discussion and planning with Pediatric and Adult Interventional Cardiology, Pediatric Cardiac Anesthesia, Pediatric Cardiothoracic Surgery, and Pediatric Cardiac Radiology. General anesthesia and a femoral arterial approach were utilized. An ascending aortic root angiogram was obtained in 2 planes to assess the ostial left main stenosis. Due to the small size of the infant aorta, a 6 Fr JR-4 guide was reshaped to engage the left main coronary artery. A BMW wire was used to cross the lesion. Since the infant left main coronary artery was small but was expected to grow with age, a somewhat larger (3.0 × 8 mm Vision bare metal) stent was carefully implanted in the proximal LMCA at less than nominal pressure to avoid distal dissection. A poststent angiogram showed that the stent had moved during implantation and missed the ostium with residual stenosis of the LMCA origin. Hence, a 3.5 × 8 mm Vision bare metal stent was placed into the LMCA ostium overlapping with the previous stent distally and protruding 1-2 millimeters in the aorta pro

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old man presented with a flu-like syndrome and right neck swelling. Fine-needle aspiration of the right neck mass revealed squamous cell carcinoma, and a CT scan of the head and neck revealed an enlarged right jugulodigastric lymph node (2.9 × 2.5 cm). A CT scan of the chest showed mediastinal and bilateral hilar lymphadenopathy with bilateral interstitial nodular opacities in the upper lobes. A diagnostic PET scan showed the right jugulodigastric node to have a standardized uptake value (SUV) of 5.98 with bilateral oropharyngeal radiotracer activity. Surprisingly, radiotracer uptake in the oropharynx was higher in the left tonsil compared to the right. The patient underwent two rounds of panendoscopy with biopsies which revealed, respectively, mild dysplasia of the right tonsil and a friable and nodular inferior border of the right tonsil containing carcinoma in situ. Diagnostic right tonsillectomy showed extensive squamous cell carcinoma in situ with a high suspicion of invasion. The left tonsil was specifically noted to be clinically unremarkable.
A repeat PET/CT was performed for the purposes of radiotherapy planning and this study confirmed the presence of a 3 cm right neck level II lymph node with an SUV of 7.3, with central necrosis (). A diagnostic head and neck contrast-enhanced CT was included as part of the PET/CT study, as is our institutional practice and review of the CT elicited concern for extracapsular spread. FDG-avidity was again noted bilaterally in the oropharynx, with the intact left tonsil showing a maximum SUV of 8.7 as compared to maximum SUV of 6.6 in the tonsillar bed on the right (). However, the left tonsil was noted to be unusually bulky and irregular on the CT portion of the imaging study (). The PET/CT also demonstrated mild, symmetric FDG avidity in the mediastinal and hilar regions, which was considered more consistent with an inflammatory rather than neoplastic process,

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 77-year-old woman who presented to the ER complaining of subacute onset of rapidly evolving skin lesions. Past medical history was remarkable for locally advanced right breast infiltrating lobular carcinoma, with a primary mass measuring up to 10 cm (cT3) and positive lymph node involvement (N3 for ipsilateral supraclavicular nodes). Pathology revealed 100% estrogen receptor expression and negative Her2 amplification with histological characteristics of the luminal A phenotype. Given the non-resectable nature of a locally advanced tumor, the patient was started on ribociclib and letrozol, which were started 4 months prior to the onset of the chief complaint. The patient was not taking any other medication.
At the first examination 3 weeks prior to the clinical development, the patient reported a new onset of symmetric erythematous plaques along the extensor surface of both upper limbs with further development of tender and brittle lesions with spontaneous sloughing and bleeding. At that time, skin biopsies were obtained, and the patient was put on topical corticosteroids and discharged home. At the time of the next examination, the skin lesions had rapidly relapsed during the past 72 hours and involved the face and lips, both upper and lower limbs, the chest, the back, and the gluteal and perianal regions. She reported a fever of up to 38.8°C and intense pain associated with the skin blisters. She also reported mouth pain and dysphagia. She denied herpetiform lesions prior to the onset of symptoms. No use of new medications or other substances was reported.
On physical examination, the patient was clearly experiencing pain and discomfort. She had coalescing erythematous maculae, some of which presented with central purpuric lesions along the whole back area and chest, as well as symmetric and bilaterally evolving lesions on both upper and lower limbs (). The scalp, palms, and soles seemed to have been spared. Tender and disrupted lesions wit

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


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

[User]
RADIOLOGY NOTE:
A 67-year old right-hand-dominant male was referred to our plastic surgery department with a 3 year history of a swelling on his right middle fingertip with no prior history of trauma to the digit. The mass had been slowly enlarging over the preceding 3–4 months, was becoming increasingly tender and occasionally bled due to a superficial abrasion on the surface. The patient had a past medical history of Grave’s disease, atrial fibrillation and a perforated gastric ulcer.
Examination revealed a 2 × 1.5cm mass over the distal pulp and hyponychium of the right middle finger. The swelling was mildly tender and there was an area of superficial ulceration centrally (). The digit was neurovascularly intact with normal range of motion and no evidence of local erythema, inflammation or discolouration. The working differential diagnosis following initial consultation included glomus tumour, ganglion cyst and haemangioma, thus the patient was booked for surgery without prior imaging.
One month following referral, the patient underwent excision biopsy of the lesion which was not found to be communicating with bone, nerve or tendon and the intra-operative impression was that of a ganglion cyst (). The initial histopathology examination reported a circumscribed multinodular predominantly solid tumour () ulcerating the overlying epidermis. There were focal papillary projections with tubular/ductal structures () where ducts were lined by a double layer of epithelium consisting of inner cuboidal cells and an outer myoepithelial layer (). There was also evidence of lymphovascular invasion (), focally high mitotic activity () and the tumour was shown to abut the margins. Immunohistochemistry was performed () confirming a myoepithelial cell population expressing smooth muscle actin, calponin, D2-40 () and p63 (). The tumour was classified as digital papillary adenocarcinoma. The histopathology sections were sent to an external institution for expert opinion and the diagnosis affirmed w

[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.