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

[User]
RADIOLOGY NOTE:
A 71-year-old man was referred to our outpatient clinic for echocardiography with symptoms of decreased exercise tolerance, exertional dyspnoea and angina pectoris. Relevant medical history reports fractional flow reserve-guided (0.78) percutaneous coronary intervention (PCI) of the right coronary artery (RCA) in 2015 due to stable angina pectoris. Angina pectoris persisted during follow-up and coronary angiography was repeated in 2016. The stent was patent with no new significant coronary artery disease. The last echocardiography performed in 2017 described mild aortic stenosis, left ventricular hypertrophy and a restrictive diastolic function. The diagnosis microvascular coronary artery disease was suspected. Treatment with calcium-antagonists was initiated with moderate improvement in symptoms. At the time of referral the patient used metoprolol 50 mg once daily, amlodipine 5 mg once daily, nitroglycerine plaster 5 mg/24 h once daily, and acetylsalicylic acid 80 mg once daily.
The patient reported a significant decline in his ability to exercise. The patient used to cycle more than 15 000 km a year but is currently only able to cycle short distances using electrical support.
Physical examination revealed a man of average stature (body mass index 24 kg/m2) with a blood pressure of 133/75 mmHg and a pulse of 57 b.p.m. A systolic murmur (Grade II/VI) was heard at the right second intercostal space. Further physical examination revealed no further abnormalities.
The electrocardiogram showed sinus rhythm 57 b.p.m., normal electrical axis, first degree atrioventricular block, QRS duration of 94 ms, low voltage in the limb leads and pseudo-infarct pattern in the precordial leads. Compared to the previous electrocardiograms low voltage in the limb leads were progressive (). Although the first electrocardiogram from 2016 does not meet the criteria for low voltage in the limb leads, it is disproportionally low compared with the amount of left ventricular hypertrophy on the

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


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

[User]
RADIOLOGY NOTE:
The patient was a 28-year-old man with a huge, necrotic, erythematous inflamed lesion on the glabella, nasal dorsum and paranasal area. On physical exam, the lesion was not tender or warm, did not have pulsation and the margins were vague. The patient first noticed the lesion when he was 9 years old. At the beginning, it had been an erythematous lesion in the nasal area which enlarged over time and used to bleed with patient’s manipulation (). No concomitant vascular lesion or family history of arterio-venous malformation was found. The patient did not receive any treatment until 20 years of age, when he was visited in another center and undergone sclerotherapy by bleomycin, after which he says the lesion enlarged.
At age 28, he was visited in our center (). MRI and CT-scan was performed which revealed a soft tissue mass without bone or cartilage involvement. CT-angiography showed a high-flow vascular lesion. Color Doppler reported a vascular lesion with dilated vessels. Stage 1: A size 90 tissue expander was inserted in the forehead area. Supratrochlear artery was identified by color Doppler and included in the flap region. Expansion was done for 10 weeks until the desired size was achieved ().
Stage 2: Embolization was done to reduce the size of the lesion and the risk of bleeding. However, no obvious change in the size, color or consistency of the lesion was noticed. Stage 3: After 48 hours the lesion was excised. Before excision, two rows of deep sutures were applied around the lesion to reduce the risk of bleeding. The feeding vessels of AVM were ligated and the lesion was completely excised off the bone and cartilage and the wound was left open ( and ).
Stage 4: After another 48 hours the patient was taken to the operating room again. The wound was irrigated. An extended forehead flap on the base of supratrochlear artery was designed and rotated to

[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 49-year-old African American woman presented with shortness of breath, who was discharged from the other hospital one week earlier with the diagnosis of acute exacerbation of CHF. Patient was given oral furosemide and carvedilol at discharge, however, she admitted to losing her prescription for carvedilol resulting in her not taking it since discharge. She exhibited bilateral leg edema on examination without crackles or jugular venous distention. Brain natriuretic peptide was elevated to 1330 pg/mL. Chest radiograph demonstrated cardiomegaly with minimal interstitial edema. Echocardiography from the other hospital showed an ejection fraction (EF) of 50%, pulmonary arterial pressure (PAP) of 56 mmHg, and normal left ventricular diastolic filling. Recurrent exacerbation of CHF secondary to idiopathic pulmonary arterial hypertension (PAH) triggered by medication noncompliance was initially diagnosed, and the patient was started on intravenous furosemide. However, no clinical improvement was noted with no reasonable urine output. The medical team doubted the diagnosis of CHF exacerbation and started to do more thorough history taking and a comprehensive physical examination.
The patient had a history of breast cancer and underwent left lumpectomy followed by 4 cycles of chemotherapy using docetaxel/cyclophosphamide and radiation therapy about a year ago. She was given 134 mg of docetaxel and 1,074 mg of cyclophosphamide on a monthly basis. On repeat examination, she demonstrated diffuse thickening/sclerosis of bilateral hands that crossed metacarpophalangeal joints extending up to bilateral proximal upper extremities (). Extensive sclerosis of skin and subcutaneous tissue of anterior chest wall and the left breast were also noted. Patient endorsed that she started to have pain and stiffness of both hands right after she finished the last cycle of chemotherapy. Echocardiography before the chemotherapy showed EF of 55%, PAP of 26 mmHg, and normal left ventricular (LV) d

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old right-hand-dominant male tennis player visited our hospital complaining of pain in the anterior aspect of the right shoulder. Four years before his visit, he had experienced sudden acute pain in the anterior aspect of the right shoulder while executing a forehand stroke. Before the injury, the patient, who was a member of a tennis club at his junior high school and a private tennis club, allowed himself only 1 day of rest each month. Despite the pain, the subject continued to participate in competitive tennis for 4 years and experienced the pain especially during the follow-through phase. The pain increased gradually. One month before his visit to our hospital, he was examined by his family doctor, who advised him to rest his shoulder. However, the pain in his right shoulder persisted even while performing daily activities. Hence, he was then referred to our hospital.
Physical examination revealed tenderness at the lesser tuberosity, with exacerbation of pain by horizontal adduction and/or by internal rotation during the elevation of the humerus. Clinical evaluation of the rotator cuff muscles revealed full muscle strength of the supraspinatus and external rotator muscles. The result of the lift-off test was negative for the subscapularis tendon. The range of motion of the right and left shoulders did not exhibit any differences in forward elevation and external rotation. The range of motion in internal rotation with the arm at the side, internal and external rotations with the arm abducted at 90 degrees, internal rotation with the arm at a 90 degrees flexion, and horizontal flexion were 60, 50, 100, 20, and 100 degrees, respectively. The patient showed negative results for joint laxity test. The results of joint instability tests, such as anterior apprehension and posterior jerk tests, were negative. The results of forced horizontal flexion test was positive. Moreover, the preoperative University of California, Los Angels (UCLA) score was 25.
Plain ra

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old male with severe MPS VI was referred due to a progressive reduction in mouth opening. The trismus was first noticed at laryngoscopy 2 years previously, and subsequent intubations for ophthalmic surgery had become increasingly difficult. Although he presented with typical MPS morphology, he was less affected than his older sibling, a difference attributed to treatment with enzyme replacement therapy from 8 weeks of age [].
On examination, the patient’s maximal inter-incisal distance was only 8 mm (). A CT scan confirmed marked coronoid hyperplasia bilaterally, and the thickened anterior borders of the rami created concave surfaces on the superolateral aspect of the mandible (). The condyles appeared hypoplastic although otherwise fully functional and non-ankylosed, and the superior aspect of the coronoid processes deviated laterally, curving over the superior aspect of the zygomatic arch on both sides. (). In addition, exophytic bone deposits had formed on the medial aspect of the zygomatic arches suggestive of either benign exostosis or reactive hyperplasia ().
The indications for surgery included difficulties with daily activities, as well as the projected likelihood of regular intubations and further surgery in the near future. The patient subsequently underwent bilateral coronoidectomies and removal of the zygomatic arch exostoses under general anaesthesia. Due to the predicted difficulty with direct laryngoscopy, a fibre-optic technique was used. Due to the young age of the patient, anaesthesia was induced by a mask, and a fibre-optic bronchoscope was placed through the nose and positioned in the trachea. An endotracheal tube was then guided over the bronchoscope, and the subsequent general anaesthesia was uneventful.
As expected, the lateral concavity of the mandible limited intra-oral access to the sigmoid notches, and a bicoronal flap was raised. Osteotomy and lateral reflection of the right zygomatic arch were required for access to divide the

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old woman presented for evaluation of difficulty swallowing and epigastric pain. Her medical and familial histories were unremarkable. Upper gastrointestinal endoscopy showed a smooth elevated lesion located 19 to 24 cm from the incisor teeth (Fig. ). Endoscopic ultrasonography showed a large tumor mass of low echogenicity in the esophageal wall. The tumor mass originated in the muscle layer, and we performed a boring biopsy of the tumor mass. However, we were unable to obtain a tissue specimen from the tumor.
A chest enhanced computed tomography (CT) scan revealed a tumor mass (39 × 28 × 56 mm) at the upper thoracic esophagus with internal heterogeneity. No metastasis to the lymph nodes or other organs was seen on the CT scan (Fig. ). FDG-PET CT showed a hypermetabolic appearance matching the tumor mass. The maximum standardized uptake value (max SUV) was 5.5 (Fig. ).
Magnetic resonance imaging of the chest revealed that the boundary of the tumor was clear and smooth. The mass exhibited isointensity or low intensity compared with the muscles on T1-weighted images and high intensity on T2-weighted images. There was no invasion into the surrounding tissue.
We performed endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) with the patient under general anesthesia. Because the specimen was small, we were unable to establish a definitive diagnosis. We suspected an esophageal schwannoma, leiomyoma, or gastrointestinal stromal tumor (GIST).
The patient underwent surgery because of her difficulty swallowing and our suspicion of malignant potential. We performed thoracoscopic surgery with the patient under general anesthesia and single-lung ventilation.
First, we attempted enucleation of the tumor. However, the mass was larger than 5 cm, and enucleation was difficult without creating an extensive defect of the esophageal wall. Therefore, subtotal esophagectomy was performed with thoracoscopic assistance.
The resected specimen measured 55 × 45 × 24

[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 43-year-old woman with a prior history of an enterocutaneous fistula, who had required multiple abdominal surgeries, including bowel resections and prior pulmonary embolism, presented to the emergency department with recurrent enterocutaneous fistula and synchronous acute pulmonary embolism. CT scan of the abdomen and pelvis on admission demonstrated rotation and mild inferior displacement of the right kidney, with the long axis of the kidney lying in the horizontal plane [Figure and ]. This was a new finding compared with multiple prior CT scans available within the last 2 years in which the kidneys were normally oriented parallel to the psoas muscles. Increased size of both the liver and right kidney was also identified. CT pulmonary angiography performed synchronously for syncope and pulmonary decompensation demonstrated a segmental pulmonary embolism and right heart strain,[] including reflux of contrast material into the inferior vena cava, interventricular septal bowing, enlarged main pulmonary artery (34 mm), and right ventricular dilatation (RV/LV ratio of 1.8) [Figure –]. The most recent CT scan done 45 days prior to this admission is shown in Figure and .
Follow-up imaging done after 10 days demonstrated normalization of the right kidney axis, position, and size, as well as decrease in hepatomegaly [Figure and ]. Calculation of liver and kidney volumes from CT scans done 45 days before presentation, on the day of admission, and 10 days following admission, using the method described by Dello et al.,[] is presented in . Repeat CT pulmonary angiogram [Figure and ] performed 10 days after presentation showed normalization of the thoracic changes including normal size of main pulmonary artery (25 mm) and normal right ventricular size (RV/LV ratio of 0.86). Nephroptosis,[] which is a condition in which the kidney descends more than two vertebral bodies (or >5 cm) during a position change from supine to upright, was excluded by ultrasound examination of the ri

[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 32-year-old female was admitted to the First Hospital of Jilin University of Changchun with a complaint of left elbow pain after a minor injury. Upon physical examination, obvious tenderness was observed at her left olecranon, but no soft tissue mass was palpated. The patient also mentioned mild discomfort lasting for 1 year prior to the visit.
Anteroposterior and lateral plain radiographs showed an expansile lytic lesion located in the left olecranon and extending into the subchondral region and the coronoid process. The lesion was well-defined without a sclerotic margin. Pseudoseptations were noted. Cortical breach was also identified in the dorsal aspect of the olecranon, suggesting a pathological fracture as a source of the pain. No periosteal reaction was observed []. Magnetic resonance imaging (MRI) showed no soft tissue extension [], but the tumor had broken through the subchondral bone and extended into the elbow joint. The chest radiograph and alkaline phosphatase and blood chemistry were normal.
The differential diagnosis included GCT of bone, solitary bone cyst, metastasis, and brown tumor of hyperparathyroidism. Based on the history and radiological findings, a benign lesion was highly suspected. A fine needle was positioned in the pathological fracture area along the operative incision after the administration of local anesthesia. A needle biopsy was then performed and a GCT of bone was identified by pathological section. In order to prevent local recurrence, en bloc resection surgery was proposed, but the patient refused. Thus, the patient was managed with intralesional curettage, allogeneic bone grafting, and plating. During the operation, incomplete fracture in the dorsal aspect of the olecranon was confirmed. The tumor had broken through the articular cartilage and extended into the elbow joint. Gross findings of the tumor indicated that it was soft in texture and yellow in color.
Histology revealed that the tumor was composed of mononuclear ovoid

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


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

[User]
RADIOLOGY NOTE:
This is a case report of a 30-year-old gravida 4 para 2 aborta 1 who initially presented to an outside hospital with complaint of a rash and was incidentally found to have a positive beta-human chorionic gonadotropin (beta-hCG). In further discussion with the patient, she reported a history of some crampy abdominal pain. Her obstetric history is significant for 1 prior miscarriage as well as 2 cesarean sections, indications were breech presentation and a subsequent planned repeat. She had no past medical history and no additional past surgical history. A first trimester ultrasound at an outside hospital revealed a low-lying embryo, after which she was transferred to our hospital for repeat ultrasound, shown in Fig. , and consultation on further management. Given temporality of this case from timing of this write up consent from the patient was not able to be obtained.
On presentation, physical exam was notable for a soft, non-tender gravid abdomen with a well-healed Pfannenstiel scar. Vital signs were within normal limits, with a heart rate of 92 bpm and blood pressure of 116/66 mm HG. Repeat ultrasound demonstrated a gestational sac with an embryo measuring 64 mm, corresponding to 13 weeks gestational age, that was implanted in the lower uterine segment likely within the cesarean section scar. There was no myometrium seen surrounding the sac. A magnetic resonance imaging (MRI) to further evaluate these findings was attempted, but the patient sustained an anxiety attack in the scanner and the exam was unable to be completed. She was admitted to the hospital with the diagnosis of cesarean scar pregnancy for inpatient observation to determine optimal management. Laboratory evaluation revealed a preoperative hematocrit of 41%, which downtrended to 34%. She was counseled regarding her options and given a pre-operative social work consult. Ultimately, she underwent a gravid hysterectomy. Estimated blood loss from the procedure was 50 cc and her post-operative course 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 57 year-old, right hand-dominant female sustained a right distal humerus fracture from a fall in mid-2009; her past medical history was significant for hypertension and depression. The patient underwent fracture fixation and collateral ligament repair at an outside institution. Due to persistent elbow pain and instability, revision collateral ligament repair was performed in late 2009. In early 2010, the patient underwent lateral collateral ligament reconstruction utilizing allograft tissue by her initial surgeon due to reported recurrent elbow instability.
Nine months after the ligament reconstruction procedure, the patient presented to our orthopaedic department with severe right elbow pain and instability (). She reported no specific history of recent trauma or infectious symptoms such as fever, chills, or other sites of infection. Given her age and functional status, the options of conservative management, interposition arthroplasty, or total elbow arthroplasty were discussed. Preoperative blood work consisting of a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) serum laboratory values was obtained and within a normal range. The patient proceeded with a long-stemmed cemented Coonrad-Morrey TEA (). Approximately 6 weeks later, in mid-2011, she developed a painless, persistent draining sinus from the posterior aspect of the elbow. The patient strongly desired to retain the elbow replacement and was agreeable to undergo a debridement procedure. Intraoperative cultures grew Candida parapsilosis, and she was subsequently placed on chronic fluconazole (). However, in late 2011, she required a resection arthroplasty after multiple debridements, a bushing exchange, and antimicrobial regimens failed to resolve the persistent draining sinus. At the time of resection, there was no evidence of implant loosening. The implant was replaced with an amphotericin, vancomycin, and tobramycin-impregnated cement spacer (Figures 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 62-year-old woman was referred to the emergency department in our hospital due to a body height fall. She was presented with severe pain in her left hip and the inability to walk. Her following examination revealed a 30-year-old femoral neck fracture. The option of treatment at that time was an arthrodesis of the left hip. Having presented with the history of trauma, we did not take into consideration a proximal femoral malignancy. However, Ungureanu et al. stated in their study that tumoral growths can be kept hidden under adipose tissue or local swelling located at the thigh level and they could appear concurrently with trauma . Therefore, the differential diagnosis was made using the patient history and the CT description given by the radiology specialist. A standard emergency anteroposterior radiograph revealed an intertrochanteric fracture, severe deformity of the left hip joint, and the migrated implants used for the arthrodesis (Fig. ). Computed tomography (CT) imaging of the left hip joint showed a displaced intertrochanteric fracture distal to the ankylosed hip joint, some artifacts due to the osteosynthesis material, and marked atrophy of the gluteus muscles (Fig. ). Due to the rarity of the pathology, several discussions with fellow surgeons were needed to establish what the best therapeutic option was. We decided to perform a surgery to remove the osteosynthesis material used for arthrodesis of the left hip and then perform the internal fixation using a locking plate and locked screws (Fig. ). The patient was positioned in dorsal decubitus; we used a lateral approach (a skin incision reaching approximately 5 cm proximal and 15 cm distal from what used to be the tip of the greater trochanter). Intraoperative passive mobilization of the limb was realized to outline some intraoperative anatomical landmarks. After initial hardware removal, normal femoral rotation was re-established and checked intraoperatively using the C-arm. A rigid secondary fixation 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:
An 83-year-old Caucasian female initially presented to the Dermatology clinic incidentally while accompanying her husband for his appointment. She presented with progressive centrofacial induration of several centimeters, in which she did not pay much attention to until it was pointed out by the dermatologist that her nose appeared quite vascular and large, and was found to be extremely hard on palpation. Although history was vague, she had noted that her nose appeared to develop a more vascular appearance over the past 12 months or longer. The patient had no previous history of skin cancer, however was also diagnosed with squamous cell carcinoma (SCC) in situ of the right cheek and basosquamous carcinoma via skin biopsy of the right upper forehead at the same time of her initial visit, and these were subsequently excised without consequence. She has fair skin with a history of multiple sunburns as a child and background of long-standing chronic sun exposure. She denied the past use of tanning beds. She had a past medical history of malignancy of the colon, long-standing hypertension, osteopenia, and atrial fibrillation.
On examination, the patient’s nose and perinasal area were noted to be extremely indurated with prominent telangiectasia. This would be certainly atypical for phymatous rosacea. Other than an indurated raised plaque and prominence of the border of the lesion extending beyond the left lateral nasal sidewall, there was no clear solitary nodule or plaque other than a grossly large and firm, telangiectatic nose. The induration extended beyond the borders of the nose up toward the medial canthi, laterally beyond the nasolabial folds, and then lowers onto the lip bilaterally, as roughly drawn in . No cervical or supraclavicular lymphadenopathy was detected on examination.
Three punch biopsies were taken from indurated areas of the left nasal sidewall, nasal bridge, and right nasolabial fold. Histopathology revealed features consistent with MAC and consist

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man presented to our Neurology Department with pain at the level of the right shoulder and right interscapular–vertebral region, with onset for about 6 months. In the last 30 days, the pain exacerbated and radiated in the anteromedial part of the arm and clavicular area. The patient also reported pain in the joints of the distal part of upper and lower limbs, especially in the small joints, which afterward became swollen.
The patient presented with a medical history of arterial hypertension for the last 10 years, treated with beta-blockers and sartans, and he was a heavy smoker (in the last period he used only electronic cigarettes).
The neurologic examination was normal, except for slightly diminished deep tendon reflexes of the lower limbs. The patient reported pain that did not correspond to any radicular or nerve territory, which was exacerbated by pressure on the distal third of radius and ulna, but was not related to active or passive movements of the cervical spine. The general examination showed clubbing of the fingers and toes (not mentioned initially by the patient, but present for about 1 year) with an increase of the shoe size of more than 1.5 sizes, enlargement of the large joints, swollen extremities with a tubular appearance (Figs. and ), a right lateral cervical mobile, painless adenopathy of 1 cm diameter, and pachydermia with thickening of the skin of the scalp, forehead, and fingers, with cranial skin folds.
Cervical magnetic resonance imaging performed in another clinic before the admission to our department showed the presence of disc protrusions from C2 to C7, with concomitant C2, C4, and C5 root compressions. The electrophysiological study revealed an active denervation in the territory of the right C5, C6, and C7 roots.
The radiographic examinations of the upper and lower limbs depicted symmetric osseous abnormalities, typical for periostosis, and linear halving of the diaphysis

[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 had abnormal X-ray findings during routine medical checkup and an enhanced computed tomography (CT) showed right aortic arch, Kommerell diverticulum (KD), and aberrant left subclavian artery (ALSA). The maximum diameter of KD was 38 mm, and the aneurysm of aorta was 63 mm (). CT revealed a 50% stenosis of the orifice of ALSA. Cerebral magnetic resonance imaging angiography showed hypoplasty of left vertebral artery. Operation was indicated because the diameter was critical, despite the fact that the patient had no symptoms due to KD.
After consideration of using 3D-CT imaging with the ribs (), it was decided to go for a posterolateral thoracotomy approach through a fourth inters costal incision.
All the aneurysm repairs were performed using hypothermic cardiopulmonary bypass and an interval of hypothermic circulatory arrest. Cardiopulmonary bypass was established with descending aortic cannulation and bicaval drainage. The left heart was vented through the right upper pulmonary vein. The right phrenic, vagus, and recurrent laryngeal nerves were identified and protected. After establishing circulatory arrest, the aorta was incised and transected proximally just distal to the orifice of the right subclavian artery. Descending aorta with KD was replaced using one branched graft for the reconstruction of ALSA. However ALSA was not able to be reconstructed anatomically and ligated because ALSA was too deep and difficult to make anastomosis. Rewarming was initiated after completion of the proximal graft to aorta anastomosis. Distal graft to aorta anastomosis was performed under descending aortic clamping and blood supplying from proximal anastomosed graft and descending aorta.
After operation, there were no symptoms of an ischemia of the left arm. The systolic blood pressure of the right arm and the left arm was 110 mmHg and 70 mmHg, respectively. Postoperative CT revealed enhanced ALSA clearly without delay, which was supplied with blood from many branc

[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 full-term 30-day-old girl born via normal vaginal delivery with no significant perinatal history developed increasing dyspnea, hoarseness, cyanosis with feeding, and lethargy. She was treated for respiratory syncytial virus (RSV) pneumonia and required supplemental oxygen and parenteral feeding. The feeding with cyanosis persisted after five days, prompting a visit to our hospital for a second opinion. Upon arrival, the patient had an oxygen saturation of 89% on room air and was admitted to the ward for further management. The oxygen saturation improved to 100% with supplemental oxygen. She was alert with no audible stridor at rest but had mild subcostal retractions. The heart and breath sounds were normal. Otolaryngology was consulted and bedside nasoendoscopy reviewed a left vocal fold paralysis. The right vocal fold was mobile and the glottic gap was three millimeters. The remainder of the scope findings was normal. There were no palpable neck masses, and thorough examination of the ears and oral cavity was normal as well. Chest X-ray showed mild air space consolidation at the right perihilar region and possibly the left retrocardiac region, likely related to underlying pneumonia. The patient was treated presumably for aspiration pneumonia and was weaned off supplemental oxygen after a few days.
To evaluate the unilateral vocal fold paralysis, a magnetic resonance imaging (MRI) scan was performed. This revealed a nonenhancing left carotid space mass measuring 2.4 × 1.5 × 1.3 cm (), with compression on the left internal jugular vein and displacement of the internal and external carotid arteries anteriorly. Ultrasound scan of the lesion showed multiple intralesional calcifications, a common finding seen in neuroblastoma [, ]. At this point, the main differential diagnosis was a cervical neuroblastoma; other differential diagnoses include nerve sheath tumors such as schwannoma or neurofibroma.
The patient underwent excision of the left neck mass. Intraoperatively,

[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 a 37 year old man of Indian ethnicity who had a thymectomy 16 years ago, in Oct 1989. He had presented with myasthenia gravis. Perioperatively the tumour was found to be adherent to the pericardium, left phrenic nerve, anterior chest wall and the left lung. A complete resection was reported and he did not receive chemotherapy or adjuvant radiotherapy at that time.
Apart from mild myasthenic symptoms managed with pyridostigmine, he had been well until early 2005 when he developed new left sided chest pain. CT scan of the thorax from March 2005 showed extensive involvement of the pleura on the left side with penetration of the diaphragm and invasion of the spleen (Masouka Stage IVA). The tumour was also wrapping around the aortic arch. He underwent an exploratory left thoracotomy in May 2005, but unfortunately surgical debulking was not possible and pleural biopsies were taken. The histology report was of a recurrent well differentiated thymic carcinoma (Fig. ).
Postoperatively he developed acute renal impairment and peripheral oedema. A renal biopsy in May 2005 confirmed minimal change nephropathy (Fig. ). His renal impairment may have also been made worse by a degree of acute tubular necrosis post-operatively. At this stage his serum creatinine was 172 umol/L with a creatine clearance of 42 ml/min and he had significant proteinuria of 24 g/L with a serum albumin of 15 g/L. His WHO performance status was 1. He was therefore started on prednisolone 40 mg daily as initial treatment for his nephrotic syndrome and was subsequently referred for chemotherapy.
Due to his renal dysfunction and proteinuria, he was initially commenced in June 2005 on epirubicin and cyclophosphamide (EC) chemotherapy at reduced doses of 37.5 mg/m2 and 300 mg/m2 respectively. Cycles were repeated every 3 weeks. 2nd and subsequent cycles were given at full doses of 70 mg/m2 and 600 mg/m2.
After 2

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old male patient was referred for treatment and follow-up in the cystinuric clinic.
Medical history included type 2 diabetes, hypertension, obesity (body mass index [BMI] 39.5), dyslipidemia, a heavy smoking background (three packs a day for 32 years), and a peripheral arterial disease that led to an internal right iliac artery graft placement 6 years ago. In 1994, cystinuria was diagnosed with a complicated kidney staghorn stone that led to a left nephrectomy.
Since then, multiple fURS sessions were performed.
The patient arrived at our urology department after being found to have a 3 cm pelvic stone with a Double-J catheter placed after two shockwave lithotripsy failed sessions (the last one was discontinued because of his overweight). At that time, his glomerular filtration rate was 59 mL/(min ·1.73 m2).
After treatment options were explained, an fURS session was planned and performed. The patient was placed in the LP as standard procedure. After 2 hours, the stone was completely dusted and a Double-J catheter was left in place. There were no intraoperative complications noted.
During the first hour in the recovery room, the patient developed severe pain in the right calf. Physical examination by a vascular surgeon showed muscle stiffness, edema, and increased volume; the patient did not tolerate external compression and had no sensory loss of or motor response failure.
Doppler ultrasound examination showed femoral, popliteal, and posterior tibial pulses. The vascular graft was permeable and the popliteal and posterior tibial arteries had adequate flow rates.
The patient was found to have a postreperfusion and compartment syndrome after suffering from an ischemic period because of prosthesis bending and collapsing in the LP. An urgent fasciotomy was performed to release the lower limb pressure. A double incision technique was done with two 15 cm incisions in the anterolateral and posteromedial areas of the calf muscle to decompress the anterior and late

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old man sustained a fall from 5 m while rock-climbing. He was transferred to the Emergency Department 1 hour after the accident. The patient sustained a pantalar dislocation with a > 10 cm sized transverse open wound on the medial aspect of the ankle (). He had no other major injuries. No distal neurovascular injury was detected. Initial radiographs showed complete absence of the talus and a tip fracture of both malleoli. The totally extruded talus was found on site but was severely contaminated with gravel, soil, and mud. It was immediately brought to the operating room. We had anticipated an inevitable avascular necrosis of the talus, as it was completely deprived of a blood supply; therefore, we planned to perform an initial subtalar fusion expecting revascularization from the calcaneus followed by ankle arthroplasty. The extruded talus was thoroughly washed and deep frozen. The talus was temporarily fixed using multiple Kirschner wires after massive wound debridement and irrigation because of the high risk for infection. Daily debridement and irrigation of the open wound was done for 3 days. A primary subtalar fusion was performed 4 days later, with reimplantation of the extruded talus and internal fixation with cannulated screws. Additional reduction and fixation of the fractured medial malleolus was performed (). Radiographs taken 6 months after the trauma, showed osteolysis on the distal tibial articular surface and loosening of the screws (). With suspicion of infection, curettage of the talar body was performed and an antibiotic impregnated cement spacer was inserted. However, the biopsy result revealed granulation tissue without significant neutrophil infiltration, with necrotic bone and marrow fibrosis. The culture reported no growth, and no abnormal laboratory findings were found. No infection was observed on follow-up evaluations. The ankle was fused using multiple screws, and a femoral head allograft was used to fill the talar defect 12 month

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 76-year-old lady with chronic obstructive pulmonary disease, peripheral vascular disease, and smoking as past medical history, presenting with 2 months of a nonproductive cough. The patient was found to have a left upper lobe nodule on a plain chest radiograph and further evaluation with a computed tomography (CT) of the chest delineating a 1.2 cm spiculated nodule (). Following a PET-CT that showed pathologic FDG uptake of the lesion, the patient underwent elective left thoracotomy with upper lobe lobectomy and mediastinal lymph node resection. Pathology showed a 1.5 × 0.6 cm papillary predominant adenocarcinoma with no lymph node metastases.
The immediate postoperative course was uncomplicated and the patient was transferred to the cardiothoracic unit for observation. Follow-up chest radiography on postoperative day-1 showed a small left lower lobe opacity with the patient complaining of mild pain at the surgical site. On postoperative day-2 the patient developed atrial fibrillation with rapid ventricular rate associated with hemoptysis and worsening left sided pleuritic chest pain. Plain chest radiography showed worsening left lung opacity with bronchial cutoff (). A CT of the chest revealed diffuse ground glass attenuation of the left lower lobe with proximal bronchial obliteration (). The patient underwent elective intubation to undergo flexible bronchoscopy that revealed a tight and obstructed orifice of the left lower lobe (). She was brought to the operating room emergently for high suspicion of lobar torsion, and a left thoracotomy showed a dark purple appearing lung (). Following detorsion the lung did not appear viable; however considering the patient's baseline marginal FEV1, 24 hours was given for the lung to recover. The patient showed no clinical improvement and underwent completion of left lung pneumonectomy the next day. Postoperative recovery was uneventful and patient was discharged after 7 days. The patient was seen in the outpat

[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 June 2015, a 43-year-old woman presented at another hospital with a swelling on the lateral side of the right knee, which clinically resembled a cyst of the lateral meniscus. A magnetic resonance imaging (MRI) scan revealed a cystic mass lying over the lateral meniscus, the femoral epiphysis and the tibial condyle. These findings seemed to be consistent with the clinical diagnosis of a cyst. For this reason, an arthroscopy was planned. A first attempt to decompress the cyst arthroscopically through a medial incision failed. The doctors then accessed the mass through a lateral incision and found that the formation had a solid consistency rather than fluid. Considering the macroscopic aspect of a malignant lesion, the tumor was enucleated and a drain was placed several centimeters below the lateral scar. The histopathologic examination demonstrated that the lesion was a high-grade pleomorphic sarcoma. In September 2015, the woman approached our tertiary referral center for musculoskeletal oncology, which boasts the presence of a multidisciplinary team. We planned the oncological re-excision on new computerized tomography (CT) scans to achieve wide healthy resection margins. The oncology–orthopedic surgeon performed the surgical re-excision, while the plastic surgeon harvested an adipo-cutaneous propeller flap based on a peroneal artery perforator at the middle third of the same leg. In addition, we used a random local flap harvested from the popliteal region to cover part of the donor site (–).
The histopathologic examination demonstrated the complete resection of the tumor with more than 3 cm cuff of healthy tissue. The patient spent 1 year and 9 months without significant complications after adjuvant radio- and chemotherapy. The woman underwent a trimestral follow-up until she suffered from a tibial plateau fracture in June 2017. The injury was treated by open reduction and internal fixation (ORIF) through the incision of the medial margin of the propeller flap.

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old woman had an invasive pancreatic neuroendocrine tumor removed by means of body and distal pancreatectomy, splenectomy, partial gastrectomy, and transversal colectomy. One-year later, multiple liver metastases were detected in both lobes. At that moment, she had chronic malnutrition despite adequate pancreatic enzyme supplementation and a Trousseau syndrome was also diagnosed. Chronic malnutrition was attributed to a combination of pancreatic insufficiency and a potential hormone-related paraneoplastic syndrome. Systemic chemotherapy with 5-fluorouracil and streptozotocin followed by transarterial bland embolization were performed, and an objective durable remission was achieved. Seven years later, liver progression was detected, restricted mostly to the right lobe. Her performance status was ECOG 1 but she had a BMI of 13.7 kg/m2 due to worsened chronic malnutrition. A left pleural effusion was also observed but no malignant cells were detected on fluid cytology. A right-lobe transarterial radioembolization (TARE) was uneventfully performed. The lung shunt fraction in the macroaggregated albumin scan performed during the TARE workup was 6.4%. The response to TARE was short lived and 9 months later liver disease progressed. The multidisciplinary team recommendation was to start Sorafenib as a special indication under informed consent instead of Sunitinib due to her profound asthenia. The dose used was progressively increased from 400 mg to 600 mg daily with good tolerability and no side effects. Two months later a thoracic CT showed a small pleural effusion in left side and ground glass in left lower lobe. Four months after initiating Sorafenib an abdominal and thoracic CT showed a lung cavity in the left upper lobe (Figure ). The patient had no respiratory symptoms.
A bronchoscopy was performed with no macroscopic findings. No malignant cells were observed on cytology of a bronchioalveolar lavage (BAL) and microbiologic cultures were negative. Sorafeni

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old woman who had been treated for hypertension for several years, with visual impairment due to retinopathy and left hemiparesis after ischemic stroke, was admitted to the cardiology department on an emergency basis because of a hypertensive crisis (RR 230/130 mmHg).
In the interview, the patient reported headaches, dyspnea at rest, decreased tolerance of physical effort and pain on the left side of the body (from the scapula and chest, to the left subcostal region). She denied typical exercise-induced angina or syncopes. The ECG did not record features of myocardial ischemia. Echocardiography showed no left ventricular systolic dysfunction and the EF was 55%; however, hypertensive myocardial damage was observed in the form of left ventricular diastolic dysfunction, ventricular septal hypertrophy and left atrial enlargement.
According to the medical records provided, the patient had been hospitalized repeatedly due to resistant hypertension. She was admitted to hospital for the first time in December 2012 to a neurological ward due to cerebral ischemic stroke complicated by left hemiparesis. Despite being given combination antihypertensive treatment, normalization of blood pressure was not achieved. The patient was then referred to a department of internal medicine, where a broad assessment of secondary causes of hypertension was performed, including thoracic aorta angio-CT (radiological features of aortic dissection were excluded), abdominal CT (multiple vascularization of both kidneys was revealed) and hormone testing (blood levels of TSH, ACTH, cortisol and renin, and daily urinary excretion of methoxy-catecholamines and vanillylmandelic acid, were within normal limits). A polysomnographic study excluded the presence of a breathing disorder during sleep. In addition, the patient was assessed for complications of hypertension, and microalbuminuria was diagnosed. During hospitalization, antihypertensive therapy was repeatedly modified to obtain a reducti

[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 seven-year-old otherwise healthy female sustained bilateral elbow trauma after a fall with outstretched elbows and landing with force on the floor (kindergarten facility at the climbing frame).
The neurovascular status of both upper extremities was intact upon the arrival of the patient to the Trauma Unit. Clinical examination revealed loss of any active movement in both elbow joints in every plane. The joint was locked in a relatively extended position with the forearm neutral to a slightly supinated position. The patient had no sign of swelling or hematoma. Clinical suspicion was guided to a complex elbow injury, possibly with the participation of various bony structures.
A gross estimation of the patient's potential hyperlaxity was performed except for the elbow joints using the Beighton scale without significant clinical findings []. Neurovascular status of the upper limbs was thoroughly re-examined, but no sign of neural or vascular impairment or compromise was found.
Plain radiographs with standard projections (anteroposterior [AP] and lateral views) confirmed posterolateral elbow dislocation bilaterally with no signs of evident fractures. Identification of the bony structures was performed, and meticulous control and confirmation of the secondary ossification centers expected for the patient's age was done to exclude any secondary damage (Figures -).
In the emergency department, the upper limbs were immobilized in a provisional plaster with the elbows in a light hyperextension and neutral rotation of the forearms to reduce any movement and relieve the pain. The reduction was achieved under sedation in the operating theater and muscle relaxation with the patient in the beach chair position and with access to fluoroscopy during the whole procedure. The maneuver included gentle manipulation of the joints by slightly rotating, distracting and giving a flexion jerk to the joint. The audible and palpable "click" sign and the complete restoration of the arch of mo

[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 Malay woman with a medical history of diabetes mellitus, hypertension, and end-stage renal disease (ESRD) presented to the Plastic Surgery clinic of Singapore General Hospital for massive lymphedema of the left breast and arm in 2014; this condition caused her pain, affected her activities of daily living, and limited her mobility. She was wheelchair-bound due to the size and weight of her breast, and had a strained relationship with her spouse as she was embarrassed about her appearance.
She was diagnosed with ESRD in 1991 and had a left brachiocephalic (BC) arteriovenous fistula (AVF) created in 1993. She subsequently received a cadaveric renal transplant in 1998, which failed in 2008, and she was re-initiated on hemodialysis.
This patient presented to the clinic with unilateral breast and upper limb swelling in late 2007; this was investigated with an ultrasound and mammogram of her breasts, as well as lymphoscintigraphy of the left upper limb (). Her breast investigations were unremarkable, and lymphoscintigraphy showed persistent pooling of tracer at the injection site, consistent with lymphatic obstruction. No axillary nodes were visualized. Her BC AVF was hypertrophied with hyperdynamic flow and was thus ligated, with the simultaneous creation of a right radiocephalic AVF.
Magnetic resonance imaging of the left brachial plexus and chest in January 2008 revealed a left axillary vein thrombosis extending slightly to the left subclavian vein. A previous fistulogram in August 2007 had shown clear central veins, and there was no central vein cannulation in the period between the 2 investigations. She completed 3 months of oral anticoagulation therapy with warfarin, but her symptoms did not improve. Central venous angioplasty showed 80% stenosis in the left brachiocephalic vein at its junction with the right brachiocephalic vein and 90% stenosis in the right subclavian vein at its junction with the right brachiocephalic vein. This was reduced to 30% a

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male patient was brought by his parents to a genetics clinic with complaints of developmental delay and tremor. He was a full-term infant with an uneventful delivery. He started walking around 18 months of age, spoke his first words at the age of two. Other problems included nervousness, immature behaviors, lack of eye contact during conversations, and aggressive behavior. His mother reported that he began to have a tremor in the hands around three years of age. Diagnostic workup included magnetic resonance imaging (MRI) of the brain, urine organic and amino acids, lactate, pyruvate, and lead levels along with chromosomal and DNA analysis for fragile X which were all unremarkable. His family history was significant for mental retardation. Maternal grandmother had three mentally retarded brothers with tremors, two of whom died in their forties. The patient’s brother also seems to have a speech delay along with tremors since the age of three.
His tremors worsened gradually, and he started to have difficulties with fine motor control including difficulty with drinking out of a cup along with increased aggression and behavioral changes. His teachers reported that he was biting, kicking, spitting and getting into conflicts with other children. He was seen by a child psychiatrist at that time and was started on risperidone, valproic acid and Adderall (amphetamine and dextroamphetamine) which seemed to help with his behaviors.
On examination, he has high nasal bridge, slightly down-slanting palpebral fissures, long philtrum, and thin upper lip. On neurological exam, he has slightly increased deep tendon reflexes throughout. Babinski sign was positive on the right, but a normal plantar response was noted on the left side. Bilateral hand tremors were noted, both at rest and in action. He was walking slowly without much arm swing and had a slightly stooped forward posture. A full psychological evaluation was done which showed a Leiter scale IQ of

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old female patient presented to our clinic with complaints of reduced vision in her left eye. The patient reported that her symptoms of reduced vision in the left eye had started 6 months earlier and that she had sought treatment for the first time 1 week earlier at a private ophthalmology outpatient clinic, from which she was referred to our clinic. On ophthalmologic examination, her best corrected visual acuity (BCVA) was 10/10 (0.0 logMAR) in the right eye and 2/10 (0.7 logMAR) in the left eye. Slit-lamp examination revealed bilateral non-granulomatous keratic precipitates and 2+ flare which were more pronounced in the left eye. Fundus examination was normal in the right eye, while macular edema and +/++ vitritis were observed in the left eye, though there was no vitreous turbidity ( and ). Fluorescein angiography revealed extensive leakage from the vascular arcades in both optic discs and macular edema in the left eye (, , , and ). On optic coherence tomography (OCT), the right macula appeared normal, and severe cystoid macular edema was observed in the left eye ( and ). The patient had no known systemic disease, but it was learned that she had lost 10 kg in the last 6 months using an herbal drug, that she tired quickly, and had complaints of numbness in the soles of her feet for the past 1.5 months. Topical treatment was initiated with 1% prednisolone acetate every hour and 1% cyclopentolate HCl 3 times daily. The patient was admitted to our clinic for etiologic study and treatment. Dermatologic examination and tests performed for differential diagnosis of Behçet’s disease were normal; neurologic examination and tests revealed no pathologies other than Chiari malformation observed on brain magnetic resonance imaging (MRI). Diffusion brain MRI and orbital MRI were normal. Electromyography test revealed no pathology other than mild sensory neuropathy. Except for elevated sedimentation rate (48

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old woman presented with a massive painless lump on both of her thighs that had been enlarging for the past 6 months. The patient denied any history of trauma, manipulation, or injection around the lump before. She was otherwise healthy despite her lumps. However, she had a history of lymph node tuberculosis on her neck about 25 years before and underwent tuberculosis chemotherapy regiment for about six months.
On the local physical examination, we found a painless non-mobile distention on her gluteal and upper femoral region bilaterally with some fluctuation and cystic consistency on palpation of the mass. The initial largest diameter of her thigh was 60 cm on the left and 45 cm on the right. There was no signs of inflammation, sinus or fistula around her thighs and buttock, or any remarkable signs on physical examinations (). Laboratory examinations however, showed elevated level of ESR and CRP. Mantoux test were inconclusive due to previous infection of tuberculosis. Radiological examination showed no signs of abnormality besides the expanding soft tissue shadow especially on her left femur region.
MRI examinations were then performed over the lumbosacral and pelvis region. Sagittal T2 weighted MR images of the sacrum showed destruction on anterior lower sacral segments, with hyperintense anterior lesion and presacral abscess. Axial T2 weighted images confirmed sacral body destruction and extension of the hyperintense lesion that involved the insertion of piriformis muscle (a and b).
Pelvic axial fat-suppressed (FS) T2 weighted images gave another extended view of the lesion, showing lateral extension of the lesion over the posterior ilium that also extended to superior and inferior filling the gluteal compartment beneath the gluteus maximus and tensor fascia lata (c). Involvement of the piriformis muscle and gluteus medius were confirmed at the coronal FS-T2 images of proximal femur, in which there was a hyperintese bony lesion at the tip of greater tr

[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 reported to our institution with the chief complaint of painless progressive swelling in the anterior region of the maxillary jaw since one and a half year. The preliminary case history revealed that the patient had undergone surgical excision of a small swelling in the maxillary anterior region of the jaw 2 years back at a private hospital. On histopathological examination, the lesion was diagnosed as PsJOF. After one and a half years, the patient developed swelling in the same region, which was rapidly increasing in size. At the time the patient reported to our department, the lesion was of massive size. Elicited medical and family history did not reveal significant findings. Extra-orally, upon inspection, the swelling extended anteriorly up to the right canine region, posteriorly up to the left side zygomatic bone, superiorly up to left infraorbital margin and inferiorly up to the alveolus and measured 6x8 cm in size. The overlying skin appeared normal (). Palpatory findings revealed the swelling was hard in consistency and non-tender. On intra-oral inspection, a huge swelling extending from the maxillary right canine up to the maxillary left first molar obliterating the nasolabial fold with no visible secondary surface changes was noted (). On palpation, the swelling was hard in consistency, non-tender, and had no palpable pulsations. Tooth mobility was noted in relation to 21, 22, C, 11 and 12.
The orthopantomogram revealed a ground glass appearance with ill-defined borders over the anterior region of the maxilla extending to the left quadrant (). The maxillary central and lateral incisors showed displacement of the crowns as well as roots. Furthermore, the un-erupted maxillary right canine and left premolar showed evidence of displacement. The computed tomography scan showed an expansile lesion involving the alveolar arch of the left maxilla and extending into the pre-maxillary region and hard palate. The central lesional area showed

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


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

[User]
RADIOLOGY NOTE:
This is a case of a 53-year-old Filipino male with a past medical history significant for hypertension and diabetes mellitus, who presented with symptoms of melena, fatigue, and lightheadedness. He denied abdominal pain, nausea, vomiting, fevers, chills, anorexia, or weight loss. He otherwise had an excellent performance status and no family history of cancer. His physical exam was normal without any dominant palpable abdominal mass or leg edema to suggest venous congestion or thrombus. The laboratory workup was significant for a hemoglobin of 6.6 gm/dL for which he received a transfusion of six units of packed red blood cells. He underwent an esophagogastroduodenoscopy that showed a bleeding mass involving the second portion of the duodenum. Hemostasis was achieved and a biopsy was performed that was consistent with renal cell carcinoma. Subsequently, a computed tomography (CT) scan was performed and showed a large mass arising off the anterior cortex of the lower pole of the right kidney with brisk arterial and peripheral enhancement consistent with renal cell carcinoma. The dimensions of this mass were estimated to be approximately 10.1 cm by 8.0 cm by 10.0 cm, protruding into the lumen of the duodenum and displacing it medially (). Coronal reformatted images obtained of the portal venous phase demonstrated extension of the mass into the lumen of the inferior vena cava (). It appeared that the majority of the infrarenal IVC was displaced and compressed medially. Magnetic resonance imaging (MRI) confirmed the findings on CT scan, and a positron emission tomography (PET) scan was also performed, which demonstrated a large hypermetabolic mass involving the right kidney without evidence of regional metastasis. CT-guided imaging of the patient's chest revealed a cluster of pulmonary nodules and irregular opacities in the left upper lobe and right upper lobe that were hypermetabolic on PET scan and consistent with metastatic disease. The patient was evaluated in a mult

[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 twenty-five-year-old second gravida at 36 weeks of gestation was referred to our institution as a case of encephalocele with preeclampsia complicating pregnancy, for further management. The patient had regular antenatal visits and was diagnosed to have preeclampsia at 32 weeks of gestation. She was not on any medication. A target scan done at 19 weeks was said to be normal. On examination, her blood pressure was 140/90 mmHg. Systemic examination was normal. Obstetric examination revealed a single live fetus corresponding to thirty-six weeks in breech presentation. On ultrasound examination (Toshiba Nemio 10, curvilinear, 5 MHz probe), there was a fetus corresponding to 36 weeks in breech presentation with an amniotic fluid index of 14. There were two echogenic masses of 4 cm × 5 cm and 3 cm × 4 cm, arising from the placenta in close proximity with the occiput of the fetus (). One was cystic, and the other showed lobulation/septation. As there was no defect in the skull, encephalocele was considered to be less likely. Their attachment to other structures could not be traced. Gross fetal intracranial anatomy was normal. On Doppler ultrasound examination, there was minimal vascularity on the surface of the mass. Although magnetic resonance imagining (MRI) is the investigation of choice when an encephalocele is suspected, this investigation could not be done due to patients financial constraints. At thirty-eight weeks of gestation, the patient was posted for cesarean section for breech presentation, and a live male baby of 2.8 kg was delivered. There were no gross external deformities or anomalies in the neonate. The placenta measured 15 cm × 12 cm × 4 cm and weighed 250 grams. Maternal and fetal surfaces of the placenta were unremarkable. There were two masses attached to the membranes measuring 5.5 cm × 5 cm and 4 cm × 3 cm, respectively (). The first mass appeared lobulated. The second mass appeared cystic. Histopathological examination

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


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

[User]
RADIOLOGY NOTE:
A 56 year-old female was transported to the emergency department by EMS after physically threatening her husband with a knife. According to the patient, she experienced altered sensorium for one week prior to presentation, primarily resulting in suicidal and homicidal command hallucinations instructing her to overdose on NSAIDs and kill her husband. She denied any headaches, vertigo, fevers, head trauma, urinary symptoms, or use of illicit substances. There was no history of psychosis, schizophrenia, mania, or depression and a review of her medication list for any potential hallucinogenic agents did not indicate a pharmacologic etiology. Her past medical history was comprised of two prior strokes, the most recent being two years ago that involved the right frontal lobe. MRI of the brain at the time also showed evidence of an old right parietal lobe infarct. An echocardiogram during that hospitalization revealed a severely decreased left ventricular function and the patient was initiated on warfarin for anticoagulation. Since the two prior cerebral infarcts, the patient and her husband denied noting any behavioral changes, cognitive impairment, or any focal neurologic deficits. On presentation, she appeared disheveled and exhibited a flat affect with minimal verbalization. Physical examination revealed only a left hemianopia without hemiplegia. All cranial nerves were evaluated as well as gait, cerebellar function, and proprioception, which were all found to be normal. The patient was alert and oriented with intact mentation.
She was initially admitted to the psychiatric unit for further evaluation where the patient participated in daily activities and reported no symptoms. Given the acute onset of her symptoms, laboratory studies and brain images were obtained in order to rule out an organic etiology. A complete blood count was normal and a basic metabolic panel revealed normal electrolytes and renal function. Additional labs included liver function tests, lipid pan

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old female with a history of hypothyroidism and essential thrombocytosis (on hydroxyurea) presented with complaints of acute-onset nausea, vomiting and diarrhea 2 days prior to admission. She had eaten seafood at a local restaurant the night before her symptoms started. Symptoms started within hours of eating that food. She complained of abdominal pain which was centered in the right lower quadrant and was colicky in nature. The intensity of pain varied from 6 to 7 on scale out of 10. On admission, the patient was found to be hypotensive. Abdominal exam revealed distended belly with hypoactive bowel sounds. A computed tomography (CT) scan of the abdomen done on admission did not show any acute findings. Mesenteric and portal veins were well opacified without any thrombus. The patient was given intravenous fluids and started on ciprofloxacin along with metronidazole. Despite this initial treatment, the patient's condition continued to worsen, with new-onset low grade fevers and persistent vomiting. Her abdominal tenderness worsened and bowel sounds remained hypoactive. A repeat CT scan on Day 3 of admission showed evidence of high-grade small bowel obstruction along with mucosal edema. It also showed thrombus in superior mesenteric vein (Fig. ) and portal vein with early gangrenous changes of small bowel. Based on these radiographic findings, she was taken for urgent laparotomy. Intraoperative findings included gangrene of the small bowel starting from 35 cm distal to the duodenojejunal flexure to the mid-transverse colon with no perforation. The superior mesenteric vein was thrombosed with cord like appearance. Based on these findings, the patient underwent a near-total small bowel resection. Postoperatively, the patient was started on enoxaparin for anticoagulation due to the findings of thrombosis in the mesenteric vein. Intravenous fluids and antibiotics were continued after the surgery. The patient initially responded favorably and was started on liqui

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman had presented 7 years ago with left hand tremor, gait disturbance related to bradykinesia of all four limbs, and postural instability. Decreased sweating during summer and recurrent syncope after standing due to an excessive fall of blood pressure had been noted 5 years ago, and MSA-P had been diagnosed based on the findings of dopamine non-responsive parkinsonism combined with autonomic failure and abnormal linear signal intensities in the putamen bilaterally on magnetic resonance imaging. Her bradykinesia and rigidity gradually increased, resulting in inability to walk and stand unassisted, while oral intake became impaired by dysphagia due to pseudobulbar palsy 1 year ago. In April 2012, she was admitted to our hospital because of frequent episodes of dizziness even in the supine position and transient episodes of involuntary twitching of her upper limbs for 3 months. There was a history of hyperthyroidism when she was 41 years old, which had been treated and was well controlled. Her family history was unremarkable.
On admission, supine blood pressure was 136/74 mmHg and it decreased to 82/46 mmHg with head-up tilt of 45 degrees. Neurological examination revealed mild dementia, a very small voice, severe dysphagia, moderate rigidity of the neck and all limbs, severe bradykinesia, exaggerated deep tendon reflexes, positive pathological reflexes in the lower limbs, diffuse muscle atrophy due to disuse, and autonomic symptoms/signs such as systemic anhydrosis, orthostatic hypotension, constipation, and dysuria. She exhibited recurrent asynchronous and arrhythmic myoclonic movements of the upper limbs and abdomen with a very short duration, which occurred at rest and were also induced by sudden sound, touch or painful stimuli. Very mild cerebellar ataxia was found in her upper limbs, but palatal tremor was not present. Ophthalmic examination (Additional file ) demonstrated involuntary eye movements, which were repetitive, rapid, random, multidirec

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


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

[User]
RADIOLOGY NOTE:
Our patient, an eight-year-old girl, presented to our clinic, with severe swelling and facial asymmetry on the right mandibular molar region. We were informed that the patient developed the swelling as a result of an infection three months previously. The patient had been treated with antibiotics, but as that treatment had not proved successful, she was referred to our clinic. In addition, a passed or congenital disease was not specified in the patient's medical history. Clinical examination revealed severe swelling without fluctuation upon palpation and submandibular lymphadenopathy in the right mandibular region. The patient's skin was of normal color and appearance. In the oral examination, the right mandibular first molar tooth was found to have a deep caries cavity and to not be mobile. The other parts of the oral mucosa were normal. The radiographic examination revealed a deep caries cavity and a radiolucent area in the apical region of the right mandibular first molar tooth. There was also a lamellar appearance on the external cortical surface of the mandible as well as at the lower edge of the mandibular corpus, showing focal new bone formation (). When the axial and cross sections were evaluated during the examination with cone-beam computed tomography (CBCT), a tunnel-like defect was identified in the cortical bone in the vestibule surface of the inflamed bone, starting from the apical region of the right mandibular first molar tooth. Bone deposition at the radiolucent area in the center was observed at the lower edge of the mandible as well as the vestibule surface in this region (). When all these findings were evaluated, it was concluded that the pathologic lesion was Garre's osteomyelitis due to the periapical infection of the right mandibular first molar tooth. In this case, endodontic treatment was considered primarily to retain the infected tooth in the mouth. However, as the patient had come from a remote rural area and could not accept such a trea

[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 88-year-old man (63 kg) had a past history of arrhythmia with severe cardiomyopathy and bilateral arthroplasties several years ago. A colonoscopy was performed and was followed a few days later by clinical signs of septic arthritis of the left knee. The patient did not have fever, but CRP was ~200 mg/L. Echocardiography disclosed no signs of endocarditis. Analysis of joint puncture showed infiltration by polymorphonuclear cells (57,000/mm3) and Pseudomonas aeruginosa susceptible to ceftazidime and ciprofloxacin grew in culture. Open (i.e., by arthrotomy) Debridement Antibiotics and Implant Retention (DAIR) procedure was performed (), followed by treatment with intravenous ceftazidime 6 g/day plus oral ciprofloxacin (500 mg bid). Three weeks after the surgery, the outcome seemed to be favorable, ceftazidime was stopped, and ciprofloxacin was prolonged for a total duration of 12 weeks. Six months later, the patient experienced a relapse of the joint knee effusion (), with heart failure. CRP was ~100 mg/L. X-ray disclosed no loosening of the prosthesis (). A knee joint puncture showed P. aeruginosa persistence, with the same antimicrobial susceptibility profile. The patient was totally bedridden with severe alteration of the general status. As general anesthesia was contraindicated to explant the prosthesis or to perform a new open DAIR, we proposed to this patient the use of phage therapy to try to control the disease. After multidisciplinary meetings in our reference center (which is certified by the French ministry of health for the management of complex bone and joint infection), () and in accordance with the local ethics committee, this case was individually discussed with the French National Agency for Medicines and Health Products Safety (ANSM), to validate that no other options could be proposed without excessive risk of death. Phages, targeting P. aeruginosa, were selected from the Pherecydes Pharma library based on their lytic activity on the patient's str

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old female with a history of prothrombin gene mutation was scheduled for living donor kidney transplantation. After developing spontaneous left subclavian and brachial artery thrombosis 17 years ago, patient underwent therapeutic anticoagulation and maintenance on warfarin for 1 year. With therapy, her thrombosis was found to have completely resolved; however, 8 years later following an arthroscopic procedure on her right knee, she developed venous thrombosis of her right lower extremity. She was subsequently found to have a heterozygous form of the prothrombin gene 20210 mutation and hence was maintained on chronic anticoagulation with warfarin. Over the past 2 years, patient developed end-stage renal disease in the setting of diabetes and hypertension.
After careful discussion and institutional approval, patient and her son elected to undergo living donor kidney transplantation. Patient underwent general endotracheal anesthesia with smooth intravenous induction. She had a tunneled internal jugular double-lumen central venous catheter placed preoperatively and radial arterial line placed after induction. Access is sometimes difficult in renal transplant recipients and more so in our patient due to history of spontaneous subclavian and brachial artery thrombosis. As a routine practice in our institution, we place tunneled catheters preoperatively with interventional radiology for our scheduled kidney transplant recipients. There was no evidence of clots or thrombi in the internal jugular vein or vessels prior to placement of the line with ultrasound examination. A peripheral intravenous cannula was placed intra-operatively for additional access.
She received methylprednisolone and thymoglobulin for immunosuppression. In view of the patient's history of prothrombin gene mutation and history of prior thrombosis, she was maintained on a heparin infusion with a aim of maintaining the partial thromboplastin time (PTT) in the range of 70-75. To achieve this targ

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old man presented for evaluation of a new asymptomatic bump on his left arm. His previous skin examination had been six months earlier and the lesion had not been present. He previously had three basal cell carcinomas (on the left temple, left side of his upper lip, and left mid back excised 32 years, four years and two years earlier, respectively) and one squamous cell carcinoma (on his right upper back that was excised seven years ago). He also had actinic keratoses that were treated with liquid nitrogen cryotherapy.
His past medical history was significant for severe acne vulgaris as an adolescent, hypercholesterolemia, hypertension, and prostate cancer that was diagnosed one year ago. He is currently with no evidence of malignant disease after treatment which included a robotic-assisted laparoscopic prostatectomy (with negative margins for tumor) and a bilateral pelvic lymph node dissection (with none of eight nodes positive for cancer). His current oral daily medications included amlodipine 10 mg and simvastatin 20 mg.
Cutaneous examination showed a six by six millimeter flesh-colored nodule on the extensor aspect of his left arm near the elbow (Figure ). A shave biopsy of the superficial portion of the nodule was performed. The site was treated topically with mupirocin two percent ointment, three times daily, until it had healed.
Microscopic examination of the hematoxylin and eosin-stained tissue specimen showed strands and nodular aggregates of atypical basaloid tumor cells in the dermis reaching the deep margin of biopsy; the overlying epidermis was thin with effacement of the rete ridges and sparse overlying orthokeratosis (Figure ). Deposition of amorphous material filled the dermal stroma between the tumor aggregates (Figure ); the amount of amyloid present was abundant (+++). The lateral aspect of the specimen showed solar elastosis in the upper dermis above the tumor and below the epidermis (Figure ).
Correlation of the clinical presentation a

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


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

[User]
RADIOLOGY NOTE:
A 9-month-old boy was first seen at the age of 5 months being delivered with multiple congenital malformations involving the anterior abdominal and chest walls. The child was delivered at term gestation and at home; the pregnancy was not adversely eventful and she had no antenatal care. However, the child has defect on the anterior abdominal wall with a huge swelling extending from the lower anterior abdomen to the lower anterior chest wall, which was pulsatile and covered by a thin membrane which was initially reddish at birth but later became thickened and darker following daily cleaning and dressing. There was no history of vomiting or constipation, child sucked directly from the breast, though interrupted occasionally to catch his breath, there was no history of difficulty with breathing and no darkening of the lips or mucous membrane. The mother was a 25-year-old stay at home mother with four other children in a non-consanguineous marriage; she neither smoked cigarette nor drank alcohol and had no adverse medical record. No similar problem was found in the family. On examination, there was a big pendulous and pulsatile mass extending from slightly above the symphysis pubis to the epigastrum measuring 12 × 10 cm [] with an epithelised membranous covering; it had visible peristaltic waves, it was pundunculated, with cardiac pulsation felt in the epigastric region []. Bowel and heart sounds were heard over the mass below the level of the diaphragm. There was a lower sternal cleft with absence of the xiphoid process. He was not tachypneic or tachycardic and had first and second heart sounds with a systolic murmur. Bowel sounds were audible and normal. His chest X-ray showed a midline heart with inferior displacement [], abdominal ultrasound showed the swelling to contain loops of bowl and echocardiography revealed a 6 mm secundum atrial septal defect. A diagnosis of pentalogy of Cantrell was made. The child is currently being

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


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

[User]
RADIOLOGY NOTE:
The patient is a 60-year-old woman who presented to our hospital with new-onset upper back pain. The patient complained of upper back pain for 6 months accompanied by left intercostal neuralgia, which was refractory to analgesic treatment. The patient underwent gross total resection of a meningeal tumor 10 years ago. The pathology result was a hemangiopericytoma with a high proliferation index that was classified as WHO grade 2. The patient received twenty-seven cycles of adjuvant radiotherapy after surgical resection. Then, the patient had an excellent post-operative course, and yearly follow-up computed tomography (CT) scans confirmed a complete resection and no recurrence of the tumor until March 2017. Ten years after resection of the meningeal tumor, her upper back pain started. First of all, the patient admitted to another hospital, the positron emission tomography/computed-tomography (PET-CT) showed the lesion at the left T3 vertebral body and in the right lobe of the liver without other sites metastasis. The diagnosis of metastatic SFT was suggested by immunohistochemistry of the T3 mass after CT-guided percutaneous thoracic puncture biopsy was performed. The immunohistochemical study demonstrated CD34(+) and STAT6(++). Then, abdominal and thoracic magnetic resonance imaging (MRI) were performed. The abdominal MRI revealed an enhanced lesion in the right lobe of the liver, with a size of ~2.7 × 2.8 × 3 cm (). The patient complained of no discomfort in the abdomen and did not present with jaundice. The thoracic MRI showed an expansive intraosseous mass at the left T3 vertebral body. The bony mass expanded along the left of the T3 vertebral body, with retropulsion toward the spinal canal and compression of the spinal cord at this level (). The thoracic CT scans showed that the size of the lesion to the left of the T3 vertebral body was ~3.7 × 5.3 cm (). The Tomita score was 4, and the Tokuhashi score was 9–11

[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 67-year-old man in whom an abnormal shadow was detected on plain chest radiography in medical checkup in February 2015. Lung cancer was detected on bronchoscopy and was diagnosed as cT4 (mediastinal fat invasion) N0M0 stage IIIA. There was no particular medical history other than treatment of hepatitis C and psoriasis. The patient had smoked 10 cigarettes per day for 40 years but had stopped smoking 1 year earlier. In blood tests, there was no elevation of tumor markers and only mild liver dysfunction (aspartate aminotransferase: 33 IU/L, alanine aminotransferase: 28 IU/L). Branching of A7 from the right main pulmonary artery was noted on preoperative CT and 3D angiography (Fig. ). There was no abnormal branching of the bronchus on bronchoscopy.
Right middle lobectomy, combined partial resection of the right upper lobe, and mediastinal lymph node dissection were performed by VATS. A7 branching from the right main pulmonary artery was observed during surgery, as detected on CT and 3D angiography (Fig. ), and attention to the A7 was required during interlobular formation between the upper and middle lobes. Surgery was completed without a trouble. The chest drain was removed on postoperative day 2, and the patient was discharged on day 7. The final pathological diagnosis was lung squamous cell carcinoma, pT2a (PL3) N0M0 pStage IB. As of 7 months after surgery, there has been no recurrence.
Low-invasive procedures such as VATS and segmentectomy are becoming increasingly used as the surgical indication has expanded for lung cancer discovered in an early stage. Preoperative confirmation of the vascular variation is particularly important for safe performance of these surgeries. Since variation of veins in the lower lobe is diverse compared to that in the upper lobe, the distribution of veins cannot be used as an index to identify arteries in segmentectomy of the lower lobe, and identification of the branching of arteries in the segment is important [].

[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 here the case of a five year-old boy, born to nonconsanguinous parents. The first child of the parents is seven years old, is normal and was born after nine months of intrauterine life. The second conception resulted in intrauterine death at seven months. Our patient is the third conception and presented with incomplete cleft of the secondary palate. The fourth conception is a one year-old child who is normal.
During the third conception, there was no significant antenatal history of viral fever, medication, or exposure to X-rays(common causes of treatogenicity). The patient was born preterm at 32 weeks by vaginal delivery with a birth weight of 1.8 kg and was kept in the neonatal ICU for seven days. The child had normal head developmental parameters with holding seen at two and a half months and social smiling at three months. There was normal development of the limbs till one year of age after which parents saw very little development in all four limbs. The child was not able to walk or hold anything till two years of age due to deformities of the hands and feet. However, the child had bowel and bladder control by the end of three years.
The child presented with microcephaly, a bird-like face, and incomplete cleft of the secondary palate []. The weight of the child was 10 kg (expected 14–15 kg), height 91 cm (expected 100 cm), head circumference 43.5 cm (expected 48 cm), lower limb: upper limb ratio 49:52 (expected 1.3:1), and mid-arm circumference 12 cm (expected > 14 cm). An X-ray of the upper limbs showed symmetrical ulnar bone shortening on both sides, the ulna measuring 11.7 cm (expected 13–15 cm) and radii absent from both hands. Only two carpal bones were present in the left and right hands, only one metacarpal on each side and one phalanx on the left side but

[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:
Reported patient is a 41-year-old male with a known history of meningioma that was first diagnosed at the age of 13 years for which he underwent resection of a right skull-based meningioma. He had a recurrence of his disease in 2007, at the age of 30 years. He had multiple surgeries for resection of his recurrent meningioma and subsequently right cranioplasty in 2009. In 2013, he developed a left frontal meningioma which was excised. His post-operative course was complicated by infection of the surgical site and he underwent removal of his right temporalis Medport which was placed in January, 2015. He also underwent debridement of the right zygomas and lateral maxilla with removal of the infected maxillary hardware in November, 2015.
The patient had progressively worsening right sided headache and magnetic resonance imaging (MRI) performed in April, 2017 showed recurrence of meningioma in the right middle fossa. While under consideration for enrollment in a clinical trial, survellance imaging showed that his meningioma tumor burden was rapidly progressing. Patient had a generalised tonic clonic seizure and an MRI peformed six months after his recent recurrence showed that the infratemporal component of meningioma had significantly enlarged and was extending intracranially through the foramen ovale. The middle cranial fossa component had also enlarged and measured 2.4 cm by 2.9 cm by 1.5 cm. The tumor resulted in severe compression of the right temporal lobe with associated progressive vasogenic edema throughtout the temporal white matter and orbitofrontal white matter. He was started on levetiracetam and a decision was made to proceed with surgical resection. Postoperative MRI showed plaque like dural thickening along the anterior frontal and temporal convexities but no residual meningioma in the operative bed.
Histopathological analysis revealed that this was a WHO Grade II meningioma. Foundation 1 genetic testing revealed NF2 mutation. His tumor was microsatellite

[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.