[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 female was admitted with fever and general weakness. The fever had developed 2 months prior, was persistent, over 38℃, and spiked 2-3 times per day with accompanying chills and headache. She thought she had caught a common cold and was observed for some time with prescription of antipyretics. The fever did not subside after 1 month and she was admitted to another hospital.
The patient had been generally well despite her fever and chills. Her blood pressure and pulse were normal. No bacteria were cultured from blood. Extended spectrum beta lactamase-negative Escherichia coli was isolated from the initial urine culture, but the fever did not subside after administration of appropriate antibiotics and conversion of urine culture status to negative. Computed tomography (CT) of the chest and abdomen revealed that the abdomen was normal, but diffuse thickening of the aortic wall, without significant narrowing or occlusion of vessels, was evident. Cerebrospinal fluid analysis and transesophageal echocardiography yielded normal results. No symptomatic improvement was evident and she was transferred to our hospital for further evaluation of the origin of fever.
On admission, she had a febrile sense, chills, and anorexia, but no change in body weight. She denied experiencing neck stiffness, tinnitus, dizziness, sweating, chest discomfort, dyspnea, symptoms of upper respiratory or urinary tract infection, claudication, arthralgia, or joint swelling. She had taken antihypertensive medication commencing 5 years prior and had no known drug or food allergies. She was a retired teacher and lived in a city. She consumed alcohol once or twice per month and did not smoke.
On examination, her temperature was 38.9℃, her blood pressure 136/66 mmHg, and her pulse 84 beats per minute. The respiratory rate was 20 breaths per minute, and the oxygen saturation 96% when ambient air was breathed. She appeared tired when the fever spiked, but otherwise did not appear to be ill. Her

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old Caucasian woman presented with a new and persistent cough. Radiographic imaging of her chest demonstrated a mass in the upper lobe of the right lung. Fine-needle aspirate biopsy demonstrated adenocarcinoma. Genomic testing showed the patient’s tumor to be EGFR-mutation positive with exon 19 deletion. She was referred to a comprehensive cancer center for treatment. Her initial computed tomography (CT) scan suggested possible mediastinal invasion at the level of the right brachiocephalic vein. Therefore, she was treated with neoadjuvant afatinib therapy prior to possible surgical intervention. The patient agreed to participate and was explained the nature and objectives of this study, and informed consent was formally obtained. No reference to the patient's identity was made at any stage during data analysis or in the report.
The patient began developing small papules within 24 hours of starting afatinib and by the fourth day of therapy was experiencing severe dermatologic toxicity. Lesions initially appeared on the face, neck, and chest. Individual lesions became confluent and involved 80% of the affected areas. The patient noted her lesions to be extremely pruritic. Her oncologist prescribed oral doxycycline 100 mg twice daily, topical treatment to her skin lesions with clindamycin 1% gel twice daily, and hydrocortisone 2.5% cream.
The patient’s cutaneous symptoms and lesions continued to progress rapidly during the next several days. She was severely debilitated to the point of considering discontinuation of afatinib therapy. Therefore, her oncologist referred her to the dermatology clinic for evaluation and treatment of the drug-associated skin toxicity. After obtaining written consent from the patient, photos of all of the affected areas were taken.
Cutaneous examination after starting afatinib revealed diffuse erythema with individual and confluent papules and pustules on the forehead, face, neck, chest, upper abdomen, and upper back (Figures -).
H

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old lady presented to the emergency department (ED) with symptoms of dyspnea, chest pain, cough, and subjective fevers since three days. The patient was reportedly in good health before she received a dose of intramuscular naltrexone for the treatment of alcohol and opiate dependence on the day of symptom onset. The patient had been smoking cigarettes consistently for the past six years. On arrival, she was noted to be hypoxic, and oxygen supplementation was initiated through a nasal cannula. Examination was pertinent for tachypnea and bilateral crackles. The patient was afebrile. While in the ED, she was placed on a non-rebreather mask because of worsening hypoxia. Chest X-ray showed diffuse bilateral pulmonary infiltrates (Figure ). A CT angiogram of the chest was ordered, which was negative for pulmonary embolism but showed diffuse bilateral pulmonary infiltrates as well (Figures , ). Initial laboratory data were pertinent for elevated WBC count with mild peripheral eosinophilia (700 cells/microliter). Levofloxacin was administered intravenously for the treatment of suspected community-acquired pneumonia.
The patient was admitted to the medicine service and was started on intravenous methylprednisolone for the management of suspected AEP secondary to injectable naltrexone given the temporal relationship between administration of the medication and onset of symptoms. Bronchodilator therapy was initiated for wheezing. Antibiotics were discontinued upon admission. The patient’s oxygen requirements improved. Pulmonology consultation was requested, and the patient underwent bronchoscopy. BAL studies showed predominance of lymphocytes (62%) followed by neutrophils (32%) with no eosinophils, which was not suggestive of AEP. However, histology of the lung biopsy sample showed the presence of eosinophils in the lung parenchyma consistent with drug-induced eosinophilic pneumonitis (Figure ). HIV viral load testing and hepatitis C serology were negative, BAL bacte

[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 72-year-old Caucasian female with a past medical history of hypertension, hyperlipidemia, cervical stenosis and depression. She originally presented with worsening dyspepsia and intermittent epigastric pain for 2 years for which she sought medical attention. During the initial evaluation, a solid, enhancing mass in the anterolateral surface of the head of the pancreas was found on abdominal computed tomography (CT) scan. There was no associated dilatation of the main pancreatic or common bile duct. Upper endoscopy revealed no lesions in the stomach or duodenum. During the following two years, the patient had multiple endoscopic ultrasound guided fine needle aspiration biopsies of the mass, which were either non-diagnostic or resulted in benign appearing pancreatic tissue. She then underwent an open pancreatic biopsy with removal of a peri-pancreatic lymph node. These all revealed benign pancreatic tissue with fibrosis and no obvious evidence of malignancy. Her CEA and CA19-9 levels were within normal limits. She was followed closely for 3 years with serial imaging and endoscopic ultrasounds, until an abdominal CT scan showed a substantial increase in the size of the pancreatic mass from 1.9x2.2 cm to 3.1x2.7 cm (). The pancreatic mass was described as a well-encapsulated tumor, without any cystic component. There were no other intra-abdominal lesions or pathologic lymphadenopathy noted. Magnetic resonance cholangiopancreatography showed normal caliber of the biliary tree and pancreatic duct. Endoscopic ultrasound confirmed a heterogeneous solid pancreatic head mass without pancreatic duct dilation (). Her serum CEA and CA19-9 levels remained within normal limits throughout. Physical examination did not reveal any concerning findings, although the patient reported ongoing intermittent epigastric discomfort. Given the patient’s ongoing epigastric pain, and the enlarging size of the mass, a decision was made to proceed with surgery due to the concern tha

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old female presented with a left sided upper neck swelling which was insidious in onset and was painless and progressively increasing in size over the past 4 years (). It was not associated with dysphagia, dyspnea, or dysphonia. There was no history of trauma. It was not associated with similar swellings in other body parts. Her head and neck examination revealed a 4 × 3 cm swelling in left anterolateral region of upper neck. It was soft, not tender, nonpulsatile, and nonexpansible on Valsalva maneuver. There was no palpable thrill. Oral cavity examination did not reveal any abnormality. The overlying skin was normal in color without local rise of temperature and it was free from the underlying swelling. Her medical and family history was unremarkable. Based on the history and clinical examination, provisional diagnosis of branchial cyst was made.
Ultrasonography revealed a well defined hyperechoic mass, suggested as a highly vascular mass. Fine needle aspiration cytology (FNAC) examination was suggestive of vascular lesion. Computed tomography (CT) scan showed an inhomogeneous hypodense lesion lying in close approximation to left ala of thyroid cartilage (). There was no obvious separation of the mass from the strap muscle. The differential diagnoses suggested from the CT scan report were vascular malformation and hemangioma.
Under general anesthesia, skin incision was given along the skin crease on top of the swelling. Blunt dissection was then carried out gently. Intraoperatively, the mass was found to be closely adherent to the left lamina of thyroid cartilage. The mass was then mobilized from the surrounding structures by ligating the feeding vessels separately and dissecting the soft tissue attachments. There was minimal blood loss during the procedure and the mass was removed in toto (). Hemostasis was secured. Corrugated rubber drain was placed to prevent hematoma formation. Wound was sutured in layers using absorbable and nonabsorbable sutures. Pr

[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 man presented at our hospital with a 5-month history of a rapidly enlarging mass in the right thigh. His past history was pulmonary tuberculosis treated with thoracoplasty and hepatitis C. Physical examination revealed the presence of a large irregular mass with multiple ulcers and necrotic tissues, measuring approximately 10 × 10 cm in the lateral side of the proximal thigh (). Admission laboratory data showed high levels of LDH, GOT, GPT, and ALP, which are 643, 80, 39, and 441, respectively. Typical tumor markers were within normal limits. A roentgenogram of the right proximal thigh showed no apparent expansion to the femur. Chest roentgenogram and computed tomography showed no apparent metastatic lesion and no focus of pulmonary tuberculosis. MR images demonstrated relatively a well defined and heterogeneous mass, which was attached to the fascia lata and expanded across the skin layer (Figures , ). The signal intensity of the mass was isointense to the adjacent skeletal muscles on T1-weighted images and inhomogeneous hyperintense on T2-weighted images. The mass was relatively well defined and enhanced with Gd-DTPA on STIR sequences (). However, partial infiltrating expansions to subcutaneous tissues of the mass made its margins unclear. Despite the mass contacted with the compression to the tensor fascia lata muscle, the gluteus maximus muscle, and the gluteus medius muscle, no apparent signal intensity changes of muscles were seen. Thallium-201 scintigrams showed a robust accumulation accorded for the mass in both of early and delayed phases (). No other abnormal accumulation was detected.
Based on clinical findings and imaging characteristics, the tumor was diagnosed as a primary soft tissue tumor and an incisional biopsy was performed. Histopathology of the permanent sections showed the nodular or sheets-like proliferation pattern of small round cells with a high nuclear/cytoplasmic ratio in the background of sparse extracellular collagen (). I

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman with good past health with no previous neurological symptom was admitted to the Prince of Wales Hospital in Hong Kong after a sudden onset of left upper limb and lower limb weakness along with unsteady gait and numbness. Examination upon admission revealed brisk reflexes over both lower limbs, reduced pinprick sensation with a sensory level at T3 over left side. Her blood pressure was 141/74 mmHg with no history of smoking, hypertension, diabetes or dyslipidemia. An MRI scan of the whole spine showed extensive intramedullary hyperintense signals at C2 to T3 levels; most discrete at the T2 level. On the other hand, no lesions were found on the MRI of the brain. The severity of the spinal lesions and lack of brain lesions prompted an immunological investigation. The patient tested positive for anti-aquaporin-4 antibody and anti-SSA antibody using immunofluorescent test which confirms the diagnosis of NMO. In addition, her rheumatoid factor and antinuclear antibody were both negative; and there were no clinical features of keratoconjunctivitis sicca or dry month suggestive of Sjogren's syndrome.
A magnetic resonance angiography (MRA) scan of the brain revealed a bilateral distal occlusion of the internal carotid arteries. Occlusions of the MCA were noted with fine collaterals in the region—reminiscent of moyamoya vessels. The ICAs and ACA were preserved; and the CCAs were normal without atherosclerotic changes. She was diagnosed with moyamoya disease as well (Fig. ).
Despite treatment, leg weakness showed no significant improvement and further deterioration of leg power was witnessed with the left leg deteriorating more than the right. Intravenous methylprednisolone 1 g daily was given for 3 days. Afterwards, she was transferred to rehabilitation after 19 days in hospital with oral prescription of 30 mg of prednisolone daily together with azathioprine 50 mg daily. On follow-up 1 month later, she had suboptimal recovery with lower limb power remained

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old female was transferred from a peripheral hospital 10 days after an elective lower uterine section caesarean section for a breech presentation for which she had an epidural anaesthetic. She presented to her general practitioner with a 2-day history of increasing right leg weakness. She was referred to her local hospital where she presented as no longer able to walk. Her examination demonstrated 0/5 power in right ankle flexion, extension, eversion and inversion with increased tone. Her cranial nerve examination was normal as was her tone and reflexes. An urgent MRI of the spine was undertaken that revealed no evidence of epidural collection or neural compression. She subsequently underwent a CT scan of the brain that demonstrated a dural-based lobulated, heavily calcified left parafalcine mass associated with extensive oedema consistent with a meningioma (). The bulk of the calcification was at the periphery of the lesion with relative sparing of the central elements. 8-mg dexamethasone was administered intravenously prior to transfer to a tertiary centre where an MRI of the brain was undertaken. This showed a left extra-axial parafalcine mass compressing the pre- and postcentral gyri and abutting the paracentral lobule. It was isointense to cortex on T2 weighted images with hypointense peripheral component corresponding to areas of calcification. The mass demonstrated peripheral enhancement and an enhancing dural tail. There was no evidence of restricted diffusion. Overall, it was felt most likely to be a meningioma with some atypical features. She underwent a left frontoparietal craniotomy and resection of the lesion. Histology demonstrated a meningothelial meningioma, WHO grade I with focal areas of necrosis and features, raising the possibility of embolization-related changes. She recovered well and was discharged home after brief inpatient rehabilitation. At her 4-month review, she was walking with 5/5 power in hip and knee flexion and extension an

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old man presented at the emergency department because of a circulatory shock with sudden onset. His medical history revealed hypertension, a dilated sinus of Valsalva (47 mm), and ascending aorta (45 mm). Physical examination revealed a highly distressed and moaning patient in deep shock (blood pressure, 65/45 mm Hg; pulse, 100 bpm; lactic acid, 3.6 g/L). The electrocardiogram showed a pattern of global ischemia ().
Transthoracic echocardiography (TTE) showed reduced left ventricular function (visually estimated left ventricular ejection fraction = 45%) and the previously established dilated aortic root. New findings included AR, which was difficult to quantify, and an abnormal configuration in the ascending aorta suggestive of an intimal flap. There was no pericardial effusion. The most likely diagnosis at this point was deemed a Stanford type A aortic dissection. However, emergency, electrocardiogram-triggered, computed tomography (CT) scanning excluded an aortic dissection. Moreover, there were no signs of central pulmonary embolisms and no signs of proximal coronary stenosis. However, a structure in the right coronary cusp (RCC) protruding into the aorta aimed at the aortic wall was seen. The exact significance of this finding was unclear at that time. A second TTE showed a situation comparable to that of the first TTE.
While the patient was still in severe cardiogenic shock, probably due to significant AR, but without a definite diagnosis, we decided to perform transesophageal echocardiography (TEE) in the operating room, taking into account the risk of further hemodynamic deterioration due to anesthesia and tracheal intubation.
As anticipated, the patient’s hemodynamics further deteriorated directly after tracheal intubation, necessitating resuscitation, which was successful. Meanwhile TEE was performed and revealed a tricuspid aortic valve, mild aortic root dilation (44 mm), and massive AR due to a flail of the RCC. The exact mechanism of the flail

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

[User]
RADIOLOGY NOTE:
A 56-year-old woman who suffered from headache and vomiting was admitted as an emergent case. The sudden onset of severe pain in the occipital area started 2 weeks before admission and got worse over 2 days. On arriving, the patient was alert and oriented. She had a history of uncontrolled hypertension, and her presenting blood pressure was 170/90 mm Hg. Intravenous hydralazine to lower blood pressure was administered. When the patient was referred for neurological opinion, she denied photophobia, sensory change or motor weakness. A further evaluation was notable for a normal neurologic examination including cranial nerves and no neck stiffness. No abnormality of ocular motility was observed. The laboratory results for coagulation profiles and tumor markers were within normal limits.
CT showed an 11 mm-sized, noncalcified, and faintly-enhancing mass in the pineal region without ventricular enlargement (). No abnormal finding in the cerebral vasculatures was detected on the reconstructed three-dimensional CT angiography. The pineal lesion appeared at MR images as ovoid, thin-walled, and well-defined cyst. The cyst was hypointense on T1-weighted and hyperintense on T2-weighted sequence. There was a blood-fluid interface within the cyst on gradient echo sequence (). No tumor or vascular malformation in the pineal region was visualized on enhanced MR studies. An imaging diagnosis of intracystic hemorrhage of PC was made by staff neuroradiologists without the need for clinical information about patient's history and findings.
Since it was unlikely that the cyst would compress the cerebral aqueduct, the patient was scheduled for managing the PC apoplexy conservatively. Her symptoms had completely resolved with use of pain medication and antiemetic drugs. The patient was discharged home at the ninth day of hospitalization with normalized blood pressure. The close observation and regular follow-up with MRI were conducted. At the 6-month follow-up, MR scans revealed the stab

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


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

[User]
RADIOLOGY NOTE:
On a freezing cold morning, a 71-yr-old male of Han nationality who was retired, but worked as a community volunteer, was brought to the neurology emergency with a history of sudden onset of left-sided weakness and difficulty in speaking while he was performing road patrol. Approximately an hour and a half had elapsed since the onset of symptoms before he was brought to the emergency room.
As for the past medical history, he had undergone a surgical procedure involving left kidney, left ureter and bladder for treatment of transitional cell carcinoma of bladder, approximately 8 months ago. One month after the surgical procedure, the results of laboratory investigations, such as complete blood count, kidney and liver function tests were within normal limits. There was no history of common risk factors of atherosclerosis, such as hypertension, diabetes mellitus, coronary artery disease and smoking.
He was conscious, had pallor, the blood pressure was 150/80 mmHg and the blood sugar level was 6.5 mmol/L. Chest and cardiac examination was unremarkable. The neurological examination demonstrated a left-sided hemiparesis with clumsy speech. The muscle strength of the left limb was grade III and the left Chaddock’s sign was positive. The patient’s upper and lower extremities were very cold, and the finger tip oxygen saturation was 76 %. However, the arterial blood gas analysis revealed the oxygen saturation of 94 % without supplementary oxygen.
A computed tomography (CT) scan of the brain revealed absence of hemorrhage, hence the diagnosis of acute ischemic stroke was highly probable. Routine blood test revealed a haemoglobin of 58 g/L, platelet count of 124 × 109/L,white blood cell count of 7.55 × 109/L, however, the number of red blood cells, hematocrit, mean corpuscular volume could not be measured due to the interference by agglutinated erythrocytes. The low level of hemoglobin combined with presence of pallor suggested severe anemia. On coagulation study, d-dim

[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 male from Tennessee with a past medical history of janus kinase 2 (JAK2) positive essential thrombocytosis diagnosed in 2014, hypertension, hyperlipidemia, and major depressive disorder presented to the emergency department (ED) with acute encephalopathy. Due to initial encephalopathy, information regarding medical history was obtained by review of previous hospital documentation obtained from his hometown. The patient was previously taking anagrelide 0.5 mg twice a day (BID) then hydroxyurea 500 mg BID for myeloproliferative disorder, however, he discontinued the medications in 2015 due to depression.
His medical history is notable for a hospitalization four months ago where he presented with fatigue, weight loss, and cough, and was found to have an enlarged spleen. During that time, a computerized tomography (CT) scan of the chest, abdomen and pelvis was performed which noted 4 x 4 x 2.3 cm mass in the right adrenal gland, and splenomegaly. Further workup at that time revealed multiple brain lesions on brain imaging, with an unclear source. The patient also had a lumbar puncture (LP) with normal cerebrospinal fluid (CSF) results, negative human immunodeficiency virus (HIV), negative acid-fast stain and toxoplasmosis. Bone marrow biopsy in the past revealed findings consistent with a myeloproliferative disorder. The patient was scheduled to undergo adrenal biopsy, however, he declined this and decided to leave the hospital. Additionally, the patient saw a neurologist one month ago for persistent neck pain for the past seven months, associated with numbness and tingling in his right hand, which had subsequently progressed to his right forearm and upper arm. Magnetic resonance imaging (MRI) of the brain showed numerous supratentorial and infratentorial ring enhancing lesions. The differential diagnosis at that time included metastatic disease, and atypical infection such as toxoplasmosis. A lumbar puncture was done, however, official results were not av

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old Indian lady, a known case of rheumatic heart disease since the age of 16 years who had undergone a successful mitral and aortic valve replacement surgery 11 years previously, sustained a fall and fractured the neck of her right femur. She was scheduled for hemireplacement arthroplasty. She had not sustained any head injury during the fall. She was a known diabetic on insulin therapy. Her past history revealed that prior to the valve replacement, she used to get breathless even while doing routine daily activities. Presently, she could climb two flights of stairs without any syncope, palpitations, fatigue, chest pain or breathlessness prior to the trauma. She was receiving oral warfarin 2 mg once daily.
Physical examination revealed her to be afebrile, with an irregularly irregular pulse-104 beats per minute, respiratory rate 18 breaths per minute and blood pressure 160/86 mmHg. Her systemic examination did not reveal any pathology. Patient's electrocardiogram showed atrial fibrillation with a heart rate of 110 per minute. Her ECHO showed 54% ejection fraction, normally functioning valves, no paravalvular leak and confirmed absence of vegetations and clots. The chest X ray revealed ball in cage mitral valve prosthesis, an aortic prosthesis, sternotomy sutures and cardiomegaly (Fig ). Her preoperative laboratory evaluation reports are given in Table .
We advised the patient to discontinue warfarin for four days and started on unfractionated heparin 4000 IU subcutaneously 6th hourly. On the day of surgery, the last dose of heparin was administered 6 h prior to surgical incision and the coagulation studies prior to starting the surgery revealed PT 16 (patient) and 14 (control) with a INR 1.1, APTT 32 (patient) and 28 (control). Two units of packed red blood cells were cross matched in view of anemia. Fresh frozen plasma and protamine were reserved for emergency use in case of undue blood loss during the surgery. Her morning dose of insulin was skipped

[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 18-year-old male presented to our institution in 2014 with headaches and vomiting for two weeks. A magnetic resonance image (MRI) of his brain showed a complex extra-axial dumbbell-shaped lesion with the epicenter in the left Meckel’s cave, extending anteriorly to the cavernous sinus and the cerebellopontine (CP) angle posteriorly with mass effect over the brainstem. He underwent a left retromastoid craniectomy and decompression of left CP angle lesion elsewhere. The histopathology was suggestive of malignant melanoma, and he was referred to our institution for further management.
His general physical examination revealed a deep gray-blue nevus over the left upper eyelid, extending to the frontal and temporal region. He had dysarthria, left upper motor neuron facial nerve palsy, and right hemiparesis with Grade 4 power in his right upper and lower limbs. The biopsy of the nevus over his left eyelid was reported as superficial, and the deep dermal dendritic melanocytosis with histological features was suggestive of a blue nevus.
The MRI of his brain showed a large contrast-enhanced extra-axial mass with solid and cystic components measuring 4 cm x 2 cm x 3 cm in the left cavernous sinus extending through the Meckel’s cave into the posterior fossa (Figure ). A whole-body positron emission tomography-computed tomography (PET-CT) scan confirmed no extracranial disease. He underwent a left temporal craniotomy and zygomatic osteotomy, and we took an interdural middle cranial fossa approach for the radical excision of the tumor.
Perioperatively, we noted the blue nevus on the left side of the forehead in the ophthalmic distribution of the trigeminal nerve. The pigmentation extended into the subcutaneous tissue and galea. The diploe of the temporal bone was also pigmented. The entire temporal dural convexity was pigmented completely black as were the dural root sleeves of the trigeminal nerve and the lateral and medial walls of the cavernous sinus. The tumor 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 66-year-old Hispanic female presented with vague abdominal pain and exertional chest pain. She had a ten-year history of worsening epigastric pain attributed to gastritis that was treated with Dexilant. A general physical exam was done and did not reveal any significant abnormalities; she also denied any fevers, chills, weight loss/gain, or change in bowel habits. Environmental history was noncontributory as she denied extensive sun-exposure or use of tanning beds and reported that she regularly would use sunscreen with a 30 SPF. Still, there was an extensive past medical history for anemia, diabetes mellitus type II, coronary artery disease, asthma, hypertension, hyperlipidemia, hemorrhoids, and osteoarthritis. She also had a broad surgical history, involving a coronary artery stent in the left anterior descending artery [2016], percutaneous transluminal coronary angioplasty [2016], tubal ligation [1985], cholecystectomy [2007], bladder prolapse repair [2012], rectal prolapse repair [2012], hysterectomy [2012], and total right knee replacement [2013].
There is no report of primary tobacco use; however, she does report an extensive second-hand smoke exposure as a result of her biological father. Her family history is significant for multiple cancers, with her father dying of cancer related complications from a head and neck malignancy at the age of 65. The patient's sister died of breast cancer at the age of 44 and half paternal sister also died of breast cancer at the age of 38. Lastly, her brother died of colon cancer at the age of 70 and her mother's death at the age of 67 was due to a myocardial infarction unrelated to cancer. Interestingly, her eldest daughter was diagnosed with melanoma found in a cutaneous lesion, in 2016. Her physical exam did not reveal any concerning skin lesions or palpable abdominal lesions and her vitals were stable.
A near total gastrectomy was performed and multiple adhesions from prior surgeries were divided at the beginning of the

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


[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 69-year-old female with a history of severe-stage primary open-angle glaucoma refractory to previous trabeculectomy and on maximum topical medical treatment in the left eye. She underwent placement of a Baerveldt glaucoma implant with a scleral patch graft (SPG) in the left eye with vicryl suture tube ligature. The surgery was unremarkable and without complications. On postoperative day 1, she was doing well, the tube was in good position, and her incision was closed with no exposure. Her IOP was 34 mm Hg, and her best corrected visual acuity (BCVA) was 20/70 in the left eye. She was treated with our routine postoperative regimen of moxifloxacin 4 times a day for 1 week and prednisolone acetate starting at 4 times a day and tapered weekly. She was also placed on her preoperative glaucoma drops, while awaiting ligature dissolution. At postoperative week 3, the patient reported irritation and discharge in the left eye and was noted to have an abscess and erosion of underlying conjunctiva and partial erosion of the SPG. Her vision was slightly improved with a BCVA of 20/60 and an IOP of 14 mm Hg at this time. A mucoid, pigmented plaque from the abscess was sent for culture. The patient was restarted on moxifloxacin 4 times a day.
Culture results were finalized as coagulase-negative Staphylococcus, susceptible to gentamicin. She was started on gentamicin, and moxifloxacin was continued. At the follow-up visit, slit-lamp examination revealed an enlarging area of thinning and erosion of the SPG with overlying avascular conjunctiva with a central area of eroded conjunctiva. There was no infiltrate and no signs of active infection. The wound was Seidel negative with no exposure of the tube.
It was at this visit that the patient reported developing a rash involving her back, right arm, and abdomen with scattered abscesses. She went to a walk-in clinic 1 week prior 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:
The patient is a 16-year-old male without a significant past medical history who was transferred to our institution after a gunshot injury to the right lower extremity. On physical examination, two bullet entry points were evident at the right popliteal fossa and dorsal soft tissues of the distal right leg. Initial radiographs were negative for fractures or dislocation.
Computed tomography angiography (CTA) demonstrated a retained bullet fragment within the popliteal fossa abutting the dorsal aspect of the popliteal artery. An 8 millimeter (mm) soft tissue density abutting the medial aspect of the popliteal artery was also identified, concerning for either a small pseudoaneurysm or short segment intramural hematoma. Streak artifact from the retained bullet precluded adequate assessment of this region. The peroneal artery demonstrated a 10 centimeter (cm) occlusion 2.5 cm distal to its origin but reconstituted distally at the level of the mid-tibia. The anterior and posterior tibial arteries were both normal in appearance and patent. The dorsalis pedis artery was unremarkable. There was subcutaneous emphysema throughout the deep and superficial posterior compartment of the knee and throughout the medial aspect of the leg.
The patient was taken to the interventional radiology suite and a right lower extremity diagnostic runoff angiogram was performed. Initial images obtained with the patient’s leg held in extension demonstrated abrupt cutoff of the popliteal artery immediately adjacent to the bullet fragment (Figure ). We then proceeded to reposition the patient’s right leg in the “frog-leg position”. A second diagnostic runoff angiogram was then performed demonstrating mild short segment narrowing of the popliteal artery immediately adjacent to the bullet fragment but with reconstitution of flow down to the level of the tibial-peroneal trunk (Figure ). The anterior and posterior tibial arteries demonstrated patency on both the extension and frog-leg positions. It 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 58-year-old female patient reported to our institute with the chief complaint of pain and swelling on the left side of the face for 10 days and painful ulcer on the left side of the palate for 2 months accompanied by fever and chills. History revealed the patient to be apparently asymptomatic 2 months back with gradual onset of left-sided facial swelling with painful intraoral ulceration in the palatal region accompanied by purulent discharge with foul taste and halitosis. Past medical history revealed that the patient was known as diabetic (recently diagnosed) and was under medication for the same. Extraoral examination revealed a diffuse soft, tender and febrile swelling on the left side of the face obliterating nasolabial fold, extending anteriorly from the corner of the mouth to the ramus area posteriorly, superiorly extending from infraorbital region to the submandibular region inferiorly [] Intraoral examination revealed an infiltrating tender ulcer in the palatal region, crossing midline, measuring around 6 cm × 3 cm in size, with slopping edges, irregular and indurated margins []. A provisional diagnosis of deep fungal infection in relation to the maxilla and a differential diagnosis of the palatal abscess, osteomyelitis and benign inflammatory salivary gland lesion was given. Orthopantomogram, plain and postcontrast computed tomography scan (CT) were normal. Complete hemogram showed all parameters to be in normal range except for a raised ESR (30 mm/1st h) and increased white blood cell count. Current blood glucose levels (fasting and postprandial) were in normal range, however, glycated hemoglobin level was 14, indicating poor glycemic control over the past 3 months, her previous biochemical reports showed the presence of glucose, and ketone bodies in urine. Other biochemical parameters were in normal range.
A cytology smear was prepared from the palatal region and stained with periodic acidSchiff (PAS) and GIEMSA stain which revealed the presence of few

[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 this work a case report of a 14 years old Caucasian boy has been described. The patient had a scooter crash without any protective head and body gear [] and referred to our attention only 4 hours after the accident.
As a consequence he underwent a dentoalveolar damageof both upper central incisors and vestibolarization of two crown fragments, with no fracture line clinically detectable. A horizontal root fracture was radiographically evident between the middle third and the apical third of the central upper incisors ().
The care plan comprised reduction, repositioning and rigid splinting of the coronal fragments. []. The initial treatment consisted in repositioning, using firm finger pressure to the coronal segments. All the maxillary elements were subsequently splinted using interproximal composite (). After 24 hours an orthodontic stainless steel arch was applied, using a photopolymeric resin after a careful assessment of the occlusal contacts (). No medication was prescribed. The splint was held 1 year long because of the presence of severe dental mobility. Despite this therapeutic solution, a correct oral hygiene was kept thanks to a professional hygiene, to a strong motivation of the patient and to the use of the dental floss (Superfloss®). Moreover, the absence of the fracture line with the oral environment prevented any bacterial penetration. Ten days later the damaged teeth did not show chromatic alterations and the thermal and electrical tests (Crio Test - Pulp Test) suggested no pulpar necrosis [].
A follow-up was performed after 20 and 30 days, through clinical and radiographic examinations. Then the patient returned for periodic clinical and radiographic follow-up after 3 months and 1, 3 and 4 years (-). After the splint removal the mobility of both incisors was within normal limits and the patient reported no discomfort with his teeth and no pain during horizontal and vertical percussion tests. The electrical test responses of both central incisors w

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

[User]
RADIOLOGY NOTE:
We report a case of 30-year-old Caucasian woman in her first pregnancy with a BMI of 25. The couple were nonconsanguineous. The partner had been tested in the past and was found to be a carrier of a balanced translocation that involves chromosomes 7 and 12. Partner's brother had an unbalanced form of this familial translocation between chromosomes 7 and 12 with severe learning disability. Also partner's mother was found to be a carrier of balanced translocation that involved the same chromosomes.
Woman's dating ultrasound at 11 weeks and 3 days showed an intrauterine pregnancy with a CRL (crown rump length) of 47.5 mm and a nuchal translucency of 2.0 mm. The risk of trisomy 21 was reported to be 1 : 3,300.
A routine anomaly scan was performed by the fetal medicine specialist at 20 weeks and 3 days in view of the family history of balanced and unbalanced translocations. Anomaly scan revealed several abnormalities (). There was marked microcephaly and alobar holoprosencephaly. Multiple facial abnormalities were detected including an absent nasal bone, microphthalmia, hypotelorism, flat profile, and single nostril. The bowel appeared hyperechogenic. All the other systems appeared normal.
The patient and her partner were counselled regarding diagnosis and poor prognosis. Due to the brain abnormalities, the prognosis was deemed to be poor with a high likelihood of miscarriage, neonatal death, handicap, and learning disability. In view of the multiple abnormalities, the possibility of an underlying chromosomal or genetic abnormality was also discussed with the couple.
The patient opted for an amniocentesis and it was performed on the same day with no complications. The patient and her partner opted for termination of pregnancy in view of associated fetal brain abnormalities. A medical termination regime was commenced and completed four days later with the delivery of a male infant weighing 320 grams. The couple opted for a full postmortem examination.

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

[User]
RADIOLOGY NOTE:
A 76-year-old male patient presented with a history of progressive dysphagia for solids for a year, which evolved to dysphagia and odynophagia for liquids in 5 months. The patient was referred from a basic health unit to the General Surgery Service of “Santa Casa de Ribeirao Preto” with esophageal obstruction and suspicion of neoplasia. The patient had a slim figure, as he lost 20 kg in 5 months. His current weight was 39 kg, his height was 1.63 m and his BMI was 14.67 kg/m2. The patient confirmed smoking habits (two packs of cigarettes a day during 50 years) and claimed he was a social drinker; the patient also denied any comorbidity. He then went through an upper gastrointestinal endoscopy (UGE), and the endoscope only entered 22 cm below the upper dental arcade, which discarded the possibility of a biopsy, which was needed for the hypothesis of neoplasia. Thoracic and abdomen CT scan showed a thickening of the gastric walls, especially at the esophagogastric junction. The CT scan also revealed an abrupt straightening of the proximal third of the esophagus (), suggesting esophageal neoplasia. As he was unable to receive oral diet, we opted to provide his diet through a Witzel’s jejunostomy in order to improve his nutritional gains. The neoplasia hypothesis indicated the need to perform a biopsy to analyze the tissue, and if positive for neoplasia, refer the patient to the oncology service for neoadjuvant therapy. The patient, then, underwent through another UGE, but this time, the endoscope passed through the obstruction and identified the presence of a Zenker’s diverticulum. Next, he underwent through an esophagogram that identified a large esophageal diverticulum (, ). Thus, the prognosis changed, and it indicated an endoscopic surgical repair of the Zenker’s diverticulum, as it is the standard procedure. Due to his low BMI and his nutritional conditions, it was opted 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 78-year-old female patient presented to our outpatient department with complaints of progressive general weakness and cognitive impairment that began a month ago. She was diagnosed with mild dementia and was admitted to a convalescence hospital but was not prescribed any medications. Despite the patient's ability to self-care at the onset of symptoms, she was unable to take care of herself or walk at the outpatient visit. Brain CT revealed bilateral subdural hygroma or bilateral CSDH with the loss of sulci markings on the cerebral hemispheres. Brain atrophy was also observed (). Considering the rapid progression of symptoms, surgery was performed to treat the bilateral lesions. CSDH can often be misdiagnosed as a subdural hygroma on brain CT. However it was thought be SDH due to reddish brown fluid with clots in the operation filed. The patient underwent evacuation through 2 burr holes (one at each parietal eminence) and catheters were placed into the subdural space through both the holes to prevent further blood accumulation. The vital signs, including BP, were normal during surgery. The patient showed improvements in cognitive and motor functions postoperatively. There was no catheter drainage on the first two days postoperatively; however, 400 cc of subdural fluid with CSF and blood was drained from the right side drainage catheter over a 24-hour period on postoperative day 3. The patient did not exhibit any changes in the neurologic symptoms, but complained of intermittent headache. An emergency brain CT scan revealed a newly developed hemorrhage in the right subdural space and a small amount of intraventricular hemorrhage (). CSF overdrainage was considered a possible cause of the remote hemorrhage; therefore, we removed the drainage catheters. When we reviewed the previous images, suspected arachnoid cysts were observed in the right temporal lobe (). One month after the surgery, a follow-up CT scan showed absorption of the hemorrhage and the area where the s

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


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

[User]
RADIOLOGY NOTE:
A healthy 11-year-old girl was presented to the National University of Malaysia (UKM) Paediatric Dental Clinic with a referral for further management of pulp necrosis of an immature lower right second premolar (tooth 45), secondary to the fractured tubercle of dens evaginatus. Two weeks earlier, she had treatment at a general dental clinic for pain related to tooth 45. Tooth 45 had spontaneous and lingering pain following cold and thermal stimuli. The tooth was diagnosed to have symptomatic irreversible pulpitis, and root canal therapy was initiated. The canal was accessed, and pulp extirpation performed before the placement of intracanal nonsetting calcium hydroxide by the general dental practitioner (GDP).
At the time of current assessment, her tooth-related symptoms had completely resolved. General oral examination showed the presence of generalised mild gingivitis with a basic periodontal examination (BPE) score of 1 in all sextants. The patient's oral hygiene was fair with a plaque score of 30%. The patient is still in her mixed dentition with the presence of the primary maxillary canines. Her upper dental arch was well aligned, and mild crowding of anterior teeth was noted in the lower arch. Tooth 45 has an occlusal glass ionomer dressing of the access cavity made for the pulp extirpation earlier by the GDP (). Cold and electric pulp sensibility testings showed positive responses to all fully erupted premolars indicative of tooth vitality expect for tooth 45. Tooth 45 also has slight tenderness to percussion. Periapical radiograph of tooth 45 showed an immature root with convergent open apex and small periapical radiolucency. The pulp space of tooth 45 is of an even width from the coronal to the apical portion (). Based on the assessments, tooth 45 was diagnosed with pulp necrosis secondary to fractured dens evaginatus and symptomatic apical periodontitis.
On the day of initial assessment, tooth 45 was isolated with rubber dam after infiltration of local anaes

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

[User]
RADIOLOGY NOTE:
A 58-year-old male on treatment for prostate cancer since two years, presented to the skin OPD with complaints of dark colored raised lesions on hands and face of three days duration. He initially noticed lesions on the face which spread to involve the neck and both forearms and hands. The lesions were associated with moderate to severe itching which increased on sun exposure. There was history of such episodic appearance of lesions for the last four to five months. He was taking docetaxel injections for prostate cancer once in three weeks since five months. The lesions had initially appeared two to three days after the first injection, according to his case history. Subsequently they would fade in two weeks but again flare up after the next injection. The patient was not administered any other drug simultaneously for the same disease or for any other associated or non associated disease condition.
On examination, violaceous, well defined, non scaly, non tender plaques were present on the dorsum of hands, extensor surface of forearms, face and front of neck [Figures and ]. Only the photo exposed parts of the face were involved. Systemic examination was within normal limits. A clinical diagnosis of drug induced photolichenoid eruption with differential diagnosis of discoid lupus erythematosus was kept in mind. On investigating, the patient had microcytic hypochromic anemia with hemoglobin of 9.8gm%. The differential white blood cell (WBC) count showed increased eosinophils with an absolute eosinophilic count of 850/mm3. All other hematological and biochemical parameters were within normal limits. ANA and dsDNA were repeatedly negative. Skin biopsy revealed a band like lymphocytic infiltrate along the dermo epidermal junction along with abundant melanophages and a mixed eosinophilic-lymphocyte infiltrate in dermis []. A diagnosis of photolichenoid eruption to docetaxel was thus confirmed. The medication was stopped and replaced by estramustine phosphate. Sunscreen, to

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old Caucasian man who had no medical history presented with sacral region pain that had continued for 3 months in April 2012. There was no significant family or psychosocial history. He did not take any medications. He was a computer engineer and his job scope was mainly office work. He lived with his wife and one child in a small flat in Istanbul. He was an active tobacco smoker with a 10 pack year smoking history. Currently, he smoked five cigarettes a day. He did not consume alcohol. His physical examination revealed tenderness and swelling in the sacral region. His vital signs were stable with blood pressure 125/65, pulse rate 70/minute, and temperature 36.2 °C. A systemic examination was normal and no neurological abnormality was detected. Vertebral magnetic resonance imaging (MRI) showed a pathological fracture in L5. After a Tru-Cut biopsy, he was diagnosed as having chondroid chordoma. He was treated with preoperative stereotactic radiotherapy to L5 vertebra at a total dose of 15 Gray in two fractions with CyberKnife followed by surgery in May 2012. We aimed to reduce surgical complications by preoperative stereotactic radiotherapy. Two years later, in May 2014, he presented with lumbosacral region pain and MRI suggested recurrent tumor involving L4, L5, and S1 vertebrae. He was not eligible for surgery and was treated with definitive radiotherapy with intensity-modulated radiotherapy (IMRT) mainly for palliative intent. Between 7 July 2014 and 8 August 2014, he received 40 Gray to L4, L5, and S1 vertebrae in 20 fractions 5 days a week for 4 weeks. In January 2016, he presented with paraplegia. Control imaging showed local recurrence, multiple lung nodules, and sternal metastasis. Imatinib 400 mg was started in February 2016 and continued until July 2017 when control imaging showed the progression of his disease. He received a total of 16 months of treatment. During this period, he received 400 mg/day

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old male with a previous medical history of chronic massive deep vein thrombosis involving the infrarenal inferior vena cava due to hypercoagulability and treatment with oral anticoagulants for 12.5 years was admitted to our hospital because of a 1-month history of resting pain in the right leg. One month prior to admission, the patient was diagnosed at another institution with acute occlusion of the right above-knee popliteal artery, but thrombectomy at this facility was unsuccessful.
Since this patient did not have an available or suitable autologous vascular conduit, he underwent right femoropopliteal arterial bypass with a prosthetic graft (GORE-TEX, W. L. Gore & Associates Inc., Newark, DE, USA). Although no immediate postoperative complications were observed, recurrent graft infections developed 1 and 4 months after surgery, and he presented with high fever (38.9℃). Blood and wound cultures were positive for MRSA. After continued antimicrobial therapy, the infected tissue, including the segment of the prosthetic graft, was completely debrided, and cryopreserved cadaveric iliac arterial allograft reconstruction was performed. Because antibiotic treatment had resulted in elevated serum creatinine concentrations, postoperative imaging was performed using Duplex ultrasonography, which showed patent flow in the femoro-popliteal arterial bypass graft. The patient was discharged without any complications.
During follow-up, the patient did well with a patent bypass graft and no evidence of recurrent arterial allograft infection. However, a CT scan performed 4 years after surgery showed huge aneurysmal changes of the cadaveric allograft, suggestive of its deterioration and degeneration (). Since there was no evidence of recurrent arterial allograft infection, a new prosthetic graft (GORE-TEX) was implanted, and the cadaveric arterial allograft was resected (). Histologic evaluation of the resected allograft revealed that the arterial wall was replaced by fibr

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old woman presented to our emergency department with a painful swelling in the suprapubic region persisted for 3 days. She had a history of LC 10 years back at our center for symptomatic gallstones and had no history of comorbidities. The patient had a history of cesarean section twice. She had a pulse rate of 92/min, blood pressure of 110/60 and a temperature of 37.4°C. Physical examination revealed abdominal tenderness in the suprapubic region, right and left lower quadrant, and exhibited signs of peritoneal irritation, muscle guarding and rebound tenderness. Laboratory tests resulted with white blood cell: 15 200/mm3, hemoglobin: 11.9 g/dl, C-reactive protein: 24 mg/dl, and other biochemical parameters were also normal. On oral contrast-enhanced abdominal computed tomography (CT) performed in the emergency room (), the mesenteric adipose planes were inflamed and contaminated. Minimal free fluid was observed in the periphery of the intestinal loop in the pelvic area. At first, it was not stated on tomographic interpretation that there were gallstones in the abdomen. Considering that the patient had signs and symptoms of acute abdomen, she underwent diagnostic laparoscopy. In exploration, it was observed that the small intestines were edematous, the omentum was inflamed in the pelvic region and the omentum was attached to the anterior abdominal wall, bladder and uterus by gato. Since a clear diagnosis could not be made in the patient for etiology, abdomen was opened with a midline incision under the umbilicus. Infected reactive fluid located between the omentum and the anterior abdominal wall and pelvic region was aspirated. Adhesions due to previous cesarean sections were removed. During the adhesiolysis, stones the largest of which was ~2 cm in size, and abscesses were detected in the omental granuloma/cake (). These stones were thought to remain in the abdomen due to the previous LC. Partial omentectomy with abscesses drainage was performed. The abdome

[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, who had been taking medication of quetiapine as an antipsychotics for depression, experienced mild dysarthria and visited the department of neurology in our hospital. Her symptom was diagnosed as drug-induced lip dyskinesia, which disappeared in a week. Screening head magnetic resonance imaging (MRI) at this time revealed stenosis of the left MCA with no brain parenchymal lesions (), why she was consulted to our department. We performed angiography, confirming moderate M1 portion stenosis (Figures and ). SPECT showed no apparent laterality in CBF, thereby we decided to observe her with no treatment.
Seven months later, the patient experienced mild weakness and numbness in her right hand and visited our department. Although MRI showed no apparent ischemic change in her brain, arterial spin labelling (ASL) of MRI detected the decrease of CBF in the left cerebrum (), which was thought to well correspond for her symptoms. She was admitted and treated with an antiplatelet agent. Two weeks later, she still complained of numbness in her right hand; thereby, we decided to perform left STA-MCA anastomosis to prevent deterioration of her symptoms. Preoperative SPECT showed no apparent laterality in CBF (). On operation, left temporal craniotomy was performed, and the parietal branch of the STA was anastomosed with the M4 portion on the temporal lobe (Figures and ). The intraoperative course was uneventful, and the patient recovered from anesthesia without any new neurological symptoms
Postoperatively, her speech was normal until postoperative day 1 (POD1). On POD2, she exhibited mild speech disturbance, which worsened day by day finally resulting in complete motor aphasia on POD6. Her comprehension was kept normal. On POD3, generalized convulsion occurred, which ceased quickly by diazepam, and levetiracetam was initiated. On the same day, she presented with mild weakness of right upper extremity, which improved gradually and disappeared on POD7. MRI and C

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


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

[User]
RADIOLOGY NOTE:
A 5-year-old boy was referred to the Pediatric Surgery Department with complaints of a large mass in the abdomen for the past 4–5 months. There were no other associated complaints such as nausea, vomiting or abdominal pain. Preanesthetic evaluation revealed no previous surgeries or hospitalization, no medication, no history of any other chronic illness or associated congenital anomalies. Airway examination was normal. Per abdomen examination revealed a tense, distended, nontender abdomen wall with a large solid mass on palpation, which seemed to occupy most of the abdomen []. Radiological evaluation revealed a large 30 cm × 20 cm tumor arising from the right kidney with no intravascular extension. He was posted for excision and surgical staging of the tumor. Preoperative investigations revealed a normal hemogram and normal electrolytes. Renal function tests were also within normal limits.
The patient was taken up for surgery after arranging adequate units of blood and taking informed high-risk consent from the parents. The child was taken into the operation theater (OT) after premedication with midazolam. After establishing basic monitoring and decompressing the stomach with a nasogastric tube, the patient was induced in a slight head up position to decrease respiratory embarrassment due to the abdominal mass. A central venous catheter was inserted into the right internal jugular vein anticipating a large amount of blood loss and fluid shifts.
The abdomen was then opened and revealed a large vascular mass arising from the right kidney []. The tumor was gradually dissected and removed over the next 1 h. Hemodynamic stability in terms of oxygenation and perfusion was maintained with isotonic crystalloids initially and later with packed red blood cells. There was no drastic hypotension noted and the operation seemed to progress uneventfully till the mass was removed from the abdomen. As the surgeons prepared to close the abdomen, suddenly a ventricular tachycardia (VT)

[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, a 12-day-old Asian male infant, weighed 1025 grams and was the second twin born of in-vitro fertilized donor eggs to a 47-year-old nulliparous woman at 301/7 weeks gestation. The pregnancy was complicated by hypertension requiring 10 days of hospitalization prior to delivery for administration of labetolol. Her condition was associated with normal liver function tests and a platelet count of 150,000/ mcl. Prior to delivery, the mother received dexamethasone and ampicillin therapy because of the unknown status of her group B streptococcus cervical cultures. Premature spontaneous vaginal delivery (ascribed to hypertension and mild toxemia) was complicated with breech presentation and poor respiratory effort requiring 30 seconds of positive-pressure ventilation. Apgar scores were 5 at one minute and 7 at five minutes. The infant was intubated for worsening respiratory distress at 20 minutes of life. Initial arterial blood gas demonstrated a pH of 7.35, carbon dioxide of 44 mmHg, PaO2 of 66 mmHg with a bicarbonate level of 23 mg/dl and a base deficit of -1.6. Beractant was delivered via endotracheal tube at 1.5 hours of life. Echocardiography revealed a 2 mm patent ductus arteriosis on the first day of life treated with 72 hours of indomethicin. Repeat echocardiography demonstrated closure of the ductus. Feeds were begun, via naso-gastric tube, on the third day of life. Antibiotic therapy with ampicillin and gentamicin were continued for a total of seven days for presumed bacteremia. Complete blood count at birth was not significantly abnormal revealing a WBC count of 7,500 /mcl, a hematocrit of 53%, however platelets were low at 132,000 and were attributed to the low maternal platelet count. Initial immature to total neutrophil ratio on admission was 0.2. Initial cranial ultrasound was normal for gestational age.
The patient weaned from conventional mechanical ventilation and was extubated to nasal continuous positive airway pressure of 5 cm H2O on the sec

[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 second case involved a 27-year-old male with chronic cervical pain, without any previous medical treatment or imaging, who was referred to our tertiary medical facility. The patient suffered from back pain. To manage his pain, the patient used the services of a chiropractor who used cervical manipulation. Immediately after such a manipulation, the patient felt a severe cervical pain; 30 minutes after manipulation the patient started feeling paresthesia in his hands and legs. The patient was admitted to our emergency room with symptoms of progressive weakness in all four extremities and weakness that was measured as 3/5. No additional symptoms were seen. Immediate MRI demonstrated an epidural hematoma at the C3-4 level ().
The patient underwent immediate surgery to evacuate the hematoma via an anterior approach and C3-4 cage placement. The day after surgery the patient showed a remission of symptoms. At 6 months follow-up his remission was complete.
The incidence of spontaneous spinous epidural hematoma (SSPE) is considered to be very low. Kuker et al. reported that SSPEs most frequently occur at the thoracic or lumbar spine, with incidences in the cervical region being quite rare—only 1 out of 7 reported cases. The hematoma can be epidural or subdural. The presenting symptoms of SSPE may be shoulder pain, interscapular pain, associated with radicular radiation into the upper extremities, neck pain, hemiparesis like in cases of Brown–Sequard syndrome,,,, progressive weakness, or even spinal shock. Symptoms of neck and upper extremity pain with bilateral signs of myelopathy with a sensory level should lead to the suspicion of acute cervical cord compression. A few case reports have shown that SSPE can follow minor traumatic injury as in a motor vehicle accident. To our knowledge, the literature includes only three reports of SSPE immediately following a chiropractic manipulation that was considered the cause of this event.– We conclude from the current case that c

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old female with a history of hypothyroidism presented with continuous cough and shortness of breath. General examination was normal and local chest examination revealed absent breathing sounds on the right side. Pulmonary function test showed a mixed obstructive and restrictive lung pathology. Chest x-ray revealed complete opacity on the right side and contralateral mediastinal shift. Computed tomography (CT) scan of the chest showed infiltrative right hilar soft tissue lesion measures 4 × 5 cm with an endobronchial extension of the lesion obliterating the right main and upper lobe bronchus (Fig. a and b). Bronchoscopy showed a large mass occluding the right main bronchus and encroaching on the carina (Fig. c). Multiple biopsies were taken but were not diagnostic. After a multidisciplinary meeting between pulmonary, radiology and cardiothoracic surgery teams, a decision was made to proceed for surgical intervention. Although, lobectomy including excision of the bronchial involvement was deemed feasible, intra-operatively, preservation of a healthy and functioning lobe was not possible and pneumonectomy was done. Initial examination of the lung specimen on the operating table showed a large mass at the right main bronchus encroaching on the carina with bronchial wall invasion extending to the extra-nodal tissue. There were multiple lymph nodes enlargement and were biopsied. Gross examination showed the main bronchus filled with mucus plug and serial sectioning revealed variable sized bronchioles filled with thick mucoid secretions. Microscopic examination showed lung parenchymal tissue with marked mucin impaction that plugged the bronchial tree and associated with bronchial dilatation (Fig. a). The adjacent pulmonary tissue showed areas of hemorrhage, lung collapse and chronic inflammation. No evidence of malignancy was seen. However, tissue fragments from the peribronchial mass exhibits an excessive numbers of lymphocytes, plasma cells, some neutrophils an

[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 Asian woman was referred to our department for a renal angiogram following 8 months of uncontrolled hypertension despite receiving medications. Initially, the patient presented with severe headache and fatigue. She had no history of smoking or drinking alcohol, was not diabetic, and had no history of diabetes in her family. She had no history of atherosclerosis. Apart from high blood pressure, the result of her physical examination was unremarkable; her general, cardiovascular system, respiratory system, and abdominal examinations were unremarkable. Neurological examination on admission showed that the patient was alert, attentive, and oriented. Her speech was clear and fluent with good repetition, comprehension, and naming. She recalled 3/3 objects at 5 min. All of her cranial nerves were intact. Motor examination revealed no pronator drift of outstretched arms. Her muscle bulk and tone were normal. Her strength was full bilaterally. Her reflexes and sensory were both intact. Her coordination and gait were normal. Laboratory investigations revealed normal complete blood count, serum cholesterol, lipid profile, and renal function (serum creatinine 119 μmol/L). Her left kidney size was normal with measurement of 9.6 cm by 4.8 cm. Renal Doppler ultrasound confirmed renal artery stenosis with renal resistive index of 0.58. The percentage of renal artery stenosis in the two branches of the left renal artery was 70% and 75%, respectively , before the first balloon angioplasty; after the first balloon angioplasty, these percentages remained the same. After the second ballooning and stenting procedure, revascularization was achieved. The patient had been attending a hypertension clinic and receiving antihypertensive drugs for the past 8 months on a regular basis under close observation. Despite this treatment and care, her blood pressure remained high at 175/110 mmHg, which the attending doctor concluded to be uncontrolled blood pressure. Initial imaging indi

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male visited our hospital because of severe pain in the popliteal area that occurred when the knee was flexed actively beyond 100° during squatting or flexed passively beyond 120° in the crossed leg position. He had struck the lateral side of his left knee against the fence alongside a ski slope while snowboarding 8 weeks earlier, and the symptoms aggravated despite conservative management. He had no history of trauma prior to that event. On physical examination, the anterior drawer test was grade 1 (4 mm) and the Lachman test result was a firm end point. The pivot shift, posterior drawer and valgus stress tests were negative. The patient complained of tenderness around the medial femoral condyle (MFC).
Plain radiographs of the knee were normal. However, magnetic resonance imaging (MRI) of the left knee showed a bone marrow contusion on the lateral tibial plateau, sprains of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL). In addition, MRI demonstrated a rounded and well-demarcated soft mass anterior to the PCL, and the ligament was slightly deformed due to the mass. The cystic lesion was seen originating from the deep recess between the posterior root of the MM and the PCL that bulged into the posteromedial joint space with a signal change in the posterior root of MM and the PCL adjacent to the cyst ().
Arthroscopy revealed a cystic lesion, about 7 mm in diameter, originating from the anterior aspect of the PCL between the posterior root of the (MM) and the PCL (). During knee flexion, the cystic lesion enlarged as it was compressed between the posterior root of the MM and the PCL, and it impinged on the articular cartilage of the posterior MFC, the posterior root of the MM, and the PCL (). In addition, a dimple was found on the articular cartilage of the posterior MFC adjacent to the cystic lesion (). When

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old woman underwent transurethral resection of bladder tumor (TURBT) at our institute in 2004; her pathological diagnosis was a high-grade UC with adenocarcinomatous differentiation (pT2a, G2>G3). Radical cystectomy was conducted. Only carcinoma in situ (CIS) was found in the surgical specimen, and the surgical margin was negative. There was no cancer cell infiltration in the resected uterus or anterior wall of the vagina, and no lymph node involvement was detected. The patient developed continuous pain and bleeding from the residual vagina in 2010, and a tumor was found in the residual vagina; magnetic resonance imaging (MRI) showed it to be located on the anterior wall (). A biopsy of the tumor revealed a pathological diagnosis of adenocarcinoma (). Computed tomography (CT) and bone scintigraphy revealed no metastasis. Based on a preoperative diagnosis of a primary adenocarcinoma occurring on the residual vagina, tumor resection was performed (). The sigmoid colon was partially resected as it was strongly adherent to the tumor. On pathological examination, adenocarcinoma and SCC were detected (); on immunohistochemistry, sections of the tumor were positive for the SCC markers CD56, chromogranin A, and synaptophysin and were negative for the urothelial carcinoma markers GATA-3, p63, uroplakin, thrombomodulin, and 34βE12. We then reexamined the original TURBT specimen and confirmed the presence of SCC (). Adenocarcinoma and SCC were mostly present in the superficial layer of the TURBT specimen, while high-grade UC was found in the deeper layers where muscle invasion was present. Based on these findings, the tumor was diagnosed as a recurring bladder tumor. Local recurrence and pelvic bone metastasis were detected via MRI 3 months after the patient underwent surgical resection of the vaginal recurrence, whereupon she underwent radiation therapy (52 Gy, 26 fractions). She developed ileus in January 2011 and underwent release surgery. Subsequently, multiple l

[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 came to our outpatient clinic because of blood pressure level abnormality (200/100 mm Hg), which had persisted for >30 years. The patient was found with abnormal blood pressure when he was 10 years old. Maximal blood pressure level at 260/110 mm Hg was recorded during the physical examination for several years. The patient had a smoking history of 20 years and no similar family medical history was reported, but suffers no other significant clinical symptoms. In recent weeks, he suffered dizziness and was treated with oral antihypertensive medications. The treatment regime was nifedipine (controlled release tablets 30 mg Bid), irbesartan and hydrochlorothiazide (tablets 150 mg qd), and irbesartan (150 mg qd). The curative effect is limited and his blood pressure remains at elevated level. On physical examination, the patient had a pulse rate of 68 bpm, a respiratory rate of 18 bmp, a body temperature of 36.7°C, and a body mass index of 23 kg/m2. The first medical evaluation in our hospital revealed a regular heart rate of 68 bpm and a grade 4/6 systolic murmur at the position of T1-T3 on back. The murmur conducted to neck. His blood pressure was measured as 183/92 mm Hg in the left arm and 175/95 mm Hg in the right arm, 96/64 mm Hg in the left ankle, and 101/60 mm Hg in the right ankle (left ankle brachial index: 0.54, right ankle brachial index: 0.56). It indicated a significant differential blood pressure between the upper and lower limbs. Echocardiography showed the left ventricle did not present severe abnormal dimensions and impaired systolic function, the descending aortic arch could not be observed, and aortic valve regurgitated moderately. Computed tomography angiogram (CTA) revealed a type A interrupted aortic arch with complete discontinuity of the aortic lumen distal to the origin of the left subclavian artery, and a massive aorta arch which included

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old right hand dominant male presented in the outpatient department with complaints of shortening and inability to extend middle finger of the left hand. On examination, there was an extension lag at the middle finger, poor grip strength, and reduced height of middle ray (). The patient had a history of incidental trauma to the left hand for which he was treated conservatively. Over the 6 months after the trauma, the patient started developing the symptoms in the form of gradual shortening and reduced handgrip strength and presented to our hospital. On investigation, blood parameters including calcium levels and parathormone levels were normal. The X-ray showed pathological fracture of third metacarpal with osteolytic lesion involving base of second metacarpal and carpal bones (). Magnetic resonance imaging showed almost complete osteolysis of the 3rd metacarpal with only the base visible and fracture of the 4th metacarpal with thinning and resorption of the bone and surrounding soft tissue. It also showed pathological fracture involving capitate with patchy areas of osteolysis (). Serial X-rays taken at 4 weeks, 8 weeks, 12 weeks, 18 weeks, and 6 months revealed that there was progressive concentric reduction of metacarpal shaft, first involving third then fourth metacarpal giving appearance of a sucked candy (). At this point in time, we kept in mind the differential diagnosis of primary bone tumor like aggressive giant cell tumor or aneurysmal bone cyst or metastasis from any other primary tumor. Positron emission tomography scan was done to rule out any tumor, however, no evidence of tumor was found. Parathyroid hormone levels were within normal limit. Biopsy suggested myxoid areas, proliferating vessels interposed with skeletal muscle fragments with no evidence of malignancy. Based on the clinical-radiological and histopathological presentation, we made a diagnosis of vanishing bone disease. Since there was increased proliferation of blood vessels, we

[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 previously healthy 38-year-old white man presented with left leg tightness and soreness. He had no significant past medical history but did have an extensive international travel history from his military service. His family history was notable for a maternal history of bladder cancer; a social history disclosed a remote 13-year chewing tobacco history with current cigar smoking accruing to approximately 1.3 cigar-years.
Over a span of approximately 6 months, his left leg tightness and soreness progressed to include his left low back along with sensory changes along his left lateral foot and heel that rendered him with intermittent physical limitation. A review of his symptoms was otherwise unrevealing with no constitutional symptoms. A physical examination was notable for “shotty” supraclavicular lymphadenopathy.
An initial evaluation at an outside institution was ultimately inconclusive. Serial magnetic resonance imaging (MRI) and computed tomography (CT) of his chest, abdomen, and pelvis showed progressive and aggressive-appearing mixed sclerotic-lytic lesions in his iliac and sacral regions. One sacral lesion extended into the left S1 neural foramen. There was associated widespread lymphadenopathy involving the supraclavicular, mediastinal, abdominal, and pelvic regions. Multiple tiny pulmonary nodules up to 10 mm were also present. All imaging appeared consistent with multifocal osteomyelitis although a malignant or infectious process could not be ruled out.
The results of cursory laboratory tests were unremarkable and notable for only a mildly elevated sedimentation rate of 39 mm/hour. Rheumatic serologies and hematologic workup were unrevealing. Extensive infectious studies yielded no identifiable microorganism.
Multiple biopsies were sought. A left axillary lymph node excisional biopsy disclosed reactive lymphadenopathy with scattered pigment-laden macrophages and extensive fatty replacement. Right and left iliac bone marrow biopsies showed marrow fibrosis

[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 18-month-old female patient was admitted to Shanghai Children's Hospital (Shanghai, China) for appearant snoring symptoms accompanied by mouth breathing and sleep apnea. In addition, the patient presented with weak aspiration and nasal leakage during fluid intake.
The routine physical examinations showed a wide fissure which split from the palate vertical anterior cleft to 1/3 of the hard palate. There was no congestion in pharyngeal mucosa with the uvula in the middle. Bilateral tonsils showed hypertrophy without exudation. Epiglottis and bilateral pear-like nest were not clear. The pear bone could be seen. Thus, the patient had incomplete cleft palate. Meanwhile, we also found an unclear-bordered uplift in the left palate and a soft mass which could be moved in the right soft palate trailing edge with endoscopy (Fig. ). Then, the patient underwent a computed tomography (CT) scan. Consistently, radiographs of the palate revealed a mass convex to the pharyngeal cavity which was about 27 mm × 21 mm × 26 mm in size (Fig. ). In addition, no obvious abnormality was found on the nasopharyngeal bone or soft tissue. According to the above examination, the diagnosis for the patient was incomplete cleft palate and soft palate vascularized space-occupying lesions (involving the left posterior wall of the nasopharynx, most likely fibrous hemangioma).
The patient was treated by palatal lump resection and cleft palate repair with endoscopic guidance from the oral cavity while under general anesthesia. During the surgical resection process, the mass was dissected from the dorsal side of the left soft palate with the pharyngeal mucosa preserved and the nasopharyngeal mucosa completely removed. At the end of the surgery, the plasma radiofrequency knife was used to ablate the residual tumor tissue. After proper hemostasis, the cleft palate was also repaired. Postoperative symptomatic treatment of infection was done with nasal feeding. Histological examination showed that there wa

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old man was admitted with sudden aphasia and right hemiplegia. His score on the National Institutes of Health Stroke Scale (NIHSS) at admission was 18. The time between the onset of symptoms and admission was 30 minutes. The medical history of this patient showed that he had been admitted to our hospital 5 months previously because of left MCA territory infarction. At that time, cerebral angiography revealed a left cervical ICA stenosis with intraluminal atheroma (). The patient was later discharged against stent recommendation. Brain CT scans performed at the same time revealed a high-density spot at the carotid and Sylvian cistern and no abnormalities except an old localized cerebral infarction in the left temporoparietal lobe along the MCA territory ().
After ruling out intracerebral hemorrhage, a full dose of rt-PA (63 mg) was administered as a continuous infusion; the door-to-needle time was 40 minutes. After administering rt-PA, the patient's NIHSS score was 17. Subsequent MRI revealed an acute cerebral infarction in the left MCA territory with a perfusion-diffusion mismatch (). Cerebral angiography revealed an embolic left terminal ICA "T" occlusion (). Intra-arterial mechanical and chemical thrombolysis (urokinase, 200,000 U) for 40 minutes did not provide recanalization. Since thrombolysis and endovascular recanalization failed and there was sufficient time to restore the cerebral circulation by microsurgical embolectomy, which must be performed within 8 hours after the onset of symptoms, we decided to perform that procedure. The preoperative NIHSS score was 16.
The patient underwent microsurgical embolectomy via a left pterional approach 30 minutes after the interventional procedure. A left ICA occlusion was confirmed in the operative field (). After arteriotomy, the embolus was removed (). The cerebral circulation was restored at 6.5 hours after the onset of symptoms. The patient's postoperative NIHSS score was 12. Postoperative angiography reve

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old female presented to our clinic as a new patient for excision of a previously diagnosed right heel leiomyoma. Six months prior, she had consulted a dermatologist for a painful area on her right heel that had been present for approximately three to six months. The area was raised, tender, firm, and was increasing in size. Physical exam at that time revealed a 2 cm raised, firm, noncompressible nodule on the posterior right heel, which was tender to palpation without any redness or streaking. X-rays were nonspecific and revealed that the soft tissue shadow was “not connecting to bone.” A punch biopsy taken at a follow-up visit with the dermatologist revealed a leiomyoma of the heel. She continued to experience pain (8/10 in severity) and was seen in our clinic for evaluation six months later. She had no other areas of bleeding, itching, or pigment changes of the skin. Physical exam revealed a palpable 2 cm x 1 cm nodule on the posterior aspect of the right heel which was freely mobile and tender to palpation (Figure ). Pulses and sensation were normal throughout in both lower extremities and no other gross abnormalities were noted.
The patient did not have a history of frequent running, gout, diabetes, constitutional symptoms, or weight loss. Due to the unusual location of this leiomyoma, Reed’s syndrome was considered in the differential diagnosis, and the patient was referred for a gynecological oncology appointment. However, because she had no personal or family history of other similar soft tissue masses, uterine fibroids, renal cell carcinoma, or skin cancer, there was a low index of suspicion. Her past medical history was nonspecific for any condition predisposing to cancer.
She was scheduled for surgery two weeks later. The tumor was excised (Figures -) and sent for pathology confirming cutaneous leiomyoma (Figure ). Follow-up visit at two weeks status post-excision showed a well-healing

[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 Korean woman visited our out-patient clinic for severe back pain that had developed spontaneously. The patient was a student at the college of physical education. The patient initially noticed a kyphosis in the lumbar area around three years ago. However, since it was not associated with any significant disability or pain, she was treated conservatively at that time. Yet after a routine exercise program for entering the college of physical education, she developed low back pain for which she was prescribed oral medication. However, the back pain did not improve with the oral analgesics and it started to increase in intensity.
At the time of presentation at our outpatient clinic, a lumbar kyphosis was noticed in the standing position. Grossly, the kyhosis and instability of the lower back were moderate to severe. The kyphosis was found to be flexible because the kyphosis could be corrected when the low back area was pushed anteriorly by the surgeon's hands. She had severe lower back pain. The visual analogue score (VAS) was 8 points. The patient also showed generalized ligamentous laxity. There were no neurological signs or symptoms. The initial radiographs showed a hypoplastic change in the spinous processes and lamina of the lumbar vertebrae, multiple spondylolysis and lumbar instability (). The magnetic resonance imaging (MRI) demonstrated the presence of kyphosis of the upper lumbar spine and multiple levels of spondylolysis (). A three dimensional computed tomography (CT) scan was performed to get a complete picture of the lesions. The CT scan showed asymmetric complete spondylolysis at the left L2/3/4 levels () and the right L1/2/3 levels (). The activities of daily living were severely limited, and so a surgical operation was performed. Obvious instability of the L2/3/4 segments was noted intraoperatively. The pars interarticularis of L2/3/4 were dystrophic, so defect repair was impossible. Posterior lumbar interbody fusion was not chosen. Becaus

[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.