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

[User]
RADIOLOGY NOTE:
A 30-year-old man underwent right hepatectomy at previous hospital, due to trauma, in August 2012. At that time, a thoracotomy in the eighth intercostal space was performed for direct closure of the diaphragm. Pooling of right pleural effusion was treated with drainage up to postoperative day (POD) 9. The patient recovered and was discharged on POD 14. In November 2012, he presented with a right DH and strangulation of the ileus of the small intestine. He underwent laparotomy at the same previous hospital, found the defect which was separated from the previously sutured area of the diaphragm, and repaired it.
In May 2017, the patient presented to the local hospital with abdominal pain and vomiting and was diagnosed with an intestinal obstruction; an ileus tube was inserted and the patient was referred to our hospital for treatment. Upon admission, the physical examination was unremarkable, and laboratory findings, including complete blood count, erythrocyte sedimentation rate, and biochemical tests, were all within normal limits. Chest and abdominal radiographs revealed colon gas in the right intrathoracic space (Fig. a, b). On contrast imaging, the ileus tube in the transverse colon was observed to be incarcerated in the right intrathoracic space (Fig. c), a finding which was confirmed on computed tomography (CT) of the chest and abdomen (Fig. d). The patient was diagnosed with a DH and underwent laparoscopic hernia repair.
The surgical repair was performed with the patient in the left half-lateral decubitus position. Four laparoscopic ports were placed in the abdomen as follows: a 12-mm port at the umbilicus for the scope, two 12-mm ports at the right lateral lesion as working ports, and a 5-mm port at the middle of the upper abdomen used as an assistant. Under laparoscopic view, the transverse colon and small intestine anastomosis were found to be adherent to the right hemidiaphragm (Fig. a), and we proceeded with careful separation

[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 woman without a medical history showed headache and fever for a few days and then suddenly presented with personality changes with violent behavior and speech disabilities requiring her admission to the department of neurology in our hospital. A diagnostic image of her brain showed minimal changes such as mild brain edema, and cerebrospinal fluid (CSF) analysis showed lymphocyte pleocytosis suggesting inflammatory changes. As the first presumptive diagnosis was either viral encephalitis or autoimmune encephalitis, intravenous high dose steroids, acyclovir, and glycerol were administrated. Several days after her admission, she also showed involuntary movements, disturbance of consciousness, and central hypoventilation; she was managed by assisted respiration and medicated with midazolam and propofol. Since autoimmune encephalitis was the most possible diagnosis according to further examinations, plasma exchange treatment was also started, and the patient was introduced to our department for examination for a potential ovarian teratoma. Nevertheless, neither internal examination nor transvaginal ultrasonography detected an ovarian teratoma. T1-weighted pelvic magnetic resonance imaging (MRI) revealed a 5 × 7 mm fat intensity in the right ovary that showed the possibility of a teratoma (). T2-weighted pelvic MRI showed that a large number of similar-sized ovarian follicles surrounded the teratoma (). Initially, abdominal computed tomography (CT) with 10 mm slice thickness did not detect any fatty component in the right ovary. However, by referencing to the MRI findings, CT with 1 mm slice thickness eventually detected the fatty component in the right ovary. The mean CT number of that showed −62.5 HU (Figures and ).
After 18 days from the first visit to our hospital, the patient underwent a laparoscopic operation for complete resection of the right ovarian teratoma. The macroscopic appearance of the right ovary did not show any abnormalities (). We perfor

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


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

[User]
RADIOLOGY NOTE:
The patient was a 73-year-old Chinese woman with osteoarthritis in both knees. In the recent half year, she had been suffering from intractable right knee pain with failed conservative treatment and prepared for right side TKA. She had a 27-year history of hypertension and her blood pressure was controlled well by medication. She had no other medical history, including smoking history. Her BMI was 24. The physical examination showed a limited range of motion (ROM) of 0°–120° without varus or valgus deformity. Preoperative X-ray showed narrow medial knee joint space and osteophyte formation without vascular calcification (Fig. ). The peripheral pulses and capillary refill were normal, although the preoperative Doppler ultrasound showed arteriosclerosis with plaque formation in the arteries in both legs.
The right side TKA with a posterior stabilized design (LPS, NexGen, Zimmer, Warsaw, USA) was performed under general anesthesia. A tourniquet was applied for 70 min at a pressure of 250 mmHg. The whole surgery was completed without any complications and there was normal intraoperative bleeding at the surgical site. The postoperative X-ray showed successful implantation for the right knee (Fig. ).
However, immediately after the surgery, routine peripheral pulse check in the operating room found absent dorsalis pedis artery pulse in the right foot. The patient was closely monitored in the recovery room. After approximately 2 h, there was no improvement in peripheral pulses, capillary refill, and oxygen saturation. In consideration of the high possibility of arterial occlusion, the vascular consultant recommended using 1000 U heparin for anticoagulation and immediate evaluation by arteriography for diagnosis. An emergency arteriography under local anesthesia showed that there was a short segmental occlusion of the popliteal artery (Fig. ). Then the angioplasty was performed with a balloon with a diameter of 5 mm for 3 min. Follow-up imaging showed excellent blood flow al

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old man with a history of melena and significant anemia presented to the Gastroenterology Department of our hospital for outpatient esophagogastroduodenoscopy (EGD).
The patient noticed melanotic stools about 2 weeks before presentation, and around the same time, he started experiencing dizziness, generalized weakness, and intermittent epigastric pain. He denied any weight loss, loss of appetite, or night sweats. The patient was a former smoker and had quit smoking cigars almost 2 years ago. He was a social drinker and denied illicit drug use. Family history was significant for colon cancer in his maternal uncle.
EGD performed by the gastroenterologist showed a large submucosal mass with central ulceration located in the proximal gastric body. A biopsy of the gastric tissue was obtained. The patient developed acute GI bleeding after the biopsy was taken. Endoscopic hemostasis was successfully achieved with epinephrine injections; however, the patient had to be transfused with multiple units of packed red blood cells due to significant blood loss and anemia. He was then admitted to the medical intensive care unit (MICU) for close monitoring.
Computed tomography (CT) scan of the abdomen and pelvis with intravenous (IV) and per os (PO) contrast revealed a 19 × 16 × 13 cm mass located in the left upper quadrant. The mass appeared to originate from the stomach’s greater curvature and was predominantly necrotic/cystic in nature, with enhancing thick internal septations. The gastric biopsy results showed moderate chronic active gastritis with lymphoid aggregation, and the biopsy specimen was found to be Helicobacter pylori (H. pylori) positive. The patient was started on triple therapy and was taken to surgery for abdominal mass resection, partial gastrectomy, distal pancreatectomy, and splenectomy. The postoperative course was complicated by an esophageal leak requiring re-exploratory laparotomy and esophageal stent placement. The stent was removed 5 weeks later

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 35-year-old African American male presented with a one-month history of worsening lower back and bilateral lower extremity pain, intermittent night sweats, and 32 kg unintentional weight loss over the course of a year. He did not have saddle anesthesia or urinary or fecal incontinence. He was initially seen in a primary care clinic and was diagnosed with sciatica. As symptoms continued to worsen, he underwent a computed tomography (CT) scan of the lumbar scan as an outpatient that was concerning osseous spinal metastasis. He was started on prednisone 10 mg daily and was referred to the oncology clinic at our center. Prednisone gave him minimal symptomatic relief. While waiting to be seen in the oncology clinic, the patient had an episode of leg weakness with near-fall prompting him to present to the emergency department of our hospital and was admitted for further evaluation. His vital signs were stable. He had no palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Neurological exam was normal with intact strength and sensation in both lower extremities.
His complete blood count and serum electrolytes were normal including a normal serum calcium level at 8.1 mg/dL. He tested negative for human immunodeficiency virus 1 and 2 antibodies. Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine showed several enhancing lesions in T11, T12, L3, L4 vertebral bodies, right sacrum, and ilium that were concerning metastatic disease. There was effacement of the right lateral recess and right neural foramen at the L3-L4 and effacement of the left lateral recess and left neural foramen at the L4-L5 due to tumor retropulsion (Figures –). In addition, a small epidural tumor was noted at the T5 vertebral level without significant spinal canal stenosis or cord compression. Imaging was also concerning osseous metastasis involving the sternum and multiple ribs. Incidentally, narrowing of the neural foramen at

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female underwent routine fetal echocardiographic screening at the 22nd week of gestation. The pregnancy was normal without any maternal complications, such as hypertension, diabetes, eclampsia, or infections during gestation. In addition, screening for Down syndrome revealed a low risk that did not indicate a need to conduct amniocentesis for a chromosomal abnormality test. However, the fetal ultrasound demonstrated severe TR, based on Vmax = 3.8 m/s, with estimated diameters of the cardiac chambers of LV = 11 × 19 mm, RV = 19 × 24 mm, LA = 12 × 10 mm, and RA = 13 × 16 mm. Subsequently, the female was referred to a pediatric cardiologist for advice. Because the age of the female was 40, which is a high-risk factor for birth defects, and since TR is quite commonly observed in fetal ultrasound screening, the cardiologist suggested genomic sequencing analysis of free fetal DNA in maternal blood. However, the parents refused this analysis.
The baby was born safely in our institute, and the first echocardiography examination postnatally demonstrated good heart function and normal structure as well as normal sizes of the 4 chambers. However, 6 months later, the baby was brought to our department due to excessive sweating and decreased milk consumption. The physical examination showed that the body temperature of the girl was 36.8°C, her heart rate was 150 beats per minute, and her respiration rate was 42 beats per minute. The blood pressure of the four limbs was as follows: 92/44 mmHg at the right upper limb, 96/58 mmHg at the left upper limb, 101/60 mmHg at the right lower limb, and 103/54 mmHg at the left lower limb. In addition, she presented a critically ill face, her lips and complexion were pale, excessive perspiration, and coarse breath were noted, but there were no rales. On auscultation, her heart boundaries were enlarged, the apex was shifted, and grade I systolic

[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 present case is about a 20-year-old male patient who presented with an asymptomatic swelling on the left fronto-parieto-occipital region of the scalp since last 10 years. The swelling was insidious in onset, started as single papular lesion in the parietal region and gradually progressed to reach the present size []. Contrast enhanced computed tomography scan of the head showed that the swelling was outside the skull bones, without any intracranial extension. Patient had gone to a plastic surgeon 5 years back and had undergone partial excision of the swelling. Excised tissue was subjected to histopathological examination at that time, but the report was not available with the patient. The swelling again increased in size and attained the present size. There was no history of trauma or any manual or other manipulation at the site prior to the development of the swelling. There was no history of spontaneous regression or reduction in size. There was no history of fainting and other localizing neurological sign. There was no feature suggestive of tuberous sclerosis such as adenoma sebeceum, seizures, ash leaf macules or confetti like macules. On physical examination, a well-defined circumscribed swelling measuring 14 cm × 11 cm, presented over scalp, involving left fronto-parieto-occipital region with some extension over right []. It was firm in consistency and non-compressible with a smooth surface. The skin and hairs overlying the swelling were normal except the brownish discoloration of the skin. Linear scar of size 13.5 cm × 0.5 cm of previous surgery was present over the swelling on the left side []. Systemic examination including skin, mucosa, nail and hair did not show any abnormality. A 4 mm incisional punch biopsy at the margin of swelling was sent for histopathological examination, which showed hyperplastic epidermis with thickened reticular dermis with dense collagen bundles that were arranged haphazardly in lower reticular dermis []. A single terminal f

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


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

[User]
RADIOLOGY NOTE:
A 28-years-old wheelchair-bound man presented to the clinic complaining of severe back pain and an inability to walk for the past two weeks. The patient had no history of actual trauma and had only suffered from minor back pain, after pulling a rug a month prior. Although the pain was initially low in severity, it had gradually increased in intensity and lead to severe disability and progressive weakness in both legs. He also complained of diffuse paresthesia in both legs.
He was a bodybuilder and the only positive finding in his past medical history was the arbitrary use of licensed and unlicensed drugs in the field of bodybuilding. On physical examination, the patient could hardly stand. Manual muscle testing revealed a bilateral weakness in the extensor muscles of the big toe (severe on the left and moderate on the right) and ankle dorsiflexors (moderate on both sides), but sphincter function remained intact. The power of the ankle plantar flexors and quadriceps were also completely normal.
In laboratory testing, a raised C-reactive protein was the only significant finding. In the review of imaging studies, we found a compression fracture in L2 and a burst fracture in L5 with canal compromise and intravertebral vacuum cleft sign in L5 (). Magnetic resonance imaging (MRI) especially on the axial plane showed a double line sign; a linear area of decreased signal intensity (vacuum cleft) within an area of increased signal intensity representing intravertebral fluid (). We could not find any paravertebral soft tissue mass or abscess in this spinal region, and a whole-body bone scan showed isolated increased uptake in only these two areas without any signs of metastatic involvement.
Due to the presence of the neurologic deficit (impending cauda equina), we opted not to take a fine needle biopsy, and instead proceeded directly to the surgical intervention (by F.O-K′ surgical team). We placed the patient in the prone position, and a total L5 lamin

[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 male, 52-year-old patient visited the Instituto Nacional de Cancerología (INC) in Bogotá, Colombia, because of the development of a mass in the back region. There had been progressive growth and multiple drainage attempts due to a suspected abscess at various referral sites without relief. He was given non-oncological surgical resection in another institution, and his pathology report was compatible with high-grade sarcoma with positive margins. Additionally, he referred to bilateral vision loss that had been evolving for one month. The initial clinical exam revealed a patient with normal vital signs who was disoriented with regard to space and time though awake and had poor communication with the examiner. He presented a hyperpigmented tumor measuring 10 x 8 cm in the back region, along with a scarred postsurgical lesion without inflammatory signs. The biopsy was reviewed by the INC Pathology Department, which indicated a high-grade sarcoma compatible with myxofibrosarcoma.
He was examined by the Ophthalmology Department, which considered bilateral retinal detachment probable. An abdominal computed tomography (CT) scan was performed, which showed a diffuse density alteration of the subcutaneous cellular tissue, without evidence of lesions, probably due to edema. A chest computed tomography (CT) scan with contrast showed an undefined heterogeneous mass dependent on the soft tissues in the posterior thorax wall, with infiltration signs in the muscular plane and the density alteration of the subcutaneous cellular tissue and skin (See Figure ). He was examined by clinical oncology, surgical oncology, and radiation oncology services, which indicated he was not a candidate for chemotherapy, surgical treatment, or radiotherapy because of the significant extension of the tumor into the upper and lower back, the inadequate response of these tumors to chemotherapy, and the patient’s poor Zubrod performance score.
During inpatient care, the patient showed substantial clinic

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


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

[User]
RADIOLOGY NOTE:
A 10-day-old male infant was referred to our hospital because of suspected congenital hypothyroidism. The patient presented with symptoms of airway obstruction, such as an inspiratory stridor and retracted breathing. A hormonal test revealed subclinical hypothyroidism with a free thyroxine level (1.44 ng/dL) within the reference range, although the thyroid stimulating hormone (TSH) level (34.6 μIU/mL) was increased beyond the normal range. Laryngo fiberscopy revealed a lingual mass compressing the epiglottis (Fig. ). Enhanced computed tomography (CT) and thyroid scintigraphy revealed that the mass was an ectopic thyroid with the absence of a normal pretracheal thyroid gland (Figs , ). The patient received oral levothyroxine at a dose of 12 μg/kg/day for 4 weeks to lower the TSH level and reduce the volume of the ectopic thyroid tissue. However, we observed no reduction in the volume of the thyroid tissue and a concomitant progression in his symptoms of airway obstruction. He underwent surgery to relieve the airway obstruction when he was 2 months old. Under general anesthesia, nasotracheal intubation was performed in a sniffing position, and a transverse skin incision measuring 2.5 cm was made at the level of the hyoid bone. We split the hyoid bone at the midline, dissected the base of the tongue towards the foramen cecum, detected the ectopic thyroid mass, and suspended the mass by suturing it to the hyoid bone (Fig. ). We used 5–0 monofilament absorbable sutures and sutured between the lingual thyroid and the hyoid bone. The bite length of both the lingual thyroid and hyoid bone was about 3 mm. The points of suturing were to the lateral side of the lingual thyroid and to the front of it. The total number of suture threads was 3. The degree of suspension of the ectopic thyroid was guided by an intraoperative laryngo fiberscopy to confirm the complete elevation of the epiglottis. The

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old woman presented with pain and active function loss in her left shoulder, and was admitted to our hospital in June 2017. Her shoulder problem had started 3 months earlier, and there was no history of trauma or fracture. At first the pain was intermittent and bearable, but then gradually increased. On examination, there were no positive signs except for localized pain. A radiologic examination on 3 April 2017 found no destruction of the shoulder (Fig. ). Pain at the shoulder joint became gradually aggravated, together with the appearance of shoulder joint dysfunction. Two months later, physical examination revealed mild swelling of the shoulder, and markedly restricted shoulder and elbow motion. Mild distal nerve function defects appeared gradually. Radiography on 3 June 2017 showed that the head of the humerus had disappeared within the past 2 months (Fig. ), which was confirmed by magnetic resonance imaging (Fig. a, b).
The patient is a healthy, active individual with no history of weight loss, anorexia, or fever during this period. General and systemic examination findings were within normal limits. Routine laboratory investigations were also normal, including levels of serum calcium, phosphate, alkaline phosphatase, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. An open biopsy of the lesion revealed that the bony tissue had been replaced by fibrous connective tissue, and small areas of bony trabeculae with occasional osteoclasts were visible (Fig. ). There was no evidence of malignancy or tuberculosis. Because of the lack of any clinical findings or supporting data for other causes, the features were confirmatory of GSD. Computed tomography of the shoulder joint (Fig. ) revealed a bony defect of the glenoid cavity.
We performed surgery involving glenoid cavity amplification with an autologous iliac bone graft and a reverse total shoulder arthroplasty. The grafts were from autologous iliac bone (Fig. , Fig. ). A deltopectoral

[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 Greek male student presented for screening test in order to get a health certificate. Physical examination revealed splenomegaly, although the patient was asymptomatic. No other clinical signs were detected. Ultrasonography and Magnetic resonance imaging (MRI) showed a hypoechogenic mass involving the spleen and the splenomegaly (Figure ). Preoperative evaluation led to the possible diagnosis of hemangioma of the spleen. The patient was subjected to laparoscopy, which demonstrated a solid tumor of the spleen. Laparoscopic splenectomy was performed. Operative time was 65 minutes. Postoperative recovery was uneventful, the drain was removed on the second postoperative day and the patient was discharged on the same day. Histologic examination showed a capillary hemangioma of a spleen weighing 850 gr. The patient remains asymptomatic 6 months after the operation.
Following induction of general anesthesia and endotracheal intubation, a nasogastric tube and a urinary catheter were inserted, and compression stockings were applied. The patient was placed on a beanbag in a 60-degree right lateral decubitus position. The right brachial plexus was protected with a pillow roll and the left arm was supported by a splint. The patient was positioned so that the table could be flexed to create a wider working space in a reverse Trendelenburg position. The surgeon and the scrub nurse stood to the patient's right, and the assistants stood to the left. The video monitors were placed on each side of the table, above the level of the patient's shoulders.
Pneumoperitoneum was established using a Veress needle to a pressure of 12 mm Hg. Four ports were used: the first 10-mm trocar was inserted at the left margin of the umbilicus. The other three 5-mm operating trocars were positioned as follows: the first trocar was on the median line, 8 cm above the umbilicus, a second operating trocar in a left subcostal position on the axillary line to enable gastroepiploic mobilization,

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


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

[User]
RADIOLOGY NOTE:
A 26-year old Caucasian man sustained multiple injuries in a motorcycle accident in 2001. He presented with a right posterior hip dislocation and acetabular fracture as well as an open right distal tibia and fibular fracture which necessitated a below-knee amputation (BKA). He was treated with open reduction internal fixation (ORIF), and within 72 hours, received post operative prophylactic RT to the right hip including the acetabulum, femoral head and neck, as well as the greater trochanter. Treatment involved an open 8 × 15 field using anteroposterior-posteroanterior (AP/PA) 6-MV photons to 7 Gy in one fraction, without bone shielding.
The patient tolerated RT well. He did have multiple revisions to the base of his right residual limb over the years for episodes of poor wound healing and necrosis, but otherwise had an uneventful course until three years after RT, when he presented with a shooting painful neuroma of the right BKA stump and femoral nerve palsy. He did well following stump revision and neuroma excision with intramedullary replacement of nerve endings, and his femoral nerve palsy resolved.
Seven years later, now 37-years old, the patient began to experience severe shooting pain along his right residual extremity. This had started just 10 hours after switching to a new prosthesis, but the pain persisted even on return to his old prosthesis, and radiographs showed several benign appearing proximal tibial and distal femoral bony cysts. He returned to the operating room for a BKA stump revision and tibal/peroneal neurectomy revision.
At the time of discharge, he began to notice a constant right sided hip pain which rapidly worsened over the next four months. The pain eventually became so intolerable that he had to remain bed ridden for three weeks, until he presented to the ED. A few days prior to presentation, he had noticed a palpable mass in the right hip. When positioned upright, he was most uncomfortable, and his pain

[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 35-year-old female was admitted to our outpatients' clinic with a compliant of an eight-month history of right heel pain which had increased gradually in the past two months. The pain of the patient often occurred at night and it was not related with daily or sporting activities and most commonly felt at rest. Her symptoms started insidiously and she did not mention any trauma. She had been smoking 20 cigarettes per day for 10 years, and she did not suffer from any medical condition. Furthermore, no hereditary disease was found in the patient's family history.
Physical examination revealed no abnormal findings. Her blood tests were all normal, including all the inflammatory markers. The patient underwent plain radiograph examination and a 21-millimeter-diameter cystic lesion was observed in the long axis of the calcaneus. The magnetic resonance imaging (MRI) examination was applied for the confirmation and it showed 22 × 20 mm intraosseous cystic lesion at the posterior part of the calcaneus which revealed hypointense signal on T1-weighted images and hyperintense signal on T2-weighted images (). The contrast-enhanced MRI was not available for this patient.
Although the lesion was radiologically benign, extended curettage and iliac bone grafting were planned to exclude the malignancy risk that may be caused by smoking history. The operation was performed under spinal anesthesia. After bone grafting from the right ilium was completed, tourniquet was applied to the right thigh. A lateral approach to the calcaneus was used. After opening a 10 × 10 mm valve from the lateral aspect of the calcaneus, the cyst was excised and the cyst walls were debrided by burr. After preparation of the area, the cavity was filled with bone grafts.
Microscopic examination revealed compact hypercellular areas with spindle cells which show nuclear palisading around fibrillary process in some areas. There was no mitotic activity. Diffuse expression of S-100 protein was observed with immunoh

[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 eight-year-old boy presented to the emergency department with a five-day history of abdominal pain and a three-day history of bilious vomiting. His medical record was unremarkable otherwise and he had no history of abdominal surgery, except for right hydrocelectomy. The results of laboratory values, including coagulation laboratory tests, were unremarkable. His abdomen was slightly rigid and distended. Erect and supine abdominal radiographs showed multiple dilated small bowel loops with multiple air-fluid levels, suggesting mechanical ileus. Computed tomography (CT) showed fluid- and gas-filled distension of the small bowel loops and a transition point was observed at the distal ileum in the right pelvic cavity (). An intraluminal tubular mass-like lesion was observed at the transition point, measuring approximately 10.5 × 3.8 × 3.6 cm (, ). The lesion was heterogeneously hyperdense without enhancement or visible septa, suggesting a complicated cystic lesion. The distal ileum was collapsed in the region distal to the transition point. There was no evidence of intussusception or volvulus. Small bowel obstruction due to a complicated cystic mass was provisionally diagnosed. The US examination revealed a multiloculated cystic mass with fine septation in the distal ileum at the transition point (). The mass comprised an echogenic portion, which was probably a hemorrhagic portion.
Laparoscopic exploration was performed for suspected small bowel obstruction caused by a complicated cystic mass. A large dark-bluish and reddish tubular cystic mass was detected at the transition point in the distal ileum (). Segmental resection of the small bowel and end-to-end anastomosis were performed. Histopathologic examination indicated a submucosal cystic mass filled with blood; these findings suggested submucosal organizing hematoma in the distal ileum. Focal dilated lymphatic spaces were observed in the mucosa and submucosa, suggestive of focal lymphangiectasia secondary to organi

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old male patient was referred to the Dental Hospital of Kyung Hee University from a local clinic for the extraction of his left third molar. He had suffered some discomfort during mastication and dull pain on his left lower posterior area beginning about 10 days earlier. On intraoral examination, the overlying mucosa of the left impacted third molar was intact. The shape and texture of the gingiva surrounding the second molar were relatively normal. Neither tenderness nor pus discharge via gingival sulcus was observed during the palpation on the left lower posterior area. Percussion was positive on the second molar, but no mobility was observed. No cervical lymphadenopathy was detected on his left submandibular area. His medical history was noncontributory, revealing controlled hypertension for the past 5 years.
Panoramic and periapical radiographic examination were performed under the clinical diagnosis of pericoronitis. Conventional radiographs showed an ill-defined periapical rarefaction coinciding with the external root resorption related with the follicular space of the impacted third molar. However, there was no any etiologic factor on the left lower second molar such as dental caries or periodontitis (). CBCT examination was performed in order to evaluate the relationship with the mandibular canal and apical radiolucency of the left lower second molar. The CBCT scan described external root resorption on the distal root and extensive bony lysis over the apex of the second molar from the follicular space of the impacted third molar (). The initial radiographic impression was pericoronitis with an advanced lytic bone lesion involving the periapical region of the adjacent root.
He underwent a surgical extraction of his left lower third molar. Despite the continous treatment for 3 months, there was delayed extraction wound healing assuming a surface osteitis.
After one year, he presented to our dental hospital with a complaint of paresthesia in the lower

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old black woman with an 18-pack-year smoking history presented to our institution with a 3-month history of a progressively productive cough unresponsive to antibiotics. In addition, she had dyspnea on exertion and a 25-pound weight loss. Her past medical history included a duodenal ulcer resulting in a perforation which required exploratory laparotomy 2 years prior to presentation. Other history included subarachnoid hemorrhage requiring craniotomy with hematoma evacuation roughly 20 years prior to presentation, as well as hypertension. Her family history included her mother being diagnosed with ovarian cancer at the age of 54. The patient is married and worked full-time at the front desk for the past 30 years for a shipping company. She reported alcohol intake of two drinks per occasion twice weekly. She denied the use of any recreational drugs. She denied any environmental exposures. Medications that the patient was receiving at the time of diagnosis included amlodipine and albuterol.
The patient underwent computed tomography (CT) of the chest, which revealed a 5.3 × 6-cm right hilar mass that was occluding the right upper lobe bronchus with narrowing of the SVC. The SVC remained radiographically patent (Fig. ). The patient’s vital signs included afebrile temperature of 37.0 °C, cardiac pulse of 100 beats per minute, and oxygen saturation of 96% on room air. Her physical examination at that time was without any clinical signs of venous congestion. She had no facial plethora and had flat neck veins and no signs of jugular vein distention. She had decreased breath sounds in the right upper and middle lung fields. The skin of the neck and breast was without any pitting or edema. Neurologically, the patient was fully functional with cranial nerves II–XII intact and 5/5 strength in the upper and lower extremities bilaterally. All laboratory test results, including complete blood count and comprehensive metabolic panel, were within normal limits.
Two weeks af

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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:
32-year-old, female.
Cough and sputum for 1 year.
The patient complained of intermittent cough and sputum for 1 year, and the patient also had dyspnea while walking upstairs, needing rest midway. For the symptoms, the patient had visited a local otolaryngologist occasionally and had received symptomatic treatments only. She visited our emergency room due to the sudden development of epistaxis. At the time, her systolic blood pressure was measured to be 190 mmHg, but no other specific findings were noted. She was discharged after epistaxis treatment with the recommendation to visit the outpatient clinic. Her blood pressure was again high at 170/120 mmHg, and admission to the department of cardiology was proposed to the patient. After admission, the blood pressures measured on both upper and lower extremities differed by more than 30 mmHg, and chest computed tomography (CT) was taken. On the CT, both lungs showed multiple centrilobular nodules. The patient was again referred to the pulmonary division for additional examinations. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy were performed. Histologically, multinucleated giant cells were observed, coinciding with the findings of HP, and the pathology suggested dental technician’s pneumoconiosis. Thus, the pulmonologist referred the patient to the Department of Occupational and Environmental Medicine to evaluate any specific relationship of the disease with her occupation.
The patient had suffered from cough, sputum, and dyspnea when walking upstairs for 1 year. The patient had not been very concerned about her symptoms at the time, and she only looked for medical treatment when these symptoms had been aggravated. She visited a local otolaryngologist intermittently and was told that her vocal cords showed inflammatory changes and nodules. After taking oral medications, her symptoms improved. She had experienced several episodes of repeated aggravation and relapse of the symptoms. Her symptoms started to ag

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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 69-year-old man was referred for the surgical management of an aortic root aneurysm found by echocardiography during a preoperative work-up for spinal surgery. He did not have a family history or cardinal features of any heritable disorder of the connective tissue. A transthoracic echocardiographic examination showed an enlarged sinus of Valsalva (55 mm in diameter) with moderate aortic regurgitation (). The maximal diameters of the sinotubular junction and ascending aortic tubular portion were 44 and 40 mm, respectively (). The left ventricular ejection fraction was 65% with no regional wall motion abnormalities. A transesophageal echocardiographic examination showed aortic valve cusp coaptation at a level close to the middle of the sinuses of Valsalva (). The patient was scheduled for aortic root remodeling with concomitant external subvalvular ring annuloplasty.
After establishing cardiopulmonary bypass (CPB) and aortic clamping, the ascending aorta was transected above the sinotubular junction. After external dissection down to the base of the aortic annulus, the wall of the aortic sinus was completely removed, leaving a fringe of the aortic wall, and the coronary artery buttons were individualized. The diameters of the Valsalva graft and the flexible ring were determined to be 26 and 25 mm, respectively, based on the internal aortic annular base diameter measured with a 28-mm Hegar dilator (). Five sutures of 2-0 polyester fiber with pledgets were passed from the inside out as U stitches in the subvalvular plane. A sixth suture without pledgeting was placed externally at the level of the interleaflet triangle between the right and noncoronary sinus due to a lesion at the bundle of H is (). The first step of aortic cusp repair for the alignment of the coaptation margin was the placement of a central plication stitch on the extended noncoronary cusp. The length of each hemi-cusp free edge between the right and noncoronary cusp was equalized (). The remodeling t

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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 73-year-old male with a past medical history of diabetes, hypertension, and dyslipidemia presented with a chief complaint of visual change for one day in his left eye. The patient reported that he was at home the previous night when he suddenly experienced loss of vision in the left eye. The patient also reported sharp, 5/10, non-radiating left eye pain during the onset of vision loss which has now resolved. He denies trauma to the eye. He also denies fever, headache, eye discharge, ear pain, nasal congestion, nausea, vomiting, diarrhea, paresthesias, or focal weakness. There is no past medical history of contact lens use, eye surgery, or glaucoma.
An examination of extraocular motility revealed full motility in the left and right eyes. The pupils were equal, round, and reactive bilaterally. The visual field testing was normal in the right eye whereas the left eye showed decreased vision in the nasal visual field. Visual acuity was 20/50 in the left eye and 20/20 in the right eye. Intraocular pressure, measured with a Tono-Pen, was 19 mmHg in the left eye and 23 mmHg in the right eye. There was no fluorescein uptake in either eye. A fundoscopic examination was performed after the application of two drops of tropicamide (0.5%) in both eyes. A funduscopic examination of the left eye revealed a black spot at 5 o’clock.
An ultrasound examination of the eyes was performed using a linear array 13-6 MHz ultrasound transducer. An occlusive dressing (Tegaderm) was placed on top of the eye to shield it from the gel. Ultrasound gel was applied to the transducer. The probe was placed in a transverse orientation to scan the axial anatomic plane. A scan of the left eye showed a hyperechoic smooth folded membrane within the vitreous, consistent with a retinal detachment (Figure ).
. The membrane can be seen "flo

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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 47-year-old man presented to our referral center in November 2017, with a history of EMC of the right shoulder improperly excised with unplanned microscopic positive surgical margins (R1). The patient underwent debulking of the primary mass in September 2017 in a non-referral center, without a preoperative core-needle biopsy. The histological examination diagnosed EMC. No post-operative treatments were provided. At our first evaluation, the patient did not show macroscopic residual disease or distant metastasis both at the clinical and the radiological assessment. The pathological review of the excised specimen confirmed the diagnosis of EMC. After MTB discussion a “watch and wait” approach was adopted. After a 4-months follow-up, the clinical examination showed an elastic soft painless mass in the right shoulder. A Magnetic Resonance Imaging (MRI) of the shoulder was performed, showing a 35 × 15 mm intramuscular solid mass (Fig. ) within the right deltoid muscle. Computed Tomography (CT) did not reveal distant metastasis. The case was discussed in our MTB where the decision was made for preoperative RT, with a total dose of 50 Gy (fractionated in 200 cGy/die) which was a administered with Rapidarc technique. Post radiotherapy MRI performed 3 weeks later showed a partial radiological response, with a mass measuring 16 × 6 mm (Fig. ).
In July 2018, a wide surgical resection including the right anterior deltoid muscle and the lateral margin of the right pectoralis major muscle was performed, with a planned macroscopic margin of minimum 3 cm and the complete excision of the scar and the field of the previous surgery. The defect was reconstructed by right latissimus dorsi myocutaneous flap and polypropylene prosthesis (Figs. and ).
The size of the excised specimen was 23.5 × 10 × 3.5. Pathological examination was negative for viable tumor cells, showing only a fibrous subcutaneous scar. The patient had a complete response to preoperative RT.

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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 61-year-old man presented with clinical stigmata of NF1. Genetic analysis had not been performed. He had no family history and had developed multiple neurofibromas and café-au-lait spots on his body (Figure ). He underwent surgical treatment for a growing tumor (details are unknown) on the posterior surface of his right thigh at another hospital in April 1982, and was referred to our institution because of regrowth of the tumor in October 1990. Wide resection was performed in November 1990 (Figure ). The histological diagnosis was MPNST developed on a background of NF1, and he received adjuvant chemotherapy. Since 1990, the patient has had repeated local recurrences (7 times, until May 2003) and has received surgical treatment for each recurrent tumor. In December 2003, the patient presented with a skin tumor of the head, and the lesion was resected. The histological diagnosis was MPNST that arose in a neurofibroma of the head skin. Two years later, the right leg was amputated at the hip joint because of local recurrence of the leg lesion, with aggressive growth and rupture. Computed tomography (CT) performed in August 2005 showed multiple lung lesions, suggestive of tumor metastases. Some of the lung lesions were resected surgically in January 2006 and diagnosed histologically as MPNST metastases. After the operation, he developed new lung metastases. In May 2007, he was admitted to our institution with sudden dyspnea and palpitations. Echocardiography revealed an enlarged heart and cardiac effusion, which did not suggest cardiac tamponade. Magnetic resonance imaging showed the presence of a large tumor (9 cm) in the inferior-posterior wall of the heart (Figure ). CT revealed an infarction of the inferior lobe of the left lung, which was derived from tumor emboli. As a result of the worsening condition, irradiation was applied to the cardiac mass (2 × 25 Gy). The patient's condition still worsened, with increasing cardiac effusion and arrhythmia. Regardless of dr

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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 63-year-old woman presented with a firm 7 cm multilobular tender mass located in the region of the right sternocleidomastoid directly above the clavicle. She had multiple comorbidities including renal failure, systemic lupus erythematosus, and protein S deficiency, a history of transient ischemic attack, deep vein thrombosis, and pulmonary embolism, and longstanding malnourishment requiring jejunostomy tube placement. The firm mass was identified 1 month after an unsuccessful attempt at placing a right internal jugular vein central line. When the central line was originally placed, she developed pain and swelling of her neck. The swelling was pulsatile at that time and enlarging. She was offered surgery as the standard of care for her condition which she refused because she did not want to undergo an invasive procedure and was aware of the risks involved with holding her anticoagulant medication. She had two thrombin injections in the mass since without success. She complained of right neck pain. She was not having any difficulty breathing and denied shortness of breath.
Soft tissue ultrasound after the two thrombin injections showed pseudoaneurysm and a 7 × 3.3 × 4 cm multilobular hematoma at the base of the right neck. CTA of the neck showed a corresponding heterogeneous mass. The pseudoaneurysm was seen measuring 1.5 cm at the internal margin of the hematoma. Serial imaging with CTA demonstrated enlargement over a 2-week interval ().
Angiogram showed blush of contrast coming off of the sternocleidomastoid branch of the superior thyroid artery identifying the location of the pseudoaneurysm (). This branch was embolized using glue. Repeat angiogram showed successful embolization and no contrast blush.
On follow-up one month later, the mass was no longer pulsatile but still present on physical exam. CTA of the neck showed a decrease in size from the previous CTA ().
On follow-up 8 months later, she was found to have a soft neck with no mass on physical exam.

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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 46-year-old man with diabetes mellitus presented to the emergency department at our hospital with symptoms of right foot pain and fever. The patient developed ASO in the right lower extremity as a complication of diabetes. Arterial occlusion started from 10 cm distal to the knee joint and involved the anterior tibial artery, posterior tibial artery, and peroneal artery. The patient had already had right second and third metatarsophalangeal joint disarticulations in the plastic surgery department of our hospital. Nevertheless, infection and necrosis in the right foot progressed rapidly and worsened to a condition requiring additional surgery (). However, because a tibial IM nail had been inserted into the ipsilateral limb, the patient was referred to the orthopedic surgery department.
Above-knee and through-knee amputations were also considered surgical options for the patient. However, it was determined that the blood flow to the distal part of the popliteal artery was intact. Also, infection and necrosis had not progressed beyond the foot. The skin color of the right calf seemed healthy on physical examination. Therefore, we decided to remove the tibial IM nail and perform a below-knee amputation. However, performing additional surgery around the knee joint to remove the tibial IM nail was thought to have a high possibility of complications. Thus, surgery was planned to remove the amputated limb and IM nail at the same time by performing an amputation with the nail fixed on the ankle by distal locking screws.
The tibial bone cutting level was determined by referring to the lateral view of the tibial plain radiograph. The tibial IM nail is designed to have an anterior angulation in the proximal part. Therefore, if tibial bone cutting is performed distal to the angulation of the nail, the nail may not be removed from the proximal part of the tibia due to the angulation of the nail. Therefore, we decided to perform tibial bone cutting at the point of the anterior an

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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 27-year-old man who was referred to Imam Khomeini Hospital with chief complaints of pain and an intensive restriction in the range of motion (ROM) in the bilateral hip joints. He was diagnosed with HME 12 years ago while he had hip trauma, and multiple exostoses around the knee, ankle and shoulder joints were found in the obtained X rays ( and ). He was diagnosed as AS 3 years ago due to low back pain (LBP) accompanied with significant morning stiffness that lasted about 1.5 h together with laboratory and radiological findings. He was diagnosed as AS based on New York criteria including clinical criteria; a) low back pain more than 3 months improved by exercise and not relieved by rest, b) limitation of lumbar spine motion in sagittal and frontal planes and limitation of chest expansion, and radiologic criteria of bilateral sacroiliitis grade 2 or more ().
The patient’s sister and his 3 brothers have multiple exostoses without any family history of spondiloarthropathy or inflammatory arthritis. He has been taking sulfasalazine 1500 mg per day and indomethacin 75 mg twice a day because the bilateral hip joint ROM limitation had caused motion dysfunction. Flexion arc was limited to 30 degrees with a maximum flexion of 60 degrees. Motion was also restricted in the adduction-abduction arc as well as the rotator arc. Specific examination for AS including the Schober test and chest expansion was positive. Lateral bending was limited.The laboratory tests revealed mild anemia (Hb: 11 mg/dl, Hct: 37%, MCV: 79 fL) and a high ESR rate (93 mm/h). C-reactive protein and HLA-B27 were positive, but rheumatoid factor, ANA, viral markers and the Wright test were negative.
Multiple exostoses were seen around the knee, ankle and shoulder joints in the X rays (). Both sacroiliac joints were fused completely and the joint spaces of both hips

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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 37-year-old female was admitted to the thoracic surgery department with dysphagia that had progressively worsened during the previous year. Endoscopy of the upper gastrointestinal system revealed a yellowish-colored, adipose-tissue-like appearance of a polypoid mass with a smooth surface covering between 25 and 34 cm of the esophageal wall (fig ). Computed tomography (CT) of the thorax revealed a posterior mediastinal mass (height × width × depth: 10 × 5 × 3 cm; fig ), which was compressed between the vertebral column, aorta and heart and pushed the lumen of the esophagus leftward (fig ). The mass had low-density tissue absorption, which was characteristic of adipose tissue when compared with surrounding tissues. A barium-swallowed contrast study disclosed an intraluminal space-occupying polypoid lesion protruding through the esophageal wall, which narrowed the lumen of the esophagus (fig ). Therefore, esophageal lipoma was considered the most likely diagnosis, and the decision for surgical excision was made.
A right-sided mini-thoracotomy was performed, the mediastinal pleura was opened and tumor location was identified. Enucleation of the lipoma was the planned operative strategy. The overlying muscle layer of the lower third of the esophagus was incised to expose the tumor, which was then completely enucleated (fig ). Expansive dilatation of the esophageal mucosa due to the outward pushing effect of the giant lipoma was observed on the barium-swallowed contrast study. After excision of the tumor, the mucosa of the esophagus, which expanded into the lumen, turned outside and led to a diverticulum (9 × 4 cm) on the right side of the esophageal wall. For confirmation of the diverticulum, a nasogastric catheter was inserted and deployed in the proximal part of diverticulum. The distal part of the diverticulum was obstructed manually; high-pressure air was applied through the catheter, and the diverticulum became more visible. Subsequently, diverticulectomy was adde

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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 38-year-old white woman presented with swelling and pain in her right upper limb that had begun 48 hours previously and that was unrelated to trauma. She was a keen amateur swimmer and had increased training in the days before the onset of the swelling. She had a history of bilateral shoulder recurrent luxation during childhood, which led to an operation on her left shoulder when she was 24-years old. Her history did not reveal any risk factors for venous thromboembolic disease (VTE): she had not recently travelled or had prolonged immobilization, nor had there been any recent surgery (the shoulder surgery occurred 14 years prior and was on her left shoulder, which was not the site of the swelling and pain that precipitated this case). Furthermore, she had no family history of thromboembolic disease or thrombophilia and was not taking oral contraceptive pills. The only historical detail of interest was bilateral recurrent shoulder dislocation in childhood, although there was no episode prior to the presentation of this PSS.
There were no signs of arterial disease; humeral, radial, and ulnar pulses on her upper limbs were present and good capillary filling was observed without skin changes. An examination revealed an increased diameter of her right upper limb, as well as an edema in all her right upper limb and deltopectoral collateral circulation. Upper limb mobility and sensitivity were normal and preserved, without paresthesia or dysesthesia that could be suspicious for nerve or arterial compression. Following the protocol of our center, ultrasound tests were performed to detect deep venous thrombosis (DVT), to evaluate compression, occupation of light, and color flow, and Doppler ultrasound was used to assess the phasic flow. The duplex ultrasound revealed a lack of compressibility, permeability, and phasic flow in the middle third and proximal region of her subclavian vein; right subclavian vein thrombosis was diagnosed. Computed tomography angiography (CTA) o

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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 15-year-old boy was brought to the emergency department by his family for evaluation of abdominal pain associated with nausea and vomiting. His discomfort started one day earlier and was localized to the right upper quadrant of the abdomen. He described a constant pressure unrelated to food intake. He reported no change in urine or stools and no melena, dysphagia, anorexia, increase in abdominal girth, or change in his weight. He was lethargic and fatigued but had no pruritus, jaundice, night sweats, fever, easy bruising, or bleeding.
The patient's medical history was notable for type 1 diabetes mellitus for 6 years, which has been poorly controlled and was complicated by several episodes of diabetic ketoacidosis. There was no family history of diabetes mellitus, autoimmune diseases, or liver disorders. His medications included insulin Lantus 22 units at night and insulin Humalog 20 units three times daily before each meal. He admitted that he had not been consistently compliant with his medications. There was no history of new medication usage. He also denied the use of any over-the-counter medication or alcohol use. There was no recent travel and no sick contact. On physical examination, the patient was noted to be thin and in no acute distress and afebrile with heart rate of 109 beats per minute and blood pressure of 109/60 mm Hg. His weight was 37 kg and his height was 153 cm with a body mass index (BMI) of 15.8 kg/m2. The jugular venous pressure was not elevated. Examination of the heart and lungs was unremarkable. Abdominal examination revealed mildly distended abdomen with mild tenderness on palpation in the right upper quadrant. There was no rebound or guarding and Murphy's sign was absent. The liver was palpable 6 cm below the costal margin, with a smooth edge. The spleen was not palpable, and there was no evidence of ascites. Skin examination showed no palmar erythema, leg

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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 45-year-old Hispanic male who underwent cadaveric renal transplant in the right lower quadrant 17 years earlier, presented to the hospital with a three-month history of generalized abdominal pain with localization to the right side for two weeks. He was on chronic immunosuppression with tacrolimus, azathioprine, sirolimus and prednisone. The pain was more pronounced in the right upper quadrant, and the ultrasound imaging of the abdomen was suggestive of cholecystitis. Laboratory studies did not reveal any abnormalities. He could not confirm if he had had any problems or surgeries on his gall bladder. Hence, he underwent laparoscopic exploration of the gall bladder fossa. During surgery, adhesions of the omentum were found in the gall bladder fossa in the absence of the gall bladder, and an inflamed appendix was found elevated due to the transplanted kidney in the right lower quadrant. Laparoscopic appendectomy was performed and the tissue underwent pathological examination. He was discharged after an uneventful post-operative course.
Pathology of his appendix by immunostaining revealed anaplastic cells strongly positive for CD3, CD56 together with strong focal EBV-encoded RNA (EBER) staining (Figures , , and ). The malignant cells were negative for CD20, CD30, CD45, CD5, Alk-1 and TCK. The tissue was found to be positive for the T-cell receptor (TCR) by gamma gene rearrangement studies by PCR analysis (Figure ). Immunoglobulin heavy chain rearrangement (IgH) by PCR analysis did not detect a clonal B-cell population, thereby confirming T-cell lymphoma. A bone marrow examination revealed no involvement with negative flow cytometry and showed normal male karyotype (46, XY). A staging positron emission tomography (PET) scan showed increased radiotracer uptake in the right cervical and left groin lymph nodes along with the 3.3 cm liver mass. Non-specific uptake in the stomach was also observed.
The patient was re-admitted to the hospital 10 days later, with increasing

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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:
The patient was a 4-week-old male infant born at an estimated gestational age of 30 weeks with a birth weight of 1665 grams and APGAR scores of 8 and 9 at one and five minutes, respectively. Gross congenital anomalies were not identified. The mother was a gravida 3, para 2, abortion 1, 21-year-old African American with an adequate prenatal care. Her pregnancy was complicated by group b streptococcus urinary tract infection and placental abruption requiring pregnancy termination. In addition, there was a history of hand-foot-mouth syndrome in his sibling two weeks prior to delivery. Immediately after birth, the neonate developed respiratory distress and cyanosis requiring intubation and admission to the neonatal intensive care unit. The initial physical exam revealed a grade III-IV holosystolic murmur and generalized edema. The initial X-rays and echocardiographs demonstrated a moderate to large patent ductus arteriosus (PDA), moderate to severe pulmonary hypertension, and biventricular changes suggestive of hypertrophic cardiomyopathy. Bedside PDA ligation was performed. Subsequent studies revealed Coxsackie B viremia (confirmed by polymerase chain reaction (PCR)); however, TORCH serology were all negative. Viral induced hypertrophic cardiomyopathy was the presumptive diagnosis. However, daily chest X-rays demonstrated progressive nonspecific calcification of the chest soft tissue and the vessels of both arms (). Despite multiple intravenous immunoglobulin treatments, loop diuretics, phosphodiesterase 3 inhibitor, and dopamine for the presumed viral induced cardiomyopathy, his symptoms progressed and the patient expired at 4 weeks of age secondary to intraventricular brain hemorrhage and multiorgan failure. At autopsy, there was severe anasarca, but gross congenital anomalies were not identified. Cardiovascular dissection revealed increased biventricular wall thickness () with evidence of gross arterial calcification along the large vessels. Microscopic sections of

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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 female was referred to our Trust by her general practitioner with a 5-month history of a painless vaginal mass, which extruded from the introitus on straining, but was otherwise asymptomatic. This was originally thought to be a vaginal prolapse; however, examination revealed a soft, well-defined pink mass occupying the upper vagina and an MRI of the pelvis was requested for further characterization.
MRI was performed using a 3.0 T system utilizing axial T1 weighted fast spin echo; small field of view axial, coronal and sagittal T2 weighted fast spin echo; and T1 weighted fat-saturated sagittal images before and after gadolinium contrast administration, obtained in the arterial and portal venous phases. Diffusion-weighted imaging was also acquired. The images demonstrated a 47 × 40 × 44 mm well-circumscribed, oval mass in the upper vagina. On the T1 weighted images, the signal intensity of the abnormality was intermediate, similar to that of the skeletal muscle (). However, on T2 imaging, there were discrete zones within the lesion; the anteroinferior aspect was of high T2 signal with no enhancement, whereas the posterosuperior aspect was of low T2 signal with avid enhancement (–). There was no restricted diffusion. The posterior wall of the retroverted uterus was demonstrated to abut the superior surface of the lesion and the vaginal lumen was deviated anteriorly. Normal vaginal wall was seen to extend around the lesion’s anterior and posteroinferior surfaces. The lesion appeared to be arising within the left posterolateral vaginal wall and there were areas of loss of definition of the outer margin of the vagina. There was no involvement of the rectum, urethra or bladder; however, there were hazy low T1 and T2 signal changes in the left paravaginal fat.
Through a MDT discussion, it was agreed that owing to the suspicious imaging features of enhancement and tissue inhomogeneity, a staging portal venous phase CT

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

[User]
RADIOLOGY NOTE:
An 87 year-old (gravida 2, para 2) Caucasian woman was referred to our clinic with a large abdominal pelvic mass, ascites, ureteral obstruction, and a serum CA-125 of 745 U/ML in November 2005. Despite her advanced age, the patient insisted on aggressive management.
The patient underwent a laparotomy, abdominal hysterectomy and bilateral salpingo-oophorectomy. She had approximately 150 cc of clear, straw colored ascites. There was a 20 cm intact, largely solid lower abdominal pelvic mass adherent to the mid and distal sigmoid colon mesenteric serosa, which extended down into the cul-de-sac and left pelvic sidewall peritoneal regions. The patient had a preoperative right ureteral obstruction that also appeared to result from extrinsic pressure related to the 20 cm abdominal pelvic mass. Further examination revealed approximately 6 to 7 cm bilateral solid, whitish ovarian tumors involving the serosa of the mid and upper sigmoid colon mesentery. There were no intra- or post-operative complications and estimated blood loss was 500 cc. The patient is currently doing well clinically ten months postoperatively and adjuvant therapy was not indicated.
Frozen section of the 20 cm abdominal pelvic mass was consistent with a benign fibroma. Pathology further reported that the ovary was white and enlarged, with a smooth and glistening surface. Cross section revealed a unilocular cyst containing yellow translucent fluid. The remainder of the tumor was solid except for small areas of yellow cystic degeneration. There was no identified necrosis. The immunohistochemical findings are significant in that the tumor is only positive for actin, which is not specific but is typically seen in fibrous or smooth muscle tumors. The findings of trichrome and reticulin positivity also favor a fibroblastic lesion.
The case was referred to Stanford Pathology for an independent review. They remarked that the low-grade spindle cell proliferation with fibroblastic features were very rare. The negati

[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 presented to his general practitioner complaining of 2 months of progressive left hip pain. Over the preceding 2 weeks he had been struggling to mobilize. His general practitioner (GP) investigated with a non-contrast computed tomography (CT) of the pelvis. This found a cystic lesion within the left psoas muscle with areas containing coarse calcification. The findings, overall, were suspicious of tumour, likely a teratoma. A CT chest, abdomen and pelvis with intravenous contrast was arranged. The pathology in the left psoas was found to represent a pancreatic pseudocyst extending from a heavily calcified pancreas, over the anterior aspects of the aorta and inferior vena cava (IVC) before reaching the left psoas muscle body ( and ). There were multiple other cystic regions noted within the pancreatic parenchyma and peripancreatic tissue. The patient was referred to the emergency department for surgical review.
On examination of the patient in the emergency department the patient was lying in a supine position with his left hip in external rotation and left knee moderately flexed for comfort. He had an antalgic gait, with discomfort that was most evident weight bearing on his left leg. He also had pain elicited upon active movement of the left hip and in particular resisted hip flexion. He had no abdominal tenderness. Blood tests, including inflammatory markers and lipase, were within normal limits, with no evidence of acute pancreatitis.
The patient had a past medical history significant for a single episode of alcohol induced acute pancreatitis 10 years earlier. He had no diagnosed repeat episodes of pancreatitis in the intervening years. On further questioning he did mention occasional episodes of mild post-prandial epigastric pain. At the time of presentation, he had ongoing issues with alcohol misuse, consuming between 6 and 8 standard drinks per day.
On review of the CT scans, the dominant cyst was deemed not to be amenable to transgastric drai

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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 male chemical worker was admitted to the hospital with a history of paroxysmal microscopic hematuria for about 2 years and nocturia with gross hematuria about five times per night for 2 months. He was a nonsmoker and denied taking any medication. He did not use hair dye or reside in an area with endemic blackfoot disease (arsenic intoxication). Social alcohol drinking was noted.
Microscopic hematuria was noted in the periodic health examinations for about 2 years, but the patient ignored it. Two months before admission, he developed nocturia about five times per night. Paroxysmal painless hematuria was also noted. Gross hematuria accompanied by lower abdominal distress occurred 2 weeks before admission. His body weight had decreased from 75 kg to 72 kg over the previous 3 months. He visited the hospital, and an intravenous urogram (IVU) showed a mass occupying half of the bladder capacity. Cystoscopy revealed a mass over the left dome area of the bladder. Cystoscopic biopsy specimens revealed a grade 3/3 invasive transitional cell carcinoma with marked necrosis. Radical cystectomy with ileal conduit combined with radiotherapy was performed because the bladder tissue showed lymphovascular permeation with lymph node metastasis. The worker is still on medical leave because of disease.
The manufacturing of MBOCA includes the reaction, neutralization, washing, purification, and packing processes. Briefly, o-chloroaniline is reacted with sulfuric acid and formaldehyde under the catalyst of stannous chloride for 3–4 hr. The MBOCA products are then neutralized with an alkali, sodium hydroxide, at a high temperature. After washing and purification, the solid MBOCA is cut into pellets. Although most of the processes are done in closed systems and are automatic, leakage of products from pipes and tanks has been reported. The work schedule in the factory where our patient worked has three 8-hr shifts, and three or four workers in each shift are assigned to each ma

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man with a background of hypercholesterolemia, type 2 diabetes, and hypertension presented to the emergency department with a 6-month history of progressive symmetrical weakness. Prior to this, he was usually independently mobile. He had been commenced on 20 mg atorvastatin 1 year prior to his admission and this was stopped 10 months later. Despite this, there was no improvement in his symptoms. The patient reported having difficulty standing from sitting. Initial assessment revealed 4/5 muscle strength proximally in all four limbs on the Medical Research Council scale for muscle strength. Power elsewhere and remaining physical examination was unremarkable. Initial investigations revealed an elevated CK at 8223 IU/L (normal 30-200) in the context of normal renal function. Subsequent electromyography (EMG) demonstrated features suggestive of proximal and distal myopathy with evidence of active denervation. MRI thighs confirmed active inflammation in the proximal muscle groups. A CT thorax, abdomen, and pelvis (requested as part of a screen for any neoplastic cause driving the myopathy) showed only a nonspecific thickening of the gastric fundus with a subsequent OGD identifying a benign lipoma with normal histology.
To investigate the nature of the patient's apparent myopathy, a muscle biopsy was arranged and confirmed features of a necrotizing myositis (Figure ). Meanwhile, a myositis-specific antibody panel was normal except for strongly positive HMGCoA antibodies 150.7 CU (normal 0-20). Altogether, this confirmed the diagnosis of statin-induced autoimmune necrotizing myositis (SIANM).
The patient was commenced IV methylprednisolone 1 gm over 3 consecutive days and then 60 mg oral prednisolone. Despite this, he deteriorated rapidly over the subsequent days with progressive weakness now involving distal muscle groups and dysphonia. Power was now 0/5 in proximal muscle groups of all limbs and 2/5 in distal muscle groups. Unfortunately, the patient develo

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


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

[User]
RADIOLOGY NOTE:
The proband is a 19-year-old male of Northern European extraction, the first child of non-consanguineous parents. Born full term at 3550 g, he was noted to have a two-vessel cord at birth and a murmur due to a bicuspid aortic valve. CT scan showed an absent inferior vena cava and a continuous dominant hemiazygos vein that drained into the azygos vein at the level of the T9 vertebral body. The azygos vein drained the right kidney. At his most recent cardiac evaluation at 18 years of age, he had stable dilation of his aorta without significant aortic stenosis or insufficiency. He has also had two episodes of symptomatic pericarditis.
A small area of hypertrichosis and hyperpigmentation in the lumbar area of his back was noted as an infant. This patch increased in size and extended to his anterior thighs and shins as he grew older.
He was noted to have localized swelling in his scrotum during his first year of life. Over time, the scrotum and mons pubis became indurated and tense. Ultrasound at age 17 months revealed normal appearing testes with echogenic material filling the scrotum and lining the wall, particularly the right epididymis. The findings were felt to be consistent with calcified meconium from meconium peritonitis. The scrotal mass increased in size until the whole scrotum was noticeably distended and by 4 years of age, the swelling also involved the suprapubic area. CT of his pelvis showed diffuse increased attenuation involving the subcutaneous fat from the level of the iliac crests to the upper thighs. An MRI at age 6 revealed bilateral inguinal lymphadenopathy.
A deep skin punch biopsy from patient 2 showed mild epidermal hyperplasia with relatively mild basal hyperpigmentation and a striking infiltrate in the deep dermis and subcutis accompanied by edema and rare hemosiderin deposition. Cellular aggregates seen at low power (Fig. ) 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 3-year-old boy presented at our emergency department with a spontaneous progressive enlarging subconjunctival hemorrhage. The boy was the first-born baby to healthy nonconsanguineous parents. He was born after a normal pregnancy and delivery with a birthweight of 3.230 kg. Immediately after birth, several vascular lesions were noted on his feet (shown in Fig. ). Over the next months, more cutaneous lesions appeared all over the body, as well as submucosal lesions in the mouth. An MRI of the forearm was performed and revealed dispersed vascular lesions without the presence of an enchondroma leading to the clinical diagnosis of BRBNS. Biopsies of the lesions on the left thigh and right flank were taken at the age of 3 months, and the diagnosis of BRBNS was confirmed. Treatment with oral propranolol was started, and the dose (2 mg/kg/day) was increased over time according to the weight. The majority of the submucosal lesions in the oral cavity was fluctuating with some cutaneous lesions fading away but also new cutaneous lesions emerging. Overall, the number and size of lesions clearly decreased over the years. In addition, the boy never presented with iron deficiency anemia nor clinical symptoms suggestive for gastrointestinal tract involvement. At the age of 3 years, he presented at the emergency department with a small subconjunctival hemorrhage on the left eye. Mother mentioned the appearance of a small red punctiform lesion 10 days before the hemorrhage emerged, suggesting a new vascular lesion in a child with the BRBNS. History revealed no recent trauma to the eye and the child did not have hypertension. The peripheral blood count including platelet count was within normal limits. No additional treatment was started. Three days later, however, he was urgently referred because of progressive subconjunctival hemorrhage (shown in Fig. ). Topical treatment with timolol maleate 0.5% eye drop once a day was started. After 2 weeks, progressive resorption of the hemorr

[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 54-year-old female with a history of hypertension and tobacco use presented with left-sided weakness and dysarthria for unknown duration. CT scan of the head showed acute right middle cerebral artery (MCA) distribution ischemic infarct. The patient was not a candidate for fibrinolytic therapy due to unknown duration of symptoms and she was transferred to our facility for thrombectomy which was successfully performed. She was transferred to the intensive care unit in stable condition. Shortly after this, she complained of nausea and chest discomfort. 12-lead electrocardiogram demonstrated acute anterior STEMI (Figure ). Bedside echocardiogram showed hypokinesia of the entire apex (Video ).
Emergent CT of the head was performed prior to possible PCI and revealed hemorrhagic conversion in the basal ganglia (Figure ). Because of the new hemorrhagic conversion, we decided not to intervene with close monitoring in the intensive care unit.
Forty-five minutes later, the patient developed polymorphic ventricular tachycardia requiring cardiopulmonary resuscitation (CPR) and electrical cardioversion. Return of spontaneous circulation (ROSC) was achieved and amiodarone was initiated. Given these findings the decision was made to proceed with emergent coronary angiogram with plans for percutaneous transluminal coronary angioplasty (PTCA) without the use of antithrombotic or antiplatelet therapy. Coronary angiography via femoral approach revealed thrombotic occlusion of the mid left anterior descending (LAD) artery (Figure ), 80% stenosis in a large obtuse marginal branch (Figure ) and chronic total occlusion of right coronary artery (RCA) (Figure ).
Percutaneous coronary intervention (PCI) with plain old balloon angioplasty (POBA) was rapidly performed using 2.0 x 15 mm compliant balloon with resultant TIMI III flow (Figure ).
Two days later the patient was started on aspirin 81 mg daily. She was discharged in stable condition with significant improvements in her neurologic st

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


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

[User]
RADIOLOGY NOTE:
A 12 hour old male neonate presented to the department with complaint of two episodes of bilious vomiting in last two hours. The patient was a full term normal vaginal delivery, delivered in the hospital. The family history was non contributing.
On examination, the general condition of the patient was good. His weight was 2.75 kg. There was no obvious congenital anomaly. On examination of the abdomen a cystic structure was felt in the right lumbar segment. X-Ray of the abdomen revealed three gas shadows in the left hypochondrium with no other gas shadow. A diagnosis of proximal small bowel atresia was made. No other investigation was done.
The patient was managed by nil by mouth and nasogastric tube placement. He was given intravenous (IV) fluid. The antibiotics given were ceftriaxone (75 mg/kg IV 12 hourly), amikacin(7 mg/kg IV 12 hourly) and metronidazole (7.5 mg/kg IV 12 hourly).
The patient was operated after about 24 hours of presentation. Under general anesthesia, the right transverse supraumbilical incision was made. On exploration of the peritoneal cavity there was presence of a mesenteric cyst in the jejunal mesentery that was felt as the cystic structure on abdominal examination (figure ). The jejunum associated with the mesenteric cyst was having a single type I atresia. The presence of atresia was 15 cm from the dudenojejunal flexure. The proximal bowel was dilated. The treatment included resection of the cyst along with the atretic bowel and proximal 7.5 cm of the dilated bowel and end to end single layer anastomosis by vicryl 5-0.
The post operative period was uneventful. The patient was allowed orally on 11th post operative day. IV antibiotics were continued for 11 days followed by oral cefixime (4 mg/kg BD) for seven days. He was discharged on 14th post operative day in satisfactory condition. The follow up of the patient is also satisfactory.

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old man presented with lower back pain that radiated laterally to his right thigh that had persisted for 3 months. During the previous 6 years, the patient had undergone 3 lumbar spine magnetic resonance imaging (MRI) examinations and 10 sessions of epidural steroid injection for recurrent back pain. His deep tendon reflexes and peripheral circulation had been normal throughout. The last of the 3 MRI examinations had revealed 3 round intradural masses along the second and third lumbar spine, although there were no specific changes in the disc space compared with the previous magnetic resonance images (). Two of the masses were homogeneously enhanced, while the third was nonenhanced (). The nonenhanced mass had moved down within the subarachnoid space, as determined by comparison with the images obtained 7 days previously (). The preoperative diagnosis was multiple IDEM tumors, possibly schwannoma, and surgery was planned.
An L3 partial laminoplastic laminotomy was performed and a durotomy was performed and a durotomy was made, revealing the two enhancing masses. One was a 0.3×0.5-cm yellowish mass located in the dorsal subarachnoid space at the L2-3 disc level and adhered to the cauda equina via vascular proliferation from the nerve roots (). The second mass was found just inferior to the first (). Following its separation from the surrounding nerve roots and opening of its capsule-like surface, the mass was removed completely (). A frozen section biopsy confirmed that the mass was composed of degenerated disc material. After careful exploration of the cauda equine, the third mass that was found to be nonenhanced and migrating along the cerebrospinal fluid space on MRI was found at the L2/3 level; it was nonvascular and did not adhere to the cauda equina (). Following surgery, the patient's back and right leg pain improved. Pathological examination of the surgical specimen showed degenerated fibrocartilage, partial capillary proliferation, interstitial ede

[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 male patient, with body mass index (BMI) of 8.45 kg/m [] and previous diagnosis of cerebral palsy, was admitted due to upper gastrointestinal bleeding Blatchford score of 10. Upon initial assessment, the patient required a blood transfusion due to hemoglobin level of 5.48 g/dl. The upper gastrointestinal endoscopy reported an esophageal ulcer Forrest IIC and esophagitis. Given the symptoms associated with chronic malnutrition and severe deconditioning, a gastrostomy was recommended. Initially an endoscopic gastrostomy was decided as the ideal approach, which was unsuccessful due to suboptimal translumination. Despite considering a new attempt to perform endoscopic gastrostomy at a later date, the patient´s nutritional and metabolic condition could worsen in case it failed a second time. Thus, an open gastrostomy was considered by the gastroenterology department to ensure an early start of the enteral nutritional route. The institutional anesthesiologist considered the patient’s high risk would be reduced once he was in adequate nutritional and metabolic so the surgery was performed without any initial complications. An upper gastrointestinal endoscopy on the third postoperative day revealed adequate positioning of the gastrostomy and enteral nutrition was initiated and well tolerated.
Ten days after surgery, patient in-hospital presented diffuse abdominal pain and multiple diarrheic episodes, of insidious origin, referring it began two days after surgical procedure and gradually increased its intensity. Laboratory results were within normal limits, and the abdominal computed tomography (CT) scan revealed extensive pneumatosis from esophagus, stomach, small intestine and partial colon. Additionally, moderate pneumoperitoneum and gas in the venous portal system were also reported (, ). The CT scan showed no evidence of an intra-abdominal collection or abscess that could otherwise explain the findings, as there was also no clinical or laboratory signs of

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female was referred to the Stomatology Hospital of Xi’an Jiao Tong University (Xi’an, China) for consultation, due to painless swelling of the right cheek that had been present for five months. The patient had no history of trauma or facial surgery. Upon physical examination, facial asymmetry and slight right-sided cheek swelling was observed (). The maximum extent that the mouth could be opened was 2.8 cm and the occlusal relationship was normal. A palpable mass without tenderness was present in the posterolateral wall of the right maxillary sinus; the mass was moderate in hardness and slight mobile. However, the whole body of the mass could not be assessed. There was no involvement of the oral mucosa and the lymphadenopathy was negative. The evaluation of the cranial nerves returned results within the normal limits. With the suspicion of a tumor from the right ITF, imaging examinations were performed. Computed tomography (CT) demonstrated a soft-tissue mass in the right ITF, compressing the posterolateral wall of the right maxillary sinus and causing deformity without osteolysis. The foramen ovale was also enlarged ( and ). Magnetic resonance imaging (MRI) revealed a 5.1×3.6-cm mass filling the superior and inferior aspects of the ITF (). The patient was otherwise healthy, with complete dentition. Fine-needle aspiration cytology (FNAC) was performed pre-operatively via an intraoral approach, but it did not result in a definitive diagnosis. Based on the clinical presentation and uncommon imaging manifestations with destruction of the foramen ovale, the primary diagnosis was of a malignant tumor. Next, the patient underwent surgical excision under general anesthesia (). A frozen biopsy sample was obtained intraoperatively, yielding the following microscopic results: The tumor was composed of uniformly shaped spindle cells, with a higher proportion of nuclei, and plasma with a rare mitotic phenomenon (). Surgical margins were microscopically tumor-free

[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.