[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 Caucasian female with extensive history of pelvic surgery but without prior urological history underwent robotic-assisted laparoscopic excision of endometriosis by gynecological surgery team secondary to chronic pelvic pain with suspected endometriosis. On initial laparoscopic evaluation of pelvic contents, visible vermiculation of bilateral ureters was noted as well as suspected findings of endometriosis-like lesions covering the pelvic peritoneum. The pelvic peritoneum was excised with sparing of the urinary bladder. Careful ureterolysis was performed bilaterally, during which the distal left ureter was found to be partially denuded, spanning 2 cm in length (). An intraoperative urologic consultation was requested, and denuded ureteral injury was confirmed by urology on laparoscopic evaluation. Given no evidence of ureteral laceration or obvious extravasation of urine from left ureter, no cystoscopy or contrast studies were performed. A 2 cm x 12 cm AmnioFix membrane was wrapped three times around the left ureter using laparoscopic robotic assistance (Figures and ). The procedure was completed without anesthesia complications and the patient was discharged on postoperative day one in stable condition.
The patient was seen by her gynecologist on postoperative day six after experiencing lower urinary tract symptoms and was subsequently started on PO antibiotic therapy. However, her symptoms did not improve, and she developed new left flank pain which brought her back to the hospital for further evaluation on postoperative day seven. She underwent noncontrast CT imaging of the abdomen and pelvis demonstrating moderate left hydroureteronephrosis to the level of the distal ureter. She underwent cystoscopy with left retrograde pyelogram demonstrating 1.5 cm distal ureteral stricture with moderate hydroureteronephrosis (). Continued contrast injection showed a small amount of extravasation from the vicinity of the narrowed ureteral segment (). However, 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 female in her early 70s was referred to our hospital for endoscopic treatment of a 15-mm laterally spreading tumor adjacent to the appendiceal orifice, which was detected incidentally during a screening colonoscopy. An ER of the lesion had been attempted at another hospital without success and only biopsy had been performed after that. Her comorbidities included hypertension, dyslipidemia, and osteoporosis. Her medical history was negative for previous abdominal surgery, allergies, smoking, and alcohol consumption.
Magnifying endoscopy with narrow-band imaging and chromoendoscopy suggested the tumor was a simple adenoma. After obtaining written informed consent, we performed ER of the tumor. We began injected glycerol into the submucosal layer and incised the mucosa bordering the appendix side of the tumor using a DualKnife® (Olympus Corp., Tokyo, Japan). Subsequently, the submucosal layer was carefully dissected using the same device. However, due to the scarring and fibrosis resulting from the previous attempt at resection, the submucosal layer did not lift adequately, and the submucosal dissection was extremely difficult. Consequently, an intraoperative micro perforation occurred but was tightly closed by clips. When the tumor was almost resected by ESD, we completely removed it using a snare. The size of the lesion was 15 × 15 mm (Fig. ). After the ESD, there was neither postoperative bleeding nor inflammatory reaction suggesting peritonitis. The patient was discharged 5 days after ESD as scheduled. Pathological examination revealed that the tumor was a high-grade tubular adenoma, and we diagnosed a curative resection of the lesion.
The patient initially did well after she was discharged. However, 10 months later she experienced sudden severe abdominal pain and a low-grade fever before a meal. She visited her family physician immediately. Physical examination disclosed localized rebound tenderness at McBurney's point at that time. The laboratory analysis revea

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman attended for routine mammography screening. She was recalled because her screening mammograms revealed three separate lesions in her right breast and one in the left. At clinical examination, there were only two vaguely palpable masses in the upper outer quadrant of her right breast and one in the upper outer quadrant of her left breast. Overlying skin was normal and no regional lymph nodes were palpable.
Mammography of the left breast revealed a 15-mm lesion in the upper outer quadrant and on core biopsy it was shown to be a grade I invasive ductal carcinoma which was oestrogen and progesterone receptor positive. On the right side, the first mass, an area of about 13-mm of micro calcification, was situated in the upper outer quadrant at the 10'o clock position, and on core biopsy was confirmed as a grade I invasive ductal carcinoma, also both oestrogen and progesterone receptor positive. The second mass was at the 11'o clock position and the third was in the lower inner quadrant and these latter two lesions on core biopsy showed lymphoma-like features but not breast carcinoma. The core biopsies were therefore sent for expert opinion but this supplementary report was also not conclusive. Therefore, diagnostic excision biopsy was recommended. In the meantime, staging computerised tomography of her chest and abdomen was performed and was found to be normal. Treatment options were then openly discussed with the patient and her family and she opted for a right mastectomy and axillary node clearance and wide local excision and axillary node sampling on the left. She felt this would be easier than a combination of therapeutic local excision of the cancers and diagnostic needle localisation of the other masses in the right breast.
Definitive histopathology supplemented by immunohistochemistry was compatible with marginal zone B-cell lymphoma of right breast and involving the lymph nodes of both axillae (Figure , ). In addition, it also confirmed in 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 32-year-old nulliparous married woman presents with complaints of chronic lower abdomen pain, dyspareunia, and infertility. Her general physical examination was normal with body mass index of 22 kg/m2. On speculum examination, a longitudinal vaginal septum was seen in the proximal portion of the vagina and the cervix was partially seen beyond the septum, at a high up position []. On vaginal examination, a single cervix was felt high up, slightly deviated to the right, and a normal anteverted uterus. An ultrasound showed a subseptate uterus with midline thick muscular septum and normal adnexa. MRI revealed septate uterus with septa extending till the cervix [Figures and ]. No anomaly was found in any other organ.
To complete the diagnosis, consent was taken for vaginal septum removal, followed by diagnostic hysterolaparoscopy. The couple was given the option of septoplasty in the same sitting or later in case of pregnancy complications. They chose to have it later.
Under anesthesia, the vaginal septum was held in between two alles forceps and divided in between the two with cautery. After the septum was removed, two dimples were seen high up in the vagina. They were double cervix confirmed by magnification with the hysteroscope. Two separate sounds could be inserted through the two cervices, ruling out any cervical atresia []. The uterocervical length in both sides was 3.5 inches. Hysteroscope was introduced through both the cervices. The septum was found to be complete till the level of the cervix delineating two separate cervical canals and two cavities. Cavities on both sides of the septum were found to be similar in size. The two ostia were visualized on the respective sides of the uterus. On introducing the laparoscope, the fundus was found to be smooth with a 2 cm fundal midline fibroid and with normal tubes and ovaries []. Thus, a diagnosis of complete uterine septum with two cervices

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old, unmarried Caucasian male presented with a history of having been sexually assaulted five days earlier in a nearby city by a group of unknown males. Reportedly they kicked and stamped on him and during the assault a glass bottle was forcibly inserted into his rectum and the bottle neck broke.
The patient appeared very agitated and requested that only females be involved in his care. The residents on call for surgery were both female. When the male on call surgical consultant arrived the patient became very agitated and uncooperative.
On examination, there was no evidence of external injury to him. His abdomen was soft and showed a well-healed lower midline incision. He attributed this scar to a laparotomy done for abdominal pain in his childhood. Plain X-Ray of his abdomen showed the broken off upper part of a glass bottle (Figure )
The patient refused a rectal examination on the ward. On examination under anaesthesia, in the lithotomy position, no evidence of perianal trauma was found. A flexible endoscope was inserted and the broken glass bottle was confirmed to be in the sigmoid colon. An endoscopic snare was passed and the broken glass bottle retrieved (Figure ). Repeat endoscopy did not show any damage to the mucosa. The neck of the glass bottle was found to have a roll of paper inserted within it (Figure ).
The following morning the patient complained of pain in his abdomen. His abdomen was tender though there was no guarding or rigidity. Due to the possibility of rectal perforation, a CT scan of his abdomen and pelvis was arranged.
Due to the unusual circumstances, the case was discussed with a second surgical consultant within the same department. Surprisingly, he recognised the patient from a previous post at a nearby hospital. The same man had presented under a similar sounding name with an almost identical history. On that previous occasion he had also claimed to have

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old man was referred to our institution for a case of facial palsy. He was treated with systemic methylprednisolone for 10 days, without improvement. On examination, he had a visual acuity of 1.0 in the right eye and hand motion in the left. Motility examination revealed limitation of abduction of the right eye. The patient had a frozen orbit with a limitation of all gazes in the left eye. Fundus examination revealed a pale optic disk, afferent pupillary defect, and an ischemic retina, indicating central retinal artery occlusion. Examination findings were also consistent with oculomotor, trochlear, and abducens nerve paresis. Mucormycosis was a result of steroid therapy, as the patient was diagnosed 2 weeks previously with an isolated cranial nerve VII and was started with steroids in a peripheral ophthalmology clinic. At his first presentation in Jordan University Hospital, he had a frozen orbit with cranial nerve III, IV, and VI palsies.
The patient was admitted, and the results of baseline investigations were normal, except for a high white blood cell count and hemoglobin A1C (HbA1c) of 10%. Systemic steroids were stopped, and the patient was started on insulin to correct his blood sugar. He was never diagnosed with diabetes mellitus before and denied any symptoms of diabetes mellitus. He was initially diagnosed with diabetes mellitus. He tested negative for ketone bodies and was treated in the ward. Results of other routine investigations, such as kidney function tests and complete blood count, were normal, except for high blood sugar and a high white blood cell count.
The differential diagnosis of his current symptoms was cavernous sinus thrombosis, a space-occupying lesion in the cavernous sinus or orbital cellulitis.
Computed tomography of the brain and orbit was performed and revealed extensive sinus disease with left complicated ethmoidal and maxillary sinusitis extending into the left orbit with abscess formation. There was also extensive orbital

[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:
Ms A, a 90-year-old woman with a known past medical history of hypertension, chronic obstructive pulmonary disease, lower extremity edema, cognitive deficit, and urinary incontinence, was admitted to the hospital for cellulitis in her right lower extremity, that initially responded to intravenous vancomycin. She was readmitted for recurrence and growth of the discolored skin area, consistent with cellulitis that did not recede after the administration of oral antibiotics (doxycycline and sulfamethoxazole). Following the last admission, she had developed an extensive area of red-purple discoloration surrounding a dark purple, raised round lesion that was 2 cm in diameter, with a smooth surface and puffy consistency. The lesion was located in the anterior aspect of her right shin.
Despite extensive discoloration of the skin area, the patient was afebrile and did not have leukocytosis. Intravenous vancomycin was resumed, and the differential diagnosis was expanded to include vasculitis and neoplasia. A small fluid collection with internal echoes was identified on ultrasound of the dark purple lesion, leading to suspicion of organizing hematoma or bacterial abscess. However, needle aspirations of the lesions yielded only a few polymorphonuclear leukocytes and the absence of bacteria (an erythrocyte sedimentation rate [ESR] of 69).
The differential diagnoses were revised to include cutaneous malignancy. Given the purple discoloration and associated chronic lymphedema, consideration was also given to CA, and cutaneous B- or T-cell lymphoma. Wedge skin biopsy was recommended by the dermatologist. However, The patient would not consent to the surgical procedure owing to cognitive deficit (associated with Montreal Cognitive Assessment score of 11/30, with the identification of cerebral atrophy on head computed tomography).
Previously, the patient authorized one of her two daughters to be a surrogate medical decision-maker. The other daughter could not commit to a definitive

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old Caucasian male presented to the clinic with concerns of brief ongoing episodes of anxiety every couple of weeks. He described a 10-year history of episodes characterized as a squeezing sensation in the chest followed by palpitations.
He reported having numerous stressful events in the recent and remote past, and a family history significant for generalized anxiety in a number of first-degree relatives. He reported worry and concern regarding his past IV drug use possibly affecting his health at this stage in life. He also described experiencing a "sharp chest pain" that did not radiate and resolved spontaneously within a couple of minutes. These symptoms caused him to stop what he was doing at work and resulted in interference with his daily activities.
He is employed in a slaughterhouse, and he described his job as "physically and mentally demanding" as he handles live animals. He reported work exhaustion and thought stress could be contributing to his symptoms.
He denied presyncope or syncope. He also denied dyspnea on exertion or at rest. He denied any symptoms suggestive of orthopnea, paroxysmal nocturnal dyspnea, weight gain, or pedal edema.
At the time of the presentation, he had been using nicotine patches for tobacco cessation. He was not on any prescription, over-the-counter medications, supplements, or herbal remedies. Otherwise, he had no other acute health concerns.
The patient denied any family history of sudden cardiac death or cardiac arrhythmias. The patient has an extensive family history of coronary artery disease (CAD) after 50 years of age. Recently his mother was diagnosed with CAD and underwent percutaneous intervention with stent placement.
Additionally, he has a history of hepatitis C, the treatment of which concluded in 2019, and a history of intravenous drug use in sustained recovery for five years. He is a current smoker and smokes half a pack a day.
The patient's vitals and physical examination including cardiovascular exami

[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-year-old female was admitted to Xinan Hospital of The Third Military Medical University on January 24, 2007 due to two months of intermittent lower left leg pain, which became aggravated in the second month and was accompanied by the growth of a mass. X-ray imaging showed osteoblastic bone destruction of the left distal tibia (). MRI showed a mixed high and low signal intensity, with a visible periosteal reaction and an anterior soft tissue swelling. The patient was diagnosed with osteosarcoma of the distal left tibia by biopsy. The symptoms disappeared following one course of AP (ADR, 60 mg/m2; and DDP, 120 mg/m2) regimen chemotherapy. On March 2, 2007, the patient underwent a sectional removal of the osteosarcoma of the left distal tibia, a reconstruction using inactivated bone and an internal fixation, under general anesthesia. The post-operative pathological examination confirmed the initial diagnosis of osteosarcoma. Chemotherapy with the AP regimen (four courses with three week intervals) was initiated subsequent to the healing of the incision (two weeks post-surgery). An X-ray captured at 29 months post-surgery showed a nonunion between the host bone and the distal side of the inactivated bone, accompanied by a posterior protrusion and varus deformity (). On July 31, 2009, the stainless steel plate-screw fixation was surgically removed from the left tibia. On April 4, 2012, 62 months after the initial surgery, the patient was hospitalized due to one month of ankle pain, which was associated with a mass (). An X-ray examination demonstrated healing between the host bone and the proximal end of the inactivated bone, but a hypertrophic nonunion existed between the host bone and the distal end of the inactivated bone, which was accompanied by a posterior protrusion and varus deformity. Screw residues were left in the inferior tibia and fibula. MRI showed an anterior soft tissue mass in the lower left leg and osteolytic destruction of the left distal tibia, s

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old male was diagnosed with a Stanford A aortic dissection when he presented to an emergency department with hemodynamic instability and a history of sudden-onset severe chest pain. A computed tomography aortogram (CTA) revealed an acute type A aortic dissection involving the aortic root, arch, and the rest of the aorta down to the left external iliac artery. The dissection flap also extended into the brachiocephalic trunk, left common carotid, and proximal left subclavian artery (LSA). There was complete occlusion of the left internal carotid artery while the right carotid artery supplied the entire anterior circulation through the intact circle of Willis; the posterior circulation was supplied by both vertebral arteries. Swiftly after diagnosis, he underwent emergency ascending aortic replacement and re-suspension of the aortic valve as a first step.
Postoperative surveillance CTA showed progression of the dissection in the left common carotid and LSA and coeliac artery dissection and re-entry into the false lumen of the thoracic aorta from the abdominal aorta []. Magnetic resonance angiography confirmed the findings on the CTA. The initial plan was to replace the aortic arch, however intra-operative assessment prompted deferring the patient to a staged procedure using endovascular technology in conjunction with surgical debranching of the innominate artery and the left common carotid artery using a Y-graft attached to the ascending aorta interposition graft.
Postdebranching CTA showed good results of the debranching procedure, but subsequent studies showed progressive dilatation of the descending thoracic aorta, and at 6 months, there was an increase in the dimension of the arch of aorta from 44 cm × 47 mm to 44 cm × 52 mm [].
In light of these findings, a consensus was made to use a customized stent-graft for reconstructing the dissected and expanding arch segment. There were also concerns that it would be difficult to transpose or bypass the dissected

[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 44-year-old Japanese male, an office worker, was transported to our emergency department with a complaint of temporary loss of consciousness. He had experienced fatigue for 3 years and had fallen easily in his daily life starting 2 months before admission. He was feverish and had a cough and phlegm for several days before admission. On the way to work, he felt drowsy and fell down the stairs of the train station, necessitating transport to our hospital by ambulance. The peripheral blood analysis noted mild elevation of white blood cells. The blood chemistry test disclosed mild elevation of C-reactive protein and mild liver dysfunction (). He was thin, i.e., his height was 174 cm and he weighed 52 kg (). Chest computed tomography (CT) showed severe infiltration in the upper posterior fields of both lungs as well as food debris in the esophagus. He was diagnosed as having aspiration pneumonia. His past medical history included diabetes mellitus that had been treated by a local doctor; glycated hemoglobin was approximately 7%. He had experienced ileus six times since age 30 years. He was not married. His father had died of dilated cardiomyopathy at the age of 70 and had also been thin. On the other hand, his mother was healthy but his maternal uncle was diabetic. His younger sister (Case 2) also had mild muscle weakness of the four extremities. Aspiration pneumonia was treated by intravenous administration of antibiotics under conditions of food-take restriction combined with temporary insulin infusion, and the respiratory symptoms subsided. On the neurological examinations after improvement of pneumonia, he presented with typical clinical manifestations of DM1 (), such as forehead balding, hatchet face with bilateral ptosis, nasal speech, mild muscle weakness of the four extremities, handgrip myotonia, and diffuse muscle atrophy. Electromyography performed to test the biceps brachii muscle and femoral quadriceps muscle on the left side revealed frequent myotonic dis

[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 63-year-old male, 10-day post completion of anti-tuberculosis regimen for pulmonary tuberculosis, known smoker and alcoholic, presented with grade-5 dysphagia associated with food regurgitation, cough and weight loss. On general examination, he was ill looking, cachexic, dehydrated and pale, not jaundiced but no lower limb edema. His vitals were blood pressure of 139/71 mmHg, Temperature of 35.8°C, oxygen saturation of 95% on room air, respiratory rate of 18 cycles per minute and a pulse rate of 73 beats per minute. He had a scaphoid abdomen with tenderness on the right lumbar region. Fine crepitations were heard with reduced air entry on the right side of his chest. Full blood picture was done which was normal with a haemoglobin of 11.3 g/dl, other investigations including renal function tests and liver enzymes were normal. Chest X-ray done showed signs of metastasis (). CT-scan of the abdomen done at the referring hospital with both oral and intravenous contrast reported structures above the diaphragm showing dilated oesophagus measuring 41 × 38 mm due to distal retro-cardiac concentric oesophageal wall thickening amounting to 18 mm with luminal narrowing with possibility oesophageal fistula tract. The gastric cavity was normal without focal lesions. OGD revealed the oesophageal mucosa was hyperemic with a blocking mass at 29 cm from the upper incisors. The scope was able to pass beyond the lesion. The cardiac, fundus and body mucosa was atrophic. There were metaplastic changes at the antrum and pylorus. Multiple biopsies were taken. Histology results revealed oesophageal well differentiated invasive squamous cell carcinoma.
The patient was scheduled for GFT insertion. Under aseptic technique, with the patient in supine position, 24 Fr urinary catheter as an improvised GFT was inserted in Stamm manner, haemostasis achieved, abdomen closed in layers and dressed (). There was no ascites and mesenteric lymph nodes were not palpable. After the procedure the patient

[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 no significant family medical history and a personal history of hypertension that had been treated for years with amlodipine, fosinopril and hydrochlorothiazide was diagnosed with PV in July 2012. Hydroxyurea and acetylsalicylic acid were prescribed one month later and he was immediately referred to our department to rule out skin cancer in the context of a prospective study of cutaneous manifestations associated with PV and associated treatments. The patient had a Fitzpatrick skin type II and a long sun-exposure history. We detected a facial lentigo maligna, two basal cell carcinomas and one cSCC that had been present for several months. All these lesions were surgically removed with no recurrences. The cSCC was located on the left leg and histologically showed poor differentiation (case 1 in ). In January 2013, five months after hydroxyurea had been prescribed, it had to be withdrawn due to hematological resistance. Ruxolitinib 10 mg twice a day was then initiated. The dose of ruxolitinib was progressively escalated to 15 mg twice a day, dose that was achieved on August 2013. In May 2014, the patient started developing rapidly growing invasive cSCCs. He developed seven primary lesions and one recurrence in sun-exposed areas that corresponded to cSCCs over an 18-month period of time (). All the tumors were rapidly growing crateriform lesions that clinically suggested keratoacanthomas (KA) (). Histologically, all these tumors consisted of cSCCs and six out of seven lesions also showed KA-like features (, ). Areas of fibrosis at the tumor invasion fronts were observed in all the lesions (). All the tumors were treated with surgical excision () with no recurrence except for lesion number 6, located on the left parietal area, which showed recurrence 2 months after removal. This lesion (case 9) was excised and irradiated with no further relapses. No decrease in the count number of leukocytes or lymphocytes per mm3 was observed during treatment wit

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old male presented to our oculoplasty clinic with chief complaints of gradual outward deviation of left eye and double vision in right gaze for the past 2 years. There was no history of pain, trauma, diurnal variation, diminution of vision, vomiting, or headache. He was not a known case of diabetes mellitus, hypertension, thyroid disorder, or any other chronic disease.
Visual acuity of both eyes was 20/20. There was right face turn with left exotropia. Extraocular movements in left eye revealed complete limitation of adduction and mild limitation of depression []. There were no signs of thyroid ophthalmopathy. Rest of the anterior and posterior segment examination were within normal limits. A differential diagnosis of thyroid eye disease and ocular myasthenia gravis was considered and a thyroid function test (serum free T3, serum free T4, and serum thyroid stimulating hormone assay) and serum acetylcholine receptor antibody were ordered.
Thyroid function test was within normal limits and serum acetylcholine receptor antibody was negative. Magnetic resonance imaging (MRI) of the brain and orbit showed hyperintensity in the belly of left medial and inferior rectus. There was no enlargement of the muscles and orbital fat content was normal [ and ]. The features on MRI were neither suggestive of thyroid eye disease nor idiopathic orbital inflammation.
On further inquiry, the patient gave history of isotretinoin intake for 3 months (1 mg/kg/day) for cystic acne just before the symptoms started and continued the drug for next 5 months. A provisional diagnosis of isotretinoin-induced myopathy was made and the patient was asked to stop isotretinoin. The patient was also started on a course of oral steroid in tapering fashion to take care of any associated inflammatory pathology. There was no improvement in extraocular motility after 3 months of oral steroids, and a repeat MRI showed no improvement, suggesting fibrosis. The patient was prescribed prism glasses to t

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old Caucasian man with recurrent hemoptysis was referred to our hospital. A diagnosis of Hughes-Stovin syndrome had already been established in a previous hospital admission []. He had had some incidents of spontaneous non-productive cough several days prior to his admission.
During his previous admission three months before his current presentation, his physical examination was normal apart from mild, tender swelling of his left thigh and calf caused by DVT (left external iliac and femoral vein) detected by color duplex examination. His oropharynx and larynx were normal, and his mucous membranes were free of ulcers. Chest radiography revealed a round opacity in the right medial pulmonary field. CT of the chest showed an aneurysm in the right lower lobe pulmonary artery, together with mural thrombus, that had a diameter of 3.5 cm in the lower lobe of the right lung. Magnetic resonance angiography (MRA) of the cerebral venosus sinuses and the pulmonary arteries (Figure ) was performed to clarify the etiology of the patient's headaches and to plan possible embolization of the aneurysm. Cerebral MRA revealed multiple chronic thromboses of the sclera mater venous sinuses. The rare diagnosis of systemic vasculitis Hughes-Stovin syndrome was made on the basis of the pulmonary artery aneurysm and peripheral venous thromboses in such a young patient. There were no findings consistent with Behçet's disease.
The patient was initially treated with corticosteroids. His hemoptysis resolved with intravenous methylprednisolone treatment after about 25 days. Upon his second admission, because of his recurrent hemoptysis, we decided to perform percutaneous embolization of the pulmonary artery aneurysm.
The aneurysm was initially embolized with steel microcoils via an infusion catheter. Subsequently, an Amplatzer Vascular Plug (AGA Medical Corp., Plymouth, MN, USA) with a diameter of 16 mm was inserted into the cavity of the aneurysm. The procedure ended without any compli

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old, otherwise healthy, young male patient presented with incidentally detected bilateral small solid renal and adrenal masses, a cystic mass at the head of the pancreas, and a paracaval mass. The patient defined no relevant family history and had no obvious symptoms. Physical examination findings (including serial blood pressure measurements) were within normal limits. Ultrasound (US) and abdominal magnetic resonance imaging (MRI) were performed to understand the nature of a recent, blunt, nonspecific upper abdominal pain and revealed 3 small, solid masses in the right kidney measuring between 1 and 4 cm and 5 masses in the left kidney measuring between 1 and 3 cm in size. All were suggestive of renal cell carcinomas (RCCs) (). An 8 cm solid mass completely replaced the right adrenal gland, while there were 5 small masses on the left side, all consistent with pheochromocytomas (). The paracaval mass, measuring 4 cm in size, could be not only an enlarged lymph node but also a paraganglioma. The imaging findings of the cystic mass at the uncinate process of pancreas were suggestive of a neuroendocrine tumor (). All other radiologic studies, including spinal and cerebral MRI, were normal. Serum and urine biochemical workup (including cortisol and vanilmandelic acid measurements) revealed normal findings regarding the functional status of the adrenal masses.
The patient was diagnosed as VHL disease and a staged surgical approach was recommended based on the radiologic findings. In the first stage, through a subcostal anterior transperitoneal approach, right adrenalectomy, resection of the paracaval mass, and enucleation for the 9 small solid renal masses were performed. Intraoperative frozen section findings were inconclusive about the actual biologic behaviour of the mass located in the uncinate process of the pancreas. Additionally, two other smaller pancreatic masses were palpated during the operation. Given the young age of the patient, we decided to perf

[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 an 11-year-old boy with no notable medical or family history. For about 3 months, he had occasional general malaise, headaches, and vomiting. The patient then began to complain of difficulty in turning his neck and was referred to an orthopedic clinic. No abnormalities were detected in the head and neck in the computed tomographic (CT) images and the magnetic resonance images (MRIs). In addition, all hematological tests were within the normal limits.
After 1 month, the patient had a transient reduction in vision, and when his vision worsened in both eyes, the patient was brought to an ophthalmologist. At the initial examination, his visual acuity was 20/200 in the right eye and 20/100 in the left eye. The intraocular pressure of the right and left eyes was 19 and 20 mm Hg, respectively. No clear differences in the pupillary light reflexes of the right and left eyes were found. A relative afferent pupillary defect was not present. The anterior segment of the eye was normal, but ophthalmoscopy showed a marked swelling of the optic disc and severe retinal exudates in both eyes (fig. ).
The patient was admitted for comprehensive examinations on the same day. Physical and hematological abnormalities were not found. Head X-rays showed dehiscence of the coronal suture, which suggested intracranial hypertension. MRI showed no space-occupying lesions in the brain, but did show tortuous optic nerves, enlarged spinal fluid cavity, and flattened posterior sclera (fig. ). MR venography did not show clear signs of a sinus thrombosis. Cerebrospinal tap demonstrated a marked increase in the cerebrospinal pressure with an opening pressure of 350–500 mm H2O, but the cerebrospinal fluid contents were normal.
Based on these findings, the patient was diagnosed with IHH, and acetazolamide, concentrated glycerin, and steroid were injected intravenously. Initially, the intracranial pressure decreased after the treatment, but after 1 month, the intracranial hypertension and

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old man was referred to our hospital and presented with dysuria for 2 months. Since the onset of the disease, there had been no incidences of low fever or night sweat and no significant changes in weight. Nevertheless, he complained about a decline in physical strength since the onset of the disease. He had a history of hypertension and diabetes for more than 20 years and had a cerebral infarction 8 years ago. On physical examination, a grade 3 enlarged prostate was found by digital rectal examination, with a hard texture, rough surface, and poor mobility. On laboratory examination, all other routine blood indexes were within the normal limits. The prostate-specific antigen (PSA) value was 0.09 ng/mL, which was in the normal range (<4.0 ng/mL), and other tumor markers, including carcinoembryonic antigen and glucosaminidase, were also within the normal limits. Urinalysis showed that all indicators were in the normal range. Based on the details above, we performed transabdominal contrast-enhanced ultrasonography and transrectal prostate biopsy.
Transrectal ultrasound showed that the appearance of the prostate was enlarged, the size was 91 mm × 63 mm × 90 mm, the outline was irregular, the internal echo was not uniform, and a necrotic liquefying area in the center was seen, with a range of approximately 78 mm × 48 mm; furthermore, color Doppler flow imaging (CDFI) revealed rich blood supply signals from the surrounding soft tissue (Fig. A), RI: 0.89. CEUS of the abdomen showed that the peritumoral parenchyma began to enhance rapidly in 12 seconds (Fig. B), the large blood vessels in the necrotic liquefying area of the tumor center enhanced synchronously with the surrounding tissues, and the enhancement was most significant at 21 seconds (Fig. C). The necrotic area shown by contrast-enhanced ultrasonography was much larger than that by two-dimensional ultrasonography. According to the enhanced area as shown by CEUS

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


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

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

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old Russian male, not known to have chronic medical illnesses, came to the ED complaining of painful swelling in the lower abdomen which had been going on for five days. Abdominal pain was severe colicky in nature with no relieving factors, associated with nausea and vomiting multiple times. There had been no change in bowel habits, fever or change in appetite. The patient had a history of lower abdominal surgery at the age of two, but he had no medical report
On physical examination the patient was conscious and had a normal body built. His blood pressure was 126/92, pulse was 88 and temperature was 36.2 °C. is symmetrically distended with a swelling in the lower abdomen 12 × 15 cm in size with negative cough impulse, erythema and tenderness on the overlying skin. The rest of the abdomen was soft on palpation with positive bowel sounds. Investigation of his hemoglobin gave 10.8 wbc’s with 11.5 sodium 139 potassium 3.2 creatinine 0.7.
The patient was admitted as a case of abdominal pain for investigation. The CT of abdomen and pelvic with IV and oral contrast was done showing thickened terminal ileum with marked luminal narrowing which appeared adherent to the urinary bladder wall with no line of cleavage. Two fistula tracts were seen superior and inferior; the superior one lead to a pocket of collection filled by contrast 36 × 20 mm in size. The inferior tract was connected to an anterior abdominal wall collection measuring about 18.7 × 14.4 mm with marginal enhancement denoting an abscess. There was diffuse anterior abdominal wall fat stranded with subcutaneous pockets of air denoting infection. Subcentemetric mesenteric lymphadenopathy was observed ().
Patient was taken to the OR for exploratory laparotomy and drainage of the abscess. Upon internce to the abdomen a large pocket of pus in subcutaneous layer was opened and evacuated and a swab was sent for culture and sensitivity. A firm mass inclosing the pelvic was dissected and found to

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old Thai woman presented with a gradually progressive enlarged mass over a period of 10 years in her left leg. She did not have any pain, fever or weight loss. She had a history of snake bite by a Malayan pit viper to her left leg when she was 14 years old. Her leg became markedly swollen and she could not walk for 2 months. She was treated by a traditional healer. Finally, she could walk again but her ankle and toes could not perform active dorsiflexion. At the first visit, a physical examination showed a 20×10cm mass in her left leg. The mass was not tender or inflamed. Sensation was decreased over the dorsum of her left foot.A plain X-ray showed a large soft tissue mass at the anterior compartment of her left leg. Cortical erosion of her tibia was observed. A sheet-like mass with an enlarged central cavity combined with peripheral calcification resembling an eggshell and multiple fragmented calcifications in her left leg were detected (Figure
).Magnetic resonance imaging (MRI) revealed a large well-defined heterogeneous iso- to hyperintense soft tissue lesion with hypointense coarse calcifications on both T1-weighted and T2-weighted images with heterogeneous enhancement after gadolinium contrast administration that mainly involved the anterior compartment of her left leg with evidence of tibial cortical atrophy from the pressure effect (Figure
a, b, c).The patient decided to observe the clinical signs and symptoms. One year later the mass progressed in size (Figure
). A repeated MRI showed soft tissue mass involving the entire anterior compartment of her left leg and increased extension to the tibialis posterior muscle of the posterior compartment. Progressive cortical erosion of tibia and fibula was found (Figure
a, b).A biopsy was done which found central necrotic tissue with peripheral calcification and a negative result for neoplastic cells. Mass excision was suggested to the patient but she refused to have an

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


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

[User]
RADIOLOGY NOTE:
A healthy 20-year-old male was referred to the dental office for pain during his breakfast, probably due to traumatic injuries to the teeth following an affray occurring the night before. On clinical examination both maxillary central incisors were subluxated and attached gingival of the right one was tender to palpation. The lateral maxillary incisors were not affected by the trauma and were tested vital. Radiographic examination revealed a horizontal fracture of the right incisor at the middle of the root and a second one of the left incisor at the coronal two third portion of the root (). No preoperative cone-beam computed tomography was taken due to limitations of emergency. Pulp testing of both incisors was uncertain.
After the informed consent, under local anesthesia, 0.022 × 0.028-in Roth prescription brackets were bonded to the labial surfaces of the right and left incisors and cuspids. A splint was made with 0.017 × 0.025-in orthodontic stainless-steel wire that was given first order bends to retain the forward passive positioning of the incisors during splinting ().
A periapical radiograph was obtained to confirm the proper positioning of the coronal fragments. The patient received instruction about soft diet and oral hygiene: brushing his teeth with a soft toothbrush after each meal and rinsing his mouth twice a day for one week with 0.20% chlorhexidine. Systemic antibiotic (amoxicillin 2 g each day for one week) and analgesic medicament on demand were prescribed. Recall visits were planned according to the International Association of Dental Traumatology guidelines. The splint was removed after 12 weeks (). The healing of both incisors was achieved with interposition of hard tissue. No sign of pulpal necrosis was observed, and the teeth showed positive response to pulp testing.
At 3-month and 12-month recall visits after the splint removal, the patient reported no discomfort and there was no sign of pathology ().

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


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

[User]
RADIOLOGY NOTE:
Patient is a 64-year-old Caucasian male presented to the emergency room at the end of December at our facility with worsening left arm swelling. Two weeks ago, he was initially admitted for the right arm swelling and tenderness. He, at baseline, has been on leflunomide for three years for treatment of rheumatoid arthritis and previously was on prednisone for the same reason. Patient reported that, in mid-November, he started to experience significant pain in both wrists and was evaluated at the rheumatologist office for possible rheumatoid arthritis flare. He had received steroid injections in bilateral wrists. During his first admission two weeks prior, he was diagnosed with deep abscesses of right upper extremity (RUE) which has later gotten incision and drainage. At that time, only bacterial cultures were sent, which grew methicillin-sensitive Staphylococcus aureus. Patient was discharged home on trimethoprim/sulfamethoxazole oral tablets but readmitted seven days later with pain and pustules now mainly on all of the fingers of the left forearm ().
He again underwent drainage and bacterial and acid fast bacilli smear and cultures were sent. M. marinum was identified phenotypically in our lab when the culture grew at 30 degrees Celsius. The sample was also sent out for biochemical sequence and further identified as M. marinum (Nichols Institute, Chantilly, VA). He was empirically treated with intravenous imipenem, linezolid, and azithromycin. During this second admission, magnetic resonance imaging (MRI) of the left arm was done which showed multiple ulcerations extending from the skin surface into the subcutaneous fat with the largest visualized at the palmar aspect of the wrist, extending deep to the level of the carpal tunnel/hook of the hamate, at the dorsal and ulnar aspects of the mid- and distal forearm at two sites and at the ulnar aspect of the distal forearm suggesting tenosynovitis with necrotizing fasciitis. He recovered well from the surgery and was d

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old competitive male soccer player, who presented with a two-year history of recurrent bilateral groin pain and stiffness, was admitted to our institution. Bilateral examination showed pain in hip flexion, adduction, and internal rotation (anterior impingement test); abduction and external rotation were normal. The patient had bilateral hip flexion up to 100° and internal rotation of 0°. Plain radiographs of the pelvis showed a well maintained joint space and a combined type FAI image. The alpha angles were 78° for the right side and 76° for the left side; the lateral centre edge (LCE) angle was 45° on the right and 47° on the left. Both hips showed a large superior rim fracture ().
A magnetic resonance arthrogram showed FAI and an anterosuperior bilateral labral tear (). A bilateral hip test with intra-articular lidocaine was positive (showing an intra-articular and labral pain). The patient was then treated with an arthroscopic procedure of each hip, with a three-month gap period in between them both. The out-in hip arthroscopy approach described by Sampson [] was used in both surgical events. A labral tear associated with a large superior fracture of the bone rim was found; the cartilage at the junction with the labrum was intact in both hips. Pincer resection was performed with power instruments, which included about 30% of the fractured segment. This was performed under X-ray supervision and the remaining bone fragment was secured with an arthroscopic assisted 3.0 mm cannulated screw () in both sides. Finally, the labral fixation was secured with 3 translabral suture anchors and an arthroscopic cam resection of the femoral neck was performed. The final examination of the hip motion under arthroscopic vision probed no impingement at all.
The patient was restricted to foot flat weight bearing and two crutches for 6 weeks and progressed back into soccer at 4 months postoperatively. Physiotherapy was indicated

[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 19 years old woman presented with approximately four weeks history of painless 5 × 5 cm breast lump/lumpiness. There was no history of trauma, nipple discharge or relation with menstrual cycle. There was no known family history of breast cancer. Palpation revealed a non-tender, mobile, hard left upper quadrant left breast lump. Mammogram was not performed given the very young age of the patient. Ultrasound revealed a prominent diffuse hypoechoic lesion. It appeared to be most likely benign lesion but as there was an element of uncertainty as to the nature of the lump on ultrasound, an ultrasound guided core biopsy (14G needle) was performed.
The core biopsy of the concerned area revealed parenchymal-rich breast tissue with columnar cell change and epithelial hyperplasia. In addition, there was fibroblastic stroma with focal elastosis containing an infiltrative adenosquamous proliferation. Diagnostic excision was recommended by the breast multi-disciplinary team (MDT) as the lesion appeared benign but with uncertain malignant potential.
As shown in Figures , and , subsequent diagnostic excision biopsy showed an ill-defined area of benign adenosis set in fibroblastic stroma with focal elastosis suggestive of a radial scar or complex sclerosing lesion. Within this lesion there was an infiltrative proliferation of angulated glands showing adenosquamous features. A proportion of these glands lacked definite myoepithelial layers and the tumour expressed immunoreactivity to p63 gene antibody assay. Both the sclerosing lesion and the adenosquamous proliferation extended up to the excised margin. Hence, a wide local excision was deemed necessary.
The wide local excision specimen showed residual spindle cell lesion with squamoid islands seen in the infero-lateral shave specimen taken during wide local excision.
External opinion was sought from international experts (as acknowledged later) in this uncommon histological subtype of breast cancer. The consensus view was that

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old girl visited the orthopedic service because of severe knee pain after a sudden fall while heading downstairs, and she was unable to stretch her leg. The patient had a history of dislocation of the patella 2 weeks ago. Physical examination showed tenderness on palpation over the upper pole of the patella and absence of active movement of the knee accompanied by swelling and joint effusion. A plain radiograph showed an avulsed fragment of the superior pole of the patella (Fig. ). Magnetic resonance imaging (MRI) confirmed a superior pole patellar avulsion fracture and dysfunction of the knee extensor mechanism (Fig. ). There were no signs of damage to the articular cartilage, meniscus, and cruciate ligament caused by previous dislocation.
Under general anesthesia, the patient underwent open surgery for reduction of the patellar fracture and reconstruction of the knee extension apparatus through an anterior approach. All of the above-mentioned imaging findings were further confirmed during surgery. Through a midline incision above the quadriceps tendon, careful dissection was performed to expose the injury site. Intraoperatively, a sleeve-like piece of bone was detected above the patella, and the proximal quadriceps tendon was attached to the bone piece (Fig. ). Then, complete removal of the blood clot and tissue debris was performed in the joint cavity and around the torn ends of the quadriceps tendon. Patellar retinaculum and quadriceps tendon with the patellar fracture piece was meticulously repaired and secured to the main patellar body by 2 Bio Composite suture anchors (Arthrex, Naples, FL) using a modified Mason–Allen stitch and was augmented by performing the figure-of-8 technique (Fig. ).
Postoperatively, the patient's knee was maintained in full extension using a knee brace, and weight-bearing was prohibited until 6 weeks after surgery. The passive range of motion exercise of the knee was started on the first day after surgery, and it was gradual

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


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

[User]
RADIOLOGY NOTE:
In October 2016, A 54-year-old male presented with bilateral crippling hip pain in the groin on both sides radiating to the front of the thigh with reduced mobility for almost 3 years and progressive worsening of symptoms. He had developed a significant limp preventing him from walking and performing routine activities independently with disturbed sleep.
On examination, he had a bilateral stiff hip, antalgic gait with a BMI of 34.1. Both hips had very limited range of motion (). He had a poor Harris Hip Score of 34.2 in the left hip and 34.3 in the right hip. Anteroposterior X-ray of the pelvis with both hip joints showed severe bone-on-bone arthritis () in both the hip joints. He elected to undergo simultaneous bilateral soft tissue sparing bikini anterior hip replacements described previously by the senior surgeon []. The left hip was operated first followed by right with a surgical time of 135 minutes total.
Post-operatively, mechanical thromboprohpylaxis was used for 24 h followed by oral aspirin 300 mg with nexium for 6 weeks. He was mobilized within few hours after surgery as part of our enhanced recovery programme. He started walking with the aid of a walking frame and even managed a dozen steps unaided the same day. He was discharged on the 2nd post-operative day. He started on his exercise bike Day 5 post op and resumed driving on the sixth day onwards as he was very mobile with a single crutch mainly for safety and not on any narcotic analgesia. He felt very confident and comfortable and had no issues driving.
On day 9 post-op, he was back at work doing light duties and clerical activities by which time he was mobile with pain free hip movements and without any mechanical dysfunction. At the 6 week mark he had a well healed surgical scar with no swelling and walked in without a limp. He was followed

[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 77-year-old Caucasian man was admitted to our emergency department with abdominal pain and nausea that had occurred for the previous 24 hours; the patient had a one-year history of intermittent abdominal pain and chest tightness during physical effort. He had been evaluated for these chest problems approximately one year ago at another center and was determined to have no cardiac issues. The plain chest X-rays that were taken at that time revealed consolidated areas in the left basal lung segments, and the patient was treated for a diagnosis of pneumonia. The patient did not have a significant history of trauma.
When the patient presented at our hospital, his abdomen was mildly distended and hyperactive bowel sounds were heard. A physical examination revealed muscular rigidity in the left upper quadrant of the patient's abdomen without rebound tenderness or signs of peritoneal irritation. The rectal examination revealed no masses or bleeding. The patient had a temperature of 37.5°C, a heart rate of 100/min, and a blood pressure of 160/90 mmHg. Laboratory analysis revealed an elevated white blood cell count of 19,000/mm3. The other laboratory results were normal. These signs were interpreted as a partial bowel obstruction of unknown origin because the patient was passing stool and flatus. An urgent computerized tomography (CT) scan with oral/rectal and intravenous contrast was performed; the scan revealed a left-sided BH, with a large segment of incarcerated transverse colon (-).
The patient was taken to the operating room for laparoscopic repair of an incarcerated BH. The patient was placed in a modified lithotomy position, and five trocars were used. The intra-abdominal pressure was maintained at 10 mmHg after the pneumoperitoneum was achieved via the open technique. The head and the left side of the patient were raised to 30°. The omentum and the distal part of the transverse colon were found to be attached to the left-sided BH (). The diaphragm was divided by a

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old male known to have hypertension and dyslipidemia, presented to our hospital with shortness of breath, fatigue and dry cough. Chest x-ray for the patient showed patchy infiltrates in the right lung. The patient was admitted under Internal Medicine service as a case of suspected COVID-19 pneumonia, which was later confirmed by polymerase chain reaction (PCR) test and was put on Enoxaparin 40 mg daily, IV fluids and acetaminophen upon admission according to hospital protocol. On day three of admission, patient started to have increased respiratory effort and was requiring oxygen support via high flow nasal cannula. He was then admitted to the intensive care unit (ICU), and his enoxaparin was increased to a therapeutic dose and was started on steroids, broad-spectrum antibiotics and intravenous fluid. A 16 Fr Foley’s catheter was inserted for monitoring urine output and was a routine measure in all ICU patients. After 3 days in the ICU the patient became stable and was transferred to general ward. He noticed that he has a constant painless erection that he thought it is caused by the Foley’s catheter and did not report it to hospital staff. Because of the high volume of COVID-19 patients and as a safety precaution, physicians did most of their rounds via Telemedicine video calls. Therefore, genital exams were only done when there is a complaint made by the patient. After spending 21 days in the hospital the patient was ready for discharge, and while removing the patient’s Foley’s catheter in preparation for discharge, the primary physician noticed the erection and the Urology team were consulted for suspected priapism. The patient reported that he has been having a constant erection for at least 10 days, which he noticed after Foley’s catheter insertion. He denied any history of, pain, trauma, use of erectile dysfunction (ED) medications or treatment. He denied any voiding

[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:
Male, 44 years old, referred to our division from another island with a huge mass on his penis and scrotum. He was injected with olive oil several times a couple of years ago. Due to the paraffinoma mass reported a heavy feeling in his scrotal and penile areas (). He also had repeated blisters at the bilateral inguinal that caused him pain and made walking difficult. He complained of pain upon erection, and the swollen mass rendered him unable to achieve satisfactory sexual intercourse. He could still urinate but had a trapped feeling about the paraffinoma mass around the penoscrotal area. The mass excision was performed by our colleagues from the Urology Division to the penis and scrotal area. The excised paraffinoma mass was firm, yellow in color, and almost 1 kilogram in weight (). The scrotal area was reconstructed with the healthy surrounding tissue and left to vacuum drain for 3 days. The penis was resurfaced with a one-sheet spiraling FTSG from the right inguinal (). The surgical technique was the same as cases no. 1 and 2. The patient also received other drugs such as antibiotics, analgesics, albumin, and vitamins. One week after the surgery, the patient had five HBOT sessions with 2.0 ATA (). The patient was discharged from the hospital on the 14th postoperative day with outpatient follow-up twice per week. After 1 year, the patient had no complaints and was satisfied with the surgical results.
Soft tissue filler is a critical component of aesthetic dermatologic surgery. In soft tissue augmentation, a variety of temporary and permanent filler compounds have been used. Paraffin, Vaseline, and liquid injectable silicone are the most commonly used. Extruded polytetrafluoroethylene and Silastic (strong silicone) implants are the simplest permanent filler fabrics approved for use in the US In the past, liquid silicone was utilized for permanent soft tissue augmentation, but the FDA has not approved the forms of liquid

[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:
81-year-old woman with a history of hypertension treated via Enalapril and dyslipidemia treated via diet. She had been evaluated some years ago by an otorhinolaryngologist and was diagnosed with bilateral hypoacusis, which was severe in the right ear and moderate in the left ear, where she had a hearing aid.
Four months prior to the consult, the patient had her first episode of MH. It consisted of childhood songs, which she had learned and liked (Manolo Escobar, folk songs). She heard them in her left ear, which was the only one that still retained partial audition with a hearing aid. She had not heard anything with her right ear for several years. The songs could last for hours and did not bother her; she assumed they came from the outside environment.
It was noted that the patient did not have any previous incidents of psychiatric illness, she had not shown symptoms of cognitive deterioration, and she had no changes in her regular treatment; she lived alone and was independent in her daily life. After the patient’s symptoms began, her family was worried about with the possibility that she had a psychiatric or neurological illness; following a consult with her general practitioner the patient was given treatment with sertraline. The family also started considering the possibility of sending her to a nursing home believing that she was showing signs of the onset of dementia.
In the neurological examination, aside from the hypoacusis, the patient did not present with alterations of interest and, in her cognitive evaluation, the tests were within normal ranges (Minimental-test, Fototest).
Because of the presence of MH, the patient was evaluated by psychiatry, which did not encounter any pathology.
In the tests performed: analytical, Holter EEG, and MRI of her brain, only diffuse cerebral atrophy was identified in the image study, and there were no other points

[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 woman presented to our hospital with a mass in her left axilla. The mass had
increased in size over the preceding 14 months. The patient was counselled for the first
time by her family doctor to undergo investigation, such as ultrasound or magnetic resonance
imaging (MRI), to obtain a differential diagnosis, but she refused because she thought it
was not necessary. Six months later, the mass was slightly larger compared with the initial
size. She still believed that it was a mammae erraticae and did not undergo any
examinations. Two months before visiting our hospital, she realized that the situation was
worse than what she thought because the contour of the mass could be seen on the skin
surface. She was then referred to the galactophore department and underwent MRI
examination.
There was no pain or paraesthesia in the involved area. Moreover, no associated family
history or clinical features were recorded. Physical findings on the initial examination
indicated a solid ovoid movable mass in the left axilla, measuring 12 cm in length and 8 cm
in width. The mass was partly covered by the pectoralis major muscle. Regular preoperative
blood tests showed normal results. MRI revealed that the mass was subcutaneous and
homogeneous (). With a
clinical diagnosis of a nerve tumor and a preoperative anaesthetist assessment, the patient
underwent surgical excision of the tumor. We explained to the patient that nerve grafting
might be performed if the involved nerve could not be preserved. The tumor arose from a
nerve in the left axilla. It was well encapsulated and located eccentrically to the nerve
trunk (). The involved nerve
was identified as the long thoracic nerve based on the electrical stimulation response.
Because it was not possible to use a tourniquet, enucleation was performed under loupe
magnification to protect the nerve during the dissection procedure. A longitudinal

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


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

[User]
RADIOLOGY NOTE:
One-month-old female baby presented with a circumferential diffuse swelling of entire right leg with reddish purple discoloration noticed since birth, which developed an abscess, ulceration and purulent discharge and sepsis. There was gross edema of right foot and thigh with inguinal adenitis []. Hematological investigations showed anemia and thrombocytopenia. A diagnosis of KMP was made and a biopsy was carried out after controlling the sepsis, which showed features of KHE. Immunohistochemistry was positive for Vimentin, CD31 and CD34, negative for Cytokeratin and GLUT 1 and Ki67 was 5-10% suggestive of KHE. X-ray of right lower limb did not show any bony involvement or osteomyelitis. MRI showed T2 hyperintense ill-defined circumferential mass involving the entire right leg and lower thigh. Underlying bones and joints were normal []. Doppler correlation of the lesion showed increased vascularity. Arterial feeders were from arteries around the knee joint and the venous drainage was into the tibial vein. The arteries from the external iliac to popliteal artery showed high resistance flow. Distal tibial vessels showed reduced but high resistance flow due to severe external compression. The baby was started on high dose Prednisolone regimen (40 mg orally on alternate days tapered to half the dose every 20 days till a dose of 2.5 mg on alternate days was completed).[] The KHE and KMP did not show any resolution and Propranolol 2 mg/kg daily orally in two divided doses was added.[] There was no improvement for five months since admission and the child required frequent hospitalizations for increasing size of the lesion, foul smelling discharge from the fungating ulcer over the lesion, the proximally spreading violaceous discoloration on to the thigh, increasing distal foot edema and life- and limb-threatening systemic and local sepsis. Hence, Vincristine was administered at weekly dose of 0.025 mg/kg[] for four weeks. The lesion resolved with local wound care and compres

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old male developed acute appendicitis for which laparoscopic appendectomy was done in another hospital. The telescope was 10 mm, which was passed via the 12-mm umbilical trocar inserted by open technique. The appendix was found to be inflamed with a fecolith and appendectomy was done in the usual way. Postoperative period was uneventful and patient was discharged on 5th postoperative day. The biopsy of the appendix was reported as chronic appendicitis. After 15 days, he developed pain in the umbilicus with no fever, vomiting, or pus discharge. Ultrasonogram abdomen showed no abnormality. Patient was treated with oral antibiotics and analgesics for 15 days. There was no response, and after 1 month umbilical exploration was planned assuming stitch abscess as the cause of pain. Exploration was done by a vertical incision around the umbilicus and no abscess was found, and the wound was closed with 1/0 Ethilon. After exploration, there was increase in the severity of umbilical pain and it was aggravated by touch. The pain was severe enough that he could not continue his school and often removes the clothing which causes pain due to rubbing over the umbilicus. The patient visited the operated surgeon 25 times in one and half year time. He was treated with oral antibiotics, NSAIDs, vitamins, and topical steroids and topical antibiotics. Once, the patient developed severe pain and fainted and became unconscious for 10 min. EEG and CT scan of brain were done, and both were found to be normal. The operated surgeon advised him to follow-up in our institute which is in close proximity to his residence and also to get psychiatrist opinion to rule out functional cause. The patient was submitted for psychiatrist, neurosurgeon, medical gastroenterologist, and cardiologist opinion before coming to our department. When we examined the patient, he was malnourished and the umbilicus was scarred with a vertical scar around it. The umbilicus was extremely tender

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man was diagnosed with chronic lymphocytic leukemia (CLL) in 2009 when lymphocytosis was noted. Interphase fluorescence in situ hybridization (FISH) studies performed on peripheral blood at that time confirmed the presence of abnormalities including homozygous deletion of chromosome 13q. Flow cytometric evaluation of peripheral blood demonstrated positivity for ZAP70 in 13% of the CD19-positive B cells. His CLL was monitored until 2012 when patient had disease progression with development of diffuse lymphadenopathy and increasing splenomegaly and was treated with bendamustine and rituximab. He was then treated with ibrutinib in 2014. He presented in February 2017 to University of Michigan Hematology Clinic for a consult with a 2-month history of neck and face swelling, cough, dysphagia, and night sweats. The patient was admitted to a local hospital prior to this consult and underwent fine needle aspiration (FNA) of the left neck mass with pathology report showing persistent CLL. Given the rapid disease progression which was not consistent with CLL, the decision was made to get a positron emission tomography (PET)/computed tomography (CT) scan and excisional biopsy of the presumed cervical lymph node with the highest 18F-fluorodeoxyglucose (FDG) metabolic activity (standardized uptake value = 23). Computed tomography showed mild splenomegaly and multifocal lymphadenopathy including a 3-cm left neck mass.
An excisional biopsy of a left neck level 2 mass was performed in February 2017. Microscopic images are shown in and . Sections showed soft tissue without definitive lymph node architecture infiltrated by small lymphoid cells with round nuclei, clumped chromatin, and scant to moderate cytoplasm. In addition to this, several foci with sheets of very large, unusually multinucleated cells with prominent nucleoli, occasional intracytoplasmic neutrophils and/or plasma cells, and increased mitotic activity are seen. These large cells are also seen scattered w

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman, presented in the emergency department with weakness of her both upper and lower left limbs for over 40 days, as well as numbness, weakness and coldness of the right upper limb for 3 days. Her parents died of cerebral stroke and cancer. One elder brother died of hypertensive cardiac infarction. She denied any history of taking contraceptive drugs. On December 23, 2008, the patient experienced weakness of the left limb without an apparent cause. Computer tomography (CT) of the head revealed a large area of infarction in the middle-sized arterial distribution area of the right brain. On the 4th day after initial presentation, she underwent a decompressive craniectomy (Fig. A). On the 38th day after initial presentation, the patient had projectile vomiting and complained of numbness in the right upper limb with palpitation and decreased skin temperature of the right hand. On the 41st day after initial presentation, the patient's right radial arterial pulsation disappeared. An ultrasound examination showed the presence of multiple embolism at the proximal end of the subclavian artery, the axillary artery, and the proximal end of the brachial artery (Fig. B). On the 42nd day after initial presentation, she was admitted to our hospital. Physical examination revealed that the pulsation of the right upper limb artery disappeared, although her bilateral dorsalis pedis arteries had good pulsation. On the second day after hospital admission, the patient complained of numbness in the right leg and foot. Blood gas analysis revealed that partial pressures of oxygen and carbon dioxide were 51.1 mmHg and 25.6 mmHg, respectively. CT pulmonary arteriography (CTPA) indicated a wide pulmonary embolism (Fig. C). The carotid arterial ultrasound visualized solid low echoes in the right common carotid artery, and an embolism was also seen in the internal carotid artery (Fig. D). Ultrasonography found that the lumens from the distal end of the bilateral popliteal arterie

[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 77-year-old female with hypertension, untreated hyperlipidemia, hypothyroidism, but without prior history of CAD or angina symptoms was referred to a cardiologist's office for a treadmill exercise test secondary to new onset palpitations. She denied any chest pain or pressure, shortness of breath, exertional dyspnea, or leg swelling. She quit smoking 36 years ago and has no family history of early cardiovascular diseases. She has a very distant cardiac work-up years ago, including a stress test and an echocardiogram, which the patient reported were unremarkable. Vital signs prior to the test were a blood pressure of 140/78, heart rate of 80, and a respiratory rate of 14. Physical exam was unremarkable except for a systolic ejection murmur that was graded II/VI at the base. EKG was at baseline with a normal sinus rhythm, normal axis, and occasional premature ventricular complexes (PVCs).
The patient underwent an exercise stress test using the Bruce protocol and was able to complete stage 1 with exercise for three minutes at a speed of 1.7 mph and a 10% incline. The test was terminated due to dyspnea and fatigue without chest pain. She reached a heart rate of 141 beats per minute which was 98% of predicted for her age. She accomplished 4.5 metabolic equivalents of exertion. With exercise, she had occasional atrial premature complexes and PVCs with a ventricular couplet in recovery. She started to notice tightness in her chest. Her peak blood pressure at the time was 218/90.
The patient was transferred onto a stretcher, and an IV line was started. She was given sublingual nitroglycerin, 325 mg of aspirin to chew, and one 5 mg IV push of metoprolol tartrate. She then received nitroglycerin paste and metoprolol tartrate IV every 5 min for two more doses. At that time, her EKG on the stretcher showed ST elevations in leads I, aVL, V5,

[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 female patient had a history of two previous uncomplicated pregnancies 4 and 7 years prior. She underwent a vaginal delivery, delivering a healthy macrosomic fetus with a vacuum assistance at an outside hospital. The patient labored for 50 minutes and received epidural anesthesia for pain control peripartum. Immediately after delivering a healthy male (9 Lb 42 oz) she developed sudden severe pain over the pubic symphysis and buttocks. She also complained of left lower extremity weakness. On exam, tenderness in the symphysis pubis and the left sacroiliac joint were elicited. Radiographs revealed an 8.8 cm diastasis of the pubic symphysis (Figure ). CT showed widening (anteriorly) of the sacroiliac joints, bilaterally with slight posterior subluxation of the left sacroiliac joint (Figure ). The treating orthopaedic surgeon called to our regional trauma center for consultation. We advised bed rest and image recheck in one week. After one week of bed rest with the hope for closure of the defect on its own, the diastasis at the pubic symphysis remained with 6.8 cm separation, and the patient was referred to our institution for further evaluation one week after delivery.
The patient was painful anterior and posterior with an apparent APC III pelvic injury, surgical reduction and stabilization was recommended. Because of the extensive soft tissue stripping, small bones, and patients need for earlier full weight bearing to take care of children, two orthogonal plates were placed on the superior and anterior surfaces. The sacroiliac joints were then examined with fluoroscopy and slight posterior subluxation was found on the left side. A sacroiliac screw was placed to reduce and stabilize the left sacroiliac joint (Figure ).
Two weeks after operation the patient's wound healed, and her pain had subsided. The patient insisted on walking with full weight bearing on both legs in order to care for her children. She complained of low back and

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old woman, para 3, with abdominal and back pain was referred to our hospital for the evaluation and treatment of a large cystic tumor. Magnetic resonance imaging (MRI) confirmed the diagnosis; the tumor was approximately 27 cm × 9 cm in area with a solid component inside the cyst []. Tumor markers for epithelial ovarian cancer were elevated as follows: Carbohydrate antigen (CA) 125, 150 U/ml; CA 19-9, 220 IU/ml. Ovarian tumor was suspected and the laparoscopic operation was performed using three port insertions. Based on the surface characteristics of the tumor, it seemed more likely to be peritoneal rather than ovarian in origin []. The tumor was connected to the uterine body by a narrow, 3-cm long band []. The tumor capsule ruptured easily when gently touched with forceps. Brown chocolate-like fluid and coagulative tissue leaked from the tumor [ and ]. Most of the cyst contents were removed by suction. Tumor attachments to surrounding structures were severed and then the tumor was packed into a specimen bag in the peritoneal cavity [], cut into small pieces inside the bag, and removed through the port site. Both adnexa were normal in size and shape, without any connections to the tumor []. Two intramural uterine myomas 5 cm in each diameter were located on the anterior wall of the uterine body, and myomectomy was performed laparoscopically []. We ultimately determined that the tumor had been connected only to the uterine body [] and to portions of the left [] and right [] uterosacral ligaments. There were no findings of another adhesions or endometriosis in the pelvic cavity. Since intraoperative frozen sections of the cystic tumor resulted in a histopathological diagnosis of the endometrial cyst without malignancy, the laparoscopic operation was concluded.
Although the solid component was not clearly identified macroscopically inside the tumor, subsequent postoperative histopathological examination confirmed the presence of the tumor epithelium, showing

[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-year-old woman presented with a slow growing pigmented protruding mass in the medial lower quadrant of her left breast. She had a history of trauma 5-years previously, after which, the mass rapidly grew bigger and became more pigmented. Aware of these changes, she underwent local excision of the mass in another hospital a year before presentation in our clinic and was told that the mass was a benign tumor without being provided with a specific diagnosis. There were no abnormal laboratory findings and her family history and medical history were unremarkable except for the lesion that was excised a year ago. On gross inspection and palpation, we noticed a 2 cm × 1 cm smooth mobile keloid-like reddish mass surrounded by a 3 cm × 2 cm brownish plaque-like cutaneous thickening in the medial lower quadrant, at the 7 o'clock position of her left breast (Figure ). On physical examination, the lesion was not tender and no regional lymph nodes were palpated. Since the clinical findings were suggestive of benign breast disease and the patient refused further evaluation, we did not perform conventional mammography or ultrasonography.
We performed a wide excision of the breast lesion with a 3 cm margin and a frozen section under general anesthesia and the defect was closed primarily.
The gross pathology of the specimens showed a grayish white ill-demarcated soft tissue mass measuring 3.8 cm × 3.1 cm × 1.1 cm (Figure , ).
On histological examination, a storiform pattern of spindle cells infiltrating into subcutaneous tissue above the mammary gland was noticed (Figure , , ). There was only mild mitotic activity (2-3 per 10 high-power fields) and no resection margin involvement.
On immunohistochemical examination, the lesion stained positive for CD34 (Figure ) and locally positive for SMA, and negative for CD68 and S-100 protein (Figure ). The mass was eventually diagnosed as DFSP. The patient

[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 53-year-old Chinese female patient with good past health presented with 4-year history of right groin pain which was exacerbated by walking and exercising. There were no other associated symptoms such as radiation of pain nor lower limb weakness, and there was no reported history of trauma or heavy weight lifting. She was referred to general surgical clinic for suspicion of inguinal hernia as a mass was felt over right groin by the patient. However, upon physical examination there was no cough impulse nor inguinal mass was found. In view of the atypical presentation of “inguinal hernia”, magnetic resonance imaging (MRI) was performed in August 2013. In view of suspicion of pathology originating from the round ligament, MRI would be ideal for soft tissue differentiation. A mass of 3.2 cm × 0.8 cm in size was found in right groin area, which was in the right inguinal canal and originated from the muscle of the posterior wall. It was isointense T1-weighted and hyperintense in T2-weighted images. The initial diagnosis was a “round ligament cyst” and she was initially managed conservatively with painkillers. In view of persistent pain, another set of MRI was performed 3 years later and it showed that the “cyst” was actually a solid mass with complete encapsulation. The size of the mass has increased from 3.2 cm × 0.8 cm to 5.2 cm × 3.8 cm over the 3 years. Differential diagnoses included round ligament cystic lesion, soft tissue tumors and hemangioma (Fig. ).
After discussion of pros and cons of surgical intervention, operation was arranged and inguinal canal was explored by open approach under general anesthesia. There was a 3.5 cm × 3 cm solid mass with intact capsule located in the right inguinal canal and originated from the muscle of posterior wall (Fig. ). The mass was resected en-bloc. As there was weakening of posterior wall after resection Bassini repair

[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 25-year-old male patient presented to emergency department after an assault with an incise wound in the external canthus of the left eye and severe alcohol intoxication, which prevented history taking. The physical exam of the ocular globe was not possible due to the large hematoma that hindered opening the eyelid. The exploration of right eye was normal. Therefore, the skin wound was initially sutured with a polypropylene 5/0 interrupted suture and an orbital computed tomography (CT scan) and skull X-ray were performed. An intraorbital foreign body with triangular shape of 4.6 cm x 2 cm was seen in the left orbit, passing through the orbit and the ocular globe, fracturing the superomedial wall of the orbit, with a probable associated fracture of the ethmoidal cells, and reaching the anterior cranial fossa, causing pneumocephalus (Figures and ). The patient did not present any neurological symptoms beyond his alcohol intoxication nor did he develop rhinorrhea at any time, and the Glasgow Coma Scale/Score was normal (15/15). He remained under observation and was treated with intravenous antibiotic (ciprofloxacin 200 mg twice daily, for five days, selected due to its broad spectrum for gram negative and positive) and corticosteroids (methylprednisolone 80 mg per day for 3 days). Surgical extraction was performed. The foreign body turned out to be a fragment of a dagger. The extraction was done locating the end of the foreign body after removing the suture of the wound and disinserting the lower eyelid to have a wider surgical field. The foreign boy was carefully extracted without exerting force. It was then possible to see a corneoscleral wound 2 cm long affecting the upper cornea 7 mm and the sclera 8 mm located from 9 to 2 o'clock positions. It was closed with nylon 10/0 suture and polyglactin 910 7/0 suture. The entrance area in the orbit was revised, with special attention to the upper nasal quadrant,

[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.