[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 11-year-old male Rwandan, a known patient of multiple hereditary exostoses (MHE), presented to our hospital with a 6-month history of unrelenting bone pain despite treatment with NSAIDs; he later developed (two weeks prior to admission) a dull persistent aching pain and swelling of his left lower thigh that was worse at night and unresponsive to morphine. His parents noticed that he had also lost weight and appetite. There was no history of trauma or a fall. He was diagnosed with MHE at age 3 and had been living a relatively normal life and attending school. None of his siblings or any other member of his family had MHE. His past surgical history was unremarkable. On general examination, he was well nourished, had mild pallor of the mucus membranes, no jaundice, lymphadenopathy, or skin rash. All the other parameters were normal. Examination of the musculoskeletal system revealed normal stature except for the curving deformity of the left leg. There were multiple palpable bony swellings bilaterally on the upper humeri and lower femurs. The lesion on the left distal femur was markedly enlarged and tender, with induration, reddening, and limited range of motion of his knee joint (). Repeat X-rays confirmed the presence of bony outgrowths (exostoses) on the medial and lateral aspects of the distal femurs bilaterally and left metaphyseal widening common in this condition as had been previously identified when he was diagnosed at age 3, and further investigations of the left distal femur swelling () with magnetic resonance imaging (MRI) revealed a distinct enhancing lesion in the distal aspect of the left thigh at the site of intense swelling and pain. MRI showed a lesion with hypointense signals on T1WI sequences and has heterogeneous signal intensities with moderate and heterogeneous enhancement on T1WI postcontrast study and on T2WI sequences; the lesion had heterogeneous signal intensities (Figures –). At surgery,

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 60-year-old female who sustained the injury when a trolley ran over her right 4th toe. It was a closed injury with no significant deformity. Radiographs showed a distal phalanx oblique fracture (). Incidentally, this patient also had symphalangism involving the middle and distal phalanges of her 4th and 5th toes.
Her past medical history included hyperlipidaemia and lumpectomy for breast cancer. She was also a hepatitis C carrier. She was on regular medication with Rosuvastatin 5mg nightly for the management of hyperlipidaemia. She was a non-smoker.
As the toe alignment and soft tissue condition were satisfactory, the patient was initially treated conservatively with buddy splinting and advised to mainly weight-bear on the heel to avoid loading the forefoot. Serial radiographs at subsequent reviews did not show any signs of union, even after conversion to a short walker boot after three months. At five months after the initial injury, the patient was still symptomatic, especially with prolonged ambulation. The patient worked as a nurse and spent a significant amount of time on her feet at work. Outside of work, the patient was an avid trekker. Having failed conservative management and given her high functional demands, she was counselled regarding open reduction and internal fixation of the fracture. In view of the short proximal fragment, stable fixation of the distal phalanx alone was anticipated to be technically difficult, and she was advised on the option of fusion across the inter-phalangeal joint (IPJ) to improve stability, to which she consented.
Subsequently, the patient underwent surgical fixation of the 4th toe distal phalanx fracture with concomitant arthrodesis of the IPJ. A transverse dorsal incision was made just distal to the IPJ to allow preparation of both the fracture site and IPJ surfaces (). The fracture site was mobile with the presence of fibrous tissue and sclerotic bone surfaces, consistent with fibrous non-

[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 79-year-old male was referred in March 2003 with a lump on the left side of his neck. The patient had noted a sudden increase in the size of the lump over the preceding two months. He did not report any neck pressure symptoms, weight loss or anorexia. His past history included right partial thyroidectomy for a solitary nodule (colloid goitre) in 1978 and repair of abdominal aortic aneurysm in 1994. He had suffered myocardial infarction in 1995 and had an episode of acute coronary insufficiency in January 2003. His recent coronary angiograms showed an occluded left anterior descending artery and echocardiogram revealed good left ventricular function. He was a non-smoker and consumed alcohol in moderation. He had been taking warfarin, diltiazem MR, lisinopril, uniphyllin, glyceryl trinitrate tablets and buccal suscard.
On examination he had left sided goitre extending superiorly into the posterior triangle and inferiorly into the retrosternal space, with variable consistency. The trachea was deviated to the right and there was cervical lymphadenopathy on the left side. Systemic examination was unremarkable and fine needle aspiration of thyroid gland showed presence of Hürthle cells. Computerised tomographic (CT) scan with contrast enhancement (figure &) of the neck and thorax revealed large left sided thyroid goitre with significant mediastinal extension. It showed mixed attenuation with foci of calcification peripherally. There was a 3 cm complex mass on the left side of the neck, posterior to the carotid sheath structures and deep to the sternomastoid, indicative of lymph node metastases. Thyroid profile and routine blood investigations were unremarkable.
Based on the above findings radical surgery was planned. On exploration of the neck we confirmed left goitre with intrathoracic extension and enlarged lymph nodes under the sternocleidomastoid close to the jugulodigastric muscle and surrounding the carotid sheath. There was no remnant thyroid tissue seen on the r

[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 81-year old female with a history of coronary artery disease, hypertension, and thrombocytosis suffered a witnessed trip and fall onto a nightstand. The patient took 75 mg of clopidogrel daily in addition to an 81 mg aspirin tablet. She reported a mild headache however had no change from her baseline mentation per family members with no evidence of obvious injury aside from a small area of ecchymosis near a small forehead laceration. She remained up and ambulatory with no further complaints. Ten hours after her injury the patient presented to the Emergency Department with stridorous and agonal respirations with a profoundly decreased level of consciousness. She was noted to have developed extensive ecchymosis on the anterior portion of her neck and chest. Her symptoms had begun rapidly shortly prior to arrival while lying in bed. Family reported that she had been in the constant company of her husband with no further falls or injuries that had occurred since her fall. The patient was intubated upon hospital arrival due to respiratory extremis with obvious swelling and crepitus noted on neck examination. A noncontrast CT scan of head was unremarkable while there was demonstration of a large retropharyngeal hematoma measuring 3.6 cm by 5.3 cm by 20 cm on a CT of the cervical spine with no evidence of fracture. Her hemoglobin was 9.5 gm/dL and platelets were 1234 per deciliter, with an INR of 3 and a slightly below normal and activated partial thromboplastin time of 23.9 seconds (reference range 25-35 seconds). A CT angiogram of the neck was subsequently obtained demonstrating active bleeding from the anterior ligaments of the vertebral column that was not felt to be amenable to embolization (). Given the extent of the hematoma intraoral surgical evacuation was performed with bleeding from the anterior vertebral spine controlled with Bovie cauterization, placement of topical thrombin, and drain placement. No reaccumulation of hematoma was noted during her hospital c

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old woman visited our emergency department complaining of voiding difficulty, weakness and sensory disturbances in both lower extremities, which had started 7 days ago prior to her visit. An initial neurological examination revealed grade III motor power for the right and grade IV motor power for left lower extremity, and she was unable to walk. Sensation was decreased below the T10 dermatome. Her anal tone was decreased, and voiding was not possible. A trauma history was denied. She had been taking an antihypertensive medication for 4 years. Otherwise she had no known diseases such as blood dyscrasias, bleeding disorders, cardiovascular disorders, and various other central nervous system disorders. Laboratory tests showed no abnormal findings. Thoraco-lumbar spine magnetic resonance imaging (MRI) revealed an intramedullary mass lesion at the T9-10 level, which showed as a high signal in a T1 weighted image () and a low signal in a T2 weighted image (). Following gadolinium injection, subtle enhancement at the periphery of the mass was observed (). Our preoperative diagnosis was hemorrhagic intramedullary ependymoma.
A T8-T10 laminotomy was performed. On inspection of the spinal cord, no abnormal findings, such as abnormal vessels or discoloration, were found. Midline myelotomy along the dorsal columns was performed, and a dark-colored hematoma was evacuated. It was mostly liquefied, but some of it was not. Keeping cavernous malformation in mind as a possible diagnosis, the dark blood clots were carefully dissected from the spinal cord and sent for histopathological examination. On careful inspection of the intraspinal cavity, neither abnormal vessels nor tumorous lesions were observed. The hematoma was near totally removed, and meticulous bleeding control was followed. Postoperative MRI revealed most of the lesion was removed, and no abnormal findings other than postoperative changes were observed (). The pathology report confirmed only hematoma. After op

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


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

[User]
RADIOLOGY NOTE:
The patient is a 39-year-old male with a clinical picture that began at six years of age. He presented muscular weakness of progressive establishment, with a frequency of one episode per month, which worsened with intense physical exertion, associated with intercurrent febrile symptoms that limited his ability to perform physical activity. The crisis was variable in intensity, some of them presenting only with mild to moderate weakness and some others with complete paralysis. During infancy, nonpotassium alteration was documented during the crisis. Although the situation was periodic, the patient did not suffer motor development delay, and he achieved all his milestones without difficulty.
Crisis worsens in adulthood, being more severe and related to physical exercise of moderate intensity. No other triggers were identified as drugs or anesthetic events. Many of the episodes required short-term hospitalizations lasting two or three days. During hospitalizations, several electrocardiograms, brain MRI, and toxic profiles were normal. Other paraclinical tests, such as renal and thyroid function, hepatic function, screening for Pompe disease, and levels of lactic acid and pyruvate, were within normal limits.
During the last crisis, the only positive findings were mild to moderately increased CPK levels (values ranged between 209 and 873 U/L). Also, potassium measurements reached levels until 5.3 mEq/L in blood samples analyzed during the weakness and paralysis episodes. The electromyography study performed by multiMUP (multimotor unit potential) showed no abnormalities. These preliminary findings were interpreted as compatible with muscle fiber disease.
He did not present with important personal antecedents, although he stated that a paternal great-uncle died at age 50 due to a condition associated with motor impairment; however, in that case, there was no specific diagnosis.
On physical examination, the patient presented weakness of proximal predominance in all the fou

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old healthy female patient was evaluated at our institution for a perirectal mass of unknown etiology. Her past medical history was unremarkable. The patient reported a perineal mass in the standing position. Her only other symptom consisted of mild occasional dysuria. Rectal and vaginal examinations were normal.
An endovaginal ultrasound performed one year before the present events to assess a known voluminous fibroma made no mention of a pelvic mass. An ultrasound of the perineal soft tissues found a hypoechogenic and heterogeneous mass of 4 x 5 cm beneath the paramedian region of the buttock. Endoscopic ultrasound showed a pelvic heterogenous mass that did not seem to originate from the rectal wall. A pelvic MRI and scan were performed and revealed a tubular structure of 13 x 7.5 x 3.5 cm in the right parametrium. It was centered around the right adnexal region, crossing the pelvic floor, reaching the ischiorectal fossae, and continuing as digital extensions in the soft tissue of the buttock (Figure ). No invasion of the muscles, sphincters, or vaginal wall was noted. The possible suspected etiologies included an endometrioma, a parametrial cyst, a low-grade sarcoma, or another mesenchymal tumor. The absence of soft tissue infiltration ruled out an inflammatory cause. A PET scan showed a mild metabolism in the tumor, suggesting a cystic lesion. The diagnosis of a low-grade mesenchymal tumor could not, however, be excluded.
This unusual case was discussed at the institutional tumor board meeting and the decision was to proceed with surgical excision. The patient underwent an open surgical resection of the tumor. Due to a voluminous uterine fibroma that limited access to the pelvic cavity, an abdominal hysterectomy was performed. The pathological examination found a lesion with a proliferation of paucicellular spindle cells in a myxoid stroma and medium to thick-walled vessels of variable caliber. The stroma was without atypia. No mitoses or necrosis were

[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 29-year-old male was referred to our emergency care unit at the third hour of his injury. He had experienced an avulsion amputation of his dominant right hand and forearm resulting from a textile slicing machine (Figure , ).
Along with the crush and volar skin avulsion amputation injuries and open fractures as observed in the right and hand forearm x-rays (Figure ), he also experienced a transection of the radial and ulnar arteries and nerves, median nerve, cephalic vein, finger and wrist flexors. The patient did not have arterial bleeding in his fingers and his hand was cold, ischemic, and had lost its tonus. His vital signs were stable.
At the emergency unit, an open fracture and amputation treatment procedure began with an intensive sterile wound irrigation, debridement, dressing, and cast stabilization. He was administered an intravenous (i.v.) antibiotic prophylaxis consisting of cefazoline sodium, metronidazole, and gentamycin. Tetanus prophylaxis was also administered with tetanus vaccination since he had not been immunized within the last five years. Moreover, he received a subcutaneous administration of enoxaparin sodium and i.v. administration of dextran with pentoxifylline. Accurate analgesic medication and antiulcer prophylaxis were delivered. The patient was then taken to the orthopedic operation room for a sterile first look debridement, temporary intramedullary osteosynthesis and a microsurgical reconstruction procedure (Figure ).
Following operating room sterile irrigation and debridement, temporary percutaneous intramedullary osteosynthesis of the radius and ulna and flexor tendon repairs, neurovascular structures of the fingers, palm and wrist were intraoperatively re-explored under microscopic vision. Ulnar digital neurovascular bundle of the thumb, radial neurovascular bundles of the second and third finger, ulnar neurovascular bundles of the fourth and fifth finger were diagnosed to be intact. At the 11th hour post-injury, the patient had a re

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old female patient was hospitalized because of known cholangitis. She had previously undergone cholecystectomy because of the cholelithiasis. Physical examination revealed tenderness of the lower quadrants of the abdomen. As part of the clinical work-up, the patient underwent an abdominal computed tomography, which demonstrated colonic distension and small bowel ileus with focal narrowing and obstruction of the transverse colon (). Mechanical obstructive ileus was suspected, and a colonoscopy revealed luminal erosion and stricture of the transverse colon. Microscopic examination of multiple blind biopsies showed erosion and vascular congestion with no evidence of malignancy. A whole body scan to evaluate the presence of metastatic lesions did not show any abnormal fluorodeoxyglucose uptake. The patient was diagnosed with colonic malignancy, and right hemicolectomy was performed.
On gross examination, the resected specimen displayed infiltrative submucosal lesions that involved the whole circumference and resulted in colonic stricture (). Histologically, the colonic mucosa was intact except for focal erosion, and the muscular layer was markedly hypertrophied at the stricture site. Further microscopic examination revealed that a benign glandular structure of gastric origin invaded the erosive colonic mucosa. These glands showed a downward growth pattern toward the submucosa and the muscular layer, gastric differentiation, and focal cystic dilatation (). Additionally, we identified an adenocarcinoma that originated in the heterotopic gastric glands in the submucosa and muscular layers. The adenocarcinoma foci were composed of glands as well as isolated tumor cells and clusters with focal mucin production and were moderately to poorly differentiated (). The tumor was distributed through the colonic wall and pericolic soft tissue. Immunohistochemically, both the heterotopic glands and adenocarcinoma showed positive results for cytokeratin (CK) 7 and MUC5AC 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 61-year-old Caucasian female with a prior diagnosis of PBC was diagnosed with T3N1M0 stage III, grade 2 left breast invasive ductal carcinoma in October 2011. The tumor was 7 × 4 cm, and a palpable left axillary lymph node was noted on examination. The tumor was positive for estrogen receptor, progesterone receptor, and HER-2 oncogene overexpression (fluorescence in situ hybridization ratio 9.91). Interestingly, her twin sister also had a diagnosis of PBC; other family history included lymphoma in maternal cousin and colon cancer in maternal uncle. Her case was presented at our institution's tumor board and neoadjuvant chemotherapy was recommended.
Due to the patient's underlying PBC, she had multiple baseline abnormalities of liver function tests, alkaline phosphatase [two times the upper limit of normal (ULN)] and grade 2 cytopenia from splenomegaly. Therefore, anthracycline-based regimens were avoided due to a concern for decreased clearance of doxorubicin leading to increased cardiotoxicity, as the patient would require trastuzumab as well. Neoadjuvant chemotherapy with 6 cycles of docetaxel, carboplatin, and trastuzumab (TCH) was given followed by bilateral skin-sparing total mastectomy and left axillary lymph node dissection with immediate reconstruction. Docetaxel was initiated with a 25% dose reduction and required a subsequent 25% dose reduction on carboplatin due to cytopenia. Postoperatively, pathology demonstrated a decrease in the tumor mass from 7 × 4 to 2.5 × 2 cm, but 4 of 20 axillary lymph nodes were positive for invasive cancer with extracapsular extension (T2N2a). Adjuvant radiation therapy was given to the chest wall and axilla (5,000 Gy). She then completed trastuzumab maintenance for a total of 52 weeks in October 2012 and started adjuvant endocrine therapy with anastrozole.
In February 2013, 3 months after the completion of trastuzumab maintenance therapy, our patient presented with skin nodules, and the clinical examination was remarkable f

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old woman was admitted to our hospital with dysesthesia of her left upper extremity. She had a past history of mild hypertrophic cardiomyopathy. There was no history of trauma and no family history of hereditary disease, including moyamoya disease or ischemic stroke. Physical examinations on admission were normal. Neurologic examinations revealed an alert consciousness, no motor weakness, and mild dysesthesia of her left upper extremity. A head computed tomography (CT) scan revealed a chronic SDH in the right frontoparietal region []. Burr-hole surgery was performed under local anesthesia. We decided on a regular burr hole at the point of maximal SDH thickness, at the parietal bone, approximately 3 cm behind the coronal suture. A burr hole was made with a hand drill, following a small linear skin incision. The dura was coagulated and a cross-shaped incision was made. No major branches of the superficial temporal artery, middle meningeal artery, or occipital artery were detected. After incision of the outer SDH membrane, a drainage catheter was placed into the subdural space. No aspiration with negative pressure or flushing with normal saline was performed. Vital signs were normal during surgery. Dysesthesia resolved completely after surgery, and the drainage catheter was removed the day after surgery. On day 3, however, the patient presented with left-sided hemiparesis. A head CT scan showed no postoperative hemorrhage, and cerebral infarction was suspected. A free-radical scavenger was administered for 2 weeks. On day 11, diffusion-weighted magnetic resonance imaging revealed elevated diffusion coefficients with high signal intensity in the right parietal cortex []. Laboratory tests were normal. Cardiac ultrasonography showed good wall motion and an ejection fraction rate of 91%. No intracardiac thrombus was detected. Cerebral angiography on day 19 demonstrated total occlusion of bilateral internal carotid arteries, with ethmoidal moyamoya vessels [], 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 27-year-old Egyptian man working as a clerk presented with a discharging sinus in the right side of his neck (). The man had a right submandibular sialadenectomy 8 years before presentation. The patient reported the sinus to appear after removing a drain which has been placed. This surgery was performed elsewhere. He also complained of pain below his chin and an increase in the amount of discharge on mastication. No history of fever. The patient reported receiving several trials of antibiotic therapy in an attempt to cure his condition. He had an X-ray done before presentation. The report of the excised gland pathological examination was not available.
On examination the man was 90 kilograms body weight and 182 centimeters height, there was a healed scar of previous surgery and a discharging sinus in the right submandibular region the discharge was purulent. No palpable swellings or enlarged cervical lymph nodes were found. Bimanual examination was done and there were no palpable swelling in the floor of mouth. A provisional diagnosis of a salivary fistula was considered.
Neck X-ray showed no abnormality. A CT fistulogram was undertaken (), which showed a blind ending track leading to cavity just beneath the right side of floor of mouth. It also confirmed excision of the right submandibular gland.
A decision to perform neck exploration was undertaken. During surgery gentle probing of the track was done then dissection was carried out revealing the sinus track passing medial the digastric muscle and up to sublingual area (). The tracks ended into a cyst below the mandible in the area where we typically ligate and divide the submandibular duct. On opening the cyst a purulent discharge appeared and irrigation of the cavity further revealed white fabric fibers (). With traction on these fibers two small sponges were found and removed (). The track was then excised and the cavity and wound copiously irrigated with saline. A suction drain was inserted and wound closed.

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


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

[User]
RADIOLOGY NOTE:
A 19-year-old man was admitted to our hospital because of recurrence of left pneumothorax. His previous history included left and right pneumothorax at the ages of 15 and 16 years, respectively, which were treated by VATS. In the previous operation, simple resection of apical bullous lesion was carried out without surgical pleurodesis or covering any prosthetic sheets such as polyglycolic acid (PGA) sheets. Although the left lung inflated quite well and air leakage disappeared immediately after chest drainage, VATS was planned for the surgical indication of second postoperative recurrence. A preoperative non-enhanced computed tomography (CT) scan of the chest showed that the abnormally dilated pulmonary artery and pulmonary vein in the lingular segment ran towards the chest wall scar remaining at the surgical port site used at the previous operation (Fig. ). In this operation, a small bullous lesion arising in segment 6 of the left lung was ligated, and the dilated pulsating pulmonary vessels at the periphery of the lingular segment adhered to the aforementioned chest wall scar remaining at the thoracoscopy port site that was previously made in the fourth intercostal space (Fig. ). After this operation, we used contrast-enhanced CT scan for a suspected diagnosis of pulmonary vessel malformation. The examination revealed an abnormal connection between the branch of the systemic artery of the chest wall and the dilated pulmonary artery and pulmonary vein in the lingular segment. Left subclavian selective arteriography also showed hypertrophic blood vessels that arose from the internal thoracic artery, the lateral thoracic artery, and the subscapular artery arising from the axillary artery, which drained into the both the pulmonary artery and the pulmonary vein in the lingular segment (Fig. ). Because the chest CT scan obtained at the first episode of left pneumothorax showed no parietopulmonary fistula, a secondary SAPVF caused by first VATS for the pneumothorax 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 30-year-old-male patient was admitted to another hospital complaining of sudden fierce headache and severe vomiting without antecedent trauma. The brain MRI was performed due to the suspicion of acute stroke. On his cerebral MRI, neither acute ischemic nor hemorrhagic stroke was detected. However, a large aneurysm of the basilar tip artery was revealed with the largest diameter of 22mm. The aneurysm exerted a critical mass effect on the pons (). He was transferred to our hospital for further evaluation on the same day.
Initial neurological examination on admission noted that he was conscious and without neurological deficit. His medical history was unremarkable. Subsequent diagnostic cerebral angiogram confirmed the present of a fusio-sacciform dissecting aneurysm in the distal segment of the basilar artery. The aneurysm had partial thrombosis, measuring 13 mm in width and 15mm in height, with an undefined neck. Its location in the trunk was just above the pontine perforators. In particular, the dissecting part involved in both P1 segments of posterior cerebral artery (PCA), causing severe stenosis of right P1 and occlusion of left P1. Regarding to the collateral circulation, the bilateral PCA was supplied by bilateral posterior communicating artery (PComA). The diameter of right and left PComA were 2mm and 2.5mm respectively ().
After taking the clinical symptoms, the aneurysm characteristics, and patient’s age into account, treatment of the aneurysm by endovascular approach was considered appropriate in order to prevent rupture and to release the mass effect on the brainstem. This proposal was accepted by the patient and his family.
The procedure was performed under general anesthesia via bilateral femoral artery. Bilateral vertebral artery was selected with Chaperon 6F guiding catheter (MicroVention, Aliso Viejo, California, USA). Angiography confirmed the presence of unchanged dissecting aneurysm in the distal segment of the basilar artery. Working projections

[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 male patient presented to the neurosurgical services with history of left focal seizure with secondary generalization for the last three to four years along with left sided weakness for the past one month. There was history of slowly progressive decreased vision in both eyes leading to complete blindness in both eyes for the past one month. On neurological examination, patient had left hemiparesis of grade-2/5 with perception of light absent in both eyes. Fundus examination revealed bilateral optic atrophy.
Magnetic resonance imaging (MRI) of the brain showed a large supratentorial heterogenous multicystic ring enhancing mass lesion involving right frontal lobe, right frontotemporal opercular region, and posteriorly abutting the central sulcus [Figures and ]. The lesion was hyperintense on T2WI and FLAIR images. The lesion was showing multiple cystic components of various sizes with smaller solid component abutting the dura peripherally; largest cyst showing ring enhancement with enhancing mural nodule in the superior aspect of the lesion. There was mild perilesional oedema and marked mass effect seen causing compression of right lateral ventricle and producing significant midline shift towards left side.
Patient underwent right frontoparietal craniotomy and near total excision of tumor. He received standard preoperative medication, including phenytoin, dexamethasone antibiotic, and mannitol on the morning of surgery. After the scalp was opened, the tumor was visible anteriorly, and there was destruction of galea and bone was present. Craniotomy was performed by using wide margin around the destroyed calavaria with the use of multiple burr holes. After the bone flap was removed, a large tumor mass was found in the extradural space anteriorly. The dura under this mass was completely intact macroscopically. The extradural mass was easily peeled off the dura. The dura was excised widely around the tumor, and attention was focused on intraparenchymal part

[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 Caucasian woman was referred to a community rheumatology service with insidious onset of lower back pain and stiffness. The symptoms gradually progressed to involve the shoulder girdle, with prominent systemic symptoms of weight loss, fever and malaise. There were no symptoms suggestive of CTD or spondyloarthritis. Owing to severe headache, the patient was seen several times in primary care, in Accident and Emergency, and was found to have a normal CT brain.
The patient’s shoulder and hip girdle symptoms had largely resolved in the 3 weeks before consultation without any intervention, after which she gradually developed severe right unilateral frontal and temporal headaches in additiont o right upper limb claudication.
On clinical examination, there was no peripheral arthritis. Shoulder active range of motion was reduced. The chest was clear on auscultation, and there was no lymphadenopathy. There was no temporal or axillary tenderness. The left temporal pulse was palpable, whereas the right was absent. The peripheral radial and ulnar pulses were normal.
Laboratory investigations revealed a CRP of 16 mg/l, ESR 17 mm/h, normal full blood count, normal renal and liver function and a mild thrombocytosis. A previous lumbar spine radiograph and CT brain were normal.
Taking into account the history and clinical presentation, a suspected diagnosis of polymyalgic onset large vessel GCA was made, and the patient was referred to the Acute Medical Unit. This is a secondary care-based service for acutely unwell patients referred from primary care. She was started on high-dose oral prednisolone 60 mg daily, with rapid improvement in her symptoms.
Before initiation of CSs, as mentioned previously, this patient had been investigated extensively with numerous blood tests, CT brain, lumbar spine radiograph and chest radiograph. Subsequently, a temporal US was found to be positive for temporal arteritis, demonstrating a halo and intima–media thickness for the right temp

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


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

[User]
RADIOLOGY NOTE:
This 54-year-old female was referred to the Neurofibromatosis outpatient clinic of the Oral and Craniomaxillofacial Surgery Department for treatment of numerous cutaneous tumors that preferentially covered her trunk and extremities. On admission, the patient described the tumors to be painless and disfiguring. Besides the cutaneous tumors the patient sought advice for treatment of a painful region of her left small finger (Figure 1 ). For some time the ulnar side of the distal phalanx of this finger had become very touch-sensitive. There was neither a tumor visible nor any other pathological alteration of the skin. However, the finger could not be examined by palpation. The suspected diagnosis was initially a glomus tumor [] or a non-palpable nodular PNF.
MRI at 3T revealed numerous, popcorn-like, contrast-absorbing, hyperintense formations on T2-weighted images, up to 1.2 x 1.9 cm² in size located on the palmar side of the left hand (Figure 2 ). These small lesions mainly affected the metacarpal bones II and III. MRI also showed a sharply defined lesion of max. 1 cm in diameter in the subcutaneous layer at the level of the radiocarpal joint and distal to first digit that reached to the tendons of the extensor musculature. The bony structures showed a homogeneous signal. The findings were interpreted as disseminated subcutaneous and cutaneous neurofibromas of the entire left hand. Structures were found on the distal phalanx of the left small finger whose intensity pattern corresponded to that of the other lesions.
During surgery for the excision and vaporization of numerous neurofibromas of the trunk and extremities, the pain sensitive finger region was also explored. After incision of the skin, no tumor was visible. Therefore, a circumscribed subcutaneous excision was taken as a tissue sample and examined histologically.
The tissue findings confirmed cutaneous neurofibromas for the numerous nodules excised from the trunk and extremities. Surprisingly, there was no

[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 50-year-old Caucasian female visited the regional dental office due to uncertain pain in the right mandibular region. No significant diseases were mentioned in the anamnesis. The patient was diagnosed with gingivitis, and treated with a non-steroid anti-inflammatory drug and oral rinsing with chlorhexidine. The condition of the patient did not improve significantly. When she returned a week later, she had no alleviation, but labial paresthesia on the right side of her lip. As the cause of the new symptom remained unidentified, she was referred to the oral surgery group. Initially, the paraesthesia affected only the right side of the lower lip, but by this time it had spread to the skin of the right side of her chin. The oral surgeons decided to extract the lower right wisdom tooth, but the labial paraesthesia still persisted. Since there was an extended composite restoration in the lower right first molar, and translucency around its apical region was visible, the lesion was diagnosed as periapical granuloma. The lesion on tooth 46 was not close to the mandibular canal; this can be seen on Fig. . Therefore, root canal treatment was carried out, despite the uncertain result of the percussion, palpation and sensibility test. The transparent lesion around the apex and the negative sensibility test lead to the decision of endodontic treatment. Diagnosis was made by a dentist who is not a staff member of our Department. The treatment revealed that the pulp was vital. Our oral diagnostic team examined the patient, and we diagnosed the case as cemento-osseous dysplasia based on the panoramic radiograph showing apical translucency lesions around the anterior teeth with vital pulp (Fig. ). The paraesthesia has been continually present ever since. Because the lesion around the lower right canine had already involved the cortical bone by CBCT scan (Fig. ), a root canal filling and removal of the apical lesion were performed. On the CBCT image the involvement of the entire pe

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

[User]
RADIOLOGY NOTE:
A 51-year-old male patient came to the hospital complaining of bilateral buttock pain that had begun 5 years earlier and bilateral radiating pain in the lower extremities. The patient history showed that he had been in manual labor for 10 years, and he had undergone a L4-5 discectomy in another hospital for the above symptoms 2 years previously. The pain had not been relieved, however, and he had been receiving drug and physical therapy, but the pain had recently worsened. The pain was exacerbated when the patient remained in one position or walked for a long time, whereas the pain was relieved when he kept still. The pain was characterized as a continual tingling pain, with a degree of 7/10 on the visual analogue scale (VAS).
The physical examination showed no mobility or sensory disorder, and the deep tendon reflex was also normal. There were no abnormalities other than a reduction to approximately 60 degrees on both sides in the straight leg raise test. Basic pre-operative testing results were normal, and only mild degenerative spondylosis was observed in the lumbar x-ray. The lumbar MRI revealed disc extrusion from the L4-5 center to the left intervertebral foramen and small disc protrusion in the L5-S1 right center, but the patient's symptoms were limited to the bilateral L5 dermatome. Recurred lumbar disc herniation and failed back surgery syndrome were suspected.
L5-selective transforaminal epidural block was performed twice in the clinic, but the improvement in symptoms did not continue for more than 5 days. Therefore, caudal epidural adhesiolysis was scheduled, and the patient was hospitalized. Before the operation, the patient was placed in the prone position, and the sacral hiatus area was disinfected with 10% povidone-iodine solution and chlorhexidine. The operating area was covered with a surgical drape. The sacral hiatus was identified with C-arm, and infiltration anesthesia was performed with 4 ml of 1% lidocaine. Then,

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old patient with an enormous uterine leiomyoma reaching beyond the navel and up to the costal arch was admitted. During the 14 years since its detection, because of the patient's extreme fear of an abdominal incision, the myoma was merely monitored and all suggested laparotomies thus far had been refused. At the moment of admission, the patient only agreed to a minimally invasive surgery. She was informed in detail about all risks, side effects, and alternatives as well as the potential risk for an emergency open abdominal surgery. Before surgery, we performed imaging diagnostics by means of computed tomography (CT) of the abdomen ().
When performing a hysterectomy of a very large uterus (>2500 g), the anatomical changes in the abdomen caused by the size of the uterus need to be taken into account. The large uterus divides the abdominal area, and only 3 narrow spaces are left to manipulate surgical instruments: between the left uterine wall and left abdominal wall, between the right uterine wall and right abdominal wall, and between the fundus uteri and liver and diaphragm. Successful surgery is only feasible when both instruments (forceps and coagulator or scissors) are in the same space simultaneously. Hence, we performed LASH with the “changeover technique” as described previously []. As such, we inserted 6 trocars including 3 on the left: one trocar in the lower, one in the middle, and one in the upper abdomen, allowing access to the left narrow space ().
The 3 trocars on the right side were placed in a mirror-like fashion. Surgery was initiated at the patient's left side, using the upper left trocar to introduce the camera () and the other two left-located trocars to introduce forceps and coagulator or scissors.
The patient was slightly tilted to the opposite side to facilitate visualization and preparation of structures. For uterus manipulation and movement, we used blunt forceps and palpation probes

[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:
Prior to her presentation with us, the 67-year-old lady had visited a major hospital in the national capital for symptoms of a rapidly progressive mass in the neck with dysphagia. There she had been diagnosed as suffering from ATC [], and recalls having being provided frank and ample information about prognosis and the available treatment options. The patient there had refused all forms of intravenous chemotherapy and surgery. She had also refused RT since she did not want to spend much time in a city away from home.
She presented to our department owing to close proximity to her residence. The already well-informed patient made aware to us that her main intention was to spend as much time as possible with her family at home, and that she was unwilling for intravenous chemotherapy, prolonged course of RT, or any form of surgery. Thus, a compromise was made to settle for a short course palliative RT of 20 Gy in five fractions. However, a month later, the patient reported progression of her symptoms, and there was clinical progression of the disease.
Though intravenous chemotherapy with either of doxorubicin or paclitaxel was again offered as an option, the patient refused the same and requested for a treatment which could be orally had at home. We thus discussed the new approach of orally delivered metronomic chemotherapy, and after a full discussion of the potential disadvantages and advantages of the new approach, the patient requested to be given the same. The metronomic chemotherapy delivered as a three-drug regimen, which was empirically designed as a pragmatic three-weekly cycle comprising oral cyclophosphamide (50 mg once a day on days 1–15); oral methotrexate (5 mg once a day on Mondays, Wednesdays, and Fridays); and oral celecoxib (200 mg once a day on Tuesdays, Thursdays, and Saturdays).
The patient experienced a dramatic response and after the first cycle, in that she was able to take oral feeds without the requirement

[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 in question was a 90-year-old female who suffered with a destructive form of erosive rheumatoid arthritis. At the time of her presentation she was living alone in a 3-bedroom flat with a substantial package of care and had become in recent months almost wheelchair bound.
At the age of 76, she had a left Neer shoulder hemiarthroplasty for avascular necrosis of her humeral head following a dislocation. For 10 years she had satisfactory level of function and was pain-free; however, at the age of 86, she was experiencing pain in her shoulder as was seen in the out-patient clinic. Clinically, she had severe rotator cuff dysfunction with anterior and superior displacement of the prosthesis, but no intervention was recommended at this time.
The patient then represented at the age of 89 with a 6-week history of her left shoulder becoming increasingly painful and stiff and with a small discharging wound over the posterior aspect of her left shoulder.
On presentation, the patient was apyrexial with normal observations and felt systemically well. There was a 1 cm sinus over the posterior aspect of her shoulder in the supra-spinatus fossa just medial to the acromium process. The wound was discharging moderate amounts of serous fluid which was causing the patient some distress and also skin irritation.
She was seen by her GP who organised some investigations including inflammatory markers and X-rays (see ). When compared to previous X-rays, a grossly abnormal left shoulder was seen with the dislocation of the humeral head. There was a loss of the lateral 3rd of the left clavicle with bony destruction of the clavicle and glenoid. There was overlying soft tissue opacification containing gas, and the overall appearances were suggestive of aggressive osteomyelitis.
Her blood tests that were taken at the time were normal, WCC 6.2, ESR 25, and an CRP of 2. Swabs and cultures were taken at this initial presentation and came back with no growth.
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 twenty year old male patient presented with headache and vomiting since 3–4 months. The patient was fully conscious with fundus examination showing papilledema. Cranial nerves were normal on testing. Magnetic resonance imaging (MRI) revealed a large extra-axial tumor in the middle cranial fossa which was hypointense on T1, hyperintense on T2 with contrast enhancement [Figures –]. The base of the tumor was on the petrous temporal bone. A diagnosis of meningioma was made preoperatively, and the patient was taken up for surgery.
The patient was operated in supine position under general anesthesia. The right side temporal craniotomy was made. The tumor was firm grayish red in color. The tumor was completely removed by standard microsurgical technique of internal debulking of the tumor followed by capsular dissection. There was bleeding at the base at the petrous temporal bone which was cauterized. After securing hemostasis and dural closure, drain was kept in the subgaleal space, and the incision was closed in a standard fashion.
In the immediate postoperative period, total right-sided facial palsy was noted. The patient was observed in the intensive care unit for 2 days. The patient remained fully conscious and was discharged on the 7th postoperative day. Histopathological examination revealed biomorphic tumor composed of sheets and cords of epithelioid cells and bundles of spindle cells []. The epithelioid component showed features of nuclear anaplasia along with frequent mitosis [].
Immunohistochemistry (IHC) revealed immunopositivity for vimentin, confirming the mesenchymal differentiation of the tumor []. The tumor cells showed patchy nuclear and cytoplasmic immunostaining for S-100, confirming the neural differentiation [Figures and ].
Glial fibrillary acidic protein, smooth muscle actin, desmin, HMB-45, epithelial membrane antigen, and cytokeratin were negative.
MRI 1 month after the surgery confirmed the total excision of the lesion []. The patient was referre

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


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

[User]
RADIOLOGY NOTE:
A 54 year old woman presented to the Uveitis Services with acute painful diminution of vision in both eyes since 10 days. She was initially suspected to have a bilateral acute angle closure glaucoma and she had undergone a surgical peripheral iridectomy in her left eye at another hospital 1 week before reporting to us. At the time of presentation, she was already using topical timolol eyedrops along with oral acetazolamide .
She had a distant visual acuity of light perception with inaccurate projection of rays in her right eye and counting fingers at one metre in her left eye. Both the eyes had corneal stromal edema along with flare + 2, cells+ 2 and a hypopyon approximately 1 mm in height along with fixed and dilated pupils, and cataract, (Fig. A & B) and no view of fundus due to hazy media. The Intraocular pressure (IOP) was 10 and 8 mm of Hg in the right and left eye respectively. An Ultrasound B scan showed choroidal detachments in all quadrants in both the eyes (Fig. C & D). A clinical diagnosis of bilateral panuveitis and bilateral endogenous endophthalmitis was considered. However, there was no history suggestive of any systemic source of infection as a cause for endogenous endophthalmitis and a systemic evaluation along with complete uveitic workup including chest X-ray to exclude sarcoidosis and tuberculosis, Mantoux test for tuberculosis, serology for HIV and syphilis and HLA B51 for Behcet’s disease was done which turned out to be negative.
On reassessing a detailed treatment history, it was found that the patient was suffering from depression and had been started on oral Topiramate (100 mg per day) which had been started 2 weeks before the onset of her ocular symptoms. The bilateral hypopyon and angle closure were considered to be induced by Topiramate and the drug was therefore discontinued. The patient was started on oral prednisolone (1 g/kg body weight) 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 male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.
A blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.
A head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as letharg

[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-yr-old right-handed woman who was a housewife was hospitalized in our department on December 30, 2008 after presenting an altered mental state. Her medical history included hypertension, coronary heart disease, and an old lacunar infarction. A neurological examination revealed consciousness disturbances, motor aphasia, right hemiparesis, superficial and deep sensory disturbances, and right-side neglect. Computed tomography (CT) scans obtained at the time of admission revealed an area of left pontine hemorrhage measuring 1.0 × 2.5 cm (). Two months after admission, CT scans demonstrated that the high-density area in the left pons had completely disappeared (), and the patient scored 25 out of 30 on Mini-Mental State Examination (MMSE). Her score on the NIH Stroke Scale (NIHSS) was 11, and 24 on the Modified Barthel Index (MBI). She had hemianopia, left facial palsy, and right hemiparesis showing grade poor on manual muscle test (MMT) for right upper limb and grade fair on MMT for right lower limb, and a visual analogue scale (VAS) result of 50 mm for the right limbs with paresthesia. She was totally dependent on others for daily living tasks because of right side weakness. At that time, she was able to name her body parts correctly, and there was no evidence of other delusional beliefs or hallucinations.
The patient repeatedly started to report that she felt the presence of another set of right upper and lower extremities protruding from her right shoulder and knee. When asked about how she knew about these arm and leg on February 25, 2009, she said that she could not see them but feel them with her extremities, and could draw her phantom limbs (). She believed that the phantom limbs did not belonged to her, and did not know why she had phantom limbs. She did not have pain on her original extremities, but complained of a squeezing and burning pain in her SPLs, 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:
63 year old male with history of active heroin abuse, non-compliance, hypertension, obesity, CHF, hypercholesterolemia, multiple prior intraabdominal surgeries, including appendectomy, cholecystectomy, several ventral hernia repairs, long history of large ventral hernia, presented with worsening abdominal pain and distention for 2 weeks. Two days prior to admission, he noticed that his ventral hernia on right side of the abdomen became more swollen and painful. In the ER he became obtunded, developed severe respiratory distress and required endotracheal intubation. Subsequent CXR showed free intraabdominal air. Plain abdominal radiograph showed markedly distended cecum pointing to the left upper quadrant and free air (). At this point surgical consultation was obtained. Vitals: T 99, BP 174/90, pulse 115, respirations 12. Clinical exam showed distended abdomen and very large tender hernia occupying all right side of the abdomen and extending to the left of midline with redness and warm skin above it. Patient had multiple surgical scars and another 2 smaller hernias in lower abdomen. Abnormal laboratory results: WBC 15,000, creatinine 4.5. Subsequent CT of the abdomen and pelvis without contrast showed tremendous amount of free air and markedly distended cecum, partially contained in the ventral hernia and crossing midline to the left, suspicious for cecal volvulus (). Patient was immediately taken to the OR, where diagnosis of cecal volvulus was confirmed. Cecum, terminal ileum, and ascending colon were twisted in axial plane, with concomitant clockwise torsion and grossly perforated hepatic flexure, significant fecal spillage and large abscess cavity along the transverse mesocolon. Size of the hernia was approximately 20 × 30 cm. Hernia contained part of the cecum. Right colon had significant adhesions from prior surgeries, including those inside the hernia sac. Patient had loss of the domain. There was another lower abdominal wall hernia containing old infected me

[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 76-year-old man with a past medical history of seizures, NPH, and obstructive sleep apnea was admitted to the hospital for an elective VP shunt for NPH. His past surgeries included laparoscopic cholecystectomy, open appendectomy, and two umbilical hernias including one with a mesh instalment. The surgery went smoothly with no immediate complications and the patient recovered well until on postoperative day 2; he developed abdominal distention, constant lower quadrant pain, and multiple bouts of bilious, non-bloody vomitus. His physical exam included vital signs within normal ranges, and was significant for a distended, tympanic abdomen with generalized tenderness, but no rebound or guarding. Initial laboratory tests (complete blood count and complete metabolic panel) were unremarkable. An X ray (Figure ) and computed tomographic (CT) scan (Figure ) of the abdomen with oral contrast showed severe dilatation of the right and transverse colon with a relative transition section at the splenic flexure. The small bowel was noted to be normal in diameter with no evident obstruction.
Gas and stool were noted in the rectum. The VP shunt was visualized terminating in the right upper abdominal quadrant around the subhepatic region, and a VP series was not indicated. A nasogastric (NG) tube was placed, and the patient was closely followed with serial abdominal exams and X-rays. On postoperative day 3, he was feeling better in terms of abdominal distension and pain with an NG tube in place, but still failed to have any flatus or bowel movements. Thus, he was started on docusate taken orally, and given a fleet enema. Finally, on postoperative day 5, the patient had a bowel movement and flatus, which significantly reduced his abdominal pain and resolved his nausea and vomiting. However, on day 8, his abdominal pain and distension returned. Due to recurrence of the abdominal pain and distension on conservative management, on postoperative day 8, the patient underwent a decompress

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old woman with history of simultaneous pancreas and kidney transplant for diabetic nephropathy presented to the ER 2 years after the transplantation for evaluation of nausea, vomiting, abdominal pain, and minimal urine output. She had an interval weight gain with BMI of 31.8 on presentation, which increased from BMI of 26.6 four months earlier. She was found to be in acute renal failure with severe increase in serum creatinine level to 9.9 mg/dL. She was hemodynamically stable and afebrile. Noncontrast CT of abdomen and pelvis demonstrated an enlarged renal allograft with moderate hydronephrosis and trace pelvic free fluid (). In retrospect, a change in orientation of the allograft was noted with the hilum directed laterally when compared to a contrast enhanced CT performed prior to torsion () when the hilum was directed anteromedially.
Further evaluation with ultrasound showed an enlarged, hyperechoic renal allograft with moderate collecting system dilatation. At color Doppler evaluation only a short segment of the proximal renal artery was seen, with the distal renal artery not visualized. No blood flow was demonstrated within the allograft on color Doppler, power Doppler, and spectral analysis (). The renal vein was not visualized. The constellation of findings was concerning for renal artery thrombosis and impending infarct.
Transplant medicine immediately took the patient to the operating room for a nephrectomy as there was concern the kidney could become necrotic and a nidus for infection. The renal allograft was found twisted 360 degrees on its vascular pedicle and ureter despite prior nephropexy, likely secondary to adhesions in its upper pole. The kidney appeared pinkish-blue indicating minimal blood flow. After taking down the band of adhesions, the allograft was detorsed and the ureter was returned to its appropriate position. A pinkish hue returned to the kidney. Intraoperative Doppler demonstrated excellent flow in the renal artery and vein. I

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old woman presented in the emergency room who had been experiencing abdominal pain for one week. Initially the pain was spread throughout the abdomen and was similar to cramps; later on, it started to be confined and localized in the abdominal inferior quadrants and was scarcely responsive to an analgesic therapy. There were no accompanying symptoms or increased inflammatory markers. The patient was aware of being affected by MRKH syndrome, which was diagnosed in puberty during a follow-up for a primary amenorrhea. The patient was also aware of a pelvic mass of unknown origin discovered 5 years prior during a routine ultrasound. During the anamnesis, the patient denied having menstrual flows and pelvic pains in the past.
At the medical examination, the abdomen was soft and non-tender except for a strong tenderness corresponding to a hardened hypogastric tumefaction. The Blumberg sign was negative. Blood tests were requested and came out normal. White blood count and C reactive protein were negative. An abdominal ultrasound was performed as well as a computed tomography, with identification of both kidneys, normal in size and position, with smooth profiles and a regular echogenicity and parenchymal thickness, without any signs of cystic alterations in their context. There was no sign of hydronephrosis on the right side; mild pyelectasis was found on the left kidney. The bladder was expanded with regular walls. A neoformation of unknown origin was identified in the pelvic region described as a voluminous pelvic expansive formation (major transverse diameter: 9 cm; antero-posterior diameter: 11 cm) likely referred to a voluminous uterine partially calcified leiomyoma. Mild perihepatic and perisplenic effusion were also detected; liver, pancreas, spleen, adrenal glands and kidneys were normal.
At the gynecologic examination, the vagina was atresic, and a hard hypomobile tumefaction was identified in the pelvic region with its extension reaching 2 cm above 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 62-year-old man, affected dysphagia, was endoscopically diagnosed with lower esophageal cancer confirmed squamous cell carcinoma on biopsy, and was reffered to our hospital (Fig. ). He had no medical history. His lifestyle has included 1500 ml beer consumption per day and 40 cigarettes per day for the past 40 years. Computed tomography (CT) showed thickening of the wall in the lower esophagus as the primary lesion was demonstrated and the tumor formed a mass with the solitary metastatic abdominal lymph node, and invaded pancreas body and gastric body (Fig. ). No other distant metastasis was detected on CT. He was diagnosed with lower esophageal cancer cT4 N1 M0, with pancreatic invasion, cStage IIIC according to 7th edition of the Union for International Cancer Control system []. At first, we considered definitive chemoradiotherapy. However, radiation oncologists evaluated that the tumor was less candidate for chemoradiotherapy because of the risk of gastric mucosal damage. For the purpose of definitive therapy, radical esophagectomy with distal pancreatectomy was planned. As neoadjuvant chemotherapy, CF therapy (cisplatin and 5-fluorouracil therapy; cisplatin was dripped 80 mg/m2 plus 5-fluorouracil was infused 800 mg/m2 on day 1 through 4 continuously) was started according to standard therapy of localized advanced esophageal cancer []. However, after once administration, he could not continue chemotherapy for the exacerbation of dysphagia, and underwent radical surgery. Preoperative evaluation of tumor was similar to initial findings on endoscopy and CT.
In findings on laparotomy, abdominal lymph node was infiltrated directly to pancreas body. As the radical surgery, Ivor Lewis esophagectomy with distal pancreatectomy and splenectomy, followed by reconstruction of gastric conduit. Two fields lymphadenectomy was performed according to the treatment strategy of the abdominal esophageal cancer. Reconstruction of gastric conduit was possible although the lymph node

[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 young woman presented with a 3-year history of experiencing numbness and pain in the right lower leg during exercise. Over the past 2 years, the patient had experienced worsening leg pain when running long distances. The patient had no cardiovascular risk factors. She had been hospitalized in the orthopaedic and physiotherapy clinic due to leg pain prior to admission to our clinic. However, her symptoms continued to persist. Examination of the right leg showed that there was swelling and no pulse below the femoral artery. Pulses were normal in left lower limb. Magnetic resonance imaging (MRI) revealed normal aortic and iliac arteries. Anterior and posterior views of MRA showed an occlusion of the right popliteal and peroneal arteries Figs. ( and ). In this case, intra-arterial thrombolysis was performed. Control angiography showed that there was a thrombus in the artery and a stricture at the mid-PA, with an irregularity of the wall. At the end of two 2 days, the angiogram demonstrated that the thrombus had largely resolved; however, the stricture of PA was present. MRI scanning was subsequently performed, which showed that the medial head of the gastrocnemius muscle, the PA and vein where it inserted in a more lateral position Fig. (). Further evidence from the MRI revealed that the PA crossed below the popliteal muscle in this patient with Type IV PAES. Contralateral limb MRI was normal. Posterior popliteal approach was preferred. An S-shaped skin incision was performed. The PA crossed under the popliteus muscle and there was a hypertrophic band, which was the cause of occlusive pressure on the PA. The hypertrophic bands and the popliteus muscle were resected. PA was opened and it was partially occluded. The tibioperoneal artery was also occluded. A thromboendarterectomy (TEA) was performed. The artery was repaired using a RA. No rest pain was detected after surgery. US showed that the distal arterial system and the RA were patent. A low molecular we

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old female patient came to the hospital complaining of left leg numbness. She had experienced a traumatic event, a fall into a waterway, one month ago. After which, she had severe low back pain and was evacuated to the nearby general hospital. Computed tomography (CT) showed an L5 left transverse process fracture and an S2 body fracture, and absolute bed rest (ABR) for one month was recommended (). During this period, her left leg numbness was progressively aggravated. To evaluate whether symptom aggravation during the ABR period was related to the patient's history of a left-side L5–S1 discectomy 2 years previously, magnetic resonance imaging (MRI) was performed. The MRI did not show recurrent disc material, but it did show an annular tear at L4–5 and postoperative scar tissue at L5–S1, and the previous doctor recommended continued conservative management. After the period of ABR was complete, the patient began ambulation and was transferred to our hospital in her hometown. She complained of left leg numbness initially upon arrival, and the more she walked, the more the pain was aggravated, showing hyperalgesia and allodynia.
Gabapentin and Selective Serotonin Reuptake Inhibitors are prescribed to treat these neuropathic symptoms. And we ordered physiotherapy and wheelchair ambulation for the first two weeks. Various nerve blocks were performed, including sympathetic nerve block. Even as the symptoms seemed to subside somewhat, skin flushing still appeared on the left lower leg when the patient was in a standing position (). The persistent skin discoloration seemed to worsen as time went on, despite frequent sympathetic nerve blocks using steroid. The allodynia became so severe that the patient was hesitant to wear a sock. To rule out the possibility of arterial injury, we performed lower extremity CT angiography, and there was no sign of arterial injury around the fracture site. We concluded that her symptoms resulted from lumbosacral plexus

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


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

[User]
RADIOLOGY NOTE:
This case describes a 23-year-old male who was struck by a motor vehicle. Upon arrival at our hospital, the patient had a GCS of 8. FAST exam, chest radiograph, and computed topography (CT) of the head and cervical spine were obtained and were negative.
Exam of the lower extremities revealed abrasions over the left knee and tenderness over the lateral joint line with an effusion. The right knee was diffusely tender to palpation without effusion. The patient had palpable pulses in both feet with well-perfused extremities. Ankle brachial indices were performed and found to be >0.9. He demonstrated guarding and pain with the attempted Lachman maneuver of the left knee and slight opening of the left knee joint with varus stress. Radiographs were obtained and revealed a left knee Segond fracture ().
Magnetic resonance imaging (MRI) of both knees was performed to evaluate for ligamentous injury. Left knee imaging demonstrated the Segond fracture along with a grade III lateral collateral ligament (LCL) tear with retraction (), a grade II tear of the popliteus tendon and anterior cruciate ligament (ACL) (), and a grade I medial collateral ligament (MCL) injury (), as well as partial thickness tears of the biceps femoris and vastus medialis. Right knee imaging revealed a grade III tear of the ACL and MCL (), grade II tears of the posterior cruciate ligament (PCL) (), LCL, and popliteus tendon, and a medial meniscus tear. The patient was placed in bilateral hinged braces with the left knee unlocked and the right knee in locked extension to aid with transfers from a bed to a wheelchair. The patient was also given a left foot drop boot for a foot drop discovered during a secondary exam. On hospital day three, the patient was discharged home.
Nine days after the accident, the patient presented to the clinic. He noted that the left-sided foot drop was improving.

[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 with a persistent pain in his lower front teeth, which made him dare not to chew for a few days, was diagnosed as pulpitis by his dentist. After a root canal treatment of teeth #42 to #32 [International Standards Organization Designation System (ISO System)], his toothache relieved a little. However, numbness on the left side of his chin occurred and progressed gradually to involve his entire chin and low lip. A month later, a throbbing pain with no trigger point attacked his chin, appearing several times every day, and lasting for hours. Chewing or touch could increase the pain intensity. The pain became so acute to affect his sleep. It was diagnosed as periodontitis and treated with antibiotics and analgesics, but the numbness and pain of the chin got worse. Magnetic resonance imaging (MRI) of the trigeminal nerves revealed a small vessel riding across the left trigeminal nerve and multiple patchy abnormal signals in pons, bilateral frontal and parietal lobes. To determine what exactly caused the trouble, he was then admitted to the neurology ward.
He had no other symptoms such as headache, visual disorders, difficulties in swallowing, and speech, limb weakness, or numbness. No weight lost in the past months. His past medical history was uncontrolled hypertension. He smoked 20 cigarettes a day for 40 years and only drank a little alcohol occasionally.
On physical examination, his teeth were black with enhancing accumulations of plaque calculus (Figure ). The oral mucosa appeared normal. His general physical examination was unremarkable with no cervical lymphadenopathy. Anesthesia was present over his chin and lower lip bilaterally while the sensation over the rest of his face was normal. His corneal reflexes and his bite force were normal. Examination of other cranial nerves and limbs including motion, sensation, and reflex was normal.
Hemanalysis showed normal in full blood count, erythrocyte sedimentation rate, plasma glucose, urea and electrol

[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-month-old boy was brought to the emergency department of our hospital with history of FB inhalation and respiratory distress. In the past 12 months, he already had two similar episodes of FB inhalation (peanut and plastic bead) and was treated at a regional hospital before being referred to us on the third occasion. The hospital notes of the past interventions mentioned the FBs lodged in the right main bronchus. In the past, the child had received treatment for asthma with corticosteroids.
The patient was born at term by a non-complicated delivery, and was in good condition with an age-appropriate development. On examination, the child had dry cough, inspiratory stridor, hoarseness, and hypoventilation of the right lung. The chest X-ray showed an air trapping phenomenon. Due to the past history of recurrent FB inhalation, a dynamic airway endoscopy was performed before the extraction of the FB. Under general anesthesia and the child breathing spontaneously the flexible transnasal laryngoscopy showed a right vocal cord paralysis with the cord lying in an intermediate position (). Subsequent ventilating rigid bronchoscopy showed complete obstruction of the right main stem bronchus by a peanut (). The FB was removed using dedicated rigid peanut grasping forceps. The distal airways were normal. In the following days, the child had an uneventful recovery.
In the past history, the child presented with dysphonia and breathy voice since birth. There was no history suggestive of viral infections and surgery. The parents did mention of him occasionally chocking especially with liquids. To complete the investigation for his unilateral vocal cord paralysis, an MRI of the brain, and CT-scan of the neck and chest were performed. They did not show any abnormalities.
Subsequently, the child was given intensive speech and swallow therapy and the parents were educated regarding modifications during feeding. The endoscopy after 1 year showed a complete recovery of the voc

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old female patient with no known history of hyperlipidemia, hypertension, coronary artery disease, trauma or previous neck surgery was admitted to our clinic with a spontaneous pulsatile mass that caused swelling in the right jugular region. Computed tomography (CT) angiography was performed previously at another medical center and an 3.31 × 2.84 cm arterial aneurysm which was located distally to the bifurcation was revealed in right internal carotid artery (ICA) (). The neck of the ICA aneurysm was clearly demonstrated and cranial distance was enough to perform end to end anastomosis (4.64 cm) (). Treatment options were revised by our team and conventional surgery was selected for the patient. The first reason for this choice is the absence of additional surgical comorbidity. The second is that the head base distance of the aneurysm fits end to end anastomosis. The third is the risk of distal embolism, which may occur with the development of spontaneous aneurysm on the atherosclerotic ground, even if it is not observed in CT angiography results. Also there was no sign of pseudoaneurysm, the aneurysm size was sufficient and the patient’s will to get rid of the mass supported our decision.
In our case, it was thought that cranial perfusion would be sufficient because of good left carotid artery circulation. There is no consensus on the routine use of EEG and shunt applications previous studies. Therefore, EEG monitoring and shunt application were not used during the operation. Under general anesthesia the patient was prepped and draped, an incision was made through the medial border of the sternocleidomastoid muscle. Common carotid artery (CCA), ICA, external carotid artery (ECA) and aneurysm were exposed by protecting cranial nerves (). Carotid artery was clamped; the aneurysm was excised with blunt and sharp dissections. After removal of the aneurysm, proximal and distal ends of the ICA were seen to be in sufficient length. Proximal and distal ends of 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 30-year-old female patient presented to our clinic with a left neck mass that she noticed a few months prior to clinical evaluation. She had a full range of motion in her neck and rarely complained of pain but did notice a lot of difficulty swallowing. The patient reported the mass has been increasing in size. She denied any fever, chills, nausea, vomiting, redness, or drainage around the mass. The rest of her history was unremarkable to the case. On physical exam, the patient was noted to have a BMI of 43.67 and all vital signs were within normal limits. The physical exam showed a left neck mass with poorly defined borders, nontender, and without inflammatory changes. The patient previously had an ultrasound of the left neck which demonstrated a circumscribed solid echogenic mass measuring 6.7 cm × 1.8 cm × 4.8 cm which corresponded to the palpable abnormality superior to the clavicle. The mass was identified as a lipoma ().
A left lateral transverse incision and dissection showed no subcutaneous mass. Intraoperative Doppler showed extreme medial displacement of the carotid sheath vessels. Then, a formal lateral neck dissection released the medial investing fascia of the sternocleidomastoid muscle enabling its further lateral retraction (). The mass was located substernocleidomastoid, from the C3 vertebral level down to the lung apex. It was medially displacing and abutting both the carotid sheath and the cervical thoracic duct as it drains into the internal jugular and subclavian vein junction. Subsequent carotid sheath dissection was performed with exposure of the internal jugular vein and common carotid artery at its internal/external branching. Also noted during the lipoma excision were large suspicious lymph nodes in the area posterior to the sternocleidomastoid. A formal left lymphadenectomy at levels II-IV was done. Free lymphatic channels near the apex of the lung and internal jugular vein were noted with small clear to milky fluid exudation

[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 29-year-old female was admitted to the Department of Osteopathy, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China in April 2018 due to shortening of the right lower limb, as compared with the contralateral side, which had been present for 18 years. She also complained of pain in the right hip that had been present for 2 months and the hip pain was aggravated by physical exertion, but pain relief occurred after rest. The patient was unable to walk more than one-block distance due to the severe pain and could not stand for more than half an hour. She had pituitary dwarfism without mental retardation or delayed sexual development. The Institutional Review Board of the Third Hospital of Hebei Medical University Ethics Committee requested that the authors seek consent from the patient for publication of this case report without full review and approval being required by the committee. Verbal consent was obtained from the patient by telephone interview for investigating and reporting her case. All necessary patient information was collected and anonymized.
The patient was of short stature, with a height of 133 cm and a weight of 37 kg. There was evidence of scoliosis (physiological curvature of the spine), the right lower limb was approximately 4 cm shorter than the left lower limb; and the right hip had reduced mobility, mainly in adduction and internal rotation. The Trendelenburg sign was positive on the right side and the Patrick test was also positive. X-ray and computed tomography examinations revealed Crowe type IV dysplasia of the right hip. The diagnosis at admission was made in the following order: (i) right hip dysplasia Crowe type IV; (ii) dwarfism.
Treatment options were discussed with the patient. The S-ROM prosthesis (DePuy Synthes Joint Reconstruction, Warsaw, IN, USA) was selected for use based on the patient’s narrow canal. A preoperative X-ray template

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old Caucasian woman presented to the emergency department of the University Hospital of Heraklion, Crete after a fall from a ladder. The patient occupied in everyday activities as a house wife and a farmer. There were no concomitant injuries. Thorough clinical examination and radiological imaging revealed a depression fracture of the lateral tibia plateau which was classified as Schatzker III/AO 41-B2 []. Radiological examination by a computed tomography (CT) scan was performed [], which showed the details and personality of this specific fracture to assist in decision making.
Estimated the clinical and radiological findings as well as the needs of the patient, surgical treatment was decided.
Taking into account that the position of the fracture was at the most posterior area of the lateral plateau and the difficulties from open reduction of the articular surface, closed reduction via a minimal incision arthroscopically and fluoroscopy assisted using balloon kyphoplasty instrumentation was performed []. After reduction of the articular surface confirmed by arthroscopy the bone defect was filled with calcium phosphate via injection []. The fracture was considered a stable one and no further support and fixation was needed.
Initial immobilization was obtained with a log leg cast for 2 days. Afterwards, continuous passive motion (CPM) was started with flexion and extension as tolerable. The patient started to walk with crutches and no weight bearing. A knee cast with goniometer was placed permitting knee exercises in flexion and extension. The patient was discharged from the hospital on the 5th postoperative day in a very good condition.
The patient was examined 6, 12 and 24 weeks after the operation regarding the movements of the joint and the muscle strength. A CT scan was ordered at the 6 week follow-up for a detailed evaluation and imaging of the tibial plateau []. The clinical outcome was excellent at the 6, 12 and 24 weeks follow-up with full range of m

[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 edentulous female patient was referred with facial asymmetry and remarkable swelling extending from the right body of mandible to the left body of mandible since 7-8 months. Pain associated with the lesion was occasional and sharp in nature. Tenderness was present over the lesion along with neural deficit (paresthesia) over the lower lip. She had a history of total extraction 14 months ago because of poor periodontal health. There was no history of trauma or dental pain, and the total extraction procedure was uneventful. The patient then got her complete dentures made, which were found to be ill-fitting at the time of reporting to our institution.
Skin over the swelling was apparently not involved and showed no evidence of scars, sinus or any discharge. There was no evidence of crepitus or egg shell crackling in relation to the lesion. Notably lymphadenopathy was absent in relation with the lesion. Intraorally the buccal plate was found to be expanded in anterior and left mandibular body region, which resulted in the obliteration of left buccal vestibule []. Floor of the mouth appeared to be raised.
The past medial history did not reveal any major illness however she was anemic and was under medication (injection vitcofol) for the same. There were no café au lait spots or subcutaneous nodules on the patient's trunk, and no evident axillary freckling noted.
Orthopantomographic findings showed well-defined radiolucency extending from right body region to left body region of the mandible []. Three-dimensional computed tomography revealed thinning of lower border and pathological fracture in left body region of the mandible. Ultrasonography of the local part showed a heterogeneous predominantly hypoechoic soft tissue lesion involving the right and left half of the mandible and no evidence of any vascularity was noted within it.
Aspiration of the lesion was negative and hence it was decided to perform an incision biopsy under local anesthesia. Fine needle a

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


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

[User]
RADIOLOGY NOTE:
A 9-year-old-male presented to the emergency department with pain to the sole of his left foot. The patient stated that he was at karate the day prior to presentation when he began to have pain. He had initially injured his foot while playing at his home 3 months prior. The family went to their pediatrician at that time and a small wooden splinter was removed. The patient was discharged with instructions for warm soaks and supportive care. Despite having had the splinter removed, the patient’s pain persisted, and he started to develop erythema and edema to the plantar aspect of his left foot. One week after the initial visit to his pediatrician, he presented to an urgent care where an x-ray of his foot was performed and did not reveal any radiopaque foreign body. The patient was diagnosed with cellulitis and was discharged with a prescription for amoxicillin/clavulanate. The patient’s symptoms gradually improved and resolved by the completion of his antibiotic course.
The patient continued to have intermittent mild foot irritation for approximately 3 months when he developed a recurrence of erythema, edema, and tenderness to the sole of his foot. His mother noted that the area was intermittently draining pus. The family re-presented to the primary care physician who diagnosed the patient clinically with an abscess of his foot. A referral was made to a podiatrist whose next available appointment was over a month away. As a result, the patient’s mother brought him to the ED for further care. At that time, the patient denied fever, chills, nausea, or vomiting. The patient was fully immunized and generally in good health with the exception of mild asthma.
Physical exam revealed a well-nourished, alert school-aged male in no distress. His vital signs were within normal limits. The plantar aspect of the patient’s left foot was significant for a patch of erythema and edema, with 2 punctate lesions within

[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.