[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 male presented to the emergency department with vague complaints of right-sided flank pain. The patient had a history of nephrolithiasis and underwent a CT abdomen (Fig. A). The scan revealed a large heterogeneous mass in the left upper quadrant. Subsequently, an MRI was performed, confirming a 16 × 9 cm2 complex mass with both cystic and solid components (Fig. B). This appeared to extend from the gastric wall and resulted in mass effect on the pancreas; however, there was no evidence of lymphadenopathy or metastatic disease. While this lesion was difficult to definitively characterize by imaging studies, a diagnosis of mesenchymal origin tumor such as a GIST was initially preferred.
The patient underwent endoscopic ultrasonography with fine needle aspiration of the mass. The lesion appeared to arise from the submucosa, as the mucosa was intact overlying the mass. On cytology, a paucity of bland spindle cells was present (Fig. A) and the cell block contained several small clusters of cells which stained strongly for CD34, but failed to stain for DOG1 or CD117 (Fig. B). Given the small amount of material present, additional testing for PDGFR and succinate dehydrogenase testing was not able to be performed at this time to confirm the diagnosis of GIST. GIST remained the favored diagnosis given the morphology and location of the tumor. The options were to repeat the biopsy or start imatinib therapy with a plan of repeat imaging after short-term follow-up. Because of extensive necrosis of the tumor, repeat biopsy was felt to be a less favorable option and the patient chose to undergo treatment with short-term imaging follow-up. Accordingly, the patient began treatment with imatinib. However, after 4 weeks of therapy, there was no significant radiologic regression. A second biopsy was performed and the specimen was sent for STAT6 immunohistochemistry (Fig. C). This revealed diffuse strong nuclear positivity and a diagnosis of SFT was made.
Patient underwent

[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 77 year old, male patient diagnosed with esophageal cancer underwent esophagectomy and gastric conduit reconstruction in an external hospital in January 2020. The patient suffered from an insufficiency of the intrathoracic anastomosis of the gastric conduit, which was treated by implanting esophageal stents.
After an episode of upper gastrointestinal (GI) bleeding that led to a hemorrhagic shock, the patient was transferred to the tertiary care hospital. Over the next few days, the patient presented further episodes of upper GI bleeding, which could not be controlled by endoscopy. In a CT scan we identified a pseudoaneurysm of an intercostal artery dorsal of the gastric conduit (see Fig. ). After an interdisciplinary discussion, we decided in favor of an endovascular therapy for the pseudoaneurysm.
The angiography was performed under general anesthesia. Access was gained via a retrograde 6 French sheath in the right common femoral artery. The intercostal artery of the right, eighth intercostal space was probed with a 6 French Guider Softip XF Catheter (Boston Scientific). Digital subtraction angiographies (DSA) were made from different projections. The maximum diameter of the pseudoaneurysm was 8 mm (see Fig. ).
The DSA images also showed a fine, vertical vessel projected onto the spine, highly suspicious of being the anterior spinal artery. The direct connection between that vessel and the intercostal artery could not be identified clearly. Also we were not able to evaluate with certainty whether this vessel would be collateralized from the opposite side if we embolized the intercostal artery completely.
Consequently, we decided to implant a stentgraft into the intercostal artery that covered the pseudoaneurysm but maintained the blood flow within the artery and all uncovered side branches of the artery. Because of the small diameter of the intercostal artery (3 mm), we chose the PK Papyrus Coronary Stent (Biotronik, 3 mm x 15 mm).
First, we had to find a stabl

[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 case we present here is about a 63-year-old man who was referred to our out-patient clinic with a gradually increasing swelling in his left calf since 3 months and associated pain since the last 1 month. He gave a history of loss of appetite and weight. He had been diagnosed to be having pulmonary tuberculosis 5 months ago for which he was receiving treatment regularly. The patient was a nonsmoker.
General physical examination revealed mild pallor and clubbing of his fingers. The left calf swelling was ill-defined and measured 5.0 cm × 3.0 cm approximately. It was firm to hard in consistency, tender and showed mobility in the transverse axis. Systemic examination revealed no abnormality except for decreased breath sounds and crepitations in both the lung fields.
Magnetic resonance imaging of the leg swelling showed a 3.2 cm × 2.4 cm × 2.0 cm mass in the lateral border of the gastrocnemius muscle encasing the peroneal nerve — suggestive of a peripheral nerve sheath tumor. Computed tomography scan of the chest revealed a fibro-cavitatory lesion in the right upper lobe of the lung which was consistent with tuberculosis. In addition, an ill-defined mass was visualized in the left lower lobe, measuring 3.5 cm × 2.7 cm, with associated collapse. This lesion was suspected to be neoplastic. Abdominal ultrasound was normal.
Hemogram showed mild iron deficiency anemia. All the biochemical parameters were within normal histological limits.
Based on the above investigations, a presumptive diagnosis of soft tissue tumor of the leg with possible metastasis to the lung and coexistent pulmonary tuberculosis was made.
The calf swelling was first subjected to fine-needle aspiration cytology (FNAC). Cytology revealed loose groups as well as singly placed polygonal and round cells with squamoid appearance []. The cells had high nuclear-cytoplasmic ratio, hyperchromatic irregular nuclei, small nucleoli and a moderate amount of dense eosinophilic cytoplasm. Few bizarre looking cells

[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 7-year-old girl presented with an approximately 2-week history of nasal obstruction and epistaxis. An otolaryngologic evaluation revealed a large intranasal mass. The patient was referred to our otolaryngology department because the nasal tumor became hemorrhagic upon performance of a biopsy. No palpable cervical lymphadenopathy was identified. Nasal endoscopy revealed a large polypoid mass obstructing the right nasal cavity, and a subsequent computed tomography (CT) examination showed a heterogeneous soft tissue mass with an ambiguous border and irregular contour. The CT scan also indicated evidence of focal plaque-like or zonary amorphous calcification (). Intravenous administration of contrast medium resulted in significant marginal enhancement without prominent hypervascular enhancement in the rest of the mass. We performed magnetic resonance imaging (MRI) to further characterize the internal architecture. The MRI results indicated that the signal intensity of the mass was heterogeneous on T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI), the signal intensity on T1WI was lower, and T2WI showed heterogeneous hyperintensity. Streak calcification captured by short T1 and short T2 signals was detected within the lesion, and the high signal intensity in some areas on T2WI indicated cystic changes (). Additionally, the diffusion limitation was not significant on diffusion-weighted imaging. The tumor involved the right ethmoid sinus, and the accompanying compression of the opening of the right maxillary sinus had led to extensive opacity, resulting in obstructive inflammation. The remaining paranasal sinuses were not invaded. The nasal septum was deviated to the left side, and the right nasal cavity was dilated. Bone defects were found in the right medial orbital wall, medial wall of the maxillary sinus, and cribriform plate (). The right medial rectus muscle and lower rectus appeared to be pushed laterally by the mass, causing slight ocular protrusion, but

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old ethnic Han Chinese female, who used to be healthy and had no history of disorders related to the nervous system, respiratory system, circulatory system, digestive system, rheumatic immune system, and also had no history of mental disorders, from a family without history of genetic disorders, hypertension, coronary heart disease, diabetes, genetic inherited diseases, etc., forming a happy family with her beloved husband and two healthy daughters, initially presented with intractable nausea and dizziness for 9 weeks. She went to local hospital. Full blood count, serum biochemical tests, gastroscopy and head CT examination showed no obvious abnormalities. She felt that her nausea and dizziness did not improve after symptomatic therapy and even followed by dysphagia, limb weakness, blurred vision, ghosting in the right eye, and fatigue. Two weeks later, she went to another local hospital. A blood test was positive for AQP4 antibodies and brain MRI found high-signal lesions (). She was diagnosed with NMO and treated with high dose of intravenous methylprednisolone. Two days later, she felt shortness of breath, hard to swallow and difficulty in walking. She was transferred to the ICU and received a tracheotomy and mechanical ventilation due to severe breathing difficulties, and a nasogastric tube feeding due to difficulty swallowing. Her condition did not improve over 2 weeks despite treatment with high-dose intravenous methylprednisolone (0.5 g per day for 3 days, 0.25 g per day for 3 days, 0.12 g per day for 2 days) and immunoglobulin (20 g/day for 5 days) followed by 3 rounds of plasma exchange.
She was transferred to our hospital at midnight, and physical examination revealed a temperature and blood pressure of 37.1°C and 96/68 mmHg, respectively. She was conscious on mechanical ventilation, with blurred vision of the right eye, shallow right nasolabial fold, upper limb muscle strength level 1, and lower limb muscle strength level 0. Laboratory tests

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


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

[User]
RADIOLOGY NOTE:
A 19 year old female with CF who had a heart and lung transplantation in 1997 presented to the Emergency Department (ED) with a one day history of severe, intermittent, central, sharp chest pain, radiating to her back and down her left arm. This was associated with intermittent paraesthesia, pallor and coldness in her left hand. The chest pain was worse on deep inspiration but was not positional or exacerbated by movement. Over the previous four weeks she had been having a productive cough with a reduced exercise tolerance but no chest pain.
On examination there was no swelling, pallor or erythema of her left arm/hand and no chest wall tenderness. She was well perfused with a regular pulse and a stable blood pressure. No murmur or added heart sound was present and vesicular breath sounds were heard on auscultation. A chest radiograph showed no acute changes and an initial electrocardiogram (ECG) taken in the ED showed a sinus tachycardia with no ST or T wave changes. Initial blood tests were normal apart from an elevated white cell count (13.64 × 109/L), creatinine (138 μmol/L) and urea (12.8 μmol/L).
The patient was admitted from the ED to the CF ward where she had a repeat ECG and a troponin I blood test after being assessed by a junior doctor. The repeat ECG showed sinus tachycardia with T wave inversion in leads I, aVL, V2-V4, but no ST changes or Q waves. The troponin I level (taken approximately 30 hours after the onset of chest pain) was 10,801. A computed tomography pulmonary angiogram (CTPA) the following day showed no pulmonary embolus (PE) and no vascular abnormalities. A coronary multi-slice computed tomography (MSCT) was not performed as it is not used as an investigation of acute MI in inpatients at St James’s University Hospital.
Later that day the patient was reviewed by a cardiology registrar who

[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 37-year-old Caucasian woman was admitted to Department of Oncological Gynaecology and Gynaecology with a large exophytic abdominal wall tumour (12 cm × 6 cm) in a caesarean section scar (). The caesarean section was performed 4 years earlier through Pfannenstiel incision. Both the surgery and postoperative period were not complicated. First pain symptoms with 2 cm tumour occurred 2 years after caesarean section. Over the next 2 years, local burning pain gradually improved and the tumour constantly enlarged in size. The patient did not undergo any hormonal treatment and reported regular menstruation periods with scanty menstrual blood flow occurring regularly every 28 days, lasting 4 to 5 days. On physical examination, there was a palpable dark-red, pigmented tumour located in the abdominal wall within Pfannenstiel incision scar. Gynaecological examination and transvaginal ultrasound showed no abnormalities within reproductive organs. The patient was qualified for a surgical procedure involving resection of the lesion in general anaesthesia. A wide local excision of the lesion with adequate 1 cm margin of healthy tissue was performed. Scar endometrioma involved rectus abdominis muscle fascia and thus wide fascia excision was performed. Side to side linear fascia closure was impossible so non-absorbable polypropylene mesh was used to close the defect. The skin was extensively undermined and mobilized up towards umbilical level cephalically and pubic symphysis caudally with careful preservation of the communicating perforator vessels. Standard subcutaneous suction drainage was used to minimize the postoperative complication of haematoma and the skin was closed with single non-absorbable sutures (). No perioperative antibiotics were used. The patient was discharged 2 days after surgery in good general and local condition. Skin sutures were removed after 10 days and wound was cleansed 3 times daily with octenidine dihydrochloride. The wound healed without complication.

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old woman with a medical history of chronic viral hepatitis presented to our clinic after sudden onset of headache with vomiting. We found no neurologic deficit and her mentality was drowsy. Her CT scan showed a diffuse SAH and mild hydrocephalus (). CTA confirmed an upper basilar abnormality (). Cerebral angiography obtained two hours later showed no vascular abnormality (). The patient received an external ventricular drain (EVD) for symptomatic hydrocephalus on posthemorrhage day 2. The patient's clinical condition improved and her level of consciousness improved to alert immediately after EVD. On the second day after EVD, her mentality suddenly deteriorated to semicoma. Immediate CT scan showed an increased amount of SAH, suggestive of rebleeding. A repeat CTA after rebleeding showed no abnormal vascular lesion. However, cerebral angiography at the same time confirmed a small cylinder like contrast stagnation from the upper basilar artery at late arterial phase, indicating pseudoaneurysm formation (). We inserted two Solitaire stents (4 × 20 mm, ev3, Irvine, CA, USA) for flow diversion and anticipating thrombus formation of the pseudoaneurysm. The patient's clinical course was uneventful, however, one-month follow up CTA still showed a saccular lesion from the upper basilar artery. Therefore, we decided to perform DSA and intervention. DSA still showed contrast stagnation at late arterial phase on the upper basilar artery and superselective microcatheter angiography confirmed a pseudoaneurysm arising from a small perforating artery of the superior cerebellar artery (SCA) (). Due to concern about cerebellar infarction, we could not sacrifice the SCA. To facilitate thrombus formation of the pseudoaneurysm, we performed repeated temporary balloon occlusion using a Sceptor XC balloon (4 × 10 mm, Microvention, Tustin, CA, USA) and achieved decreased contrast inflow to the pseudoaneurysm (). On follow-up at 11 months, the patient had no neurologic deficit, 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 52-year-old man complained of nasal stuffiness along with bleeding, headache, and vomiting. He was referred to our department after magnetic resonance imaging (MRI) showed an enormous mass occupying the nasal and paranasal cavities and extending into the bilateral frontal base [Figure and ]. No neurological deficit other than anosmia was identified. The tumor spread beyond the nasal cavity and paranasal sinuses, and was therefore classified as stage C based on the modified Kadish clinical staging system [].[] Total removal of the tumor was achieved surgically, using a transnasal approach in combination with a bilateral front basal craniotomy [Figure and ]. The dura along the anterior skull base was opened partially and the cranial base was reconstructed using the pericranial flap. Histological examination of the tumor demonstrated proliferating tumor cells with large, oval nuclei containing prominent nucleoli. Scattered necrotic changes, nuclear fission, and Homer–Wright rosettes were identified. These findings were consistent with Hyams grade III ONB [].[] No neurological deficit other than olfactory analgesia was observed after surgery, however, the patient suffered from meningitis caused by cerebrospinal fluid rhinorrhea that developed 1 week postoperatively. Because complete eradication of the rhinorrhea and meningitis required 9 weeks of treatment, radiation therapy was started 10 weeks after the surgery. Large-field irradiation of the resected area, from the nasal cavity to the frontal lobe, was administered with a total of 60 Gy in 30 fractions. The patient was discharged 17 weeks after the surgery and was followed-up on an outpatient basis. At the time of discharge, whole-body enhanced computed tomography (CT) revealed no apparent distal metastasis or tumor recurrence.
At 24 weeks postoperatively, the patient noted numbness in both upper limbs, which gradually worsened. He was readmitted 25 weeks after the surgery because of rapidly deteriorating symptoms.

[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 male was admitted to the emergency room with retrosternal chest pain. A year ago, he underwent implantation of a dual chamber permanent pacemaker due to symptomatic complete atrioventricular block. Because he experienced pacemaker failure 2 months earlier, a single chamber permanent pacemaker was implanted in the right ventricle for him through right subclavian vein. Chest x-ray findings indicated a dual chamber leads through left subclavian vein and a single chamber permanent pacemaker lead through right subclavian vein in the right ventricle (). The angiography report revealed that the patient had a patent left main artery (LMA) and a 3- vessel disease involving the left anterior descending (LAD), second obtuse marginal (OM), and right coronary arteries (RCA). Therefore, the patient was a candidate for elective OPCAB surgery after reprogramming the pacemaker to VOO mode.
Under general anesthesia with standard monitoring for cardiac anesthesia using a bipolar ESU (electro surgical unit) and after completion of the anastomosis LIMA to LAD while lifting the cardiac ventricular apex for anastomosis to OM artery, suddenly the RV was perforated by the tip of the ventricular lead of the previous dual chamber pacemaker (). Then, blood pressure decreased rapidly and the patient unexpectedly experienced cardiac arrest. Immediately, the patient was resuscitated with administration of epinephrine (up to 4 mg), atropine (up to 2 mg), and internal cardiac massage for 7 minutes. After establishing CPB (cardio-pulmonary bypass), dexamethasone 8 mg, thiopental sodium 3 mg/kg, lidocaine 1 mg/kg, and magnesium sulfate 30 mg/kg were administrated intravenously according to our institutional protocol. When all the grafts anastomoses were performed successfully, the RV perforation was repaired with a pledgetted mattress suture, and the perforated lead was withdrawn slowly as the suture was tightened.
Subsequently, the patient was rewarmed and weaned off CPB with the same

[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 woman presented with swelling in the left breast near the nipple as early as October 2009, but this became prominent within one month, and she eventually went on to have fine needle aspiration cytology, which showed plasmacytoid cells in the background, followed by a core biopsy that showed infiltration by immature plasma cells, which were positive for CD138, MUM1, and CD56 and weakly positive for cyclin D1 and EMA. There was lambda light chain restriction. The cells were negative for CD20, CD19, PAX-5, and EBER. They were also negative for MNF 116 and CK7. This supported a diagnosis of plasmacytoma. There was no evidence of any secretory paraprotein in the patient’s blood or urine, and her serum free light chains were normal. An MRI of her spine was clear, as was her bone marrow, which only showed 5% plasma cells. Subsequently, she underwent radical radiotherapy (40.05 Gy in 15 fractions over three weeks).
Six months later, she re-presented with a lump in her right breast that was 2 cm in size felt clinically, which pointed to a recurrence in the contralateral breast (). An ultrasound scan and core biopsy confirmed recurrent disease. Again, investigations, including a PET scan, failed to show myeloma or other lesions. The lump was PET positive (). She commenced treatment with CTD (cyclophosphamide, thalidomide, and dexamethasone) in June 2010 and completed five cycles.
Six months later, she presented with increasing back pain when she was due to start her sixth cycle of chemotherapy. She subsequently developed numbness in her feet and loss of power in her legs. An MRI scan showed a mildly enhanced soft tissue mass posterior to the T9, causing moderate cord compression (). The patient was treated with urgent radiotherapy (five fractions). She subsequently had another MRI of her spine, which showed resolution of this mass. Her PET scan was clear, as was her bone marrow

[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 67-year-old woman was admitted for evaluation of an incidental finding of carotid bruit on physical examination. She had been treated for hypertension and diabetes mellitus for 10 years. On admission, her blood pressure was 140/100 mg. On neurological examination, she was normal. Magnetic resonance imaging (MRI) revealed multiple old infarctions in the bilateral parieto-occipital junctions and right internal border zone area. MR angiography revealed occlusion of the right proximal internal carotid artery (ICA), and severe stenosis of the left proximal ICA and orifices of both vertebral arteries (VA). Digital subtraction angiography demonstrated total occlusion of the right proximal ICA, 73% stenosis of the left proximal ICA and more than 70% stenosis of both VA orifices (). The patient was pre-treated with aspirin and clopidogrel for 5 days before undergoing stenting at the left proximal ICA and right VA orifices via a transfemoral approach under local anesthesia (). There was no transient hypotension or bradycardia during the periprocedural period. Anti-hypertensive drugs including a calcium channel blocker (CCB) were administered to maintain systolic blood pressure below 140 mm Hg. After close observation for one week, she was discharged without any complications.
Three weeks after CAS, the patient presented to the emergency room with generalized tonic-clonic seizure for 40 minutes and stuporous mentality. Blood pressure had risen to 190/110 mm Hg. On neurologic examination, the withdrawal response in the right extremities was decreased, but there was hyper-reflexia in all the extremities, with pathologic plantar reflexes bilaterally. Brain MRI showed high signal intensities in the left hemispheric white matter on FLAIR, without diffusion restriction, pointing to vasogenic edema (). Neck computed tomography angiography revealed no significant stenosis in the previously stented vessel. Slower waves were recorded on the left than on the right hemisphere on electro

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


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

[User]
RADIOLOGY NOTE:
The patient was a 37-year-old woman, G2P1, with an unremarkable family history. She had been diagnosed with bronchial asthma by her family doctor at the age of 33 years. The use of steroid inhalation therapy did not appear to impact her condition []. Her previous pregnancy had resulted in an emergency cesarean delivery at 33 weeks of gestation due to severe hypertensive disorders of pregnancy (HDP) and fetal growth restriction (FGR). She became pregnant for the second time and was referred to our hospital owing to her previous birth history. Her estimated due date was confirmed from the CRL value during the first trimester. Her pregnancy was uneventful; however, she developed fever and cough at 26 weeks of gestation and was subsequently diagnosed with sinusitis due to deteriorated bronchial asthma. She was admitted to the hospital under the care of the respiratory team and was administered ceftriaxone. However, despite administration of antibiotics, the wet cough associated with asthma persisted. She suffered from pneumonia at 28 weeks of gestation, and atelectasis was detected in the left lower lobe using a chest radiograph. Although her symptoms began to improve, bronchoscopy was performed at 34 weeks of gestation due to recurrent pneumonia. Bronchoscopy showed a tumor with a smooth surface measuring approximately 1.5 cm in the left main lung bronchus. The tumor obstructed nearly 100% of the trachea () []. Further enlargement of the mass would have led to complete tracheal obstruction, suggesting a risk of sudden left lung atelectasis and maternal hypoxia; therefore, early medical intervention was necessary. Additionally, her blood pressure was elevated at 32 weeks of gestation and fetal growth was restricted at -2.0 SD of normal fetal growth, so that she was diagnosed with preeclampsia (PE-EO). Following counseling with the patient, her family, and respiratory medicine doctors, a bronchoscopic tumor resection was planned following the delivery of the baby. A cesa

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


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

[User]
RADIOLOGY NOTE:
A previously healthy, 52-year-old Caucasian man presented to his family physician a week after having a tonic-clonic seizure. A magnetic resonance imaging (MRI) scan showed a 10 cm left frontal tumor, which was confirmed as an atypical meningioma following craniotomy and resection (Figure ).
Postoperatively, he took 400 mg of phenytoin PO once a day. He had no seizures postoperatively or afterward. The patient uneventfully received 60 Gy of adjuvant radiation therapy to the postoperative bed in 30 fractions. Three months after the resection of the tumor, the patient began a trial of phenytoin but nine days later, he developed symptoms consistent with a generalized seizure. He resumed his daily phenytoin prophylaxis with good effect.
Two months later, he complained of blood in the stool and after an evaluation was diagnosed with a locally advanced nonmetastatic adenocarcinoma of the low rectum (Figure ). A curative-intent dose of 50.4 Gy in 28 fractions of neoadjuvant radiation therapy was prescribed, with 2000 mg PO BID of concurrent radiosensitizing capecitabine []. After 20 of the planned 28 fractions, he began to feel unwell and experienced new, right-sided upper and lower limb dysfunction and an unsteady gait. A contrast-enhanced computed tomography (CT) scan of the brain showed no suspicious findings but his phenytoin level was dramatically elevated at 138 µmol/L, compared to 49 µmol/L just prior to neoadjuvant therapy (normal range: 40-80 µmol/L). His albumin level from a few weeks prior to these symptoms had also been normal at 39 g/L (normal range: 34-46 g/L), and he was taking no other medications other than an occasional stimulant laxative. Capecitabine was discontinued, and the patient was treated with charcoal and admitted for observation. Phenytoin was temporarily discontinued and then reintroduced at the previous dose of 400 mg PO per day once levels began to normalize. His symptoms quickly resolved and he showed no further

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 1-year-old Saudi female child who was referred from another hospital after PDA ligation, left inguinal hernia repair, accidental fracture of her right ulna and radius, and prolonged mechanical ventilation for severe respiratory syncytial virus infection complicated by acute respiratory distress syndrome. The patient was sent to our hospital for further evaluation due to ongoing respiratory distress and hypoxemia. Our patient was the third child of nonconsanguineous Saudi parents and was born via cesarean section at 36 weeks gestation due to fetal distress. The child was admitted to the neonatal intensive care unit for 5 days because of respiratory distress and was ventilated for 36 hours. The mother has epilepsy and the father has been diagnosed with Behcet's disease. Since the age of 2 months, the child had multiple lengthy admissions in different hospitals (for 1 to 3 months at a time) for recurrent cyanotic events, respiratory distress, frequent choking with feeding, and significant vomiting. The child had accumulated the following diagnoses: severe gastroesophageal reflux disease (GERD), failure to thrive requiring prolonged nasogastric tube feeding, patent ductus arteriosus, pulmonary hypertension, anoxic convulsions, chronic lung disease with prolonged oxygen dependency, reversible bronchospasm, left external iliac vein thrombosis, and developmental delay. She had two prior prolonged stays at our institution.
The first admission was due to rhinovirus infection and clinically diagnosed recurrent aspiration secondary to aberrant right subclavian artery (dysphagia lusoria) with prolonged oxygen therapy. The second admission was for respiratory failure that required prolonged intubation including high-frequency oscillatory ventilation complicated by recurrent lung atelectasis and right lung pneumothorax. She failed multiple trials of extubation and unfortunately died of cardiac arrest due to sepsis while receiving maximal supportive therapy. An in

[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 woman presented with a complaint of generalized right knee pain. Physical examination of the right knee joint revealed nothing remarkable. The patient had a history of chronic alcohol consumption exceeding 400 mL of ethanol per week for the past 20 years. There was no history of steroid intake or trauma. One year before presentation, she had undergone a bipolar hip replacement for avascular necrosis of the left hip. She referred to our hospital due to the right knee pain. Radiographs revealed no destruction of the articular surfaces of the right knee, but increased radiodensity was evident in the proximal half of the tibia extending from the joint line (). MRI demonstrated large demarcated regions of abnormal signal intensity in the proximal half of the tibia and medial femoral condyle, with features of osteonecrosis (). A bone scintigram showed the abnormal uptake in the right hip, and the right and the left knee joints (Figures , , and ). A full blood screen including autoantibodies, a clotting profile, ALP, and AMY gave normal results (). Human immunodeficiency virus (HIV) and hepatitis B and C viruses and antibodies were negative. The patient complained that she had often felt mild pain in her right hip and left knee joint after a short walk. Physical examination of the right hip and left knee revealed no abnormality. However, radiographs demonstrated increased radiolucency in both, and MRI revealed demarcated regions of abnormal signal intensity in the central portion of the right femoral head with typical features of osteonecrosis (). Left knee MRI showed multiple demarcated bone marrow abnormalities with double-line sign in the distal shaft of the left femur, compatible with bone necrosis ().
The patient was instructed to maintain only partial weight-bearing with wheelchair mobilization for eight weeks and then to return gradually to full weight-bearing over the next two months. Eleven months after the initial presentation, she complained of mil

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old woman attended our office for oral cavity assessment and treatment planning for complete oral rehabilitation. Her medical records showed she had been diagnosed with progressive systemic sclerosis but had not been taking any medications. She complained of occasional dry mouth and inflamed gums, which is a typical oral manifestation of this disease (). An X-ray of the jaw (digital panoramic image) revealed that teeth 14, 24, and 27 needed to be extracted or undergo root canal treatment (). Horizontally positioned impacted upper canines were also observed, which were asymptomatic and free from any pathology. Almost all teeth had large, inadequate fillings. After thorough dental examination, an endorestorative treatment was proposed, followed by final rehabilitation of the lower jaw with full ceramic crowns. For the upper jaw, given that the impacted canines would interfere with the traditional implant-supported rehabilitation (fixed ceramic bridges), a combined prosthodontic solution was proposed (fixed ceramic crowns in the frontal region and a removable prosthesis in the back) following all necessary extractions and restorative preparations. The patient was informed that this solution for the upper jaw bares some long-term risks due to her primary diagnosis and chronically dry oral mucosa. The patient refused the removable prosthodontic solution for the upper jaw and asked for a fixed one. Two alternative options were proposed: (1) initial extraction of the impacted canines after bone augmentation, followed by later insertion of the implants, or (2) a novel, experimental approach called transdental implant insertion. The patient was informed that the second procedure was relatively new, had not been fully validated by evidence-based contemporary dentistry, and was based on several published case reports and follow-ups.
Both the benefits (avoidance of aggressive, invasive surgery including bone grafting; reduced financial cost; and increased speed of the

[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 69-year-old man presented with upper abdominal pain that had lasted for 3 months. His past medical history was unremarkable. Evaluation with abdominal magnetic resonance imaging (MRI) (Fig. A, B) and contrast-enhanced computed tomography (CT) (Fig. C) revealed a well-circumscribed cystic lesion in the ventral pancreas measuring approximately 3.7 × 2.1 cm in diameter. Results of all laboratory tests were normal. On the basis of these imaging and laboratory results, the lesion was diagnosed as a benign cystadenoma. The case was discussed by the institute's tumor board, and ventral segmentectomy was suggested as the most appropriate management option.
The patient underwent ventral segmentectomy along the EFP. An exploratory laparotomy via a middle incision was performed with the patient under general anesthesia. The gastrocolic and duodenocolic ligaments were first dissected to expose the pancreatic head, duodenum, and superior mesenteric vein. A limited Kocher maneuver was performed to facilitate slight mobilization of the duodenum and palpation of the intrapancreatic common bile duct (CBD). The posterior aspect of the mesoduodenum was identified and carefully preserved. Palpation and intraoperative ultrasound examination were performed to confirm the presence of a cystic mass in the ventral segment of the pancreas. The inferior pancreatic head was then exposed by careful dissection. A faint line of loose fibrous connective tissues was visible in the inferior pancreatic head (Fig. A). This line was identified as the EFP, situated at the interface between the posterior ventral segment and the anterior dorsal segment. This plane, which appeared as a fibrous septum running from the anterior-inferior aspect to the superior-posterior portion of the pancreatic head, was easily dissected without major bleeding, and the ventral and dorsal segments were separated (Fig. B). The main pancreatic duct was identified at the left side of the EFP (Fig. B), penetrating the fusion pl

[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:
We report a case of a 52-year-old woman with a large left atrial tumor. The patient complained of 2 months of exertional dyspnea. She had no history of cardiovascular disease, and denied having fever or weight loss lately.
At the time of consultation, she had blood pressure of 130/80 mm Hg, a heart rate of 74 bpm, respiratory rate of 20 breaths per minute, temperature of 36.2 °C, and oxygen saturation of 99% on room air. No remarkable signs were found on physical examination. The results of laboratory tests showed a hematocrit of 35% without other significant data. The electrocardiogram was normal. Chest radiography showed a slight redistribution of flow to the vertices without other pathologic findings.
The patient was studied with transthoracic Doppler echocardiogram. The study showed preserved systolic left and right ventricular function. A big heterogeneous multi-lobed mass, highly mobile, attached to the posterolateral atrial wall, was observed (). The tumor prolapsed through the mitral valve into the left ventricle in diastole producing functional mitral valve stenosis. Mitral transvalvular mean gradient was estimated in 8 mm Hg. Pulmonary systolic artery pressure was 45 mm Hg. Afterwards, the examination continued with a transesophageal echo. The study showed a huge multi-lobed auricular mass, 67 mm in length, with a large base of implantation to the posterolateral aspect of the left atrial wall (). Another small sessile mass was observed in the anterior surface of the left atrium (). Pulmonary veins were not affected.
In order to better investigate the disease, a cardiac MRI was performed. The study showed again two masses in the left atrium. The larger multi-lobed mass, measuring 64 × 19 × 18 mm, was seen prolapsing into the left ventricle during diastole. Of note, the tumor was widely attached to the posterolateral wall of the left atrium. Moreover, the other sessile mass in the anterior wall contiguous with the rear wall of the aorta measuring 13 ×

[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 37-year-old man presented to our office with right buttock pain radiating to the leg. There was no weakness or sensory changes, and his lumbar MRI revealed a huge central disc extrusion and sequestration at central L4-5 region (). The patient was first treated with five epidural steroid injections (two by an interlaminar approach and the others by a transforaminal approach). Although this improved his pain level, the effect did not last for more than three weeks; the patient continued to complain of pain with a score of 7 on the NRS, and he could not walk for more than three minutes. His functional score on the ODI was 38.
PEA and decompression with the inflatable balloon neuroplasty catheter were planned and prepared as described above. A caudal epidurogram, performed before the insertion of the inflatable balloon neuroplasty catheter, showed a filling defect in the anterior epidural space above the level of L5. When the inflatable balloon neuroplasty catheter was inserted and advanced to the level of L5, some resistance against the catheter was felt. Gentle adhesiolysis of the anterior epidural space by intermittent balloon inflation was performed as described for Case 1, and the spread of contrast medium above the level of disc herniation was confirmed. At the end of the procedure, a Perifix epidural catheter (B. Braun Melsungen AG, Melsungen, Germany) was left at the target site through the balloon catheter lumen. After test injection of 1 ml lidocaine, 6 ml of a mixture of 1% lidocaine and 1,500 IU hyaluronidase was administered through the Perifix catheter. After 10 to 15 minutes of monitoring, another 4 ml of a mixture of 10% hypertonic saline and 20 mg triamcinolone was injected through the catheter. The catheter was removed on the day of the procedure. There were no complications during the procedure. At the follow-up visit after one month, the patient's pain was found

[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 asthmatic male patient presented to our center with 12 days history of melena. He denied any previous episode of melena or hematochezia or bleeding from another site. The patient did not have any other associated symptom, and had no other co-morbidities, or medication use. Upon referral, he was uncomfortable and looked pale. He was vitally unstable, with a blood pressure of 90/60 mmHg and a pulse rate of 120 beats/min. The examination revealed the presence of clotted blood on the anal verge, and some tarry stool on digital rectal examination. The hemoglobin level was 7.7 g/dl, the hematocrit was 22.8, and the blood urea nitrogen was 8 mg/dl. The prothrombin time and the partial thromboplastin time were normal.
Resuscitation was performed with transfusion of 2 units of packed red blood cells and intravenous fluids. He was admitted to the ICU for intensive monitoring. After admission and stabilization, upper and lower endoscopies were performed without demonstrating the bleeding site. They only revealed clotted and red blood throughout the colon.
Technetium-labeled red blood cell bleeding scan was done to localize the site of bleeding. This scan showed no evidence of early focal increased uptake in the abdomen to indicate active gastrointestinal bleeding during early images, but in the delayed images, it revealed that there was a focal uptake in the right and transverse colon. After that, capsule endoscopy was also performed without findings. As the angiography became available, the patient underwent selective angiography without findings noted at that time. These tests were inconclusive because they were performed while the episodes of bleeding ceased.
After 8 days of conservative management and negative investigations to define the cause of the bleeding, a sudden drop in hemoglobin level from 10.8 mg/dl to 6.9 mg/dl occurred over 12 h, which mandated operative management. Exploratory laparotomy was performed. Extensive jejunal saccular pouches were 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 62-year-old female patient was transferred due to acute onset of gait disturbance, radiating pain (VAS 7) in all extremities during admission at gynecological clinic. She also had features consistent with KFS, including a short neck and low posterior hairline. There was a 10-year history of posterior neck pain, occipital hypoesthesia, radiating pain and numbness in all extremities, and subjective gait disturbance. She never visited a hospital for the problems because the symptoms had been mild without any disturbance in the activities of daily living.
Neurological examination revealed normal motor power in the arms. However, there were positive Hoffmann's sign and mild spasticity bilaterally. She had mild paraparesis (grade IV) with spasticity in the legs and showed an unstable gait. Pain and temperature sensation was normal, but proprioception was decreased in the legs bilaterally.
The forms of deformity, stenosis, and cord lesion were similar to those of case 1 on cervical spine radiograph, CT, and MRI (). The ADI was 2.5mm on both flexion and extension lateral views without any definitive craniocervical instability (). There were stenosis and spinal cord compression by anteriorly displaced C1 arch on preoperative CT and MRI (). The patient's presentation was consistent with Type I KFS according to Feil's classification, and Type III according to Samartzis' classification.
We also planned to decompress spinal cord by removing C1 posterior arch without craniocervical fixation (). In this case, we had to perform suboccipital craniectomy and partial removal of C2 spinous process and lamina in order to make space for the route reaching to the C1 posterior arch (). Immediately after decompression, there was an improvement in the radiating pain of all extremities (VAS 3), and muscle power recovered to grade V in the legs bilaterally. The unstable gait, spasticity, and proprioception also showed a substantial improvement. Additional physical therapy was not needed, 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 30-year-old male reported to our department with chief complaint of painless but progressively reducing mouth opening for 5 months. He was the victim of a motor vehicular accident which occurred 6 months back, sustaining trauma to the face and was diagnosed as a case of Lefort III # with midsymphysis of the mandible #. He was operated and lateral suspension was done for Lefort III # and miniplate fixation was done for midsymphysis #. The patient was discharged uneventfully after 1 week and was advised for regular follow-up. One month postoperatively, the patient noticed a gradual reduction in mouth opening. The patient was advised active jaw physiotherapy but there was no benefit. The patient was lost on follow-up but he reported with the chief complaint of reduced mouth opening [].
Medical history including review of systems was nonsignificant. Extraoral clinical examination showed slight asymmetry of the face. Diffuse solitary ill-defined growth was present on the right side of the face at malar region measuring approximately 3 cm × 3 cm in maximum dimensions. Swelling was bony hard in consistency and nontender. There was no palpable depression in the right zygomatic region and there was no evidence of diplopia or infraorbital dysesthesia. Maximum interincisal mouth opening was 15 mm with mild deviation of the mandible to the injured side []. Protrusive and lateral jaw movements were restricted. On extraoral palpation, no rotary or translatory movements of condyle were perceptible. On intraoral examination, occlusion was found to be satisfactory and no other abnormalities were noticed. The patient was subjected to further investigations.
Water's view [] revealed an irregular-shaped radio-opaque mass over the right zygomatic region. There was loss of normal architecture of the coronoid process and zygomatic arch on the right side. The right coronoid process was enlarged, deformed, and in continuation with the bony mass over the right zygomatic region. A computed

[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 24-year-old female with a sickle cell disease presented with mild chest pain, an episode of vomiting, and no history of trauma or chronic illness; she was hemodynamically stable, afebrile with regular abdomen examination. Chest examination revealed decreased left air entry, chest X-ray showed left consolidation, and ultrasound thorax confirmed the presence of bowel loops and left kidney within the thoracic cavity. Contrast-enhanced computed tomography (CECT) of the thorax and abdomen showed colon, small bowel, left kidney in the thoracic cavity with scoliosis (Cobb angle of 24 degrees), fused 12th thoracic and 1st lumbar vertebral bodies, and displaced left diaphragmatic crus and its defect (
,
).
The patient received preoperative antibiotics, nebulization, and bowel preparation with normal blood investigation. Following left thoracotomy, the thoracic cavity was accessed through the fifth intercostal space, which contained a hypoplastic lung, the colon, small intestine up to the duodenal jejunal flexure, and left kidney with no hernia sac. The normal colonic mesentery was adherent to the aorta and pericardium (
). Following vascular adhesiolysis and laparotomy, intrathoracic contents were transpositioned to normal anatomical positions. Primary partial diaphragmatic repair, pedicled intercostal muscle flap raised between the sixth and seventh ribs, followed by partial excision of the sixth rib obliterated posterolateral defect. Polypropylene mesh was placed over the primary repair and around the flap with Prolene 3-0 to provide diaphragmatic stability (
). A single drain was placed in the chest and abdomen, followed by a closure. Mild splenomegaly was not an indication for splenectomy. Extubated patient was maintained nil by mouth for 24 hours. She received one unit (350 mL) of packed red blood cells and Ryles tube feeding with fluids on the first and second postoperative days followed by oral feeds and a soft diet from the third and fourth days. The postoperative

[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 4-month-old entire female Persian cat was referred to our institution for chronic constipation and acute vomiting. The cat had been treated with mineral oil (PO q12h) and rectal enemas with partial response since the beginning of the clinical signs. Physical examination revealed low BCS, crackles in all lung lobes in the lung auscultation and abdominal discomfort on palpation. Thoracic radiographs showed diffuse increased soft tissue opacity within the lungs, more marked in the cranioventral aspect of the thorax, with an alveolar pattern in the right and left cranial and the right middle lung lobes. There was also a focal alveolar pattern with a perihilar distribution in the caudal and accessory lung lobes (,). Severe diffuse colon distension was noted in the abdominal radiographs. Marked scoliosis of the lumbar spine, partial fusion of the L5–S1 vertebral bodies and decreased pelvic diameter were also noted, so secondary obstructive megacolon was suspected. Rectal enema was performed and supportive treatment based on antibiotics, systemic corticosteroids, bronchodilators and IV fluids was established for the suspected aspiration pneumonia. Mineral oil was immediately discontinued. The patient improved after 2 days and was discharged with antibiotics, systemic corticosteroids, lactulose and a low-residue diet.
Two months later, follow-up thoracic radiographs showed an alveolar pattern (similar to that previously described) with granular mineral opacities and ‘sponge-like’ appearance of the previously affected lung lobes (,). Multiple recurrent episodes of respiratory signs were recorded during a year, which partially responded to systemic corticosteroid and bronchodilator therapy. Owing to the refractory medical management, subtotal colectomy was elected as the treatment for the obstipation 1 year later. CT of the thorax was performed prior to surgery, showing an alveolar pattern with air bronchograms in all lung lobes, with a ventral distribution in the cranial 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 male famer aged 68 years old was admitted to our institute for a tumor in his lower lip. This patient has a history of smoking (30 pack-year) and consuming alcohol for more than 30 years (approximately 200 ml per day). He was diagnosed as systemic lupus erythematosus (SLE) 20 years ago and had been treated with methylprednisolone for 17 years. For the last three years, his SLE status has been stable and thus, he discontinued the SLE treatment.
The patient reported that the tumor in the middle of his lower lip had appeared for a year and gradually increased in size without any pain or bleeding. He did not receive any treatment because of his financial issue. For the last few months, the tumor had rapidly grown, bled and become painful, so that he could not eat or clean his teeth.
On examination, there was a 3 x 4 cm, raised, ulcerous, and bleeding tumor, developing in the lower lip and expanding to 1/3 external upper lip (). The submental lymph node was around 2 cm in diameter, firm, and hardly moveable. Ultrasound revealed a suspected metastatic submental lymph node with absent echogenic hilum. MRI Scan demonstrated a lesion in lower lip with size of 13 x 31 mm, which increased in T1W signal and T2W signal, strongly enhanced after contrast and did not invade surrounding tissue. A 2 cm and round lymph node was also identified (). The fine needle aspiration (FNA) result of the lymph node presented a metastatic squamous cell carcinoma and the biopsy result of the tumor confirmed squamous cell carcinoma (SCC). No abnormality was detected by a metastatic work-up. Therefore, the clinical staging of this patient was cT2N1M0. In addition, other para-clinical tests including full blood count, biochemistry profile, ds-DNA, ANA were normal, which indicated a stable status of SLE.
The patient underwent surgery including a complete removal of the lower lip and 1/3 external

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old white male presented with dyspnea associated with generalized weakness and lethargy for the past 4 months. In the past month, his breathing had further worsened with episodes of syncope with exertion. He also reported an intermittent fever and had lost 40 pounds in 2 months. He smokes cigarettes and drinks alcohol regularly along with intravenous (IV) methamphetamine once or twice per week.
On presentation, he was febrile, tachycardic, and hypotensive and was admitted to the hospital for the management of septic shock. The examination showed a Grade 2 systolic murmur in the mitral area and tenderness of the upper abdomen. He was treated with IV fluids and broad-spectrum antibiotics as per protocol. Computed tomography (CT) of the abdomen showed geographical enhancement of the spleen suspicious of infarction, along with multiple small renal infarction. On the basis of these findings, infective endocarditis with embolization was suspected. Echocardiogram confirmed 2.5 cm × 1.5 cm vegetation in both mitral leaflets with evidence of severe mitral regurgitation [].
While being worked up for mitral valve replacement, he suddenly developed numbness of his left arm. On examination, the left arm was pale with an absent radial pulse. Bedside, arterial Doppler revealed a possible obstruction of the proximal brachial artery with maintained blood flow distally. Meanwhile, his blood cultures grew A. defectiva (nutritionally deficient Streptococcus [NVS]) from both of the bottles []. Vascular surgery was consulted, and CT angiogram of the left upper extremity was performed, revealing an occlusion of the left brachial artery distal to the deep brachial branch point []. There was a reconstitution of flow distally within the ulcer artery, which was patent to the level of the wrist, and the radial artery did not become opacified until just proximal to the wrist joint, suggesting extension of the thrombus into the radial artery. The patient was initiated on anticoagulatio

[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 current case report describes a retired, white, female patient who was 82 years old and from Spain. She was diagnosed with FL in August 2010 and presented with lymphadenopathy in the right femoral region with FL, grade 3A, a Follicular Lymphoma International Prognostic Index risk score of 1, low tumor burden, and no bone marrow involvement. A timeline of the patient history, interventions, and clinical findings is shown in Fig. . The patient had no relevant prior medical history. She was treated with radiotherapy (40 Gy in 20 fractions) for stage I localized disease and achieved a complete response (CR) with no major concerns.
In June 2012, approximately 18 months after CR was achieved, the patient experienced FL progression, presenting with a submandibular mass. A biopsy revealed grade 3a, stage Ia FL. The patient refused chemotherapy at that time, so she was treated with repeat radiotherapy (40 Gy in 20 fractions) and achieved CR with no toxicities. However, 9 months following the second CR, the patient experienced FL progression, presenting with lymphadenopathies in the left axillar region and splenic lesions, and biopsy revealed grade 1, stage IIIa FL. She was treated with six cycles of rituximab-chlorambucil in lieu of more toxic treatment options that the patient had refused. She achieved a partial response and refused further treatment at that time. Four months following the last treatment, the patient experienced FL progression (refractory FL) and presented with lymphadenopathies in the left axillar region and grade 3/4 lymphedema in the left arm. Biopsy revealed grade 1 FL. The patient also showed left pleural effusion (not investigated further in this case study). She was enrolled in a randomized, double-blind, phase 3 study evaluating rituximab in combination with an investigational therapy versus rituximab and placebo. The patient progressed after 4 months.
Based on the refractory nature of the disease following two lines of chemoimmunotherapy (inclu

[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 referred to the Department of Dentistry from a local dental dentist with the chief complaint of severe and continuous pain in the mandibular right teeth region for 6 months. The patient gave a history of severe pain, and it aggrevated while taking cold and hot foods while lying down on the bed and while sleeping and the pain relieved only for few hours after taking the analgesics. No significant medical history was observed. The intraoral clinical examination revealed a decayed tooth in relation to #36. The tooth #36 was tender on percussion. The provisional diagnosis of chronic irreversible pulpitis was made based on the subjective and objective findings. An IOPA radiograph was advised in relation to #36 region. The IOPA revealed an ill-defined radiolucency extending into the pulpal region with a significant widening in the periodontal ligament at the apical region of mesial and distal canals []. The provisional diagnosis was confirmed with the investigations, and a final diagnosis of chronic irreversible pulpitis was made for the tooth in relation to #36.
The root canal treatment was planned and under local anesthesia (2% Lignocaine 1:200000 Epinephrin) access opening completed similar to case report 1. The tentative working length was determined with 10 and 15 number K files []. The working length files have shown a blunt curvatures in the apical portions of the distal canal. The consideration of the significant curvatures in the apical portions of distal canals the biomechanical preparation was planned with the ProTaper Next rotary system. In the second appointment, with the copious irrigation, the biomechanical preparation was completed with the ProTaper Next rotary system as explained in the case report 1. The single-cone obturation was completed with the 6% gutta-percha points with the AH plus sealer []. The permanent restoration was done with the fiber-reinforced composite resin, and the patient recalled after 3 months for evaluati

[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 82-year-old elderly female with a history of severe right-sided TN was previously treated unsuccessfully with numerous medications and percutaneous rhizotomy. She was referred to the radiation oncology clinic for consideration of SRS after neurosurgical evaluation.
The patient’s right-sided facial pain began initially in the 1980s, but she reported a long period of disease quiescence until symptoms recurred in 2007, one year after suffering a right cerebral hemispheric embolic stroke. At that time, her TN was treated with carbamazepine with a good initial response, but in 2010 this was discontinued due to an increasing dose requirement associated with the development of intolerable side effects. Multiple alternative medications were prescribed including gabapentin, Lyrica, fentanyl transdermal patches, and sumatriptan, without significant improvement of her pain.
In December 2014 and January 2015, she underwent percutaneous rhizotomy with radiofrequency ablation to her right trigeminal nerve, but despite these interventions, her facial pain persisted. In February 2015, she underwent brain magnetic resonance angiography/magnetic resonance imaging (MRA)/(MRI) to include her right internal auditory canal. Imaging demonstrated a right superior cerebellar artery (SCA) loop abutting CN V, causing a mass effect on the nerve near the root entry zone (REZ). The patient was subsequently referred to neurosurgery for possible surgical intervention. After neurosurgical evaluation, due to her age and multiple medical comorbidities, she was not considered an ideal surgical candidate for MVD and was referred to radiation oncology for consideration of SRS.
The patient was initially seen by Radiation Oncology in March 2015. During consultation, she described her facial pain as unilateral located on her right side and spanning from her lip to her temple region near the auricle. The pain episodes were characterized as sharp, intermittent, unpredictable, and severe. On average, her p

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male was admitted to the Pulmonary Oncology Department of University Hospital Centre Zagreb in November 2017 with cough and hemoptysis. He smoked 27 packs/year, had an alcohol abuse history, and displayed no evidence of present or past soft tissue neoplasms or history of radiation exposure. His Karnofsky performance score was 80. Subsequent physical examination revealed reduced air entry in the left lung. His complete blood count and biochemical parameters were within the normal range. Initial chest x-ray showed an extensive consolidation in the left lung suggesting possible malignancy; CT of chest and abdomen was recommended. The CT scan showed an extensive partially necrotic tumor in the left upper lobe (LUL) extending from the left hilum with infiltration of the LUL bronchus to the visceral pleura, measuring 74 mm in the largest diameter (Fig. ).
There was no evidence of nodal or visceral dissemination at presentation. Bronchoscopy examination with biopsy was performed, and specimen from the LUL bronchus was taken. Histopathological analysis showed an almost completely necrotic tumor with a share of less than 10% viable pleomorphic tumor cells expressing vimentin and CD99 and focal positive desmin. There was no expression of AE1/AE3, p40, TTF-1, napsin A, epithelial membrane antigen (EMA), CK7, and S100. The most likely diagnosis was poorly differentiated sarcoma.
For final staging, PET/CT scan was performed, showing no extra thoracic spread of the disease. The multidisciplinary tumor board deemed that lung surgery was the best treatment alternative, and several weeks later, left pneumonectomy with mediastinal lymph node dissection was done. Final pathohistological analysis noted a tumor size of 100 × 85 × 71 mm, more than 80% of which was necrotic. The pleomorphic tumor cells showed the same immunohistochemical profile as in biopsy specimen. Synovial sarcoma-associated translocation was negative. All surgical margins and dissected mediastinal lymph

[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 1-year-old boy was noted to have protrusion of his right eye and was diagnosed with the fetal type of orbital rhabdomyosarcoma in October 2008. The size of the mass was reduced by a peripheral blood stem cell transplantation, chemotherapy and radiation therapy with 50 gray units in the period from November 2008 to June 2009. He developed a cataract in the right eye in May 2011, and his visual acuity in that eye decreased to hand motion. He underwent phacoemulsification and aspiration, and intraocular lens implantation in the right eye in July 2011. There were no abnormal findings on fluorescein angiography, which was performed soon after the cataract surgery. His visual acuity after the cataract removal was 20/200 and, with amblyopia training, his visual acuity improved to 20/25. In May 2016, he underwent YAG-laser posterior capsulotomy and his visual acuity was maintained at 20/25.
At a regular examination in January 2017, his visual acuity was 20/60 in the right eye and 20/20 in the left eye. The intraocular pressure was 13 mm Hg in both eyes, as measured with noncontact tonometry. Slit-lamp microscopy showed superficial punctate keratopathy of the right eye. The left eye was clear. The bulbar conjunctiva was not injected in either eye. The anterior chamber of the right eye was deep and there were no signs of inflammation. The depth of the anterior chamber of the left eye was normal and the lens of the left eye was clear. Examination of the fundus by indirect ophthalmoscopy showed neither a retinal detachment nor retinal hemorrhages in either eye. Optical coherence tomography (OCT) showed macular edema in the right eye (Fig. ). There were no soft exudates or retinal hemorrhages (Fig. ). Fluorescein angiography showed a hyperfluorescent site on the right side of the fovea of the right eye, but there were no nonperfused areas (Fig. ). The macular edema was considered to be due to the prior radiation therapy.
As mentioned

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


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

[User]
RADIOLOGY NOTE:
In June 2016, a 9-year-old girl (elementary school student of Caucasian race, weighing 42 kg) was referred for consultation with an interdisciplinary team in the Vascular Anomalies Center of Guarneri Clinic (Rome, Italy) to address a painful and progressively increasing mass in the right thigh. The consultation team included vascular surgeons, interventional radiologists, hematologists, oncologists, plastic surgeons, and pathologists.
The patient had an unremarkable medical history.
At clinical examination, the girl showed functional impairment of the right knee (limited flexion of 30%), muscle contracture, and localized pain (). In the days before her hospitalization, the reported daily mean visual analog scale (VAS) score for chronic pain was 7 ± 1. Neurologic examination revealed normal patellar tendon reflex, full strength of the surrounding musculature, and normal superficial and deep sensitivities. Dermatological examination revealed normal skin characteristics.
It was reported that no therapeutic procedure had been carried out previously, and the pain symptoms had been controlled with pain relievers, when necessary.
Laboratory blood tests for coagulation were performed, according to the high rate of variations in coagulation states that are found in patients with vascular anomalies. No abnormalities were observed in our young patient.
In addition to clinical signs, diagnosis of FAVA was based on both ultrasound and magnetic resonance imaging (MRI) examinations. Both imaging modalities showed a complex mass of 11 cm × 8 cm × 8 cm in the right thigh, a finding compatible with FAVA malformation, located in the vastus medialis muscle and marginally in the rectus femoral muscle. The T1-weighted MRIs showed heterogeneous and hyperintense signal related to the fat component (), and the injection of intravenous contrast clearly revealed the malformed venous component. The solid mass was found to have partially replaced the normal vastus medialis muscle fibers, with f

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old male patient sought a maxillofacial surgeon because of difficulty in swallowing and in chewing, pain complaint, and an internal nodule hardened on the tongue. On visual and palpatory clinical examination, a free and well-defined rounded nodule was found, with the tongue showing normal color, but with an enlarged aspect in the central region (). In the initial clinical interview, the patient did not remember whether he had eaten anything that had hurt his tongue. To assist in the diagnosis and try to elucidate the fact, the patient was asked for a complementary ultrasound examination of the tongue. The ultrasound device was a linear matrix probe, with a frequency of 12 Mhz. In the result, it was possible to observe a 5 mm hyperechoic linear image with a 1.2 × 0.7cm granuloma formation. The lesion was located on the left lateral border of the distal third of the patient's tongue, 0.1 cm from the surface.
The echographic aspect suggested a foreign body inside, showing an image compatible with a spine, with granuloma formation (). On the patient's return, when asked about the possible spine on the tongue, he recalled that he had eaten pequi a while ago but that he was not sure exactly regarding the time, leading us to a more consistent diagnostic hypothesis of a foreign body granuloma caused by a pequi spine. Complete surgical enucleation of the lesion was then performed, with bilateral anesthetic block of the lingual nerve. Surgical access was performed through a linear incision in the lingual dorsum on the left side, close to the most superficial region of the lesion (). The lesion was divulsed, using blunt-tipped instruments, from the adjacent tissue planes, having been cleaved without the rupture of its evident lining capsule (). No vascular rupture with subsequent hemorrhagic accident occurred, despite the close proximity of the lesion with lingual arteries and veins. The visualization of these large lingual vessels was perceived by the surgeon during

[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 male presented with hematuria, increased frequency, and burning sensation during micturition along with left flank pain for 2 months. There was a history of generalized weakness, weight loss, and loss of appetite during this period. On examination, the patient was poorly nourished with the presence of a palpable left-sided abdominal mass.
Ultrasonography (USG) of the abdomen showed the presence of right ectopic kidney and left-sided hydronephrosis. A heterogeneous mass was noted in the left kidney. Another polypoidal mass was also seen in the lumen of the urinary bladder, attached to its posterolateral wall.
Contrast-enhanced computerized tomography (CECT) of the abdomen helped in the renal anatomy and characterization of the mass, which revealed L-shaped crossed fused renal ectopia. The right kidney was not present in the right renal fossa and was in the midline, anterior to the aortic bifurcation at the L4-L5 level. It was malrotated and fused with the lower pole of the left kidney. The left kidney was enlarged, with a large soft heterogeneous tissue density mass involving the interpolar and lower pole regions that exhibited heterogeneous enhancement with central non-enhancing areas. Few calcified foci were seen in the mass, along with moderate hydronephrosis. In the delayed phase (15 minutes), no contrast excretion from the left kidney was recorded. The interpolar region of the right kidney was contiguously infiltrated by the left lower pole renal mass. Small tumor thrombi were present in the segmental right renal veins draining the interpolar region. Aortocaval, para-aortic and left renal hilar lymphadenopathy were also noted.
Along with these findings, a well-defined polypoidal mass was seen in the left posterolateral wall of the urinary bladder, infiltrating the left vesicoureteral junction. The middle and distal parts of the left ureter were contiguously involved by this urinary bladder mass. A peripheral rim of calcification was present.
Becaus

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


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

[User]
RADIOLOGY NOTE:
The second patient is a 44-year-old male who presented to the emergency room in January 2015 with an aortic dissection from the sternal notch to the bifurcation of the aorta. Forty-eight hours later, he developed bilateral lower extremity compartment syndrome requiring decompressive, four-compartment fasciotomies of the right and lower extremities. A wound vac was placed in the operating room. Amputation due to poor motor control was discussed with the patient and his mother. They requested that we “do everything” to save his legs. He had a prolonged and very complicated hospitalization with resulting end-stage-renal disease on hemodialysis at discharge, blindness due to posterior ischemic optic neuropathy or central retinal artery occlusion. He required hand grafts for upper extremity fasciotomies. He developed a pseudomonas infection of his G-tube site. He developed a Stage 2 pressure ulcer on his occiput. He developed ischemic bowel s/p colectomy/partial small bowel resection/ileostomy as well as a circulatory arrest. He had postoperative respiratory failure requiring a tracheostomy. A right and left pneumothorax required chest tubes. He was discharged to a skilled nursing facility in May 2015 with wound vacs to bilateral lower fasciotomy sites. He was admitted to a shared room with a patient on contact precautions. He had been walking with a front wheeled walker but had to stop due to leg pain. The wound vac was removed and wet-to-dry dressings applied. Three weeks later, he was admitted to our hospital with sepsis due to wound infections. Wound cultures grew klebsiella pneumonia and enterococcus species. Further debridement was required. The patient was eager to resume his rehabilitation and return home given his previous prolonged hospital stay. The VAC VeraFlo was applied in an effort to hasten granulation tissue and his return home. The patient was discharged three weeks later to his home, with granulation tissue over bone, on oral antibiotics, and with a wo

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man with a history of bullous pemphigoid treated with a monoclonal antibody was admitted to another hospital due to a balance disorder. A neurological examination identified a left hemiplegia with no sensory deficits. An immediate CT brain scan showed a ring-enhancing cortical-subcortical lesion on the right frontal-parietal hemisphere. In view of the CT scan findings, gadolinium MRI of the brain was performed. MRI showed a caudal extension of the lesion with irregular enhancement and a necrotic region (). Blood cultures were collected before initiating antimicrobial therapy. A few days later, his blood cultures grew Listeria monocytogenes. Based on organism sensitivity, intravenous therapy with ampicillin 3 g/6 h + gentamicin 80 mg/8 h + vancomycin 1 g/12 h was initiated. Steroid therapy was also administered due to the associated moderate mass effect. The patient was then transferred to our Infectious Diseases Department for further workup and management. Forty-eight hours after the initiation of target therapy, the patient was afebrile. Twenty days later, he showed progressive clinical and neurologic deterioration characterized by visual hallucinations, frontal symptoms with disinhibition, and persistent hemiplegia. An MRI brain scan showed a substantial increase in lesion size, and new lesions appeared on splenium of corpus callosum and right temporal lobe with a significant mass effect on the right lateral ventricle. Trimethoprim/sulfamethoxazole 160/800 mg/8 h was added. The patient underwent a surgical biopsy of the lesion. Molecular identification of the brain tissue using PCR identified Listeria monocytogenes DNA. At the follow-up appointment five weeks later, additional imaging studies were performed which showed a considerable reduction in the size and enhancement of the lesions. Ampicillin, gentamicin, and vancomycin therapy was stopped while trimethoprim/sulfamethoxazole therapy was continued. The patient's neurological condition improved.

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


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

[User]
RADIOLOGY NOTE:
A 3.5-months-old girl was admitted to our department with right-sided hemihypertrophy. Screening with abdominal ultrasonography showed an enlarged right kidney with a large hypoechoic region presenting no corticomedullary differentiation as well as multifocal hypoechoic parenchymal foci bilaterally in both kidneys, suggesting PLNB. Magnetic Resonance Imaging (MRI) revealed multiple hypodense and nonenhancing cortical masses at both kidneys; the largest with a diameter of 2.65 cm was localized at the enlarged right kidney and presented reduced diffusion and faint enhancing tissue at periphery (Figures and ). As all lesions were homogeneous without enhancement after contrast administration and a lenticular shape the diagnosis of PLNB was further suggested by the MRI findings. Spherical shape, heterogeneous, and enhancing nodules that would be suspicious for a WT were not present in the MRI. A second abdominal ultrasonography 2 months later showed enlargement of the already existing and new foci of NB bilaterally.
Some years ago we presented the case of a 23-month-old boy, who did not received any treatment for the initial diagnosis of right NB and developed WTs 24 and 42 months later at the left and the right kidney, respectively, despite regression of initial lesions of NB []. Review of the literature on the management of NB revealed one large retrospective study and several case reports describing in most cases adverse outcome in nontreated patients. Thus, our female patient initiated chemotherapy according to SIOP Wilms Tumor/2001 protocol and received vincristine and actinomycin D for 4 weeks. Abdominal ultrasonography at 4 weeks showed decrease of lesion's size (shrinkage of the large right kidney mass volume from 7,56 cm3 to 3,26 cm3) and the patient received further cycles of vincristine and actinomycin D every 14 days for the next 3 months. Follow-up ultrasound at 4 months of treatment showed additional decrease of lesions dimensions (). However, the follow-up

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old man with no known prior medical history presented with right leg pain with stable vital signs. The right leg pain continued from a week prior and chest pain was extreme a week before, but showed improved state on arrival at the hospital. The right leg showed resting pain and coldness, but motor and sensory activities were intact and viable.
In CT angiography, total thrombotic occlusion was revealed from right common iliac artery to superficial femoral artery (). An electrocardiogram demonstrated anterolateral myocardial infarction. Transthoracic echocardiogram demonstrated several thrombi at left ventricle apex and akinesia from left ventricle apex to apical anterior wall () but ejection fraction was maintained at 55%. The largest thrombi was measured at 17.4 mm.
Cardiac enzymes showed normal results of troponin I and creatine kinase-myoglobin and blood tests identified no abnormal findings. For hypercoagulability study, laboratory results of homocystein, antiphospholipid antibody, antithrombin III, protein C activity and factor V leiden mutation were normal, but protein S activity was slightly decreased at 59% (normal > 77%). Drug screen tests of Cocaine, Cannabinoids and Morphine were negative.
From arrival at our institution, heparin was infused continuously. After contacting the Cardiology Department, coronary angiography was performed, which demonstrated dissection of left anterior descending (LAD) coronary artery ().
Currently, left ventricle thrombi do not induce severe heart failure, and coronary artery dissection is vulnerable and distal flow is maintained. Therefore, conservative treatment is maintained using heparin, and intervention will take place when dissection is stabilized.
Therefore, thrombectomy was performed on the right ileofemoral thromboembolism under general anesthesia. First, through the right femoral artery of the inguinal, proximal and distal thrombectomy was done with Fogarty balloon catheter and for the tibial lesions of th

[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 man presented to us with a 12 month history of infection around his lower right tibia and ankle. There was no history of fracture; rather, the infection was attributed to a soft tissue injury sustained after impact with a concrete bollard whilst running. Before presentation to us he had undergone incision and drainage of a large volume of pus as well as windowing of the tibia and two bony debridement procedures, the last 6 months previously. A wound swab taken at the time of injury had grown a fully sensitive Group A haemolytic streptococcus, and a single intraoperative sample from the right distal tibia taken at the time of the last debridement had grown Staphylococcus aureus (resistant to erythromycin). Blood cultures had remained negative throughout. He had completed a short course of oral clindamycin 300mg QDS (5 days) and oral flucloxacillin 500mg QDS prescribed by his GP at the time of initial presentation, as well as a second short course of oral flucloxacillin and two short courses of oral amoxicillin immediately after each of his surgical procedures. He was a smoker, but had no other significant medical co-morbidities.
At the time of our assessment he was afebrile and systemically well, though complained of ongoing ankle discomfort and swelling. On examination there was a scar over the anteromedial border of the tibia, with a small amount of skin discolouration and dry crust over the lower third. He had strong pedal pulses, normal sensation and a good range of ankle movement. Pre-operative imaging was consistent with Cierny and Mader Anatomic Type 3 osteomyelitis of the right lower tibia (Figure ).
He was taken to theatre for surgical excision, deep tissue sampling and reconstruction. The previous bone window was extended and the cavity was curetted back to healthy bleeding bone. Five deep samples were taken using a validated sampling protocol ,. Briefly this protocol recommends that when suspecting infection, 5 or more deep samples are taken

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old woman was admitted to our hospital who presented with sudden onset of headache without any accompanying neurological deficit. A computed tomography (CT) scan of the head revealed a subarachnoid hemorrhage, which was positioned mainly in the left slyvian fissure and interpeduncular and basilar cisterns. Computed tomography angiography (CTA) indicated a posterior communicating artery aneurysm in the left side, and the ACP was closely related to the internal carotid artery and the aneurysm (Fig. A–D).
A left pterional approach craniotomy was performed in the standard fashion. After cutting the bone flap, the neuroendoscope was introduced, and a cutting drill was used to remove the lesser sphenoid wing from the medial part of the sphenoid ridge. Then, a small diamond drill was used to “egg-shell” the cortical bone of the ACP, with continuous irrigation to avoid heat injury to the nerve. Finally, the thin layer of bone of the ACP was fractured using a fine curette and was removed with a needle holder, and the ACP was completely resected. Then, the dura matter was opened, the sylvian fissure was split, and the posterior communicating artery aneurysm was revealed. After the neck of the aneurysm was carefully separated, it was completely clipped under the neuroendoscope (Fig. A–I). During the surgery, the endoscope was hold by assistant and adjust the angle and direction at any time according the procedure of the operation. The duration of the operation was 3 hours and the blood lost was around 100 ml. The patient was follow-up to 3 months and recovered well after the procedure, and the post-operative image view revealed that the ACP had been removed and that the clip was located just at the ACP area (Fig. A–C).
Written informed consent was obtained from the patient's family for publication of this case report and the accompanying images. All procedures were performed according to the guidelines of the ethics

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman underwent liquid silicone injections for augmentation mammoplasty 42 years previously. Eight years prior to admission, siliconomas were removed due to discomfort. She visited a hospital with the chief complaint of a painful mass in her left breast. The mass was resected and a histopathological examination revealed the tumor to be an invasive micropapillary carcinoma. The surgical margin was positive for malignant cells and she visited the hospital for further treatment. She was a healthy-looking woman. The left breast was craggy and it came in contact with the axilla, which thus made it difficult to palpate the tumors. No breast tumor was palpable on the other side. The laboratory parameters did not show any abnormalities and there was no evidence of distant metastasis. She was not on any medication. She had never taken oral contraceptives nor received hormonal therapy. She had experienced three pregnancies and delivered once. Her family history revealed no malignancies.
A subsequent dynamic magnetic resonance imaging (MRI) examination with Gadolinium (Gd)-DTPA enhancement demonstrated the four tumor shadows with similar enhancement at distant portions. Because it was unlikely that four malignant tumors existed at the same instant, they were thus considered to be coexistent malignant tumors and siliconomas. Ultrasonography revealed masses with an irregular shape and contour, extensive hypoechogenicity or shadowing. The tumors with a heterogeneous internal echo with a slight degree of Doppler signaling were considered to be malignant tumors; those with homogeneous internal hypoechogenicity with no Doppler signaling were considered to be siliconomas.
A left-sided mastectomy and complete axillary lymph node dissection was thus performed. The histopathological findings of the mastectomy specimen were as follows. The siliconomas were observed to be spread around the operational scar. Three tumors were identified, all in immediate contact with the sili

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