[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 2010, a 70-year-old Caucasian woman was referred by an infectious disease specialist to the Bone and Joint Infection Unit of our Orthopaedic Department because of a Candida albicans periprosthetic infection of the left hip joint. This was confirmed by joint fluid cultures and laboratory tests. The patient was immunocompromised due to immuno-suppressive therapy with steroids and methotrexate, taken for rheumatoid arthritis and Sjogren's syndrome. Her orthopaedic history consisted of a total hip arthroplasty in 2004 and a subsequent early revision for prosthetic instability in the same year. In 2005, she was referred to our center for a coventry type II MRSA infection and underwent a two-stage revision total hip arthroplasty with an antibiotic-loaded cemented metal-on-polyethylene prosthetic implant. During the following years, she was free from infection having periodical ambulatory orthopaedic and infectious diseases checkup. However, at the last followup, the patient presented with a pain-free hip joint and a swelling of the greater trochanteric area, due to a pseudotumor mass containing a large amount of fluid which was aspirated under ultrasound guide. Cultures tests detected Candida albicans infection.
At initial clinical exam in our department, the patient presented apyrexial, with a local swelling to the left hip but without redness or rise of local temperature. The range of joint motion of the hip was slightly limited but in line with a well-functioning prosthetic implant. Laboratory tests revealed increased levels of erythrocyte sedimentation rate (69 mm/sec) and C-reactive protein (34.1 mg/L). The patient was undergoing fluconazole therapy (200 mg/day) prescribed immediately after fungal infection detection. The radiographic exams did not show signs of periprosthetic bone resorption or implant loosening (). The patient was informed about the complexity of pathology, and a two-stage prosthetic revision was offered, but due to absence of pain and limitatio

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

[User]
RADIOLOGY NOTE:
A 42-year-old woman was admitted to an oral and maxillofacial surgery clinic for the evaluation and treatment of a large radiolucent lesion with a light aching pain in the
region of the left maxilla. The patient presented with a past medical history of a swelling in her left zygomatic area treated by antibiotic. She also had a history of an
erythema and radiolucent lesion of gingival tissue in the maxillary posterior teeth region around the porcelain fused to the metal bridge
of teeth 21-23 ).
The pathological evaluation of the lesion following biopsy had shown dental granuloma with chronic abscess. After ccomplete curettage of the bony lesion, hard and soft
tissue augmentation had been performed to repair severe bone loss at bridge area. Root canal therapy (RCT) of the teeth number 24-26 had also been done to control pain
in the posterior maxilla; however, the region had remained painful.
Finally, a large ill-defined radiolucent lesion of the left maxilla had been observed in the panoramic view. The clinical examination showed light erythema on
left maxillary gingiva without any bony expansion. Grade 3 mobility was also found in the tooth number 25 ().
Routine hematological and biochemical indices
(complete blood count differential and the immunoglobulins) were within normal reference range except for ESR (27 mg/dl). The outcome of the cone beam computed
tomography (CBCT) revealed a wide spread ill-defined radiolucent lesion between the teeth numbers 11 to 27, with severe destruction of buccal and palatal bones
and loss of sinus and nasal floor in some areas; while, there was no sign of root resorption. Floating in air appearance of the tooth number 25 was also seen
(-
). The periapical radiography showed an ill-defined radiolucent
lesion around the teeth number 24 and 25 (). After flap preparation and under
local anesthesia, a biopsy was taken and sent for histopathological evaluation. A granulation-like tissue

[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 previously healthy boy aged 7 years and 11 months was brought to the hospital emergency department suffering from persistent headache and vomiting. He had had a temperature of 38°C for a week and presented a motor deficit of the right arm associated with paresthesiae. A brain CT scan revealed a left fronto-parietal abscess (). Neither his medical history nor the clinical examination provided evidence of ENT (Ear, Nose, and Throat) infection. His mother reported that he had had dental treatment for decay in the left temporal molars three weeks earlier. A brain MRI scan showed a left fronto-parietal lesion of approximately 45 × 52 mm with a right lateral deviation of the median line (). He was immediately taken to the operating theatre for drainage and cleaning of the abscess. Intraoperative bacteriological specimens were taken, and broad spectrum antibiotherapy was set up using cefotaxime and metronidazole. Corticotherapy (Solumedrol®) was started the following day and continued for six days. Targeted antibiotherapy was set up when the bacteriological analysis results were available. Direct examination of the bacteriological culture found Gram + cocci in chains, and aerobic and anaerobic culture revealed the presence of Streptococcus intermedius. Two days after surgery, the child was apyretic, with normal heart rate and blood pressure but persistence of a motor deficit of the right arm. A dental examination revealed root abscesses on temporary molars 64 and 65, which were extracted under general anaesthetic thirteen days after the child's arrival at the emergency department (). Initial dental treatment was insufficient to manage a potential infection that later became acute.
Twenty-three days after the initial drainage, a control MRI performed because of headaches and vomiting imaged an increase in the volume of the abscess, justifying a second drainage (). Bacteriological culture showed the specimen to be sterile. Two months after the first operation, the neurolog

[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 41-year-old female was admitted to our department of gynecology with metrorrhagia. Pelvic ultrasonography revealed bilateral pelvic tumors and a myoma of the uterus. To make a definitive diagnosis of the bilateral pelvic tumors, total hysterectomy with bilateral salpingo-oophorectomy was planned.
At the same time, she was referred to the breast cancer outpatient clinic for bilateral breast pain and swelling. She had no particularly relevant past history or family history. Physical examination revealed diffuse induration with uneven surface and tenderness in the bilateral breast. Although the density of the bilateral breast was high, mass or calcification was not detected by mammography. Ultrasonography showed diffuse mottled hypoechoic lesions in the bilateral mammary glands. Magnetic resonance imaging (MRI) of the right breast showed an extensive enhanced area in the mammary gland () with edema of retromammary adipose tissue and skin in the delayed phase (). Axillary lymph node swelling was also detected by MRI. Core needle biopsy of the right breast revealed diffuse infiltration of signet-ring cells in the mammary gland (), and intracytoplasmic lumens also were seen ().
Because the pathologic examinations of the resected pelvic tumors also revealed signet-ring cells in the bilateral ovaries, suggesting that the tumor metastasized from another site, upper gastrointestinal endoscopy was performed to identify the primary site. Upper gastrointestinal endoscopy showed an ulcerative lesion similar to a Borrmann type 4 tumor in the lower part of the stomach. Pathologic examination of a biopsy specimen from the stomach revealed infiltration of signet-ring cells similar to the infiltration observed in the breasts and ovaries. Immunohistochemical analyses showed positive staining for p53 in the stomach and breast lesions. In addition, staining of MUC5AC and HIK1083, which are specific markers of gastric gland mucin, was also positive in the stomach and breast lesions. Bas

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

[User]
RADIOLOGY NOTE:
A 32 year old male presented to us with complaints of pain and swelling of multiple joints of one month duration. The symptoms started in the right knee but soon involved the left knee, both ankles and hips. The pain was associated with morning stiffness which persisted for around one hour. Small joints of the hand were not involved. There were no ocular complaints. The patient also complained of backache which began at around the same time as the joint pain. No complaints of numbness, parasthesias, root pain, falls, and bladder or bowel symptoms were present. A fortnight later the patient developed skin lesions which began as fluid filled lesions over the back and later involved all limbs and the forehead. The patient also complained of some lesions over the penis. The patient gave history of multiple unprotected extramarital sexual contacts. He gave a history of dysuria prior to the onset of joint pains. He was a chronic smoker and occasionally took alcohol.
On examination he appeared pale but had no lymphadenopathy. He had multiple discrete to coalescent erythematous plaques with brown crust and dirty white scales on the back, forehead, all four limbs and buttocks (Figure ). Grattage test was positive but Auspitz sign was negative. Toe nails had nail plate discoloration and subungual hyperkeratosis. Multiple pin head sized erosions were present over glans penis and corona of penis in a circumferential manner suggestive of circinate balanitis. The chest expansion was reduced. The examination of cardiovascular and gastrointestinal system was normal. Testing for power was limited due to pain in joints. However, the patient had lower limb hypereflexia, sustained ankle clonus and extensor plantars. There was no evidence of any sensory loss, root pains, bladder or bowel involvement. Examination of spine revealed tenderness at second to sixth thoracic and the lumbar vertebrae. Straight leg raising test was negative. Modified Schober test revealed lumbar

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

[User]
RADIOLOGY NOTE:
Patient is a 45-year-old female patient, with past medical history of gastritis. Six months before she sought medical attention, she was complaining of mild upper abdominal pain, however, due to her previous condition she was medicated with proton pump inhibitors assuming that the pain was due to her gastritis. In the last 3 months, she noticed a mass in her upper abdomen and the pain became more severe and started to affect her daily activities, thus she presented to a routine physical exam. No weight loss or other constitutional symptoms were noticed. Also no history of malignancy in her family was mentioned. On clinical examination, a 12 × 15 cm2 mass was discovered on her upper abdomen, mild pain was found on palpation but no tenderness was present. An abdominal ultrasonography revealed a 15 × 15 cm2 septate thin-walled giant cystic mass, it was anechoic and had a volume of ~735 ml. The cyst occupied most of the hepatorenal space and it was in intimate contact with the liver, right kidney and pancreas (Fig. A). Due to the size of the mass, CT was requested, it revealed well-defined 19.7 × 15 × 10 cm3 giant cyst, the cyst was located within the small bowel mesentery and it was in intimate contact with the liver, gallbladder, pancreas and right kidney (Fig. A). Nevertheless, the tomography could not rule out that the mass had some sort of communication with the bile duct or the pancreas. This is why a magnetic resonance cholangiopancreatography found that the cyst was attached but had no communication with the bile duct or the pancreas (Fig. A). CBC and blood work was normal.
Due to the size of the cyst and clinical condition surgery was planned. At laparotomy, a 19 × 15 × 10 cm3 mesenteric cyst was discovered (Fig. B), the cyst was near the root of the small bowel mesentery but did not compromise its main vessels, it had

[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 40-year-old Hispanic man with a past medical history of human immunodeficiency virus (HIV) was brought to the emergency department complaining of right upper extremity (RUE) weakness and numbness for four days with associated bitemporal headache and generalized fatigue. The patient reported first time use of intranasal cocaine and heroin, after which he lost consciousness and woke up approximately four hours later with new onset RUE and headache. His cluster of differentiation 4 (CD-4) count was reported above 500 cells/mm3 and viral load (VL) was undetectable. The patient did not have any known CNS complications in the past.
On physical examination, his blood pressure was 151/97 mm Hg and pulse was 82 and regular. He was alert and cooperative. His cranial nerves were intact. His motor exam, however, was abnormal in the RUE with 3/5 arm strength and wrist drop; the strength and tone of the other extremities were normal throughout. Deep tendon reflexes were normal bilaterally, but his gait could not be evaluated. His sensory function decreased to pin sensation at the RUE and normal sensation was noted in the rest of the extremities and face. Laboratory testing was normal except for an elevated creatinine of 6.9 mg/dl, creatine phosphokinase (CPK) of 7855 IU/l, alanine transaminase (ALT) of 139 IU/l, and aspartate transaminase (AST) of 109 IU/l. Urine toxicology was positive for metabolites of cocaine and heroin. Magnetic resonance imaging (MRI) of the brain was done and it revealed two areas of increased T2/FLAIR signal within the medial aspect of both basal ganglia, measuring 16 mm in the right and 12 mm on the left involving each globus pallidus and the genu of the internal capsule, as can be seen in Figures -. His chest radiography was normal, computerized tomography (CT) of the brain, as can be seen in Figure , and cervical spine were normal. His electrocardiogram

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

[User]
RADIOLOGY NOTE:
A 46-year-old female patient reported to the Department of Oral and Maxillofacial Surgery, Postgraduate Institute of Dental Sciences, Rohtak, Haryana with the complaints of pain, slight swelling on the left side of mouth floor and discomfort during swallowing and limitation in mouth opening. Patient history revealed that a month earlier she had undergone an unsuccessful surgical procedure under local anesthesia performed by a general practitioner for removal of an impacted third molar on the left side of the mandible. The tooth fractured during extraction. The procedure described by the patient as being difficult and complicated. On clinical examination, the root was not palpated on the posterior region of the mouth floor and submandibular region extraorally. After the history and careful assessment of the socket, the patient was advised panoramic radiography. Panoramic radiograph showed the presence of a radiopaque mass that is similar to the appearance of the third molar tooth root. Two-dimensional radiographs were inadequate in this case. For detailed radiographic examination, computed tomography (CT) scans were taken by spiral technique and axial sections were obtained . Images were reconstructed to form sagittal and coronal sections and examined. CT examination demonstrated the presence of a high-density area located in the left submandibular region demonstrating the position of root fragment. Careful evaluation of the CT and orthopantomography (OPG) revealed the position of displaced root in submandibular space . After routine blood investigations and preanesthetic check-up, it was planned to retrieve the tooth from submandibular space via extraoral submandibular approach under local anesthesia with conscious sedation.
The surgical site was exposed carefully with layer-wise dissection. The dislodged root was started locating using blunt dissection with small artery forceps with extreme care because there are increased chances of root displacement into pharynge

[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 28-year-old female had experienced intermittent abdominal pain for 3 months and visited the Asan Medical Center, Seoul, South Korea, for further evaluation and treatment. An abdominal-pelvic computed tomography scan taken in January 2010 at the Asan Medical Center revealed a huge mass involving most of the lower abdomen and pelvic cavity with multiple septations and areas of enhancement (). The provisional diagnosis on the basis of the image findings was either borderline or malignant ovarian neoplasm. Neither ascites nor metastatic lymphadenopathy was found.
The patient had a history of radical nephrectomy for Wilms' tumor of the right kidney 25 years previously, at the age of 3 years, in April 1985 at an outside hospital. After surgery, she had been treated with intravenous injection of dactinomycin 25 mcg for 5 days and vincristine 1 mg on the 7th day after the operation. Since then, she had been healthy with no evidence of recurrence or metastasis until she noticed abdominal pain in September 2009.
Under the clinical diagnosis of an ovarian tumor, the pelvic mass was resected in February 2010. During surgery, the mass was noted to occupy the entire lower abdominal cavity without involving both adnexa. Intraoperative consultation was made and the frozen section diagnosis was malignant gastrointestinal stromal tumor or other malignant mesenchymal tumor such as leiomyosarcoma with pending evaluation of permanent sections.
The original slides of the Wilms' tumor, resected 25 years ago, could not be reviewed because the slides were not available in the file of the outside hospital. However, the outside pathology report stated that the size of the tumor was 12 cm and it was located at the right kidney. The tumor was abutting the head of the pancreas, and in the operation record it was written that the tumor was not completely excised. Microscopically, the tumor was shown to be a classic Wilms' tumor with predominant epithelial tubular elements and minor blastemal an

[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:
In a work-up of a 40-year-old female with a history of low back pain, a routine MRI of the lumbar spine identified an incidental lesion. The axial T
1 weighted image showed a 21-mm round, homogeneous lesion of low signal intensity interforaminally in the left S2 segment of the sacrum. The axial short tau inversion-recovery image showed a well-defined lesion with an inhomogeneous signal intensity throughout the lesion with high peripheral rim intensity. The axial T
1 image with fat saturation after contrast media injection showed moderate enhancement throughout the lesion and in the peripheral rim (). A radiograph of the pelvis was performed to further characterize the lesion. On clinical examination, the sacral area was not painful to palpation. Owing to the atypical appearance of the lesion and the non-specific nature of the MRI signal pattern, a bone scan was performed that showed a solitary lesion on the left side of the sacrum with increased metabolic activity. For further characterization, and in the search of a potential primary tumour, positron emission tomography (PET)-CT was performed, which showed a well-defined sclerotic lesion with mild fludeoxyglucose (FDG) avidity (average standardized value 2.5) in the S2 segment and no other abnormalities (). Owing to the metabolic activity of the lesion, the patient was referred to the orthopedic oncology department for image-guided biopsy of the lesion. The biopsy specimen consisted of a few small fragments of bone marrow, some skeletal muscle, fibroadipose tissue and blood clots. Infiltration of the otherwise normal bone marrow with scattered small groups of big foamy cells was identified (). The foamy cells had vacuolated cytoplasm and small centrally located nuclei. The cells were negative for cytokeratin AE1/AE3, CD68, barchyury, Melan A, HMB 45, desmin and smooth muscle actin but positive for S100 protein (). The cells contained multiple lipid droplets and numerous large mitochondria; the existence of the

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

[User]
RADIOLOGY NOTE:
A 65-year-old female was referred with seven-month history of right flank pain and weight loss. She did not have haematuria.
On examination, she was wasted. She had no pedal edema or supraclavicular lymphadenopathy. A mass was palpable in the right lumbar region extending to the right hypochondrium and crossing the midline. The mass had an irregular surface and was tender and ballotable.
The patient had a computerized tomography (CT) scan of abdomen and pelvis which showed a large (92 mm × 80 mm × 90 mm) lobulated mixed density renal mass arising from the upper pole and involving the ipsilateral adrenal gland. The extrarenal component indented the inferior and posterior surfaces of the liver. Enlarged lymph nodes were seen in the region of celiac axis, portocaval, and retrocaval area measuring 6 cm in largest diameter. Main renal vein on the left side revealed no definite luminal filling defect. There was narrowing of the IVC. Multiple tiny nodules were noted in the lung parenchyma bilaterally ().
Under general anesthesia, the patient was placed in the supine position with the right flank elevated with sand bag to 30° to facilitate mobilization of the tumour. The skin was prepped from nipple-line to the mid-thigh and patient draped in the usual fashion. A right transverse upper abdominal incision was made from tip of 12th rib crossing the midline 2 cm above the level of the umbilicus and extending to lateral border of the left rectus abdominis muscle. The peritoneal cavity was entered and entire abdomen explored. A firm, irregular brownish-yellow mass measuring 19 cm × 10 cm was found. This had almost completely replaced the right kidney. tumor had infiltrated the Gerota's fascia and was adherent to the inferior surface of the liver. The right renal vein and adjacent IVC wall were infiltrated. There was perihilar and para-aortic lymphadenopathy. However, there was no palpable liver metastasis.
The colon and

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

[User]
RADIOLOGY NOTE:
Female patient, aged 55 years, with a history of nodular goitre for two months, diagnosed on routine ultrasound (US) examination. On physical examination, there were no palpable nodules, although cervical US revealed a single hypoechoic nodule (19 mm in diameter) in the left lobe. Doppler showed the presence of peripheral and central flows. US-guided thin-needle biopsy was suspicious for follicular cancer. The patient had a history of breast cancer that had been diagnosed and treated nine years prior and was being followed up by an oncologist; she was also undergoing clinical treatment for hypertension, lactose intolerance, and psoriasis. The patient was euthyroid. A new US was performed during the preoperative period and showed a single hypoechoic nodule (now 23 mm in diameter two months after the first US) in the left lobe, with a regular contour, microcalcifications, and the absence of lymphadenomegaly. The left lobe was accessed using the conventional technique to determine whether the RLN was below the inferior thyroid artery (ITA) and followed until its entrance into the larynx. The left lobe was removed without complications, preserving the laryngeal nerves and the parathyroid glands. Frozen section biopsy revealed papillary carcinoma, and thyroid resection was indicated for this patient. To access the right lobe, the standard approach to the nerve below the ITA was also used, but the right RLN was not found along its usual course, and the dissection had to be advanced in the cephalic direction. An NRLN was identified and exposed parallel to the ITA. The nerve was fully identified and followed from its origin in the vagal nerve until its entry into the larynx. Along its path, the NRLN was completely enveloped by thyroid tissue from the right lobe in the region of the ZT immediately after its path became parallel to the thyroid artery (). The patient did not present with laryngeal motor abnormalities or hypocalcaemia and is under treatment with oral thyroid re

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

[User]
RADIOLOGY NOTE:
A 25-year-old man presented to our epilepsy center for evaluation of seizures. He was born at term without any developmental delays and had no risk factors for epilepsy including traumatic brain injury, brain surgery, febrile seizures, central nervous system infections, or family history of seizures and no significant past medical or psychiatric comorbidities. Three years prior to his presentation he had his first seizure. He did not remember the event, but while attending basic training in the Army, he was reportedly found in the shower confused by his fellow soldiers. There was no tongue bite or urinary incontinence, but he was disoriented afterward for much of that day. He had another episode within the same month while he was performing physical training exercises, whereby he collapsed and remained confused for hours, but no report of witnessed convulsions. An evaluation at that time was unrevealing. He had 12 episodes in the next 3 years. They were all similar, some associated with lateral tongue laceration suffered during the event. He was seizure-free for 6 months and then began to have spells at least monthly. He denied an aura or premonition preceding his seizures. His wife reported at night that he would “cry” at the onset and then appears to have clonic jerking bilaterally and symmetrically, up to 3 minutes in duration. He was reported to be distressed for a few minutes after the episodes. Brain MRI was reportedly normal and EEG abnormal, but the reports were unavailable. He had been taking levetiracetam 3000 mg daily with topiramate 50 mg daily. He had also tried valproic acid but reportedly had abnormal labatory studies so this was discontinued. At his appointment, it was determined that he would continue his current regimen of levetiracetam, and topiramate was increased to 100 mg total daily. A presumptive diagnosis of epilepsy was made upon clinical grounds though the classification included

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

[User]
RADIOLOGY NOTE:
In 1993, a 30-year-old man without accompanying comorbidity, was hospitalized for a sudden bilateral spastic paraparesis. General physical examination revealed progressive bilateral lower extremity weakness associated with hypoesthesia distal of the dermatome level of T9. A plain myelography showed epidural block of contrast flowing along the spinal canal from the level of T7. Therefore, laminectomy was performed at the T7-T9 level which revealed a dark, pigmented, extradurally located tumour measuring 2.5 × 1 cm., without infiltration of dura and spreading through vertebral foramina. Histopathologic and immunohistochemical analysis confirmed a malignant melanoma (Figure and ). The patient did not receive any radiotherapy because surgical resection appeared completely without opening the dura. The patient was also subjected to further clinical and oncological evaluation which did not reveal any other melanoma lesions or metastases and other primary process could not be established. With these data and according to Hayward's criteria [], the diagnosis of primary spinal melanoma was established. He was discharged from the hospital in a good general condition with the recommendation for a regular follow-up and he was cleared disease-free a few years after the operation without any need for specific oncological treatment.
In 2010, 17 years later, the same patient was admitted to our rheumatology department with a three-month history of low back pain, fatigue and loss of body weight. He was treated with medication and physiotherapy, but his symptoms did not subside. Physical examination showed a right sacroiliac joint tenderness on palpation with a positive Mennel's sign, Lasègue's sign was bilaterally negative and the lumbar vertebral segment motility was very painful. In this period he had no history of fever or pain in other joints, bones and muscles. He did not notice any skin lesions and he didn't have any other problems other than the above. The stool and urine wer

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


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

[User]
RADIOLOGY NOTE:
A 34 year-old woman previously operated for a solitary encapsulated papillary thyroid microcarcinoma in the right lobe of the gland, without familial history of breast or thyroid malignancy, was admitted to the Institute of Oncology and Radiology of Serbia, Belgrade, after feeling soreness at breast self-examination followed by a suspicious mammographic finding in the left breast. A lump measuring 30 × 30 × 20 mm in size was surgically removed. Grossly, the resected specimen featured a cyst (15 mm in diameter) with an intracystic proliferative lesion 10 × 10 × 8 mm in size. Histopatholological examination revealed an intracystic IDP without evidence of malignancy (Figure ). No axillary lymphadenopathy was found at the time of surgery. Whereas no changes were seen in the patient's breast on ultrasound or mammography during follow-up, an enlarged lymph node became palpable in the left axilla 10 years later. A metastatic carcinoma in ALN was suspected and the patient was subjected to excisional biopsy.
A lymph node sized 15 mm in diameter was removed. Histology revealed a proliferative epithelial lesion measuring 11 mm in the largest dimension in the cystic space of the node. The proliferative lesion consisted of papillary and tubular structures lined by luminal cuboidal cells and a distinct outer layer of myoepithelial cells which were very similar to IDP of the breast (Figure and ). Apocrine metaplasia was found. No mitoses, necrosis or cells with atypical features were detected, suggesting the benign nature of the neoplasm. In addition, both the proliferative papillary lesion and small clusters of duct-like structures were also observed in the lymphoid tissue surrounding the cystic area (Figure and ). Immunostaining with a series of antibodies (all from Dako, Carpinteria, CA, USA) was used to confirm histogenetic origin of tumor cells in ALN. Staining for AE/AE3 was diffusely positive in tumor epithelium and staining for alpha-smooth muscle actin and p63

[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 58-year-old man was referred for patent foramen ovale closure following a presumed cryptogenic stroke. The patient presented with transient hemiparesis, with MR imaging suggesting a previous additional, unrecognized cerebellar infarction. CT angiography of the neck and intracranial vessels was unremarkable. Ambulatory ECG monitoring did not detect any atrial fibrillation. Contrast transthoracic echocardiography suggested the presence of a patent foramen ovale with subsequent transoesophageal echocardiography confirming the presence of a PFO with an aneurysmal interatrial septum. In view of the absence of alternative mechanisms of stroke, MR imaging suggesting previous embolic events, and the desire to avoid lifelong anticoagulation, the patient was referred for percutaneous device closure.
Under general anaesthesia and transoesophageal echocardiography guidance, a 30 mm Amplatzer fenestrated atrial septal occluder was delivered using a 9 Fr delivery system. The device was released uneventfully () and the final appearance on fluoroscopy () and transoesophageal echocardiography was excellent; device position was confirmed with a “push-pull” maneuver prior to device release. A transthoracic echocardiogram was performed the following day demonstrating satisfactory device position with no evidence of pericardial effusion. The patient was then discharged on aspirin and clopidogrel. The patient remained asymptomatic. Routine repeat transthoracic echocardiography was undertaken six months following device implantation to assess for any residual shunt. The Amplatzer occlusion device was not visualized on transthoracic imaging with strongly positive right to left shunt noted. Subsequent transoesophageal imaging demonstrated absence of the occluder across the interatrial septum consistent with device embolization; the device could not be visualized in the main or branch pulmonary arteries. CT angiogram of the thoracic and abdominal aorta was performed and the device was loca

[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 26 year-old man attended our ophthalmic ward in April 2017 with intermittent bleeding of the right eye, from which there was also strong odor. The patient was a heavy smoker but had no other underlying conditions. He had no history of drug-use. From his medical history it was noted that the patient had undergone a right ophthalmectomy 24 years previously due to retinoblastoma, and implantation of an artificial right eyeball in 2014 (timeline shown in Additional file ).
On admission, his pulse rate was between 80 and 100 beats/min. His body temperature and respiratory rate were both normal. Physical examination showed narrow conjunctival sac in right eye and the exposure of ocular prosthesis, which was discharging a yellow-green secretion along with a strong odor. The visual acuity of left eye was 0.3, and the intraocular pressure was 15 mmHg. All other characteristics of the left eye were normal. A auscultation did not show any abnormality in the lungs, and no signs of carotid murmur were found. Interestingly, laboratory investigations did not reveal abnormal inflammatory markers such as leukocytosis or any increase in neutrophils or C-reaction protein. According to clinical and laboratory investigations, infectious endocarditis was not suspected. The patient had no history of other immunosuppressive conditions, except smoking and a retinoblastoma 24 years previously. The patient did not report any direct contact with animals; however, he did work in a clothing factory so would have been contact with wool and cowhide for one month of the year. Three months had elapsed between the patient last coming into contact with wool and cowhide and the appearance of clinical symptoms. Considering the results of these investigations, partial artificial eye infection, especially anaerobic organism infection, was suspected.
Imaging workups were completed, which included chest x-ray, transthoracic echocardiography and eye magnetic resonance imaging. As shown in Fig. , eye magnet

[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 13-year-old girl was referred to our tertiary young adult hip service by a local general practitioner for evaluation of a painful left hip, which had been affecting her for over 6 months. She complained of a deep-seated pain in her left groin particularly after any strenuous or sporting activity, and along with the pain she also complained of mechanical symptoms of clicking in her hip joint. She had no definite history of injury, which had led to the onset of her symptoms. However, her mother gave the history that she had clicky hips as a child and had spent 10–20 weeks in a Pavlik harness between 2 and 4 months of age.
Examination of her left hip revealed that she had a normal gait and Trendelenburg’s test as well as the single leg hop test were negative. There was minimal tenderness over the abductors on resisted abduction and over the flexors on resisted flexion, while no tenderness over the adductors on resisted adduction. Flexion was up to 100°, internal rotation in 90° of flexion was 40° and external rotation in 90° of flexion was 45°. Impingement test as Faber test were negative. Mechanical symptoms such clicking were not clearly reproduced during clinical examination. Dorsalis pedis was well palpable.
Plain radiographs did not reveal any obvious abnormality. MRI showed an labral tear with a shadow with abnormal intensity around the femoral neck, which corresponded with the area of the medial synovial fold ().
Since she was tender over the muscles and the impingement test was negative, we decided to proceed with a diagnostic hip injection using local anaesthetic to elucidate whether the pain was intra or extra-articular in origin. This resolved her symptoms temporarily indicating an intra-articular source of pain. However, she continued to remain symptomatic and it was therefore decided to proceed with arthroscopic surgery of her hip. At arthroscopy, she was found to have a small anteroinferior lab

[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 43-year-old right handed woman presented in 2006 with difficulty writing, impaired dexterity of the right hand, and mild unsteadiness with walking. Her sole initial symptom was difficulty writing with the right hand and with time, other dexterous movements with the right hand became affected. Her left hand was asymptomatic. On examination, she scored 30 on the MMSE. There was a subtle dysarthria. She walked well except for a slight tendency to veer to either side. There was mild bilateral upper extremity dysmetria and mild ataxia with heel-to-shin. With the hands outstretched, as well as when performing movements with the right hand (especially writing), the proximal and distal thumb flexed involuntarily into the palm. When attempting to write, there was flexion of the right thumb, extension of the wrist, and excessive flexion at the PIP joint of all fingers. She did not notice any sensory tricks for dystonia and did not have mirror dystonia. Her reflexes were 2+ in the upper extremities and 3+ in the lower extremities. Brain MRI demonstrated cerebellar and brainstem atrophy.
Her mother was reported to have a progressive gait disorder, presenting with unsteadiness, hand clumsiness and dysarthria. We later learned that her mother had been diagnosed with SCA2 with 37 CAG repeats. Prior to death, her mother had a resting tremor, nystagmus, and cervical dystonia. Our patient’s maternal grandmother, two of three siblings and several maternal uncles and cousins were all similarly affected; a total of ten individuals were considered symptomatic in a three generation pedigree (Fig. ).
The patient was not seen again until eight years later, at age 51. During that time, there had been only mild progression of cerebellar symptoms but the dystonia of the right hand continued to worsen to the extent that she was barely able to write and the dystonia also impaired many other tasks with the

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


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

[User]
RADIOLOGY NOTE:
A five-year-old developmentally normal boy was hospitalized with fever on and off for more than three months. Fever was found to be high-grade and was associated with painless and clear discharge from both ears. There had been discharge offrank pus from his right ear with pain and impaired hearing in the week before hospitalization. He had received both oral and topical medications (comprising fluoroquinolones and aminoglycosides) for his ailment from several practitioners without any respite to his symptoms. He had been immunized appropriately.
On examination, he was found to be febrile, toxic, and undernourished with wasting. His submandibular, cervical, and axillary lymphnodes were found to be significantly enlarged bilaterally. His left upper deep cervical lymph nodes were found to be matted. There were multiple healed perforations in both tympanic membranes with granulation tissue, furuncle, and pus discharge from his right ear. The pus was swabbed and sent for microbiological examination. A fine needle aspiration cytology of the left upper deep cervical node revealed caseating granulomas suggestive of tuberculosis. A chest X-ray which was obtained showed miliary mottling []. Tuberculin test elicited no response, and HIV I and II ELISA were also found to be negative. The history had to be reviewed again for possible contact with a known tuberculosis case but was found to be negative.
As the child was toxic with high-grade fever and chills, a complete blood count was ordered which showed neutrophilic leukocytosis. The ear swab culture grew S.aureus and smear for acid-fast bacillus (AFB) and culture was reported to be negative (probably because the child had been on aminoglycoside ear drops for variable periods before presentation). The child was treated with appropriate antistaphylococcal antibiotic based on culture and sensitivity of the organism. In view of the chronic symptoms, chronic and painless clear aural discharge initially and miliary mottling on chest

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


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

[User]
RADIOLOGY NOTE:
A 77-year-old female with a body mass index (BMI) of 33.3 kg/m2 presented after falling on her left hip. An intertrochanteric fracture of the left femur was diagnosed, which was treated by open reduction and internal fixation with compression hip screws in other hospital. Fourteen months after the index operation, she visited our clinic because of severe left hip pain. She could not stand or walk without a walker. Plain radiographs revealed loss of fixation and possible nonunion (). After close observation for 4 months, the patient underwent conversion THA with a fully coated femoral stem (Versys beaded fullcoat; Zimmer, Warsaw, IN, USA). The stem had a diameter of 14 mm and a length of 150 mm (). Migration of greater trochanteric fragment with breakage of circlage cables was noted on the radiograph taken at 6 weeks after the operation. Despite greater trochanteric nonunion, she did not complain of left hip pain and was able to walk with a cane. Four years after the operation, she presented to the emergency department of our hospital for left hip pain after having fallen from a chair. Plain radiographs demonstrated a transverse fracture in the femoral stem and the breakage of multiple cerclage cables (). Although the level of bone defect was 2.5 cm distal to collar of stem, fractured level was different from the level of bone defect. It was 8 cm distal to collar of the stem. The femoral component was revised using a modular femoral stem 18 mm in diameter and 140 mm distal with 55 mm proximal parts in length (Revitan; Zimmer). The remaining trochanteric fragments were reduced and fixed with a reversed anatomical plate for the right distal femur () together with a mixed auto- and allogeneic bone graft. Autograft was harvested at the iliac tubercle at the ipsilateral side. Mobilization with toe touch using walker was started 1 week after the operation. Use of

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old male patient was admitted to the orthopedic ward with chief complaints of pain, restriction of movements, and difficulty to bear weight on the left hip. The patient was a known case of SLE and on treatment with prednisolone 40 mg twice daily over the previous 6 years. In addition, he also had complaints of rashes over the trunk and pain in small joints of both hands for 2 months. The patient did not report any episode of fever over the preceding months. There was no history of trauma, prior surgery, or abdominal discomfort. There was no history of illness suggestive of typhoid fever in any of his family members. Local examination of the left hip region showed tenderness and the movements were painfully restricted. The laboratory findings were haemoglobin 9.8 gm%, white blood cell count 13,180 cells/cu.mm with neutrophilic leukocytosis. Peripheral smear showed microcytic normochromic anemia. Pus aspirated from the hip joint was inoculated in brain heart infusion broth, nutrient agar, 5% sheep blood agar, and MacConkey agar and incubated for 24 hours at 37°C. The gram stained smear of the pus showed plenty of polymorphonuclear leucocytes and gram negative bacilli. The culture yielded nonlactose fermenting colonies which was confirmed as Salmonella typhi by biochemical methods and serological typing. It was susceptible to ampicillin, trimethoprim-sulphamethoxazole, chloramphenicol, ciprofloxacin, cefotaxime, and ceftriaxone and resistant to nalidixic acid by disc diffusion method. The blood culture was found to be sterile. The Widal test was non-contributory. Fecal culture done on 3 consecutive days to detect carrier state or subclinical infection was negative. The radiograph and the magnetic resonance imaging of the left hip showed evidence of avascular necrosis of the neck of femur (). In view of resistance to nalidixic acid, therapy with ciprofloxacin was not considered. Treatment with injection ceftriaxone 1 gram, intravenously twice daily was institu

[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 11 years old male was referred to the emergency department of Virgen de las Nieves University Hospital due to a slight periodontal bleeding of 5 days of evolution. An orthopantomography was performed to focus the diagnosis. The OPG evidenced a dubious periapical image compatible with a small cyst of dental origin. Hence, the doctors of the emergency service decided to contact with the maxillofacial surgery department. A new clinical examination evidenced a spontaneous alveolar bleeding and high mobility of the first and second molars of the fourth mandibular quadrant. The patient denied cervicofacial trauma or pathologies of the coagulation system. Thus, a CT scan of the cervicofacial area was performed to reach a diagnosis. Surprisingly, this test evidenced a large high-flow intraosseous arteriovenous malformation extending from the right mandibular body to the homolateral pterygoid region and the infratemporal fossa (Fig. ). Moreover, a selective arteriography and a MRI of head and neck were also carried out to identify the limits of the malformation and the key vessel (Fig. ). Considering these findings, we contacted with the interventional radiology unit of the Hospital in order to plan a combined approach. However, after a careful analysis we decided to treat the patient only with an endovascular approach. Specifically, a very large drainage vein was identified with the radiological tests. Hence, we hypothesized that the embolization of this vein and the selective embolization of the main arterial vessels might be enough to treat the pathology. Thus, under general anesthesia and femoral approach, the embolization of the main drainage vein and of the most accessible arteries was carried out. The patient was maintained intubated and sedated for 24 hours and he was extubated when the bleeding had completely stopped. He was discharged from the hospital 7 days after the procedure. In fact, a control arteriography performed 5 day after embolization showed a signifi

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old male presented to our clinic with recurrent episodes of hemoptysis over a 4-week period with 3 distinct events. He stated that this started with an incidence of heavy coughing. He then would cough up to 2–4 tablespoons of blood. After presentation to the emergency room, it was initially thought this was related to epistaxis, and he was sent home with treatment for allergic rhinitis. He had no other symptoms, denying fever, weight loss or gain, chest pain, easy bruising, dyspnea, or rash. He did complain of chronic postnasal drip, nasal congestion, and occasional pruritis, which he attributed to allergies. He had a past medical history of eosinophilic colitis, obsessive-compulsive disorder, history of an aneurismal bone cyst status post-removal, and allergic rhinitis. He had also been recently diagnosed with hypogonadism over the last 5 months, and was on injectable testosterone supplementation. He denied smoking, alcohol, and illicit drug use and had no known inhalant exposures and trauma to the airway that he could recall. His family history included a brother with eosinophilic colitis and his mother had vascular ectasias of her spinal cord. He did note that these episodes seemed to occur 5 days after his dose of intramuscular testosterone. Physical exam was otherwise unremarkable and laboratory values were unrevealing. Computed tomography did not reveal any notable lesion of the upper airway or lung parenchyma.
Upon flexible bronchoscopic evaluation, the following lesion was seen in the distal trachea (). The purple, vascular lesion was approximately 1–1.5 cm in size located 3 cm from the carina at the 5 o'clock position along the posterior wall attached by a short pedicle. A biopsy was taken at that time which only showed fibrin products and inflammatory cells. Hemostasis was difficult to obtain without use of cold saline, several injections of topical epinephrine and Argon Plasma Coagulation. Due to unavailability of pathology 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 26-year-old Thai woman presented with a foreign body in her left orbit that had been retained for 8 months. Eight months previously, she had sustained a gunshot injury to her left eye. There was only a small wound on her left eyelid (Fig. ); she had normal eye movement, a normal visual field, and no pain. A plain radiograph was performed at that time; it detected a round-shaped metallic foreign body located medially in her left eye globe. She was then diagnosed as having a retained foreign body in her left orbit and she was advised to have clinical observation. However, 8 months later, she developed pain in her left eye without any sinonasal symptoms. After discussion about the risk of surgery and retention of an orbital foreign body, an ophthalmologist referred her to our department for the minimally invasive procedure option of removal of the foreign body using an endoscopic transnasal approach. On examination, the movements of her left orbit were not restricted and there was normal visual acuity (20/20) with no proptosis or chemosis. A computed tomography (CT) scan of her left orbit revealed a round-shaped metallic foreign body in the medial intraconal space, and lateral attachment of posterior ethmoid sinus, measuring 6 mm (Fig. ). A transnasal endoscopic approach, with navigator assistance (Brainlab), was used to remove the bullet. Uncinectomy and anterior-posterior ethmoidectomy were performed. The location of the intraconal metallic foreign body was confirmed with a navigator system, then part of the lamina papyracea was removed and the periorbita incision was done. The defect was enlarged and the fibrotically encapsulated bullet was found lying in the orbital fat (Fig. ). The fibrotic capsule was dissected, and the bullet was delivered through her left nostril with probes and curetted (Fig. ). No intraorbital bleeding or damage to any soft ocular structures was noted. A relative afferent

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


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

[User]
RADIOLOGY NOTE:
The patient is a 66-year-old African-American female with complex past medical history pertinent for renal failure on hemodialysis, hypertension, heart failure, and hepatitis C requiring previous liver transplantation. She had several hospitalizations for hypertension and pulmonary edema. She was maintained on carvedilol and nifedipine for hypertension, as well tacrolimus for her liver transplantation immunosuppression. Regarding her hypertension, her systolic blood pressures were consistently 180–190 mmHg. Her social history was pertinent for ongoing tobacco use, with an approximately fifty pack-year smoking history.
The patient was evaluated for a scalp lesion. This nodule was problematic for her as it caused discomfort when she brushed her hair. She denied ever noting drainage, bleeding, or spontaneous pain in the area. On exam, the nodule was located on the superior-most portion of her scalp and approximately 1.5 cm in size. It was mobile, firm, and non-tender. Due to the nature of the nodule, it was believed to be a lipoma or a sebaceous cyst. As this nodule was problematic for her, she elected to pursue excision. Surgical consent was obtained.
The day of surgery, her systolic blood pressure was elevated to 190 mmHg. After several hours of pharmacologic intervention, her systolic blood pressure was able to be brought down to the 160 mmHg range, and she was taken to the operating room. Given her hypertension and complex medical history pertinent for persistent pulmonary edema, her excision was performed under local anesthesia.
The patient was placed on the operating table in supine position. Clindamycin was given within half hour of skin incision. The lesion appeared to have a small umbilicated area, raising the suspicion that the lesion was actually a sebaceous cyst. After infusion of local anesthetic, an elliptical incision was made in a transverse fashion over the lesion. Sharp dissection was used to encircle the lesion which was approximately two centimeters

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


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

[User]
RADIOLOGY NOTE:
A 53-year-old woman was admitted to our department with two episodes of painless gross hematuria during the last three months. She had no history of systemic diseases, constitutional symptoms and familial history of urological disorders. Physical exam revealed a palpable ill-defined mass in the right upper quadrant with extension to the umbilical region. Serum creatinine was 1.4 mg/dL, and urine analysis revealed microscopic hematuria (20-25 RBC / HPF). Urine cytology was negative for malignancy. Intravenous Urography (IVU) revealed left side fused crossed renal ectopia and filling defect within the pelvis of the crossed kidney (). A filling defect was evident in the left crossed fused kidney in retrograde pyelography (). Computerized-tomography (CT) scan confirmed the presence of left crossed renal ectopia associated with an enhancing mass, arising from the pelvis and pyelocaliceal system of the crossed kidney (, ). Cystoscopy showed no abnormality within the bladder. Ureteral orifices were normal. Chest X-ray and liver function tests were normal. The patient underwent surgery applying a midline incision. Left kidney showed a lump pattern, embedded in the lower pole of the right kidney. Both pelvises of kidneys were located anteriorly. Left renal pelvis and parapelvis tissue were firm.
The main renal arteries were dissected thoroughly. Interestingly, when the left main renal artery was clamped temporarily, both kidneys became partially ischemic, whereas clamping the right renal artery was associated with right renal ischemia with no effect on the crossed left sided kidney. During the right renal artery clamping, left nephrectomy was performed. All bleeding sites were ligated with absorbable sutures. Left ureter was resected near the bladder. Frozen section from margins indicated no evidence of tumor involvement. No palpable regional lymph node was detected. Post-operative course was uneventful. Macroscopic evaluation of the specimen revealed a 9 × 7 × 5.5 cm kidney

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old gravida 2 para 1 at 25 weeks gestation was transferred to our institution from an outside hospital. She complained of a two-week history of progressively worsening orthopnea and shortness of breath that left her unable to perform daily activities. An initial transthoracic echocardiogram obtained at the referring hospital had demonstrated a depressed ejection fraction (35%) as well as mild pulmonary hypertension. The patient was transferred to our institution for further evaluation and management.
Her past medical history was significant for chronic hypertension, class F diabetes mellitus, super morbid obesity with a BMI of 53, and chronic kidney disease. Two years before, she underwent an emergent cesarean delivery at 35 weeks gestation due to preeclampsia with severe features and nonreassuring fetal status. The patient had no previous history of congenital, ischemic, or valvular heart disease. She had no family history of heart disease and never had an echocardiogram before. On admission she required 2 L/min of oxygen per nasal cannula to maintain an oxygen saturation of 95%. The remaining vital signs were within normal limits. Notable findings on the physical exam were presence of S3 and S4 heart sounds, positive jugular venous distention, bilateral crackles on auscultation, and 2+ pitting edema of the lower extremities. A baseline electrocardiogram revealed normal sinus rhythm. Chest x-ray demonstrated pulmonary interstitial edema and bilateral pleural effusions. A transthoracic echocardiogram demonstrated a moderately dilated left ventricle, eccentric left ventricular hypertrophy, and a severely reduced left ventricular systolic function with an ejection fraction of 20-25% as well as global left ventricular hypokinesis. Mitral inflow pattern and tissue doppler were indicative of grade 3 diastolic dysfunction. The right ventricular function was mildly to moderately reduced. The right ventricular systolic pressure was elevated at 50-60 mmHg and there

[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:
Case 1 This is a 42 years old male with a history of a ruptured appendiceal mucinous neoplasm that was removed 23 years ago. He was asymptomatic until the fall of 1999 when he started complaining of recurrent small bowel obstruction and weight loss. He had undergone multiple investigations and was thought to have underlying Crohn's disease. A computed tomographic (CT) scan of his abdomen in January 2000 demonstrated a large abdominal mass. A laparoscopy was performed for tissue diagnosis of a possible lymphoma. However, at the time of laparoscopy, a large gelatinous mass was found and the diagnosis of PMP was confirmed by histopathology. Debulking surgery with small bowel resections was performed following this diagnosis at the Royal University Hospital of Saskatchewan. Since then he remained well and was reviewed regularly in the outpatient clinic. Four years later (2003), the patient began experiencing obstructive symptoms again due to recurrent disease and he had a further extensive debulking surgery in January 2004. This was followed a year later by another cytoreductive surgery with small bowel resection in 2005. He is currently doing well at a 3 months post-operative follow-up visit.
The specimens from 2000 consisted of a portion of small bowel with several gelatinous, "mucinous" masses attached to the peritoneal surface of the serosa of the bowel wall accompanied by the presence of lobulated polypoid gelatinous tissue (Figure ). The specimens from 2004 and 2005 had a similar gross appearance. Histologically, however, the tumor showed significant progression over the years from a predominantly hypocellular, benign looking single layer of bland epithelium in extracellular pools of mucin in year 2000 (Figure ) to a mild increase in epithelial proliferation in 2004 to a hypercellular lesion associated with cytological atypia and numerous free "cell clusters" floating in the extracellular mucin pools and infiltrating the submucosa of the small bowel (Figure ) repr

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old gentleman presented for a health maintenance examination. His medical history was significant for diabetes mellitus type 2, hypertension, hyperlipidemia, and IgM monoclonal gammopathy of unknown significance. He reported no symptoms and maintained an active lifestyle by exercising several times per week. Physical exam findings revealed a BP of 139/81 and heart rate of 70 beats per minute with a regular rate and rhythm and no murmurs or gallop. Other systems were unremarkable, including the absence of systemic symptoms. The patient's baseline ECG showed minor abnormalities. In the setting of chronic hypertension and ECG abnormalities, a TTE was obtained and showed normal left ventricular size and function, but incidentally revealed a subaortic membrane in addition to a highly mobile mass arising from the membrane (). Differential diagnosis of the mass included endocardial tumor, thrombus, or endocarditis. Due to the highly mobile nature of the mass, endocardial thrombus was less likely. Additionally, in the absence of clinical evidence of infection, endocarditis was ruled out. The patient was referred to cardiovascular medicine for further investigation of the cardiac mass.
TEE confirmed the presence of a mobile 9 mm × 3 mm mass on the subaortic membrane within the LVOT suspicious for a PFE () (video ). No Doppler evidence of significant left ventricular outflow tract (LVOT) obstruction was present; however, due to the size, mobility, and location of the mass, cardiothoracic surgery was consulted for surgical removal of the mass.
In preparation for surgery, the patient received a preoperative cardiac CTA which showed an insignificant coronary atherosclerotic plaque and confirmed the presence of the mass on a nonobstructive subaortic membrane 11 mm from the aortic valve (Figures and ).
The operation was performed through a median sternotomy, and the patient was placed on cardiopulmonary bypass. Inspection of the LVOT revealed a multifaceted mass extendin

[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 Caucasian male with a history of hypertension, hypercholesterolemia, coronary artery disease status post five vessel coronary artery bypass grafting presented to the emergency room with chest pain for four days which radiated to his jaw and along the left arm (Figure ).
Electrocardiogram (EKG) showed old Q waves in inferior leads and new ST depression in leads I, AVL, V5 and V6 and troponin peaked up to 15.8. At the time of presentation, the patient was also short of breath with initial chest plain, a radiograph (X-ray) showing pulmonary edema is depicted (Figures and 3).
The patient was electively intubated before urgent cardiac catheterization, which was performed within 12 hours of patient’s arrival, and revealed 100% occlusion in right coronary, left main coronary, and the proximal portion of the circumflex artery as well as diffuse disease of the grafted vessels to circumflex. Furthermore, during catheterization, the patient was also noted to have hemodynamic compromise with blood pressure observed to be 86/63 mmHg and a heart rate of 115 beats per minute, which prompted emergency echocardiography (ECHO) showing partial disruption of medial papillary muscle with severely flail posterior MV leaflet and severe MR. He subsequently underwent venoarterial extracorporeal membrane oxygenation (ECMO) pump placement by cardiothoracic surgery for hemodynamic support accessing through the right common femoral artery and right femoral vein (Figure ).
Heart team specialists thus discussed the possibility of performing an MV clipping, and it was decided in favor of proceeding with the transcatheter procedure as the patient had a history of median sternotomy and previous bypass surgery. The patient remained intubated and was taken to cath lab on the fifth day of hospitalization. The femoral vein was accessed using ultrasound guidance, and the transseptal puncture was performed using intraoperative transesophageal echocardiography. This was then followed by prepp

[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 healthy woman, without a significant medical family history, presented with a lump in the lower inner quadrant of her left breast 24 months prior to her referral to our center. At that time, the mass was diagnosed as a benign lesion after incisional biopsy. She became pregnant and about 1 year after child delivery, the left breast mass grew significantly larger. On clinical suspicion of malignancy with global infiltration of the left breast, she was referred to our center. Mammography showed an asymmetric increased density in the left breast. Multiple-site core needle biopsy was performed, but it led to no definite pathological diagnosis. Consequently, the patient was scheduled for open biopsy. Under general anesthesia, the mass was entered via an incision on the most prominent site. After the removal of a 2×2 cm tissue biopsy, a cavity was opened beneath the excised tissue which was full of blood clot. Following the removal of the clot, active bleeding occurred. Bleeding was diffuse and uncontrollable, such that within a few minutes, the patient lost about 1500 cm of blood. Effective packing was performed. The next day, after the patient had stabilized, she was retransferred to the operating room for the removal of the pack. However, due to severe bleeding after the removal of the pack, packing was reapplied. Chest computed tomography scan revealed a large, well-enhanced mass in the left breast without invasion to the skin or pectoralis muscles and also enlarged left axillary lymph nodes ().
According to the final pathology report, histological sections of the mass demonstrated a vascular tumor with interconnecting blood channels lined by atypical, pleomorphic endothelial cells. Mitotic figures and areas of necrosis were also seen (). The tumor cells were immunoreactive for CD31, CD34, and vimentin but not for cytokeratin. The Ki-67 labeling index was about 30%.
As the pathology study of the sample was suggestive of an angiosarcoma, the patient underw

[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 21-year-old man presented with acute vision loss immediately following his own finger gouging of his right eye while accidentally falling down during jogging. Visual acuity was counting fingers at 1 meter in the right eye and 20/20 in the left. The left eye was normal. A relative afferent pupillary defect was noted in the right eye. Intraocular pressure was 12 mmHg. Slit-lamp examination revealed a subconjunctival hemorrhage affecting the temporal aspect of the right eye. The cornea and lens were intact and clear. Dilated fundus examination revealed peripapillary subretinal hemorrhages and vitreous hemorrhage most prominently in the inferior vitreous cavity. Mild peripapillary edema and choroidal folds were observed. Fluorescein angiography revealed the masking of fluorescence due to intravitreal hemorrhage around the optic disc []. The patient was treated with a 20-day course of tapering systemic steroid (prednisolone, 64 mg, peroral). Subsequently, vitreous hemorrhage settled and partial ONA at the lower half of the optic disc was recognized 20 days after the injury [].
Magnetic resonance imaging (MRI) of the orbits showed intact optic nerve bilaterally. But focal contrast enhancement was observed at the right optic nerve.
For structural evaluation, optical coherence tomography (OCT; Stratus OCT, Carl Zeiss Meditec, Dublin, CA) was performed after one month from the injury. Cross-sectional vertical scan from inferior to superior quadrant of the optic disc with OCT signal strength 7 revealed deep cavity at the inferior-temporal half [Fig. and ]. Circumpapillary scan showed thin inferior retinal nerve fiber layer (RNFL) with a thickness of 96 microns with respect to OCT normative database in the thickness profile graph and quadrant analysis []. RNFL thickness of the fellow eye was 133 microns for the inferior quadrant, 81 microns for the temporal quadrant, 150 microns for the superior quadrant, and 94 microns for the nasal quadrant. The analysis with the compariso

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old girl presented with a 7-month history of frontal headaches and intermittent left-sided proptosis. On examination, she had dilated and engorged scleral veins on the left eye (evident on inspection), mild dysdiadochokinesia and past pointing on the left side. A brain computed tomography (CT) with contrast showed an enlarged left superior ophthalmic vein and a prominent left cavernous sinus. An interventional radiography (IR) cerebral angiogram under general anaesthesia was performed, which revealed evidence of an indirect CCF fed by ophthalmic branches of the left internal carotid artery and filling from multiple ethmodial branches of the distal internal maxillary artery. From the fistula, the ophthalmic vein was markedly hypertrophied and drained the cavernous sinus anteriorly. The fistula was also feeding from the right side through ethmodial branches into the right cavernous sinus and across to the left cavernous sinus (Fig. ).
After a discussion that involved the neuroradiology team, neurosurgical team, the patient and her family, a decision was made to proceed with endovascular treatment of the fistula. Following informed consent from the patient's parents, the procedure was performed under general anaesthesia. Axis to the right common femoral artery was achieved with a 6-French micropuncture kit. A 6-French sheath was inserted into the right common femoral vein. A 6-French guide catheter was placed in the left internal jugular bulb. Thereafter, 4-French sheath was placed in the left common femoral vein. Then, a 4-French Weinberg catheter was placed in the left common carotid. A Headway microcatheter was advanced into the cavernous sinus trough the petrosal sinus into the cavernous sinus and subsequently into the dilated ophthalmic vein. Multiple coils were then placed into the ophthalmic vein throughout its course in the orbit back as far as the anterior section of the cavernous sinus. This resulted in near complete occlusion of the fistula. No imm

[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 Japanese woman (gravida 4 para 4) presented with a 6-month history of light but intermittent postmenopausal vaginal bleeding without abdominal pain. Pelvic examination revealed a 12-mm hypertrophic endometrium via transvaginal ultrasound, and endometrial cytology revealed a few suspicious atypical endometrial cells; however, these findings did not confirm the diagnosis of EC (Fig. ). An outpatient endometrial biopsy performed with a curette followed by endometrial cytology also suggested that there was not sufficient pathological evidence to diagnose the presence of EC. However, contrast-enhanced magnetic resonance imaging (MRI) of the pelvis showed the disruption of the junctional zone in the posterior wall of the uterus and suggested myometrial invasion of the EC. FIGO stage IB EC was suspected (Fig. ). The discordance between the findings of the endometrial biopsy and MRI warranted a second endometrial biopsy to obtain histological evidence of EC. The second endometrial biopsy was performed with the aid of an outpatient diagnostic hysteroscopical vision using a 3-mm flexible hysteroscope (Olympus Corporation), but no obviously elevated mass was detected. We observed only irregular gradual eminence on the posterior wall (Fig. ). The obtained specimen contained only a small number of fused glands lacking stroma, which was not sufficient to conclusively confirm the presence of malignancy (Fig. ).
We subsequently performed an operative hysteroscopy with a resectoscope for tissue sampling under general anesthesia, since we hypothesized that the deep location and the hard consistency of the tumor made endometrial biopsy difficult. An irregularly elevated lesion was observed in the posterior wall of the uterine cavity using an 8.3-mm rigid hysteroscope (Olympus Corporation), and part of this lesion was incised with a loop electrode (Fig. ). This 5-mm-thick collected tissue included not only endometrium but also adjacent myometrium. Pathological examination

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old boy presented with the complaints of hitting the bed or wall with his head during sleep, with a frequency of one or two nights per week. He was oblivious of what was happening in the night, but was informed by his parents regarding his abnormal activity during sleep. Because of the same reason, his parents did not allow him to spend night away from his home. Thus, it was interfering with his social life and he wanted medical help. On the other hand, parents sought consultation because they were worried about not only the abnormal activity during sleep but also the possibility of a head injury during these episodes.
The parents reported that this problem started at the age of 1 year where he would usually bang his head on the bed or pillow during sleep. Each episode would last about 2-5 min and was self-limiting. During these episodes, the child would assume prone position with knees close to his chest and then he would hit the bed or pillow or wall with his forehead. The movements were rhythmic and stereotyped. The episodes used to recur at varying intervals each night during which it was difficult to wake up the child. Often, the banging used to be so strong that the child had injured himself. A decrease in the frequency of the episodes was noticed after the age of 10 years. During childhood, the episodes were recurring at a frequency of three to five nights per week; but after the age of 10 years, they had reduced to one or two nights per week. Moreover, these episodes became limited to the second half of the night. Whenever he was woken up from these episodes, he reported amnesia regarding the movement.
The child was following a regular sleep schedule with bed time at around 11 p.m. He used to fall asleep easily and wake up by himself at around 6 a.m., feeling fresh. He regularly took 1-h nap 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 67-year-old female presented with three months of hoarseness and dysphagia following an upper respiratory infection. Her past medical history included invasive ductal carcinoma of the breast (ER positive, PR negative, and HER2 negative) treated by mastectomy two years prior to presentation. On clinical examination, she was found to have paralysis of the right vocal cord, and a follow-up CT scan of the neck revealed an enlarged thyroid gland with multiple bilateral thyroid nodules. FNA of a right-sided 3.5 cm thyroid nodule was diagnosed as atypia of undetermined significance (Bethesda category III). A repeat FNA three months later yielded a diagnosis of benign follicular nodule (Bethesda category II). Persistent hoarseness and compressive symptoms, combined with atypical findings on the initial FNA, necessitated right thyroid lobectomy and right vocal cord injection. Intraoperatively, the right thyroid lobe was noted to be moderately enlarged with multiple nodules but no evidence of extrathyroidal extension.
The right lobectomy specimen measured 4.6 cm in greatest dimension and weighed 16 grams. The cut surfaces of the thyroid parenchyma showed multiple variably sized brown gelatinous nodules, with focal areas of hemorrhage and cystic change.
Histologic examination revealed evidence of nodular thyroid hyperplasia, along with multiple scattered subcentimeter foci of metastatic breast carcinoma, which were present in 7 out of the 16 submitted tissue sections. Most of the smaller metastatic foci, measuring around 1 millimeter each, consisted of a few irregularly shaped nests of epithelioid tumor cells interspersed between thyroid follicles (). The largest metastatic focus measured 0.6 cm and was comprised of tumor cell nests arranged along the periphery of a sclerotic stroma containing cords of tumor cells showing retraction artifact (Figures –). These areas resembled the dense amyloid-type stroma often seen in medullary thyroid carcinoma (MTC). Additionally, there w

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


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

[User]
RADIOLOGY NOTE:
A 15-year-old male patient presented to our orthopedic outpatient department with a rapidly enlarging protruding tumor on the left chest anterior wall, which had gradually increased in size over the preceding year. He had no history of preceding trauma or local irritation. The tumor was asymptomatic but was a physical obstacle due to its protruding nature. On examination, a protruding lesion was noted on the left chest wall, measuring approximately 4 × 3 cm in size (). Magnetic resonance imaging revealed a tumor measuring 4 × 3 × 3 cm, protruding subcutaneously superior to the clavicle (Figures and ). Computed tomography revealed that the tumor had not invaded the clavicle. Histopathological examination following hematoxylin and eosin staining of the needle biopsy specimen revealed that the mass comprised fibromyxoid tissue with focal spindle cell proliferation and inflammation in a loosely myxoedematous matrix with extravasated red blood cells (). Further diagnostic testing via FISH analysis with a USP6 Dual Color Break Apart Probe was performed. FISH analysis revealed many USP6 rearrangements by splitting of the red and green signals in both nuclei in this field, strongly suggesting a diagnosis of NF (). Although the histopathological results did not match the clinical course, such as extremely rapid growth, he was followed up without treatment. The tumor size rapidly increased to 8 × 6 cm, and the tumor protruded further in a few weeks. One month later, the tumor spontaneously separated and fell off (). The separated tumor measured approximately 6.5 × 5.3 × 3 cm and was mostly a necrotic lesion with bleeding. Following this, the remaining tumor on the chest wall continued to grow rapidly ().
Although histopathological results confirmed the diagnosis of NF, the clinical findings, which included a protruding lesion that separated and fell off spontaneously, large tumor size, and rapid enlargement, suggested the possibility of malignancy, prompting the need for wide

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old man, previously radically resected for a renal cell carcinoma, was diagnosed with an 11-cm tumour located at the stomach 15 years ago (November 2005) (shown in Fig. .1; Table ). This gastric tumour was primarily resected with free margins. Histopathology reported an epithelioid GIST, immunohistochemically positive for CD117 and CD34. A mitotic count of 20 per 50 high-power fields under lineated high risk of progression was found according to the AFIP criteria [].
In April 2006, a recurrence in the lymph nodes in the lower pelvic and in the inguinal was discovered on imaging. First-line treatment with imatinib 400 mg orally per day was initiated. The disease progressed in May 2006, and thereby the dose of imatinib was increased to 400 mg orally twice daily. A week later, the patient developed epidermolysis. The treatment was stopped in July 2006 after 3 months of treatment due to imatinib intolerance. Due to the skin reaction, prednisolone 50 mg orally was administered. The following PET-CT showed regression of the disease, and therefore it was concluded that the presumed recurrence most likely had been a reactive change in the lymph nodes since it disappeared while on treatment with prednisolone.
Sixteen months after stopping imatinib, PET-CT revealed a recurrence with 3 intra-abdominal tumours of 4.5 cm, 3.1 cm close to the liver and 2.6 cm close to the gall bladder (shown in Fig. ), and it was verified by biopsy. Treatment with imatinib 200 mg orally once daily was reintroduced. Again, the patient developed a severe skin reaction after a few days of treatment. Second-line treatment with continuous sunitinib 25 mg orally once daily was initiated covered by 3-week treatment with prednisolone 25 mg daily. The dose was then increased to 37.5 mg sunitinib orally daily.
After 3 months of treatment with sunitinib, the disease progressed on PET-CT scan in 2 tumours intra-ab

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


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

[User]
RADIOLOGY NOTE:
The patient is a 48-year-old male who presented with gross hematuria in February 2017. Computed tomography (CT) of the chest, abdomen, and pelvis (CAP) showed bilateral renal masses, numerous bilateral pulmonary nodules, and mediastinal and right hilar lymphadenopathy. Pathology from a transbronchial lymph node biopsy (station 11R) revealed metastatic renal cell carcinoma. He was started on sunitinib 50 mg daily for 14 days every 21 days cycle and experienced a partial response (PR) until April 2018 when he developed worsening flank pain. CT CAP showed progression of disease (PD) with an enlarging right renal mass and right hilar lymphadenopathy. He was started on nivolumab 3 mg/kg every 14 days. After 8 cycles of nivolumab, patient developed worsening headache and blurry vision of the left eye, which prompted a magnetic resonance imaging (MRI) of the brain that showed a 2.5 cm enhancing, right parietal mass associated with hemorrhage and edema as well as punctuate areas of enhancement in the left frontal lobe and left cerebellar peduncle. Of note, a baseline MRI brain obtained after his initial diagnosis was negative for metastatic disease. Repeat CT CAP also showed PD with an enlarging left renal mass and worsening mediastinal lymphadenopathy. Patient was started on third-line cabozantinib 60 mg daily and received a course of dexamethasone 4 mg twice daily with referral to radiation oncology for treatment of his brain metastases. Three weeks after starting cabozantinib, a repeat MRI brain was obtained for radiation planning and showed complete resolution of the right parietal mass with now encephalomalacia of the area (). Patient also reported improvement of his headache and blurry vision. Due to resolution of the right parietal mass, radiation therapy was no longer deemed necessary and the patient remains on cabozantinib 60 mg daily. A CT CAP, obtained 8 weeks after initiation of cabozantinib therapy, showed partial response with reduction in size of mediastinal

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old man was admitted to our hospital complaining of fever, chills, sweating, and dyspnea. He has a history of admission to our hospital for evaluation and management of suggested deep neck infection with small amount of left pleural effusion, which was improved with antibiotic and symptomatic therapy. He had smoked 1 pack per day for 25 years, and taken herbal medication for 1 month before admission, which ameliorated his symptoms a little. He had no underlying illness such as hypertension, diabetes, or autoimmune diseases. On physical examination, he showed generalized edematous appearance with venous engorgement of neck and upper chest. The lung sound was diminished on both side of lung during auscultation of chest.
Routine laboratory test including liver function test and renal function test showed normal range of results. Autoimmune markers such as fluorescent antinuclear antibody and anti-neutrophil cytoplasmic antibody also showed negative result. Chest X-ray showed massive pleural effusion in both pleural cavity without parenchymal abnormality (). Neck computed tomography (CT) and chest CT showed thrombophlebitis at left innominate vein, subclavian vein and left internal jugular vein and enlarged lymph node at left neck and axillar area with both pleural effusion and ascites and diffuse soft tissue edema (, ). Two-dimentional echocardiography showed spongiform appearance with prominent trabeculation of left ventricle (LV) with preserved LV systolic function, and no significant valvular dysfunction.
Pleural fluid analysis showed lymphocyte predominant exudates nature. But that did not suggest any specific disease. Pleural biopsy through video-assisted thoracoscopic surgery showed chronic inflammation with lymphoplasmacytic infiltration and fibrosis. Plasma cells were positive for IgG and IgG4 in immunohistochemical stain, and the ratio of IgG4 to IgG-positive plasma cells is 0.24 (). Lymph node biopsy of neck on previous admission for evaluation and

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old woman presented with a mass on the left upper lip and difficulty in pronunciation. The mass developed after she bit the upper lip 5 years earlier. The volume of mass was not reduced; however, the patient complained of pain. One year after the development, she visited an otolaryngologist. The mass was diagnosed as mucocele and aspirated. However, only blood was aspirated from this lesion, and the lesion's size was not reduced. Two years after aspiration, the size of mass increased, and she visited a plastic surgeon. The lesion was diagnosed as hemangioma by magnetic resonance imaging (MRI). Ethanol was injected into the lesion twice. Although the lesion was slightly reduced at the first injection, it did not change at the second. She consulted a dental clinic two years after the second injection and then was referred to our department.
Oral examination revealed a circumscribed submucosal single nodule, approximately 30 × 20 mm in size in the left upper lip. The overlying mucosa was smooth, with bluish discoloration. On palpation, the nodule was elastic firm and mobile (). Cervical lymph nodes were not palpable. MRI revealed a relatively well-demarcated lesion in the left upper lip. The lesion showed low signal intensity on T1-weighted images; however, it had a high signal area suspecting the subacute bleeding image in the centre of tumor. The lesion showed mostly high signal intensity on T2-weighted images (). Under the clinical diagnosis of hemangioma, surgical enucleation was performed under local anesthesia. The tumor was removed with ligation and ablation of the inflow blood vessels. The overlying mucosa was partly removed, and the wound was closed by sutures (). Postoperative course was uneventful. The patient was free of recurrence 2 years after surgery ().
The size of excised the lesion was 30 × 20 mm. The specimen had reddish brown surfaces covered by thin-walled capsule including the mucosa of partial lower lip and inflow blood vessels which we

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