[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 Caucasian male with a 60-pack-year smoking history and no other co-morbidities or medical conditions initially presented to an outside hospital with a large left-sided chest wall neoplasm. (Figure A) Biopsy revealed a high-grade pleomorphic sarcoma. At the time of presentation, there were numerous pulmonary metastases and therefore he was not felt to be a surgical candidate. He received 3 cycles of doxorubicin and ifosfamide chemotherapy resulting in a modest radiographic response in the pulmonary metastases. There was no appreciable change in the primary neoplasm and he subsequently received radiation therapy to the chest wall with a total of 5,000 cGy over 25 treatments. Six weeks after receiving radiation, he developed significant skin and tumor ulceration resulting in diffuse bleeding refractory to multiple local hemostatic measures including cauterization and application of numerous topical agents. He required constant blood transfusions, a total of 8 units over a 12-week interval. Hematologic studies revealed no evidence of an underlying bleeding disorder. Attempts at percutaneous transarterial coil embolization of several chest wall arteries were subsequently performed however they were unsuccessful and the bleeding and skin ulceration worsened. (Figure B) As the patient’s metastatic disease was felt to be controlled, he was referred to our institution for urgent chest wall resection.
At the time of surgery, wide chest wall excision was performed with an approximately 3 cm circumferential gross tumor free margin. Ultimately, ribs 4 through 8 were excised anteriorly from the costal cartilages to the anterior axillary line posteriorly. The resultant chest wall defect measured approximately 15 cm by 20 cm (Figure B). Chest wall reconstruction was accomplished with a double layer of prolene mesh covered by transverse rectus abdominus myocutaneous (TRAM) flap (Figure C). Pathologic analysis demonstrated an undifferentiated high-grade pleomorphic sarc

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old African American male presented to our hospital with a generalized skin rash for the past 3 days. He developed a productive cough, sore throat, and fever one week prior to developing this rash. He also noted rhinorrhea and pink eyes with visual blurring and was prescribed erythromycin eye ointment by a physician. The rash appeared one day using the ointment and was described as a nonpruritic, painless eruption of “bumps” starting on his back and rapidly spreading over his chest and hands. The rash progressed over 3 days and he experienced swelling of both eyelids along with blistering and crusting of his lips. He also experienced mild dysphagia and decided to come to the hospital for further evaluation. He admitted to being allergic to sulfa drugs; however, he had not received any antibiotics other than the erythromycin ointment. He denied any travel, animal exposure, or insect bites. He also denied having any sexual encounters in recent weeks. He had a history of occasional tobacco and marijuana usage, and his last use had been over 6 months ago.
On physical examination, he had a low-grade fever of 100.5 Fahrenheit, his pulse rate was 90 beats per minute, respiratory rate was 20 breaths per minute, blood pressure was 130/70 mm of Hg, and he was saturating 90% on room air. His upper and lower eyelids were swollen bilaterally and he had obvious conjunctival erythema (). There were marked necrosis and mucosal sloughing involving his lips (). He had generalized macules and patches on his chest and back (Figures and ), which to a lesser extent also involved his face, abdomen, and arms. The rash appeared in different stages of healing, and targetoid lesions were noted on selected sites most notably his palms (). His genitalia and lower extremities were not involved. On pulmonary examination, the right lower lung fields had fine end-inspiratory rales.

[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 primigravida was referred to our tertiary care hospital with a suspicion of either a chorioangioma of the placenta or a placental teratoma on the second-trimester anomaly scan performed from a secondary care hospital. The patient had no known comorbidities apart from being diagnosed with pregnancy-induced hypertension. The conception was planned and was not assisted by any interventional or medical means. There was no history of congenital anomalies in the family or of twin pregnancies. Ultrasonography at our institution revealed a single intrauterine fetus, corresponding to 27 weeks and two days of gestation, displaying a normal interval growth from the previous ultrasound. The presence of a multiloculated cystic mass with septations and calcifications was also noted. This mass was devoid of any vascularity (Figure ).
On color Doppler examination, no vascularity was noted and the mass, reported as measuring 104 x 53 mm, appeared as arising from the anterior wall of the uterus. The differential diagnosis of placental teratoma, chorioangioma, hemorrhagic placental degeneration, or degenerating fibroid was considered. A repeat scan in the third trimester revealed the same findings.
At 36 weeks and five days of gestation, the patient gave birth, via C-section, to a fetus with good Apgar scores (9/1, 9/5). A second congenitally malformed fetus was also delivered, which was devoid of cephalic end structures. Only the feet and lower limbs of the fetus were discernable (Figure ). A single placenta measuring 515 grams was also delivered, containing two umbilical cords. The patient was discharged in a stable condition on the sixth day of admission.
A histopathological examination of the placenta revealed placental discs measuring up to 19.5 x 14 x 4 cm. The placental membrane measured 30 x 16 cm, with two umbilical cords. The separately lying fetus showed gross malformation with the absence of the head and both upper limbs. However, both lower limbs were partia

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old female with previously treated tubercular lymphadenitis presented with left flank pain and gross painless hematuria of 15 days duration. On evaluation with contrast-enhanced computed tomography (CECT) scan of the abdomen and pelvis there was a 4.4 cm × 2.9 cm × 4.4 cm heterogeneous enhancing mass in the interpolar region of left kidney []. She underwent left open radical nephrectomy via flank incision and the histopathology specimen revealed clear cell carcinoma Fuhrman grade II confined to the kidney (T1BN0M0). She recovered well from surgery and was on regular 3 monthly follow-up with clinical examination, serum chemistries and ultrasonography when she noticed gross painless hematuria 2 years after radical nephrectomy. CECT was normal and urine cytology was inconclusive. On cystoscopy bloody efflux was seen from left ureteric orifice and retrograde pyelogram and ureteroscopy identified a mass lesion in residual ureteric stump. Using a Gibson's incision the ureteric stump and cuff of bladder were excised and there was a 1 cm × 0.5 cm clear cell cancer Fuhrman grade II similar to primary RCC extending up to submucosa and deep muscles were free. One year after the resection, she presented with a 2 cm × 2 cm firm mobile nodule in left iliac fossa at the margin of Gibson incision []. Fine-needle aspiration cytology revealed clear cell cancer and it was widely excised and was localized to subcutaneous tissue. Final histopathology was clear cell cancer Fuhrman grade II similar to primary tumor. She was kept on close surveillance and was asymptomatic for 2 years when she again developed gross painless hematuria with passage of clots. CECT showed two small lesions on the posterior wall of urinary bladder as the only abnormality []. On cystoscopy, there was a solitary 1 cm × 1 cm pedunculated growth in midline over interureteric bar with overlying calcification, which was completely resected and deep muscle and random bladder biopsies taken. On histopathology,

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old man accidentally fell from a cliff and hit his right flank on the ground while camping. Initially, he was able to barely walk, but he ultimately became unable to walk at all due to severe flank pain. His colleague called an ambulance. He had no remarkable personal or family history and was a social drinker.
Initially, he was transported to a local hospital, but computed tomography (CT) revealed right renal injury with massive retroperitoneal hematoma, so he was transported to our hospital by a physician-staffed helicopter 2 hours after the accident. Upon arrival, he showed clear consciousness but was in a hemorrhagic shock state. His vital signs were as follows: blood pressure, 84/50 mmHg; heart rate, 140 beats per minute; respiratory rate, 30 breaths per minute; percutaneous saturation; and 98% under 10 L/minute of oxygen via mask. He had marked right flank pain. A focused assessment with sonography in trauma was positive at Morrison's pouch. He urgently received 6 units of different-type blood transfusion, and his blood pressure temporarily increased. Enhanced CT revealed extravasation of contrast medium from the injured right kidney with massive retroperitoneal hematoma, which had pushed the visceral organs up into the ventral side (). Blood test findings on arrival are shown in . On returning to the emergency room, he suffered hemorrhagic shock again and subsequently underwent repeated massive blood transfusion, including red blood cells, cryoprecipitate, fresh-frozen plasma, and platelets, and also received tracheal intubation and an indwelling intra-aortic balloon occlusion catheter (IABP) at zone I as a prophylactic measure against cardiac arrest. He was moved to the angio suite for interventional radiology and underwent transarterial selective renal artery embolization, after which he was admitted to the intensive care unit. His vital signs stabilized on hospital day 2. The IABP was removed without inflation. He received 12 units of red blood c

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old gentleman presented to the Accident and Emergency Department following a 3-month stay in India. Four weeks into his return, he started developing daily episodes of fever and night sweats. Whilst in India, he was asymptomatic although he did not take any malaria prophylaxis or salmonella vaccine during his travel.
The patient had no comorbidities except for a renal calculi detected in 2004. He was also known to have a simple cyst measuring 5 cm in diameter in the right lobe of the liver, incidentally found on routine abdominal ultrasonography (USG). He did not take any regular medication, and was otherwise in good health.
On examination, he had a temperature of 38.2°C, pulse 90 beats per minute regular, and blood pressure of 116/60 mmHg. Systemic examinations of cardiovascular, respiratory, abdominal, and neurological systems were unremarkable.
His initial blood biochemical examination showed normal liver and kidney functions but a raised c-reactive protein (CRP) of 129 mg/dL. His haematological parameters showed a raised white cell count of 12 000/cumm with predominant neutrophilia. No malarial parasites were detected. Chest X-ray did not show any signs of underlying infection.
Repeated blood and urine cultures were obtained and abdominal USG requested to find any abdominal collection as a source of sepsis. Our differential diagnosis at this stage was malaria, salmonellosis, or amoebiasis. The delayed start of his symptoms vis a vis his travel history made viral aetiology, namely, dengue fever unlikely.
His blood culture grew Salmonella paratyphi A. Serologies for amoeba and hydatid disease were negative. Abdominal USG showed a collection in the right liver lobe, the same site as the simple cyst noted on the previous scans. The area was significantly larger than previously noted with an underlying abscess. Abdominal and pelvic CT scan did not reveal any further abscesses.
The liver abscess was drained under ultrasound guidance using a pigtail catheter

[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, a 30-year-old Tibetan man, was treated in the Lhasa Hospital for right tibiofibular fracture December 2012 (Fig. ). After the swelling subsided, he underwent right tibia fracture intramedullary internal fixation. Two weeks after the operation, the patient was able to walk with double crutches without load, and was able to walk without crutches and with some load 3 months after the operation. However, the patient complained of pain in his right lower extremity, especially when moving downhill or down stairs, and experienced a limping gait and obvious tenderness at the fracture end. Three years after originally presenting at Lhasa Hospital, the patient was experiencing persistent pain in the right lower extremity, and his daily activities were severely affected. Thus, he was re-diagnosed with nonunion of the right tibial fracture after internal fixation (Fig. ). The main causes of the nonunion of the fracture were considered to be the excessively thin intramedullary nails and unstable fixation of the fracture. The operation was repeated with replacement of the crude intramedullary nails and grafting of iliac bone (Fig. ). Three months after the operation, the tibial fracture had failed to heal, and further surgical treatment was performed. The proximal locking screw of the intramedullary nail was removed with an expectation to eliminate the stress shielding effect and to promote fracture healing by increasing the microdynamic force while retaining the static interlocking nail. Five months after the operation, the patient abandoned the crutches and was able to walk with a heavy load. Nevertheless, 2 years after the operation, active pain of the right leg persisted with some tenderness around the fracture, especially when moving downhill or down stairs. August 2018 the patient was admitted to our hospital. Physical examination revealed that two old incision healing scars, approximately 2 cm in length, were present at the proximal and distal ends of the righ

[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 Japanese woman presented to our clinic with a 4 month history of bilateral groin pain and right buttock pain. Her right hip was more painful than her left hip. There was no history of trauma, alcohol abuse, or steroid use. Her medical history included iron-deficiency anemia diagnosed 2 years earlier, after which she had been on iron supplements. She had no fracture episodes, including fragility fractures.
Her height, body weight, and body mass index were 155 cm, 42 kg, and 18.7 kg/m2, respectively. She was able to walk for approximately 10 minutes without a stick, albeit at a slow speed. Limitations in the passive motion of her bilateral hip joint were observed thus: flexion, 100°, internal rotation 5°, external rotation 15°, and abduction 20°, on both sides. She was able to perform a straight-leg raise of the right limb with substantial pain. The neurovascular status of both lower extremities was intact. The Japanese Orthopaedic Association scoring system for the evaluation of hip-joint function (JOA hip score) was 46 points for her right hip and 56 points for her left hip. The score was based on a total of 100 points, comprising 40 for pain, 20 for range of motion, 20 for the ability to walk, and 20 for activities of daily living [].
Standard radiographs of both hips (Fig. a–c) demonstrated no characteristic findings such as the crescent sign, sclerotic band pattern, and collapse of the femoral head, and no joint space narrowing was seen in either femoral head. MRI of both hips (Fig. d, e) presented a low signal line in the subchondral region of the femoral head in the T1 weighted image and high signal region in almost all of the femoral head in the short tau inversion recovery (STIR). The oblique axial views of the proton density-weighted image showed a low-signal sinuous line in the anteromedial region

[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 13-year-old adolescent girl was admitted to the Department of Child and Adolescent Psychiatry with complaints of lack of enjoyment of pleasurable activities, sleep disturbances, suicidal thoughts, binge eating episodes, self-induced vomiting episodes and excessive exercising, leading to significant weight loss last 1 year in association with a situation of a family conflict.
The patient lived with her mother and sister. She was very distressed and unhappy because her mother forced her to talk with her father. She stated that her father had deserted them for someone else 9 years ago, she did not talk and see him until this time anymore and she found this difficult to accept him and everyday her father phoned her mother and insisted on establishing a new relationship. In this month, she began to take money from home without permission, especially after each time her father called her mother. And she started to have conflicts with her peers and siblings.
She was admitted to the paediatric inpatient clinics in two different hospitals because of self-induced vomiting episodes and weight loss before admission to the Department of Child and Adolescent Psychiatry. She had no complaints of dysphagia, retrosternal pain and heartburn; physical examinations and detailed investigations including blood tests and abdominal-pelvic ultrasound and endoscopy were normal on both paediatric occasions. Paediatric gastroenterology specialist reported that this medical condition was not associated with any primary oesophageal motility disorders (achalasia, diffuse oesophageal spasm, nutcracker oesophagus, etc.) and secondary oesophageal motility disorders (diabetes mellitus, scleroderma, etc.). Following this, she was referred to a child and adolescent psychiatry outpatient clinic along with a pre-diagnosis of psychiatric disorders to be able to associate with secondary oesophageal motility disorders.
At the psychiatric evaluation, she expressed no fear of getting fat but her self-esteem

[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:
On October 12, 2011, a 57-year-old Chinese female was admitted to our institution with complaint of upper abdominal distension for 2 weeks. She denied any abdominal trauma or surgeries in her life. No specific findings were noted in her family history and personal history. And, she was taking no medications. Before this treatment, she went to the local hospital where an abdominal ultrasound was performed revealing a mass in the head of the pancreas. No abnormalities were detected upon clinical examination and in laboratory investigations. The computer tomography (CT) scan (Fig. ) revealed a 4.0 × 3.2 × 3.0-cm hypodense mass in the porta hepatis, mildly enhanced in arterial phase, and moderately enhanced in portal phase. There was no clear boundary between the mass and the caudate lobe of the liver, and the lower edge of the lesion was close to the neck of pancreas, pressing down on the common hepatic artery. No enlarged hilar lymph nodes or exogenous caudate lobe tumor were identified. The magnetic resonance imaging (MRI) (Fig. ) showed the long T1 and T2 signal mass in the porta hepatis, with 4.0 × 3.0 cm. The imaging feature on MRI was similar to CT. Fine needle aspiration guided by endoscopic ultrasonography revealed spindle cells arranged in bundles and palisades, with no nuclear atypia, suggestive of a spindle cell neoplasia. With a high suspicion of a GIST, diagnostic laparoscopy was performed. The tumor was located in the porta hepatis, tightly pressing the hepatoduodenal ligament, and the caudate lobe and the pancreas were not involved. Then, after careful dissection, the tumor was found to be in close contact with the common hepatic artery and cystic artery. Subsequently, the patient underwent laparotomy, and intraoperative frozen-section examination revealed a mesenchymal tumor in the porta hepatis, highly suspicious of a GIST. So, the tumor was macroscopically resected en-bloc with the invaded

[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 14-month old boy presented with respiratory distress, wheeze and hypoxia. This was preceded by 24 h of coryza, fever and reduced feeding. He was admitted directly to intensive care, where he was diagnosed with pneumonia. Treatment was started with empirical antibiotics. He was intubated and ventilated for 4 days, after which he was extubated and stepped down to high dependency unit (HDU) on continuous positive airways pressure (CPAP) ventilation. He continued to have persistently increased work of breathing, persistent expiratory wheeze and symptoms and signs of air trapping.
Though he did not progress to respiratory failure, weight gain and oxygenation was achieved only by initiation of Heated Humidified High Flow Nasal cannula therapy (HHHFNC).
Polymerase chain reaction (PCR) testing of nasopharyngeal aspirates (NPAs) revealed the persistence of rhinovirus and adenovirus for 10 weeks in both NPAs and bronchoalveolar lavages (BALs), with parainfluenza type 3 found in just one NPA sample. Adenovirus was also found in blood by PCR testing. Rhinovirus is not normally tested for in blood samples and there was no validated assay available for this. One BAL and one urine sample were screened for cytomegalovirus (CMV) by PCR also, and found to be negative. One stool sample was tested and found to be negative for rotavirus and adenovirus (despite the persistence of adenovirus in the respiratory samples at this time).
There was no significant family history of any genetic diseases and the patient was born at term. Mum is a smoker but states that she did not smoke during her pregnancy. During pregnancy, intrauterine growth restriction was identified. At the time of admission his weight was < 0.4th centile, but this was increasing. His parents report poor feeding since birth and an increased work of breathing from 5 months old. He is known to the allergy services for severe eczema and faltering weight, and has been diagnosed with cow

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


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

[User]
RADIOLOGY NOTE:
A 60 year old woman presented with a twelve month history of fatigue, anorexia, weight loss and abdominal distension. She had a history of well controlled hypertension and type II diabetes mellitus.
Liver function tests were slightly abnormal (ALP: 383IU/l; GGT: 216IU/l). CT of the abdomen demonstrated a large pancreatic mass (13 × 9 × 5 cm) compressing the confluence of the portal and superior mesenteric veins (Figure ). The right colon and antrum of the stomach also appeared to be intimately involved with the tumour. Additionally, a 12 cm diameter mixed cystic/solid mass was noted to occupy the majority of the right hemi-liver (Figure ). Her serum CgA level was elevated at 507IU/l (range: 0-17.2) and an octreotide scan showed avid uptake within the pancreatic mass and within the periphery of the liver lesion.
Laparoscopy was performed to exclude additional peritoneal disease and biopsies of the right liver tumour were taken. Biopsy specimens confirmed the diagnosis of a neuroendocrine tumour with a Ki-67 index of 4%.
At a multidisciplinary oncology team meeting, consensus of opinion was that the patient should be offered resection. Volumetric analysis demonstrated a 24% future remnant liver volume. A right portal vein embolisation was performed with a view to inducing left lobe hypertrophy. Four weeks later, reassessment of the liver volume confirmed that the future left lateral section remnant volume had increased to 32%.
A midline laparotomy was performed. Exploration confirmed that the pancreatic mass had invaded into the greater curvature of the stomach and adjacent transverse colon. Initially, an extended right hepatectomy (segments 4a, 5, 6, 7 and 8) was performed including excision of the terminal part of the middle hepatic vein flush with the IVC. The left hepatic duct was divided, and the right hepatic artery was divided 1 cm distal to its confluence with the left hepatic artery. An extended Koc

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).
Then, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.
During the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.
Then, the operation continued in the usual fas

[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 female patient accompanied by her uncle was referred to the Department of Periodontics, ACPM Dental Collage and Hospital, Dhule, (Maharashtra) for the complaint of progressively enlarging gums. According to her, gums started growing about 1 year back beginning in the upper left back tooth region and gradually progressively involved all the teeth on that side. Similar enlargement of gums was also noticed with the lower back tooth region of that side. As the patient had difficulty in chewing from that side she continued to chew from the opposite side. Over a period of time, as the enlargement took a massive form and caused difficulty in mastication and compromised her esthetics, the school authorities brought it to the notice of her parents and they approached for treatment for it.
On further communication, the patient's past medical history and dental history was non-significant and was reporting for the first time to dental hospital.
Extraoral examination revealed a slight asymmetry of the face on the left side []. Intra-orally massive gingival enlargement was noted in the maxillary as well as mandibular gingiva, but only on the left side whereas the right side gingiva appeared normal. The gingival enlargement extended from distal aspect of maxillary left lateral incisor to second molar []. The mandibular gingiva enlargement extended from distal aspect of lower lateral incisor up to the second molar and almost encroached the occlusal surface leaving a small view of it. The degree of enlargement was categorized as grade 3 (Angelopoulos 1971) [].
The color of the gingiva appeared pink with consistency being firm and fibrous with no evidence of stippling on the affected side. Traces of plaque, food debris and calculus were noted on the affected side. Bleeding on probing was minimal/evident/present. Periodontal examination revealed deep periodontal pockets in relation to 25, 26, 27, 35, 36 and 37. Mobility of grade 3

[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:
We present a 5-year-old female child who was symptomatic since the early neonatal period with skin lesions, intermittent painless vaginal bleeding, and breast enlargement. For these complaints, the parents took the child to the nearby health facility, but they were reassured. Compared to her peers, her growth in length was fast since her early childhood, but she had poor weight gain. At the age of 3 ½ years, she presented to an orthopedic clinic with bowlegs for which she was seen and sent home without any intervention. But after one week, she had a trivial fall down accident, and she sustained pathological fractures on both upper and lower extremities. Plaster of Paris (POP) cast was applied for the lower left arm, and open fixation with plate was done for the left femur.
During the procedure, tachycardia was detected, for which she was investigated and diagnosed to have hyperthyroidism. She was initially put on propylthiouracil (PTU) and propranolol. After eight months of the procedure, there was displacement of the plate. The orthopedic surgeon decided to revise the operation, but the thyroid function was not controlled for which she was referred to a paediatric endocrinology clinic for better management of hyperthyroidism.
On physical examination at the paediatric endocrinology clinic, she was emaciated. Her weight was 16 kg (between 10th and 25th percentiles) and her height was 115 cm (on the 95th percentiles). Weight for height was far less than 5th percentile (underweight), based on CDC growth charts. Her pulse rate was 123 bpm, and she had protruded eyes. CAL spots were noticed on her face, neck, and trunk (). There was a 5 cm by 3 cm anterior neck mass with an irregular surface (). There was also breast enlargement. She had a grade III early systolic murmur best heard at the left upper sternal border. There was swelling and tenderness at the right midshaft of the humerus and short

[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 Han Chinese woman presented with a lesion on her left medial tibial plateau. She was an office employee with no athletic history; she denied any injury or symptom before she experienced a sudden sharp pain and instability of the affected knee while going downstairs. Her symptoms did not spontaneously relieve after 2 days of rest so she presented to our hospital. A physical examination revealed a swollen knee joint with Floating patellar test (+), Anterior drawer test (−), Posterior drawer test (−), Lachman test (−), Abduction stress test (−), and Adduction stress test (−). A McMurray sign could not be done accurately due to pain and swelling in her knee from 20° of extension to 120° of flexion. She had no neurological symptoms and no other physical signs were apparent. Of interest, a mistaken diagnosis of a lower insertion avulsion fracture of anterior cruciate ligament could be made at first glance at X-ray and magnetic resonance imaging (MRI) (Figs. and ).
She was treated with arthroscopy (Fig. ). During the operation, a primary diagnosis of OCD on her medial tibial plateau was indicated by an osteochondral fragment near the lower insertion of her anterior cruciate ligament, and the fragment was removed arthroscopically. Microfracture of the defect area was then performed. Histological examination which was done by a pathologist after the operation supported the positive pathology of OCD.
Postoperatively, weight-bearing was disallowed for the repair of the osteochondral defect where the microfracture was done, whereas quadriceps muscle training, such as straight leg raising, was encouraged. Continuous passive motion was also used for extension and flexion of her knee for 3 weeks after her operation. Three weeks later, rehabilitation began from partial weight-bearing up to total weight-bearing with no effusion of her knee joint. At 3 months of follow-up, she could walk and ride a bicycle freely except for

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


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

[User]
RADIOLOGY NOTE:
A 56 year old male patient was admitted to our clinic with complaints of shortness of breath ongoing for three months. He reported that the severity and frequency of his complaints had increased recently. On admission, the patient was orthopneic and dyspneic and described a feeling of constriction in the chest. He had no other atherosclerotic risk factors except for tobacco abuse. On physical examination, blood pressure was 90/70 mmHg and pulse was 130/min. Bilateral crepitant rales were heard along the lungs. The patient had 1 + edema in both legs. Cardiac oscultation revealed 1/4 diastolic rulman and a 2/6 systolic murmur at the apex and at the mitral focus. Electrocardiography (ECG) revealed T wave negativity on chest derivations C4-6. A venous blood sample showed hypercholesterolemia and a sedimentation rate of 81 mm/hour. Based on these findings, transthoracic echocardiography was performed and revealed a 44 x 31 mm mass in the left atrium. The mass was arising from the atrial side of the anterior mitral valve and was moving in and out of the left ventricle with each cardiac cycle and causing obstruction of the mitral valve (). Global systolic function was normal. Both atria were enlarged and pulmonary artery systolic pressure was 48 mmHg. Surgical removal of the mass was decided due to the size of the mass, stenosis in the left ventricular inflow tract and high risk for thromboembolism and sudden death. Based on the patient’s complaints, risk factors and ischemic ECG findings, preoperative coronary angiography was decided. Coronary angiography showed critical stenosis of the left anterior descending artery (LAD) and circumflex artery (LCx) and noncritical stenosis of the right coronary artery (RCA) (). Coronary angiography showed no findings suggestive of tumor vascularity. Ventriculography was not performed due to the potential risk of embolism. The patient was advised to undergo surgery for the resection of the left atrial mass and coronary bypass surgery. T

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 15-year-old girl born in Sweden after 40 weeks gestation as the third of four siblings from Assyrian consanguineous parents originating from Iraq. Contact with the national health system was sparse until the age of 5 years, when she presented with sensorineural hearing impairment and developmental delay. After application of bilateral hearing aids her development accelerated in all domains. In retrospect her parents reported frequent loss of balance as a toddler. Our patient was referred from her school physician to a child neurologist at the age of 7 years and 8 months due to her toe-walking gait. Except for her Achilles tendons being tight, almost spastic, no other neurological abnormality was noted. Brain imaging at the age of 8 years showed a central lesion in the mesencephalon, from the nucleus ruber dorsocaudally down to the cerebellar peduncles. A magnetic resonance imaging (MRI) scan of her spine was normal. After physiotherapy and orthoses her gait improved, but her motor skills were still abnormal for her age. At the age of 12 years she showed bilateral muscle weakness on her peroneal muscles with absence of peripheral reflexes. Neurography and electromyography showed sensorimotor polyneuropathy and chronic neurogenic changes in her leg muscles. An MRI scan of the brain was repeated showing the same lesion as described at the age of 8 years (Fig. ). At the age of 13 she presented cognitive delay, impaired gross and fine motor skills, and tremor. At this point, a neurometabolic disease was considered. At the age of 14 she presented learning difficulties and obvious generalized muscle weakness. Her fingers are extremely flexible, her feet are in plan valgus position and she has problems with her balance. At the age of 15 she shows no signs of puberty. Growth is also delayed with a skeletal age of 10.7 at chronological age of 14. Hormonal tests have shown nonfunctioning ovaries. She has no retinal changes and normal optic nerves. One of the y

[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 59-year-old female patient developed chronic renal failure secondary to focal and segmental hyalinosis and began hemodialysis in 1987. In 1988 she underwent a renal transplantation but presented an acute rejection that required transplantectomy. A second RT was performed in 1991. After years she developed a chronic allograft dysfunction that made her return to hemodialysis in 2009, as well as undergoing another transplantectomy because of graft intolerance syndrome. Third RT was performed in 2010, using a renal allograft from a deceased male donor. Immunosuppressive therapy used was thymoglobulin, corticoids, tacrolimus (FK506), and mycophenolate. Immediate renal allograft function was achieved, and her baseline creatinine serum levels were around 1,2 mg/dL. After 14 months of third RT, in a routine review, ultrasound examinations revealed a heterogeneous renal mass located on inferior pole with moderate hydronephrosis associated. CT confirms the suspect () and shows a big mass in the kidney graft depending on the pelvis and probably infiltrating fat.
Antegrade pyelography showed a big filling defect with amputation of medium and inferior calyxes. Selective urinary cytology was positive for a high grade urothelial carcinoma, and cystoscopy was negative for tumor invasion in the low urinary tract. Once again, a transplantectomy including ureter and bladder cuff was performed. Histological analysis revealed a high grade urothelial carcinoma of the pelvis allograft with fat invasion (). Surgical ureteral margin was free of tumor (stage pT3(m)G3). Cytogenetic analysis of the tumor's cells () showed the presence of chromosomes XY, so it allowed us to establish the origin of the neoplasm in the donor cells, which was probably accelerated by high doses of immunosuppressants used.
Both patients had a successful postoperative period, returning to dialysis (first with hemodialysis and later with a peritoneal catheter) immediately. At the present moment, and after 24 and 14

[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-month old girl was referred to our pediatric oncology department for further investigation of an abdominal mass. On initial physical examination her weight was in 90th percentile, length in the 75th percentile. Her right cheek was slightly fuller than left cheek. The right arm and forearm were thicker than counterparts on the left. The right leg was thicker and measured approximately 2 cm longer than left leg. We noticed a right sided complex hemihyperplasia (, ) as well as a right-sided abdominal mass of 10 cm dia-meter. Her blood pressure and other vital signs were normal. A detailed medical history showed that the mother first noticed the asymmetry of her legs when she was three months old and took her to a pediatrician. The physician's presumptive diagnosis was congenital hip dislocation. Therefore a hip ultrasonography (US) was performed which showed no evidence of hip dislocation. An orthopedic surgeon was consulted, who ruled out a hip problem. Then the family was told it was something constitutional and no other recommendation was made. The infant was otherwise healthy during the following months, however the family noticed that the cheeks were also growing asymmetric but they took no other action since they were told it was constitutional and would do no harm to the child. The family history was unremarkable and she was the first and only child of the parents who was born weighing 3.5 kg after an uneventful pregnancy.
At the age of 12 months, when she developed macroscopic hematuria, an abdominal US showed a right sided renal mass. The patient was then referred to our hospital for further investigation and management. A renal mass and hematuria in an infant with isolated hemihyperplasia strongly suggested a Wilms’ tumor. An abdominal US and a computed tomography (CT) scan confirmed a cystic/solid mass of 10 cm in diameter at the right kidney consistent with Wilms tumor (). Left renal vein and inferior vena cava were free of tumor infiltration. Right ki

[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:
23-year-old woman presented with 3-year history of abnormal movements of the head and neck. Her neck movements were jerky, periodic and semi-rhythmic. The movements looked myoclonic. The head was pulled down symmetrically, but she reported episodes of sustained torsion of the head toward the right or left. Her jaw would briefly open during these movements.
Initially, the movements were less frequent but gradually became more prevalent. They were happening every 5��s when she was seen at our clinic. The movements caused extreme pain and discomfort and had affected patient's quality of life tremendously. The movements continued during early stages of sleep based on a video recorded by her family. On the first visit, she denied any preceding urge or any relief after the movements. She could suppress the movements by stiffening her neck muscles. The movements would subside while she was talking, singing or chewing. Physical or emotional stress made her movements worse. Alcohol worsened her movements to the point that she stopped drinking alcohol completely.
Work up including blood work for complete blood count, complete metabolic panel, Serum TSH, ceruloplasmin and serum copper had been all normal. MRI brain with and without contrast and MRI cervical spine were unremarkable. EMG of upper extremities was remarkable only for occurrence of myoclonic jerks. EEG showed no spikes or any other abnormalities previous to the movements.
She had been diagnosed with different conditions; e.g., focal or segmental myoclonus, cervical dystonia and also functional movement disorders. A trial of clonazepam did not provide any relief. Cyclobenzaprine was not tolerated by the patient due to drowsiness. She tried botulinum toxin injection three times with minimal benefit only and at times she experienced adverse effects like swallowing difficulty and neck extension weakness with head drop. As the clinical picture did not clearly favor any diagnosis, we performed a physiological study to ch

[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:
Mr. R is a 36-year-old right-handed male who was admitted to Neurology service for his altered mental status. The patient has a history of hypertension, fibromyalgia, obstructive sleep apnea, depression and substance abuse. One month prior to his presentation, he underwent cardiopulmonary resuscitation (CPR) when he was found unresponsive at his home. The CPR reportedly lasted for 3-4 minutes. He was hospitalized and was found to be in respiratory failure and acute renal failure. He was intubated and was treated for his renal failure. He gradually recovered and was discharged. His family members started to notice gradually worsening behavioral changes and short-term memory problems because of which, he was brought back to the hospital again.
During the course of hospitalization, the patient showed gradual deterioration in his mental faculties. He underwent two magnetic resonance imaging (MRI) studies – first one during the initial admission and the second one, 10 days later. The initial MRI showed T2/FLAIR hyperintensity signal involving the cerebral white matter. The repeat MRI showed significant worsening of the T2 Flair hyperintensities in white matter (Figures , ). Neuropsychiatric evaluation showed that the patient showed significant deficits in his mental faculties including judgment and memory. A battery of blood and cerebrospinal fluid (CSF) studies including complete blood count (CBC), thyroid function studies, vitamin B12, human immunodeficiency virus (HIV), hepatitis panel and paraneoplastic antibody testing was ordered for the evaluation of his rapidly progressive cognitive decline and none of them came out to be abnormal. The patient later underwent a single-photon emission computed tomography (SPECT) scan followed by brain biopsy, which showed an area of demyelination. Post-biopsy, the patient was administered a trial of steroids which did not change his course. By this time, the patient’s cognitive decline came to a halt and was discharged to a nursin

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


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

[User]
RADIOLOGY NOTE:
A 32-yr-old woman was referred to our institution for the evaluation of an oropharyngeal mass. She reported that the mass was found incidentally at the age of three. However, because it was asymptomatic there was no further diagnostic work up or treatment. The patient had no symptoms such as swallowing difficulties or upper airway obstruction; however, she did report an occasional foreign body sensation. Flexible laryngoscopy revealed a pedunculated mass attached to the left posterior oropharyngeal wall (). A Gadolinium-enhanced T1 weighted MRI showed a 5×3×1.5 cm tumor that originated from the posterior pharyngeal wall with central enhancement and hypointense portions (). The mass had not invaded the adjoining structures. The peduncle of the mass was located at the level of C3 and the inferior portion of the mass filled the left pyriform sinus. These radiologic findings suggested a rare benign pharyngeal tumor such as a fibrous polyp and rhabdomyoma, but the radiologic diagnosis was not clear.
Although the mass didn't cause any symptoms at that time and it showed completely benign features according to the history and the MRI finding, we recommended a simple excision since the mass had the potential risk of upper airway obstruction due to its location just above the larynx and its huge size. A preoperative procedure for making the histological diagnosis was not performed because of the potential risk of blood aspiration and airway obstruction caused by swelling that would occur after the biopsy at the out-patient department.
Under general anesthesia, a pedunculated 5×3×1.5 cm sized mass was exposed with using a McIvor mouth retractor. The mass was completely excised from the posterior wall of the oropharynx with using monopolar electrocautery. The prevertebral fascia was exposed after the resection; the mass had not infiltrated to the adjacent structures. Frozen biopsy was not performed since the mass had benign features and an adequate resection margin was acquire

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


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

[User]
RADIOLOGY NOTE:
A 55-year old Caucasian male experienced 6 months of behavioural change and mild headaches. He was previously fit and well and a relatively affluent New Zealander. Initially his wife noticed an insidious loss of motivation and an increase in time spent over everyday tasks. Although the patient himself ultimately became aware of this he did not seek medical review until he developed associated nocturnal occipital headaches. Of note he was pain free during the day, including when supine, coughing, sneezing or straining. Both the patient and his wife denied any changes to his vision, speech, sensation or movement. He also denied any recent sinus symptoms. His general practitioner diagnosed depression and referred him to a psychiatrist. On review the psychiatrist became suspicious of an organic cause and, unusually, referred him directly to neurosurgery for workup.
On arrival his neurological examination was entirely normal with the exception of reduced olfaction. There were no obvious cervical lymph node enlargements. However, he was noted to be extremely anxious about the care he received to the point of paranoia. For example, he obsessively complained about the cleaning fumes on the ward and was convinced they played a role in his illness.
CT and MR imaging revealed a large soft tissue mass extending from his right nasal cavity and ethmoid sinus through the anterior skull base with erosion of bony walls and infiltrating into the frontal lobe causing significant mass effect (Fig. ). The intra-axial section of the lesion had a large cystic component which appeared to contain sediment material. His case was discussed at the local multi-disciplinary team. The consensus decided against an initial transnasal biopsy as there was significant intracranial mass effect and brain shift. A direct combined neuronavigation guided transcranial (bifrontal) and endonasal approach was planned and performed. Intraoperatively it became apparent that the right olfactory bulb was missing 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:
Chest radiography was performed for a 7-year-old girl with persistent cough and fever who was unresponsive to oral antibiotics and showed loss of volume of left lung sustained by almost total atelectasis. The patient was then admitted to the pediatric ward to begin intravenous antibiotic therapy. Serological tests for
Chlamydia pneumoniae
,
Mycoplasma pneumoniae
, and QuantiFERON test for tuberculosis were negative. A computed tomography (CT) scan showed an extended mass that occupied the entire upper lobe with axial dimensions of 70 × 47 mm and assumed discreet enhancement in all the study phases. The bronchi for the upper lobe were no longer patent with endobronchial projection affecting the middle third of the main left bronchus. The mass caused posterior dislocation of the pulmonary arterial vascular axis and inferior dislocation of the superior pulmonary vein. Based on the radiological reports, the patient was referred to our pediatric surgery unit. To better define the characteristics of the lesion, a magnetic resonance imaging was performed. The pictures confirmed the presence of an expansive pulmonary lesion with a probable origin from the upper left lobe with transverse diameters of 57 × 45 mm and longitudinal extension of 85 mm. The lesion infiltrated the pulmonary hilum and invaded the bronchial structures up to the left main bronchus ∼2 cm from the carina. It appeared adherent to the common trunk of the pulmonary artery and to the pericardium at the level of the left atrium and ventricle with infiltration of the superior pulmonary vein. The mass appeared to be surrounded by a thin rim of consolidated lung parenchyma; therefore, it does not seem to infiltrate the thoracic wall (
). For a complete diagnostic work-up, positron emission tomography–CT was performed; the findings showed softened uptake of the tracer at the voluminous expansive formation that tended to accentuate along the margins. Echocardiography revealed a 7-mm ostium secundum atrial defect

[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 man presented with a 3-day history of fever of 39°C and cough producing yellow sputum. He also appeared general malaise with nausea and vomiting. On examination, the man had rough breath sounds. An abdominal examination revealed mild epigastric tenderness without other definite positive signs, and the patient denied have had previous episodes with abdominal pain. A chest roentgenogram suggested bilateral pneumonia. His leukocyte count was elevated at 16×109/L. He had a history of diabetes for 5 years, which was treated with insulin. He was diagnosed with pneumonia. Unexpectedly, during the 3 days of treatment with azithromycin in the Department of Pneumology, his fever never decreased. He gradually developed right lower quadrant pain with guarding and rebound tenderness. Reexamination revealed an 8×8×6 cm mass. Ultrasound showed decreased echo owing to inflammation. Abdominal computed tomography (CT) revealed gas-liquid levels and dilatation of the intestinal tract (). The appendiceal area was obscured. According to the above examination, we judged that he already had a periappendiceal abscess at that time. The leukocyte count increased to 23×109/L at this time. Then, the patient was transferred to the Department of General Surgery with conservative treatment according to his long medical history and the formation of the appendicular abscess. We used cefoperazone sodium and sulbactam sodium combined with ornidazole. After 3 days of conservative treatment failed, surgery was performed via a right rectus abdominis incision. There was 500 mL of yellow-white festering around the paracolic sulcus. The tenia coli were traced down to their confluence, and the base was identified with a perforation. We decided to determine whether it was terminal, but we separated more than 10 cm without locating the terminus. Due to the severe adhesions, we used silk to bundle the appendix and cut it into two parts (). Then, we separated it to a size of approximately 5 cm 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:
34-year-old female Gravida 5, Para 4 in her 39th week of gestation with spontaneous labor was transferred to our hospital. Her pregnancy was uncomplicated. She denied smoking and had a BMI of 24 kg/m2. Her past medical history was unremarkable.
The first stage of labor was uneventful and lasted for 4 h. At the end of the second stage of labor which had lasted for 30 min, the patient complained of breathlessness and right-sided chest pain. Physical examination revealed the blood pressure was 140/90 mmHg, pulse was 102/min, and the oxygen saturation was 95 % on room air oxygen. The patient was found to be moderately tachypnoeic with breath rate of 22 cycles per minute. She received oxygen supplementation by facial mask and after pushing for 10 min, the labor ended with a vaginal delivery. A healthy, live female infant (4400 g) with Apgar score of 8/9 in the first and fifth minute was delivered.
Ten minutes later she felt worse. Palpation revealed mild subcutaneous crepitus in the neck and subclavian regions corresponds to subcutaneous emphysema. In a few minutes there was marked emphysema extending from the upper anterior chest wall up to the face. The deterioration of respiratory status was observed, still the patient's condition remained stable.
Chest X-ray was performed which showed pneumomediastinum and pneumothorax. Computed tomography () confirmed right-sided tension pneumothorax, pneumomediastinum and subcutaneous emphysema. A team of thoracic surgeons were required urgently. A pigtail catheter was placed in the 5th intercostal space. The pneumothorax was resolved during few hours. The chest radiograph was repeated 5 h later which showed resolution of pneumothorax. As the clinical condition had stabilized, the chest tube was removed. The patient was observed closely for 7 days in hospital, without a specific medication with proper analgesia during the first 48 h. The symptoms regressed and repeat chest X-ray confirmed disappearance of pneumomedi

[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 female presented to an outside hospital complaining of long-standing right knee pain. There was no history of trauma and her past medical history was otherwise unremarkable. Four months prior, she had undergone bilateral knee intra-articular high molecular weight hyaluronic acid injections. Physical examination of her right knee revealed full but painful range of motion and tenderness especially on the medial compartment. Radiographs of the knee revealed radiographic characteristics of osteoarthritis including joint space narrowing and sclerosis (). The patient underwent total knee arthroplasty for management of knee osteoarthritis. Intraoperatively, there were extensive arthritic changes in all three compartments. At that time, the surgeons observed that the lateral part of the synovial membrane in close proximity to the quadriceps muscle was found to be thickened and had an associated “fatty mass.” A specimen was sent for pathology, but at the same time, the findings were attributed to reactive synovitis, secondary to knee arthritis and the ongoing total knee arthroplasty (posterior stabilized design) proceeded per routine (). One week postoperatively, pathology results showed a biphasic malignancy composed of a mixture of spindled mesenchymal cells with admixed glandular epithelial elements. Immunohistochemically, the tumor was positive for vimentin, CD99, keratins AE1/AE3, keratin 7, epithelial membrane antigen, focally positive for S100, keratin 19 and keratins 8 and 18 of the epithelial-like cells. The aforementioned morphologic and immunohistochemical findings were consistent with a biphasic SS (). The patient was subsequently referred to the Musculoskeletal Oncology Department at the University of Athens School of Medicine for consultation and further management. An MRI of the right knee showed a large soft-tissue mass on the anterolateral side of the distal thigh. The mass was extending into the substance of the vastus lateralis, presenting a

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


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

[User]
RADIOLOGY NOTE:
A 44-year-old woman was diagnosed with iron deficiency anemia but showed no abnormalities on gastrointestinal tract endoscopy 5 years prior to the current presentation. A blood test for health screening showed anemia with hemoglobin 7.6 g/dL, and uterine fibroids were suspected on abdominal ultrasonography. She was diagnosed as having an intra-abdominal tumor on magnetic resonance imaging (MRI) for detailed examination and was referred to our hospital.
The abdomen was flat and soft, with an elastic mass of poor mobility which was the size of an infant's head was palpable below the umbilicus to above the pubis. There were no blood test abnormalities; CEA, CA19-9, SCC, and the interleukin 2 receptor level were within normal limits. Abdominal MRI revealed a homogeneous and well-demarcated 74 × 98 × 122 mm mass near the cranial end of the uterus, with a low signal intensity on T1-weighted image, and mostly low signal intensity and partially high intensity on T2-weighted image (Figures and ). Abdominal-enhanced computed tomography (CT) showed a well-demarcated and contrast-enhanced oval mass with a smooth margin in the pelvis. The tumor was supplied by the superior mesenteric artery, and the surrounding lymph nodes were enlarged (Figures and ). Upper gastrointestinal tract endoscopy showed an easily bleeding tumor with an ulcer in the third part of the duodenum, involving half the circumference (). The biopsy results were inflammatory exudates and granulation tissues. FDG-PET/CT showed heterogeneous uptake inside the tumor with SUVmax 6.3 (Figures –). A slight 18F-FDG uptake was observed in the enlarged lymph nodes with SUVmax 2.6. Along with the facts that there were no malignant cells detected by endoscopic biopsy and the CT image showing enlarged surrounding lymph nodes, the patient was suspected of nonepithelial malignancy of the duodenum such as gastrointestinal stromal tumor (GIST) and malignant lymphoma. As we could not make a definite diagnosis preoperatively, sh

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


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

[User]
RADIOLOGY NOTE:
A 58-year-old female patient presented with pain in abdomen and urinary incontinence with hematuria in April 2012 for which she was evaluated. Past medical history revealed that she had bilateral hydronephrosis for which she had undergone stenting. She also had Parkinson's disease and rheumatoid arthritis for which she was under regular medical management. A CT scan was taken which revealed a large ill-defined irregular mass in the uterine cervix with bilateral parametrial infiltration. The mass measured 5 × 4 cm at its widest point, infiltrating the lower uterine myometrium, extending anteriorly infiltrating the posterior wall and trigone of the bladder involving both vesicoureteric junctions. Posteriorly, the mass had infiltrated the anterior wall of rectum. Few enlarged internal ileac nodes were present bilaterally. Biopsy revealed the mass to be squamous cell carcinoma. She also had bilateral L5 spondylosis with grade II anterolisthesis of L5 over S1. She was treated with external radiation to the pelvis with a dose of 6000 cGy in May 2012. After radiotherapy, the PET-CT in June 2012 () showed residual cervical thickening and residual retroperitoneal lymphadenopathy with increased F18-FDG uptake in the aortocaval and retrocaval lymphnodes with the largest measuring 1.5 × 1.4 cm. Degenerative changes were also noted in the spine. For the residual lymphadenopathy, considering the factors like invasive nature of the surgery and the comorbid conditions of the patient along with fragile nature of her physique making chemotherapy, a high-risk one, the treating physicians recommended autologous natural killer (NK) cell and activated T lymphocyte based immunotherapy termed as autologous immune enhancement therapy (AIET). The first AIET cell transfusion was done in July 2012 and the second and third cell transfusions in August 2012. For each transfusion, approximately 70 mL of peripheral blood was withdrawn and the isolation, in vitro expansion cum activation of the NK c

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman was referred to the Oral and Maxillofacial Pathology Department with swelling over the buccal aspect of her right mandible. The swelling had been present for the last one year and had increased gradually in size over that period. The patient denied any trauma or pain but reported an unusual feeling in that area. Her medical history was unremarkable; she was not taking any medications and had no history of known drug allergy.
Extra-oral examination did not reveal any obvious facial swelling or asymmetry and there was no cervical lymphadenopathy. Intraoral examination demonstrated a round, painless swelling of about 2 cm in diameter in the buccal cortex of right mandible at the apical region of the lower right second premolar. This bony hard swelling showed no history of parasthesia or surface changes. The overlying mucosa was pink and appeared normal. Radiographic examination [] revealed a round radiolucency with a well-defined margin at the previous extraction site of first premolar, close to the apex of the lower right second premolar. The first premolar had been extracted more than 10 years ago and the patient could not remember any specific reasons for its extraction. The second premolar showed a normal response to vitality test and there was no root resorption.
Considering the size and clinico-radigraphic features of the lesion, cyst enucleation was done under local anesthesia and the specimen was submitted for histopathological examination. Its gross examination revealed a spherical, yellow cyst measuring 1 cm in diameter containing a milky, semi-translucent viscous fluid. The thickness of the cyst wall was about 1 mm.
Microscopically, hematoxylin and eosin stained sections showed a cyst lined with stratified ameloblastic epithelium consisting of relatively palisaded basal cell layer with plump epithelial cells, granular cytoplasm, small nuclei and distinct borders. These granular cells were closely packed cells distributed in groups through

[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 who was working as an international migrant worker sustained a crush and degloving injury to the right elbow while operating a waste agitator at an industrial waste management site. On initial examination, the patient was found to have massive skin and soft tissue defects on the anterior aspect of the elbow. The median nerve and brachial artery were exposed and contaminated (). In addition, the proximal part of the entire extensor muscle group was lost, along with segmental loss of the radial nerve with a 6-cm gap. The patient could not extend the right wrist or fingers, and severe muscle weakness (0 or 1 on manual muscle testing) was found in the area innervated by the median and ulnar nerves. The distal area of the right arm showed signs of perfusion, albeit weaker than that in the contralateral arm. The wound was irrigated and debrided, but a bacterial infection was detected after a few days and threatened to obstruct the brachial artery further. The patient was returned to the operating room for additional debridement, a saphenous vein bypass graft to reperfuse the occluded artery and placement of a muscle flap to close the open wound using the distal part of the extensor muscles, which were not salvageable due to the proximal muscle injury and the radial nerve defect.
The infection resolved following those surgical procedures. Six months later, the ulnar collateral artery was found to perfuse distally due to occlusion of the saphenous vein graft. Muscle strengths in the area innervated by the median and ulnar nerves improved to 2 or 3 on the manual muscle test, but there were no signs of recovery in the extensor muscles (). Protective sensation was confirmed in the area innervated by the median and ulnar nerves. Reconstruction of the finger extension with stabilization of the wrist were planned. The tendons of extensor carpi radialis and the tendon of abductor pollicis longus were secured to the radius under 30° of dorsiflexion at the wrist

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old elite collegiate football player (starter Division I Pac-12 conference) was in the middle of a play when he planted his foot and sustained a noncontact hyperextension injury to his right knee, resulting in a traumatic posterior knee dislocation. He was emergently reduced and immobilized on the field and then taken to the visiting team's trauma center for further evaluation. On initial presentation, good Doppler flow at the foot was noticed; however, over the next few hours, an arterial injury was highly suspected. The athlete was then taken to the operating room for angiography and arterial repair. Intraoperatively, acute occlusion of the distal popliteus artery at the bifurcation of the anterior tibial and tibioperoneal trunks was observed. A double interposition bypass with great saphenous vein using a posterior approach was ultimately performed, returning excellent flow distally. Finally, a long posterior splint was used to protect the bypass and stabilize the knee.
Once the patient had stabilized at the visiting team's hospital, he was referred to our outpatient facility. He was seen 5 days later for definitive management of his MKI. Physical examination was notable for decreased sensation in the CPN distribution, grade 4 weakness with ankle dorsiflexon and eversion, and moderate effusion with ecchymosis. Lachman's was positive as well as gross varus laxity. Review of the MRI revealed a KD III L MKI, complete anterior cruciate ligament (ACL) tear, partial posterior cruciate ligament (PCL) tear, lateral collateral ligament (LCL) fibular avulsion, and bicep femoris avulsion from the fibula. To assist with repair and clearance, vascular and plastic surgery were consulted. Once the team was established, it was decided that reconstruction would be performed in two stages. The first stage would be an open exploration of the CPN to determine the extent of injury and possible repair with plastic surgery, followed by repair versus reconstruction of the LCL

[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:
We describe the case of a 38-year-old right-handed male nonsmoking computer technician who was known to have dilated cardiomyopathy. He noticed a soft lump around the right 4th metacarpophalangeal joint measuring 1.5 × 1.5 cm. The lump had been present for almost 1 year and had started to become painful, hard, and increasing in size in the last couple of months. The patient underwent magnetic resonance imaging (MRI), which showed evidence of tumor depicted on the dorsal subcutaneous aspect of the hand at the level of the 3rd and 4th metacarpal head digits measuring 2.4 × 2.1 cm in axial dimension and 3.7 cm in craniocaudal dimension, with volar extension to invade the muscles surrounding the 4th metacarpophalangeal joint, in close relation with the cortex of the 4th metacarpal bone and the proximal phalanx without definite invasion (Fig. ). It was reported that no signs of metastatic disease were found. A biopsy was done, which showed clear cell sarcoma, melanoma of the soft part, grade 2. The patient underwent incomplete excision outside our center, and the tumor was removed using a double incision (volar and dorsal approach).
Upon his initial visit to our facility, the anterior and posterior incisions were completely healed and a drop in the ring finger was noted due to loss of extensor tendon, which was involved by the tumor as well. The specimen was reviewed and showed multiple peripheral and volar margins involved by the tumor. MRI of the right hand showed evidence of an ill-defined infiltrative soft tissue enhancement between the 3rd and 4th metacarpal bones extending through the metacarpophalangeal joint distally, but no definable well-defined nodules or masses. The enhancement was reaching the surrounding major tendons. Whole body positron emission tomography-computed tomography and brain MRI showed no evidence of metastatic disease. The multidisciplinary clinical decision was to proceed with 3rd and 4th ray amputation

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old man presented to the Emergency Department complaining of acute chest pain while he was dancing with his wife. He described his pain as a crushing precordial sensation with profuse sweating, without any radiation and not related to respiratory movements. It lasted for 30 minutes, being gradually relieved with rest. He denied palpitations or any other associated complaints.
He had a history of hypertension and epilepsy for which he was receiving treatment. No past history of ischemic heart disease was mentioned. He quit smoking many years ago and denied alcohol or drug consumption.
On admission in A&E, he was completely asymptomatic. On examination, he looked well, although he was tachycardic and haemodynamically compromised with a systolic blood pressure of 85 mmHg. The rest of his general clinical examination was unremarkable.
A 12-lead ECG showed a broad QRS complex tachycardia which at first sight resembled a ventricular tachycardia on limb leads (). On close inspection, the precordial leads displayed an irregularly irregular rhythm with broad and bizarre complexes at a rate of 145 (), alternating with a few narrow QRS complexes in sinus rhythm.
Blood glucose was elevated (without previous known diabetes mellitus) and the rest of blood tests were normal, including creatine kinase, cardiac troponin T, serum electrolytes and full blood count.
Given the patient risk profile (old age, hypertension, newly diagnosed diabetes), an acute coronary event was a concern and in the heat of the moment a decision for rapid reperfusion therapy was initially considered. It was then ruled out as the few normal complexes on the ECG showed no ST-segment elevation and an urgent transthoracic echocardiography demonstrated no regional wall abnormalities. The rest of the echocardiographic examination demonstrated mild concentric left ventricular hypertrophy with overall good systolic function and no significant valvular lesions.
He underwent DC cardioversion performed under

[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 previously healthy boy was elbowed in the neck during a football game. He continued to play after the incident; however, later on that day, he started having headache which prompted his visit to the Emergency Room. He had no other symptoms, and his neurologic exam was normal.
A CT scan of the head was done, and it was suspicious for a right internal carotid artery (ICA) dissection at the level of the skull base involving the extracranial portion of the artery. MRI and MRA of the brain and neck were subsequently performed and confirmed the diagnosis of a dissection resulting in minimal narrowing of the lumen of the ICA (Fig ). The patient was admitted to the hospital for observation, and was started on aspirin 81 mg daily. Work-up for collagen vascular disorders which may have predisposed him to carotid dissection was negative. He remained neurologically and was discharged home.
At 1 month of follow-up, he was asymptomatic with significant improvement of his headache. Follow-up MRI and MRA were performed and showed an unexpected progression of the dissection with high-grade stenosis of the true lumen of the right internal carotid artery (Fig ). The finding was confirmed with conventional angiography. Clopidogrel was added in addition to aspirin. After consulting the patient and his family, the patient underwent stenting of the right ICA at 2-month postinjury (Fig ).
Using a micropuncture set and under fluoroscopic guidance and strict sterile technique a 6 French femoral sheath was inserted into the right common femoral artery. ACT was kept between 250 and 300 with systemic anticoagulation.
The pretreatment internal carotid arteriogram demonstrated a persistent spiral dissection of the distal cervical segment of the right internal carotid artery with associated pseudoaneurysm. Following the diagnostic angiogram, and via a right internal carotid artery a small microcatheter was advanced over the wire through the spiral dissection. Over an exchange wire a

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


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

[User]
RADIOLOGY NOTE:
A 1-year-old girl presented with breathlessness and failure to gain weight since birth. Breathlessness was relieved by upright position. The child was born by normal vaginal delivery at home. The milestones were delayed. On examination, the child was pale and afebrile with breathlessness and irritability. The pulse rate was 100 per minute and respiratory rate was 50 to 70 per minute. On systemic examination, there was decreased air entry and presence of crepitations on the left side of thorax. Chest X-ray was consistent with pulmonary hypertension and showed left-sided diaphragmatic hernia for which she underwent surgery.
Intraoperatively, there was a large diaphragmatic rent with migration of more than 50% of small intestine, spleen and a part of large intestine into the left thoracic cavity. There was also evidence of malrotation of gut with colon on the left side and small intestine on the right side. The left lung was hypoplastic. A separate lobe of lung with no bronchial communication was seen in left hemithorax which was attached to diaphragm [] and was supplied by descending thoracic aorta. The sequestered lobe was resected and was sent for histopathological examination. The contents of the diaphragmatic hernial sac were reduced and the diaphragmatic rent was repaired.
Unfortunately, condition of the patient deteriorated and she died 2 hours after the surgery due to terminal cardiorespiratory failure due to pulmonary hypoplasia with pulmonary hypertension.
We received an ovoid mass of lung tissue measuring 6 × 3.5 × 1.6 cm for histopathological examination []. It was completely covered by pleura and showed a vascular pedicle without bronchus []. Pleural surface showed congestion. Cut surface showed few tiny cysts.
Histopathological examination revealed lung tissue with dilated bronchioles, alveolar ducts and alveoli []. Some of the bronchioles were tortuous with undulating cuboidal to columnar epithelium [] and abnormal cartilage plates []. Some areas were ch

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


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

[User]
RADIOLOGY NOTE:
A female child aged 11 years reported to the Department of Periodontia, of JKKN Dental College with the chief complaint of overgrown gums in both upper and lower jaw. The patient history reveals that her complaints started at 3 years of age and enlargement increased progressively covering the crowns of teeth []. Clinical examination revealed the presence of gingival enlargement and facial dysmorphism, with no relevant medical and familial history. There was no eye complaint, but there was upturning of eyes. On examination, psychomotor skills were normal. Computed tomography (CT) brain scan shows absence of neurological involvement. No skin pigmentation or other pathology was evident. Serum alkaline phosphatase level was normal.
Intra orally, gingival enlargement without interdental papilla was evident. Gingival enlargement completely covers the teeth and obscures the lip closure []. The enlargement was non-erythematous and on palpation it was firm and leathery in consistency.
Panaromic radiograph showed a bilateral multilocular radiolucency involves the body and ramus of the mandible, with sparing of condyle and thinning of the inferior border of the mandible was also evident. It also revealed the progressing osteolytic lesion pushing the permanent molar tooth bud to the inferior border of the mandible and also showed missing of lower right permanent canine tooth bud and upper left premolar tooth bud [].
Gingival biopsy reveals multinucleated giant cells scattered throughout the connective tissue [].
Bone biopsy was taken in the right retromolar region of the mandible under local anesthesia. The section shows vascular fibrous stroma with scattered multinucleated giant cells. The fibrous stroma is arranged in whirled pattern, which is abetting on the bony trabeculae. The giant cells are showing prominent nucleus and nucleolus. Few areas of the blood vessels show the collagen cuffing, but it is not prominent []. No malignant changes were seen.
Three dimensional fronta

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


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

[User]
RADIOLOGY NOTE:
A 40-year-old female patient reported with a complaint of pain and increased swelling on the right side of the face of 1-week duration. The swelling was first noticed by the patient on the right cheek region 4 years back and was not associated with any trauma or chronic irritation. The swelling had gradually increased in size and was asymptomatic until a week before reporting to us during which the patient claimed that the swelling exhibited rapid increase in size and was associated with continuous moderate pain which aggravated on manipulation. No meal time variation in size of swelling was noted and patient did not give history of dryness of mouth. The patient's medical history was otherwise noncontributory.
Clinical examination revealed a solitary diffuse extraoral swelling on the right cheek, measuring about 2 × 2 cm. The skin overlying the swelling was normal with no secondary changes. On palpation, the swelling was tender, with no local rise in temperature, soft to firm in consistency, and lobulated with a smaller hard nodule palpable at the inferior portion of the swelling (). The swelling was nonfluctuant, nonreducible, noncompressible, and nonpulsatile. The swelling was not fixed to any underlying or overlying structures and was freely mobile. There were no signs of altered sensations in the area involved. Intraorally a mild fullness of the right buccal mucosa was noted with no secondary changes with similar palpatory findings as performed extraorally ().
Soft tissue radiograph of the lesion using puffed cheek technique revealed 3 well-defined radiopaque concentric calcifications which were also visible on posteroanterior skull view and on the panoramic radiograph they were superimposed over the right mandibular third molar region (Figures , , and ).
Ultrasonographic examination of the lesion revealed a fairly well-defined hypoechoic mass in the right cheek devoid of vascularity. Three foci of calcifications were noted within the right masseter muscle. 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 previously healthy 57-year-old woman, with no significant past medical history, presented to the surgical department of our hospital for definite management of a primary pancreatic leiomyosarcoma, after being treated with adjuvant chemotherapy.
One year before her last admission, she was initially admitted to our emergency department due to abdominal pain, fatigue, and weight loss. She was totally healthy prior to these symptoms. She then underwent magnetic resonance imaging (MRI) that was indicative of a pancreatic head lesion along with possible metastatic liver lesions, superior mesenteric vein occlusion, and portal vein infiltration (Fig. a, b). The decision was to undergo an endoscopic ultrasound (EUS) biopsy in order to determine the exact nature of the lesion. EUS report was indicative of pancreatic leiomyosarcoma.
Multidisciplinary team’s decision was to use gemcitabine- and docetaxel-based chemotherapy as up-front treatment to assess tumor response. Follow-up CT scan and magnetic resonance imaging (MRI) after the completion of chemotherapy regimen showed downsizing of the pancreatic mass, as well as downsizing of suspicious for malignancy segment III liver lesion (Fig. c, d).
Based on the response to chemotherapy, tumor characteristics, and physical status of the patient, multidisciplinary team’s decision was to proceed to surgical exploration. Due to local expansion of the pancreatic tumor, its relation with the superior mesenteric and portal vein, and the underlying SMV thrombosis, excision of the pancreatic tumor was not feasible. Intraoperatively, a small piece of tumor was excised in order to be sent for histopathology. Surgeon’s decision was to ablate the tumor with irreversible electroporation (Fig. ). Metastatic liver lesions were identified with the use of intraoperative ultrasound. Segment III liver lesion was resected, while smaller lesions of the right lobe were ablated using microwave ablation.
The patient had an uneventful postoperative reco

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old woman presented with an asymptomatic pea-sized brownish nodule in right labium majus pudenda for 6 months. She had no remarkable medical or family history. Clinical examination revealed a dome-shaped elastic nodule, measuring 0.5 cm in diameter in right labium majus pudenda. No cutaneous ulceration was found, and no lymph node was palpable in the bilateral inguinal areas. There was no mass lesion was palpated in the bilateral breast. Routine laboratory test results provided no positive finding, suggesting no bodily biochemical abnormality. The mass excision was performed under the impression of an epidermal cyst or skin fibroma. Intraoperative finding revealed that the mass had no fibrous capsule and located in the deeper dermis. The mass was found to adhere to the underlying tissue, and the border between the mass and subcutaneous fatty tissue was indistinct. However, the mass was not observed to invade the epidermis. The mass was totally removed.
The surgical specimen was received and routinely fixed in 10 % neutral buffered formalin after tumor resection. Four micrometer thick sections were cut and stained with H&E. Microscopic examination revealed the tumor was solitary and located in the deep dermis without epidermal connection. The mass had an infiltrating border, and tumor cells were observed to spread into the subcutaneous fatty tissue with neural invasion. The tumor was composed of two types of cells. One was round to polygonal cells, which had eosinophilic, relatively narrow cytoplasm. The other had abundant pale or foamy cytoplasm. Both two types of tumor cell had enlarged nuclei with distinct nucleoli. These tumor cells were arranged in a micronodular or formed massive solid nests separated by densely fibroblastic stroma. However, scattered glandular or rosette-like structures representing ductal lumina were identified within the tumor nodules. There was no bluish mucinous material observed in the duct lumina. Both tumor cells showed mild t

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


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

[User]
RADIOLOGY NOTE:
An 18 year old female presented to the clinic with a 4 month history of pain and swelling in the right foot. The patient had no history of trauma and denied any recent history of fevers and chills. Pain was insidious in onset and gradually worsened causing difficulty in walking. Pain had increased markedly during the two months prior to presentation to our clinic. The patient had a liver abscess at the age of 4 and past open heart surgery for total correction of tetralogy of fallot at the age of 7 years. On examination the patient had tenderness and a swelling on the outer aspect of the right foot in the calcanocuboid region. There was no soft tissue involvement even though the overlying skin was warm. No appreciable lymphadenopathy was noted. She could not bear weight on the right foot. Motor function was difficult to asses due to excruciating pain on movement; she would drag her foot on the ground while walking suggesting that dorsiflexion was severely affected.
Conventional radiographs showed a lytic lucent area within the right cuboid bone (Figure &). Septations were seen, but the cortex was intact. No fractures or dislocation of the cuboid was noted.
MRI showed cystic areas with fluid filled levels in the right cuboid bone (Figure ). Mild expansion of the bone was noted. However no cortical break or involvement of other tarsal bones was seen. The lesion appeared hypointense on T1 and hyperintense on T2 images and also showed post contrast enhancement. Based on the imaging studies the foremost differential diagnosis of giant cell tumor, chondroblastoma, and aneurysmal bone cyst were made.
An open biopsy was thereafter performed. Microscopic examination of the tissue revealed sheets of cells exhibiting oval to elongated nuclei and moderate eosinophilic cytoplasm with distinct highlighted cell boundaries. Cells were indented with lobulated nuclei (Figure ). Occasional mitotic figures and scattered giant cells were also identified. Focal areas of fine

[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.