[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 female presented to our hospital with a right abdominal palpable tumor and pain of 7 days’ duration. She had slight tenderness at the right abdomen on physical examination. Laboratory tests that included a coagulation test showed no remarkable findings. Serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were 0.9 ng/mL and 14 U/mL, respectively.
Contrast-enhanced computed tomography (CT) revealed a 73 × 63 mm homogenous mass lateral to the second part of the duodenum and medial to the right kidney with IVC thrombosis (Fig. ). Anticoagulant therapy was performed with heparin, which was infused at 5000 U/day for first 24 h. The dosage was then increased to 20,000 U/day until the APTT value increased to twice the standard value. Magnetic resonance (MR) imaging revealed a mass with ring-like enhancement on T1- and T2-weighted images, and thrombus was seen in IVC (Fig. ). After 4 days, enhanced CT was used to evaluate the mass and thrombus. It showed that there was no remarkable change in the mass, but there was proliferation of the thrombus (Fig. ).
Therefore, based on the diagnosis of retroperitoneal tumor with thrombosis of the IVC, an IVC filter was installed, followed by resection of the tumor and thrombectomy.
Intraoperatively, the hematoma was seen below the liver between the second part of the duodenum and the right kidney. The tumor was separated on all sides while carefully avoiding damage to the right renal artery and other veins. The communication between the hematoma and IVC was identified. The right and left veins, and VC were clamped above and below the tumor before the tumor was excised, and the thrombus was seen extruding from the neck of the tumor. After thrombectomy, the venotomy was sutured with fine nonabsorbable sutures. During venotomy, about 1000 mL of rapid blood loss occurred, although several main veins were clamped. This bleeding was

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old female farmer in northeast China sought clinical attention owing to the swollen feeling of a cervical mass for 1 month. She had no family history and had not received any treatment or medication. The patient denied cervical pain, dysphagia, hoarseness, and other past medical conditions. On the local examination, a 5-cm painless movable nodule could be touched in region III of the left neck. Ultrasonography demonstrated that a hypoechoic nodule (size: 57.4 × 42.4 mm) was located in the left lobe of the thyroid, accompanied by regional lymph node enlargement in ipsilateral region IV. Doppler scan showed augmented internal blood flow in the mass. Subsequent computed tomography (CT) of the thyroid found a heterogeneous enlargement at the left lobe of the thyroid, a metastatic lesion in left cervical lymph node, and slight airway constriction (right shift of the trachea, ). Endocrinological tests showed that thyroxine and thyroid autoantibody levels were within the normal range (), indicating that the thyroid function of the patient was normal. The patient underwent left thyroidectomy and lymph node biopsy, and the initial diagnosis was SETTLE or FDCS. Subsequently, the patient was sent back to the operating theater for a total thyroidectomy and left modified radical neck dissection. Based on the histologic morphology and the immunohistochemical features of the resected cervical lesions, a pathological diagnosis of thyroid FDCS was ultimately made. Only one metastatic lymph node was distinguished in the left cervical dissection sections. After L-thyroxine replacement therapy, the patient became euthyroid with no evidence of disease 11 months after treatment.
Grossly, the left lobe of the thyroid was almost completely affected by the tumor (measured size: 6.0 × 4.0 × 4.0 cm), and the right lobe showed a diffuse goiter. The encapsulated tumor was solid, grayish yellow, tough, and did not show obvious necrosis or hemorrhage (). Microscopically, the tumor compr

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 77-year-old ambulatory man with hypertension, sarcoidosis, complete atrioventricular block status post-pacemaker implantation, chronic kidney disease due to FSGS, and right facial nerve paralysis, who presented with sporadic gait and right face numbness. He was diagnosed with sarcoidosis by biopsy of a tumor in front of the right tibia 14 years before presentation. Since the tumor and abdominal lymphadenopathy were the only manifestation of sarcoidosis and no other signs of organ involvement were present, he received no immunosuppressive treatment. The abdominal lymphadenopathy had been stable over time. Nine years before presentation, he was referred to our nephrology clinic to determine the cause of chronic kidney disease. His serum creatinine level was 1.2 mg/dL and he had proteinuria of 0.4 g per day. Hematuria was not present. Renal biopsy revealed six globally sclerotic glomeruli among all 34 glomeruli (18%) and some residual glomeruli with segmental sclerosing lesions, but no involvement of sarcoidosis. He was diagnosed with primary FSGS. Since the proteinuria was mild, he did not receive immunosuppressive treatment.
One year after that, the patient experienced palpitations and was diagnosed with complete atrioventricular block. Coronary angiography showed no significant stenosis of the coronary arteries, and he underwent pacemaker implantation. Whether sarcoidosis contributed to the complete atrioventricular block was unclear. The abdominal lymphadenopathy and the dyskinesia of the ventricular septum were stable and did not progress over time.
The patient was stable for eight years, until when he started to suffer from sporadic gait and right face numbness that occurred and resolved within a day every few weeks. Three months later, the symptoms recurred along with sudden dysarthria and left limbs weakness. Physical findings were notable for pronator drift on the left side. Perfusion computed tomography (CT) with iodinated contrast an

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


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

[User]
RADIOLOGY NOTE:
The second case is that of an 8-year-old female with a history of juvenile rheumatoid arthritis, scleroderma, bilateral genu valgum, and right external tibial torsion who underwent supramalleolar 40-degree derotational osteotomy. The tibial osteotomy was performed with an oscillating saw under irrigation and completed with an osteotomy. Concomitant fibular osteotomy was again performed to permit adequate correction. Fixation was achieved with a 6-hole 2.7 mm plate in compression (). Concomitant bilateral distal medial femoral 8-plate hardware removal and extensor tendon releases to the lesser toes were performed.
Postoperatively, the patient was immobilized in a cast. At the 2-month postoperative visit, it was noted that the patient had been very active in her cast including jumping off the bed onto the ground resulting in procurvatum and valgus displacement at her osteotomy site (). The patient was treated with prolonged cast immobilization for the subsequent 4 months followed by continued immobilization in a walking boot for another 2 months, activity restriction, and the use of a bone stimulator. The patient was managed conservatively for a total of 10 months postoperatively, at which point, a computed tomography scan was obtained showing persistent hypertrophic nonunion at the tibial osteotomy site.
The patient was taken back for revision open reduction and internal fixation with correction of the apex anterior and valgus deformity. Intraoperatively, significant mobility was appreciated at the site of nonunion. Perpendicular plating was performed. A 4-hole 2.7 mm plate was placed anteriorly and a 6-hole 3.5 mm plate was placed laterally, both in compression mode. The patient was again cast-immobilized and made nonweight-bearing for the first 10 weeks, at which time she was transitioned to a walking boot and advanced to weight-bearing as tolerated. At this point, radiographs demonstrated bridging callus across three of four cortices at the osteotomy site. At her

[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 with no significant past medical history presented after being struck in the face by a ball while playing water polo. The patient felt pain in her jaw, which was the chief complaint when she presented to the emergency department. Upon neurological assessment, the patient complained of midline tenderness from the skull base to midline cervical spine over C3; denied headaches, changes in vision, speech or swallowing, extremity weakness or paresthesias. A maxillofacial computed tomography (CT) scan did not show evidence of an acute facial fracture. However, the CT scan did reveal a radiolucent, ovoid-shaped lytic lesion arising in the left lateral mass of C1, between the anterior tubercle and the transverse process. Magnetic resonance imaging (MRI) studies further confirmed an enhancing osseous lesion at the left lateral mass of C1, with cortical breach and extension into the left lateral atlantodental joint space (). Of note, three years prior, patient had a CT cervical spine which, upon retrospective review, demonstrated a similar but much smaller lesion.
Differential diagnoses underlying this vertebral cortical erosion included those of infectious etiology, as well as oncologic lesions, such as giant cell tumor of bone, aneurysmal bone cyst, osteoblastoma, osteosarcoma or even Langerhans histiocytosis (LCH). Oncology recommended that the cervical spine lesion be biopsied for tissue diagnosis. Due to the unusual location of the lesion and risk of locally aggressive pathology, or possible tumor seeding along the biopsy track, interventional radiology was unable to perform a CT guided needle biopsy. It was therefore decided that the patient would require open neurosurgical biopsy for diagnosis.
Due to the anterior and lateral location of the vertebral lesion, an anterior transoral approach to the C1 lesion was performed, in order to obtain a sufficient amount of the contrast enhancing component of the mass for pathologic diagnosis. The transoral ap

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

[User]
RADIOLOGY NOTE:
A 44-year-old woman with no remarkable family history was admitted to our hospital with the following medical history: after undergoing modified radical mastectomy for cancer of the right breast (papillotubular carcinoma, T3N1M0) in March 2009 at another hospital, the patient received postoperative chemotherapy (4 courses of docetaxel+trastuzumab followed by 14 courses of trastuzumab). However, in March 2011, local excision was performed because of a recurrence that appeared at the site of the surgery, and adjuvant chemotherapy was administered. No relapses were observed thereafter.
When the patient was admitted to our hospital, the patient was of moderate build, was well nourished, had no yellowing of the bulbar conjunctiva, had no conjunctival pallor, and displayed no unusual finding in the heart or lungs. The abdomen was flat; the liver and spleen were not palpable. No remarkable finding was observed. An elastic, hard tumor approximately 20 mm in diameter with relatively distinct boundaries was felt in the left C region. The tumor was observed to be not fixed to the pectoral muscle, and it had not infiltrated the skin. No abnormal nipple discharge was observed, and axillary lymph nodes were not palpable. Peripheral blood and blood biochemistry test results were normal.
By mammographic examination, a high-density tumor with irregular margins and internal calcification was observed and was classified in Category 4. Because the imaging system at our institution has been changed and all previous imaging data were deleted, there are no mammograms to display here. Ultrasonographic analysis revealed that a 10 × 11 × 9 mm hypoechoic area was observed in the C region of the left breast. The lesion had a Tsukuba elasticity score of 2 and internal blood flow, and malignancy was suspected (Fig. ). By positron emission tomography and X-ray computed tomography (PET-CT), an area of greatly increased uptake was observed in the upper outer quadrant of the left breast (SUV max: 8.

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope.
He reported 3 month history of progressive neck mass. Physical examination revealed a temperature of 37.7 degrees, blood pressure of 130/87 mmHg, pulse of 92 bpm, and respiratory rate of 17 bpm. There was extremely large left sided neck mass extending into the left axilla and multiple palpable left and right cervical lymph nodes. The lungs were clear to auscultation, and there was a 2/6 systolic ejection murmur heard best at the bases. The abdomen was soft and nontender, without palpable organomegaly. There was a 5x2 cm right gluteal non-tender, non-mobile mass with central ulceration and also a 2x2 cm spherical mass at the left upper back with small central ulceration. There was 2+ pitting edema of the lower extremities bilaterally. There was differential swelling of left upper extremity. Electrocardiogram showed normal sinus rhythm, left axis deviation, low voltage and mild t wave inversion in V2–V4 ().
Initial CT scan of the abdomen and pelvis showed diffuse metastatic disease of the visualized lower chest, abdomen and pelvis including superficial soft tissues, left kidney, and probable right kidney. There was diffuse confluent adenopathy and massive right inguinal lymphadenopathy, along with pronounced diffuse anasarca. There are multiple renal masses. There are solid masses arising off of the lateral aspect of the left kidney involving the upper, middle and lower lobe (). The left kidney mass was described as an exophytic lesion. There was a mass along the anterior aspect of the heart that measures approximately 5 cm but incompletely visualized. CT head was negative.
Transthoracic echocardiogram revealed a large mass measuring 4.8 cm x 3.0 cm extending from the apex to the mid RV cavity, and extending into the RV outflow tract stopping just short of the pulmonic valve (). There

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


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

[User]
RADIOLOGY NOTE:
In March 2011, a 60-year-old woman presented at the gastroenterology unit of our hospital (AZ Nikolaas, Sint-Niklaas) with gastrointestinal bleeding (table ). Her medical history reported a deep venous thrombosis with lung embolism in 1999, gallbladder lithiasis, uterus myomatosus and a psychiatric disorder (anxiety and depression). Gastroscopy revealed esophageal varices that were successfully ligated. In addition, a CT scan of the abdomen showed a large tumor (diameter approximately 10 cm) in the left hypochondriac region, located cranial to the tail of the pancreas and expanding into the spleen area (fig. ). The tumor contained multiple calcifications in the spleen area and around the fundus of the stomach. A pancreatic tail tumor extending into the spleen or a primary splenic tumor was suspected. There was no invasion of the kidneys or adrenal glands, no retroperitoneal adenopathy, no parenchymal metastasis in the liver and no bone lesions. A diagnostic laparoscopy was performed. Anatomopathological examination of limited biopsy material showed the presence of a tumor with morphological and immunohistochemical features suggesting metastasis or extension of a clear cell renal cell carcinoma in the pancreas, although the possibility of an adrenocortical carcinoma could not be excluded. Hematoxylin and eosin staining revealed a lesion with a solid and nested growth pattern containing cells with clear cytoplasm, well-defined cell borders and small, slightly pleomorphic nuclei (fig. ). The tumor showed a strong positive reaction to staining for vimentin (fig. ) and focal positivity for CD10 (fig. ). It also showed strong staining with pancytokeratin (CK AE1/AE3) and focal positivity for synaptophysin; there was no immunoreactivity for CD45 (LCA).
Due to the widespread nature of the tumor in the upper abdomen and the inconclusive anatomopathological examination, the patient underwent surgery in a university center (UZ Leuven). In June 2011, the tumor was resected with

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old Saudi female presented in July 2014 complaining of bilateral nasal obstruction for 10 years, for which she sought medical attention and underwent septoplasty and functional endoscopic sinus surgery 7 years ago at a different institute. Postoperatively, the patient noticed minimal improvement in her symptoms with persistence of right nasal obstruction. She also noticed right nasolabial fold fullness for a year, which increased in size over time associated with right facial pain. Clinical examination revealed a swelling in the right nasolabial fold measuring 2 × 1 cm. It was tender to palpation, hard in consistency, but with normal overlying skin. Anterior rhinoscopic examination of the right nasal cavity revealed lateral nasal wall swelling obliterating 90% of the nasal vestibule with normal overlying mucosa and skin colour externally. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-defined subcutaneous soft tissue density measuring 1.6 × 1.6 cm located in the right nasolabial fold. The lesion demonstrated isointensity with no drop in fat saturation T1 but showed hypointensity on T2 and homogeneous enhancement postcontrast ().
In August 2014, the patient underwent surgical excision of the mass through a sublabial approach, and the mass was found to be encapsulated with no infiltration to surrounding tissues and was excised completely with its capsule with uncomplicated postoperative period. Histopathological examination of the mass revealed spindle cells proliferation, forming fascicles and whorls on a background of collagen fibres. The fascicles were associated with foci of mixed inflammatory cells infiltrate composed mainly of lymphocytes and plasma cells, along with scattered eosinophils and neutrophils. The lesion infiltrates the surrounding striated muscles and fatty tissue with no infiltration to cutaneous and subcutaneous tissue. Moreover, immunohistochemical studies on the spindle cells revealed they are diffusely p

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old Caucasian woman with no known past medical history presented to the emergency department with complaints of bilateral lower extremity edema and erythema with a clear serous discharge. The patient first noticed some small blisters on her left lower extremity which subsequently opened with some clear serous drainage. She also experienced progressively worsening swelling first of the left lower extremity and then her right lower extremity which prompted her to come into the hospital. Except for a cough, the patient had no other symptoms.
Preliminary evaluation at the emergency department indicated the patient had cardiomegaly and bilateral pleural effusions with a BNP of 1260. She also had atrial fibrillation with rapid ventricular response. The patient was not complaining of any chest pain, fevers, chills, nausea, vomiting or diarrhea. Her chest x-ray showed evidence of cardiac enlargement with interstitial densities and bilateral air-space processes possibly associated with asymmetric pulmonary edema. Large bilateral pleural effusions were noted, with the left greater than the right side. Incidentally, some evidence indicating a compression fracture of indeterminate age involving the upper lumbar/lower dorsal spine was observed.
The patient had no known medical history. In fact, she had not been seen by a physician for the last 15 years. Besides taking aspirin occasionally, she was not on any medications. She did not use alcohol, tobacco or illicit drugs. Physical examination did not reveal any specific concerns other than bilateral lower extremity edema.
CT angiogram of the chest showed large bilateral pleural effusions with bilateral lower lobe enhancing volume loss and worse on the left. Cardiomegaly was noted and there was no evidence for a pulmonary embolus. In addition, there was no evidence of deep venous thrombosis in the venous Doppler studies of her lower extremities bilaterally.
Echocardiogram indicated the left ventricle with some mild hyper

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


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

[User]
RADIOLOGY NOTE:
In 2007, a 58-year-old white male with no history of tobacco use, hypertension, diabetes, or hypercholesterolemia, and no family history of coronary artery disease, was found to have a large solid right renal mass and associated tumor thrombus of the inferior vena cava and right atrium. He underwent right radical nephrectomy and tumor thrombectomy performed under extracorporeal circulation. Cardiac function was investigated, including coronary angiography and transthoracic and transesophageal echocardiography. These studies documented normal cardiac function and normal morphology of the coronary arteries. Pathological examination of the surgical specimens demonstrated pT3cN0Mx conventional (clear cell) renal carcinoma, Fuhrman Grade 3 with negative surgical margins. A regular follow-up program was started. A few months later, hepatic and contralateral renal metastases were detected. The patient started treatment with the tyrosine kinase inhibitor (TKI) sorafenib on a dose-escalation protocol. Treatment led to an initial partial response followed by stable disease for 6 months. During December 2008, in a setting of stable disease, he underwent hepatic resection and enucleation of the left renal mass. The hepatic and renal masses were confirmed to be metastases. Early radiological assessment after surgery showed no residual hepatic or renal disease, but possible involvement of the mesenteric lymph nodes. Sorafenib treatment was therefore restarted at a standard dose of 800 mg/day. Treatment led to complete disease response within a few months, and was very well tolerated by the patient, who did not experience any of the typical adverse effects of the drug.
During February 2011, after 30 months of sorafenib treatment (6 months at 1600 mg/day and 24 months at 800 mg/day), the patient started to complain of worsening chest pain precipitated by normal physical exercise. A cardiac stress test showed exercise-induced ischemia. Coronary angiography showed critical sub-occlus

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old healthy female was admitted to our hospital with a new-onset tender bulge in her left groin, associated with subjective fevers and chills. Four days prior to presentation, she noted a sudden protrusion in her left groin with associated pain. Given worsening pain and intermittent nausea, she presented to our emergency room. On admission, physical examination revealed a soft, non-distended abdomen that was tender to palpation in the left lower quadrant. A soft, mobile, exquisitely tender, and non-reducible mass was appreciated in her left groin, concerning for an inguinal hernia. She had an unremarkable medical and gynecologic history and no prior surgical history. Laboratory data were notable for a leukocyte count of 6.7, a hematocrit of 36.9 and a lactate of 1.4 in the setting of normal electrolytes. An outside ultrasound showed an avascular complex cystic lesion measuring 2.1 cm in the left groin. A subsequent computed tomography scan of the abdomen and pelvis revealed a tubular cystic structure along the left inguinal canal, coursing along the expected path of the round ligament, without surrounding fat stranding or herniation of bowel loops. Given her symptoms and the unclear etiology of the hernia, she was admitted to the hospital and taken to the operating room for exploration (Fig. ). In the operating room, a 6-cm dark purple cystic structure was visualized within the sac of an indirect inguinal hernia, travelling along the round ligament down toward the mons pubis (Fig. ). The cystic structure was dissected away from the round ligament and the cyst was opened and noted to contain clear liquid. Ultimately, the patient underwent left indirect inguinal hernia repair, with Gore Bio A absorbable mesh, and excision of a left inguinal hydrocele of the round ligament. Final pathology revealed fibromuscular tissue lined by mesothelium consistent with a hernia sac and a hydrocele with concordant endometriosis. The patient's post-operative

[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 42-year-old male, Caucasian, presented to his stomatologist in May 2013 with a painless lump in the right jaw with 3 months of evolution. His Eastern Cooperative Oncology Group Performance Status was 0. The patient was an active smoker (24 pack-year) and denied drinking alcohol. He didn´t have other comorbidities. Oral cavity inspection revealed an ulcero-infiltrative lesion on the gingival margin of tooth 45 with extension to the tongue. In the lymph node assessment, an enlarged right submandibular node was palpable. The remainder of the physical examination was unremarkable. He had a normal complete blood count and biochemical profile. A biopsy of the lesion was performed and revealed a squamous cell carcinoma of the oral cavity. The patient was then referred to our institution.
A cervical and thoracic computed tomography (CT) scan revealed a lesion in the right alveolar ridge of the mandible with bone reabsorption, and multiple bilateral enlarged cervical lymph nodes with high contrast enhancement (
). No other anatomical changes were reported. The tumor was clinically classified in T4 N2c M0.
The case was discussed at the Head and Neck multidisciplinary team meeting (MDT) and a surgical approach was decided.
In August 2013, the patient was submitted to a partial glossectomy, right hemimandibulectomy and bilateral neck dissection. Histological analysis confirmed a squamous cell carcinoma of the oral cavity with cervical lymph node metastasis in 2 of 18 lymph nodes of the right lymph node dissection; the 12 lymph nodes dissected from the left side of the neck were clear from metastasis. The surgical margins were negative although the tumor was 1mm from the deep margin (pT4 N2b M0).
Due to the presence of positive lymph nodes, high T stage and close margins, the patient underwent adjuvant radiation therapy (60 Gy/30 fr over 6 weeks) from October to November. During the treatment he developed a grade 3 mucositis requiring a nasogastric feeding

[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 underwent transurethral resection of bladder tumor (TURBT) at our institute in 2004; her pathological diagnosis was a high-grade UC with adenocarcinomatous differentiation (pT2a, G2>G3). Radical cystectomy was conducted. Only carcinoma in situ (CIS) was found in the surgical specimen, and the surgical margin was negative. There was no cancer cell infiltration in the resected uterus or anterior wall of the vagina, and no lymph node involvement was detected. The patient developed continuous pain and bleeding from the residual vagina in 2010, and a tumor was found in the residual vagina; magnetic resonance imaging (MRI) showed it to be located on the anterior wall (). A biopsy of the tumor revealed a pathological diagnosis of adenocarcinoma (). Computed tomography (CT) and bone scintigraphy revealed no metastasis. Based on a preoperative diagnosis of a primary adenocarcinoma occurring on the residual vagina, tumor resection was performed (). The sigmoid colon was partially resected as it was strongly adherent to the tumor. On pathological examination, adenocarcinoma and SCC were detected (); on immunohistochemistry, sections of the tumor were positive for the SCC markers CD56, chromogranin A, and synaptophysin and were negative for the urothelial carcinoma markers GATA-3, p63, uroplakin, thrombomodulin, and 34βE12. We then reexamined the original TURBT specimen and confirmed the presence of SCC (). Adenocarcinoma and SCC were mostly present in the superficial layer of the TURBT specimen, while high-grade UC was found in the deeper layers where muscle invasion was present. Based on these findings, the tumor was diagnosed as a recurring bladder tumor. Local recurrence and pelvic bone metastasis were detected via MRI 3 months after the patient underwent surgical resection of the vaginal recurrence, whereupon she underwent radiation therapy (52 Gy, 26 fractions). She developed ileus in January 2011 and underwent release surgery. Subsequently, multiple l

[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 6-year-old boy presented with a history of lower back pain for the past 10 days with worsening of symptoms at night time, disturbing his sleep, and restricting his normal activities and play. He gave a history of a trivial fall on the back at the school, a few days before presentation. He had no other constitutional symptoms. The child was initially managed with local analgesic creams and massage therapy. He was later taken to family physician who had advised symptomatic therapy attributing it to mechanical and postural causes. However, in view of worsening of pain, the child was evaluated for tuberculosis spine. On examination, child had no lymphadenopathy or hepatosplenomegaly. On local examination, there was tenderness over the lumbar spine. Antalgic gait and scoliosis were present. The rest of the musculoskeletal system and neurological examination was normal.
Blood investigations revealed normal erythrocyte sedimentation rate and C-Reactive protein. Chest X-ray showed normal lung and Mantoux and sputum for Acid-Fast Bacilli was negative. The spine X-ray showed collapse of L4 vertebral body. With a provisional diagnosis of infective spondylitis, magnetic resonance imaging (MRI) spine done showed a lesion involving the right side of the L4 vertebral body and pedicle, with extension into the right L4–L5 neural foramen [ and ]. Pediatric oncologist opinion was sought and advised biopsy of the lesion. Computed tomography-guided biopsy of L4 vertebra showed aggregates of eosinophils and histiocytes having nuclear grooving and there was no evidence of granulomas. By immunohistochemistry the lesional cells were diffusely positive for S100, vimentin and focally positive for CD68 and CD1a, confirming the diagnosis of LCH. The work up for diabetes insipidus was normal. Bone scan showed abnormal increased tracer uptake only in the region of body of L4 vertebra. Bone marrow aspiration and biopsy to rule out marrow involvement was normal. He was started on LCH III protocol

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


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

[User]
RADIOLOGY NOTE:
A 9-year-old Caucasian girl was referred to the Department of Paediatric Cardiology and Rheumatology of Medical University of Lodz with a history of bone pain for the last one month. The pain was localized in the lower extremities, waking up at night and making it difficult to walk. Any peripheral joint oedema had been observed. The patient was otherwise healthy, no fevers, chills or weight loss were reported. She had no family history of bone or joint abnormalities, including tumors. She had no history of trauma or any triggering factor for the onset of the pain.
At the time of initial evaluation, she was reporting pain throughout the day and night. Pain was quantified as 8 out of 10 in the visual analogue scale (VAS). The left ankle was slightly swollen and was tender to touch, but no increase of the local temperature was observed. The active and passive motion ranges of the lower extremity joints – such as hips, knees and ankles - were decreased, due to severe pain. In otherwise general physical exam including skin and neurological exam was normal, no infection foci were found elsewhere in the body.
Her initial blood work revealed high rates of inflammation markers (CRP 119,1 mg/l N < 5,0; ESR 135 mm/h) with normal hematological and biochemical parameters (including lactate dehydrogenase, alkaline phosphatase or uric acid). At the day of admission, ultrasound examination of peripheral joints of the lower limbs was performed, no joint effusion and any other joint inflammation features were found. Empirical antibiotic (ceftriaxone) therapy together with non-steroidal anti-inflammatory drugs was implemented, however, the inflammatory markers’ levels were worsening in the control laboratory tests. Antibiotic treatment was extended with aminoglycoside, the girl reported aggravating of the night pain, migrating from bone to bone, night sweats were additionally observed. Blood culture was negative, but serologic tests had detected positive antibody titers to various pat

[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 man was admitted to the emergency room with complaints of a quadriparesis attack that had occurred 3 hours prior to the visit. There was no facial or respiratory muscle weakness or autonomic symptoms. The patient reported mild muscle pain after exercising the day before the visit and consumption of a lot of bread for dinner. Paralysis of the upper and lower limbs appeared bilaterally and started in distal areas such as hands and feet and progressed to the proximal area. The patient reported no paresthesia or hypoesthesia.
He had no respiratory or swallowing difficulties, he denied facial muscle weakness, and conversation was possible. He did not report any medications or herbal supplements, and there was no history of thyroid disease. The patient reported no underlying disease and no history of arrhythmia, chest pain, or dyspnea. In addition, the patient mentioned that he had experienced intermittent episodes of weakness in the lower extremities after exercising since his early twenties, although the symptoms were temporary and improved with time. There was no similar episode or specific disease history in the patient's family ().
On physical examination, the patient's blood pressure was 134/78 and the heart rate was 84 beats/min. His body mass index was 19.96, indicating normal weight. No jugular venous distension, goiter, or lymphadenopathy was observed. On auscultation, a regular heartbeat was noted, and there was no murmur. There were no specific findings on chest and abdominal examinations. There were no deformities or edema of the extremities, and the distal pulses were present and bilaterally equal.
Neurological examination revealed motor grade 1 and flaccid paralysis of all extremities. There were no specific findings in the sensory test. His blood sugar test indicated hypoglycemia or hyperglycemia.
Initial electrocardiogram(ECG) revealed a heart rate of 78, a flat T wave, and QT prolongation (QT/QTc 542/621 ms) (). The results of the blood tes

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


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

[User]
RADIOLOGY NOTE:
A 48-year-old African-American man with multiple myeloma presented with multiple bony lesions. Past medical history was significant for hypertension and hyperlipidemia. He was a bus driver. He received induction therapy with bortezomib 1.3 mg/m2 IV on days 1, 4, 8, and 11, cyclophosphamide 300 mg/m2 IV on days 1 and 8, and dexamethasone 40 mg PO on days of bortezomib. Cycles were repeated every 21 days. After three cycles, he achieved partial remission and underwent autologous peripheral blood stem cell transplantation. He then achieved complete remission. After he finished the third cycle of bortezomib, he developed BIPN with tingling, numbness, and burning pain of feet below the ankle despite being off bortezomib therapy and relatively low cumulative dose of the drug. His symptoms worsened over the next four months to the point that he was not able to stand or walk normally because of the severe pain. He was started on neurontin in escalating doses but was unable to tolerate doses over 1200 mg daily due to side effects, mostly dizziness. He was given morphine sulphate (MS) contin 15 mg PO twice daily with oxycodone 5 mg PO every 4 to 6 hours for breakthrough pain with no significant improvement. Pregabalin 75 mg PO twice daily was added without significant pain relief. His BIPN symptoms persisted with pain, tingling, numbness, and poor quality of life from the pain and pain medications. In addition, he was unable to drive because of pain and side effects of his pain medications. He was referred for acupuncture treatment.
During the patient's initial visit he had significant paresthesia/in bilateral lower extremities. No autonomic symptoms were reported. His self-reported overall pain score was 8 out of 10 on a 11-point visual analog scale (VAS). Neurological exam showed reduced sensation to light touch, pin, and vibration in distal part of his feet and absent ankle reflexes bilaterally. Muscle strength was five out of 5 throughout

[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 11-month-old girl presented with failure to thrive and dyspnoea secondary to cardiac dysfunction. She was found to be hypertensive. Blood pressure measurements demonstrated a persistent systolic pressure over 180 mm Hg. She was initiated on antihypertensive and diuretic medication. There was no family history of significance and no stigmata of autoimmune disease or neurofibromatosis. There was no syndromic phenotype. Biochemistry revealed marginally renal function (creatinine 25 mmol/L), but urinalysis was normal. Vasculitic screen was negative. Echocardiogram revealed left ventricular dysfunction and hypertrophy. Renal Doppler ultrasound demonstrated a reduced blood flow through a comparatively smaller right kidney (1 SD below mean) with abnormal spectral trace in the right renal artery. Divided renal function was estimated at 30% on the right and 70% on the left. No dysplastic changes were seen. Dimercaptosuccinic acid (DMSA) demonstrated a small right kidney and a divided renal function of 6% on the right and 94% on the left.
At this time, the patient was referred to our tertiary centre for a review at a multidisciplinary team (MDT) meeting to consider angioplasty versus nephrectomy as a treatment. The tests had not at this point identified any pathology in the left kidney (which DMSA had demonstrated to contribute to 94% of renal function), renal function was only slightly deranged, and bilateral RAS was thought to be usual. The decision was made to perform a right nephrectomy in the belief that the poorly functioning right kidney, and associated reduced renal perfusion, was driving a compensatory hypertensive response via the renin-angiotensin system. This was confirmed on biochemical assay of renin and aldosterone levels. At this point, she was taking 5 different classes of antihypertensive medication and the DMSA had shown only 6% function from the right kidney.
The nephrectomy was performed and the resected right kidney demonstrated no h

[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 woman presented to the emergency department with a stuporous mental state, ophthalmoplegia, and severe dysarthria. She had a prior history of cardiac valve replacement surgery for both mitral and aortic regurgitations 10 years earlier. Her National Institutes of Health Stroke Scale (NIHSS) score was 14 and modified Rankin Scale (mRS) score was 5. A CT scan of the head five hours after the onset of symptoms showed a hyperdense basilar artery on two consecutive 5-mm cut images, indicating an acute basilar artery embolism. After obtaining written informed consent for the endovascular therapy from the patient's family, the angiographic procedure began 5.5 hours after the onset of stroke. Angiography revealed a complete occlusion of the distal basilar artery (). At this point, a loading dose of abciximab (0.25 mg/kg) was administered intravenously. Rapid recanalization was achieved using a minimum dose of thrombolytic agents by performing direct angioplasty first followed by intra-arterial thrombolysis. Angioplasty was performed using a 2.5 mm diameter coronary balloon catheter. The balloon catheter was advanced into the occlusion site and inflated to 4 atm for 30 seconds. Immediately after the angioplasty, the basilar artery was partially recanalized with a restoration of the blood flow to the both superior cerebellar arteries. A microcatheter was then placed just proximal to the occlusion site, and 400,000 units of urokinase were infused at a constant rate for one hour. The completion angiograms demonstrated a partial recanalization of the basilar artery with embolus remaining in the basilar tip and the restoration of blood flow to both the posterior and superior cerebellar arteries. In addition, angiograms demonstrated a single perforating thalamic artery that was divided into two branches (). After the endovascular procedure, the patient showed progressive clinical improvement and regained complete consciousness within a few hours.
A non-enhanced CT sca

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old woman (gravida 5, para 3+1) had been delivered of 2 healthy sons and 1 healthy daughter via lower segment CSs in other hospitals 15, 11, and 8 years, respectively, prior to the current presentation. At 32+1 weeks of gestation, she presented at the emergency department of our hospital because of spotting. Her current pregnancy was not registered with any hospital and she had received no antenatal care. She had noted intermittent minor spotting between 28 and 30 weeks of gestation but had not visited any hospital or received any treatment.
On presentation to our hospital, she was found to have a hemoglobin (HGB) concentration of 87 g/L. Ultrasonography revealed that the lower edge of the placenta was completely covering the internal cervical orifice and was suspicious of the presence of PPP (Fig. ). A plain magnetic resonance imaging (MRI) revealed that the pernicious placenta previa was completely covering the internal cervical orifice, she had diffuse placenta accreta and also placenta percreta on the lower anterior uterine wall, and distended and twisted vessels were visible on the surface of the lower anterior uterine wall (Fig. ). A diagnosis of PPP was made. The patient was admitted to the obstetric ward and treated with dexamethasone to promote pulmonary maturation.
At 33 weeks gestation, she had 450 mL vaginal bleeding and was immediately transferred to the operation room for emergency CS. On arrival at the operating room, her blood pressure was 125/75 mm Hg and heart rate 90 beats/min. A resuscitation team comprising senior staff of the departments of gynecology, obstetrics, anesthesiology, and neonatology, the intensive care unit (ICU), blood bank and laboratories, and a nursing team was immediately established. The anesthesiologist immediately punctured an artery to enable invasive blood pressure (BP) monitoring, and devices for autologous blood recovery were assembled. Nurses established four 16 G intravenous lines immediately for fluid infus

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old right-handed woman was referred for evaluation of daily headaches occurring for a 3-week period. Her headaches were associated with nausea and vomiting. Magnetic resonance imaging (MRI) demonstrated a very large intracranial frontal fossa mass with significant bifrontal edema []. She was placed on steroids and neurosurgical follow-up was arranged.
Upon presenting to the neurosurgical clinic, her headaches, nausea, and vomiting had all resolved. She denied any seizure history, balance difficulty, or speech difficulty. Her family did note that her motivation had decreased over the past few years. Her past medical history includes uterine fibroids, arthritis, and fluid retention. Her past surgical history includes a hysterectomy, tonsillectomy, and lumbar laminectomy. She has no allergies.
On physical exam, the patient was found to be neurologically intact, except a decreased sense of smell. A review of her MRI demonstrated a dural-based mass that followed the olfactory groove which was associated with an infiltrative cap-like mass that was not typical for a meningioma.
A bilateral subfrontal approach was utilized. The tumor was initially noted to be of soft consistency and to have well-defined margins. However, as the resection progressed to the superior surface of the tumor, the macroscopic characteristics changed. In this region, the tumor was noted to appear infiltrative without a clear border. A specimen from this area was sent for pathologic review. Frozen section showed numerous “small blue cells” concerning for lymphoma. At this point, the surgical resection was stopped because it was felt that the meningioma component of the tumor had been completely removed. The patient awoke from anesthesia and was noted to be neurologically intact.
Pathologic review of surgical specimens revealed two different neoplasms. The first one was a WHO grade I meningioma that comprised cells exhibiting numerous whorl formation and occasional psammoma bodies. Also, foc

[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 woman reported to the outpatient department of our tertiary care hospital with lower abdominal pain, vaginal spotting, and severe nausea lasting 10 days. At the time of presentation, she was primigravid at 18 weeks and six days of gestation according to her last menstrual period. The pregnancy was a planned conception occurring within three months of marriage. The pregnancy was confirmed with a positive urine pregnancy test. Further questioning about menstrual history revealed cycles of four to five days every 28 to 30 days. Past medical, surgical or family history was unremarkable. On physical examination, she was alert and pale with a blood pressure of 150/90 mmHg and a pulse of 80 beats/minute. Her abdomen was soft, non-tender with a 32-week fundal height. A speculum examination revealed no active bleeding or discharge; the os was closed. Apart from the elicited anemic signs, the remainder of the physical examination findings were within normal limits. An ultrasound examination revealed a single live fetus of 18 weeks and two days in duration (Figures -). We also noted a partial mole indicated by mass resembling a bunch of grapes and measuring 19 cm by 8 cm. The molar vascularity was insignificant on the Doppler evaluation. We ordered additional investigations through our hospital’s designated laboratory.
At 20 weeks of gestation, a repeat ultrasound revealed a single live fetus of 20 weeks duration with no gross fetal anomaly. A large mass with multiple short cysts was noted in the fundal region at the site of the placenta. We also noted evidence of a partial mole in the anterior fundal region of the uterus measuring 19.7 cm by 10.9 cm, bulging into the amniotic cavity and compressing the fetus. Repeat serial measurement of β-hCG at this point of pregnancy was 561,771 mIU/mL. At 20 weeks and two days, she reported concerns of a passage of grape-like vesicles, and spontaneous abortion followed.

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old male visited our clinic immediately after discharge from a psychiatric hospital with the status of a leaning head at 45° and a salivating mouth; he seemed to be drug intoxicated. His legs were flexible under holding arms, his eyes were nearly closed as though he felt they hard to lift up, pupils were too bleary to focus, and it was obvious that conversation was impossible. Medical information was obtained from his mother and grandmother as guardians. The patient exhibited gradually worsening sleep and concentration from 7 years of age and was prescribed neurological medications. In middle school, the patient was diagnosed with depression, and symptoms became more severe. Since then, he has been admitted to the psychiatric hospital several times a year. Whenever the patient is leaving the hospital, he showed an increased sedation including this intoxicated-like status. As a routine assessment, we examined the patient’s pulse, and it was strong at 95 bpm.
Type C of chimsband was attached to the chest (), both sides (), and upper back () of the patients. Typically, we palpate using finger pressure to elicit a sensitive or painful response. However, in this case, we attached tapes based on our previous study and practical experiences omitting this typical examination, because we could not obtain exact response from the patient. After attachment, the pulse decreased to 82 bpm. Additionally, when we asked what he felt, he became extremely emotional and started to cry. His grandmother stated that she had never seen him cry since diagnosis of depression. We provided instructions to the guardians on how to attach the medical tape on the same points used in our clinic and how to check the patient’s pulse. After 1 week, the grandmother reported that he slept >14 h/d with no special symptoms, and his face became clearer than before the treatment. Although the guardians worried about him

[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 36-year-old woman, gravida 1, parity 1, had just given birth to a baby via cesarean delivery at a local delivery clinic due to cephalopelvic disproportion. The postoperative course was uneventful. On her 8th postpartum day, she started taking Shenghua decoction twice per day. On the 11th postpartum day, sudden onset of massive vaginal bleeding was noted, and she was then sent to her delivery clinic, where endometrial curettage was performed and intravenous uterotonic agents were administered for her postpartum hemorrhage, but massive vaginal bleeding persisted. The total estimated blood loss was approximately 2000 mL at that time. Hence, she was transferred to our emergency department. She arrived at our emergency department at 7:57 am, and her blood pressure was 110/46 mmHg, her pulse rate was 130 per min, and her oxygen saturation was 96%; therefore, we started fluid resuscitation. At 8:05 am, her blood pressure could not be measured, and her pulse rate was 140/min, oxygen saturation was down to 89%, and change in consciousness was noted. Intensive resuscitation was performed, including central venous catheterization, blood component therapy, endotracheal intubation, and administration of uterotonic agents and vasopressor. Her hemoglobin was 2.6 g/dL, her hematocrit was 8.5%, and heavy vaginal bleeding continued despite uterotonic agents []. Owing to her extremely unstable hemodynamic status and continuous heavy bleeding, we did not consult interventional radiology for possible emergent transarterial embolization; instead, she was transferred to the operation room and underwent emergency total hysterectomy []. During hysterectomy, there was no retained product in the uterine cavity, and her cesarean wound of the uterus remained intact. A total of 20 units of packed red blood cells, 14 units of fresh frozen plasma, and 4 units of aphesis platelets were transfused during hospitalization [].
The pathological examination of the uterus revealed that the endometrium w

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old male, originally from China, with a past medical history of hypertension, diabetes, paroxysmal atrial fibrillation, and a stroke with residual left-sided deficit and waxing and waning mental status was brought to the hospital for weakness, urinary incontinence, confusion, and poor oral intake. On the day of his presentation, the patient was noted to appear weak on the left side more so than at baseline. The patient was brought to the emergency department as a stroke code; computed tomography (CT) scan of the head ruled out acute stroke. Vital signs were significant for a heart rate of 94 beats per minute and respiratory rate of 31 breaths per minute. The patient was admitted to the hospital for sepsis and workup for possible toxic, metabolic, or infectious insults leading to recrudescence.
The patient was started on empiric antibiotics, which were narrowed when blood cultures revealed gram-negative bacteremia speciating to Klebsiella pneumoniae, ampicillin-resistant, but sensitive to ceftriaxone. A CT scan of the abdomen and pelvis demonstrated the presence of a large cystic region with air-fluid level in the left lobe of the liver ( and ). Under the suspicion that this lesion was the source of the patient’s bacteremia, the patient underwent percutaneous drainage of the lesion by Interventional Radiology, which produced 80 cc of purulent fluid, also growing ampicillin-resistant, ceftriaxone-sensitive Klebsiella pneumoniae. While a stool ova and parasite examination on the patient was negative, further workup revealed that the patient was positive for Entamoeba histolytica antibody in the serum, detected via enzyme-linked immunosorbent assay and indicative of either current or prior infection. The patient had lived in the United States for several years, had no recent travel history and, to the knowledge of his family, had never been diagnosed or treated for E histolytica infection in the past; as such, he was started on metronidazole and paromomycin fo

[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 year old male patient was referred to the Department of Otolaryngology, Head and Neck Surgery at the University Hospital Tuebingen in August 2002. Diagnosed at the age of two he underwent tracheostomy and since had been treated for juvenile onset recurrent respiratory papillomatosis (JORRP) through multiple surgeries. Papillomas were detectable in the larynx, trachea, and main bronchi and the patient had progressive lung manifestations. At the time of referral the patient had already undergone 116 operations. A total of 16 surgical excisions and laser ablations were performed during the following 5 years. In addition to ablative therapies, the patient was treated with the antiviral drug cidofovir for three years (2004–2007): first intralesionally, later systemically and finally via inhalations.
At the age of 18, he presented with a tracheal stenosis that was treated by balloon dilatation; he was also affected by pneumothorax and subcutaneous emphysema of his upper body, which was treated by a thoracic drainage. One year later the patient developed symptoms of Leriche’s syndrome caused by thromboembolic occlusion of the aortoiliac bifurcation. An embolectomy was performed. Additional thromboembolic events caused minor infarctions in both kidneys and the spleen. An ischemic stroke in the supply area of the left middle cerebral artery caused aphasia, hemiparesis and facial nerve paresis. Four days later, another thromboembolic crisis led to an occlusion of both femoral arteries. Magnetic resonance imaging revealed a suspicious mass in the left cardiac atrium, involving the right pulmonary vein. About one month later a series of thromboembolic events involving the brain, liver, heart, kidneys, aorta, and pelvic arteries occurred. The patient finally died and an autopsy was performed at the Institute of Pathology, University Hospital Tuebingen.
To characterise the patient’s viral infection in more detail, DNA was extracted from surgically removed laryngeal papilloma

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


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

[User]
RADIOLOGY NOTE:
A 3-year-old boy was brought into hospital because of developmental regression. His medical history revealed little problems, except for a bronchiolitis caused by respiratory syncytial virus, for which he had been in hospital as a toddler. Uptill a few months earlier his neuromotor development had always been on schedule. Six months before admission to our hospital he was hospitalized in a different clinic with convulsions, thought to be caused by a viral infection with enterovirus. Afterwards he progressively developed constipation, limping, and an inability to play in his normal manner. The boy is the firstborn son of two nonconsanguineous parents of Afro-Caribbean origin. The mother and maternal grandmother of the boy are known to have ROWD. A maternal uncle was diagnosed with systemic lupus erythematosus.
During the diagnostic workup in a neighbouring general hospital an MRI scan of the spinal cord was performed (). It showed a spinal vascular malformation with a large aneurysm at the level of the lower thoracic spinal cord, causing massive compression of the lumbar spinal cord. The boy was transferred to our university hospital for further diagnosis. Spinal angiography (under general anaesthesia) identified the vascular malformation as a spinal arteriovenous fistula with an associated large venous aneurysm at the level of the fistula. The dilated arterial feeder as recognized from MRI originated from the intercostal artery at T9. It was thought to be a single fistula. Due to the low weight of the boy, only a limited amount of contrast could be administered and more distal thoracic levels were not checked. An embolisation of this AVF at T9 was carried out, using a coil and a liquid embolic agent (). The idea was that the aneurysm would gradually shrink in time, whereas initial aneurysm occlusion would result in an oedematous reaction with increase in spinal cord compression. Postoperative high-dose dexamethasone was given to prevent oedema of the spinal cord. Th

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


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

[User]
RADIOLOGY NOTE:
In February 2003, a 61-year-old white female with a history of partial gastrectomy due to a peptic ulcer, and mastectomy due to breast cancer twenty years before, presented with an indolent erythematous mass on her left hard palate and attached gingiva. Her dentist had originally diagnosed periodontal disease, and she was unsuccessfully treated with antibiotics and non-steroidal anti-inflammatory drugs; she subsequently also underwent otolaryngological and radiological examinations of the mouth, but both were negative.
In September 2003, a hard palate biopsy led to a histopathological diagnosis of a chorion metastasis from a breast adenocarcinoma, but the results of subsequent mammography, abdominal ultrasound, chest X-ray and neoplastic marker analyses did not reveal any evidence of a tumour. One month later, a second hard palate biopsy revealed an undifferentiated carcinoma with a focal microglandular and diffuse signet-ring cell growth infiltrating the subepithelial chorion mucosa consistent with a gastric origin (Fig. ). Although the patient was asymptomatic, gastroscopy showed an ulcerated lesion of the greater curvature of the stomach, and histopathogy revealed an undifferentiated gastric carcinoma with signet-ring cells (Fig. ).
She was admitted to our Institution in October 2003, when a physical examination revealed left supraclavicular adenopathy, left exophthalmus, and a firm and painless erythematous mass of nearly 4 cm on her left hard palate, with no evidence of bleeding at palpation (Fig. ). She was negative for neoplastic markers, and denied any weight loss or gastrointestinal symptoms during the previous weeks. The results of chest and abdominal CT scans were negative, but magnetic resonance imaging of the maxilla revealed an enhanced 2.7 × 2.3 cm lesion on the left hard palate, with thickening of the genal mucosa and no bone involvement (Fig. ).
A review of the slides of both the oral and gastric lesions confirmed the diagnosis of a mucosal metastas

[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 Japanese woman came to our hospital in 2004 complaining of abdominal discomfort. Computed tomography with contrast enhancement revealed a unilocular cystic lesion, 17 cm in diameter, in the left lobe of the liver preoperatively. No nodular components were identified in the cystic lesion and no contrast enhancement was observed in the cyst wall. T2-weighted magnetic resonance imaging revealed septum-like structures in the cystic lesion (Figure ). Ultrasonography also showed floating septum-like structures in the lesion. ERC was not scheduled. She had been afebrile before the operation. The white blood cell count and levels of C-reactive protein, carcinoembryonic antigen, and CA19-9 were within normal limits. Based on this preoperative information, the cystic lesion was diagnosed as a simple cyst or biliary cystadenoma and the attending surgeon scheduled an operation for cyst fenestration or left lobectomy. At the beginning of the operation, the surgeon punctured the cyst and found that the fluid was turbid brown. Although the total bilirubin concentration in the fluid was 2.1 mg/dl and cytological examination showed no atypical or malignant cells, the surgeon worried about the possibility of infection in the lesion and its spread to the abdominal cavity, so a left lobectomy was performed. The postoperative course was uneventful and the patient was discharged on postoperative day 16. The patient remains alive at nine years postoperatively.Macroscopically, the cystic lesion, 200 by 150 mm in size, was unilocular, had no solid lesion inside, and did not contain mucin. Whole liver specimens were cut into 5 to 10 mm thick pieces, which were then sliced into 5-μm sections. Histologically, the cyst wall was lined by low columnar epithelia with slight cellular atypia (Figure ). All sections were examined at the time of surgery, but no OS or BDC were seen throughout the specimens. We diagnosed the cystic tumor as biliary cystadenoma based on the WHO classificati

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


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

[User]
RADIOLOGY NOTE:
A 3-year old girl presented with swelling over the root of the nose. Her parents had noticed swelling 7 months previously, which was gradually progressive and was the size of a small lemon at the time of presentation. The swelling was not associated with fever, nasal obstruction, bleeding or any other nasal complaints. The patient was prescribed antibiotics and anti-inflammatory drugs by the general practitioner, following which the swelling decreased slightly. The patient had recurrent episodes in which the swelling increased in size. The size of the swelling decreased on medication, but never completed resolved. There was no history of tubercular contact or any other family history of tuberculosis. On examination, the root of the nose was broadened by the ill-defined 2.5×2.0 cm swelling, but the overlying skin was normal ().
On palpation, the swelling was soft and non-tender with a normal temperature. Anterior rhinoscopy revealed no abnormality. Blood analysis showed raised erythrocyte sedimentation rate (ESR; 38mm). The patient had a positive Monteux test, and a chest X- ray showed no abnormality. Contrast enhanced computed tomography (CT) of the nose revealed an enhancing soft tissue mass lesion in the superior aspect of both of the nasal cavities, measuring 2.0 ×1.8 × 2.8 cm (AP × TR × CC), eroding the intervening nasal septum, frontal and nasal bones at the glabella and reaching to the subcutaneous tissue ().
The base of the skull was eroded with a small intracranial extension. Magnetic resonance imaging (MRI) of the brain and paranasal sinus revealed enhancing soft tissue mass in the basifrontal extra-axial region with dural enhancement extending inferiorly into the superior parts of the nasal cavities with osseous destruction ().
The patient underwent endoscopic examination and biopsy under general anesthesia. On endoscopy, a smooth reddish mass was seen in the left nasal cavity. The mass was friable and found to be eroding the nasal septum, reaching the opp

[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 Caucasian man, known to have generalized NF1 since the age of 21, presented at our clinic complaining of a swelling in his left forearm. He reported that his complaint started 1.5 years previously, when he noticed a slow-growing swelling. The patient was assured that the swelling was a simple lipoma that could be electively resectioned. The patient's history revealed no preceding trauma or inflammation. The swelling was not painful. His family history revealed no similar conditions, but his father and grandmother were operated on for bowel carcinoma. According to the physical examination, the patient had generalized cutaneous neurofibromas all over his body and some papillomas in his mouth. He is of average build and was of normal health and without any other systemic diseases. Local examination showed a hard, lemon-sized, non-movable tumour in the ventral aspect of the left middle forearm. The skin was not affected. The range of movement of the left forearm and hand were free, as was the range of movement at the wrist.
Radiological examination started with X-ray imaging of the left forearm. It showed a soft tissue tumour with no bone affection. Ultrasonography showed a 91 × 52 × 50 mm inhomogeneous condensed tumour with a well-defined border. Contrast-enhanced magnetic resonance imaging (MRI) showed a 95 × 55 × 49 mm well-defined, highly inhomogeneous tumour with liquid and fat equivalent parts. It displaced surrounding tissue (Figure ).
Following radiological criteria, the tumour was suspected to be malignant. Therefore, we took an open biopsy of the central tumour region. Pathological examination revealed a heterogeneous tumour. There was a region of myxoid ground matrix with parallel elongated spindle-shaped cells with hyperchromatic nuclei and another region of enlarged cells with clear cytoplasm and hyperchromatic and deformed nuclei. We identified multiple apoptosis and some mitosis. Some regions of the tumour were necrotic. Moreover, thrombosed

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


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

[User]
RADIOLOGY NOTE:
A 4-year-old boy presented to the emergency department with complaints of abdominal distension and pain for five days. He had a history of bilious vomiting with worms in the vomitus for past four days. There was a history of constipation for four days. The boy did not have fever or trauma to the abdomen. He was from a rural area in India, with frequent day to day contact with cattle. His parents were farmers by occupation and were illiterates. He weighed 14 kg and never had a previous history of passing worms in stools. He had a history of pica. There was no history of loss of appetite until recently for past one week. He was managed conservatively in another hospital for three days and referred to us for further management. On examination, the child was febrile, pulse rate 120 per minute, and blood pressure: 90/60 mm Hg. The abdomen was distended with few visible dilated bowel loops. On palpation, there was guarding and rigidity in the centre of the abdomen; no organomegaly. Bowel sounds were sluggish. Digital rectal examination revealed an empty rectum.
Blood investigations were as follows: Haemoglobin 10 g/dl, total counts 20,000/mm3; differential count: Neutrophils 76%, lymphocytes 16%, eosinophils 10%. Renal function tests were normal, Widal test result was negative and blood culture was reported as “no growth”. Chest X-ray erect showed no free air under the diaphragm. Abdominal X-ray revealed dilated gas filled small bowel loops. In view of abdominal signs and hypotension, written informed consent was obtained from the child’s parents and the boy underwent emergency laparotomy after adequate resuscitation.
On laparotomy, the entire small bowel was dilated and filled with worms. Distal ileal volvulus () was present with a single 1 cm sized perforation in the antimesenteric border of the ileum and a worm was seen protruding out through the perforation (). The rest of

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old male, Kabaddi player, presented to Pravara Rural Hospital, Loni in January 2021 with right knee instability of 6 months duration, positive Lachman test, complete ACL tear and medial meniscus posterior horn Grade III tear on magnetic resonance imaging (MRI). He was treated with arthroscopic ACL reconstruction using semitendinosus and gracilis (HT) graft fixed with 15 mm closed-loop button on the femur and 25 mm × 8 mm titanium screw on the tibia and medial meniscus balancing. Post-operative radiographs confirmed well-fixed button and good tunnel positions (). The patient was started on knee rehabilitation, closed chain exercises, and full weight-bearing.
Two months after the surgery, the patient met with a road traffic accident and fell from a moving motorcycle with twisting injury to the same knee. The patient presented to us 7 days later with severe pain, even on slight movement, moderate effusion in the right knee with an inability to bear weight. Lachman and varus and values stress test were positive. An anteroposterior radiograph revealed a double joint line sign of lateral femoral condyle with the button sunk inside the lateral femoral cortex. Oblique radiograph confirmed a fracture passing through the femur tunnel with the button inside the fracture (). MRI showed a spiral displaced fracture of the lateral femoral condyle (), intact but lax graft fibers, and a button artifact inside the fracture line with intact medial collateral ligament and lateral collateral ligament ().
Arthroscopy assisted fracture reduction and internal fixation with an assessment of graft and possible salvage were planned. Arthroscopy revealed an intra-articular spiral fracture of the lateral femoral condyle involving the femur tunnel with intact graft fibers trapped into the fracture site making the fracture reduction difficult. The fracture plane was coronal distally inside the joint (as seen in arthroscopy) then attended para-sagittal orientation as it exited at the lat

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old man with a 3-year history of progressive loss of peripheral vision in his right eye was referred to our clinic following the discovery of a suprasellar mass on imaging. He denied any headaches, history of seizures, recent changes in weight, breast discharge, heat or cold intolerance, or changes in shoe size or facial features. His only complaint was a progressive visual field defect in the right upper quadrant of the right eye. He had no significant other medical or surgical history, and, apart from a visual field defect of the right eye (quadrantanopia), he had an otherwise unremarkable physical exam including intact cranial nerves III to XII. Endocrine workup was unremarkable. Magnetic resonance imaging (MRI) with and without contrast of his brain revealed a multilobulated complex mass with both cystic and solid components in the suprasellar region measuring 28.7 mm × 34.5 mm × 37.2 mm (AP by TR by CC) []. The radiological differential diagnosis was craniopharyngioma.
The patient underwent surgery for the resection of the suprasellar tumor through an endoscopic endonasal transsphenoidal approach. The intraoperative visualization of the tumor showed that the mass appeared to be arising from the optic chiasm rather than the Sella. Furthermore, intraoperative resection was complicated by significant adherence of the tumor capsule to local structures, including the carotid arteries. To prevent damage to the surrounding structures, the operation was concluded with an estimated 50–60% of the tumor resected. Intraoperative frozen pathology sections results revealed nonspecific glial reactive tissue. Postoperatively, the patient remained at neurologic baseline except for a new left lower quadrant visual field defect. He did not have any oculomotor nerve palsy. MRI confirmed expected partial resection of the suprasellar mass as well as the decreased mass effect on surrounding tissues []. The patient’s postoperative course was unremarkable, and he was discharg

[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 10-month-old girl born of nonconsanguineous marriage with normal developmental history, with no prior medical problems, was brought to our emergency room with history of fall on the head when the child was trying to walk on her own. She cried for a brief period and there was no loss of consciousness. There was no vomiting or convulsions following the head injury. Next day morning, about 12 hours after the injury, child developed weakness involving right side of the face, right arm, and the right leg. Child was unable to sit or stand. On examination child was conscious and active showing decreased movements in the right half of the body with muscle power 2/5 in both right upper and lower extremity along with right sided UMN type of facial palsy, with a positive Babinski sign on the same side. There were no signs of raised intracranial pressure or meningeal irritation. Other neurological examinations were normal. Child did not have any signs suggestive of nonaccidental injury and did not have any external signs of trauma to the head or elsewhere on the body. Child had no clinical history suggestive of varicella, measles, or ear discharge in the past. There was no history of feeding difficulty which suggests that there was no lower cranial nerve involvement. Perinatal history was uneventful. There were no significant family history suggestive of thromboembolic disorders and no history of recent vaccination. Investigations like routine blood count, peripheral smear, serum electrolytes, bleeding, and coagulation profile were done and found to be within normal limits. MRI brain suggested acute infarct involving the left capsuloganglionic region (Figures and ). Child was managed conservatively with osmotic diuretics to reduce perilesional oedema and also was started on anticoagulant therapy subcutaneously. Low molecular weight heparin was given for a total of 5 days and was stopped without any continuation of oral antiplatelet therapy. Parents could not afford other rele

[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:
36-year-old woman who was hospitalized by the psychiatry department due to abnormal behavior and frequent mood changes for 2 days was referred to the department of infectious diseases on day 6 for continued fever, which lasted for 2 more days. She had been healthy with no particular medical history, but complained of chills and headache starting 5 days before her hospitalization. Two days before her hospitalization, she showed frequent mood changes, such as suddenly crying about difficult work and then smiling soon after, saying she felt better. She also complained of visual hallucinations and insomnia, and showed hyperactivity such as desultorily walking around the house. She was diagnosed with type 1 bipolar disorder and was hospitalized by the psychiatry department. After calming down, she remembered everything she had said and done. On the second day of hospitalization, she shouted that she gave birth to a baby and bit her own and her mother's hands, indicating catatonia. She then developed a fever and was referred to the infectious disease department. At the time, the patient looked at other people only when she was called, and she spoke in gibberish with unclear pronunciations. She had strained her limbs, but was not spasmodic. Her temperature was 38.8℃ and she had no headache or nausea. Blood pressure was 150/100 mmHg, heart rate was 109 per minute, and respiratory rate was 23 per minute. She had no catheters in her body. There was no sign of meningism. Her test results for cranial nerves, movement, senses, and reflexes were normal. She had lacerations on her right thumb and left forefinger. The nail bed of her right thumb required a suture. The brain MRI conducted on the first day of her hospitalization showed no special findings. Due to continued catatonia and abnormal behavior, the patient was administered lorazepam and valproic acid. The hematologic test results showed a white blood cell count of 13,

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. His past history is pediatric asthma. The diameter of his middle esophageal diverticulum was 47 mm, and the accumulation of contrast medium was observed in the diverticulum. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row (Fig. ), and the diverticulum mucous membrane was partially covered by adherent white matter that was unstained with iodine (Fig. ), and narrowband imaging which revealed type A. We performed a biopsy, and the pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient placed in the prone position and four trocars inserted into the right thoracic cavity. A 12-mm trocar was inserted into the fifth intercostal space on the posterior axillary line. Only the left lung was ventilated, and a pneumothorax in the right chest was created using CO2 gas at 6 mm. Twelve-mm trocars were inserted into the seventh and ninth intercostal spaces at the level of the inferior scapular angle. A 5-mm trocar was then inserted into the seventh intercostal space on the posterior axillary line. The thoracoscope was inserted via the 12-mm port in the ninth intercostal space at the level of the inferior scapular angle. The operator used the 12-mm port in the seventh intercostal space on the inferior scapular angle line 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 56-year-old female with well controlled diabetes mellitus for 12 years and no history of diabetic nephropathy presented with generalized weakness and lethargy for 12 days duration.
12 days prior to presentation, whilst on a pilgrimage, she had consumed 200 ml of concentrated juice of six star fruits as a herbal remedy for diabetes mellitus. 5 h following the ingestion she had developed bouts of severe nausea, vomiting and abdominal discomfort which settled the following morning. Over the next few days she had felt weak and tired with loss of appetite and noticed a mild reduction in urine output. Her diabetes was well controlled on Insulin. Apart from that she was not on any other medication or vitamin C. She had no prior history of urinary tract stones or a family history of kidney disease. On presentation her clinical examination was unremarkable with no neurological signs and a blood pressure of 138/80 mmHg. Investigations revealed a serum creatinine which had risen from her baseline value of 80 µmol/L and eGFR of 68.4 ml/min/1.73 m2 from 1 month before to 290 µmol/L with urine full report showing trace amounts of protein and 20–25 pus cells/hpf. Urine culture did not reveal any bacterial growth. Ultrasound scan of kidneys revealed normal kidneys with normal echogenicity with preserved cortico-medullary demarcation. Renal biopsy confirmed the presence of oxalate induced acute tubulo-interstitial nephritis of moderate to severe degree characterized by the presence of tubular obstruction and associated damage by many oxalate crystals which polarized with polarizing light (Fig. ). The interstitium was oedematous and had a moderate infiltration of lymphocytes. Evidence of CKD such as interstitial fibrosis, tubular atrophy and glomerulosclerosis were not present. Glomerular features of diabetic nephropathy were not present. A short course of oral prednisolone was given due to the presence of interstitial nephritis and her serum creatinine normalized to previous value

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old man presented with a mass in the right parotid area that had become rapidly enlarged for 2 months. His medical history included a subtotal gastrectomy for a gastric ulcer 20 years earlier and low anterior resection for moderately differentiated adenocarcinoma of the rectum (Stage T1N0) 1 year earlier. Preoperative computed tomography (CT) showed a relatively well-defined heterogeneous enhancing solid lesion with calcification in the superficial lobe of the right parotid gland, with no indications of metastasis to the regional lymph nodes (Fig. ).
Fine-needle aspiration specimen showed that the tumor contained many clusters of malignant epithelial cells and scattered atypical spindle cells on a necrotic background. Under suspicion of a malignant tumor, the patient underwent total parotidectomy. Gross examination of the specimen revealed a multifocal, ill-defined, grayish-white, and heterogeneous solid tumor, accompanied by calcification and measuring 3 × 2.5 cm. Microscopically, the tumor was composed of two malignant components, carcinoma (Fig. , ) and sarcoma (Fig. ), with multifocal invasion (> 1.5 mm) of the capsule and adjacent tissues on a background of pre-existing pleomorphic adenoma (Fig. . The carcinoma component of the tumor consisted of squamous cell carcinoma and poorly differentiated adenocarcinoma, whereas the sarcoma component consisted mainly of osteosarcoma, characterized by neoplastic bone and severe cellular anaplasia. Many mitotic figures and necrotic foci were observed. The external resection margin showed tumor involvement. Immunohistochemical staining showed that the carcinoma cells were positive for cytokeratin AE1/AE3 (Fig. ) and the osteosarcoma component was diffusely positive for vimentin (Fig. ). Both components showed some degree of nuclear immunoreactivity for p53 (Fig. , ).
Following surgery, the patient received postoperative radiation therapy. Six months later, he complained of abdominal pain. Abdominal CT showed a dis

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


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

[User]
RADIOLOGY NOTE:
The patient is a 57-year-old man (height, 173.5 cm; weight, 61.7 kg), and the remaining teeth in his lower jaw were 1, 2, and 3 on the right side and 1, 4, and 5 on the left side. The patient had chronic apical periodontitis and severe periodontal disease. There was teeth movement, and it was difficult to preserve them. We planned to extract these teeth and place six implants (Figure ).
A physician had suspected the presence of VWD when the patient was aged 21 years, but no detailed testing or treatment was performed. The family history was not relevant, and the patient was on no current medications.
In terms of preoperative chest findings, the chest X-ray was normal (Figure ) with a normal cardiothoracic ratio of 42%, and there were no particular issues. Blood test results are shown in Table . The platelet count, a hemostatic factor, was 360,000/µl, the activated partial thromboplastin time was 35.4 s, and the prothrombin time was 11.7 s; all were within normal limits. However, coagulation factor VIII was 49%, VWF activity was 24%, and VWF antigen was 26% indicating that the coagulation factor was lower than normal. Based on detailed testing carried out by our hospital's hematology department, the patient was diagnosed with Type 1 VWD, in which there is a quantitative decrease in the VWF.
There was nothing of particular note in terms of family history. Implants in the upper jaw had already been placed at a different hospital, and there had been some difficulty stopping the bleeding when the teeth were extracted. In this case, after consulting with the hematology department, we decided that surgery would be possible by transfusing heat-treated factor VIII concentrate (Confact F®), which contains VWF. This transfusion was done to prevent abnormal bleeding during surgery. Furthermore, considering the risk of bleeding due to fluctuations in hemodynamics

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


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

[User]
RADIOLOGY NOTE:
A healthy 27 year-old immunocompetent male was referred for orthopaedic oncology evaluation of a possible neoplasm involving the inferior pole of his left patella. The man described a four month history of progressive anterior knee pain and swelling. Suspecting a knee infection, his orthopaedic surgeon performed two separate aspirations for culture, both of which were negative for any microorganisms including fungus. Radiographs demonstrated a lucent lesion in the inferior pole of the patella, and a CT and MRI of the knee were ordered. The initial radiologist’s interpretation was suggestive of a primary bony neoplasm, and orthopaedic oncologic consultation was obtained.
The patient presented to our clinic with left anterior knee pain and limited range of motion. He reported an episode of “Valley Fever” two years previously when he worked in the Central Valley of California. The isolated pulmonary infection was ultimately confirmed to be Coccidioides spp. by sputum culture. He was treated with a 6-month course of oral fluconazole with complete resolution of all symptoms. Notably, he never had any musculoskeletal complaints during that episode. On review of systems he described a 10 to 15 pound weight loss over the past month with intermittent nocturnal fevers and sweats.
On physical examination, the patient walked with an antalgic gait. There was a left knee effusion and warmth. He had localized tenderness along the inferior pole of his patella. His passive range of motion was limited from 5 to 95 degree. There was no palpable mass about the affected knee.
Radiographs of his left knee demonstrated a joint effusion and lucency involving the inferior pole of patella, which was visualized best on the lateral view (Figure ). On CT performed at an outside hospital, a low attenuation lytic lesion was more clearly defined without associated soft tissue calcification (Figure ). The outside MRI demonstrated knee joint effusion with extensive synovitis extending into Hoffa’s f

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