[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:
At 8 years after coronary artery bypass graft surgery a 53-year-old man was admitted to the emergency room with sudden onset of dysarthria and left hemiparesis. His blood pressure was 130/70 mm Hg, and the pulse was regular with no pulsus paradoxus. Cardiac examination was normal except for a systolic ejection murmur. There was no marked jugular venous distention or edema of the extremities. Radial and dorsal pedis arteries were symmetrically palpable. Neurological examination revealed disturbance of consciousness, dysarthria, and left hemiparesis. Electrocardiography was normal except for the rare premature atrial contractions, and chest X-ray findings were in the normal ranges. His erythrocyte sedimentation rate was high (56 mm/h), but other laboratory data were in the normal ranges. Head magnetic resonance imaging (MRI) revealed multiple hyperintense lesions on the bilateral cerebral hemisphere. A low-molecular-weight heparin, enoxaparin was started. On the fourth day after he began to improve, gained his consciousness and was able to talk again, recurrent transient ischemic attacks (TIA) began to occur, causing transient loss of consciousness. For evaluation of the embolic source, we performed transthoracic echocardiography. Two-dimensional echocardiography showed highly mobile, snake-like structures with a slightly higher echodensity as compared to myocardium, in the right and the left atria as well as the left ventricular apical septum (). There was moderate tricuspid valve regurgitation and minimal mitral valve regurgitations. Wall motions and echo densities as well as the pericardium were normal. Vena cava inferior was in normal calibration, and no mass was detected. A primary cardiac tumor or probable metastasis was suspected. We were planning to perform further diagnostic tests such as cardiac MRI, transesophageal echocardiography and computed tomography scanning of the body; however, the patient experienced a severe transient ischemic attack under anticoa

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

[User]
RADIOLOGY NOTE:
A 74-year-old male presented in February 2016 with increasing dysphagia. There was no history of prior abdominal infection or surgery. On esophagogastroscopy, a necrotic and circumferential friable tumor was seen at 33 to 40 cm from the incisors, with an endoscopic appearance of involvement of gastroesophageal (GE) junction and the proximal 2 cm of the stomach. Biopsies of the distal esophageal tumor confirmed poorly differentiated adenocarcinoma. The patient was anemic with a hemoglobin of 89 g/L. Staging endoscopic ultrasound suggested a breach of muscularis propria and four enlarged paraesophageal nodes. Neoadjuvant chemoradiotherapy followed by esophagectomy was initially considered; however, a staging positron emission tomography (PET) scan demonstrated 18-fluorodeoxyglocose (FDG) uptake not only in the primary tumor, but also in the paraesophageal region near the GE junction and upper abdominal lymph nodes extending as far inferiorly as the right renal vessels, in a retrocaval location (Figure ).
A radiation oncology consultation was sought regarding treatment options of such extensive lymphadenopathy. Palliative radiation therapy (RT) was recommended. The patient was also evaluated by a medical oncologist who advised that chemotherapy may be considered after assessing the response to palliative radiotherapy.
From March 21, 2016 to April 5, 2016, the patient received palliative RT to the symptomatic primary tumor and closest adjacent nodes using a pair of anterior and posterior fields. A total dose of 30 Gray (Gy) was prescribed over 10 daily fractions. As the lymphadenopathy in the lower abdomen was not symptomatic, and would have contributed to increased toxicity, this region was deliberately excluded from the high dose RT volume (Figure ). Other than very mild odynophagia, the patient had no other RT-related side effects. On the first follow-up visit, one month following treatment completion, he had improved swallowing function and a weight gain of six poun

[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 31-year-old gravida 4 para 0 African American woman at 22-weeks gestation presented with vaginal bleeding to an outside hospital. Her obstetric history was significant for 2 therapeutic abortions and 1 spontaneous abortion. During prenatal care, the fetus was noted to have a unilateral dysplastic kidney. The patient’s family history was significant for two family members with cervical cancer and two family members with endometrial cancer. She was placed on bedrest with inpatient admission. 48 h after admission she developed pelvic pain and uterine contractions. She expelled a mass vaginally measuring 11 × 9 × 5 cm with no fetal contents. The pathology from the outside facility showed a showed a highly cellular tumor composed of spindle-shaped cells and bizarre multinucleated giant cells with focal myxomatous change with mitotic count is greater than 50 per 10 high power field (Positive for CD10, SMA, ER, PR, EMA) with the differential diagnosis including endometrial stromal sarcoma and undifferentiated uterine sarcoma. The patient underwent examination under anesthesia, demonstrating a 3 × 3 cm defect of the posterior vaginal wall with active bleeding, which was sutured for hemostasis. The cervix was long, closed, and high with no evidence of bleeding and the fetus was intact with normal heart tones. She was discharged in stable condition.
At 27-weeks, the patient was referred to our institution for maternal-fetal medicine, and gynecology oncology consultation. On initial evaluation, she reported no prior abnormal gynecology history and no history of infertility issues. She denied dyspareunia and bulk symptoms prior to or during pregnancy, and her periods before pregnancy were normal. A pap smear at 27-weeks gestation was normal and negative for human papilloma virus. Her intake physical exam at our institution revealed a normal pelvic exam with no evidence of residual vaginal mass, and an ultrasound revealed no intrauterine myomas.
Given the differential diagnosi

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


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

[User]
RADIOLOGY NOTE:
A 31-year-old male patient has a history of a multiple fracture involving the left femur shaft, the middle and distal segment of the left tibiofibula, as a result of a traffic accident in October 2008. Subsequently, the patient underwent an open reduction and internal fixation (ORIF), using titanium alloy plates and screws. Ten months after ORIF, an X-ray examination showed no displacement of the fracture site, and the bridging callus was visible on two standard views with partial obliteration of the fracture line. However, the patient did not undergo reoperation to remove the metal implants due to financial difficulties.
In August 2011, the patient complained of a 3-month history of a gradually enlarging left thigh mass. Physical examination revealed a 12 × 10 cm firm, tender and fixed mass in the anteromedial left thigh, with local superficial venous engorgement and skin temperature increment. Percussion pain in the axial direction of the left lower limb was absent. The inguinal lymph nodes were not palpable. Routine chest radiograph and abdominal ultrasound examination showed no abnormalities. Other routine tests, including plasma biochemistry, liver function tests and urinalysis, were normal.
The X-ray examination demonstrated an ill-defined osteolytic lesion with disappearance of the medial cortical bone in the middle of the left femur shaft, as well as an ambiguous image of a soft tissue mass. Computed tomography (CT) images clearly showed a partial bone defect approximately 9.7 cm in length on the medial border of the left femur shaft. A 9.7 × 11 × 19 cm irregularly shaped soft tissue mass was observed around the left femur, with the surrounding tissues compressed and shifted significantly (Figure
). CT findings also showed that the soft tissue mass was heterogeneous in density with CT value of 36 HU, in which small pieces of slightly high-density lesions were found. These imaging findings suggested that the mass was neoplastic.
Tissue biopsy was performed,

[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 50-year-old female with no ocular history and a medical history of diabetes mellitus presented to the oculoplastic service for management of right eye lagophthalmos due to Bell's palsy. The patient reported that 4 months prior to presentation her right face became swollen and painful following a tooth extraction. This facial swelling was attributed to a dental abscess, and she went on to require intensive care unit (ICU) level care at an outside hospital for cellulitis in the setting of diabetic ketoacidosis. Her swelling resolved with antibiotic therapy, and she followed with her primary medical doctor for the next four months (a total of eight office visits with no documentation of a cranial nerve examination) for persistent complaint of right-sided facial pain and weakness. Concurrently, she was followed by an ophthalmologist (three visits) for difficulty closing her right eye. Lagophthalmos and corneal exposure with inferior corneal scarring were noted but neither the patient's visual acuity nor the function of cranial nerves other than the facial nerve were documented at these ophthalmologic evaluations. Both providers documented concern for “Bell's Palsy,” and the patient was treated with oral corticosteroids. After 4 months, her medical doctor recommended neuroimaging (magnetic resonance imaging [MRI]) but she was referred to oculoplastics for further management of her persistent lagophthalmos prior to obtaining this study.
On presentation, she had no light perception visual acuity in the right eye. Her examination was also significant for House-Brackmann grade 4 palsy of the right facial nerve and loss of sensation in the V1 distribution of the right trigeminal nerve. (Figure ) The severity of keratopathy limited posterior examination, but the right optic nerve appeared pallid. Further workup was performed, and a dedicated MRI of the orbit with and without gadolinium contrast demonstrated optic nerve atrophy, abnormal enhancement along the trigeminal nerve

[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 gravida 2, para 2 woman aged 44 years with a history of two cesarean sections was referred because of recurrent urinary tract infection and urinary leakage through the abdomen. In her past medical history, she had Sjogren’s syndrome and optic neuritis. In her past surgical history, she had a bladder injury in a caesarean section, which was repaired with a primary suture. One month later, she presented with a 10 cm subcutaneous hematoma at its largest dimension. The hematoma was drained surgically, and during the exploration, no source of bleeding was found. Four months later (in total, five months after the cesarean section), she was admitted to the hospital and referred for urinary leakage through the abdomen, about 5 cm below the level of umbilicus. The leakage was periodic and she had an episode of subcutaneous abscess, which was managed conservatively using antibiotics and non-steroidal anti-inflammatory drugs.
A fistula tract was observed in a retrograde fluoroscopic examination; however, the distal end of the fistulous tract was not clear (). An ultrasound examination was also not helpful to clarify the lesion. Contrast-enhanced magnetic resonance (MR) urography () revealed a defect of 1.2 cm on the anterior wall of the bladder in the midline. Between this defect and subcutaneous fatty tissue, a fistula tract of 2 cm at its widest diameter was evident. In the subcutaneous fatty tissue, a 6x6.4x3.7 cm collection was directly related with the fistula tract. There was inflammation and possible infection surrounding the collection due to the dense contrast enhancement.
The patient underwent a laparotomy with the plan for excision of the fistula tract and repairing the bladder defect. A suprapubic incision parallel to the Langer’s lines of the skin was made with a 1.5-2 cm margin with the fistulous tract. The fistula tract was about 12 cm in length and 4 cm wide, and was totally excised with the involved skin (, ). The defect on the

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


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

[User]
RADIOLOGY NOTE:
A 67-year-old woman was evaluated for a left flank mass and axillary swelling. Excisional biopsy of the mass and lymph node dissection revealed metastatic melanoma with the involvement of all four axillary lymph nodes. A left periorbital lesion previously diagnosed and treated as squamous cell carcinoma at an outside hospital with resection and subsequent radiation was also retrospectively read as metastatic melanoma by our institution’s pathologist. A subsequent PET scan demonstrated areas of fluorodeoxyglucose (FDG) uptake in cervical, mediastinal, and inguinal lymph nodes, as well as in the right tibia and multiple subcutaneous nodules. BRAF analysis demonstrated a V600E mutation, and thus, she was started on vemurafenib at 960 mg twice a day. After a week of treatment, she developed cutaneous toxicity manifested by erythema noted diffusely and folliculitis on her head, trunk, and extremities, along with blistering on the soles of her feet. The dose was reduced by 50% while she was treated with prednisone for the cutaneous symptoms. However, upon taper of steroids, her skin manifestations returned with a limitation of ambulation secondary to hyperkeratotic lesions on feet, so the dose was further reduced by 25% at week 8.
After a total of nine months of treatment, whole body PET/CT and MRI scan of the head demonstrated a complete response and the vemurafenib was discontinued due to cumulative toxicity. The cutaneous toxicity gradually improved off therapy, although with the persistence of burning mouth syndrome. Serial imaging continued to demonstrate disease stability for 19 months. The disease then recurred with subcutaneous trunk nodules and lymph nodes in the pelvis. Biopsy confirmed the recurrence of melanoma. Since combined BRAFi and MEKi had been FDA approved in the interim, the patient was started on dabrafenib and trametinib with the intention to pursue intermittent therapy. She had a complete response after less than two months of therapy, at which poin

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

[User]
RADIOLOGY NOTE:
Mr. BH, 39 years old, right-handed, presented with a Bennett fracture of the first right metacarpal following a work accident. The fracture was initially treated in another institution by reduction and percutaneous pinning using Iselin’s technique. Three weeks later, the patient developed an inflammatory reaction around the entry point of the distal pin, at the second metacarpal. A purulent discharge led to early removal of the distal pin. The isolated organism was a methicillin-sensitive Staphylococcus aureus. Regular topical treatment was given, and antibiotic therapy was initiated for five weeks based on laboratory results. Bone healing of the Bennett fracture was obtained in the sixth week after the accident, and the proximal pin was removed.
Three months later, the patient was referred to us by his doctor because of persistent pain at the second right metacarpal, accompanied by attacks of inflammation and intermittent purulent discharge. Standard hand X-ray demonstrated the presence of an area of osteolysis surrounded by osteocondensation at the second metacarpal, indicating a focus of osteomyelitis along the path of the distal pin (). An MRI was performed on the hand. It confirmed the diagnosis, revealing the extent of the focus of osteomyelitis, the path of the fistula, and the inflammatory extension into neighboring soft tissues ().
Surgical treatment called for the induced membrane technique.
The first stage included a segmental resection of the area of osteomyelitis through a dorsal approach with excision of the reformed tissue while preserving the index finger extensor tendon.
The second metacarpal was stabilized with a mini external fixator, and a cement spacer was interposed ().
Antibiotic therapy was initiated for six weeks based on sensitivity testing. The external fixator was then removed, and the hand temporarily immobilized with a splint until there was healing along the path of the inserts.
The second stage was performed in the eighth week. The ce

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

[User]
RADIOLOGY NOTE:
A previously well 55 year old Caucasian male presented to gastroenterology out patients clinic in November 2003, with a three week history of worsening dysphagia to solids and weight loss of 4 kilograms. He described a sensation of food sticking at the level of the lower sternum. He had suffered in the past with mild heartburn for which he took a proton pump inhibitor on an as required basis. He was a married and worked as an accountant. He had never smoked. Physical examination including the body mass index and blood pressure was unremarkable.
Initial investigations revealed proteinuria (++) on urine dipstick, a haemoglobin of 11.8 (normal indices) with an otherwise normal blood count and film. Urea and electrolytes, estimated glomerular filtration rate, liver enzymes, thyroid stimulating hormone, random blood glucose, bone profile, haematinics and urine culture & sensitivity were normal. The ESR was 96 mm/hour. Unfortunately 24 hour urinary protein quantification was never been considered as the patient's presentation did not suggest nephrotic or nephritic syndrome.
Oesophagogastroduodenoscopy including biopsies from the mid and lower third of oesophagus were normal thus excluding eosinophilic oesophagitis.
Although a liquid barium swallow showed no abnormality, a swallow with a solid medium (bread soaked in barium) detected a significantly abnormal non-specific dysmotility of the lower oesophagus (,). This was performed because the use a solid medium during a barium swallow increases the sensitivity of the test by generating a greater amplitude and duration of peristalsis []. The dysmotility that was seen was confirmed with oesophageal manometry.
A chest radiograph obtained during his barium swallow identified a “coin shaped” lesion in the periphery of the left lower lobe of the lung (). On the same day his ultrasound scan of the abdomen detected a mass arising from the left kidney measuring 8x6x6 cms. A computed tomography scan confirmed a large tumour arising f

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

[User]
RADIOLOGY NOTE:
A 37-year-old male consulted our department with a 7-month history of mild thoracic spine pain after a fall; in addition to the thoracic spine pain he noticed a painful, slowly growing mass. He had no past medical history, and physical examination was unremarkable except for the presence of a hard and tender thoracic spine mass. His father died of hepatic cancer. Clinical blood examination did not show any abnormality, including alkaline phosphatase.
Initial posteroanterior chest radiograph revealed the presence of a left-sided soft tissue mass located at the level of the aortic arch (). The lesion's margins and the absence of a positive “silhouette” sign with the mediastinal structures indicated an extrapulmonary and posterior position, a finding that was verified in the lateral chest radiograph. A CT examination was subsequently performed upon request, which showed a predominantly soft tissue tumour with internal areas of mineralisation. The mineralised elements were amorphous, scattered, ring-like, and arcuate-shaped. Rib destruction and infiltration was also noted. Furthermore, widening of the adjacent neural foramina was depicted and an MRI examination was done to clarify this finding. MRI verified neural foramina invasion as well as significant spinal cord compression and contralateral displacement. Despite that fact, the patient remained completely asymptomatic, which was attributed to an indolent and slow growth of the tumour. The mass showed low signal intensity in T1-w images and heterogeneous but predominantly high signal intensity in T2-w images. An associated superficial component of the tumour, which corresponded to the palpable finding, was also better demonstrated on MRI (). Mineralised areas that were depicted in the CT examination demonstrated low signal intensity in all pulse sequences. Gadolinium enhanced T1-w fat saturated images showed intense, heterogeneous tumour enhancement. The mass extended from the anterior to the left of the vertebral bo

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

[User]
RADIOLOGY NOTE:
A 40-year-old female patient presented with a painless sudden loss of vision in her right eye of one month duration. The loss of vision was preceded by a binocular diplopia which worsened on the right gaze for the past 3 months. A right sided upper molar tooth extraction was done prior to the onset of symptoms. She also gave a history of repeated headaches for the past 3 years. She had no systemic illnesses. A non-contrast computerized tomography (CT) scan done previously was essentially normal with some non-specific inflammatory changes involving the sphenoid sinus. With a clinical suspicion of right sided optic neuritis, she had received a treatment regimen of injectable steroids for 3 days followed by tapering doses of oral steroids elsewhere.
On examination, her best corrected visual acuity (BCVA) was perception of light in the right eye and 6/6 in the left eye. Anterior segment examination showed a relative afferent pupillary defect in her right eye with an abduction restriction consistent with a right sixth nerve palsy. Fundus examination showed a resolving disc edema in her right eye. Her left eye was normal. Other cranial nerves were normal. A detailed systemic workup including a complete blood count examination showed an elevated erythrocyte sedimentation rate (ESR) of 87 mm/h. Diabetes and any signs of immunosuppression were ruled out. Chest X ray and Mantoux test were negative.
Magnetic resonance imaging (MRI) was advised and mucosal thickening was noted in both compartments of the sphenoid sinus. Areas of altered bone marrow signal intensity with adjacent bone destruction were observed involving the walls of the sphenoid sinus (Figure 1A ), bilateral posterior clenoid processes, right anterior clenoid process, dorsum sella, the proximal half of clivus, and the right petrous apex region. Posterior one third of the intraorbital portion and of the intracanalicular portion of the right optic nerve, the right half of the optic chiasm was enlarged and showed h

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

[User]
RADIOLOGY NOTE:
The volumetric CBCT dataset of a 67-year old female was referred to our department for the pre-implant evaluation of an edentulous left maxilla in the region corresponding to the first molar (and ). A medium-volume CBCT was prescribed by the implantologist and was acquired in the office of the periodontist who referred the case to us. A Carestream CBCT CS 9300 (Carestream Inc., Atlanta, GA, USA) was used with a voxel resolution of 200 µm. A limited field of view was used to capture the maxilla. No significant medical or dental history was reported by the periodontist. The patient had not been hospitalized in the recent past, and she was stable and alert at the time of presentation. The dental examination revealed multiple dental restorations, including root canal treatments, that had been done over a period of time. The left maxillary first molar was missing in the arch and the patient expressed interest in having an implant placed in that region. The office staff proceeded with the radiographic examination after the clinical examination was completed. The limited-volume CBCT was referred for radiographic consultation and reporting to the Case Western University School of Dental Medicine.
Multiplanar CBCT reconstructions and 3D reformations demonstrated the area in question and appropriate measurements were made as part of the pre-implant evaluation of the left maxillary first molar region ( and ). In addition, an incidental finding was noted, unrelated to the clinical question. In the axial slices, a large low-attenuation area within the occipital region on the right side in close proximity to the mastoid region was observed (,,). It was a well-defined, noncorticated, transosseous defect with a homogenous density similar to that of soft tissue. Volume rendering helped isolate the mastoid foramen for better visualization (,,). Based on the radiographic examination, and since no other clinical signs and symptoms indicated intracranial abnormalities, the diagnosis of

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

[User]
RADIOLOGY NOTE:
A 7-year-old boy, 107 cm in height and 17 kg in weight, had been previously presented with fever and convulsion and was diagnosed with acute encephalopathy at the age of 3 years. Dental treatment at our hospital was scheduled under general anesthesia due to his multiple caries and uncooperative behavior.
At 1 month after his initial diagnosis, the patient had received a tracheotomy for chronic respiratory failure, and at 5 years of age, he received trachea closure surgery because his respiratory condition stabilized. After computed tomography (CT) confirmation of tracheal granulation tissue under the vocal cords at 7 years of age, the patient regularly received follow-up observations (). The neurological status of the patient was poor with severe mental retardation and cerebral paralysis. He could not speak or walk without support and we could not communicate with him. The patient had been taking antiepileptic drugs daily and was without seizure activity for more than two years. However, due to tracheal granulation, the patient had a few episodes of wheezing and stridor. On admission, clinical assessment of his airway was difficult, but his respiratory condition was stable and his oxygen saturation (SpO2) was 98% in room air. No abnormal findings were observed on a chest X-ray, in laboratory data, or in cardiac function.
On the day of dental treatment, no premedication was administered, and the patient was transferred to the operating room. Anesthesia was induced with inhalation of sevoflurane at 1–8% in oxygen after the initiation of noninvasive monitoring for SpO2 (100%). After the loss of consciousness, mask ventilation with an oral airway was uncomplicated, and we began electrocardiogram (ECG; sinus rhythm), blood pressure (BP; 90/58 mmHg), and heart rate (HR; 105 bpm) monitoring. Atropine at 100 mcg and rocuronium at 6 mg were administered after peripheral intravenous access was obtained. Insertion was carried out without difficulty with a size 2 FLMA (). Anest

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

[User]
RADIOLOGY NOTE:
A 62-year-old male presented to our outpatient department with painless swelling of both his shoulders and restricted movements of the bilateral shoulder joints. His condition began when he was approximately 35 years old and he started experiencing reduced sensation in the bilateral upper limbs. No medical treatment was taken and the patient went to some osteopath who gave him some oil for local application. Patient condition did not improve and he started experiencing reduced sensations in the bilateral lower limbs. Despite that, he did not seek medical attention and his condition gradually worsened. There was no history of significant trauma in the past. Physical examination revealed generalized swelling about the shoulder, more on the left side []. On the right side, there was abnormal motion, distal to where the shoulder joint would be expected . On the other hand, the left shoulder joint was found to be dislocated, with humeral head anterior to glenoid cavity, leading to significant restricted joint movement. On palpation, the shoulder joints were nontender. Bilateral shoulder movements were restricted. Active forward flexion was 40 on the right and 30 on the left side, abduction 30 on the left and 25 on the right side and internal rotation bilaterally up to the sacrum. He had 4/5 shoulder abductor strength and 4/5 shoulder flexor and extensor strength bilaterally. Range of motion for passive movements was significantly higher than on active movements, more on the right side. Passive movement was painful on terminal range of motions. His biceps strength was 4/5, triceps strength was 5/5 while motor strength in bilateral distal extremities was 5/5. There was decreased sensation involving the entire upper extremities bilaterally and healed trophic ulcers found on the fingers and dorsal and ulnar border of the hand and forearm . The biceps, triceps and brachioradialis reflex were absent. There was muscle wasting in both upper limbs.
Patient was worked up and X-ray

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old male was driving his car when he suddenly experienced bilateral blurred vision []. Unable to use his car or phone properly due to the abrupt onset of his visual deficits, the patient reportedly remained in his car for three days. He was found by police, who brought him to the emergency department. On initial evaluation, the patient reported that he had been driving to visit his daughter in another state when he suddenly needed to pull over to the side of the road. He then recalled, ‘I was found by a priest who invited me into his home, took me in, and fed me a nice meal. The priest then called the ambulance to pick me up.’ The patient reported several weeks of increasingly frequent ‘lightening-like’ bright flashes of green and yellow in his right eye, but denied the presence of floaters, curtain loss of vision, or diplopia. He reported that his visual acuity was 20/30 bilaterally at his last complete ophthalmology examination one year prior to presentation.
Physical examination revealed an irregularly irregular rhythm and tachycardia. EKG was remarkable for atrial flutter with 2 to 1 block and heart rate of 150 beats per minute (). Ophthalmology evaluation demonstrated significantly diminished visual acuity (< 20/200 bilaterally with 360° constriction of confrontational visual fields), intact pupillary reflexes and ocular movements bilaterally, and no evidence of retinal, macular or choroidal pathology on dilated fundus examination. The patient was deemed cortically blind, prompting further evaluation with computerized tomography (CT) and magnetic resonance imaging (MRI) of the head. CT brain without contrast demonstrated findings compatible with bilateral subacute parieto-occipital infarcts with local sulcal effacement, without mass effect or hemorrhagic transformation (). Magnetic resonance imaging (MRI) of the brain without contrast showed acute to subacute bilateral posterior cerebral artery territory infarcts with associated mild petechial hemorrh

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old woman applied for a breast reshaping surgery for aesthetic purposes. There were no other complaints in her medical history. The patient underwent simultaneous mastopexy according to classical Lejour vertical scar technique and breast augmentation surgery using round silicone TSF - 415 mL implants under the pectoral muscle and a breast lift under general anesthesia (). During the operation proper hemostasis was achieved using electrocoagulation. Drains were removed next day after the operation with minimum serohemorrhaging fluid volumes. The later postoperative period was also uneventful.
The patient was discharged from the clinic on the second day after the surgery. Five weeks after the operation patient arrived at the clinic because of tenderness and swelling of the right breast. The patient stated that she had not sustained any traumas. During clinical examination, the upper right breast area was found to be significantly swollen and firm (). Ultrasound examination showed a 2.5 cm heterogeneous liquid strip accumulated around the implant (). The implant was intact. Complete blood count showed an increased amount of leukocytes, and red blood cells and hemoglobin were at the lower limit of the normal level.
No coagulopathies were found. The patient was taken to the operating room where she underwent revision surgery. The purpose was to remove the fluid and to find and stop the cause of its accumulation. During the operation (), a blood clot of 650 mL was removed (). Bleeding from one of the internal mammary artery branches in the implant pocket between the rib cage and the pectoral muscle lower pole was detected and stopped. After the revision, the implant was returned to the lodge. Vacuum drainage was used for one day only. One year after the surgery, there was no recurrence of bleeding, also no clinical evidence of the implant capsule contracture formation was found ().
All procedures performed in this study were in accordance with the ethical standa

[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 was referred to a community oncology center by his neurologist due to complaints of a recurrence of lancinating, “shock-like” pain in the left side of his face from the preauricular area into the left side of his upper and lower jaws. The patient stated that the pain was intermittent, 10/10 in intensity (on a scale of 1 to 10, with 10 being the worst), and was triggered by several actions including eating, brushing gums, cold sensations, and touching his face. The patient stated that the pain was accompanied by tenderness and sensitivity to touch around the outside margin of his left eye, but he denied numbness or other change in sensation in the affected area.
The patient stated that his symptoms began as an “annoyance” approximately 4.5 years prior and progressed slowly over the course of the next 3 years, at which time he was diagnosed with TN by his dentist. An MRI of the brain performed at the time of diagnosis demonstrated a tortuous basilar artery abutting the left trigeminal nerve. He was initially started on Gabapentin, which provided only mild relief. Carbamazepine was added later, but it caused him to become excessively drowsy, which resulted in a significant fall and concussion. Due to his fall, the medications were discontinued.
Following failure of medical management, the patient was offered further treatment options including microvascular decompression (MVD), radiofrequency gangliotomy, and GKRS. The patient elected to undergo GKRS which was performed with a Leksell model C gamma knife to the trigeminal nerve root entry zone with 201 cobalt sources (4 mm shot size) to a dose of 42 Gy prescribed to the 50% isodose line for a maximum point dose of 84 Gy (see ). Shortly after the procedure, the patient experienced mild relief of pain but had a sudden recurrence in the second division of the trigeminal nerve within 2

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


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

[User]
RADIOLOGY NOTE:
A 53 year old female presented to her General Practitioner with heavy menstrual bleeding and was referred to a gynaecologist at her local hospital. Her previous medical history included one normal vaginal delivery aged 28, a Mirena IUS in situ, and, a normal cervical screening history. Drugs prescribed included ranitidine and citalopram. Family history included an identified BRCA mutation carried by her mother and aunt. She had not been genetically tested herself but underwent regular 6 monthly checks from ages 41 to 50.
Multiple fibroids were identified on a trans-vaginal ultrasound of the pelvis. In view of her ongoing symptoms, the patient was offered a hysterectomy with a bilateral salpingo-oopherectomy.
The histology of the uterine specimen demonstrated one fibroid measuring 70 mm diameter and showing an abnormal focal area and central cystic necrosis consistent with a low grade leiomyosarcoma surrounded by normal tissue with no evidence of vascular infiltration. The leiomyosarcoma border was 10 mm clear of the serosal surface. A CT scan of the chest, abdomen and pelvis found no evidence of residual or metastatic disease and her case was discussed at a Gynaecologic Oncology multi disciplinary meeting (MDT). It was agreed that the likelihood of further metastasis was remote and she was discharged from follow-up.
Six months later, the patient presented to the accident and emergency department with a complaint of numbness in her lower left lip. A full neurological examination was normal so the patient was assured it would likely resolve. However, following a consultation with her dentist, she was referred to the maxillofacial department. The patient was known to grind her teeth due to anxiety. Altered sensation over left chin was reported, followed by numbness in her left lower lip. On examination, she was found to have decreased sensitivity to soft touch in the left mental nerve distribution area and an electric shock like sensation through her lip when pressure

[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 young woman was admitted to our hospital with intermittent periumbilical abdominal discomfort and pain. She had a history of depression and was otherwise a healthy individual. She complained that the discomfort was ongoing for six to eight months, and she usually rated it three to four out of 10 on the pain scale. There was no association with her menstrual cycle or food nor was there any associated nausea, vomiting, constipation, or diarrhea. There were no alleviating factors but she reported exacerbated discomfort with a strenuous workout at her school. The pain and discomfort were infrequent and usually occurred five to six times per month with a duration of one to two hours of constant brief episodes. It usually resolved spontaneously, and for this reason, she did not pay it much concern. There was no increase in frequency or intensity of the discomfort. She never noticed a fever nor any distention, bloating, or dyspepsia. There was no history of known abdominal trauma. She had no family record of any similar symptoms or history. Vital signs, including blood pressure, heart rate, respiratory rate, and body temperature, were all in normal ranges. However, while the physical examination was negative for tenderness, it revealed a non-specific mass of 5 cm x 3 cm that was palpable in the left upper quadrant. The mass seemed to arise from a deep origin below the abdominal wall; it had a smooth surface without any tenderness. It was freely mobile below the abdominal wall and appeared fluctuant. Blood test results found that the hemoglobin level was 11.6 g/dL (normal range 12 g/dl - 15.5 g/dl), the white blood cell was 10.5 K/µL (normal range 4 /lµ - 11 /µl), the platelet count was 149 K/µL (normal range: 150 K/lµ - 450 K/µl), the erythrocyte sedimentation rate was 5 mm/h (normal range: 0 mm/h - 29

[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 was admitted to the hospital on 15 August, 2003 with severe left loin pain, and hematuria. Abdominal ultrasonography revealed left loin mass. Subsequent computed tomography (CT) scan confirmed a left renal mass of 6×7 cm confined to the left kidney with no evidence of spread or vascular invasion. The patient underwent left radical nepherectomy on 25 August, 2003. Pathological examination demonstrated renal cell carcinoma, clear cell type grade II. The tumor was limited to the kidney with no invasion of perinephric tissue or vascular invasion. Surgical margins were free and the patient was classified as tumor stage II (T2aN0M0). The patient was followed up every 3 months for 2 years then annually for 3 years guided by clinical examination, annual laboratory investigations and radiological imaging. Her last CT scan evaluation was September 2008, and was unremarkable with no detected disease compared with previous scans. Her annual visit was 4 months away when she discovered her breast lesion. She was disease free clinically and radiologically until March 2009, when the patient presented to the breast clinic with a painless, palpable, and rapidly growing left breast mass discovered during breast self examination 2 months previously. Clinical examination confirmed a non-tender, palpable, mobile, and firm mass in the upper outer quadrant of left breast at the 3 o'clock position with no skin infiltration. There was no clinically palpable axillary lymphadenopathy.
Bilateral mammography showed a dense well circumscribed solid mass, speculated intramammary lesion measuring 4×3 cm located in the lower outer quadrant of the left breast with adjacent parenchymal distortion and no signs of micro or macrocalcifications, and no skin or nipple retraction (Breast Imaging Reporting and Data System [BIRADS] score was IV of left breast) (). No evidence of enlarged lymph nodes. For the right breast, the BIRAD score was I, and no intramammary lesion. Breast ultrasonog

[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 75-year-old woman had an 18-year history of headache, progression of gait disturbance, dysarthria and auditory disorder. At the time of admission, she was alert and oriented. Neurological examination revealed right-dominant severe hearing loss, dysarthria, and urinary disturbance. The finger-nose tests showed her incoordination. The patient also had cerebellar ataxia and mild motor loss in her lower extremities. Analysis of CSF indicated an increased red blood cell count and a low opening pressure. MRI showed low intensity areas on T2-weighted images on the superficial brain and spinal cord by hemosiderin deposition. Furthermore, MRI and computed tomography (CT) myelography confirmed fluid collection in the anterior spinal canal at T1 to T4 (). The constructive interference in steady state (CISS) magnetic resonance (MR) images detected a dural defect at the T1/T2 level (). Surgical intervention was determined to be necessary. The spinal cord appeared discolored and yellow after laminectomy from T1 to T4 level. Verrucous vegetation and epidural fluid collection around the ventral dural defect were confirmed by intraoperative US imaging before incision of the posterior dura matter (). Intraoperative US also detected ventral dural defect on the right side of spinal cord (). Therefore, to allow the spinal cord to be moved forward, the operating table was rotated slightly to the left. Then, the posterior dural incision was made in a manner that was slightly more right lateral than standard midline. Some dentate ligaments were separated from spinal cord side as needed. With space between the spinal cord and defect, a 5-mm ventral dural defect with verrucous vegetation was confirmed on the right side near the midline at the T1/T2 level (). The ventral dural hole was identified after removal of vegetation (). A secure working space was maintained by rotation of the operating table. The dural closure was carefully performed without retraction of the spinal cord. The anteri

[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 49-year-old trans man who had been on testosterone therapy for 10 years presented to the emergency department with central chest pain. His high-sensitivity cardiac troponin was 24 ng/L (female reference range <16 ng/L, male reference range <26 ng/L). How should he be managed?
Cardiac troponin is released from damaged cardiomyocytes and is one of the most common biomarkers used in the prediction of myocardial infarction. There is considerable debate regarding the use of sex-specific reference ranges for high-sensitivity cardiac troponin (hs-cTn), as there is uncertainty whether the use of sex-specific reference limits impact upon clinical management or outcome prediction (). However, as upper reference limits based on sex-specific 99th percentiles for hs-cTn are subtly higher for people recorded as males than those recorded females in population studies (), use of sex-specific cutoffs for hs-cTn assays have been endorsed by the International Federation of Clinical Chemistry and Laboratory Medicine (). The difference has been attributed to people presumed male at birth having a larger cardiac mass as well as subclinical coronary artery disease (). No studies have been performed to examine cardiac mass changes that may occur with masculinizing hormone therapy in people presumed female at birth. There are however data in polycystic ovary syndrome in which high testosterone concentrations are a clinical feature (albeit far lower than testosterone concentrations seen in transgender men). Polycystic ovary syndrome has been associated with higher left ventricular mass index and larger left atrial diameter over 5 years of follow-up, even after adjustment for blood pressure, body mass index, glucose, and lipids (). Large population-based studies have also shown that left ventricular mass correlates with body weight, lean body mass, and fat mass (). There is currently insufficient data to draw an inference regarding the appropriate reference range in people using gender-affi

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 30-month-old male who was brought to the family medicine clinic with a complaint of abdominal bloating and persistent diarrhea after every feeding for four months. His stools were foul-smelling and occurred more than four times a day. The diarrhea was associated with a failure to gain weight. The parents reported that the child has a normal appetite with no history of vomiting or feeding intolerance. There was no history of fever, night sweats, rash, cough, or joint pain. The child did not have any recent sick contact. The patient was seen by several general practitioners for the same complaint, but no diagnosis was obtained.
The patient had an unremarkable past medical history. He did not have any previous hospital admissions. He had no history of previous surgeries. He does not take any medications and was not known to have any food or drug allergies. Regarding the perinatal history, the child was full term with a birth weight of 3.5 kg. The labor and delivery were unremarkable for any complications. The child was up to date with his vaccination schedule. Regarding the developmental history, the child reached the developmental milestones at the appropriate ages, and there was no parental concern regarding his development. The social history was noncontributory. There was no history of diseases running in the family. The child was not born of a consanguineous marriage.
Upon examination, the child was awake and alert and did not appear sick. No dysmorphic features were noted. The patient was below the second standard deviations for weight and height. He appeared pale, and there was no scleral icterus. His vital signs were as follows: heart rate of 90 bpm, blood pressure of 80/52 mmHg, respiratory rate of 22 bpm, and temperature of 36.8°C. Abdominal examination revealed a soft and non-tender abdomen with no organomegaly and had normal bowel sounds. Neurological examination, including hearing and vision tests

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


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

[User]
RADIOLOGY NOTE:
A healthy 11-year-old boy was referred to the clinics of Department of Pediatric Dentistry, following a severe facial trauma as a result of automobile accident. He complained of pain in his jaw and was unable to open his mouth. Initial physical examination showed abrasions and lacerations on the facial skin and the lips (). Limited opening of the mouth and lateral deviation of the mandible toward the right side on mouth opening were noted. Intraoral examination revealed a missing maxillary left permanent lateral incisor, an uncomplicated crown fracture of his maxillary right central incisor, and subluxation of his maxillary left central incisor. CBCT examination revealed a nondisplaced mandibular body fracture in the right second molar region, an oblique greenstick fracture on the left lingual side extending between the canine and first molar tooth, and a unilateral medially displaced subcondylar fracture on the right side (Figures -). The vertical height of the ramus was decreased in fractured side. Avulsion of the maxillary left lateral incisor was verified by radiograph and a horizontal root fracture of the maxillary right central incisor was also detected (Figures and ). The maxillary lateral incisor was lost at the site of the accident.
Closed reduction techniques were chosen to manage the mandible fractures. A vacuum formed splint was fitted in the lower arch for functional repositioning of the mandible (). Arch bars that were cut to the appropriate size were bonded to vestibuloposterior parts of the splint using acrylic, and brackets were attached to the maxillary posterior teeth (). Orthodontic elastics (1/4 inch, medium strength) were used to prevent uncontrolled movements of the jaw within the first week of treatment (Figures -). The splint helped the child avoid doing excessive mouth opening and closing movements. The patient was instructed to wear the splint continuously during 24 h removing it only for eating and cleaning. A soft diet was also recommend

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


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

[User]
RADIOLOGY NOTE:
A male, 35 years old, with no known comorbidities was admitted to the emergency department, referred by the Basic Health Unit, due to edema and non-painful violet lesions in lower limbs without clear etiology, in addition to losing more than 10 kg in 2 months.
The patient reported that the clinical picture started 12 months ago, initially with edema of the left lower limb, accompanied by a longitudinal erythematous cord that extended from the thigh to the ipsilateral foot, in addition to a single verruciform lesion located in the plantar region of the second toe (). The patient reported that he visited several hospitals and medical centers, in which he made use of antimicrobial treatments, with no resolution of the condition. In addition, he informed that the disease progressed in these 12 months, stating that the verruciform lesions started to affect the other toes of the left foot, and later, the involvement was similar in the right lower limb, with bilateral lesions and edema at that moment generating pain and important limitation to ambulation. He also reported that he has sexual intercourse with men, that for about 2 months, he had no appetite, and that 3 years, ago he had herpes zoster.
On physical examination, the patient presented with pale mucous membranes and was emaciated. Upon inspection of the lower limbs, edema 4+/4+ without locker, in addition to evident hyperchromic lesions and hyperpigmented plaques with irregular edges and verruciform lesions, especially in the toes of both feet (). In addition, there were similar violaceous lesions on the right forearm, with a single lesion on the back. In the oral cavity, he had oral candidiasis.
Laboratory examinations of the patient’s arrival were performed. It was observed that the patient had anemia and leukopenia with lymphocytopenia. In addition, he was diagnosed with HIV on his arrival at the hospital. He had a CD4 of 31 cells/µL, a CD

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


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

[User]
RADIOLOGY NOTE:
This is a 50-year-old white male who originally presented in 2004 with complaints of epigastric abdominal pain. The patient's past medical history was significant for hypertension, 30-pack per-year history of tobacco use, occasional ETOH use, diabetes, hyperlipidemia, and regular marijuana use. Workup at that time revealed elevated amylase and lipase levels, a dedicated gallbladder ultrasound was unremarkable, and the final diagnosis of thiazide-induced pancreatitis was made. The medication was discontinued, laboratory values normalized, and the patient was discharged. The patient presented again in 2005 with similar complaints and lab abnormalities. Upon questioning, the patient stated he continued his thiazide medication since prior discharge; the thiazide was again discontinued. Following clinical improvement the patient was discharged and switched to an ACE inhibitor for blood pressure management. In the outpatient clinical setting, the patient continued to have unresolved epigastric abdominal discomfort despite unremarkable amylase and lipase values. In light of this, a computed tomography (CT) scan of the abdomen and pelvis was performed in early 2006 demonstrating a hypervascular retroperitoneal mass intimately related to the pancreas (Figures , , and ). A positron emission tomography (PET) scan performed 7/2006 demonstrated intense FDG uptake in the region of the pancreatic head without locoregional nodal or distant metastatic disease. Fine needle aspiration of the mass was suggestive of poorly differentiated carcinoma. These findings prompted surgical consultation and a Whipple procedure was planned for resection of the possible pancreatic head mass. In 8/2006 surgical exploration revealed a retroperitoneal mass situated inferior to the uncinate process which extended to the infrarenal abdominal aorta. The mass demonstrated close involvement with the inferior vena cava and superior mesenteric vessels. Direct involvement of the pancreas and adrenals was not

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


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

[User]
RADIOLOGY NOTE:
A 50-year old male, a diagnosed case of anaplastic carcinoma of thyroid, presented with a large thyroid swelling causing respiratory distress. A decision for emergency tracheostomy was made by the surgical team and the patient was transferred to the operation theater. Comorbidities included hypertension, for which he was on regular medications. Chest X-ray showed tracheal deviation to the right [] and Hopkins (indirect laryngoscopy) examination showed decreased right vocal cord movement. All other investigations were normal.
The procedure was explained to the patient and informed consent was taken. All standard monitors were attached and basal vital parameters were noted. Intravenous access was secured and a difficult intubation trolley was kept ready in the theater with all airway adjuvants.
After preoxygenation, inhalational induction was performed with sevoflurane and direct laryngoscopy was performed. The vocal cords were sprayed with 4% lignocaine and the airway was secured with an endotracheal tube. Anesthesia was maintained with a mixture of oxygen and air with sevoflurane and intravenous drugs including fentanyl and vecuronium, which were given after confirmation of endotracheal tube in the trachea by auscultation and waveform capnography.
On neck exploration, there was a plaque of disease infiltrating various tissue planes. The trachea that appeared to be shifted on the right side could not be seen or felt because of disease plaque. The endotracheal tube that was passed also could not be felt. Usual test of tracheal puncture, with aspiration of air through syringe, was also not helpful. Therefore, it was considered unsafe to make an incision blindly on a structure that was assumed to be the trachea.
To locate the trachea, a fiberoptic bronchoscope was then introduced through the endotracheal tube, which helped, as it was seen as a trans-illumination, and the tracheal position could be confirmed []. The rest of the tracheostomy was uneventful. Endotracheal t

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old male Iranian patient with a history of recurrent acute neurologic deficit in the past 18 months, including previous stroke 3 months earlier, was admitted to our emergency department in January 2020. Our patient had no symptoms such as migraine headaches, cognitive deterioration, seizure, vision problems, or psychiatric problems. In clinical neurologic examination, he showed acute-onset dysarthria, right-sided hemiparesis and hemihypoesthesia. Other neurologic examinations showed no pathologic findings, and he had no evidence of venous thrombosis. His past medical history indicated a previous hospitalization for ischemic stroke. He had no vascular risk factors (diabetes mellitus, hypertension or smoking). He had been taking aspirin 80 mg/day and rosuvastatin 20 mg/day for the past 2 months.
Brain MRI with diffusion-weighted imaging revealed an acute infarction in the left internal capsule and left corona radiata (Fig. ). In addition, there was confluent bilateral white matter (T2) hyperintensity in both cerebral hemispheres as well as the pontine area (Fig. ). There was no evidence of venous thrombosis or micro-bleeding on brain MRI. Brain and cervical MRA did not detect any significant arterial stenosis. Findings of transthoracic echocardiography and duplex ultrasonography were normal. Routine ECG examination showed normal sinus rhythm without abnormal changes. Applying a transesophageal echocardiography (TEE), we found no cardioembolic condition. There were no episodes of atrial fibrillation in 48-h ECG monitoring. There was no minor-risk embolic source identified in our evaluation. His routine blood test, vasculitis screening profile and blood complement levels were normal (Table ). The patient was monitored in the hospital for 5 days.
Complementary workup investigations for thrombophilia revealed reduced protein S activity (18%), which was confirmed in a repeated test after 4 weeks. He had not been receiving any medication with possible effects on 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:
An 86-year-old female was diagnosed with moderate spinal stenosis in the L2-L5 lumbar spine region. She had a history of chronic LBP and lumbar radicular pain on both sides since 2015. Over the last year, she had been pharmacologically treated with nonsteroidal antiinflammatory drugs and acetaminophen. Her medical history included hypertension and an old cerebrovascular accident, for which she was taking ginko.
She had recently complained of severe back pain and radicular symptoms around the distribution of the L5 nerve root. Neurological examination results were normal with a bilateral motor strength of 5/5 in the lower extremities. Her blood tests were all in normal ranges. She agreed to stop taking ginko during her visit for treatment. She laid prone and a pillow was placed under her lower abdomen. The TFESI was performed under fluoroscopic guidance, with a 22-G Tuohy epidural needle at both intervertebral foramen between the L5 and S1 levels. After penetrating the skin, there was no evidence of intravascular uptake or intrathecal distribution. We injected 3 ml of contrast on both sides, but the anterior spreading did not work well, so we decided to inject another contrast to check anterior spreading. As soon as the contrast was injected to the left, she complained of extreme pain and the fluoroscopy image showed the contrast spreading well. The lateral view showed the contrast to be anterior spreading ().
During recovery, she continuously complained of pain and an inability to move. For pain relief, 25 mg of intravenous pethidine was administered, but the pain did not improve. An MRI scan was performed within three hours which revealed a large amount of epidural and subdural hematoma at the lower T-L spines and sacrum with cord compression at the T spine ().
Physical examination showed that lower extremity motor function was a grade 5/5 and anal sphincter tone was normal. Under fluoroscopy-guided, the procedure was performed with the patient in a prone position

[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 years old male patient presented to our department with dental trauma that had occurred 1 week back resulting in coronal fracture of the left upper central incisor (). Electrical pulp testing revealed positive results hence, indirect pulp capping was done and patient was recalled at regular intervals. No symptoms were reported by the patient but on clinical assessment, electrical pulp testing yielded negative results and radiographic assess-ment at the 6 months recall visit showed the apical root development of the tooth to be arrested (). It was, therefore, decided that apexification was indicated before endodontic treatment could be carried out for the affected tooth. The treatment plan was to form an artificial apical barrier after cleaning and decontamination of the canal with sodium chloride solution. Access cavity preparation was done for the tooth under rubber dam and working length was determined by the radiographic method (). Shaping was limited to the coronal third of the canal (with gates glidden drills) to facilitate direct instrument access to the foramen. Biodentine is an inorganic non-metallic compound presented in the form of a capsulated powder and a liquid twist cap bottle (). The capsule con-taining the powder was tapped and opened, followed by the addition of five drops of liquid from the single dose container to the capsule. The capsule was then closed and placed in an amalgamator for 30 seconds. The mix obtained is creamy in consistency, can be manipulated for 6 minutes and takes a further 6 minutes for setting.
The canal was filled with two increments of Bioden-tine with an amalgam carrier. The first increment of Biodentine was inserted into the canal using a reamer of the largest diameter fitting into the canal–ISO size 110. The material was then delicately pushed toward the apex with a root-canal plugger of ISO size 100. Several increments were similarly inserted and then condensed to form a plug of adequate thickness (> 4 mm). After ve

[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:
Patient is a 73 year-old right hand dominant female who initially presented to the office complaining of atraumatic right shoulder pain with activity and limited range of motion of longstanding duration. On physical exam, she was found to have significantly limited active range of motion of the right shoulder and clinical signs of impingement. Radiographs at that time demonstrated superior escape of the humeral head with impingement of the greater tuberosity on the acromion and early acetabularization of the acromion (Fig. ). MRI findings were consistent with her x-ray and also demonstrated a lack of contiguous supraspinatus or infraspinatus tendon. At this juncture, the patient was diagnosed with rotator cuff arthropathy and elected to proceed with reverse total shoulder arthroplasty.
The patient was brought to the operating room and placed in the beach chair position. An incision was made from just lateral to the coracoid to the medial border of the proximal humeral shaft in line with the axillary fold. Subcutaneous tissue was dissected and the cephalic vein was identified. As the cephalic vein was mobilized and the clavipectoral fascia was incised, a discrete, branching, fascicular nerve was identified lateral and deep to the cephalic vein within the deltopectoral groove (Fig. ). The nerve was further dissected and traced both proximally and distally. Distally, the nerve and all branches were found to be diving into the anterior deltoid muscle. Proximally, it was found to run deep to the conjoined tendon, towards the brachial plexus. The nerve was freed from the deltoid muscle belly, allowing enough excursion to access the glenohumeral joint via a small deltoid window. The remainder of the operation concluded without complication and the wound was closed primarily (Fig. ). The patient was neurovascularly intact post-operatively with intact sensation in the axillary nerve distribution and able to fire her deltoid muscle. She healed without complications. At 4-

[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 March 2007, an otherwise healthy 41-year-old Caucasian female veterinarian from Instituto Lauro de Souza Lima, Bauru, São Paulo, Brazil complained of a slowly growing subcutaneous nodule on the inner side of her left hand middle finger. The patient did not recall any previous trauma in that particular anatomical area. The nodule had appeared 10 months earlier as a small hard cutaneous swelling on the proximal articular side of the middle phalanx, resembling a synovial cyst. The nodular skin lesion was very small and painless, therefore the patient did not seek immediate medical attention. In the following months after she had first noted the tissue swelling, the nodule increased in size and interfered with flexion of the affected finger. It was difficult to determine whether the nodule was attached to the skin or to the subcutaneous tissue at palpation. Clinical examination of the subcutaneous nodular lesion (~2.0 × 1.5 cm in diameter) by a surgeon led to diagnosis of a giant cell tumor of the flexor tendon, and surgical excision was advised. Physical examination revealed that the patient was in good general health and had no other similar skin lesions. Surgery was performed 10 months after the initial onset.
The granulomatous 2 cm × 0.5 cm × 0.5 cm excised mass was attached to the dermis, nerves and tendons of the affected finger. It consisted of a firm yellowish tumoral-like mass resembling a lipoma, with a smooth bright surface. Because of the initial diagnosis of a benign tumor, microbiological testing (including culture) was not requested. Histopathological examination of hematoxylin-eosin stained sections showed a granulomatous infiltrate constituted by histiocytes and giant cells filled with numerous thick walled yeast-like cells, either singly or in chains, characteristic of L. loboi (Figures and ). The majority of the fungal elements in the infected tissues showed clear cytoplasmic content, a morphological characteristic of viable L. loboi yeast-like cel

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


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

[User]
RADIOLOGY NOTE:
A 22-years-old woman came to our hospital with chief complaints of slurring of speech, hemiparesis, disorientation, confusion, and restless movement of the right half of the body. The restless movement of the right half of the body was followed by weakness of the left half of the body, which was insidious in onset, progressive in nature. According to the patient party, she was unable to perform normal daily activities with normal conversation five days ago. The weakness of the left half of the body first appeared in the left lower limb, followed by worsening of that of the left upper limb. The patient developed slurring of speech and global aphasia later. There was a history of fever for 20 days, which was intermittent; the maximum temperature recorded was 103 degrees F associated with chills, rigor and excessive sweating. The patient also complained of multiple episodes of vomiting. History of clenching of teeth, up rolling of eyes, and abnormal body movements was also present.
The chest examination was normal. Cardiac rhythm and rate were normal with no murmurs. The abdomen was flat, soft, and non-tender with normal liver and spleen. Muscle strength of the right upper and lower limb was normal, but in the left upper and lower limb power was 0/5. Thalamic contracture of the right hand was also seen. All deep tendon reflexes were normal and plantar response was bilateral extensor. Signs of meningeal irritation were present. A computed tomography (CT) of the brain revealed infarct in the anterior limb of the right internal capsule and left the lentiform nucleus, bilateral lateral third ventricles including the 4th ventricle, were dilated. That signified communicating hydrocephalus and infarct on the genu of the corpus callosum on the left side ().
Cerebrospinal fluid (CSF) from lumbar puncture revealed specific gravity of 1.015, white cell count (WBC) of 3 cells/cumm/mm3, all lymphocytes,

[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 apparently healthy boy presented with a gradually increasing painful swelling of 4 months' duration over his lower back. The pain was localized to the lower back, severe in intensity, and piercing in nature; it did not radiate and increased with movements. It was associated with urinary incontinence for the same duration. There was no history of trauma. There was no history of any significant medical or surgical illness in the child or his family.
Local examination of the site revealed a small tender swelling in the lumbosacral region, with no signs of inflammation, no visible scar / sinus, and no abnormal pulsations. The swelling was fixed to the underlying structures and the overlying skin was freely mobile. The child was anemic, with hemoglobin of 10.2 gm%; the ESR was 62 mm in the first hour (Westergren's method). The other routine investigations were within normal limits.
Radiographs of the pelvis and lumbosacral spine revealed posterior scalloping of the sacral vertebrae and widened ill-defined neural foramina; there was an overlying right-sided soft tissue haze. MRI of the lumbosacral spine revealed a lobulated soft tissue mass with both intraspinal and extraspinal components in the sacral region (S2–S4). It was isointense to pelvic muscles on T1W and hyperintense, with areas of necrosis, on T2W images [ and ]; there was intense enhancement on postcontrast scans []. It had caused widening of the spinal canal and the sacral foramina and showed clubbed finger-like projections along the path of the sacral spinal nerves. There was presacral extension and infiltration of the pyriformis and right erector spinae muscles bilaterally. Based on the MRI findings, we made the diagnosis of a complex nerve sheath tumor / soft tissue sarcoma of the sacral nerve roots.
An open biopsy of the lesion revealed a proliferative growth. Microscopically, there were monomorphic-appearing small round cells arranged in sheets

[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 girl was admitted to our hospital for history of intermittent fever and nonproductive cough of 1-month duration. The mother reported a history of choking with seeds 3 weeks before the onset of symptoms. She had no other associated symptoms. The family history was relevant for leukemia from the paternal side. On physical examination, the patient was active, not in distress with diminished breath sounds along the left lung. The rest of physical examination was unremarkable. A chest radiograph showed complete collapse of the left lung (). Laboratory investigations showed a white blood cell count of 23000/mm3 with 73% of polymorphonuclear cells and 17% lymphocytes, hemoglobin 10 g/dL, hematocrit 30.5%, and platelets 543,000/mm3. CRP was 8.5 mg/dL (negative < 0.3). The purified protein derivative (PPD) test was negative.
Rigid bronchoscopy revealed a small part of seed surrounded by a grayish-white polypoid mass adherent to the bronchial wall and completely obstructing the orifice of the left main stem bronchus. Removal of the foreign body and excision of the surrounded polypoid mass were performed. The chest X-ray done after bronchoscopy showed almost complete expansion of the left lung (). However, five days later, the patient started to develop high grade fever with persistence of cough. Repeat chest radiograph showed again complete collapse of the left lung. CT scan of the chest with IV contrast revealed complete obliteration of the mid left main stem bronchus by an ill-defined hypodense/enhancing lesion, causing obstructive changes in the left lung with near complete collapse and mediastinal shift to the left with air bronchogram at the base. There were small scattered lymph nodes, subcarinal and left superior mediastinal (13 × 18 mm). The right lung was clear with no pleural or pericardial effusions.
The biopsy specimen taken during bronchoscopy revealed a mixture of tubules and solid areas. The tumor cells were large with round normochromic, often cle

[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 nine-year-old boy presented to our outpatient department with complaints of deformity in both knees, inability to straighten the knee, difficulty in standing and walking. On further questioning, the parents gave history of full term born, normal delivered child, with deformed knees since birth. Partially flexed knees noted at the time of birth, gradually worsened from the age of one and a half years, when he started walking. Deformity was more on the left knee, which made it difficult for him to walk.
On examination there was bilateral absence of patella. Femoral condyles were prominent. Absence of both patellae and a hollow sulcus seen in between femoral condyles were the hallmark clinical features []. Femoral condyles were large and prominent. Fixed flexion deformity in knee measuring 80 degrees on the left side and 30 degrees on the right side was noted. The power of quadriceps hamstrings and gluteus maximus were good. Nails were clinically normal. No other deformity was present in the patient. Examination of upper limbs and other systems was clinically normal. His blood parameters were within normal limits. Ultrasound abdomen was normal. No renal abnormalities were noted. Radiographs of both knees [Figures and ] showed absence of both patellae and flexion deformity more on the left side.
Computerized axial tomography [] was done to measure the limb length discrepancy and to look for other associated disorders in both lower limbs. Limb lengths were equal on both sides. No femur or tibial anomalies were seen.
Left side fractional hamstring lengthening was done under spinal anesthesia. Sutures were removed after two weeks. Active and passive resisted physiotherapy was started after six weeks. Gait training was given. The patient was on regular follow-up every two months a year. Patient was 13 years old at the time of last follow-up. He can now walk with a bipedal independent gait with minimal flexion at the left knee and mild equinus

[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:
History and examination
A 41-year-old Hispanic male originally presented to the neurology service for evaluation of low back pain with a burning sensation in bilateral lower extremities. During the exam, it was noted he had brisk reflexes. Therefore, the neurologist recommended a cervical MRI which ultimately demonstrated severe cervical stenosis at C1 with severe cord compression (Figure ). The patient was referred to the neurosurgery clinic where he endorsed inability to carry things for long periods of time due to hand weakness that had been worsening over six months. Moreover, he stated that he was unable to perform his job as a butcher due to inability to hold his knife. Upon reviewing the patient's MRI and based on clinical exam of hyperreflexia throughout, bilateral clonus, bilateral Hoffman's, and 4+/5 strength in bilateral deltoids and grip, it was quickly determined that the cervical cord decompression was a priority, and he was scheduled for a C1 laminectomy with intraoperative neuromonitoring.
Operation
Prior to positioning as well as intraoperatively, somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) were present, equal, and reproducible in all four extremities. Anesthesia was asked to keep mean arterial pressure (MAP) greater than 85 mmHg throughout the entire surgery. After removal of the posterior C1 arch, all SSEPs and MEPs were still present and reproducible. Shortly thereafter, the neuromonitoring technician was manipulating the needles in the scalp and when asked the reasoning, we were informed that SSEPs were gone from the hands, followed by all extremities, followed by loss of MEPs in the upper extremities. At that time, we stopped all surgical manipulation, and the MAP was confirmed to be greater than 85 mmHg that we requested at the beginning of the case. Nonetheless, we asked to push the MAP greater than 95 mmHg. An intraoperative fluoroscopic lateral image was obtained which confirmed no subluxation or malalignment

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


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

[User]
RADIOLOGY NOTE:
The patient was a 54-year-old Hispanic male who presented with a one-day history of sudden onset of severe right flank and right lower quadrant abdominal pain with radiation to the right inguinal area accompanied by nausea and vomiting. The patient denied any fever or chills and no significant family history was reported. On examination, the abdomen was soft with minimal tenderness on deep palpation of the right lower quadrant without guarding or any distention. Laboratory workup revealed evidence of elevated creatinine, but leukocyte count was within normal limits. A contrast-enhanced CT of the abdomen and pelvis revealed an obstructing stone at the right ureterovesical junction (Figures -). The appendix was visualized to be a well-circumscribed and partially calcified cystic structure measuring 3.2 x 2.5 x 4.5 cm; there was no radiographic evidence of inflammatory changes.
The patient’s clinical picture was initially attributed to ureterolithiasis and was treated accordingly. However, the cystic structure on the appendix was concerning for a mucocele. Consequentially, the decision was made to take the patient to the operating room for a diagnostic laparoscopy with a possible appendectomy. Intraoperative findings were significant for an enlarged appendix (measuring approximately 8 x 1.3 cm) with a thickened partially calcified wall, without evidence of inflammation. An enlarged and elongated cystic structure was noted in the mid-appendix. The rest of the abdominal cavity was unremarkable, without mucin or free fluid noted. A laparoscopic appendectomy was performed in the usual fashion. However, given the intraoperative findings, the decision was made to include a distal segment of the cecum in the resection. No surgical complications were encountered during the procedure.
The patient's postoperative course was uneventful and final pathology was obtained three days after surgical intervention (Figures , ; Figures -), reporting a well-differentiated low-grade appendi

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old man was admitted to our hospital with right fronto-parietal aSDH with left ankle tri-malleolar fracture/dislocation after a road traffic accident. After consultation with the neurosurgical team, the aSDH was managed conservatively and the patient was kept under close observation in the high dependency unit. The patient had intense headache that persisted for several days requiring frequent doses of intravenous analgesics; otherwise, his hemodynamic parameters and neurologic profile were stable. He was not able to ambulate because of the skeletal traction applied on the lower limb. After about one week of conservative management, the orthopedic team suggested the fracture should be fixed soon to allow the patient to mobilize and prevent ankle-joint dysfunction, limb wasting and infection. During the preoperative assessment, we explained the patient in detail about the anesthetic plan including regional and general anesthesia, and the risks associated with the surgery. Informed written consent was obtained from the patient, which also included consent for publication of case details and the pictures.
On the day of surgery, standard monitoring was applied in the preoperative holding area. Midazolam 1 mg and fentanyl 50 µg intravenous were given for procedural sedation. Lumbar plexus block (Shamrock technique) was administered on the left side under combined ultrasound (USG) and peripheral nerve stimulator (PNS) guidance with 25 mL 0.375% bupivacaine (). Subsequently, proximal (para-sacral) sciatic nerve block was done on the same side under combined USG and PNS guidance with 25 mL 0.375% bupivacaine (). Ten minutes later, the adequacy of the block was confirmed after testing for motor and sensory modalities, and the patient was transferred to the operating room. The patient was calm and relaxed throughout the surgery. Hemodynamic parameters were normal throughout, and the patient had no pain complaints. The procedure lasted about three hours, after which

[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 2-year-old boy was referred to the Department of Oral and Maxillofacial Surgery of Children's Medical Center, Tehran, Iran, with a history of a painless mass in the right side of his lower jaw before 2 months []. On extraoral examination, no associated lymphadenopathy was observed, and the mass was non tender. On intraoral examination, swelling in the right side of the mandible with firm consistency was evident. Computed tomography (CT) demonstrated a lesion extending from the first left primary molar to the right ascending ramus []. The patient's parents reported that he underwent a previous surgical treatment for a lesion in the same area about 1 year ago []. The previous surgeon with an initial diagnosis of benign spindle cell tumor enucleated the lesion and used a titanium plate for reconstruction. The patient after less than 1 year presented with the recurrence of the lesion around the plate in the same anatomical site. The differential diagnoses based on perforation of the mandibular cortex and aggressive behavior of the lesion were primary bone sarcomas such as osteosarcoma or chondrosarcoma and other intraosseous soft-tissue sarcomas. Aggressive benign spindle cell tumors such as DF should be ruled out. Under local anesthesia, an incisional biopsy of the lesion was obtained. Histologically, a nonencapsulated hypocellular lesion composed of proliferation of oval-to-spindle-shaped cells with minimal atypia in the fibromyxoid background which infiltrated the muscular bundles and regional trabecular bone was observed [ and ]. Based on histopathologic features, the differential diagnosis included neurofibroma, DF, and low-grade sarcomas such as low-grade leiomyosarcoma or fibrosarcoma. Immunohistochemically, the tumor cells showed strong immunoreactivity for vimentin and B-catenin but were nonreactive with S-100 protein and desmin, and the MIB-1 (Ki67) index was low (1%) and ]. Based on the clinical, radiological, and histopathological features, a diagnosis 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:
We described the clinical course of a 64-year-old Chinese man who was admitted to the hospital with septicemia and necrotic soft tissue inflammation of the right lower limb.
Fourteen days prior, a 64-year-old man, whose only known comorbidity was diabetes mellitus history, sought medical attention at another institution. He presented with pain, swollen, deformity of the right leg caused by falling from a height without any open trauma or neurovascular problem. The comminuted tibia fracture was confirmed with radiographs of the affected leg. Approximately 8 days after the injury, he underwent an uncomplicated routine MIPO surgery of the tibia fracture (Fig. ), when the blood glucose levels near normal and the swelling subsided. And the patient as usual received a single dose of cefazolin preoperatively for a prophylactic antibiotic coverage.
On the second postoperative day, the patient had fever as well as pain and redness around the distal operative incision of the leg, despite postoperative antibiotics (cefazolin) were used for prevention. More seriously, the incision started discharge of foul-smelling white exudate the following day. Cellulitis was initially suspected, the sutured wound was opened immediately, and intravenous antibiotic (cefmenoxime) therapy was given empirically. However, the erythema, edema, and then serous-filled bulla progressed to the right proximal leg and distal foot over a 12-hour period. The patient was promptly taken to the operating room for emergency exploratory operation the same day; soft tissue necrosis and pus accumulation beneath the fascia were discovered when the leg was opened. And the patient underwent debridement of the right leg and foot without involving the thigh. On the second day of debridement surgery, the leg infection progressed, with the erythema extending to the distal portion of the right thigh.
The patient was then transported to our unit, which was the level-I trauma center in our region, 4 hours after the sudden

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


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

[User]
RADIOLOGY NOTE:
The patient was a 56-year-old female who came to us during an episode of mania and psychosis while receiving treatment at an addiction treatment center where she was taking a phenobarbital taper for chronic lorazepam use. She displayed symptoms of aggressive posturing, verbal abuse to staff, delayed response, and racing thoughts. She did not describe suicidal thoughts. She had 4 prior psychiatric hospitalizations. At age 33, she exhibited depression, anxiety, and paranoia that lead to her first hospitalization. At age 44, she attempted suicide via acetaminophen overdose. Her first reported manic episode was at age 45, during which bipolar type 1 disorder was considered as her differential and subsequently diagnosed. Her symptoms accompanied delusions during this episode, without suicidal ideation. Her most recent hospitalization was at age 49 for depression and paranoia with delusions of being wiretapped and people reading her mind. At age 55, the patient presented with optic neuritis and diagnosed with MS after a lumbar puncture showed oligoclonal bands.
Family history revealed depression in father and alcohol use disorder in mother. Past medical history described an acute onset dizziness when moving eyes left to right or vice versa and when standing up from a lying position.
Neurology consult found no focal or lateralizing findings. MRI analysis showed greater than 15 foci of T2 hyperintensity within white matter where some lesions were within periventricular and juxtacortical white matter of both cerebral hemispheres, consistent with a demyelinating disease. A single focus of enhancement in the posterior corona radiata was suggestive of active demyelination. No demyelinating signs were seen in the thoracic spine. However, no significant difference was seen compared to previous MRI.
During the present hospitalization, patient's prior bupropion was reduced due to concern for further mania activation. Lithium 600 mg twice a day was prescribed for mood stabilization.

[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.