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

[User]
RADIOLOGY NOTE:
A 14-year-old boy complained of short of breath for 10 months was admitted to our hospital. Computed tomography (CT) revealed a giant multilocular mass of approximate 20 × 20 × 25 cm in size with right pleural effusion. It compressed the heart, superior vena cava, and diaphragm with the total right lung atelectasis. The tumor contained multiple cysts with calcifications and fat. Tumor cells were not found in the pleural effusion (Figure ). The teratoma was considered unresectable and malignant, which contained immature components by CT guided fine-needle biopsy 8 month ago in a foreign hospital. The boy took 4-cycle BEP chemotherapy. But the tumor didn’t shrink evaluated by CT scan. Then the patient received an exploratory thoracotomy 3 month ago by another hospital. But the huge size, widespread adhesions and abundant new vascularization of the tumor resulted in massive bleeding allowed only a small part of the mass excised for pathologic diagnosis. Pathologic findings revealed a mature teratoma. Cranial MRI, upper abdomen CT scan and bone nuclear scan revealed no further lesions in our hospital. The right-sided posterolateral thoracotomy was performed on July 18, 2013. Venous conduit bypass between the right jugular vein and right femoral vein was established immediately before operation in case of SVC replacement. Because of the widespread and severe adhesions among the tumor with surrounding chest wall, diagram, lung, pulmonary vessels, SVC, and pericardium, great care was taken for the dissection. Reducing the tumor volume to facilitate the dissection, the fluid contents of the mass were aspirated via a small incision of the wall. With partial resection of the dense adhesions of the pericardium, and wedge resections of the severe adhesions of the right upper, middle, and lower lobes of the lung, en bloc resection of the huge tumor was completed (Figure ). The tumor weighed 4320 g and its largest diameter was 25 cm. Considering the weight of the tumor, continued

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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 23-year-old married woman was admitted to hospital because of primary amenorrhea and
failed sexual intercourse for 5 years. The patient was able to urinate, but not smoothly,
and she had leakage of urine for as long as she could remember, especially after running or
a long walk. Although the amount of urine leakage was small, a protective pad still needed
to be used. She had undergone laparotomy (her operation record was unavailable and details
were unknown) because of lower abdominal pain with poor urination more than 15 years
previously. After this operation, her abdominal pain disappeared, but leakage of urine was
not relieved. Growth and development of this patient were similar to other normal peers, and
her intelligence was normal. She married at the age of 21 years without a history of
pregnancy. Her father and husband are healthy, but her mother died in a car accident many
years previously. Through information provided by her father, we learned that her mother had
not taken any special drugs during pregnancy. The patient was an only child with no similar
medical history among her family members.
After a physical examination, we found that bilateral breast development of the patient was
normal. The vulvar fissure was short with only one opening in the vestibule. The urethra and
vagina opened together in the vaginal vestibule. Additionally, urine was flowing out of the
common mouth in forced urination. On a rectoabdominal examination, there was a hard mass of
approximately 8 cm in front of the rectum. The activity of the mass was poor, but the
boundary was still clear. When the mass was pushed, urine flowed out of the common opening.
An 18F latex catheter was inserted into the common opening, which was approximately 14 cm
deep, and a small amount of turbid liquid was drained, accompanied by obvious stench. The
d

[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 Korean male patient was referred to our emergency department with cramping abdominal pain for three days. He also had dyspnea and chest discomfort. He had diabetes mellitus and no history of trauma. Upon his arrival at the emergency department, his blood pressure was 150/100 mmHg, heart rate 102 per minute, respiratory rate 22 per minute and body temperature 37.5°C. On physical examination there was direct tenderness on the whole abdomen and we could hear rale in both lower lung fields. Laboratory studies showed leukocytosis and a leukocyte count of 1,500. An x-ray of the chest showed abnormal air shadows above the diaphragm (Figure ). Computed tomography showed what appeared to be a loop of intestine in the pericardium (Figure ). We performed an emergency operation with median laparotomy. The small bowel was herniated to the pericardial space through the diaphragmatic defect and the herniated bowel was edematous and strangulated. We pulled the herniated bowel for an easy manual reduction. After the reduction of the herniated bowel, we identified the diaphragmatic defect. The defect was located at the left side of the central tendinous portion and had no communication with the pleural space. The defect was 3 × 3 cm in size with a round shape, and the margin of the defect was smooth and thick. We could see the heart beat through the defect. We resected the strangulated small bowel and performed end-to-end anastomosis. The defect was closed with Gortex patch with interrupted ethibond sutures. On chest x-ray after operation, no bowel gas was seen in the chest (Figure ). The patient received ventilator care during the immediate postoperative period. On the fourth postoperative day, the patient was transferred to a general ward and the postoperative course was uneventful. The patient was discharged on the ninth postoperative day. We concluded that the patient’s final diagnosis was small bowel strangulation due to peritoneopericardi

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


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

[User]
RADIOLOGY NOTE:
A 6 year-old girl was first referred to our institution for a mediastinal lesion found incidentally on a chest radiograph at the age of 27 months. She was born healthy at full-term with a birth weight of 3400 g via caesarean section without complications during pregnancy or the delivery. At the age 6 years, she presented with recently developed recurrent vomiting. The physical examination was unremarkable and laboratory studies, including the hematological profile and serum chemistry, were within normal limits. She was again referred to us for further evaluation of the known mediastinal mass.
The chest radiograph showed a 4.2-cm-long, ovoid, thin-walled lesion in the left paravertebral space (Fig. ). Chest CT at that time revealed a thin- and smooth-walled cystic mass containing an air-fluid level in the left paravertebral space. The cystic lesion had several inner circular folds like valvulae conniventes (Fig. ). The inferior tip was located between the thoracic spine and left diaphragm crus. On CT, we could not find a communication between the lesion and abdominal cavity or bowel loop. Our first radiological impression was a type I congenital cystic adenomatoid malformation because of its internal unilocular air density, or a variation of Bochdalek hernia because of its location and characteristic inner-wall enhancement. Endoscopy was performed to look for a communication between the mass and esophagus, but none was found.
The patient underwent video-assisted thoracoscopic surgery. The cystic mass was located between the aorta and heart, measured 9 cm in length and 5.5 cm in diameter, and had a smooth, bowel-like outer surface and inner circular folds that looked like valvulae conniventes. No definite connection was found between the mass and any intrathoracic organ. The inferior end of the cystic lesion was not found at surgery, so we could not confirm communication with the abdominal cavity. Histopathological examination of the tissue confirmed an enteric duplic

[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 12 years and 8 months old female presented with a double structural thoracic and lumbar scoliosis associated with Arnold-Chiari 1 malformation and an extensive cervicothoracic syringomyelia. At age 11 years and 11 months she developed acute weakness affecting both hands and feet with associated pins and needles down the arms and legs, as well as altered sensation affecting the right upper limb below the elbow while her bladder and bowel function was normal. The patient underwent an urgent cranio-cervical decompression including a posterior fossa craniotomy and C5/C6 laminectomy with syringostomy and placement of a syringopleural shunt to drain the syrinx []. She recovered well following surgery and there were no residual neurological signs or symptoms at the time of presentation in our clinic.
On clinical examination at age 12 years and 8 months, she had a progressive thoracic and lumbar scoliosis extending from T5 to T10 measuring 60° and T10 to L3 measuring 50° respectively. Neurological examination was normal. The patient had normal function including sport activities. She was skeletally immature and pre-menarche with Risser grade 1. An MRI of the whole spine demonstrated adequate decompression of the cranio-cervical junction and a small residual cervical syrinx which was considered to require no further treatment at the time by our neurosurgical colleagues.
The patient underwent posterior spinal arthrodesis extending from T4 to L3 at age 12 years and 10 months with the use of segmental pedicle screw and rod instrumentation and autologous iliac crest bone graft []. Spinal cord monitoring was performed during the procedure recording motor and sensory (cortical and cervical) evoked potentials which remained stable throughout. Postoperative neurological examination was normal. The patient had 3 doses of intravenous (IV) cefuroxime; one at induction to anaesthesia, and 2 after surgery at 8-hourly intervals.
In the postoperative period, the patient developed prolong

[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 69-year-old postmenopausal caucasic woman with previous two pregnancies and two deliveries was referred to our department for a vaginal recurrent leucorrhoea which lasted for over one year despite multiple vaginal local treatments. Her past medical and surgical histories revealed two episodes of diverticulitis managed with antibiotics, appendectomy, and breast cancer treated with breast-conserving surgery followed by radiotherapy and hormonotherapy with complete remission of the disease. Unlike other cases from the literature reports, our patient presented with gynecological problems and her only symptom was the vaginal discharge, the patient did not complain about abdominal pain, fever, or other symptoms. The clinical examination was unremarkable, and vaginal swab revealed the presence of Escherichia coli and Streptococcus constellatus. The transvaginal ultrasound examination showed a heterogeneous intrauterine collection. Hysteroscopy was performed as an additional exam. The presence of air in the uterine cavity in the absence of uterine fistula or neoplasic process made us suspect the tubo-intestinal fistula. The endometrial biopsy was compatible with endometritis secondary to E. coli. To confirm the diagnosis, CT scan and hysterosalpingography were performed and the communication between the tube and sigmoidal diverticulum was visualized ( and ).
Based on the medical history, age, and symptoms, elective surgical treatment was performed by gastrointestinal surgeons. This was a one-stage surgery with sigmoidal and concomitant left salpingo-oophorectomy and primary anastomosis. Intraoperative, the affected area of the colon was densely adherent to the left fallopian tube. Inflammation was present in the proximal rectum, therefore dissection was extended more distally and a low anterior resection with primary anastomosis was performed. The colon and fallopian tubes were successfully separated using finger fracture technique. Pathological examination confirmed 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:
This patient was a generally healthy 62-year-old male with a left lobe complex nodule within a nontoxic multinodular goiter that had been enlarging for approximately 3 years. In 2015, the patient had a FNAB reported as benign, BC II. Because of continued growth, he had a second FNA biopsy approximately six months later reported as a Hürthle cell neoplasm or suspicious for a Hürthle cell neoplasm, BC IV with Oncocytic / Hürthle cells dispersed mostly singly and in small fragments in a background of lysed blood. CKAE1/AE3, TTF-1, and thyroglobulin immunostains were positive (). Molecular testing with ThyroSeq® v2 revealed an absence of gene mutations or fusions but overexpression of the MET gene with an uncertain increased risk of malignancy. After repeat ultrasound imaging, the nodule had grown from 4.9 to 6.0 cm over the course of 1 year. He was euthyroid with negative anti-thyroid antibodies. There was no family history of thyroid cancer or known radiation exposures in his youth. He had no obstructive symptoms despite the size of the mass and denied shortness of breath, dysphagia, neck pain, neck pressure, or recent voice changes. His weight had been stable and appetite good. His past medical history was significant for a retinal detachment, hypertension, and inguinal hernia with a surgical history limited to eye surgery and hernia repair. He denied tobacco or alcohol use. On exam, the patient had an enlarged, firm thyroid gland with the left thyroid lobe causing significant tracheal deviation to the right. A neck CT scan demonstrated a markedly enlarged left thyroid lobe (7.2 cm in sagittal height) causing significant rightward tracheal deviation, minimal tracheal compression, and slight early substernal extension (). He had multiple opinions from both endocrinologists and surgeons with various recommendations from left thyroid lobectomy to total thyroidectomy. The patient had initially contemplated a hemithyroidectomy due to concerns for voice impairment that cou

[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 report a case of a 24-year-old woman referred to us due to a retroperitoneal mass observed adjacent to her left kidney. This was an accidental finding on a magnetic resonance imaging (MRI) prescribed due to lower back pain. A well-circumscribed heterogenic mass posterior and inferior to the left kidney, measuring 9.5 × 4 × 4 cm, was revealed (). The tumour presented two compartments; the upper compartment showed both cystic and solid elements, while the lower compartment was divided by septa and presented only cystic elements. From the patient’s personal history, learning difficulties had been reported since she was 6 years old. She also reported altered vision at the age of 8. At this time, an epiretinal membrane near the macula in the right eye, strabismus, myopia and astigmatism in the left eye were diagnosed. At the age of 14, the patient started suffering from lower back pain. By the age of 22, she could not walk easily due to muscle weakness and imbalance. During the past year, the patient’s hearing declined, and lower back pain worsened, radiating to the right lower extremity. There were no other findings from her personal and family history.
Clinical assessment revealed a positive Lasègue sign at the right side, left side nystagmus and a left side positive Romberg test. She also presented cerebellar gait. Slit lamp examination revealed optic papilla oedema.
The routine laboratory study was within the normal range. Brain, orbits, cervical, thoracic and lumbar MRI showed bilateral VS, multiple meningiomas and schwannomas and ependymomas in the cervical, thoracic and lumbar spinal cord. The right VS was 1 × 2 cm, whereas the left one, which was larger, at 4.7 × 3.5 cm, was compressing and displacing the brainstem and the fourth cilia (). Schwannomas derived from the right and left trigeminal nerve were of 1.5 and 2 cm in diameter, respectively. Schwannomas seen

[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 68-year-old Caucasian gentleman presented to the Emergency Department with a 3-week history of left hip pain, clicking, and difficulty weight bearing, with no antecedent trauma. This occurred on a background history of an ipsilateral ceramic on ceramic (CoC) uncemented THA implanted 10 years previously, with a complicated immediate post-operative course involving a dislocation requiring closed reduction. He suffered from no further complications and was asymptomatic up to this presentation. His background history was significant for a right uncemented CoC THA 6 years previously, type-2 diabetes, and chronic venous disease.
On examination, the patient displayed an antalgic gait with no obvious leg length discrepancy. Inspection revealed no evidence of infection at the previous THA incision. The patient suffered from pain on both active and passive movement at the hip, with an audible clicking sound throughout. There was no associated neurovascular deficit.
Plain radiographic evaluation revealed superolateral subluxation of the ceramic femoral head in relation to the ceramic acetabular component with no associated periprosthetic fracture or dislocation (). Serological evaluation revealed normal infectious markers, consistent with clinical assessment showing no evidence of infection. Further imaging using computerized tomography revealed superolateral deficiency of the acetabular component, with a diagnosis of ceramic acetabular component fracture presumed to be the mechanism behind the patient’s symptoms.
Following initial inpatient management, the patient’s symptoms improved, but nevertheless, he continued to suffer from discomfort and limitation of his activities of daily living (ADL’s). Following outpatient re-evaluation by a specialist revision arthroplasty orthopedic surgeon, a shared decision was made to proceed to revision THA, with the intended goal to address the presumed ceramic acetabular component fracture.
This was undertaken utilizing the anterolateral

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old female presented to the plastic surgery clinic with a chronic open wound in the left temporal lesion. Five months prior to this, the patient had undergone craniectomy for an acute subdural bleeding. The patient gradually recovered and underwent reconstructive cranioplasty two months prior to the presentation to the clinic.
On exam, a pressure sore measuring 6×4 cm was located in the left temporal region (). There were severe scarring near the lesion caused by previous operations. The location and size of the defect precluded many local flap options, and the patient consented to a free flap reconstruction of the soft tissue defect. The patency of superficial temporal artery was confirmed using a hand-held Doppler, and the superficial temporal vein was assumed to follow the course of this artery.
Under general anesthesia, the wound was debrided, after which the defect measured 8×6 cm. The wound was carefully explored, and the superficial temporal artery was followed from a proximal to distal course until we were able to find an appropriate recipient vessel about 3 cm away from the inferolateral margin of the defect.
A 8.5×6.5 cm fasciocutaneous flap was elevated in a spindle shape from the left lateral arm. The flap included a 1-mm diameter artery and two veins. The donor site was closed primarily, and the harvested flap was attached to the defect using a 4-0 nylon stay suture. Under a microscope, the flap artery was anastomosed to the frontal branch of the superficial temporal artery, but no recipient vein could be identified. Because of this, we decided to use one of the veins as a drainage channel. This adventitia of the venous end was fixed to the skin using 9-0 nylon. The remaining border of the wound was closed with temporary drains in place.
Postoperatively, the patient was initially managed in the intensive care unit. Postoperative hemoglobin and hematocrit were 9.5 and 27.6, respectively, and these values were kept within 8-10

[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 now 76-year-old male underwent buried PD catheter insertion in 1998 at the Ottawa Hospital. He had membranous glomerulopathy and stage 5 chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of 13 mL/min/1.73m2. Over the ensuing years, he continued to have subnephrotic proteinuria and was managed with perindopril. The renal function remained relatively stable and only began to decline in late 2017. He consented to initiation of PD in February 2018 after his eGFR dropped to 7 mL/min/1.73m2. A plain radiograph of the abdomen showed the PD catheter optimally positioned in the true pelvis ().
The exteriorization procedure was performed in the Home Dialysis Unit. A 0.5 cm skin incision was made 2 cm distal to the superficial cuff and a loop of the catheter was mobilized and the fibrin was cleared off the catheter. The distal catheter did not glide out easily. With the assistance of a surgeon, a second incision was made over the distal end of the catheter and it was separated from the subcutaneous tissue by dissection and the end of the catheter was cut off (). A large fibrin plug was removed from the lumen of the catheter with push and pull syringe aspiration. The flow remained very sluggish. Tissue plasminogen activator (tPA) was instilled into the catheter and by the following day the inflow significantly improved but outflow was still slow.
Two days later, a cathetergram and guide wire manipulation of the catheter was then arranged through interventional radiology. The initial contrast injection showed the PD catheter localized within a pocket of fibrous tissue communicating with the greater peritoneal cavity along the right pelvic wall. Two angled glide-wires were utilized to clear fibrin out of the lumen of the catheter and a torque cable was then used to flip the draining loop out of the fibrous pocket into the greater peritoneal cavity. Following this, outflow improved and the patient was able to

[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 79-year-old right-handed male with a medical history of diabetes, hypertension, coronary artery disease, and chronic kidney disease underwent the EVAR procedure with a left renal stent for an incidental finding of a juxtarenal AAA on CT scan (). According to the vascular surgery operative report, the procedure was completed successfully through access of the bilateral femoral arteries and the left brachial artery (). After the procedure, there was no immediate recognition of any major complications other than a small contained hematoma at the brachial catheter insertion site that formed after withdrawal of the catheter.
The patient then presented to our outpatient pain management clinic 2 months following the procedure with symptoms of atrophy and weakness of the left forearm and pain in the left hand. During the initial examination, a pulsatile mass of 2–4 cm was palpated in the medial left upper arm in the antecubital fossa. Motor assessment of the upper extremities revealed bilateral biceps flexion/extension 4/5, left finger flexion 2/5, and left hand grip 2/5. The patient's presentation was concerning for an aneurysm of the left brachial artery. An immediate ultrasound of the left upper extremity was ordered and revealed a pseudoaneurysm of the left brachial artery. The patient was urgently referred to vascular surgery and was taken to the operating room to repair the pseudoaneurysm the following day.
Four months after repair of the pseudoaneurysm, the patient returned to our clinic and his left upper extremity sequelae worsened. He now demonstrated significant guarding of his left hand and allodynia to the median nerve distribution and had skin changes and contracture of his digits with significant weakness and atrophy. An X-ray of the hand demonstrated significant osteopenia. A diagnosis of CRPS type II was established. The patient was referred for conservative treatment, which included but was not limited to pharmacologic intervention, occupational therapy

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old male patient presented at the emergency service of oral and maxillofacial surgery of a private hospital in Recife, Brazil, with complaints of a painful hard swelling in the submandibular region (). He had undergone extraction of the left third molar seven days before presentation (). He has noncontributory medical or socioeconomic history, since he was not hypertensive, did not have diabetes mellitus or sexually transmitted infections such as HIV or syphilis, and did not smoke or drink alcoholic beverages.
A computed tomography revealed a hypodense image in the submandibular region accompanied by the presence of gas in their interior (). Respiratory rate and blood pressure changes were not observed. On extraoral examination, the skin of the submandibular region was tender bilaterally and of normal color. Intraoral examination revealed maximal interincisal opening (<20 mm), as well as absence of the left mandibular third molar. Blood cultures were performed, and intravenous Metronidazole (500 mg, 8/8 hours) and Rocefin (1 g, 12/12 hours) were empirically started.
On the third day, there was a slight hyperemia in the cervical region and in the thorax, and the patient reported dysphagia and dysphonia. Due to the persistence of the infection, the antibiotic was changed and a new cycle was started with 1.5 g Tazocin injected intravenously every 6 hours. To monitor the clinical status of the patient, daily laboratory tests were carried out, which showed that the body continued to exhibit marked leukocytosis (15,290). There was also positivity and an increase in the 7.32 reference value for C-reactive protein, indicating that there was still a significant infection in the body.
A new contrast-computed tomography of the face, neck, and chest clearly showed the presence of a purulent collection in pharyngeal spaces, with a descending path to the mediastinum and marked deviation of the trachea (). In view of the emergency situation, after antisepsis of the regio

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old male patient came to our department with a huge cauliflower-like progressive ulcerated neck mass and bilateral axillary lymphadenopathy for 8 months with grade intermittent fever, weight loss, and fatigue for the past 4 months.
Eight months before, he was diagnosed tubercular lymphadenitis by fine-needle aspiration cytology (FNAC) and given ATT (anti-TB treatment) for the past 6 months. After complete the anti-tubercular drug (ATD), the neck mass was again progressively increased with bilateral axillary lymphadenopathy. Patient also complained low fever, loss of appetite, weight loss, and night sweat. After 1 month, he came to our outpatient department.
In our department, the physical examination revealed a bulky ulcerative cauliflower-like diffuse anterior neck mass measuring 8 cm × 8 cm involving the submental and anterior cervical region and bilateral axillary lymphadenopathy measuring 3 cm × 2 cm each [ and ]. FNAC from the solid area of ulcerated neck mass and axillary lymph node were done, and the cytosmear revealed sparse large atypical lymphoid cells over a background of necrosis and acute inflammatory cells. Thus, the diagnosis was suspicion of NHL []. His routine blood examination was normal except for increased erythrocyte sedimentation rate and neutrophilic leukocytosis with left shift. Serological test such are HIV, hepatitis B surface antigen, and HIV were negative. X-ray and ultrasonography abdomen and pelvis findings were unremarkable. Computed tomography scan of the neck showed cervical lymphadenopathy with central necrosis. Punch biopsy from the ulcerated mass was done and histopathology section showed the presence of atypical lymphoid cells characterized by large cells with round morphology. Some amount of eosinophilic cytoplasm, fine chromatin, and prominent central nucleoli scattered over a loose fibro-collagenous stroma. Some cells had plasmacytoid morphology. There were areas of dense neutrophillic aggregation and necrosis. The d

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old woman with progressive exertional dyspnoea and World Health Organization functional class (WHO FC) III–IV and a recent episode of haemoptysis was referred to our Pulmonary Hypertension Centre. She had no cardiovascular risk factors and family medical history was not available because the patient was adopted at the age of 12. She had no history of human immunodeficiency virus infection, no exposure to drugs or toxins involved in the development of PAH, no history of chronic liver disease, deep vein thrombosis, or connective tissue disease. At our first physical examination, the patient did not have elevated jugular venous pressure, hepatomegaly, ascites, or peripheral oedema; but the auscultation revealed an accentuated pulmonary component of the second heart sound. The electrocardiogram showed sinus rhythm and right bundle branch block. Transthoracic echocardiography confirmed the suspicion of pulmonary hypertension (PH): systolic pulmonary arterial pressure was estimated to be 80 mmHg, the pulmonary artery trunk was dilated and the right ventricular (RV) outflow tract acceleration time was shortened. No pericardial effusion was detected. Six minutes walking test (6MWT) showed impairment in functional capacity (220 m). Cardiac magnetic resonance (CMR) imaging showed a hypertrophic, normal-volume right ventricle with mild depressed global systolic function (RV ejection fraction 51%) and no evidence of congenital heart disease. The left ventricle ejection fraction was normal with flattening of the interventricular septum (Figure ). High-resolution computed tomography excluded parenchymal lung disease and perfusion lung scan was negative for mismatched perfusion defects, ruling out the suspect of chronic thromboembolic PH (Figure ). Although the patient had never been complaining of angina coronary angiography was performed to exclude left main stem coronary artery compression by the dilated pulmonary artery trunk. The exam did not demonstrate any coronar

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


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

[User]
RADIOLOGY NOTE:
We describe the case of a 34-year-old gravida II para l woman, with a gestational age of 26 + 3 weeks at admission, who had a relatively healthy 4-year-old child with her 40-year-old husband of non-consanguineous marriage. She had been on injectable contraception for 2 years and had regular menses for 6 months before the pregnancy. She had antenatal care at a local health center and was vaccinated with tetanus toxoid once and supplemented with iron for 3 months. She was screened for retroviral infection, hepatitis, and syphilis and it was documented nonreactive. She had no anatomic scan at early gestation. She came to Felege Hiwot Referral Hospital with the chief complaint of severe and persistent headache of a day’s duration which was occipital in location associated with blurred vision and generalized body swelling of 1 week’s duration. She had no other danger signs in pregnancy. Her past gynecologic history, medical history, and surgical history were uneventful. She is Amhara by ethnicity. She had no known family history of hereditary or chromosomal disorders.
Her blood pressure at admission was 180/120 mmHg and pulse rate was 84 beats per minute; her respiratory rate was 22 breaths per minute and she was afebrile. She had pink conjunctiva and non icteric sclera, 24 weeks-sized gravid uterus, no abdominal tenderness, no organomegaly, no sign of fluid collection in her abdomen, and the fetal heart beat was positive. She had no vaginal bleeding or discharge. She had pedal and pretibial edema. She was conscious and oriented to person, place, and time. Her deep tendon reflex was +2 and her motor and sensory examinations showed no motor or sensory problems. Other parts of systemic examinations were normal.
Her hypertension was controlled with intravenously administered hydralazine 5 mg two doses at our emergency department. In her complete blood count her white blood cells were 7300 cells/micL,

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old gentleman was referred to our unit following debridement, plate fixation and pedicled gastrocnemius flap and split-thickness skin graft of a degloved open femur fracture on the right. He was referred three weeks post-initial injury. The patient initially presented to an out of region major trauma centre with a crush injury to his right thigh from a heavy goods vehicle. He was taken to theatre on the same day for exploration of the degloving injury where the femoral nerve and artery were both intact. The fracture was temporarily fixed with T-Plates. This was followed by a further debridement of the thigh two days later. On day four post-injury, the patient had an open reduction and plate fixation of a distal femur fracture with soft tissue coverage of a medial knee defect using a pedicled gastrocnemius flap and split skin graft.
On arrival, there was a large area of skin necrosis that extended from the proximal thigh and along the anteromedial border and lateral border of the femur, with an underlying deep soft tissue infection (). A healed, grafted gastrocnemius flap covered the medial aspect of the knee. A mature scar was visible on the lateral right thigh from a previous free tissue transfer for chronic osteomyelitis of the ipsilateral tibia five years prior to his current injury.
Radiological imaging showed extensive comminution of the distal femur with malalignment of the posterior aspect of the femur and angulation of the fracture fragment (). Locules of gas were noted in the anterior compartment of the thigh with some subcutaneous oedema.
Revision surgery was undertaken involving removal of all primary metalwork and radical excision of the distal femur and soft tissues, leaving a defect on the anteromedial aspect of the distal femur that extended from the proximal to the distal thigh. Bone fragments, soft tissue and pus specimens were sent for culture and sensitivity. Excision of the full thickness eschar resulted in a soft tissue defect on the a

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


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

[User]
RADIOLOGY NOTE:
A case of left parietal calvarial osteomyelitis due to actinomycosis in a 32 years old previously healthy woman is described []. She presented in the puerperal period. There was no extracranial focus. She responded well to a combination of surgery and antibiotics.
Our case is unique for both the site of occurrence and the relapse after 11 years. In the first episode in 2010 he had osteomyelitis involvement of only the outer table of calvarium. Adequate surgical excision was done, however, he did not comply with antimicrobial therapy and lost from follow up. The second episode was in the same site which suggests that it was a relapse rather than reinfection. This time lesion penetrated the inner table with extension to epidural space. Fortunately, there was no brain parenchymal involvement. No other focus of involvement with actinomycosis infection was identified in our patient.
In the case series reported by Smego et al., out of 70 patient with CNS actinomycosis only one patient had relapse []. This patient had temporal lobe abscess treated with needle aspiration followed by antibiotics, duration was not specified. He had relapse of actinomycosis as multiple brain abscess after 29 months. Relapse of actinomycosis have been described in many scenarios, all due to inadequate duration of antimicrobial therapy [, , , ]. Review of the cases reported before and our case indicate that Actinomycosis of the skull is a disease of young, immunocompetent patients. The presentation is usually insidious. Intracranial extension is common with some patients presenting with neurologic deficits. Imaging especially CT scan or MRI are very valuable to identify the lesion, however culture and histopathology are necessary to confirm the diagnosis. The mainstay of management for actinomycosis is medical therapy [], with surgical drainage indicated if the collection is large or to establish a diagnosis. Penicillin is the drug of choice. Patients with actinomycosis require prolonged (6- to

[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 59-year-old male visited the rehabilitation department because of ongoing difficulty swallowing. Two months earlier, a 15-kg piece of iron was dropped on his neck from a height of 10 m. He was admitted and diagnosed with whiplash injury and a compression fracture of the fifth thoracic vertebra. He was treated conservatively, and the neck pain subsided. As the swallowing difficulty continued, he visited the rehabilitation department.
On physical examination, there was slight atrophy of the right sternocleidomastoid and upper trapezius muscles. The tongue was deviated to the right, and the gag reflex was impaired but the uvula was not significantly deviated. He complained of mild dysarthria and a hoarse voice. Examination of the upper and lower extremities revealed no weakness, but the power of right scapula elevation, head tilt to the right, and neck rotation to the left were decreased. The sensory examination was normal.
In a motor nerve conduction study, the compound muscle action potential of the right accessory nerve was not evoked. Needle electromyography revealed abnormal spontaneous activity in the right trapezius and sternocleidomastoid muscles. Injury of the accessory nerve was confirmed, although the other cranial nerves were not checked because the patient would not cooperate.
A videofluoroscopic swallowing study (VFSS) revealed that lip closure and jaw movement were normal, but the soft palate and tongue movements were impaired. There were decreased epiglottic inversion, laryngeal elevation and movement of pharyngeal wall and delayed pharyngeal transit time. There was no penetration or aspiration of liquid, semisolid, or solid, but a large amount of material was retained in the right vallecula and pyriform sinus ().
To identify the cause of the dysphagia, brain and cervical magnetic resonance imaging (MRI) were performed. Brain MRI showed no abnormal findings in the brain parenchyma, and therefore, a brain lesion was excluded. Cervical MRI showed medull

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


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

[User]
RADIOLOGY NOTE:
A 55-year-old female with no significant past medical history initially presented in 2006 with vague abdominal pain. Her past social history was negative for alcoholism or smoking. Work up of the patient including physical examination and laboratory indices were all normal. A multi-detector CT of the abdomen and pelvis utilizing a pancreatic mass protocol (arterial, portal venous and delayed phases) was performed which revealed a diffusely enlarged pancreas with extensive parenchymal calcifications (). No discrete mass was identified in the pancreas. Minimal pancreatic ductal dilatation was noted on the CT examination. The patient was diagnosed with chronic pancreatitis and followed clinically for several years. In 2015, the patient presented with recurrent abdominal pain. A CT of the abdomen and pelvis with pancreatic mass protocol was repeated (), which revealed new hypoattenuating masses in the pancreatic neck and tail. Some of the smaller tumours were hypervascular on the arterial phase imaging. There was redemonstration of extensive parenchymal calcifications. No pancreatic atrophy was identified. The pancreatic duct remained minimally dilated. Given the new masses many of which were arterially enhancing, the possibility of neuroendocrine tumour was raised. A MRI of the abdomen with pancreatic mass protocol (T2 with fat saturation, MRCP, in and out of phase T1 and unenhanced T1/arterial/portal/ 5 min delayed post-contrast T1) was performed (). The MRI confirmed multiple well-circumscribed masses throughout the pancreas, many of which had increased T2 signal with cystic change. The pancreatic duct was at most mildly prominent, and no lesions were identified outside of the pancreas. The largest pancreatic mass in the tail measured approximately 3.5 cm, with peripheral enhancement and central hypointense signal (). An endoscopic ultrasound was performed, which confirmed a hypoechoic mass in the tail of the pancreas, two isoechoic masses in the head of the pancreas

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


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

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

[Assistant]
ICD-10-CM Coding based on findings:
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 8-year-old boy presented with progressive and asymmetric enlargement of both scrotum and swelling of the penile shaft since birth and acute bleeding from right-sided scrotal skin for 1 day. Bleeding was spontaneous with no history of any recent or remote obvious trauma or any other diseases. The patient was resuscitated immediately with intravenous fluids and blood transfusion. Local control of bleeding was achieved with direct pressure. After control of bleeding, local examination revealed large irregular swelling involving both scrotum (right > left) and the penile shaft more on dorsal surface. An ulcer of 3 cm × 2 cm size was present on anterolateral side of right hemiscrotum, and there was bleeding from the floor and edges of ulcer. Surrounding scrotal skin was edematous and indurated []. Bilateral testes were normally descended and palpable and were free from overlying swelling and ulcer. Hemogram and coagulation profile were within normal limits. Clinically, the provisional diagnosis of a vascular anomaly was made. Color Doppler Ultrasonography (USG) of the penile and scrotal region showed diffuse vascular lesion, involving subcutaneous tissue of right scrotum, part of left hemiscrotum, and penile shaft showing both arterial and venous waveforms. Both testes were free from the lesion; however, the right testis was smaller in size. A provisional diagnosis of scrotal AVM was made, and it was confirmed with computerized tomography (CT) angiography of scrotum and penis. CT angiography revealed a tangle of vessels in the subcutaneous tissue of right hemiscrotum, part of left hemiscrotum, and penile shaft showing high flow both during the arterial and venous phase. The left testis was normal, but the right testis was smaller [].
After the control of bleeding, the child's parents refused any sort of invasive intervention either angioembolization or surgery for definitive therapy. Therefore, after explaining the potential complications or side effects of using prop

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old woman with no history of trauma was referred to the emergency department for acute thoracic pain superimposed on a background of chronic long-standing back pain. The patient was complaining of walking difficulties. Neurological examination demonstrated an incomplete spastic paraplegia, grade 2 motor power in both lower limbs, with sensory level in T9, with pyramidal syndrome in the inferior limbs bilateral plantar extension responses, with hyperreflexia of both Achilles tendons reflexes were present. Sensory, bladder, and bowel functions were unremarkable. Imaging a spinal magnetic resonance imaging (MRI) was performed and revealed a large cystic formation compressing dorsal side of thecal sac from T7–11 () and at the level of the sacrum (). The cysts were isointense to the cerebrospinal fluid (CSF), hypointense on T1-weighted sequences and hyperintense on T2-weighted ones with peripheral contrast enhancement. Based on the imaging findings, a diagnosis of SEAC was suspected. For spinal cord decompression, we did laminectomies at the level of interest from T7–11 exposing the SEACs. The dura matter was exposed and then we found three SEACs (). The cysts were dissected carefully from the underlying dura after removal of the CSF. We found nerve tissue in the cysts. It was possible to identify during surgery the location of the defects making the communication between the dura and the cysts. These defects were located on the right side of each cyst connecting with each other. The lesion was situated in close vicinity to the dorsal root ganglion of T9 to 11. We completely excised the cyst and preserved the nerve roots at the end of the surgery. Then, a duraplasty was performed to close the defects with autologous grafts from the patient's lumbar fascia. Following the complete removal of the cyst, Valsalva maneuver was performed. There was no evidence demonstrating CSF leakage. Regression of the symptoms, primarily the gait impairment, occurred after surgery

[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-month-old female infant presented to another hospital with acute circulatory failure and severe abdominal distention. Severe anemia and intraperitoneal echo-free space was detected, and she was transferred to our hospital for emergent operation. There were no indications of trauma on her body surface. Computed tomography (CT) revealed intraperitoneal hemorrhage, but extravasation and any other findings were not detected (Fig. ). Blood transfusion was performed; however, circulation was not stable, and emergent laparotomy was performed. A large amount of bloody ascites was present, but the active hemorrhage point was not detected. A fistula with clot was identified on the transverse mesocolon near the Treitz ligament. Therefore, it was suspected that the hemorrhage occurred around the pancreas. When the bursa omentalis was dissected and the transverse mesocolon was explored, sudden arterial hemorrhage reoccurred from the middle colic artery. Hemostasis was achieved with sutures. Ectopic pancreatic tissue with a small hole was detected at the first portion of the duodenum (Fig. ). The ectopic tissue was not resected, because it was not suspected to be associated with the arterial wall rupture. The patient almost fully recovered; however, intraperitoneal re-hemorrhage with circulatory failure occurred 1 month later. Hemostasis occurred spontaneously. After her condition stabilized, CT revealed a large pseudopancreatic cyst and another small cyst attached to the first portion of the duodenum (Fig. a). Ultrasonography showed the small cystic lesion with hyperechoic mucosa surrounded by hypoechoic muscular layers (Fig. b), and a duodenal duplication cyst was diagnosed. We considered that the duodenal duplication cyst was actually the ectopic pancreatic tissue and small hole identified at the first operation.
Percutaneous drainage of the pseudopancreatic cyst was performed, and high pancreatic amylase was detected in the contents. As the size of the pseudopancreatic cy

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old Caucasian woman, 35 weeks into her first pregnancy, presented to the emergency department for acute right-sided hip pain which precluded weight-bearing. Her right leg was shortened and externally rotated - there was no bruising or evidence of trauma.
The patient’s history was significant for hereditary thrombophilia (Factor V Leiden) and secondary anemia. Hip radiography revealed an unstable, displaced, right-sided femoral neck fracture with no evidence of osteonecrosis (Figure ). The decision to administer radiography, in this case, was based on the American College of Radiology guidelines, which cite an absence of in-utero deterministic effects of ionizing radiation effects after 27 weeks of gestation. Unfortunately, it was not possible to evaluate the symptoms of the patient with MRI at this time due to the coronavirus disease pandemic-induced stress on the healthcare system of our country.
The patient denied falls or trauma during the pregnancy, nor was there any history of smoking, alcohol abuse, use of glucocorticoids, or presence of rheumatologic/oncologic disease. Additionally, the patient was not malnourished, she underwent routine antenatal care, and took multivitamins. Serologic tests for inflammatory markers, as lab tests for serum calcium, phosphate, alkaline phosphatase, parathyroid hormone, vitamin D, and D-dimer returned normal.
During multidisciplinary rounds, it was decided that delaying surgery was the best course of action out of fear of causing either mechanical or fluoroscopy-induced damage to the fetus during total hip arthroplasty. Five days later the patient experienced premature rupture of membranes, which was managed with emergency cesarean section (C-section) - no complications were encountered and a healthy 2300 g female was successfully delivered. Three days later the patient was transferred to our orthopedic surgery department for the treatment of the fracture. The significant degree of displacement (grade IV) of the frac

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old male patient presented to our emergency room with a history of right nasal mass for 10 years. The patient reported occasionally experiencing epistaxis and in the last six months, there had been a slow, gradual growth. However, it had not been noticed during that period.
He had a round, soft, well-defined mass on the lateral nasal wall (Figure ). An ultrasound revealed a solid oval lesion with some internal vascularization in the right wing of the nose, measuring 15 x 11 x 19 mm, which apparently caused an interruption of the cortical bone. For additional characterization of the lesion, a CT scan was performed. The CT scan showed a homogeneous nodular structure of soft tissue, centered on the region of the frontal maxillary apophysis on the right, with its erosion, and extending into the nasal vestibule. The structure measured approximately 17-18 mm in diameter; it had smooth, regular contours, and the adjacent bone limit was molded, constituting characteristics suggestive of benignity (Figures , ).
The surgical removal of the mass was performed. The macroscopic findings during the procedure suggested that the primary site of the mass was the right lateral wall, with expansion to the vestibule and without invasion of the nasal septum. The mass was totally excised along with the area of the surrounding skin. The postoperative period was uneventful and the patient was discharged on the same day.
Microscopically, the tumor had the appearance of classic acinic cell carcinoma. Necrosis and mitosis were absent. The neoplasm was intersected by the margins (fulguration). Given the unexpected histological diagnosis, a staging CT was performed, which showed a total excision of the lesion and no signs of local recurrence or metastasis. It was decided that the patient should undergo radiotherapy by the oncology department. At the follow-up six months later, the patient had no signs of recurrence (Figure ).

[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 G7P2 female at 12 weeks gestational age presented to the emergency department with a six-day history of worsening rash and swelling of her right hand and ankle (Figure ). This started at the right fifth finger and progressed to involve the dorsum of the same hand, along with the second to fifth metacarpophalangeal (MCP) joints. There was associated pain throughout and decreased range of motion of the right wrist and hand joints. The patient noted recent chills and body aches but no fever. She had originally seen her family physician two days prior and was prescribed cephalexin and ceftriaxone for a presumptive diagnosis of cellulitis. On a subsequent emergency room visit the next day for no change in the disease course she was prescribed clindamycin, once again with no improvement.
On presentation to the inpatient unit, due to infectious disease, her antibiotics changed to daptomycin and meropenem for broad coverage. Further history included no recent travel, infection, or exposure to pets. She denied insect bites and close contacts with similar symptoms. Her medical history was significant for hypertension, treated with lifestyle changes, and gestational diabetes. Social history was negative for smoking and drug use, and she had no family history of autoimmune disease. There was no history of sexually transmitted infections. Physical examination revealed an edematous, light pink plaque on the right dorsal hand and wrist that spread proximally up her arm with satellite firm, pink papules on the forearm. Numerous similar appearing papules were present on the left forearm. A small lesion was present near her right fifth MCP that had a gray, dusky appearing hue. On her right foot, there was a dark red/tan edematous plaque. Lab results on admission included an unremarkable complete blood count (CBC) and comprehensive metabolic panel (CMP). Differentials considered were broad, and included cellulitis, parvovirus, Lyme disease, disseminated gonococcal infect

[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 45-day-old boy presented with progressively increasing neonatal obstructive jaundice and acholic stools. He was born by normal vaginal delivery at term with a birth weight of 2500 g and normal APGARs. The pregnancy was supervised and uneventful with two normal prenatal ultrasounds. There were no maternal risk factors identified. The neonate was well till day 3 of life when the parents noticed yellowish discoloration of the sclera followed by pale colored stools. He was evaluated and treated by several pediatricians in his hometown, without any avail, before being referred to us. There were no symptoms of bleeding diatheses. His general condition was well preserved but he was deeply icteric. He had a firm liver palpable 3 cm below the costal margin. Liver function tests (LFT) showed mildly deranged coagulation profile with a total bilirubin of 14.5 and direct bilirubin of 7.8mg/dl, elevated liver enzymes and normal proteins. The fasting ultrasonography revealed an enlarged liver with a normal gall bladder (GB) and common bile duct (CBD). There was no evidence of any subhepatic cyst but postprandial contraction of the GB could not be demonstrated. His TORCH titres were positive for Cytomegalovirus (CMV) IgM antibodies; however urine sample was negative for PCR detection of CMV, thus ruling out congenital CMV infection. A HIDA scan after 5 days of oral phenobarbitone revealed no excretion of radioisotope into the gut after 24hrs. Liver biopsy and MRCP were not done. Since the preoperative evaluation was highly suggestive of type 3 EHBA, he was taken up for laparotomy on day 54 of life without any further delay. At laparotomy, the liver was found to be cirrhotic. A normal looking GB, 2.7 cms long, was found to be communicating with a 4 x 4 cms cyst replacing the CBD (Fig. 1).
Needle aspiration did not reveal any bile. The above findings were confirmed by intra

[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 male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.
The procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.
At four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube inse

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old man was admitted for acute right hemiparesis and a mild speech disturbance (3 on the modified Rankin Scale). He was well before admission without a history of hypertension, diabetes mellitus or hypercholesterolemia. On admission, the MRI scan revealed watershed and a small cortical ischemic infarction at the left cerebral hemisphere with diffusion abnormality on the diffusion weighted image (DWI, ) and a decreased apparent diffusion coefficient (ADC). MR angiography () revealed severe stenosis at the left proximal ICA.
Three days after admission, digital subtraction angiography (DSA) was performed to plan for CAS. The DSA showed complete occlusion of the left proximal ICA without forward flow to the distal ICA from the point of occlusion, moderate to severe stenosis at the left proximal external carotid artery and atherosclerotic plaque with ulcer at the distal common carotid artery (). The delayed phase of the left common carotid angiography () showed retrograde filling of contrast media from the supraclinoid ICA to the cervical ICA distal to the occlusion. The left arteries of the anterior circulation were seen from the prominent transdural collateral vascular supply of the distal external carotid artery (ECA) branches via the transopthalmic route, and from the right anterior cerebral artery via the anterior communicating artery. There was no evidence of aggravation of the patient's neurologic status as compared with his neurologic status at the time of admission. We did not attempt to recanalize the occluded ICA because the patient already had acute ischemic infarction and he showed no neurological aggravation. He was medicated with only aspirin (300 mg/day) and clopidogrel (75 mg/day). The patient's neurologic status then slightly improved.
A follow-up DSA () was performed four weeks after ictus for attempting to insert a stent into the severely stenotic proximal ECA and ulcerated CCA, and the DSA revealed spontaneous recanalization of the left pro

[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:
The patient was a 44-year-old female craftswoman who had been suffering pain in the right upper limb for several months. The pain had increased progressively over the previous 3 months. She described pain at rest associated with coldness, pallor, and paresthesia of the limb. She had fallen from stairs when 9 months old, fracturing her clavicle, which was managed conservatively.
Physical examination revealed discrete deformity at the level of the mid third of the right clavicle. The right hand was cold and blue and ulnar, radial, brachial, and axillary pulses were all absent. Continuous wave Doppler detected no blood flow distally and monophasic flow in the brachial and axillary arteries. The chest X-ray showed a deformity of the mid third of the right clavicle, compatible with pseudarthrosis ( ).
Doppler ultrasonography demonstrated segmental occlusion of the subclavian artery with distal refilling via collateral vessels and very fine, threadlike flow in the axillary artery with occlusion of the brachial and radial arteries and refilling of the distal ulnar artery. Magnetic resonance angiography confirmed the Doppler ultrasonography findings ( ).
The pseudarthrosis was treated surgically, via a right supraclavicular incision, with resection of the mid segment of the clavicle ( ). The right subclavian artery was compressed and had thrombi with a chronic appearance inside. Thromboembolectomy of the subclavian artery was conducted with a 3F Fogarty catheter, followed by closure of the arteriotomy with a patch harvested from the saphenous vein in the thigh. Thromboembolectomy of the brachial, radial, and ulnar arteries was then conducted via an arteriotomy in the brachial artery, resulting in considerable improvement in terms of pain, temperature, color, and perfusion of the limb.
Throughout the examination, Doppler ultrasound of the hand showed triphasic flow in the radial and ulnar arteries. The patient was kept on clinical anticoagulant treatment with warfarin, maint

[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 girl was diagnosed to have severe pulmonary artery hypertension (PAH) during evaluation of an earlobe hemangioma []. Computed tomographic scan of the brain showed a small cerebellar pial arteriovenous malformation (AVM) []. As the AVM was too small to account for the PAH, she underwent further evaluation to look for the etiology of PAH. Ultrasonogram of the abdomen revealed a large portosystemic shunt between the left portal vein and the suprahepatic part of the inferior vena cava. The intrahepatic portal venous radicals were barely discernible and computed tomography of the abdomen confirmed these findings. Gastroenterology evaluation including esophagogastroduodenoscopy and liver tissue elastography were done to rule out portal hypertension. As there was no evidence of portal hypertension and the liver function was normal, the child was subjected to cardiac catheterization. PA pressure was 60/32 mmHg with mean PA pressure of 44 mmHg. Hepatic venous pressure was 6 mmHg. The portal vein was entered through the portosystemic communication and the portal pressure was 8 mmHg. On balloon occlusion of the portal vein with 6 Tyshak balloon, the distal portal venous pressure rose to 28 mmHg. Selective angiogram into the portosystemic shunt through internal jugular venous access showed diminutive portal radicals with good arborization [ and ].
The abnormal portosystemic communication measured 5 mm and a size 6 mm muscular ventricular septal defect (VSD) occluder was chosen for occlusion. As there was a significant hepatoportal gradient on occlusion of the malformation, we decided to manually fenestrate the device. An 8 Fr Flexor sheath was introduced into the shunt over a 0.035' exchange length Teflon wire. The muscular VSD device was fenestrated near the screw with a puncture needle followed by serial dilatations with increasing size of short dilators up to 7 Fr []. The device was then screwed to the cable and loaded in a standard manner into the sheath. After

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 51-year-old otherwise healthy man, who suffered from rapid visual loss in the left eye following contusion. Ocular trauma was caused during a football match by a ball, which hit an index finger located just in front of the bulbus. The patient attended our department on April 27, 2004, one week after the injury, when the vision in the left eye decreased to light perception with inaccurate light projection and hand movements in a lower part of visual field. The best-corrected visual acuity in the right eye was 1.0. Intraocular pressures were 18 mmHg in the right eye and 45 mmHg in the left eye. Examination of the anterior segment and fundus of the right eye revealed no pathology. The left eye showed discrete injection of the conjunctiva and keratic precipitates with mild anterior chamber flare and cells. There was iridodonesis, cleft syndrome and a relative afferent pupillary defect in the left eye. The fundus examination of the left eye revealed swelling of the optic disc, large ischemic macular edema, superficial retinal hemorrhages, narrowing of the arterioles and dilatation of the venules (Figure ). Fluorescein angiography of the left eye showed macular edema and vascular leakage in the venous phase (Figure ). Duplex Doppler ultrasonography and computed tomography scans of the brain and orbits were normal.
Based on the clinical findings, the presumed diagnosis of ocular ischemic syndrome was made. The patient was initially treated with vaso-active drugs in addition to corticosteroids. Intravenous methylprednisolone (500 mg daily for 5 days) followed by 60 mg of oral prednisone daily was indicated due to swelling of the optic disc and macular edema. Despite intensive therapy, the fundus examination showed progression of ischemic lesions. Visual acuity in the left eye was light perception with inaccurate light projection. The finding on the right eye was without changes. The patient was discharged on oral prednisone 50 mg daily.
On May 24, 200

[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 70-year-old white man developed right knee pain and swelling followed by left ankle pain and swelling over a week. Over the next 4 months, his symptoms progressed to include both knees, both feet, and both hands. Due to the severity of his symptoms he was unable to ambulate or carry out normal activities of daily living. He initially took ibuprofen 800 mg three times daily with some mild improvement, but at the time of presentation, it offered no relief.
In addition, he endorsed morning stiffness that persisted for most of the day. Due to the stiffness in his joints, he could no longer ambulate and presented to our clinic in a wheelchair. He previously was fully functional and independent in his activities of daily living. He was an avid fisherman and was unable to pursue his interests at all.
His past medical history was significant for metastatic melanoma initially diagnosed 2 years ago. His initial lesion was located over the left side of his neck and he had a Mohs procedure with negative margins. He was monitored closely for 1.5 years until he was found to have new right lower lobe lung nodules on positron emission tomography (PET)/computed tomography (CT) with increased fluorodeoxyglucose (FDG) uptake. Wedge resection of the right lower lobe revealed metastatic melanoma with wild type BRAF and no C-KIT mutations. Continued surveillance demonstrated an increasing number of right pulmonary nodules over the next 6 months. Dual therapy nivolumab (1 mg/kg every 3 weeks for four doses followed by 240 mg every 2 weeks) and ipilimumab (3 mg/kg every 3 weeks) immunotherapy was started. After the second cycle of his immunotherapy he developed severe non-infectious colitis requiring hospitalization. His immunotherapy was stopped and his colitis resolved with supportive care and glucocorticoids. Without further immunotherapy, he developed new left pulmonary nodules within 6 months that were increasing in size. Single agent immunotherapy with nivolumab (240 mg every 2 wee

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male patient was referred to the emergency room with epigastric pain, dyspnea, fatigue over the last 13 days, and intermittent fever. His medical history included hypertension and dyslipidemia. At admission, he was in good general condition, afebrile, and tachycardic. The abdomen was tender on the right hypochondrium, but no signs of peritoneal irritation or visceromegaly were present. Acute cholecystitis was the initial diagnostic hypothesis.
The initial laboratory investigation showed leukocytosis with left shift, elevated inflammatory markers, increased hepatic enzymes, and negative serology ().
The contrast-enhanced abdominal and pelvic computed tomography scan (CT scan) showed a hypodense and septated lesion in the hepatic segment V with peripheral enhancement, consistent with a liver abscess and with an estimated volume of 60 ml (). He was hospitalized and promptly treated with intravenous saline, antibiotics (ceftriaxone + metronidazole) as the clinical status worsened.
On the second day, the clinical status improved. There was defervescence of fever and complete improvement of the abdominal discomfort, which was well evidenced in the initial five days of hospitalization. Abdominal ultrasound demonstrated a slightly thickened gallbladder wall with a 10 mm gallstone; meanwhile, it was not impacted in the infundibulum, generating doubt about the initial diagnostic hypothesis. Clinical and expectant treatment was maintained.
On day 6, a control CT scan showed an increase in the lesion volume (264 ml). Due to the unavailability to perform percutaneous drainage, the laparoscopic approach was performed. The procedure disclosed a thickened gallbladder wall, adhesions, and a hepatic bulging close to the gallbladder bed. After the release of adhesions, the abscess was drained – a thin and elongated foreign body of approximately 4.1 cm, resembling a rosemary twig (), was found and removed from inside the liver abscess cavity (liver segment V). The abscess

[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 case of a 68-year-old female presented to the clinic for a 2-month history of recurrent left ankle pain, associated with swelling and edema. The patient had a history of thyroid follicular adenocarcinoma which was treated surgically with total thyroidectomy and postoperative iodine treatment 25 years prior to presentation. At 12 years post thyroidectomy, she was diagnosed with a calcaneal mass of the same pathology and diagnosed with delayed distant thyroid carcinoma metastasis to the calcaneus. 10 years after calcaneal mass excision, the patient was diagnosed with a proximal tibial mass that turned out to be also delayed metastasis of the same pathology.
At the first presentation 15 years ago, she initially presented complaining of mild edema of the left ankle with intermittent pain upon daily activity. Physical exam showed full range of motion of the ankle joint with intact motor power and intact neurovascular status. There were no cutaneous lesions.
Plain radiographs of the left ankle showed a 3-centimeter oval lytic lesion in the anterior aspect of the calcaneum ().
An MRI of the left ankle showed a 3.2 cm well-defined benign-looking lytic lesion of the calcaneal neck reaching the cortex which appeared to be mildly irregular with mild degenerative disease of the posterior subtalar joint consistent with an intraosseous ganglion cyst of the calcaneus ().
Medical treatment with NSAIDs and paracetamol was initiated, along with partial weight bearing and relative rest with no improvement at follow-up at 4 weeks. Surgical intervention was decided due to the persistent pain. The cyst was resected with a margin of surrounding fibro-osseous tissue and the bone grafted. Histopathological evaluation revealed a metastatic carcinoma of the thyroid gland. Immunostaining showed that the cells expressed cytokeratin, cytokeratin 7, and thyroglobulin, all of which confirm the diagnosis ().
For further confirmation, the recently excised cyst slides were compared to the 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 11-year-old girl was referred to our hospital in August 2010 with a lesion in the right cheek area which was progressively enlarging. The patient complained that her nose and mouth corner were crooked and that her face was swelling. In clinical examination, the patient had a slight asymmetry in the right midface as a result of buccal and palatal cortical expansion from the right maxillary canine to the molar region, resulting in depression of the nasal alar and mouth corner (Fig. ).
A panoramic radiograph showed an increased bone density on the right maxilla and zygoma and obliteration of the right maxillary sinus. Computed tomography (CT) revealed a 4.5 × 4 × 4.5 cm, expansile ground-glass opacity lesion involving the right maxillary sinus, right maxillary alveolar process, zygoma, and hard palate. Bone scan revealed an irregularly shaped hot uptake in the right maxilla, and no abnormally increased uptake was observed at any other sites (Fig. ). The physical examination did not show any other lesions, and the patient had no history of pain, trauma, loosening of teeth, or trismus. Based on the typical radiologic findings, the patient was diagnosed with FD, and no additional biopsy was performed. The patient had regular follow-up every 6 months to monitor the lesion’s progress. At the 1-year follow-up, the development of tooth germ within the lesion was normal, and slight expansion of the lesion to the bucco-lingual side was observed. Because we thought the patient was still growing and increasing in height, we decided to conduct an ongoing progress observation.
About 3 years later in December 2012, there were no significant changes of the FD lesion, but the distance from the mouth corner to the inner canthus was about 2 cm longer on the right side than on the left. Periodic observation was continued, and in August 2017, corrective surgery was planned because the maturation of the lesion was confirmed to be complete and there

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


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

[User]
RADIOLOGY NOTE:
A 13-year-old right-handdominant boy presented with pain and locking while moving the right shoulder during basketball activity and recurrent swelling around his right shoulder. There was no history of trauma, major illness, or surgery. His pain did not improve with conservative treatment, which included nonsteroidal anti-inflammatory drugs and physical therapy. On physical examination, he had a swollen right shoulder, but there were no signs of erythema, warmth, or muscle atrophy in his right shoulder. Active forward elevation of the right shoulder was 160°, external rotation was 70°, and internal rotation was at level T8. Plain radiographs of the right shoulder showed no abnormal findings (), but computed tomography (CT) and magnetic resonance imaging (MRI) showed several loose bodies in the axillary pouch and a large calcified mass lesion in the subscapular bursa ( and ). Arthroscopy under general anesthesia in the beach chair position was performed through standard posterior and anterior portals. Arthroscopic examination showed several loose bodies in the glenohumeral joint (). However, intrasynovial chondroid nodules were not seen in the glenohumeral joint. A sublabral foramen was found at the anterosuperior portion of the glenoid that communicated with the subscapular bursa (). Multiple large calcified mass lesions and intrasynovial chondroid nodules were seen in the subscapular bursa, suggesting Milgram Stage 2 (transitional phase) (). Loose bodies both in the glenohumeral joint and in the subscapular bursa were removed through a standard anterior portal, and proliferative thickened synovium of the subscapular bursa was also resected using a motorized shaver through the sublabral foramen. The histological examination of the loose bodies confirmed cartilaginous synovial metaplasia consistent with primary synovial chondromatosis (). The range of motion exercise was initiated from the day after surgery. Three weeks after the operation, he was symptom free with f

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


[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 man in whom a mediastinal mass had been present for twenty years was admitted to hospital, complaining chiefly of hemoptysis. Surgery had been recommended, but he had refused this option, denying up to the time of hospitalization any symptoms related to this lesion.
Chest radiograph revealed a 10×12 cm mass in the anterior mediastinum, as well as ill-defined consolidation in the left upper lobe. Contrast-enhanced CT scanning demonstrated a lobulated, inhomogeneous cystic mass with a fat component (HU = -45) and calcified wall in the anterior mediastinum. The lateral wall of the mass was focally disrupted and consolidation with the fat component in the adjacent left upper lobe was noted, thus suggesting that the tumor had ruptured (). An inhomogeneously enhanced solid portion was noted in the medial aspect of the mass and extended to the upper mediastinum, obliterating the fat plane between the mass and the mediastinal vessels ().
Thoracotomy demonstrated that the mass was rubbery, with hard components, and invaded the right brachiocephalic artery, the innominate vein, the ascending aorta, and the pericardium. The mass had ruptured into the left upper lobe, but due to extensive invasion by vessels, was incompletely resected. Decompression and plication of the left upper lobe was performed, and pathologic examination showed that the excised mass was a 10×8 cm cystic tumor with a rugged, pale brown external surface. It contained yellowish brown material with a few hair like structures, and cut section revealed a round, pale gray solid area in the wall that was firmly attached to the mediastinal structures. Microscopically, while most of the mass was mature teratoma with hemorrhage and necrosis (), the solid portion of the wall was found to be poorly differentiated adenocarcinoma (). The final histologic diagnosis was poorly differentiated adenocarcinoma arising from a mature teratoma. One month after surgery, the tumor recurred at the resected site, despi

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 35-year-old woman who had no history of radiation exposure was brought to our institution after complaining of severe headache and left monocular blindness. Her consciousness level on arrival was E1V4M5 on Glasgow Coma Scale. Brain computed tomography (CT) revealed a diffuse SAH with a central low density [], and on the sagittal reconstructed view, no enlargement of the sella turcica was observed []. There were no brain aneurysms on the brain CT angiography [], and thus, brain magnetic resonance imaging with gadolinium was subsequently performed. The intrasellar mass was depicted as a low-intensity signal on nonenhanced T1-weighted sequence [], with strong, heterogeneous contrast enhancement after gadolinium administration [Figure and ], and the posterior pituitary lobe appeared to have been displaced posteroinferiorly by the tumor. On a T2-weighted image, the mass is depicted as heterogeneous high intensity, and a dense subarachnoid clot was also observed in the prepontine cistern []. Based on the clinical history and imaging studies, a presumptive diagnosis of SAH occurring secondary to hemorrhagic pituitary adenoma was made. The blood levels of the anterior lobe hormones collected preoperatively were mostly below the normal range, except for prolactin (63.9 ng/mL) which was mildly elevated.
For removal of the tumor, we chose a transcranial approach via frontotemporal craniotomy rather than a transsphenoidal approach, with a hope of reducing the amount of SAH in the basal cistern, and the patient was brought to the operation room following administration of intravenous hydrocortisone. During surgery, the tumor was found to be soft and was easily aspirated. However, the tumor could only be partially removed due to profuse bleeding from the tumor and swelling of the surrounding brain tissue as a result of SAH. The interface between the tumor and the diaphragma sellae could not be fully inspected, and the position of the pituitary stalk could 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:
An 18-year-old female patient reported to department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore with a complaint of discolored teeth since childhood. Her past dental history revealed similar type with early loss of tooth structure in deciduous dentition. Her medical history revealed presence of multiple dermal lesions, which started appearing immediately after birth, which was later diagnosed as EB. She is second child from a consangious marriage and her sister is also affected with similar dermal lesions since childhood. Her gait was abnormal owing to non-healing ulcer in feet. Blisters were seen on the lower part of feet with irregular borders and yellowish slough present at the base of the lesions []. Scarring of healed lesions on knee was also noticed [].
On examination, diffuse reddish pseudo membranous area is seen extending from external occipital protuberance and spreading bilaterally until ear and extends until scapula. Loss of hair is seen with respect to that area. There was presence of itching and burning sensation in the affected area. Surface was erythematous with yellowish slough []. On intra oral soft tissue examination, a vesicle was seen on the right rugae area on the hard palate []. However, there was no abnormal eruption pattern noticed. From a functional point of view, she had been avoiding hard food substances and carious lesion was noticed affecting enamel and dentin of teeth.
On detailed hard tissue examination, it was found that she had a normal complement of teeth. Height of teeth was reduced because of complete chipping of enamel and exposing dentin. Underlying dentin appears to be normal. The surfaces of the teeth were rough. The teeth, in general, exhibited a yellowish brown discoloration, with diffuse pitting present on the exposed tooth surfaces, more prominent on the labial and buccal aspects. The emergence pattern and timing of teeth seemed to be within the normal range. No occlusal dishar

[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 80-year-old female with undiagnosed linitis plastica was referred to our institution for epigastric pain. Before visiting our hospital, she had undergone endoscopy at another hospital and was suspected of having Borrmann type IV advanced gastric cancer; however, histological examination had not confirm the malignancy. She showed epigastric tenderness after eating, which had gradually aggravated in the last month. Results of her initial physical examination were unremarkable except for epigastric pain. Her family health history was negative, whereas her medical history included medications for hypertension and diabetes mellitus over the last 10 years. Laboratory values for the serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. Abdominal computed tomography of the patient revealed irregular wall thickening extending from the gastric body to the antrum, with no remarkable findings such as metastasis and infiltration of the lymph nodes or peripheral tissues (). No additional information was obtained from positron emission tomography-computed tomography (). Upper endoscopy showed severe mucosal fold thickening with a narrow gastric lumen and normal mucosa (), raising a suspicion for Borrmann type IV advanced gastric cancer. Multiple biopsies were performed; however, results of pathologic examination with endoscopic biopsy were negative. EUS (TGF-ME1; Olympus Optical Co., Tokyo, Japan) showed normal mucosal and muscular layers and diffuse, homogeneous, and slightly hypoechoic submucosal thickening (approximately 12 mm thick) of the gastric wall. Although enlargement of lymph node was not observed, a small amount of ascites was detected in perigastric area (). Using EUS-guided biteon-bite biopsy, multiple biopsies were performed over the thickest lesion at the antrum (eight bites per lesion) to acquire the submucosal tissues. Histopathologic examination showed small, dense, uniform tumor cells with hyperchromatic nuclei and

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