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

[User]
RADIOLOGY NOTE:
A 36 year old woman was admitted to her local hospital following a collapse at work, she had a 3 month history of dyspnoea, weight loss and abdominal swelling.
Clinical examination demonstrated a large mass occupying most of the abdomen and pelvis which was confirmed on CT scanning as shown in Fig . Additionally there were bilateral pleural effusions, but no other apparent pulmonary abnormalities. A CT scan of the brain showed no apparent abnormalities.
The routine haematology and biochemistry blood tests were unremarkable, however the serum hCG level was elevated at 1322 IU/L (nr 0-4), the CA-125 was also elevated at 1475 U/ml, whilst the serum AFP level was normal.
The clinical diagnosis made was of an advanced malignant ovarian germ cell tumour and shortly after transfer the patient's condition worsened with bowel obstruction and a pneumothorax in addition to the bilateral pleural effusions. This difficult clinical situation mandated rapid treatment and urgent chemotherapy was commenced with two days of etoposide (100 mg/m2) and cisplatin (20 mg/m2) using dexamethasone and ondansetron as the anti-emetics. The initiation of chemotherapy lead to a significant improvement in the clinical condition and the chemotherapy regimen was then changed to the POMB/ACE combination [].
Following a brief stay in ITU for the treatment of hypotension and neutropaenic sepsis the patient was discharged home 1 month after admission to continue outpatient based chemotherapy with the hCG falling to normal 6 weeks after commencing treatment.
Two weeks after hospital discharge, the patient represented with a short history of impaired consciousness and pyrexia. Investigations demonstrated neutropaenia and hypokalaemia but with a normal CT scan of the brain and normal serum hCG levels.
At this point the diagnosis was unclear and the patient received empirical treatment for neutropaenic sepsis, viral encephalitis and tuberculosis. Two days later the patient's condition deteriorated further

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old patient, gravida 2 para 2, was admitted to the hospital with a complaint of worsening lower abdominal pain occurring on each menses for 8 months. Her external and internal genitalia, including the cervix, were normal except for the 6 cm accessory cavitated left uterine mass suggestive of hematometra that is compressing the urinary bladder without any other genitourinary system pathologies shown on ultrasound examination (). Diagnostic hysteroscopy revealed a single cervix without any vaginal malformations and a relatively small uterine cavity with right tubal ostium and without left tubal ostium. It was decided to remove the left uterine horn (Class U4a/Hemi Uterus)( by the laparoscopic route. Evaluation of the abdominal cavity revealed a left non-communicating rudimentary horn tightly residing on the lateral abdominal wall and two grossly normal ovaries and tubes (). A probable occult occlusion of the tube might be present, and this tubal occlusion might cause this late occurrence. However, neither endometriosis nor any prior tubal or abdominal operation history was noted.
First, to remove the fallopian tubes from the left uterine horn, they were coagulated and divided by careful tissue transection. Second, the vesicouterine peritoneum was divided to create the bladder flap from the cervix and the left uterine horn. Third, dissection of the retroperitoneal space beneath the round ligament to identify the ureter and the left hypogastric artery branches was performed. The broad ligament was fenestrated to lateralize the left ureter and facilitate transection of the utero-ovarian pedicle. The retroperitoneum was dissected, and the ureter tract was followed. Posterior peritoneum was also opened to create distance from the ureter and provide a place for the division of the horn by a monopolar hook. After the dissection and coagulation of the left uterine artery at the origin of the left hypogastric artery to minimize the bleeding during excision of the ute

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old woman presented to the emergency department with complaints of severe abdominal pain, multiple episodes of vomiting and obstipation for one day. She was a known case of abdominal tuberculosis and had received anti-tubercular treatment for two months. Vital signs showed a blood pressure of 100/64 mm Hg, heart rate of 110 per minute, respiratory rate of 18 per minute, oxygen saturation of 96% on room air and a temperature of 100.5°F. She was cachectic with a weight of 28 kg which was less than 5th percentile for gender and age matched normal population. Physical examination revealed diffuse abdominal tenderness and rigidity. Her erect abdominal radiography showed gas under right dome of the diaphragm. Clinical diagnosis of perforation peritonitis was made and the patient was wheeled to the operating room for emergent laparotomy. Intraoperatively, a 3 cm x 2 cm single ileal perforation was found 1 foot proximal to the ileocecal junction, with unhealthy bowel margins and multiple mesenteric lymphadenopathy. Resection of perforated bowel segment with proximal ileostomy and mucus fistula of distal ileum was performed. Later, histopathology report confirmed tubercular etiology showing caseous necrosis in mesenteric lymph nodes and epithelioid granuloma in ulcer edge biopsy. Two days after the surgery, the patient was started on oral feeds and was accepting meals orally subsequently. Ten days following surgery, the patient had multiple episodes of bilious vomiting with stoma output decreasing to less than 100 mL per day. Her abdomen remained flat with no increase in bowel sounds. Abdominal radiography showed dilated stomach with no air fluid levels. Oral feeds were stopped and a nasogastric tube was placed for drainage of gastric contents. A contrast enhanced computed tomography (CECT) abdomen was done to determine the cause of obstruction which revealed a decreased aortomesenteric angle of 15° (Figure ).
As a result of this decreased angle, an abrupt collapse

[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 presented to us with chronic, progressive midline low back pain associated with right lower extremity radiculopathy. The patient described the pain as radiating and achy. On the physical exam, the patient had decreased sensation in the lateral aspect of the right lower extremity. Radiological findings demonstrated multilevel central stenosis and neuroforaminal narrowing with a degenerative scoliotic deformity of the lumbar spine (Figures , ). A conservative trial for up to a year with physical therapy, chiropractic and interventional pain modalities provided partial and short-lasting relief. As the pain continued to progress, the patient decided to proceed with surgery.
Various surgical options were considered. Eventually the patient underwent an ALIF at the L3-S1 levels using a retroperitoneal approach followed by a T10-pelvis posterior spinal fusion and a right L4-L5 laminotomy and decompression in two stages (Figure ). The post-operative course was complicated by abdominal distention that occurred on post-operative day eight. Computed tomography (CT) scan of the abdomen and pelvis demonstrated a large collection of retroperitoneal fluid measuring 11 x 9 x 22 cm in the left pelvis and left flank area with mass effect on the left kidney and ureter causing hydronephrosis (Figure ). After a consult with the general surgery team and the approach surgeon, the patient underwent ultrasound-guided drainage of fluid with temporary drain placement.
The fluid was serosangionous in nature with a high output of greater than 1500 cc/day. Fluid gram stain showed no organisms and cultures also revealed no growth. He was discharged home with the drain in place for a total of 22 days after which the drain was discontinued upon clinic follow-up. The lymphocele recurred four days after the drain was removed, and the patient presented back to the emergency room with recurrence of abdominal distension. A new drain was placed again in the fluid collection, and was fina

[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 33-year-old male presented with progressive breathlessness and dry cough since the last 5 months and right sided pleuritic chest pain for 10 days. Patient was diagnosed elsewhere as miliary tuberculosis and was under antitubercular treatment (ATT) for four months. He was not a smoker. He worked as a bore-well driller for the past 10 years.
Blood hemogram and renal and liver functions were normal. Admission chest radiograph showed bilateral, diffuse, well-defined large rounded nodular opacities with right secondary spontaneous pneumothorax ().
Patient was managed with tube thoracostomy, supplemental oxygen, and analgesics. After three days patient complained of acute onset chest pain on left hemithorax and dyspnoea.
Chest radiograph revealed a new pneumothorax on left side for which immediate chest tube was placed. Subsequently, patient had symptomatic relief. Fibre optic bronchoscopy revealed normal airway. Bronchoalveolar lavage cytology showed only benign bronchial epithelial cells and smear and culture for Mycobacterium tuberculosis were negative. The diagnosis of military tuberculosis was questionable in view of larger size and nonresolution of nodules although four months of ATT and silicosis was more probable, considering his occupation. Hence, percutaneous biopsy of right lung was done that yielded a tiny tissue and showed only lymphoplasmacytic infiltrates. ATT was stopped and he was discharged after bilateral pleurodesis. Six months later he was brought to emergency with signs of severe respiratory failure. His condition deteriorated faster and despite adequate measures, he sustained a cardiopulmonary arrest and succumbed.
Limited autopsy was done. Postmortem biopsy of bilateral lungs and liver was done. H and E sections of bilateral lungs revealed multiple collagenous nodules, some of which coalesced to form larger nodules (Figures and ). The periphery of the nodules contained dust laden macrophages and inflammatory cells, predominantly lymphocytes (). T

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old Japanese man was admitted to our hospital due to multiple brain metastases. He was aware of coughing 6 months previously and had a headache 3 weeks ago, so he visited our hospital. Brain magnetic resonance imaging (MRI) revealed multiple brain tumors in the bilateral cerebellum and cerebrum (Fig. ). Chest computed tomography (CT) showed a 15-mm nodular shadow in the middle lobe of his left lung, and he was referred to our Department of Respiratory Medicine (Fig. a). He was admitted for further examination because he was suspected of having lung cancer with brain metastases. There was no special mention in his medical history; there was no alcohol drinking or tobacco smoking history. On physical examination, his body temperature was 36.7 °C, his blood pressure was 122/78 mmHg, his pulse was 56 beats per minute, and his respiratory rate was 12 breaths per minute. His oxygen saturation was 98% in room air. Lung and bronchial sounds were normal. Head, eyes, and nose examinations were unremarkable. His neck had no lymphadenopathy. An examination of his heart, abdomen, and extremities showed no abnormalities. Blood test findings revealed elevation of tumor markers such as carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC). On day 4 after admission, bronchoscopy was performed. The histology at bronchoscopy for the middle lobe of his left lung is shown in Fig. . Adenocarcinoma cells exhibiting a papillary pattern were found, and he was diagnosed as having papillary adenocarcinoma of the left lung according to the World Health Organization (WHO) classification, 4th edition. His adenocarcinoma was positive for ALK according to immunohistochemistry and fluorescence in situ hybridization (FISH) method (Fig. ). Based on this observation, he was diagnosed as having ALK-positive lung cancer with cerebral metastases, and administration of alectinib 600 mg/day was started from day 23 after admission. Adverse events such as allergic reactions, inte

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


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

[User]
RADIOLOGY NOTE:
The patient, a 76-year-old male, was admitted to our hospital on March 13, 2015 due to recurrent shortness of breath after activities for over 2 years, which became more serious when it manifested with edema of lower limbs 1 day previously. The patient suffered from: coronary heart disease with unstable angina pectoris, triple-vessel disease, and permanent atrial fibrillation, and an extremely risky 3rd degree high blood pressure. With consideration of the possibility of insufficient cardiac functions, the patient was admitted to the Cardiovascular Department for heart failure treatment. Examinations upon admission revealed shortness of breath, thick breath sounds in both lungs, decrease in breath sounds on both bottom sides of the lungs, small number of dry and wet rales, and no pleural friction sounds. The apical pulse moved slightly to the left; the border of cardiac dullness expanded to the left and right, with a heart rate of 120 beats per minute and arrhythmia. In the aortic valve, 3/6-degree diastolic respiratory murmur can be heard in the left armpit, with no pericardial fricative sound. The related examinations were improved after the patient's admission to our hospital. Myocardial markers, cardiac enzymes, and B-type brain natriuretic peptides did not increase. Temporarily, the symptoms were not considered to be caused by cardiac insufficiency. The chest computed tomography (CT) examination revealed that there were pleural effusions on both sides, and some extent of compressive atelectasis in the 2 lower parts of the inflamed lungs, without space-occupying lesions. There were multiple small nodules which were likely benign in the right upper lung, with massive pericardial effusions. Multiple small lymph nodes existed in the mediastinum. There was aortosclerosis and coronary arteriosclerosis. Coronary heart disease has been considered based on the symptoms while the possibility of cardiac insufficiency remained to be removed. The color Doppler ultrasound ex

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


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

[User]
RADIOLOGY NOTE:
A 24-year-old man was admitted to the ER with a large, painful (VAS 8), and recurrent bleeding mass in the right upper chest quadrant, increasing in size for two months before admission. Before the surgery, the mass dimension was 14 cm × 9 cm × 6 cm, with the pathological result of a grade II myxofibrosarcoma. The patient did not suffer from cough, dyspnea, or fever. There was no family history of malignancy in the family. MRI () and CT Scan () showed that the patient had a recurrent tumor.
The histology slides were examined, and the morphological features showed spindle cell sarcoma reminiscent of low-grade fibromyxoid sarcoma with extensive necrosis. Immunohistochemical staining was not entirely specific due to extensive necrosis, but as a low-grade fibromyxoid sarcoma, the morphology could still be supported []. We performed wide surgical excision with removal of the pectoralis major muscle and obtained a primary tumor measuring 22 × 13 × 18 cm with a non-tumor-free margin. A high-grade sarcoma of the spindle cell was the postoperative pathological outcome. Immunohistochemical staining revealed epithelial membrane antigen (EMA) focal positivity, and CD99, BCL2, and CD56 positive, smooth muscle actin (SMA) negative, and desmin and S100 protein-positive results. This staining pattern was mostly associated with monophasic synovial sarcoma along with the morphology []. We then performed a PET scan with no tumor cells. Thereafter, the patient refused to receive radiation and chemotherapy for 2 months and chose to be treated by a medicine man for two months rather than receiving chemotherapy. Meanwhile, the mass reappeared in the right upper quadrant of the chest and in the right upper extremity, which had been growing in size as large as an adult head. The patients suffered from a swollen right hand and active hemorrhage in the masses (). Multiple blood transfusions were needed, and several treatments, including corticosteroid injections, betadine dressing, flamazine,

[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 female patient presented at the surgical consultation for perianal hitching and bleeding. The patient's complaints started 12 months prior, with progressive worsening. Her past medical history included hypothyroidism, glaucoma, and hemorrhoidectomy 30 years previously. Her family medical history included hepatic cirrhosis (father) and coronary artery disease (mother) but no cancer. Physical examination showed a 3 cm plaque-like eczematous lesion, circumferentially involving the perianal skin and extending to the anal verge (). A biopsy of the perianal mass demonstrated a well-differentiated mucinous adenocarcinoma. Serum carcinoembryonic antigen level and other laboratory tests were within normal range. A pelvic MRI showed that the lesion had invaded the skin tissue without involvement of perirectal structures and anal sphincters (). An endoanal ultrasound confirmed the absence of invasion into the anal canal and anal sphincters. A colonoscopy showed two polyps in the ascending colon that were both removed and histologically examined; they were both tubular-villous adenomas with low-grade dysplasia. A total-body CT scan did not show any associated visceral malignancy or lymphadenopathy. The patient was discussed within a multidisciplinary team including surgeons, oncologists, radiotherapists, radiologists, and pathologists. Since no anal canal involvement was identified and because of the patient's refusal of a permanent colostomy, a wide local excision was planned with a flap to close the perianal defect, and a protective colostomy. A biopsy of the inguinal sentinel node was also scheduled to rule out inguinal lymph node metastasis.
The day before the operation, a lymphoscintigraphy was performed which showed uptake in the right inguinal region. The patient underwent surgery the following day under general anesthesia. A sentinel inguinal lymph node was retrieved at the right groin region. A laparoscopic lateral colostomy was performed on the sigmoid c

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 21-year-old female patient who presented in our Radiology and Imaging Department with the appearance of two subcutaneous swellings in her right arm at the extremities of a scar from previous surgical interventions. The history and clinical data has shown that the patient was diagnosed in childhood with hemangioma of the arm, with the onset at 7 years old and six recurrences within 14 years. At 7 years old, she presented with a skin tumor located in the lower third of the right arm, which was surgically removed. The histopathology diagnosis was hemangioma. Three months after the surgery, the tumor recurred for the first time. After 9 years, the patient accused swelling and local pain and was subjected to another surgery for tumor excision, with a favorable postoperative evolution. After three months, another subcutaneous formation appeared, without changes in skin coverings, which grew in size and was slightly painful to effort. Another recurrence of the tumor for which the patient underwent surgical excision was at the age of 18 years and three months after.
The last recurrence was at 19 years old, when the clinical examination revealed the presence of postoperative local dehiscence upon which there was a soft tissue tumor, measuring 10 cm in large diameter. The patient accused local pain exacerbated by exercise, the increase in tumor size during exercise and paresthesia.
The plain X-ray revealed a nonspecific soft-tissue mass in the lower third of the upper right limb with calcification inside, without any changes in the adjacent bone structures ().
The MRI exam demonstrated round-oval heterogeneous signal tumor mass in the biceps brachial muscles, with high signal intensity on T2 weighted images and septa (). On T1 weighted images, the tumor had an intermediate signal with diffuse areas of fat increased signal (). On T2 fat-sat sequences, punctuate signal voids areas related to phleboliths can be seen (). The imaging features were specific

[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 52-year-old male with history of obstructive coronary disease status post multiple percutaneous coronary interventions and ischemic cardiomyopathy presented to the emergency department for gradually worsening severe dyspnea at rest in the last 3 days and severe chest pressure. His examination revealed moderate respiratory distress, hypotension, tachycardia, jugular venous distention, S3 gallop, bilateral rales in lower and mid lung fields, and mottled cool lower extremities with 3+ edema. Electrocardiogram revealed a new complete left bundle branch block which was considered an ST-elevation myocardial infarction equivalent. The patient was taken emergently to the cardiac catheterization laboratory in cardiogenic shock (CS) and was intubated.
Coronary angiography performed from a right RA revealed multiple patent stents without significant in-stent restenosis or thrombosis and no recurrent obstructive epicardial disease. Left ventricular filling pressure was severely elevated. Urgent limited transthoracic echocardiography (TTE) revealed severe left ventricular systolic dysfunction (ejection fraction of 10%) with severe left ventricular dilatation and severe global hypokinesis.
Norepinephrine and epinephrine drips were quickly up titrated during the diagnostic case to maintain adequate systemic perfusion. An Impella CP was then emergently implanted from an ultrasound (US) guided right CFA micropuncture access after distal abdominal aortography with bilateral iliac arteriography, performed from the RA, revealed no evidence of obstructive arterial disease. TTE confirmed an adequate inlet position and mechanical support was quickly increased up to a maximum of 3.5 L/min.
Right CFA angiography performed from the side port of the 14 Fr sheath revealed absent flow below the access site. In order to allow for right lower extremity (LE) perfusion, an antegrade 4 Fr SFA sheath was placed under US guidance using the micropuncture technique.
Since right RA had been obtained fo

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


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

[User]
RADIOLOGY NOTE:
A 50 year old female patient previously healthy has undergone an abdominal ultrasound demanded by her primary care physician when her routine checkup blood test showed a slightly elevated level of liver enzymes with no other lab abnormalities. This ultrasound showed right adrenal lesion of 9 cm of diameter. An Abdominal MRI was then done and revealed a soft tissue necrotic encapsulated mass of 10 × 9 cm of right adrenal gland origin. She was completely asymptomatic and the physical exam was strictly normal. Endocrinological evaluation was done with normal hypothalamic-pituitary-adrenal axis function and no hyper secretion of catecholamines. The patient was considered to have a non-secreting right adrenal mass for which an adrenal scan was done and showed a well encapsulated 10 × 9 × 7 cm heterogeneous right adrenal mass with areas of necrosis and calcifications without local invasion (). The decision of right laparoscopic trans peritoneal adrenalectomy was taken with the patient. The surgery was done under general anesthesia after central and arterial lines insertion, the patient was on left decubitus position. 5 trocars were inserted as follows: The first 12-mm port was inserted at the lateral border of the rectus abdominis muscle just above the level of the umbilicus to accommodate the camera. Two subcostal 11 mm ports were also placed; one in the midclavicular line and the other in the lateral border of the rectus abdominis muscle. The forth 5-mm subcostal trocar was inserted in the anterior axillary line to retract the liver and the fifth 5 mm one was inserted in the epigastrium and used specially for aspiration and irrigation. After liver retraction, the peritoneum along the lateral aspect of the IVC was incised to expose the IVC just below its intrahepatic course. The duodenum which was diverted by the mass was mobilized. Dissection was next carried inferiorly by incising the peritoneum along the lateral edge of the vena cava to the superior edge of the renal

[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 four-year-old female patient was admitted to the pediatric infectious ward due to a fever of unknown origin in January 2020.
She was a known case of Marfan syndrome with a family history of this syndrome in her mother. Both of them had a history of anterior
lens dislocation that led to surgery.
She also had a history of congenital heart disease, including atrial septal defect type 2 (ASD2), mitral regurgitation (MR),
and MV prolapse regarding fever, headache, and meningeal signs a lumbar puncture was performed. She was treated for probable
bacterial meningitis since the result of her cerebrospinal fluid (CSF) test was positive and active; moreover, the white blood
cell was observed in CSF fluid.
After five days and secondary to the changing of heart murmur intensity that revealed progressive severe MR, she was referred to
a tertiary referral center for the evaluation of cardiac involvement. Transthoracic echocardiography (TTE) revealed a large dense
heterogeneous and oscillating mass (18 mm×12 mm in size) attached to the atrial septum closed to the hinge point of the anterior
leaflet of MV with independent movement towards the heart valve (an argument for the fungal endocardial vegetation)
(Figures ,,).
Results of color Doppler flow imaging revealed an abnormal regurgitation flow at the areas of A3 anterior leaflet of mitral suggestive
of perforation of MV. In addition, valvular destruction, perforation of the anterior leaflet at the site of the lesion, as well as
the existence of perivalvular infection and severe eccentric MR reduced left ventricular ejection fraction. Sub-systemic pulmonary
hypertension was found with mild pericardial effusion due to acute heart failure, previous history of congenital heart disease, and ASD2.
Neurologic physical examination for the evaluation of meningeal involvement contains clinical examination and paraclinical data.
The cerebrospinal fluid analysis showed meningeal irritation and brain magnetic resonance imaging revealed a sm

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old female with a one-year history of a progressively enlarging right parotid mass was referred for pediatric otolaryngology evaluation. The patient had no known risk factors for head and neck malignancies. There was no family history of thyroid or other malignancies and no history of childhood radiation. Examination revealed a 2 cm right parotid mass with associated cervical lymphadenopathy. Workup for autoimmune disease revealed CBC, ESR, ANA, and immunoglobulin tests to be within normal limits with no immunophenotypic evidence of ALPS. CT demonstrated enlarged right intraparotid and cervical lymph nodes. Ultrasound-guided biopsy of the parotid mass revealed a reactive lymphoid process. Excisional biopsy of the multiple cervical lymph nodes revealed florid follicular lymphoid hyperplasia with few follicles demonstrating infiltration of the germinal center by small mature mantle zone lymphocytes consistent with a pathologic diagnosis of PTGC. Due to the potential association with NLPHL, PET/CT was performed, and increased uptake was noted in the right parotid, bilateral jugulodigastric chains, right supraclavicular region, right axilla, peripancreatic region, and bilateral inguinal regions (). Additional excisional biopsy of a particularly high FDG uptake supraclavicular lymph node revealed PTGC without any evidence of malignancy (). The patient was followed up clinically and the lymphadenopathy remained stable for two years. Incidentally, the patient was evaluated by her primary care physician for thyroid abnormalities after developing unexpected weight gain and fatigue. Laboratory workup was negative for hypothyroidism. Thyroid ultrasound demonstrated an isolated left thyroid nodule and subsequent FNA was suggestive of papillary thyroid carcinoma. Total thyroidectomy with central neck dissection was performed. Despite the presence of persistent bilateral jugulodigastric lymphadenopathy, the lateral necks were not addressed surgically. Pathology confirme

[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 female patient came to the Department of Pediatrics and Preventive Dentistry, with the complaint of reduced mouth opening and discolored upper front tooth for one year. History revealed that she had a fall from the terrace three years back and did not receive any treatment for the same. There was a gradual reduction in mouth opening for one year, consequently she was not able to eat and maintain oral hygiene properly.
On examination, a reduced mouth opening of 4 mm was observed with discolored permanent left maxillary central incisor and left mandibular lateral incisor as well (Figs and ). Due to reduced mouth opening, complete intraoral examination was not possible in the first visit. The patient was referred to Oral and Maxillofacial Surgery Department for the needful treatment. On radiographic investigation with computed tomography (CT) scan, the condyle head was found fused to the articular surface of temporal bone and revealed a bony ankylotic mass with the left TM Joint (Figs and ). Based on these findings patient was diagnosed as unilateral ankylosis of TM Joint left side (Type II Sawhney's Classification).
After thorough clinical and radiological assessment, a surgical management was planned. Interpositional arthroplasty with temporalis muscle flap on left TMJ was performed under general anesthesia, without the need of coronoidectomy either ipsilateral or contralateral side, as the adequate mouth opening was achieved as per the Kaban's protocol. Following the surgical procedure, postoperative physiotherapy/mouth opening exercise was done regularly and advised to continue for the period of 6 months. After one month follow-up, mouth opening was satisfactorily maintained to about 40 mm (Figs and ). Patient was kept under follow-up for the next six months to one year.
Patient was then referred back to the Dept. of Pediatric and Preventive Dentistry for the further dental treatment procedures. On intraoral examination generalized debris and calculus

[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 with a diagnosis of perforation peritonitis with chronic renal failure and coronary artery disease was brought to the emergency department. Due to his poor peripheral venous access and for CVP guided fluid therapy, the plan was made to get the central venous access. After ensuring appropriate coagulation status, the right subclavian vein was chosen for catheterization. A seven French percutaneous 15 cm length triple lumen catheter was used by Seldinger technique. Under all aseptic precautions, the vein was cannulated with introducer needle in first attempt by a resident doctor in the absence of expert supervision and assistance. Following this guidewire was introduced through the needle without any resistance (length of guide wire introduced inside vein was not noticed). During threading of catheter over the guide wire, patiently made a sudden jerky movement which distracted the trainee doctor. To prevent patient movement, he tried to hold the patient's right shoulder with one hand and started putting the catheter with wire inside the subclavian vein without holding guide wire tip as such. This lead to loss of guide wire inside the catheter inadvertently but on gently pulling out the catheter, no part of the guide wire was found outside puncture site. Immediately call made to senior doctors for this mishap. Urgently chest X-ray was obtained which showed the proximal tip of the guide wire in a subclavian vein near the junction with IJV []. Although patient remained stable throughout this period, the plan was made to remove the guide wire by surgery. Patient was explored under general anesthesia through a transverse incision in the right supraclavicular fossa. Meticulous dissection was carried out to expose right subclavian vein and tip of the guide wire was felt in subclavian vein with a finger. A small venotomy about1 cm made proximal to the junction with IJV, through which guide wire retrieved and the incision closed with 6-0 proline. Following t

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old African American female presented in February 2015 in our department with the chief complaint of gross hematuria and dysuria that started in December 2014. Prior to urology evaluation, she had received two courses of antibiotics without resolution for her presenting symptoms. The patient denied history of urologic trauma, nephrolithiasis, chronic Foley catheter, family history of genitourinary (GU) malignancy, or previous GU surgeries. The patient had a history of stage IA adenocarcinoma of the right upper lung in 2011 and a 20-pack year history of smoking.
Cystoscopy revealed a large complex bladder mass on the right lateral wall and right trigone involving the right ureteral orifice. Abdominal and pelvic CT scan revealed right-sided bladder mass involving the right ureterovesical junction, right hydronephrosis and right-sided pelvic lymphadenopathy. Transurethral resection of the bladder tumor (TURBT) was performed and pathologic examination showed a prominent inflammatory background with admixed high-grade undifferentiated tumor cells arranged in sheets with ill-defined cytoplasmic borders imparting a syncytial appearance diagnostic of the LEL variant of urothelial carcinoma (Fig ). Foci of urothelial carcinoma in situ were also noted involving the surface urothelium. Muscularis propria invasion was present.
Patient was treated with four cycles of neoadjuvant chemotherapy of gemcitabine and cisplatin. Repeat CT two weeks after the last round of chemotherapy revealed smaller right-sided bladder mass (6.1 x 2.9 cm vs. 6.9 x 3.4 cm). Two months after the last round of chemotherapy, the patient underwent a radical cystectomy with ileal conduit diversion and pelvic lymph node dissection in July 2015. The operation was complicated by extensive adhesions from previous appendectomy, hysterectomy, and hernia repair with ventral mesh placement necessitating small bowel resection.
Final pathology report showed three high-grade tumor foci in the bladder with th

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old Indian male, painter by occupation, presented to us with a painless swelling along the ulnar aspect of his right distal forearm since the last four months. To begin with, it was the size of a peanut but had gradually increased to its present size. There was no history of any other swelling in the body, fever, loss of weight or appetite, or history of similar complaints in the past. The family, occupational, recreational and drug histories were not significant. The general physical and systemic examinations were within normal limits.
On examination, there was an oval swelling 6 × 4 cm, occupying the distal third of ulna. The overlying skin was of normal colour and temperature. There was no overlying scar, sinus or prominent veins. The swelling was diffusely tender and homogenously firm in consistency. It was free from the overlying skin but adherent to the underlying bone. The range of motion of wrist was normal and painless. The distal neurovascular status was normal and grasping power equal in both hands.
Serum biochemistry studies were within normal limits. Plain radiographs of the right ulna showed an expansile, multiloculated lytic lesion at its lower end with absence of periosteal reaction (). Plain chest radiographs were within normal limits.
Magnetic Resonance Imaging (MRI) study was planned to delineate the extent of soft tissue involvement, but the patient was very poor and chose not to have the investigation.
A clinical diagnosis of GCT was made, which was confirmed post operatively by histopathological examination. The condition, its prognosis and various treatment modalities were discussed at length with the patient.On the basis of clinical and radiographic evaluation, the lesion was graded as Stage 3 (aggressive) as per the Enneking Staging system for benign bone tumors []. As per the standard recommendations for Stage 3 lesions, a wide resection was planned after obtaining informed and written consent from the patient. The resection margi

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old female presented with exertional chest pain for one month. Chest pain was retrosternal and occasionally radiated to left arm. Patient had history of significant coronary artery disease with a critical lesion of the left main coronary artery ostium, posterior descending artery (PDA), first diagonal artery, and therefore underwent coronary artery bypass surgery three years ago prior to current presentation. She had left internal mammary artery (LIMA) graft from left subclavian to distal left anterior descending (LAD) artery, which bypassed the proximal LAD lesion. She also had two aortocoronary saphenous vein bypass grafts on to the PDA artery and another to the diagonal. A prior catheterization for abnormal stress test (moderate inferior ischemia) revealed an atretic LIMA graft, however patent SVG graft to diagonal artery maintained TIMI-3 flow to LAD via the diagonal artery. The SVG graft to PDA was occluded with significant disease in right coronary artery. This correlated with the area of ischemia on the nuclear stress test and was thus treated with percutaneous coronary angioplasty. On this presentation her vitals were stable and remaining physical examination was grossly unremarkable. EKG showed normal sinus rhythm without evidence of ischemia. Cardiac enzymes were also normal. Given the nature of pain and her prior history of significant CAD, further risk stratification was done by performance of a vasodilatory nuclear stress test. The myocardial perfusion study revealed uniform perfusion, however transient ischemic dilation (1.39) was observed which was indicative of possible balanced ischemia due to presence of multi-vessel disease. Therefore the patient underwent cardiac catheterization which showed an eccentric 70% lesion at ostium of the left main. The first vein graft to right coronary artery was totally occluded with patent stents in the RCA. The second venous graft to the diagonal vessel was widely patent and was providing TIMI-3 flow to t

[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 69-year-old man with a history of hypertension, bilateral thalamic hemorrhage, and decreased kidney function was admitted to our hospital because of congestive heart failure with extracellular volume overload. Volume control with drugs, such as diuretics, was unsuccessful and he was started on hemodialysis. Thereafter, he received various antibiotics for bacterial infections, including pneumoniae and urinary-tract and catheter-related infections. Simultaneously, he had continuous watery and sometimes bloody diarrhea, the etiology of which was considered to be CDAD due to a positive stool test for CD toxins. Despite treatment with metronidazole and vancomycin, the severity of the diarrhea was not ameliorated. Abdominal X-ray and computed tomography did not reveal any causal factors, and laboratory tests showed only slight elevations in the white blood cell count and C-reactive protein level. We suspected involvement of uncontrollable CDAD or other type of infection (such as mycosis, tuberculosis, or cytomegalovirus infection) and inflammatory bowel disease (IBD).
Colonoscopy showed multiple segmental ulcers in the ascending, transverse, and sigmoid colon, but not the rectum, which suggested infectious colitis or ischemic colitis (Fig. ). A biopsy specimen showed loss of glands, fibrosis, congestion, and edema, suggesting ischemia, with no findings of infection (Fig. ). Given these results and the fact that the patient was on dialysis and had severe arteriosclerosis, we provisionally diagnosed ischemic colitis caused by arteriosclerosis and hemodialysis. We stopped or adjusted enteral nutrition, avoided low blood pressure, and withdrew antibiotics; however, his diarrhea persisted. It was impractical to perform a second colonoscopy, as his performance status was severely worsened. Finally, he died of cardiac arrest 193 days after admission. The autopsy showed longitudinal and annular ulcers in the sigmoid colon. An autopsy specimen of the ulcers showed inflammatory p

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male with edentulous maxilla was referred to the University Department of Oral and Maxillofacial Surgery of the “Evaggelismοs” general hospital due to a migrated implant into the right maxillary sinus. The patient suffered from chronic obstructive pulmonary disease and therefore he had quitted smoking. Five years ago he underwent dental rehabilitation with the placement of six implants in the maxilla and four in the mandible. In less than 2 months after initial placement, all implants had failed to osseointegrate. A year and a half later the patient underwent guided bone regeneration with bovine-derived xenograft and 7 months after this point, another 10 implants were inserted into both the maxilla and mandible. Two months later, all implants had once again failed to osseointegrate. During the attempt of removal by the dentist, one of the implants was displaced into the maxillary sinus, without the dentist being able to retrieve it. The patient then visited another dentist, who could not either remove the migrated implant.
Upon arrival to our clinic, a full medical and dental record was retrieved from the patient, and he was scheduled for surgical removal of the implant. Prior to operation, the patient underwent a radiographic examination with water’s X-ray (Fig. ), as well as CBCT examination (Fig. ) which confirmed implant migration and revealed its exact position inside the maxillary sinus.
Surgical procedure initiated with local anesthesia by injecting xylocaine 1% andepinephrine 1:100,000 solution in the soft tissues involving the right half of the maxilla. After a crestal incision, a full-thickness mucoperiosteal flap was raised, exposing the anterior-lateral wall of the maxilla in an area extending from canine to molar region. Using a high-speed rotary instrument under sterile saline solution irrigation, a rectangular window was created in the anterior-lateral maxillary wall. The implant was detected through the bony window and captured by a mos

[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 51-year-old Japanese woman presented to our facility for her regular physical examination. Chest radiographs showed pleural wall thickening on the right side of the apex and upper lung field, which had been seen for several years on her annual regular examinations (Figure A). She had had a mild dry cough for two weeks without symptoms of a common cold such as sore throat and fever. She was a smoker (20 cigarettes per day for 20 years). She had no history of lung disease, such as bacterial pneumonia or pulmonary tuberculosis.
A chest high-resolution CT scan was performed for detailed examination and showed multiple nodular lesions (mostly GGOs) throughout the lung fields, approximately 1cm or less in diameter, which were not detected on chest radiographs (Figure B). No cystic lesions, pleural effusions, or mediastinal lymph node swellings were observed. Bone sclerosis lesions were detected at Th3, Th6, and the first costal bone (Figure C). The findings seen on the right side of the upper lung fields on chest radiographs were evaluated as old inflammatory changes based on the chest CT scan; their etiology seemed to be different from the multiple nodular GGOs (data not shown).
Our patient was referred to our hospital for further investigation and treatment. The differential diagnoses of the lung GGOs were atypical adenomatous hyperplasia (AAH), highly differentiated adenocarcinoma in situ (AIS), lymphoproliferative disease, and MMPH. Her physical findings were normal. Breath sounds were normal, and no rales were heard on chest auscultation. No skin lesions such as facial angiofibroma and hypomelanotic macules were observed. A neurological examination showed no abnormalities. She had no intellectual disability and no history of epilepsy or other diseases. There was no family history of TSC. There were no abnormal laboratory test results at the time of her first visit to our hospital. Arterial blood gas analysis results were also normal. Pulmonary function tests were

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old child reported to the department of pedodontics and preventive dentistry with a chief complaint of a swelling with respect to the right side floor of the mouth since 20 days.
The child noticed a small swelling in the region 20 days ago that gradually progressed to its current size on the day she reported to the outpatient department.
The swelling was painless, with no associated difficulty in swallowing, no paresthesia. No change in size during meal times was noticed by the child. Intraoral examination showed a massive swelling on the right side of the floor of the mouth, measuring approximately 5 cm × 4 cm × 1.5 cm in length, breadth, and depth, respectively. Its anteroposterior extension was from the distal surface of mandibular first molar up to the mesial aspect of mandibular lateral incisor. Swelling appeared translucent, bluish and dome-shaped with some fluid retention within it. No secondary changes such as ulceration, fistula formation, infection, or discharge were observed [].
No history of any similar swelling in the past was noted. Medical history was noncontributory. There were no associated neck swellings.
Patient and parent were explained about the treatment options, and they opted for the least invasive method of management. An informed consent was taken for the same.
The area was disinfected with 0.1 solution povidone iodine. The area of interest anesthetized using an inferior alveolar nerve block. Six interrupted silk sutures using 3–0 silk were passed through the lesion superficially, and loose knots were tied in place to secure them [Figures and ]. The child was instructed to maintain good oral hygiene and rinse twice daily with chlorhexidine mouth rinses. The follow-up was done on a weekly basis to evaluate if the sutures were still in place and if the child was maintaining satisfactory oral hygiene. On day 20, only 1 suture was lost, and the remaining ones were removed. It was observed

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


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

[User]
RADIOLOGY NOTE:
The first patient was a 55-year-old man with no previous cardiac history who suffered three times from syncope. The ECG suggested presence of a VT originating from the LV (). After intravenous administration of amiodarone the tachycardia converted to sinus rhythm with frequent ventricular premature complexes (PVC) of the same morphology as the clinical VT. Echocardiography showed global hypokinesia with LV ejection fraction (LVEF) of 45% and LV end-diastolic diameter (LVEDD) of 57 mm. A coronary angiogram showed no significant coronary artery disease. An electrophysiologic study was performed and the clinical VT was induced. The VT met ECG criteria for an epicardial origin. No ablation was performed. Cardiac magnetic resonance imaging (MRI) showed LVEF of 41% and LVEDD of 58 mm, confirming the results of the echocardiogram. An epicardial scar at the posterolateral basal part of the LV also was identified. Subsequently, a single-chamber implantable cardioverter defibrillator (ICD) was implanted. A second electrophysiologic study was performed as described above and a posterolateral basal scar on the epicardium of the LV was identified, with evidence for E-DCs and two channels going through the scar tissue: one close and parallel to the mitral annulus and the other more apical (). The RF ablation of the first channel was successful and uneventful as there was no PN capture. Before starting RF ablation on the site of the second channel, the PN could be captured along the whole trajectory of the identified channel (). Without extra precautions RF ablation would have been impossible at these sites. Therefore saline was injected as described above and after injection of 200 ml PN capture was lost. The patient was in sinus rhythm before, during and after the injection, invasive systolic arterial blood pressure remained above 80 mmHg (). Then all E-DCs could be eliminated by targeting the late potential channel entrance without any collateral damage. After successful comple

[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 year old Chinese lady with a six months history of bilateral nasal obstruction, tinnitus, associated headache and dizziness presented to the local hospital on November 3rd, 2009. Nasoendoscopy revealed a large mass in the nasopharynx, a biopsy of which confirmed non-keratinizing squamous cell carcinoma, WHO type 2.2 []. Staging MRI and CT scans showed a large tumor measuring 5 × 3 cm occupying the roof and the posterior wall of the nasopharynx which invaded the inferior part of the clivus. Cross sectional images also revealed bilaterally enlarged lymph nodes in the upper neck. According to the 2002 AJCC staging system [], she was diagnosed as a NPC patient of stage cT3N2M0. She was treated with 2-phase lateral opposed facial-cervical fields at a 2 Gy daily fraction (Figure ), 5 times a week to a total dose of 70 Gy with concurrent cisplatin from November 10th to December 31st, 2010. Complete response was achieved after concurrent chemo-radiotherapy. 3 cycles of adjuvant chemotherapy consisting of Cisplatin and 5-fluorouracil was given following concurrent chemo-radiotherapy.
However, 1 year after radiation therapy the patient developed moderate to severe headache and dizziness. She returned to the local hospital to seek medical intervention for her symptoms on March 2nd, 2010. There was no associated history of fever, blurring of vision, nausea or vomiting. Physical examination was unremarkable. No abnormal neurological signs were noted. Her hematological and biochemical profile as well as her liver function test results were normal. However, Brain MRI scan showed abnormalities in the white matter of bilateral inferior portions of the temporal lobes. A large heterogeneous lesion with circumferential rim enhancement surrounded by extensive edema was found in the inferior part of the right temporal lobe. Small homogeneous lesions with limited edema could also be seen in the left temporal lobe (Figure , ). However, these findings in the contralateral temporal lobe

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


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

[User]
RADIOLOGY NOTE:
A female patient, aged 52 years, attended the Department of Oral Medicine at West China Hospital of Stomatology, Sichuan University in June, 2006, with painless white patches over the right bucca and palate for over a year. One year earlier, the patient had discovered the white patches on her right bucca and palate, which felt coarse but were painless. The local hospital diagnosed them by biopsy as leukoplakia, but did not treat them.
The patient came to our hospital as the situation worsened. On a physical examination, her face was symmetrical and not swollen. Extensive white lesions, with multiple peaks on their surfaces, were seen over the right bucca, which were coarse and tough on palpation, but with no congestion or erosion. A white patch like crepe paper was apparent on the C5-7 buccal gingiva and vestibular sulcus. An even white patch, with a soft mucosal texture was present on the left buccal mucosa, along the line of occlusion. White patches occurred from the palatal gingiva, close to A6-7, to the midline. Some white patches, similar in size to rice grains or soybeans, appeared over the lingual rim on both sides and the dorsum. A biopsy of the most affected part of the right bucca showed that the condition was verrucous leukoplakia with mild to moderate dysplasia (Figure ). By combining the characteristics of the oral lesions and the pathological changes, a primary diagnosis was drawn of either OVL or PVL. Because the patient rejected the surgery proposed by a maxillofacial surgeon combined with P53 biotreatment, we proceeded as follows: 1) an overall physical examination was suggested to exclude any hidden malignant tumour; 2) the patient's immunity was enhanced, and retinoic acid and nystatin were given as topical therapy; 3) close surveillance was undertaken, with periodic checks upon request. The physical examination revealed that the patient only suffered from chronic superficial antral gastritis, and no malignant tumour was found

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old female patient presented with an indolent but progressive swelling of the right mid femur over the last 2–3 months in our outpatient consultation hour of our university hospital. She reported of a known osteogenisis imperfecta type V, being the only member of her family suffering from it. Clinical phenotype was characterized by short statue, a mild kypho-scoliosis, a short neck and a mild ligamentous hyperlaxity. She did not report of a trauma or any inflammatory disease. Although numerous fractures of the lower extremities occurred over the last decade which were treated conservatively as well as operatively by intramedullary nailing, HPC or extraordinary swelling never developed.
Conventional radiographs of the affected area showed a massive osseous tumor of the right femoral mid-shaft (). Radiographically the lesion was characterized by a massive irregular hypertrophic lamellar ossification with an irregular sunburst pattern as well as the appearance of spiculae, showing potential periosteal signs of malignancy. Laboratory tests only showed an elevated level of alkaline phosphatase of 257 U/l.
In the assumption of a malignant osteosarcoma, further tumor staging was initiated, including contrasted computed tomography of thorax, abdomen and pelvis. Furthermore a contrasted magnetic resonance Imaging (MRI) () of the affected femur and a scintigraphy () were performed. MRI showed massive irregular periosteal hypertrophic lamellar ossification with an irregular sunray pattern, additional infiltration of the surrounding musculature and soft tissue could not be clearly ruled out. Skeletal scintigraphy showed a massive enhanced tracer accumulation in the mid femoral shaft, but, as well as contrasted computed tomography of thorax, abdomen and pelvis showed no additional lesions. A mini-open biopsy under consideration of tumor-surgical aspects was performed by two senior surgeons. Histopathologic analysis of the bioptic specimen showed distinctive zones with

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old woman with athetoid cerebral palsy suffered a displaced femoral neck fracture of the left hip in 2004. She had been able to transfer from the bed to the wheelchair independently before the injury, but she lacked ambulatory ability in a community setting.
Radiography revealed that the sharp angle of the left hip was 40° at injury []. The patient had no acetabular pathology prior to fracture. Five months later, she underwent bipolar hemiarthroplasty at another hospital and recovered uneventfully []. She had been able to return to her previous lifestyle, but she presented to us with a two-month history of severe pain in the left groin nine months after the hemiarthroplasty. Pain was aggravated by athetoid movement and increased muscle tone even at rest. Non-steroidal anti-inflammatory drugs did not relieve the pain.
At the first visit to our hospital, standard radiographs of the left hip demonstrated lateral migration of the prosthetic bipolar head []. Laboratory examinations revealed a normal C-reactive protein level and white blood cell count. Physical examination revealed mild restriction of left hip motion due to pain. She tended to adduct and extend her left hip with increased muscle tone. Antispasmodic drugs (p.o.) had little effect on pain.
Four weeks later, in view of the severe continuous pain, we removed the outer head and placed the acetabular component with cement and without a bone graft. Intraoperatively, the lateral aspect of the acetabulum was found to be denuded of cartilage. We concomitantly performed release of the adductor muscles and medial hamstrings. A sample of clear synovial fluid taken from the joint at the time of surgery did not produce bacterial growth on culture.
At two years follow-up after the conversion, she could transfer independently between the bed and wheelchair with mild pain in the left groin, but the pain subsided at rest even with increased muscle tone. A plain radiograph revealed no signs of loosening or change i

[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:
Patient 2 was a 38 years-old male diagnosed as left temporal glial neoplasia in May 2014 after a seizure. MRI showed an expansive infiltrative lesion predominantly in the subcortical region, with poorly defined contours located in the left temporal lobe, involvement of the upper, middle, and lower temporal gyrus, and an increase in the left temporal gyrus cortex. The lesion compromised a large part of the temporal lobe and extended to the temporal isthmus, the posterior aspect of the insula, and was deep in the trigeminal effigy of the left lateral ventricle. There was diffuse erasure of the regional cortical sulci and the Sylvian fissure, as well as a slight compression over the atrium of the left lateral ventricle. Stereotactic biopsy on April 2014 indicated a diagnosis of oligodendroglioma grade II. He received TMZ 1,875 mg with cycles every 23 days (during the 5 days of use he received a dose of 375 mg/day) from September 2014 to July 2015, with no tumor growth until the beginning of 2016. After checking the evolution of the tumor by MRI in February 2016, there was an increase in the dimensions of the remaining lesion, notably in the temporal isthmus, which had a similar expansive effect on the adjacent encephalic structures. The patient was submitted to a partial surgical resection followed by chemoradiation and lasting 6 cycles of PCV associated with CBD. The CBD dosage was ranging from 100 to 200 mg/day.
During the chemoradiation he had an excellent clinical performance, practiced sports, and had few symptoms of fatigue and/or nausea.
MRI control immediately after chemoradiation (Figure ) was used to characterize post-operative changes and showed a significant reduction of the infiltrative components of the tumor. The result of the pathological study after the first surgery (Figure ) was oligodendroglioma grade II. After the second surgery, he was diagnosed as oligodendroglioma grade III characterized by an increase in Ki67 staining of 9% and

[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:
We present a case of a 65-year-old female patient admitted to the Cardiac Surgery Department in Wroclaw in January 2018 with severe mitral regurgitation (MR) and the history of ischemic heart disease, after elective percutaneous coronary intervention of the circumflex branch of left coronary artery with two drug-eluting stents (DES) implantation 4 years earlier. Furthermore, the patient diagnosed with many chronic conditions, such as metabolic syndrome, obesity with BMI 33 and gastroesophageal reflux disease. Currently, with an exercise dyspnoea for about 2 years, intensifying in recent weeks, she was hospitalized in the Cardiology Department for further diagnostics. The transthoracic echocardiography (TTE) revealed non dilated left ventricle with a normal systolic ejection fraction of 60%, and no evidence of segmental wall motion abnormalities, severe MR with the prolapse of the A2 segment and systolic restriction of the posterior leaflet. Colour Doppler showed a highly distinctive eccentric turbulent jet directed towards the lateral wall and the base of the left atrium with ERO 0.6cm2 and regurgitant volume of 60 ml. Additionally, in the performed coronary angiography, hemodynamically significant narrowing was found in the area of the previously implanted DES. The patient was then consulted by the cardiac surgeon and qualified for surgery. After admission to the Cardiac Surgery Department, as part of the pre-operative preparation, TTE was again performed, in which the severe MR was confirmed and no pathological structures in the right atrium were described. Due to the unclear image in the right pulmonary field, described by the radiologist in the chest X-ray (Fig. ), diagnostics was extended by performing a computed tomography of the chest, which excluded the presence of pathological shadow in the lung parenchyma. There was no referral to the atrial septum in the CT report. The patient was scheduled for mitral valve repair surgery and coronary artery bypass grafti

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

[User]
RADIOLOGY NOTE:
A 32-year-old woman in her first pregnancy presented at 37 weeks gestation to the obstetric review centre in the late evening with a two-hour history of new onset right-sided leg pain and numbness. She was able to mobilise short distances and was otherwise well. Initially her symptoms were most suggestive of sciatica, a common complaint during pregnancy.
Her symptoms progressed rapidly over the next two hours and she reported bilateral lower limb numbness and severe shooting midthoracic back pain and was unable to move her legs. Initially she had no urinary retention or faecal incontinence. She also reported no history of trauma or any similar symptoms in the past.
She had an otherwise low risk pregnancy and there were no signs of fetal distress on arrival. Her past medical history included asthma, allergic rhinoconjunctivitis, and depression. She was a smoker and migrated to Australia from England several years earlier.
On initial examination, vital signs were normal. She was afebrile. Cardiotocograph revealed no concerns for fetal wellbeing. Her neurological examination was inconsistent but nevertheless concerning. She was found to have patchy bilateral sensory loss up to a sensory level of T10. Lower limb examination revealed reduced power bilaterally (1-2/5) across all myotomes with hyperreflexia, clonus, and upgoing plantar reflexes. Upper limb neurological examination was normal. There was no bony tenderness on palpation of her spine. Insertion of a urinary catheter five hours after presentation drained 700 ml of urine. This was suggestive of urinary retention, particularly in the context of her advanced gestation. However, she reported normal perineal sensation on catheter insertion, again inconsistent with her other symptoms and examination findings.
Due to her pregnant state, an urgent CT was not performed. An after hours MRI was not considered necessary as it was felt an acute surgical cause for the presenting signs and symptoms was unlikely. A kidney ultr

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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 33-year-old male patient had developed a 0.5 × 0.5 cm pyogenic papule in the left cervical area one month prior to presentation. At that time, the patient had been evaluated at a community hospital where the lesion was diagnosed as cellulitis and was given topical steroid and IV antibiotic treatment for two weeks without appropriate response. In the subsequent two weeks leading up to presentation at our hospital, the lesion continued to grow in size while the patient began to experience consistent fever and chills.
Initial physical examination revealed a painful 9×4 cm ulcerative lesion in the left cervical area (). The patient reported a history of chemical burn on the left chin 13 years earlier and three scar revision procedures had been performed for keloid. The patient had been receiving local steroid injection therapy up until three years before the development of ulcer.
Upon admission, debridement and bacterial culture tests were performed to exclude the potential for necrotizing fasciitis. Histopathologic examinations were conducted to assess the possibility of malignant neoplasms. The white blood cell (WBC) count increased to 17.56 × 103, and the patient continued to experience febrile episodes (39℃-40℃) two to three times a day. Findings characteristic of a widely spreading ulcer were observed. No microorganisms were identified in the wound culture. The histology of wound sample demonstrated papillary proliferation on keratinized squamous epithelium with significant chronic inflammation. The possibility of malignant neoplasms could not be excluded, although no stromal invasion or cellular an aplasia was observed ().
In cooperation with the pathology department, additional debridement was performed 8 days after admission. No necrotic findings were observed in the platysma fascia intraoperatively, and no cancer cells could be identified in the marginal ulcer area in frozen sections. Despite the consistent fever and increases in WBC count, bacteria were not

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old healthy bricklayer male, born in eastern Europe, presented with right-knee pain caused by a fall on the knee during his work, a few weeks prior. During his childhood, a clinically evident bilateral dislocation of patella was observed and described without the assistance of imaging. Nevertheless, the pathology was asymptomatic, and he never reported difficulty in walking. Therefore, the malformation had never been treated and the patient conducted a normal life including time served in the army.
Physical examination revealed that the patient could walk normally, with a very mild stumble on the right knee, which was referred as absent before the trauma. There was conspicuous muscle wasting of each thigh (particularly on the medial side, with a clear depression on the vastus medialis) and 15° of genu valgum. The patellae were lying laterally to the lateral femoral condyle with the knee in the position of full extension () and they displaced more laterally during the flexion (). The proximal tibiae were rotated outward. The knees could be extended actively against maximum resistance, with full range of motion. Both the femoral quadriceps worked as knee extensors, and their strength was 5/5. The knees showed no signs of instability or ligamentous deficiency. The right knee was painful on the lateral side, and the clinical signs were positive for pathology of the lateral meniscus.
Roentgenograms of bilateral knees revealed small, laterally displaced patellae with slight degenerative changes in the tibiofemoral joints with subluxated tibia (). The medial joint spaces were widened. Lateral roentgenograms showed marked lateral rotation deformities of the tibiae (). A skyline view showed an increased deep of the trochlear groove, with laterally dislocated patellae forming a sort of new joint with the lateral aspect of the condyle ().
Magnetic resonance imaging (MRI) showed a lesion with dislocation of the lateral meniscus on the right knee. On both sides, the MR

[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:
A 32-year-old woman was admitted to our hospital with complaints of vague abdominal pain a day prior to presentation. She reported having undergone conversion of laparoscopic to open abdominal surgery secondary to symptoms misdiagnosed as pan-peritonitis at another hospital a year ago. She revealed that she underwent only exploratory laparotomy without bowel or other organ resection during the previous surgery. There was no other history of surgery and medicine. Upon admission, her body mass index was 20.2 kg/m2, and her vital signs were stable. Palpation of the abdomen revealed direct tenderness in the periumbilical area without rigidity, distension, and/or a mass-like lesion. Blood tests revealed that her white blood cell count had increased to 11,900/μL, although other parameters were within reference ranges. An abdominal X-ray revealed a nonspecific bowel gas pattern. Abdominopelvic computed tomography (CT) demonstrated an abnormal location of the cecum, which was positioned towards the pelvis, and an ileal segment showed kinking of the mesenteric vessels located below and at the right lateral aspect of the ascending colon (). An emergency operation was performed because of persistent abdominal pain and the risk of bowel strangulation, although no bowel dilatation and/or abnormal bowel perfusion were observed on CT.
The patient initially underwent a single-port exploratory laparoscopy via the previous operative site. Laparoscopically, after we performed adhesiolysis, an ileal segment was observed on the lateral aspect of the ascending colon, and herniation was observed below the cecum(). Careful reduction was performed using a laparoscopic bowel grasper; however, marginal mesenteric tearing of the ileum caused hemorrhage, necessitating conversion of the laparoscopic procedure into an open abdominal surgery. After manual reduction of the herni ated ileum, the hernia orifice was noted as a form of the membranous band between the posterior cecal wall and the right

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old man with nephrotic syndrome treated with immunosuppressive therapy presented with acute urinary retention and a three-day history of lower abdominal discomfort. He was unable to void completely despite straining. These complaints were preceded by the eruption of a vesicular erythematous rash over the right side of his lower abdomen which extended to his right scrotum and thigh. The rash appeared approximately seven days before the voiding complaints and was not associated with pain or itching. He did not have similar symptoms previously. He had no fever and no other urinary symptoms such as dysuria, urgency, and increased frequency. He denied a history of lower back pain, abnormal sensation in the legs, and weakness and did not have constipation or loss of sexual ability. He had a history of childhood chickenpox.
The patient had a known history of nephrotic syndrome with stage III chronic kidney disease for two years. Although his renal biopsy was suggestive of minimal change disease with mesangial immune complex deposits, another biopsy performed five months prior confirmed a diagnosis of the tip lesion variant of focal segmental glomerulosclerosis. His medications were prednisolone (15 mg daily) and mycophenolate mofetil (1000 mg twice daily), both for approximately six months. These were not altered at admission.
The patient was vitally and clinically stable at admission. He had central obesity with corticosteroid-related cushingoid features such as a moon-like face, suprascapular fat pads, and abdominal striae. He had suprapubic tenderness, and his bladder was palpable above the symphysis pubis. There was a non-tender vesicular rash on a densely erythematous base with areas of purpura involving the L1 to L4 dermatomes (Figures -). The ruptured vesicles led to the development of ulcerations with crusted lesions of the same distribution. The rash also involved the S2 dermatome as evidenced by the right scrotal rash and erythema (Figures -). The patie

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old Caucasian woman was admitted for kidney transplantation. Renal history began at 10 years of age when she was hospitalized for several episodes of ureteral colic due to recurrent stone disease. She was married with four children. During each pregnancy, she was treated for hypertension. At 40 years of age, she was evaluated for severe arterial hypertension. Investigations revealed proteinuria (2 gr/24 h) and an increase in plasma creatinine (12 μmol/dL). Renal ultrasound showed multiple stones in the left kidney and bladder, while the right kidney was atrophied. The diagnosis of primary hyperoxaluria type I was established by the detection of the G170R mutation in the peroxisomal alanine-glyoxylate aminotransferase (AGT) gene. The residual activity of AGT was less than 28% in biopsied liver tissue from our patient. As chronic renal failure progressed, our patient experienced, at 44 years of age, multiple embolic episodes involving the femoral arteries, hypogastric arteries, splenic artery and renal arteries, and requiring surgical thrombectomy. Transthoracic echocardiography revealed an intraventricular thrombus associated with hypokinesia of the apical region and the interventricular septum. Hematological studies including tests for thrombophilia (protein C and protein S deficiency, factor V Leiden, anti-thrombin III deficiency, and anti-phospholipid antibody syndrome) and serum homocysteine concentrations yielded normal results. An electrocardiogram did not reveal any signs of atrial fibrillation or myocardial infarction.
Our patient was discharged with long-term treatment with anti-vitamin K. Terminal renal failure was precipitated by bilateral renal artery embolism requiring the initiation of hemodialysis, which was performed five days per week because of hyperoxaluria. Kidney transplantation was performed two years following the initiation of dialysis, but the graft was rapidly lost at day seven post-transplantation, secondary to thrombosis of the g

[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 89-year-old man presented with an erythematous patch on his penoscrotal skin. He first noticed the skin lesion 5 years before the consultation, expanding gradually. Topical moisturizing creams did not improve the lesion. On local examination, an erythematous patch of 8 cm in the penoscrotal region was observed ( and ). He did not report any itching or tenderness. A skin biopsy revealed the invasion of Paget’s cells into the dermis ( and ). Neither regional lymphadenopathy nor distant metastases were detected on computed tomography. A discussion with the patient and his family revealed their preference for a nonsurgical treatment strategy because of the patient’s age. We decided to administer electron beam therapy, which could eradicate a tumor with minimal adverse reactions in normal tissue such as the rectum and bladder. Informed consent was obtained from the patient and his family.
RT was delivered conventionally (2.2 Gy/day, 5 fractions/week) using a single anterior 6 MeV electron beam (). To reduce the risk of skin recurrence by minimizing the skin-sparing effect of the electron and photon beams, a 10 mm tissue-equivalent bolus was added to the skin surface during the RT. Clinical target volume included 2 cm margins for the clinically visible disease. The tumor response in the irradiation field was observed to be inhomogeneous at the completion of administration of 19.8 Gy in 9 fractions; thus, in a subsequent RT, an additional dose of 42 Gy at 2 Gy per fraction was delivered using a single anterior 4 MV photon beam using a uniform 10 mm thickness bolus (). Eventually, the patient received a total dose of 61.8 Gy in 30 fractions. The skin over the treatment area was mildly hyperpigmented, but it was otherwise unaffected. The tumor completely disappeared after the completion of the RT. As of 6.5 years after the treatment, the tumor had not recurred and no severe late adverse events were observed ().

[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 63-year-old female patient presented with reduced vision in her right eye. She reported experiencing sudden-onset pain, loss of vision, and redness in her right eye 7 years earlier, but did not seek medical treatment at that time. She had no history of ocular trauma or surgery. Best corrected visual acuity (BCVA) in her right eye was light perception and intraocular pressure was 18 mmHg. Anterior segment examination revealed hypermature cataract. The iris stroma showed diffuse atrophy and appeared hypochromic. Ultrasonography demonstrated retinal attachment. Cataract surgery was recommended, but the patient refused.
At 1-year follow-up examination, the patient stated that her vision had improved. BCVA was 20/25 in the right eye (with +12 D correction) and 20/20 in the left eye. Although her right eye appeared aphakic on anterior segment examination, no surgical scar or signs of trauma were detected. The cornea was clear and the conjunctiva appeared normal. Despite the hyperchromic appearance and stroma atrophy of the iris, there were no findings suggestive of inflammation (keratic precipitates in the corneal endothelium, posterior synechia, or anterior chamber inflammatory cells). The left eye appeared normal (). Intraocular pressure was 18 mmHg in the right eye and 16 mmHg in the left eye. The areas that could be visualized in fundus examination were normal. A peripheral retinal scan was done to see the crystalline lens. An ideal evaluation could not be performed because the patient had sunken eyes and incomplete pupil dilation. However, no crystalline lens material was observed in the visualized areas. The absence of crystalline lens material in peripheral retinal examination raised the suspicion of crystalline lens subluxation behind the iris. Ultrasound biomicroscopy (UBM) was performed, but UBM images did not show any lens material behind the iris (). B-scan ultrasound revealed a hyperechoic appearance in the inferior peripheral retina suggesting luxation ().

[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 four-year-old female child with acyanotic congenital heart disease, that is, moderate ostium secundum ASD and branch pulmonary artery stenosis, since three months of age presented with classical features of facial dysmorphism such as frontal bossing, triangular facies, deep-set eyes, a pointed chin, and mild joint laxity (Figure ). Delayed development was noted with mental development more delayed than motor development along with poor speech. Ocular examination revealed posterior embryotoxon and mild pigmentary retinopathy in the right eye. Chest X-ray showed abnormal segmentation in the T5 vertebrae (butterfly presentation) (Figures , ) and past history was positive for recurrent infections and negative for neonatal cholestasis and maternal abnormalities. The above findings were highly suggestive of ALGS.
A confirmatory cardiac CT scan was performed which revealed a moderate ASD of ostium secundum type along with hypoplastic main right and left pulmonary arteries, with a McGoon ratio of 1.65 and Nakata index of 169.36 mm2/m2 (Figure ). The common hepatic artery was seen arising from the proximal portion of the superior mesenteric artery, and a small vertical midline cleft in the body of the T5 vertebra, mainly in the posterior portion, was noted; these findings appeared to be congenital variants.
Further detailed evaluation and a preoperative color Doppler revealed severe bilateral branch pulmonary artery stenosis with moderate ostium secundum ASD and bidirectional shunting. Right ventricular pressure was significantly elevated with hypertrophy and dilatation of the right atrium and the right ventricle with normal biventricular function. Ultrasonography of the abdomen and pelvis reported no significant findings.
The patient was planned for bilateral branch pulmonary artery plasty with glutaraldehyde treated pericardial patch and direct closure of the atrial septal defect leaving a patent foramen ovale (PFO). The patient tested negative for severe acute respirato

[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 male patient reported to Department of Oral and Maxillofacial Surgery with a history of ulceroproliferative lesion involving the lower lip for the last 5 months. He had a habit of smoking 15 cigarettes/day for last 12–13 years and had habits of alcohol consumption 2–3 times a week for last 10 years. The lesion extended from left commissure of mouth upto midline of lower lip involving the labial and buccal mucosa till left 1st molar region []. The oral hygiene was a bit compromised and foul odor was present. The ipsilateral Level IB (Submandibular) group and Level IA (Submental) group of lymph nodes were palpable, enlarged, and not fixed to underlying structure. The provisional diagnosis of malignant neoplasm was made which was confirmed by incisional biopsy which was suggestive of moderately differentiated type of squamous cell carcinoma.
Magnetic resonance imaging and contrasted computed tomography were the preferred radiography to rule out the extent of lesion in soft and hard tissue, respectively. The infiltration was seen deep into the orbicularis muscle and part of buccal mucosa; however, no bony erosions were noted. The patient was informed about his condition, and surgical procedure was explained enumerating the possible risks and complications of it before surgery. Informed consent for the use of photographs relating to the case, for medical, scientific, or educational purposes, was likewise secured. The ethical committee approval was taken from the local institutional ethical committee approval board.
Under general anesthesia, the patient was subjected to the left side supraomohyoid neck dissection and full thickness excision of lower lip with safe margins of 1 cm. The defect was reconstructed with Karapandzic flap. The flap consists of a horizontal incision along the lower border of the defect in the mentolabial sulcus and bilateral perioral incision in nasolabial fold []. The neurovascular bundle was preserved to maintain flap viability. Whe

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old woman was referred to our hospital with pancreatic head and neck carcinoma for more evaluations and surgical operation. She had been suffering from abdominal pain for about 1 year, and the pain has become more intense in the last 6 months. The pain was postprandial and localized to the right upper abdomen. She has become icteric with generalized spread plus itching since past 2 months. The patient had no history of alcohol consumption or smoking. The patient was referred to us with a highly probable diagnosis of pancreatic head and neck carcinoma to be consulted for surgery. Also, a plastic stent was implanted for her in the previous health center due to intra- and extrahepatic duct dilation for the relief of patient symptoms and signs. After admission to our hospital, she was evaluated by abdominal computed tomography (CT), endosonographic imaging, and diagnostic ampullary biopsy. The abdominal CT scan with contrast exhibited an 18 mm × 20 mm hypodense mass at the head and neck of the pancreas (). Also, endosonographic imaging was performed to rule out periampullary lesions (). A 20 mm × 19 mm lesion was seen in the pancreatic head and neck region, and the main pancreatic duct was slightly dilated in the body of the pancreas. Moreover, the common bile duct (CBD) was distally thickened and contained sludge. Subsequently, diagnostic biopsy for pathological assessment was done. The biopsy revealed an irregular gray-creamy soft tissue which had undifferentiated malignant tumor features at microscopic evaluations. During the Whipple procedure, after cutting the neck of the pancreas in the left side of the portal vein, the frozen section revealed more involvement of pancreatic tissue. Although additional 2 cm was resected, the pancreas residue still had tumor involvement, macroscopically. Therefore, the patient was undergone total pancreatectomy.
Postoperative pathological studies were established and indicated a tumor with the greatest dimension of 4 cm wh

[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.