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

[User]
RADIOLOGY NOTE:
A 54-year-old male patient presented with a two-day history of severe left-sided, lower back pain which disappeared with the appearance of left-sided lower limb pain felt deep inside the whole lower limb and described by the patient as intense internal pressure (VAS 8/10). On examination, power was 5/5 with no sensory deficit and normal reflexes. The patient received NSAID painkillers and active bed rest was advised. However, on the patient's insistence, a lumbar spine X-ray and MRI were done which showed mild IVD protrusion. The patient was reassured and sent home. A week later the patient presented to the ER with an 18-hour history of heaviness and difficulty in raising the left foot when walking, with numbness along the lateral part of the leg and dorsum of the foot. The pain was moderate (VAS 5/10). No sphincter-related symptoms were observed. According to the patient, the decreased pain caused the delay in presentation, against the instructions on first evaluation. On examination of the foot dorsiflexion was 2/5 (movement on gravity alleviation) with decreased sensation along the left L5 dermatome. There were normal reflexes and sphincters. The patient underwent immediate, new lumbar MRI which showed a large disc sequester with disc migration. His status was fully explained; he was admitted and underwent microdiscectomy L4/5.
The initial back pain lasted for 2 days, mostly caused by stretching and pressure on the weakened annulus fibrosis. This type of pain disappears or decreases once the annulus opens and nucleus pulposus leaks to the spinal or root canal. Initial left lower limb pain is a typical description of painful radiculopathy where mass pressure and inflammatory irritation of the nerve root and dorsal root ganglion cause neuropathic pain. This is different from nociceptive and referred pain types. Dorsal root ganglion hosts the cell bodies of sensory nerves with bidirectional connections (to the periphery and spinal cord). Injury

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


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

[User]
RADIOLOGY NOTE:
A healthy 20-year-old male presented to the musculoskeletal oncology department after incidental diagnosis of a cystic lesion located in the left femoral head (A). The lesion was found incidentally after the patient underwent an MRI of the lower abdomen for suspected appendicitis. Six months after the incidental finding the patient began to complain of left groin pain.
The patient had hip pain with flexion abduction and external rotation and a negative FADDIR test. CT scan demonstrated a lobular lesion in the epiphyseal region of the femoral head sparing the articular surface (B). The lesion measured 2.3 × 15 × 1.6 cm. Due to continued symptoms and the subchondral location at the weight bearing zone of the femoral head, hip arthroscopy including biopsy samples, debridement and curettage was suggested. Due to the size and location of the lesion bone substitute was used to fill the cavity.
Hip arthroscopy was first performed with traction for evaluation of possible articular penetration of the lesion. A lateral portal was established under fluoroscopy and then a mid-anterior portal [] was created under arthroscopic visualization with the aid of fluoroscopic guidance. Capsulotomy between the two entry points was performed with a hooked radiofrequency probe (VAPR; DePuy Mitek, Raynham, MA, USA) to facilitate instrument maneuverability. The femoral head was probed and appeared to be intact (C). Traction was then released and the peripheral compartment was inspected. The location of the lesion was identified using fluoroscopy (D). The capsule was further divided in a T shape. A small window on the lateral cortex of the femoral head was created. The lesion was excised using a curette and a shaver to the underlying bleeding bed of bone (E). The cavity was than filled with an osteo-conductive (HA) Bone Paste (BoneSource BVF, Stryker, Mahwah, NJ, USA) (F). The capsule was closed at the end of the procedure and the

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old previously healthy African-American female presented with an enlarging inner left cheek mass with overlying ulcer of 2 months duration. A computed tomography scan with contrast demonstrated a large irregularly outlined peripherally enhancing mass located between the anterior margin of the ramus of the left mandible and maxilla protruding outward. An incisional biopsy was performed followed by a wide local excision 3 weeks later. The excision included a composite resection of left buccal mucosa, a left modified radical neck dissection, a left partial maxillectomy, a right anterior thigh flap placement, and a left parotidectomy. A whole-body computed tomography survey demonstrated a 5-mm lingular lung nodule and a 7-mm right hepatic hypodensity. These areas were determined to likely be incidental findings; however, further workup was suggested.
The patient had an unremarkable surgical recovery and was discharged from the hospital 1 week later. An incisional biopsy was performed followed by a wide local excision 3 weeks later. She recovered well postoperatively but refused to follow-up chemoradiation therapy.
Six months later, she presented with altered mental status secondary to hypercalcemia from bony metastases. She was discharged to a hospice facility as per her family's request.
The excised specimen displayed a pedunculated, exophytic, ulcerated, dark purple mass, appearing to arise from the buccal mucosa. The mass measured 6.0 cm × 5.4 cm × 2.8 cm in greatest dimensions. The cut surface revealed a light tan interior with scattered areas of hemorrhage and necrosis and an infiltrative margin involving the underlying subcutaneous tissue but sparing the overlying skin and adjacent maxillary segment [].
Histologic sections of the incisional biopsy specimen revealed a diffuse hypercellular pleomorphic ill-circumscribed lesion with extensive necrosis. The viable areas exhibited slit-like vascular space and micropapillary architectural patterns and focal 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 63-year-old man presented to the emergency room of another hospital with muscle weakness of the limbs after a cow struck his neck and chest. Magnetic resonance imaging of the cervical spine performed at that time revealed a dislocation of the 6th and 7th cervical vertebrae. An anterior internal fixation was conducted from the 6th cervical vertebra to the 1st thoracic vertebra on the day of the injury and a conservative treatment that involved maintaining a supine position was recommended. The patient was admitted to our hospital for rehabilitation treatment 99 days after the injury. The neurological level of injury was determined to be C5 according to the American Spinal Injury Association Impairment scale B. At that time, the patient was using an NG tube. A videofluoroscopic swallowing (VFS) test was attempted at 1 week after admission, but the test could not be performed because the patient could not remain in the required position. Hence, the test was performed 128 days after injury, after confirming that the patient could maintain the required position for the procedure. The oropharyngeal examination during the VFS test showed that the swallowing reflex and processes had progressed without any abnormal findings; therefore, the NG tube was removed and the oral feeding of a dysphagia diet was initiated.
The patient complained of swallowing during the feeding because of food stuck in the throat ; moreover, he experienced intermittent vomiting after the feeding. The ability to swallow at that time was estimated to be of grade 2 on the Functional Oral Intake Scale (FOIS) []. A laryngoscopy performed 3 days prior to the occurrence of symptoms revealed no abnormal findings like as laryngeal swelling. First, the patient underwent a surgery to treat a concomitant complaint of sore coccyx. Subsequently, an esophagogastroduodenoscopy (EGD) was performed 27 days after the initiation of oral feeding. This EGD indicated a stricture at 35 cm below the inferior pharyngeal con

[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 healthy woman presented with difficulty breathing and dissatisfaction with her facial appearance. She had a history of childhood trauma resulting in nasal septum deviation and external nasal deformity. Four months after a successful and uneventful septorhinoplasty, she presented to the emergency department with blunt nasal trauma resulting in a septal hematoma, which was drained successfully; the patient was discharged with no adverse sequelae.
Four months later, the patient sustained nasal trauma again, this time accompanied by clear nasal discharge, raising suspicion of cerebrospinal fluid (CSF) leak. The patient was discharged after managing the nasal injury, as the CT brain showed an intact cribriform plate with no evidence of a CSF leak. Ten days later, she presented at the emergency department with dizziness and an unstable gait. She also had complaints of paresthesia for the past two months, beginning in her right hand and progressing to the right shoulder, arm and leg, associated with some difficulty in the execution of movements in the first and second finger of the right hand. Her right leg was quite stiff with difficulty in walking. On close inquiry, she gave history of pain in the right eye and double vision many months back, which had resolved spontaneously. Examination showed a positive Romberg’s and Lhermitte’s sign, with right-sided sensory impairment.
Magnetic resonance imaging (MRI) of the brain, cervical and thoracic spine demonstrated demyelinating lesions in the brain and cervical segment of the spinal cord (Figure ). Some of the lesions demonstrated enhancement on post gadolinium administration sequences, suggestive of active demyelinating diseases like MS. A lumbar puncture was performed which demonstrated the presence of oligoclonal bands in the CSF. The diagnosis of MS was confirmed by a neurologist and treatment was initiated.
The initial neurological symptoms have largely vanished with only persistent light paresthesia in the

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


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

[User]
RADIOLOGY NOTE:
An 8-month-old female infant had coronary reimplantation at age 3 months for ALCAPA. Postsurgical ejection fraction showed early improvement with subsequent deterioration. A diagnostic left heart catheterization performed as part of a heart transplant evaluation revealed severe ostial stenosis of the LMCA. She was referred for PCI of the left main coronary artery to relieve her heart failure and preempt transplant. Her physical exam was significant for congestive heart failure and failure to thrive. The patient's echocardiogram showed markedly depressed left ventricular function. A cardiac computed tomography angiography (CTA) and initial diagnostic nonselective root aortogram demonstrated stenosis of the LMCA at the site of ALCAPA reimplantation. Selective left coronary angiogram revealed severe kinking of the reimplanted LMCA at the ostium ().
The procedure was performed in the Pediatric Cardiology interventional suite after extensive discussion and planning with Pediatric and Adult Interventional Cardiology, Pediatric Cardiac Anesthesia, Pediatric Cardiothoracic Surgery, and Pediatric Cardiac Radiology. General anesthesia and a femoral arterial approach were utilized. An ascending aortic root angiogram was obtained in 2 planes to assess the ostial left main stenosis. Due to the small size of the infant aorta, a 6 Fr JR-4 guide was reshaped to engage the left main coronary artery. A BMW wire was used to cross the lesion. Since the infant left main coronary artery was small but was expected to grow with age, a somewhat larger (3.0 × 8 mm Vision bare metal) stent was carefully implanted in the proximal LMCA at less than nominal pressure to avoid distal dissection. A poststent angiogram showed that the stent had moved during implantation and missed the ostium with residual stenosis of the LMCA origin. Hence, a 3.5 × 8 mm Vision bare metal stent was placed into the LMCA ostium overlapping with the previous stent distally and protruding 1-2 millimeters in the aorta pro

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


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

[User]
RADIOLOGY NOTE:
A 23 year old young Fulani man presented to the Accident & Emergency room in the early hours of the morning with history of stab in the abdomen with a hand-held cow horn. An hour earlier he was at a local party with his peers when a scuffle ensued and he was stabbed with a cow horn on the left side of the abdomen. He had severe abdominal pain and noticed that his intestine was protruding through the wound. He was helped to the hospital by his friends. There was no loss of consciousness. He bled from the site of injury. No vomiting or abdominal distension. There was no hematuria. Examination revealed an anxious young male who was not pale. He did not have any alcohol smell or evidence of any parenteral drug abuse, but no objective alcohol test was done. There was tachycardia of 92/min and a blood pressure of 100/60mmHg. Chest examination was normal. There was an obvious eviscerated hyperemic loop of bowel in the left paraumbilical region. The abdomen was moderately tender but there was no evidence of significant free peritoneal fluid collection. Rectal exam was normal.
He was resuscitated with intravenous fluids and antibiotics, and tetanus prophylaxis was given. Eviscerated bowel was covered with sterile warm moist gauze soaked in saline. Complete blood counts, electrolytes and urea laboratory test results were within normal limits. Abdominal ultrasonography suggested minimal fluid collection in the peritoneal cavity. At surgery, the eviscerated bowel was found to be viable. It was thoroughly lavaged with saline. Via a midline incision, the abdomen was then opened. The peritoneal cavity was found to be relatively clean with just about 30 mls of hemoperitoneum in the pelvis. There was a 7 cm transverse rent involving all layers of the anterior abdominal wall to the left of the umbilicus, through which about 35 cm loop of jejunum eviscerated. There was no mesenteric injury. All other abdominal organs were normal

[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 female came to our hospital for a routine pregnancy check-up.
The patient was in the 12th wk of pregnancy.
The patient had no significant pathological history, and she was in her second pregnancy and with prior vaginal delivery. She had no relatives with cardiac disease or any malformations. Her first daughter was healthy.
The patient had no significant personal nor family history.
Patient´s physical examination did not show any abnormality. She was a healthy pregnant woman.
The first trimester aneuploidy screening was 1/518 for trisomy 21 and 1/10000 for trisomy 13 and 18. The cell-free fetal DNA test was performed due to the intermediate risk for trisomy 21 and the echographic findings suggestive of heart disease. It resulted in a risk for trisomy 21, 13, and 18 less than 1/10000, and male gender. The serologies were negative for human immunodeficiency virus, syphilis, hepatitis B, and toxoplasma, and the patient was immune to rubella. Her blood group was rhesus factor-positive and irregular antibody count was negative. No thyroid or glycemic changes were observed during the follow-up of this pregnancy.
The first trimester ultrasound was performed, wherein a live fetus of 55 mm craniocaudal length was observed. Echocardiography revealed a pericardial effusion that reached the atrioventricular valves (Figure ) in the heart with synchronous ventricular contractions, patent atrioventricular valves, and no ventricular asymmetry. Similarly, the outflow tracts of the great arteries were observed with correct arrangement, with preserved crossing. No abnormalities were observed at any other level.
Early echocardiography was performed at week 15 of pregnancy considering the finding of pericardial effusion on the first ultrasound. Pericardial effusion had disappeared, and echocardiography was normal. Morphological ultrasound was performed at week 21 of gestation, and echocardiography did not reveal any pathological findings, nor did the rest of the structures

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old female patient presented to our orthopedics department with right hip pain which was exacerbated after active movement for 3 hours. There was a history of sprain when she missed a step during walking down the stairs. The physical examinations revealed slight swelling of the affected hip joint, tenderness in the lateral part of the right hip, and limited movement of the hip due to the pain. The AP view of the X-ray showed incomplete fracture of the right femoral neck and the classification was Garden type I (Fig. A). Further computed tomography (CT) and magnetic resonance imaging (MRI) were used to confirm the diagnosis of this type fracture, which showed that the superior cortex of femoral neck was discontinuous and the inferior cortex remained intact (Fig. B, C). The patient was given conservative treatment including additional immobilization devices (cast of right lower limb) of the affected lower limb and strict bed rest during the first 3 weeks after injury. Analgesic was used when necessary during the early stage. Then bed-to-wheelchair transfer training and half-to-full weight bearing mobilization supported by a walker began in the following 6 weeks. In case of the secondary displacement, Routine X-ray of the hip joint was performed for the 1st week after injury. Treatment outcomes in patient were assessed by multiple imaging techniques including X-ray and CT scanning as well as functional recovery Harris hip score (HHS) and visual analog scale (VAS).[ There was no secondary displacement, signal of osteonecrosis of the femoral head or other complications of conservative treatment observed during the 24-month follow-up. Fracture union was achieved at the time of 3-month follow-up. The HHS of this case was improved from 72 to 95 at the time of 3-month follow-up after treatment. The VAS score of the hip pain declined to 0 at the time of 3-month follow-up while the VAS score was 6

[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 to the First Affiliated Hospital of China Medical University with leg pain and was unable to extend his knees. His injury occurred when he suddenly twisted his body. He had a known history of chronic kidney disease and had received regular haemodialysis in our hospital for 9 years.
The physical examination showed that both of his knees had massive suprapatellar swelling and that there was apparent depression of the soft tissue above the bilateral patella. Both knees were very soft and could touch the area over the suprapatellar region, and the patella could move freely over a larger range of motion than normal. Upon palpation, the continuity of the quadriceps tendons had defects. In addition, the patient could not complete knee extension adequately.
An X-ray of the knees showed that the superior pole of the patella moved downward, and there were calcified deposits in both quadriceps tendons. An MRI scan showed that the continuity of both quadriceps tendons was interrupted at the superior pole of the patella. The patient was diagnosed with bilateral quadriceps tendon rupture.
The patient underwent bilateral quadriceps tendon suture surgery under combined spinal and epidural anaesthesia (Fig. ). In the operating room, the patient was placed in the supine position. The surgical area was cleansed and draped, and the same operation was performed on both legs. A longitudinal incision of approximately 8 cm was made on each knee to expose the bilateral quadriceps tendon and the proximal patella. After the haemorrhage and blood clots were cleaned, complete rupture of the quadriceps tendon at the patella superior pole extending to the quadriceps muscle was observed, and the tissue stump appeared dark brown. The surface of the patella was smooth, with no residual tendon tissue attached. We used a spherical burr to roughen the upper pole of the patella after cleaning the inactivate quadriceps tendon tissue and implanted two anchors into the patella.

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 70-year old Caucasian woman who was referred to the thoracic oncology unit of our hospital for the management of a retrosternal mediastinal mass. She had been well 8 weeks before admission when she experienced the sudden onset of sharp left anterior chest pain. The pain was worse in the area adjacent to the sternum and also worsens when she takes a deep breath. In 1999, she underwent radical left side mastectomy followed by CEF (cyclophosphamide, epirubin and fluorouracil) chemotherapy and radiotherapy. The clinical and histological characteristics of the primary breast cancer revealed a Stage IIIa adenocarcinoma with positive axillary lymph node metastasis. Her estrogen receptor assay, as well as the amplification of the human epidermal growth factor receptor type 2 (HER 2/neu) was negative. Expression of her progesterone receptors was defined as low (Reiner score for staining of tumour-cell nuclei). On admission our patient's vital signs were normal. She had neither jugular venous distension nor cervical or supraclavicular lymphadenopathy. Her chest was clear on auscultation. There was no tenderness on palpation of her ribs or sternum. The remainder of her examination results was normal.
Computed tomography (CT) scanning and magnetic resonance imaging (MRI) of our patient's chest revealed a 74.2 × 37.7 × 133.6-mm mass in her anterior mediastinum adjacent to the main pulmonary artery, the right ventricle, and ascendens aorta contiguous to the pericardium (Figures and ). There was no specific direct evidence of vascular invasion but we raised the question of pericardial invasion. Our patient was vigorously scrutinized for metastatic disease, which included routine blood chemistries and the determination of lipid associated sialic acid, carcinoembryonic antigen (CEA) and CA 15-3 serum markers. CT scan of her neck and abdomen for restaging revealed no other foci of metastatic disease. A bone scan showed uptake only in her sternum.
Our patient w

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


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

[User]
RADIOLOGY NOTE:
We present a case of an 81-year-old female who had surgical fixation performed for a comminuted four part left intertrochanteric fracture 3 years previously at the same institution with an intramedullary device. After an initial uneventful post-operative recovery (), she returned 13 months post-fixation with groin pain, with radiographs confirming avascular necrosis of the femoral head with resultant cut-in of the blade (). Having failed initial conservative management and with worsening function and pain, the patient eventually opted for surgery.
Pre-operative computed tomography scan of the left hip was performed, revealing a healed intertrochanteric fracture without any peri-implant fractures, as well as flattening and deformity of the femoral head with degenerative changes in the hip joint suggestive of avascular necrosis. The patient was consented for removal of implants and total hip replacement and underwent the surgery 38 months post-index procedure.
Intraoperatively, difficulty was encountered during the removal of the distal interlocking screw. This was likely secondary to a divergent trajectory of the bolt resulting in cold welding to the screw to the intramedullary nail. Attempts were made at removal using vise grip pliers, which failed due to insufficient purchase on the screw head. Subsequently, the Synthes broken screw set was utilized to attempt screw removal, with conical extraction screws as well as extraction bolts. This was also unsuccessful. With every attempt at screw removal, the screw head became progressively more deformed, making subsequent removal increasingly difficult.
We then decided to use a different approach for the screw removal. A high-speed burr was used to burr around the screw, helping to “square” the circular screw head so as to achieve a better grip on the screw head with the extraction devices. With this, it was now possible to achieve adequate grip on the screw head with vise grip pliers, and the screw was then removed in en

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old woman with a past medical history of hypertension, scoliosis and depression presented with 1 week of flu-like symptoms (diffuse body aches, fatigue, and chills) and generalized weakness that rapidly progressed over several days in June 2018. Her social history is significant for living in a trailer in a wooded area in Florida, living in areas close to a mix of salt and river water, and exposure to mold, rats, and bat droppings near her home. On initial neurological examination, the patient was lethargic but oriented to person, place and time. She had impaired concentration and required occasional tactile or auditory stimulus to maintain attention. There were no cranial nerve deficits. Strength was 4/5 in the bilateral upper extremities and 3/5 in the bilateral lower extremities. There were no pathologic reflexes and sensation to light touch was intact in all extremities. The patient then had a rapid deterioration requiring intubation and mechanical ventilation. Serum laboratory results and serology testing throughout the hospital course are presented in –. Ceftriaxone, acyclovir, vancomycin, and ampicillin were started due to suspicion of meningitis based on the initial clinical presentation and serum testing. Computed Tomography (CT) angiogram of the head was unremarkable. Initial MRI Brain without contrast (hospital day 1) showed abnormally increased T2 FLAIR signal in the deep gray nuclei bilaterally, most prominent in the striatum (). Blood cultures were negative throughout her hospitalization. Cerebrospinal fluid (CSF) analysis was suggestive of meningitis and is presented in . Her CSF arboviral antibody panel is shown in and was initially unremarkable except for California encephalitis IgG 1:256.
Electroencephalogram (EEG) showed diffuse background slowing and rare left temporal sharp waves. On hospital day 4, neurological exam in the setting of pharmacologic sedation and mechanical ventilation was significant for a comatose state with absent bra

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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 64-year-old male patient consulted with the complaint of chronic cough, unresponsive to medication and lasting for more than four weeks, in July 2009. He had a history of smoking with one package a day for 30 years. In chest X-ray a large soft tissue mass centrally located in left lung was detected and thoracic computerized tomography (CT) revealed a left hilar mass in soft tissue density, surrounding left main bronchus and descending aorta. The mass was invading mediastinum with extension to subcarinal region. There were also multiple parenchymal nodules in both lungs and enlarged N2, N3 lymph nodes consistent with metastatic involvement. Histopathological findings after transbronchial biopsy revealed small cell lung cancer. Synchronously F 18 FDG PET/CT scan was done in order to identify any possible distant metastasis and complete the staging procedure. PET/CT study was performed using an integrated PET/CT scanner which consisted of a full-ring HI-REZ LSO PET and a 6-slice CT (Siemens Biograph 6, Chicago, USA). Patient was instructed to fast for at least 6 h before F 18 FDG injection. The patient was injected 555 MBq F 18 FDG. After 50 minutes of waiting in a semireclined relaxed chair, the patient was imaged using an integrated PET/CT scanner. The CT portion of the study was done without an iv contrast medium, just for defining anatomical landmarks and making attenuation correction on PET images. CT was acquired first with the following parameters: 50 mAs, 140 kV and 5-mm section thickness. Whole-body CT was performed in a craniocaudal direction. PET images were acquired on a 3D mode, from the base of the skull to the mid-thigh, with five to seven bed positions of 3 min each and PET data were collected in a caudocranial direction. The CT data were matched and fused with the PET data. Multiple metastatic lesions showing moderate to high F 18 FDG uptake in the spine, both

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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 52-year-old G4P3 female presented to the gynecology outpatient clinic with complaints of heavy irregular menstrual bleeding for several years and new right elbow pain and swelling. The patient denied any unintentional weight loss, lightheadedness, palpitation, shortness of breath, urinary symptoms, or difficult defecation. The pelvic exam demonstrated normal external genitalia with a large lower uterine-cervix mass. The physical examination was remarkable for an enlarged firm right supraclavicular lymph node. The right elbow appeared swollen with a severely compromised range of motion due to pain. The patient underwent an exam under anesthesia with a biopsy of the uterine mass.
Ultrasound of the pelvis () showed heterogeneous echotexture of the uterus with possible masses, a thickened endometrial stripe, and a vascular soft tissue lesion within the posterior wall of the urinary bladder. Computed tomography (CT) of the chest, abdomen, and pelvis () demonstrated a large heterogeneous mass centered within the uterus and cervix which involved more than 50% of the myometrium. There was local invasion to the urinary bladder, bilateral pelvic and retroperitoneal lymphadenopathy, and suspicious findings for a rectovaginal fistula. A right supraclavicular lymph node was found, and the patient underwent ultrasound-guided biopsy of the lymph node. A right elbow radiograph showed findings concerning an aggressive lytic lesion within the proximal ulna (). Magnetic resonance imaging (MRI) of the right elbow () confirmed an enhancing mass centered within the proximal ulna with soft tissue invasion.
The pathology report from the cervical biopsy () revealed infiltrating malignant high-grade carcinoma with areas of undifferentiated sarcomatous morphology, which was positive for vimentin. The mutation pattern studied by molecular pathology study suggested an endometrioid differentiation with ARID1A mutation and lack of p53 mutation. The aggressive behavior of the tumor and morpholog

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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 70-year-old male with known coronary artery disease and stable angina was admitted to our facility with a prolonged chest pain episode at rest, associated with dyspnea. His electrocardiogram revealed diffuse ST and T wave abnormalities indicative of ischemia and his plasma troponin I levels increased from 0.07 to 0.23 ng/mL. He was treated for non-ST-elevation myocardial infarction and underwent left heart catheterization. This revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease (). The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to proceed with high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device and temporary venous pacemaker support. Left femoral artery angiogram, accessed through a 45 mm Arrow sheath, revealed severely tortuous and calcified aorta, left external iliac and left common iliac artery. The left femoral access was pre-dilated and a 14-inch Impella sheath was introduced through the left common femoral artery. He developed groin pain at the access site with mild hypotension thought to be due to sedation given, including versed and fentanyl, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of Synergy (Boston Scientific) drug-eluting stents (). Following PCI, the patient suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle (LV) and right ventricle (RV) systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right in

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old woman visited our emergency room with severe dyspnea. Four months before, the patient had developed cardiogenic shock while attempting stent insertion (Endeavor 3.0~18®) into the obstructed left main coronary artery (80%), which necessitated urgent institution of extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump. After coming off extracorporeal life support systems, she underwent stenting (Taxus 2.75~38®) of the obstructive left anterior descending coronary artery (LAD), which resulted in second attack of cardiogenic shock and ECMO support, which was successfully weaned off. She had been discharged home after these events, and had been followed up in the outpatient department. On arrival at ER, her consciousness was clear, and chest x-ray showed pulmonary congestion. Electrocardiogram showed acute exacerbation of chronic myocardial infarction. On echocardiography, severe mitral regurgitation due to restricted valve motion was noted, and left ventricular ejection fraction was 28%. She developed the third attack of cardiogenic shock during emergency coronary angiogram, and was put on ECMO again (). Coronary angiogram on ECMO support showed restenosis of the previous LAD stent (80%) and complete obstruction of the left circumflex and right coronary arteries. We elected to perform emergency coronary artery bypass grafting and mitral valve replacement. After ECMO circuit was converted to conventional cardiopulmonary bypass using the same femoral artery-vein cannulae, a great saphenous vein graft was anastomosed to the LAD and an additional saphenous vein graft was placed from the LAD graft to the posterior descending coronary artery in an inverted-Y fashion. Operative findings of the mitral valve consisted of severe fibrotic change of the anterior leaflet, dilatation of the mitral valve annulus, and central non-coaptation. A bioprosthetic valve was placed while the native mitral valve leaflets were preserved. The patient was able to c

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old male patient was sent to the emergency department because of high fever (40°C) with chills and right upper abdominal colicky pain. He complained of nausea and had dark urine as well as jaundice. His medical history revealed a cholecystectomy 33 years earlier. Fifteen year before the current presentation he was diagnosed with stones in the common bile duct for which he underwent ERC, papillotomy, and stone extraction. He was without complaints until the current presentation. Laboratory results were consistent with cholestasis (Table ). Ultrasound imaging showed dilated intra- and extrahepatic ducts with the suggestion of stones in the common bile duct. Aerobilia was present, and sludge was seen in the hilar region. The patient was treated for ascending cholangitis with fluid resuscitation and intravenous antibiotics. An ERC was performed. The previous papillotomy was not visible anymore, hence a new one was done. Many stones were extracted from the common bile duct.
The patient recovered well. However, 3 months later he experienced recurrent complaints. Ultrasound showed retained stones in the common bile duct. In two ERC sessions all these stones were removed. Contrast cholangiography showed complete clearance of the bile ducts.
Over the next 4 months the patient experienced four episodes of chills with a temperature of 38–39°C and right upper abdominal complaints without colics. The laboratory findings during these episodes are shown Table . Repeated ultrasound investigations showed no abnormalities. The bile ducts were normal. On each occasion the patient received antibiotics, with excellent clinical response. Blood cultures remained negative.
Renewed medical history revealed that the patients had done heavy lifting work, such as moving furniture, the day before each of the four episodes. It was concluded that the repeated episodes of cholangitis resulted from influx of duodenal contents into the common bile duct due to heavy lifting in the presence

[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 17-year-old adult male was referred to our hospital with a tail-like appendage in the middle of lumbosacral region that was present since birth. He presented to us with a complaint of difficulty and slight pain while sitting. He also started having discomfort while doing daily activities such as wearing clothes due to this long tail. He was first child of healthy young mother and was born after normal full-term pregnancy with uncomplicated labor and delivery. He was delivered at home and no consultation was made with doctors even after tail-like structure was discovered. There is no family history of such appendages or any other congenital anomaly. The exact length of tail at birth is unknown, but according to mother, it was less than half the size of adult little finger.
On examination, the patient had no neurological deficit and bowel/bladder involvement. At sacrococcygeal area, exactly in midline, a straight 18-cm long tail was present covered with normal skin. There was no hyperpigmented patches or hypertrichosis along the entire spine. The tail had 2.7 cm × 1.7 cm diameter at the base and tapered toward the tip. It was soft in consistency. No movement of this appendage was observed [].
Computed tomography [] is suggestive of spina bifida at level of L5 and S3–S4. The tail was attached to trunk at S3–S4 level. The tip of coccyx was everted and had bony spur which was directed posteriorly toward base of the tail. Magnetic resonance imaging (MRI) scan [] is suggestive of midline discontinuity of posterior spinal elements and deep lumbosacral fascia near the attachment of tail. The conus is lying at L3 spinal level. There is no connection seen between tail and neural element; however, the fibrous band connecting tail to dura is visible.
The patient was operated under general anesthesia. At operation, an elliptical skin incision was made around base of append

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


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

[User]
RADIOLOGY NOTE:
An 86-year-old Caucasian male presented to our department complaining bilateral thigh pain and ambulatory disability. His only comorbidity was arterial hypertension, successfully treated with ACE inhibitors. He lacked any history of traumas. In 2005, the patient had developed a prostate cancer (PC) treated by radical prostatectomy and adjuvant radiotherapy without early complications. Ten years later, the patient came to our attention having already performed a computerized tomography (CT) scan at another health facility. The CT scan demonstrated an erosion of the pubic symphysis () associated with an inflammatory collection within the pelvic cavity, extending throughout the femoral triangles and within the layers of the abductor muscles of the thighs bilaterally. Lab tests were not significantly altered, with serum leukocytes of 9,030 cells/mm3 and C-reactive protein (CRP) of 11.9 mg/L.
The abscess of the left limb appeared to be small, deep and close to the femoral vessels, thus rendering its drainage dangerous, and in our opinion potentially counterproductive. Therefore, we decided to perform a surgical drainage of the sole right limb, whereas to treat the left conservatively at first. The drainage of the right abscess revealed an opalescent fluid in which various colonies of a pan-sensitive Candida albicans were isolated (fluconazole minimum inhibitory concentration: 0.5 mg/L). Therefore, the previously empirical antibiotic therapy with intravenous (IV) imipenem was stopped, and the patient was started on IV fluconazole (800 mg as loading dose and then 400 mg daily).
The early postoperative course was complicated by local infection of the surgical wound. Pseudomonas aeruginosa was isolated from a wound tissue sample, thus leading to the decision of starting adequate IV antibiotic therapy with ciprofloxacin and ceftazidime. On the 10th postoperative day (POD), a CT scan was performed to check the evolution of the local situation. The radiological images showed 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 18-year-old female with no personal or family history of interest had a right parotid mass with slow progressive growth over the past 18 months, and initially, it was asymptomatic. On physical examination, a soft, elastic, painless, fluctuating and nonpulsatile mass without trophic skin changes with 4 cm × 4 cm of maximum diameter. Cervical lymphadenopathy or other masses were not palpable. During her initial diagnostic approach outside our hospital, a fine-needle aspiration biopsy was made, reporting only hemorrhagic content and a computed axial tomography which reports an image suggestive of an arteriovenous malformation. With these findings, an angiography for diagnosis and therapeutic purpose was performed, and a hemangioma of the parotid gland that depends on the right internal maxillary artery and the right facial artery was diagnosed but was not suitable for embolization attempts due to technical difficulties. The patient was prepared for surgery [].
The patient was led to the operation room for a parotidectomy through facelift incision; patient in dorsal decubitus, with neck hyperextension (Rosier position), neck projected preauricular incision (Lahey) is made for parotid exposure and progressive layer dissection until parotid pseudocapsule is reached. Skin flap is made for complete exposure of the gland deformed by the tumor of 4 cm long on the upper lobe and hemangioma. Dissection of platysma and anterior border of sternocleidomastoid muscle is done to identify thyrolinguofacial trunk, detecting inflammatory adenopathy overlying the internal jugular vein, posterior approach of vascular package of the neck with resection of cervical ganglia in level 2 and 3, allowing the exposition of the primitive carotid artery, continuing its dissection, exposing its bifurcation, and identification of the superior thyroid branch, and the ligation of the external carotid artery is made above this point with silk 1-0 []. We continued the dissection of the sternocleidomas

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


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

[User]
RADIOLOGY NOTE:
A 70 year old lady was referred urgently to the colorectal clinic with a palpable abdominal mass. She presented to her General Practitioner (GP) with left sided abdominal pain, diarrhoea and weight loss. Her GP found a suspicious left sided abdominal mass on examination and referred her urgently under the two week colorectal cancer rule. Her past medical history included hypertension, chronic obstructive airways disease and appendicectomy. She also had a previous total abdominal hysterectomy and bilateral salpingo-oopherectomy for large uterine fibroids.
On examination in the outpatient clinic a 10 × 7 cm firm, fixed lump was found in the left iliac fossa area of the abdomen. Urgent colonoscopic examination revealed mild sigmoid diverticular disease with no evidence of colonic malignancy. Computer Tomography was preformed (Figure ) and showed the mass to be arising from the anterior abdominal wall muscles, in particular the internal oblique and transversus abdominis. There was no evidence of distant metastatic disease to the liver or lungs. The clinical suspicion was of a malignant abdominal wall sarcoma. Fine needle aspiration or percutaneous biopsy was not performed. En-bloc surgical resection of the tumour was performed via a left flank incision (Figure ). At surgical resection the tumour mass involved the internal oblique, transversus abdominis and there was a small area of peritoneal ulceration. No distant disease was found at surgery. The tumour was excised en-bloc with a surrounding margin of healthy tissue (Figure ). Part of the external oblique aponeurosis was preserved to allow adequate closure. The large abdominal wall defect was closed using a sheet of Permacol® mesh (Tissue Science Laboratories plc, Hampshire, England). The Permacol® mesh was sutured to the posterior leaf of the rectus sheath medially and the internal oblique laterally using a slow absorbing polydioxanone suture. The remaining external oblique muscle was closed over the mesh and the sub

[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:
ML is a 52-year-old male who presents to our clinic complaining of severe left anterolateral arm pain after being involved in a motor vehicle accident 10 years prior to presentation. At that time, he had suffered a left mid-shaft humerus fracture treated with open reduction and internal fixation, as well as a traumatic brain injury and multiple other injuries to the right lower extremity resulting in the below-knee amputation. For the last several years he has had severe pain in the anterolateral aspect of the left arm, but denies any weakness or parasthesias. On physical examination, he demonstrates localized tenderness to palpation along the anterolateral aspect of the mid-humerus ~8–10 cm proximal to the lateral epicondyle. The patient had full motor function, though somewhat limited by pain, and sensation was intact to light touch throughout the radial nerve distribution. Plain films (Fig. ) and CT-imaging (Fig. ) show a healed fracture with acceptable alignment and hardware in good position. The patient elected to undergo lidocaine injection at the site of maximal tenderness, which gave excellent, albeit temporary pain relief, for about a week. Electrodiagnostic studies obtained at that time revealed chronic radial nerve neuropathy above the spiral groove.
Surgical risks, benefits and alternatives were discussed and the patient elected to proceed with left radial nerve neurolysis and decompression. An anterolateral approach to the humerus was utilized with the incision centered over the point of maximal tenderness. Dissection was carried down to the biceps, which was retracted medially. The fascia over the brachialis and brachioradialis was then incised and the plane between these two muscles was bluntly developed with finger dissection. The radial nerve was then identified in the distal portion of our field and traced proximally to the lateral intermuscular septum. Significant compression of the radial nerve was noted proximally as it pierced the lateral inter

[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 39-year-old man was involved in a high-velocity motor vehicle accident. He sustained an open fracture of the right elbow, with significant loss of the external humeral condyle and partial loss of the olecranon. This fracture was classified as a Gustillo type IIIA injury. There was no neurovascular compromise. The patient was treated in a community center, close to the accident, where he received surgical care (debridement and partial excision of the olecranon). The wound was fully closed. The upper arm was then immobilized in a splint (). IV antibiotics (cefazolin-gentamicin) were started for 5 days.
The day following his elbow surgery, the patient fell in a staircase and sustained a C7-C8 and C8-T1 fracture-dislocation. This injury caused neurologic damage (quadriparesis), and his right arm became his only functional limb. Following this injury, the patient was moved to our tertiary center to get spinal fusion. During the spinal surgery, the elbow was tested under fluoroscopy. The patient's elbow showed varus instability and a positive pivot shift test. A CT scan of the elbow was obtained the following day and showed bony loss from the external humeral condyle and subluxation of the radial head ().
We decided to treat the patient's elbow surgically. The surgery underwent nine days after the initial trauma (after transfer from the community center, spine procedure and elbow imaging). A posterior approach to the elbow was used along with an extensive elbow debridement. A tricortical iliac crest graft was then collected from the patient's right side to replace the humeral condyle bone loss. A tendinous graft was collected from his third and fourth extensor digitorum longus tendons to reconstruct the lateral collateral ligament. The tendinous graft was fixed to the bone graft through two tunnels (anterior to posterior and lateral to medial). The iliac crest graft was then fixed to the humerus with a cancellous screw. A five-

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female, gravida 1, and para 0 at 31 weeks of gestation was transferred to our cardiothoracic intensive care unit (CTICU) for further management of her aortic valve endocarditis. Her past medical history included intravenous drug use (currently on methadone maintenance), hepatitis C discovered during this pregnancy, bipolar disorder, and depression with multiple prior suicide attempts. Of note, the patient also had a root canal two weeks prior and was started on ampicillin for a dental abscess.
She initially presented to an outside hospital one week earlier with severe right thigh and groin pain, which had progressed to the point of inhibiting ambulation. A right lower extremity Doppler study revealed an occlusive thrombus in the deep femoral artery. She was started on therapeutic enoxaparin and transferred to a second hospital, where a transthoracic echocardiogram (TTE) revealed large vegetative lesions on all 3 leaflets of the aortic valve, including a mobile vegetation measuring 0.8-1-cm on the ventricular side of the valve (Figures
–). Mild to moderate aortic insufficiency was present. Blood cultures grew yeast but had not yet speciated upon transfer to our hospital. Amphotericin B was initiated and, after an initial infusion reaction, she was able to tolerate subsequent doses with premedication. Micafungin was added until speciation of the yeast was final. She remained hemodynamically stable requiring no inotropic or pressor support.
Anticoagulation was withheld despite her thrombus due to concern for cerebral embolic infarction and risk of hemorrhagic conversion in the setting of mobile aortic endocarditis. A magnetic resonance angiogram (MRA) of the brain was obtained to rule out a mycotic aneurysm, given that her endocarditis was known to be fungal in nature. The MRA showed a 2.2 mm aneurysm of the anterior communicating artery. An ophthalmologic exam was negative for fungal endophthalmitis. She received betamethasone and magnesium sulfate for

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old Korean man with hypertension and a history of appendectomy presented with perianal pruritus and a rash. He was treated with topical and oral medications at a local dermatologic clinic for a year, but his clinical symptoms did not improve. He visited Severance Hospital and underwent a perianal skin biopsy, and was finally diagnosed with EMPD. The 6.5 cm2 × 8 cm2-sized skin lesion was oval shaped and located from under the coccygeal area to the perineal body. The lesion abutted the anoderm 1 cm from the anal verge, but had not invaded the penis, testes, or both thighs. Abdomino-pelvic computed tomography and rectal magnetic resonance imaging were performed to evaluate preoperative staging and to detect other diseases. They showed no abnormalities, including no regional and inguinal lymph-node enlargement. A colonoscopy showed no intraluminal abnormalities. Thus, the authors decided to perform a wide local excision and to make flaps for the large area of skin and the soft tissue defects.
The patient received a bowel preparation with polyethylene glycol one day before surgery because of the possibility of conversion to an abdominoperineal excision. He was placed in a jack-knife position on the table (). Surgical margins 1 cm around the main lesion were demarcated based on a preoperative multiple-punch biopsy at eight locations which were all proven to be basal pigmentation or eczematous change. A wide local excision was performed (). The size of the lesion was 6.5 cm2 × 8 cm2. However, we carefully resected the lesion over the demarcation because the patient was too old to tolerate the time required for the frozen biopsy to confirm the proper margins. As a result, the final size of the specimen was 9 cm × 14 cm (). For the skin and the soft tissue defects, bilateral inferior gluteal artery perforator flap transpositions were performed (). Two closed suction drains were inserted at both flap sites

[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 male was admitted to hospital emergency due to 4 h of chest pain in 13 January 2016. In fact, he had suffered from fatigue after activity for more than 10 days and felt chest tightness and chest pain for 4 days before admission. The patient, a taekwondo trainee, had a healthy body, and his family history was unremarkable. Emergency aortic computed tomographic (CT) scan showed a thickened aortic wall, bilateral pleural effusion and pericardial effusion (Figs. a and b). Cardiac colour ultrasound suggested aortic hematoma or dissection (Fig. ). On the basis of the condition and the results of auxiliary examination, the formation of aortic dissection should be considered. The next day, after excluding surgical contraindications, the patient was performed an emergency operation. Cardiac surgeons underwent ascending aortic replacement and aortic arch replacement. They developed postoperative comprehensive treatment measures, including anti-infection, adjustment of cardiac function, nutritional nerve and symptomatic supportive treatment, and the patient recovered well and was discharged after 15 days. The cause of aortic dissection was unclear, although the surgeons extracted arterial tissues and pericardial tissues and sent them for pathological examination. In fact, postoperative pathology of the aortic wall tissue showed aortitis, such as visible necrosis, granulation tissue hyperplasia and a large number of acute and chronic inflammatory cell infiltration (Figs. b, c and d). However, the surgeons and the pathologist at the time did not consider the cause of aortitis or aortic dissection due to GPA because of a lack of understanding of GPA-induced aortitis or aortic dissection. This event is one of the starting points of our study. We want to attract the attention of clinicians. GPA is also a common cause of aortitis and even aortic dissection.
On the first day of 2017, the patient was re-examined for aortic CT because of a 6-day fever and right chest pain

[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 71-year-old man was referred to our department with a diagnosis of squamous cell carcinoma of the lung, clinical stage IA. Computed tomography showed a pulmonary tumor 2 cm in diameter in the left lower lobe and a right aortic arch (Figure
, A and B). Three-dimensional chest computed tomography revealed that three arteries originated from the ascending aorta in order of the left common carotid artery, the right common carotid artery, and the right subclavian artery (Figure
, C). Moreover, it showed that the left subclavian artery branched from the descending aorta and that the origin of the left subclavian artery had dilated into a cystic form, known as a Kommerell diverticulum (Figure
, D). There were no abnormalities of the pulmonary arteries, veins, or bronchi (Figure
, E). The lengths of the left and right bronchi were 4.8 and 1.2 cm, respectively. It is normal size for adult male. The anatomy of the brachiocephalic veins and the superior vena cava was normal. They located anterior to the trachea and posterior to the ascending aorta. The azygos vein drained into the superior vena cava as usual. Echocardiography revealed no cardiac abnormalities.
The patient underwent a VATS left lower lobectomy and mediastinal lymph node dissection. All procedures were performed with 3-cm anterior and 2-cm posterior access ports in the 5th and 6th intercostal spaces without rib splitting. There was no aortic arch or descending aorta in the left thoracic cavity, but the esophagus. There was no anomaly in the location and branching of the pulmonary arteries, veins, bronchi, and the lobulation of the lungs. A left lower lobectomy was performed in the usual manner. The upper mediastinal lymph node dissection followed the lower mediastinal dissection. First, we identified the vagus nerve at the level of the left pulmonary artery. When we proceeded with the dissection in the cranial direction, the arterial ligament was found between the left subclavian artery and the left

[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 12-year-old boy presented with painful swelling on his left thigh after being kicked by his friend. Plain radiography revealed a concentric cystic lesion with cortical thinning and ballooning in the mid-portion of the femoral shaft accompanied by a pathologic fracture (). The cystic lesion was extensile without a periosteal reaction. The patient underwent curettage of the cystic bone lesion and autogenous bone grafting, followed by open reduction and internal fixation for the pathologic fracture (). Intraoperative biopsy revealed a unicameral bone cyst () and, therefore, it was decided to continue close observation of this case without any further intervention. Two years after surgery, plate removal was performed based on radiographic evidence of complete healing of the cystic bone lesion (). Although 1.5 cm femoral shortening was initially noted after surgery, the leg length discrepancy appeared to have increased with age. Therefore, the patient was scheduled for annual follow-up until skeletal maturity. At the age of 19 years, no recurrence of the cyst was seen on plain radiographs of the femur (), and the final leg length discrepancy was 3.5 cm (). The patient complained of abnormal gait and posture resulting from the 3.5 cm discrepancy, for which lengthening of the shortened femur was planned in the near future.
At the age of 20 years, 8 years after the initial surgery, the patient complained of pain in the left thigh. A review of his plain radiographs revealed an impending pathologic fracture caused by a recurrent simple bone cyst in the left femur (). Magnetic resonance imaging (MRI) scan demonstrated a 6.6 cm × 3 cm × 3 cm-sized, well-defined cystic lesion in the left distal femur (). Comparison of the radiographs and MRI findings revealed the presence of a linear pathologic fracture accompanied by a periosteal reaction. For treatment of the fracture, curettage and autogenous bone grafting combined with internal fixation using an intramedullary nail () 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 24-year-old healthy male was referred under the suspicion of an inguinal hernia. He was seen at our emergency department with a palpable mass in the lower right abdominal quadrant, which he first noticed 5 days earlier. He had no abdominal pain or symptoms of intestinal obstruction. During physical examination, a non-tender mass was felt which did not increase with the Valsalva maneuver. Sonography revealed a mass of 10.4 × 6.6 cm2. A computed tomography was done for further analysis, and showed an intra-abdominal located pear-shaped mass of 9.5 × 7.1 × 9.1 cm3 along the right ureter and surrounded by small intestines, without invasion of abdominal structures (Figs and ). It further revealed a congenital malrotation of the small intestine. The differential diagnosis included sarcoma, lymphoma and DTF. A sonography-guided biopsy was performed, and pathological examination confirmed DTF with positive beta-catenin nuclear enhancement. Additional analysis were negative for hormonal receptors. Family history, as well as colonoscopy, were negative for colon polyps. The patient was therefore diagnosed with a sporadic form of DTF. A watchful waiting approach was initiated, as the tumor was asymptomatic and surgery would probably imply significant intestinal resection.
Sonography after three months showed a reduction in size to 9.4 × 5.4 cm2. On request of the patient, who was anxious of having a tumor which was treated conservatively, a second opinion was performed at an University Medical Center. They acknowledged the conservative approach and advised follow up with magnetic resonance imaging (MRI) 1 year after diagnosis. This MRI showed regression of the tumor with a small residue of 2.2 × 1.2 × 1.9 cm2 (Figs and ) along the right ureter and a minimal hydronephrosis of the right kidney without loss of renal function. A second MRI 6 months later and a third MRI 1 year later showed persisted regression without hydronephrosis. Both scans showed no other masses. The patient

[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 woman visited our hospital with a palpable left neck mass in April 2010. Her medical history showed that she had been diagnosed with left breast cancer (cT2N0M0) in December 2004, and she underwent modified radical mastectomy of the left breast in our hospital. An histopathological examination showed invasive ductal carcinoma with nuclear grade 2, and the absence of axillary lymph node metastases. Immunohistochemistry studies showed positive staining for ER and PR and negative staining for HER2 (score 0). She received five cycles of adjuvant CMF chemotherapy followed by tamoxifen (20 mg daily) for 2 years. She then on her own authority stopped taking tamoxifen and ceased regular surveillance.
We performed CT scans of the neck and breast, bone scan, and PET/CT. CT scans showed multiple enlarged lymph nodes in the left axillary region and the left lower cervical chain, and PET/CT showed multiple conglomerated enlarged lymph nodes with high FDG uptake (SUVmax, 7.02) in the left axillary, retropectoral, subclavian, internal mammary, and cervical lymph nodes. There were no metastatic sites except the lymph nodes. A core needle biopsy of the left axillary lymph node was performed, and pathological examination revealed metastatic adenocarcinoma, which was positive for ER, negative for PR, and equivocal for HER2 (score 2). She was postmenopausal based on the serum follicle-stimulating hormone level, and she started receiving the nonsteroidal aromatase inhibitor letrozole in May 2010. She also received radiotherapy to her left chest wall and regional lymphatics including the cervical chain (total dose, 5,040 cGy) between August 18 and September 30, 2010. Follow-up CT scans showed a complete regression of the previously invaded lymph nodes in November 2010.
About 10 months later, she complained of a mild throbbing pain in the right buttock area that was aggravated by walking. On physical examination, there was no palpable mass and tenderness in the buttock area.

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old Caucasian right hand dominant man presented with a 10-year history of a progressively enlarging and mildly tender mass over the bony olecranon of his right elbow. He had initially noted the mass without any previous trauma or pain, and felt the mass was relatively stable in size. During one acute episode after a fall about three years prior to presentation, the mass had seemed to become larger and more bothersome, but was not investigated further. Over the past two years, the mass had been somewhat variable in size, but continued to enlarge slowly. More recently, it had also become mildly tender and particularly uncomfortable when the elbow was placed on a table or desk. He did not have a history of gout or inflammatory arthropathy.
No imaging studies were obtained. Our patient's family doctor made the diagnosis of chronic olecranon bursitis. Two corticosteroid injections were attempted without any change in symptoms. Eventually, a referral was made to an orthopedic elbow surgeon. The first examination by the surgeon revealed a vague mass over the olecranon, measuring approximately 3 × 3 cm. There were no skin changes, and no excessive warmth or erythema to suggest infection. A neurovascular examination demonstrated some decreased sensation to pinprick over the dorsal first web space of the affected hand, with full motor power in the distribution of all major nerves including the radial and posterior interosseous nerves. No other sensory deficits were identified.
Our patient chose to continue observing the mass. At a follow-up appointment about six months later, the decision was made to proceed with surgical treatment with excision of the olecranon bursa for presumed chronic aseptic olecranon bursitis. At that time, the sensory deficit in the hand had almost completely resolved. No further imaging or investigation were pursued.
At the time of surgery, a standard posterior approach to the olecranon bursa was employed. Upon dissection through the subcuta

[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 Caucasian female with a BMI of 35 kg/m2 from Egypt, with no past medical history of clinical significance presented to the outpatient clinic one month after a normal delivery with severe headache and blurring of vision. Fundus examination showed evidence of bilateral papilledema, brain CT scan was normal and the patient was diagnosed with benign intracranial hypertension. She underwent therapeutic CSF aspiration and was maintained on carbamazepine and acetazolamide to decrease intracranial pressure.
After 5 days of carbamazepine therapy the patient started to complain of generalized skin eruptions in the form of irregularly shaped macules distributed on the face, trunk, upper and lower limbs as illustrated in figure . This was followed by grayish discoloration and mottling of the skin and mucous membranes. Mucosal involvement was noticed in the form of conjunctival injection and oral lesions.
The patient was admitted to the Intensive Care Unit with high fever, extensive skin sloughing, clinical evidence of dehydration and severe pain mandating continuous morphine infusion. Skin lesions showed a positive Nikolsky sign and ophthalmological examination revealed bilateral conjunctivitis. Initial workup revealed clinical and laboratory evidence of sepsis in the form of hypotension, leukocytosis, elevated Erythrocyte sedimentation rate, metabolic acidosis, high serum lactate level and otherwise normal biochemical profile. Skin lesions were pathognomonic of Toxic Epidermal Necrolysis (TEN) with more than 30% skin involvement. Detailed history taking revealed the recent introduction of carbamazepine therapy for treatment of pseudotumour cerebri. Drug induced TEN was suspected and carbamazepine was withdrawn.
The patient was managed with Lactated ringer solution together with the use of sterile skin dressings to reduce pain and risk of infection. The patient was started on immunosuppressant therapy in the form of cyclophosphamide. Blood and skin cultures were 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 68-year-old female presented to the emergency room with complaint of gross hematuria, intermittent right-sided flank pain, and forgotten right ureteral double J stent. A CT scan showed an enhancing 7 cm solid pelvic mass displacing the bladder and rectum ().
She had a history of T3N0 rectal cancer status post low anterior resection with diverting colostomy followed by adjuvant chemotherapy in August 2006. Two years later, she developed pulmonary metastases. Early in 2007 she underwent right ureteral stent placement for hydronephrosis at an outside hospital. Her followup was interrupted due to her moving between two different parts of the country and between several hospitals.
She was seen at our institution in September 2007 for small bowel obstruction that required abdominal exploration, lyses of adhesions, and small bowel resection with primary anastomosis. Final pathology revealed no carcinoma. Later that year she had progression of her pulmonary metastasis and was started on additional chemotherapy. In February 2008, she developed a small right-sided extraperitoneal bladder perforation with a possible small colovesical fistula. At this time she denied any trauma, recent surgery, pneumaturia, or fecaluria. Cystoscopy and biopsy were negative. Her fistula was managed with catheter drainage alone and at 3 months a cystogram showed complete healing.
On this hospital admission at initial evaluation, given her active hematuria and pelvic mass she was taken to the operating room for cystoscopy, possible transurethral resection of tumor, control of bleeding, and possible removal of retained stent. Given the length of time the stent was indwelling, the stent was likely encrusted and would require more invasive maneuvers to remove. Given that her main problem was hematuria from an apparent pelvic mass, the likely encrusted and retained stent was a secondary objective at the time of surgery.
On cystoscopic exam, her bladder showed no lesions or tumors. There was an old 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 21-year-old, gravid 1 woman with term pregnancy attended an academic hospital with labor pain. She had two prenatal care visits in the first and second trimester with normal appearance and did not have any appointment with obstetricians in the third trimester due to COVID-19 pandemics. She experienced mild episodes of dyspnea during the third trimester of pregnancy that did not consider important for her to seek consultation. Her pulse rate was 88 beats per minute with a respiratory rate of 14 per minute, blood pressure 132/88 mmHg, and oral temperature 37.5° centigrade. She had no dyspnea. In cardiovascular exam, the heart sound was normal and the lung was clear. The O2 saturation was 97%. On vaginal examination, cervical dilatation was 3 cm with effacement 50%; cephalic presentation, and intact amniotic membrane. The fetal heart rate was 140 beats per minute. The patient was admitted to the labor unit due to the regular uterine contractions. In general appearance, she looked good with no apparent distress.
According to the patient's biography, this was her first pregnancy. She denied a history of any disease or surgery except a subtle common cold about 2 weeks ago. Her family history was non-significant. She did not take any medications other than iron and multivitamin supplements. Labor progressed without any problems and after about 8 h she delivered a full‑term girl with the Apgar score of 9 and 10 in the first and the fifth minute, respectively.
The third stage of the labor between deliveries of the newborn until the placenta last about 10 min without abnormal hemorrhage. For PPH prophylaxis 30 IU of IV Oxytocin in 500 ml NaCl 0.9% was administered in this stage. After delivering the placenta, she experienced an onset of uterine atonia and postpartum hemorrhage (about 700 ml) that was controlled with intravenous oxytocin and uterine massage. After the second episode of bleeding (about 550 ml) in 15 min, because of deteriorating hemodynamics despite intraveno

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old lady presented with sudden onset lower abdominal pain. She had a single episode of vomiting. There was no significant past medical history except for mild intermittent abdominal discomfort. She was married with two children and her last menstrual period was three weeks ago. She was afebrile with systolic blood pressure of 120 mmHg and heart rate of 113 beats per minute. She appeared pale and lethargic. Her abdomen revealed generalised tenderness with guarding over the suprapubic region. A bedside ultrasound revealed free fluid in the abdomen. Blood tests revealed a hemoglobin level of 5.5 g/dl with a normal platelet count, renal function, liver function, amylase and coagulation screen. Her serum human chorionic gonadotropin (hCG) level was 508,017 mIU/ml.
In view of the anemia, tachycardia, abdominal pain, free fluid and raised β-hCG, a ruptured ectopic pregnancy was suspected and an emergency diagnostic laparoscopy with evacuation of the uterus was planned. Intraoperatively, hemoperitoneum and a bleeding left corpus luteum cyst were evident. There was no ectopic pregnancy. Bilateral fallopian tubes appeared normal but were ligated as per the patient's request. The uterus was evacuated and had minimal tissue. Postoperatively, her hemodynamic parameters did not return to normal, and hence, a computed tomography (CT) scan of the thorax, abdomen and pelvis was performed. It showed subcapsular lesions in the spleen with intraperitoneal rupture and hemoperitoneum. CT scan also revealed metastatic nodules in both lungs and liver. Pulmonary embolism was also noted in the right anterior segmental pulmonary artery. An emergency laparoscopic splenectomy was performed (). Histology confirmed splenic metastases secondary to choriocarcinoma (). The tumour infiltrated through the splenic capsule, and immunohistochemistry showed positive stains for cytokeratin (AE1/AE3), hCG and human placental lactogen.
Postoperative day 1 and day 3 drain amylase levels were normal

[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 61-year-old man presented with a painful mass overlying the lower left scapula of four months duration. His pain deteriorated the last three weeks and was accompanied by limitation of the range of motion of the left glenohumeral joint.
Physical examination revealed a subcutaneous tender uniformly firm mass in the lower left scapular region measuring 4.5 × 4.5 cm in diameter. There were no signs of superficial skin inflammation. The patient had not a previous history of melanoma and/or other skin tumors.
Radiological examination showed an osteolytic lesion in the lower left scapula while bone scanning was positive with increased uptake in the same area. CT scans and MRI images of the thorax and shoulder showed a soft tissue mass 45 × 45 mm localized in the lower scapular region between infraspinatus and teres minor muscles with bone invasion of the lower part of the scapula (Figure , , ). There were no lung metastases neither axillary nor mediastinal lymph nodes.
The open biopsy specimen consisted of a rubbery, homogenous, white tissue with no attachment to the skin, implying deep location of the tumor. There were compact nests and fascicles with large rounded and spindle-shaped cells separated by connective tissue septa. The large rounded cells had pleomorphic nuclei and large amounts of clear cytoplasm while the spindle-shaped cells had palely staining eosinophilic cytoplasm. Mitoses were moderately numerous. There were areas of necrosis and hemorrhage and tumor spreading into the surrounding muscles and scapula. Immunohistochemical stains were performed with negative staining for CD68, actin and desmin antigens and with positive staining for tumor markers S-100 protein, HMB-45, NSE, EMA, cytokeratins and myosin. Histochemical stains for melanin presence were negative. Pathologic findings were compatible with a CCSTA with osseous extension into the lower scapula (Figure , ).
After three days a wide excision was carried out and the tumor was removed together 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 43-year-old woman was diagnosed with cancer in the right breast during health screening. Magnetic resonance imaging (MRI) showed a 70 × 40 × 36-mm non-mass-like enhancement from the exterior of the right breast to the nipple region. Ductal carcinoma in situ (DCIS) was diagnosed on core needle biopsy; thus, mastectomy was considered necessary. As the patient desired to undergo immediate breast reconstruction, she was referred to our department. She underwent nipple-sparing mastectomy (NSM), sentinel node biopsy (SNB) performed by a breast surgeon and breast reconstruction with a de-epithelialized DIEP flap using thoracodorsal vessels as recipient vessels performed by a plastic surgeon (). The cancer was pathologically diagnosed as DCIS. Postoperative hormone therapy was continued at a nearby medical facility. At an outpatient visit three years and eight months after surgery, a tumor measuring 5 mm was detected by palpation at the lower right region of the right breast and a tumor shadow was identified on ultrasound. Fine-needle aspiration cytology indicated the possibility of C4 local recurrence. Thus, we performed enucleation of the lesion, and a subsequent pathological examination confirmed that the tumor was invasive ductal carcinoma (IDC) with the ductal spread. In addition to the enucleated tumor, a contrast-enhanced lesion extended from the upper exterior area to just below the nipple on MRI. The patient was diagnosed with multiple cancer recurrences in the reconstructed breast. As the patient desired to undergo autologous breast reconstruction again, extensive extirpation of the nipple-areola, breast skin including the buried DIEP flap and initial breast reconstruction with an anatomical tissue expander (TE) were performed at another hospital (). We did not give an irradiation to the breast in this case because surgical margins were free from cancer by the intensive pathological examination with 5-mm serial sectioning on the surgical specimen. At one year an

[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 one-year-old boy with no known medical illnesses had bilateral postauricular swelling for five days, which was noticed by his parents in early March 2018. They initially sought medical help at the local hospital. A CT image showed a destructive soft tissue lesion in both the mastoid area and the petrous part of the temporal bone, causing narrowing of the ear canal.
The case was referred to a tertiary care center. Upon presentation to a tertiary care ENT clinic, the child's history was taken, revealing a healthy, full-term child of normal vaginal delivery with no health-related issues, except for the postauricular swelling in the absence of any other ear or vestibular symptoms. Perinatal and family histories were unremarkable.
Upon examination, he was found to be an alert and active child with no facial dysmorphic features. There was a bilateral swelling in the postauricular area, which was more prominent on the right side, with no tenderness or discharge. The ear canal was almost blocked; however, no discharge or any other swelling was seen. The rest of the ENT examination, including cranial nerves and flexible scope, was unremarkable.
The CT scan showed bilateral bony destructive lesions in the temporal bone area, which was larger on the right side, with a soft tissue component and intracranial extensions involving the external and internal ear cavities. An MRI of the temporal bone showed heterogeneous enhancement of the lesion bilaterally (Figure ). A positron emission tomography (PET) scan was performed to detect any other foci of the disease, and it showed a fluorodeoxyglucose (FDG)-avid bilateral temporal bone lesion with cervical lymphadenopathy and spleen involvement/reactive.
After confirming the location and characteristics of the mass, the patient was taken for a mastoid lesion incisional biopsy under general anesthesia. A biopsy of the right mastoid showed the proliferation of Langerhans cells in a dense eosinophilic infiltrate (Figure ). Immunohistoche

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old male patient presented with a painless tumor of the right cheek, located below and laterally to the right zygomatic bone. The mass had existed for at least six months and was slowly increasing in size. Hypertension, diabetes, hyperuricemia, and hypercholesterolemia were mentioned in the medical history. No previous significant pathology or surgery was reported in the head and neck area. Computed and magnetic tomography, with 1.25 mm thickness cuts in the transverse plane and with image reconstruction cuts of 1.25 and 2.5 mm in coronal and sagittal planes, respectively, revealed a lesion of 1.64 cm × 4.8 cm in dimensions which occupied the right buccal space, originating from the right major zygomaticus muscle, and extending to the right anterior part of the parotid gland (Figures and ). There was homogeneity in composition with a distinguishable contrast intake in comparison with the healthy side and discrete vessels throughout the circumference of the lesion. The tumor had smooth outlined limits with projections in the anterior area of the right parotid gland and the lateral portion of the masseter muscle. A malignant lesion in the buccal space could not be excluded from the differential diagnosis. However, the characteristics of the lesion were not exactly compatible with typical malignancies of the area, including salivary gland carcinoma and lymphoma. Blood tests did not reveal any specific findings, with white blood test count on the lower normal levels. The patient did not present any B-type symptoms or showed any signs of localized lymphadenopathy. FNA biopsy was performed, retrieving numerous lymphocytes and nonspecific atypical cells, and was characterized as nondiagnostic (). The patient refused to undergo a second FNA biopsy. The decision for excision under general anesthesia was then taken as the possibility of a malignant lesion could not be excluded. The patient underwent resection through a modified parotidectomy incision (Figures –). 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 67-year-old female presented with three months of hoarseness and dysphagia following an upper respiratory infection. Her past medical history included invasive ductal carcinoma of the breast (ER positive, PR negative, and HER2 negative) treated by mastectomy two years prior to presentation. On clinical examination, she was found to have paralysis of the right vocal cord, and a follow-up CT scan of the neck revealed an enlarged thyroid gland with multiple bilateral thyroid nodules. FNA of a right-sided 3.5 cm thyroid nodule was diagnosed as atypia of undetermined significance (Bethesda category III). A repeat FNA three months later yielded a diagnosis of benign follicular nodule (Bethesda category II). Persistent hoarseness and compressive symptoms, combined with atypical findings on the initial FNA, necessitated right thyroid lobectomy and right vocal cord injection. Intraoperatively, the right thyroid lobe was noted to be moderately enlarged with multiple nodules but no evidence of extrathyroidal extension.
The right lobectomy specimen measured 4.6 cm in greatest dimension and weighed 16 grams. The cut surfaces of the thyroid parenchyma showed multiple variably sized brown gelatinous nodules, with focal areas of hemorrhage and cystic change.
Histologic examination revealed evidence of nodular thyroid hyperplasia, along with multiple scattered subcentimeter foci of metastatic breast carcinoma, which were present in 7 out of the 16 submitted tissue sections. Most of the smaller metastatic foci, measuring around 1 millimeter each, consisted of a few irregularly shaped nests of epithelioid tumor cells interspersed between thyroid follicles (). The largest metastatic focus measured 0.6 cm and was comprised of tumor cell nests arranged along the periphery of a sclerotic stroma containing cords of tumor cells showing retraction artifact (Figures –). These areas resembled the dense amyloid-type stroma often seen in medullary thyroid carcinoma (MTC). Additionally, there w

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