[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-month-old male was admitted to our Department of Gastroenterology because of a more than one-year history of abdominal distension with anaemia. His symptoms of abdominal distension was obvious after eating and improved slightly after defecation and flatulence. Meanwhile, the patient’s stool appeared yellow and loose with visible food residue and was voided twice to four times a day.
In the past, the patient was once admitted to the local hospital with cervical lymphadenectasis and mild anaemia. At that time, he received oral iron treatment at home, but his abdominal distension showed no remission. The patient’s first admission to our hospital was due to recurrent fever for over half a year in May 2018, and he was diagnosed as bronchopneumonia with pleural effusion and liver and cardiac damage according to the examination results. The patient was born through a full-term natural delivery and showed no abnormalities in the perinatal period. He had repetitive respiratory tract infections, and fever always occurred after vaccination. Perianal abscess resection was performed at the ages of 6 months and 8 months. His parents and sister were healthy.
Physical examination indicated that the patient’s weight was 10 kg (z score: − 1.55), and his height was 80 cm (z score: − 2.05). Hardened, enlarged lymph nodes were found on the neck and bilateral sides of the groins. Abdominal distention extended from the xiphoid to the bilateral sides of the groins where the vena epigastrica was exposed. The patient’s abdominal circumference was 50.5 cm. The soft liver and spleen extended 4 cm below the rib cage. We also found that he had two surgical scars because of a perianal abscess.
The abdominal CT suggested hepatosplenomegaly, a slightly thickened and strengthened intestinal wall of part of the abdomen (the left abdomen was more obvious), and multiple lymph nodes in the mesenteric, retroperitoneal and bilateral inguinal region (Fig. ,

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old male patient presented to the emergency department with nausea and upper abdominal pain after food intake. His past medical history included an appendectomy, overweight and ~20 kg weight loss in the past 3 years through exercise and dieting. After weight loss, he developed recurrent episodes of vomiting and mild abdominal pain. At that time, vomiting was variable, with episodes occurring once a week to up to three times a day and happened mostly after meals. It was also accompanied by mild depression. Bowel movements were regular and no other symptoms were acknowledged.
With this history, he attended to a physician consultation. Clinical examination was unremarkable, laboratory tests including an upper endoscopy appeared normal at that time. Considering his history and the fact that he had concerns about his body and shape, without any apparent physical dysfunction, an eating disorder was contemplated for which he received 2 years of psychological support. After treatment the vomits and weight loss, to some extent, were controlled. However, he stated that his eating patterns had significantly changed during these years as he mostly ate mushy blended food with liquids; and that even after the treatment pain persisted.
At the time of the assessment in the emergency room, clinical examination revealed dehydration, and abdominal examination revealed periumbilical pain without any tenderness or masses. Laboratory exams revealed anemia and stomach distention was noted on abdominal x-ray. An upper endoscopy was performed revealing a tortuous duodenum in its second and third portions and an extrinsic compression that partially limited the pass of the endoscopy at this point. Due to these findings, surgical consultation was required. A contrast-enhanced CT showed a narrowing at the SMA origin without signs of obstruction (Fig. A). An angiotomography with a vascular reconstruction (Fig. A) later revealed a 20.5° aortomesenteric angle (Fig. B) and 5.26 mm of aort

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


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

[User]
RADIOLOGY NOTE:
In 1996, a 41-yr-old man underwent surgical excision of a solitary cerebellar mass with the pathological diagnosis of HB (). He had no family history or clinical stigmata to suggest the presence of VHL disease. Gross total removal of the tumor was possible, and no evidence of residual or recurrent disease was observed on magnetic resonance imaging (MRI) performed 1 yr after the surgery (). Ten years after the surgery, he returned to the hospital complaining of low back pain and hypesthesia in his right posterior thigh. MRI of the brain showed multiple mass lesions in the suprasellar area and in the anterior aspect of the upper spinal cord accompanied by diffuse leptomeningeal enhancement (). Whole-spine MRI revealed numerous tiny enhancing nodules suggestive of leptomeningeal metastasis along the spinal cord and cauda equina (). No retinal lesion was found on examination of the fundus. Computed tomography (CT) of the abdomen showed no abnormal findings. A blood sample was collected from the patient after informed consent was obtained. Genomic DNA was isolated from peripheral blood leukocytes using a Wizard genomic DNA purification kit according to the manufacturer's instructions (Promega, Madison, WI, U.S.A.). The three exons of the VHL gene as well as their flanking introns were amplified and sequenced by an ABI 3730 sequencer (AME Bioscience, Toroed, Norway). Mutation was not found. The patient underwent surgical resection of the cauda equina lesion and subtotal removal of the tumor. Histopathological examination confirmed the diagnosis of HB, and the microscopic findings were identical to those of the cerebellar HB operated on 10 yr earlier (). He subsequently received fractionated radiotherapy (a total dose of 3,600 cGy) for a residual lesion in the cauda equina. Brain MRI scans obtained 6 months after the diagnosis of recurrence revealed interval growth of the suprasellar lesion, and gamma knife radiosurgery was performed. He also underwent ventriculoperitoneal

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


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

[User]
RADIOLOGY NOTE:
A male preterm 980 g by birth weight was born to 25-year-old primigravida with 28 weeks of gestation. The baby was delivered with a cesarean section for the indication of fetal distress. In view of respiratory distress, the baby received single dose of natural bovine surfactant within half an hour of birth and was ventilated with nasal continuous positive airway pressure. A PICL (Vygon, Germany) was inserted electively on the 5th day of life through the right saphenous vein. The chest X-ray confirmed the position of the catheter tip at the junction of inferior vena cava and right atrium just above the diaphragm. On the 7th day of life, the baby suddenly deteriorated in the form of desaturations, tachycardia, and hypotension. On examination, the neonate appeared cyanosed, with saturations of 85% and delayed capillary refill time. On auscultation, the heart sounds were feeble and blood pressure showed a systolic reading of 30 mm mercury. The baby was therefore immediately intubated and was put on mechanical ventilation with pressure control mode and 100% oxygen. Systemic hypotension was corrected with inotropes. In view of this sudden deterioration, a chest roentgenogram was called for, which showed marked cardiomegaly and a cardiothoracic ratio of 0.68 []. In view of the above findings, a two-dimensional echocardiogram was performed, which showed a massive PCE []. There was a diastolic collapse of the free wall of the right atrium, indicating cardiac tamponade. Pericardiocentesis was immediately performed, and 9 ml of yellowish fluid was aspirated through a subxiphoid percutaneous approach. Subsequently, the skin color of the neonate improved rapidly, his vital signs gradually returned to normal, and his oxygen requirement decreased from 90% to 30%. Echocardiography done later showed increased contractility with resolution of the PCE []. The PICL line was immediately withdrawn. Inotropic support was gradually reduced and omitted after 24 h; the pressure support 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:
A 26-year-old female presented to office with an insidious onset of pain in her left distal femur that had been present for several months. The patient reports no history of trauma. Physical examination reveals that the patient was a febrile. There was no evidence of a rash or wound and weakness or numbness, but the patient did note swelling of the involved extremity. Normal pulse times were noted in all four extremities. Pushing/pulling provoked pain. Of note, the patient reported a recent molar extraction as her only past surgical history. The pain persisted and increased in severity over the course of several months before amagnetic resonance imaging (MRI) was obtained. MRI interpretation revealed a large marrow-replacing lesion in the distal femoral shaft with a posterior cortical breach and associated posteromedial soft tissue component ( and ). Subsequent biopsy demonstrated osteomyelitis, and cultures revealed methicillin-resistant Staphylococcus aureusas the offending microorganism. The patient elected to proceed with surgical intervention to ream and irrigate the femur and debride the abscess present in the posteromedial aspect of her Cierny–Mader 3A distal femoral osteomyelitis. Pre-operative antibiotics were held until more cultures were obtained.
A thorough review of the MRI revealed that the main foci of infection of her distal femur and posteromedial fluid collection were roughly 12 cm proximal to the superior pole of the patella. On measuring 12 cm from the superior pole of the patella to the lateral thigh, a 6-cm longitudinal incision was made. Bovie electrocautery was used throughout the procedure to coagulate superficial vasculature. A longitudinal incision was made in the iliotibial band in line with that of the skin. The anterolateral compartment of musculature was identified, and Bovie was used to gently lift the compartment off the lateral intermuscular septum, revealing the femoral shaft. The periosteum of the femoral shaft was longitudinally

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


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

[User]
RADIOLOGY NOTE:
The patient is a 50-year-old African American female with a history of bilateral breast reduction twelve years ago, iron deficiency anemia, and obesity, who presented to the surgeon's office complaining of tenderness of her right breast. The patient reported that recently she had been developing keloids along the scar of the right breast with some areas having a blue hue; her left breast was unremarkable. She noticed that after wearing a sports bra there was increased pressure and abrasions to the keloid, leading to cellulitis and edema. She was previously treated with two courses of antibiotics for what was presumed to be an infected keloidal scar of her right breast but with minimal improvement. On exam, she had a large 10 cm diameter keloidal region on the inferior and lateral aspect of the right breast with edema and cellulitis. The keloidal area had no palpable fluctuance; she exhibited no nipple discharge or palpable adenopathy of the right axilla ().
The patient had a benign-appearing mammogram 8 months prior, and all of her screening mammograms since her breast reduction have been without signs of malignancy. Another mammogram was ordered but was not performed due to patient discomfort. An ultrasound of the breast was preformed and suggested marked edema and skin thickening suggestive of infection but no definitive fluid collection or underlying suspicious mass was observed.
The patient underwent a right breast partial mastectomy for cosmesis and resection of the infected keloidal area. Intraoperatively, the mass was highly vascular, firm, but not fixed to the chest wall. Postoperatively, the pathology revealed a high-grade primary angiosarcoma of the breast with negative margins.
Patient underwent a computed tomography of the chest, abdomen, and pelvis, which did not show any evidence of gross metastatic disease. The patient then underwent completion mastectomy and scheduled for adjuvant chemotherapy with combination gemcitabine and Taxotere, followed by ra

[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 previously fit and healthy woman, presented to the Accident and Emergency Department with acute onset stridor and difficulty breathing. She had been feeling unwell for the previous two days and had put her symptoms down to a common cold. She had a background of hoarse voice for more than a year for which she never sought medical attention. On arrival to the department she was found to be stridulous and in respiratory distress. She received immediate airway management in the A&E with one millilitre of Adrenaline mixed with four millilitres of normal saline nebulised and 200 milligrams of Hydrocortisone intravenously. On examining her larynx with a flexible nasal endoscope, a limited view of the glottis was obtained secondary to significant supraglottic oedema. There were no signs of systemic sepsis although her initial haematological and biochemical investigations revealed nonspecific inflammation with elevated levels of C-reactive protein (25.6 mg/L) and erythrocyte sedimentation rate (48 mm/h). She did not respond to conservative treatment and was, thus, intubated with a size 6.0 Fr endotracheal tube with the help of the ENT team.
Direct laryngoscopy at the time of intubation revealed a mass over her right glottic area which was almost completely obscuring the laryngeal inlet. She was then transferred to the intensive care unit, where she remained sedated and ventilated. She was treated with intravenous antibiotics for a suspected supraglottitis given her clinical picture and the appearance of her larynx.
Over the next 48 hours, it became apparent that there was no demonstrable leak around her endotracheal tube cuff despite medical management. A decision was made to perform a microlaryngoscopy and to attempt extubation in theatre.
Suspension laryngoscopy was performed with supraglottic jet ventilation, and a bulging mass was then seen protruding over her right subglottic area and partially obstructing her laryngeal inlet (). She was reintubated, and h

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man with a 45-year history of perianal fistula who had recently been suffering from mucinous discharge, pain and perianal induration was referred to hospital for treatment. Two years before, he had undergone surgery at another institution for incision and drainage of recurrent perianal abscess. Physical examination revealed an indurated, ulcerative lesion 7 cm in diameter with an external anal fistula opening (fig. ). The internal opening of the fistula was indicated at the right side of dentate line. There was no tumor in the rectum on digital examination. Histological examination of a biopsy specimen taken from the induration revealed mucinous adenocarcinoma. Magnetic resonance imaging (MRI) demonstrated a large demarcated tumor at the level of the anorectal junction with extension to the right side of the ischiorectal fossa and presacral space (fig. ). No enlarged pelvic lymph node was observed, nor was there evidence of distant metastasis. Neither colonoscopy nor barium enema showed any evidence of mucosal lesion in the colon or rectum. Laboratory data showed renal dysfunction caused by pyelonephritis, and the carcinoembryonic antigen serum level was extremely elevated to 40.8 ng/ml (normal <5 ng/ml).
To increase resectability and decrease the rate of local recurrence, preoperative radiotherapy was proposed without chemotherapy because of the renal dysfunction. Preoperative radiotherapy was given with 40 Gy in 25 fractions for 5 weeks through posterior and bilateral portals. After radiotherapy the tumor was markedly shrunk (fig. ) and carcinoembryonic antigen serum level gradually decreased to 13.0 ng/ml.
8 weeks after radiotherapy the patient underwent radical resection. An APR with lymph node dissection was performed. The skin surrounding the tumor was excised with adequate tumor-free margin. The resected specimen revealed that the tumor had developed in the ischiorectal fossa, but there was no evidence of cancer extension to the mucosal surface

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


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

[User]
RADIOLOGY NOTE:
A 14-year-old boy presented to the emergency department (ED) after sustaining a twisting injury to his right ankle while playing basketball. Clinical evaluation showed significant swelling and deformity around the ankle. There were no neurovascular deficits. He was unable to bear weight. Radiographs showed a displaced distal tibia SH type II physeal fracture and a transverse fracture of the fibula with valgus angulation ().
An initial attempt at closed reduction performed in the ED under conscious sedation was unsuccessful; the fracture could not be moved from its displaced position after sustained traction and manipulation (). The patient was taken to the operating room, and a second attempt at closed reduction was performed with the patient under general anesthesia and muscle relaxation. Again, the fracture could not be moved from its displaced position. Tendon interposition was suspected and open reduction of the fracture was performed by making an incision on the anteromedial aspect of the distal tibia centered over the metaphyseal spike. The fracture site was exposed, and the posterior tibial tendon was found interposed within the physeal fracture site. The tendon was bowstringing around the metaphyseal fragment from the proximal-posterior to distal-anterior direction between the metaphysis and epiphysis (). Traction on the distal fragment increased the tension and worsened the bowstringing of the tendon. Hence, the traction was released and the interposed tendon was retracted out from the fracture site. This allowed the fracture to be reduced without difficulty. The tendon had mild fraying but did not show any laceration or tear (). The fracture reduction was confirmed on fluoroscopic evaluation, and two 4 mm partially threaded cannulated screws were used for fracture compression and fixation across the large Thurston-Holland metaphyseal fragment ().
Postoperatively, the leg was immobilized in a boot and nonweight bearing with crutches was used for 4 weeks, fo

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old female patient with an unremarkable medical history visited our clinic with complaints of swelling, ecchymosis, and pain on the left side of her face. The dental history revealed that an endodontic retreatment therapy had been initiated on her maxillary left first premolar tooth 10 days previously, which was followed by a second session on the previous day. During the first session, the patient had felt light swelling, which resolved spontaneously a few hours later. At the second appointment, the treatment had to be stopped because of severe pain and hemorrhage from the root canal during irrigation of the root canal. No attempt had been made to restore the tooth other than placing a cotton pellet into the endodontic cavity. Another appointment had been scheduled by the general dentist to complete the treatment. The patient noticed swelling in her cheek several hours following the procedure, but she did not contact her doctor. However, her facial swelling worsened significantly over the next 24 hours, and the general dentist referred her to our clinic.
Approximately 48 hours after the incident, extraoral examination revealed significant soft tissue swelling extending from the left infraorbital region to the mandibular border. Infraorbital ecchymosis and slight bruising near the nasolabial fold were observed (). Intraorally, there were no signs of mucosal ulceration or necrosis. The tooth being treated was tender to vertical and horizontal percussion. Panoramic radiography showed evidence of a previous root canal therapy with periapical radiolucency ().
The root canals were irrigated with saline solution, and the tooth was restored temporarily. To prevent the risk of infection, intramuscular clindamycin (600 mg twice a day) was administered for three days, and ibuprofen (400 mg) was prescribed for pain management, to be taken as required. Use of cold packs externally for the first day was replaced by warm compresses on the second day for treatment of 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 42-year-old male fell during work on a fence resulting in a severe perineal impalement injury leading to life threatening bleeding and an obvious anal injury. A midline lower abdominal incision was made. No intraperitoneal injuries could be seen, and a defunctioning colostomy in the left lower abdomen was done. The perineum was debrided and the open anal mucosa sutured. At this stage no attempt was made to reconstruct the anal sphincter mechanism. The right internal iliac artery was ligated, but the bleeding could only be controlled by packing the small pelvis with large swabs. This was done through the open perineum. After patient stabilization, a helicopter transfer was organized to a tertiary trauma centre. The CT scan at that stage showed isolated extra peritoneal soft tissue injury from the perineum extending into the left small pelvis (). No active bleeding, bowel, or bladder injury could be determined. Clinical examination confirmed an open book fracture of the pelvis, total ventral full thickness disruption of the anal sphincter complex, and total disruption of the dorsal urinary sphincter complex. There was a big defect in the perineum, demonstrating the extent of the impalement injury (Figures and ). Both the anal and urethral sphincters were repaired using an approximation technique. Mattress sutures were used for the anal sphincter and simple sutures were used for the urethral sphincter. The corpora cavernosa that were ripped far apart were also approximated ventral to the sphincteric urethra. After sphincter repair, a vacuum device was placed until it was safe to perform secondary wound closure. The transurethral catheter was left in position for three weeks. A micturating cystourethrogram was done at the time of catheter removal and no extravasation was noted. At this time, the patient was still incontinent of urine and a transurethral catheter was placed for another 6 weeks until the patient was mobilized. The patient became continent after pelvic f

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old male with past medical history of coronary artery disease status post coronary artery bypass graft (CABG), aortic valve replacement along with replacement of the root of the ascending aorta 10 months prior to presentation and recent hemorrhagic cerebrovascular accident (CVA), came to the hospital with complains of acute onset of severe abdominal pain and melena for 1 day. He also attested to chronic abdominal pain and a 30-pound weight loss over the last 8 months prior to these acute symptoms. His physical exam on presentation was positive for severe bilateral lower abdominal tenderness. Apart from a hemoglobin of 10 mg/dl and a positive stool occult blood test, the rest of his basic lab work up was unremarkable (white blood cell/platelet count, comprehensive metabolic panel, and PT/INR included). Hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) testing were negative. The electrocardiogram (EKG) showed sinus rhythm and left ventricular hypertrophy (). An emergent computerized tomography (CT) scan of the abdomen revealed features suggestive of an embolic infarct in the left kidney (Figures and ) and within the mid-one-third of the superior mesenteric artery causing luminal narrowing and also suspected to be extending to the takeoff of small bowel branches. Segmental mural thickening of at least one small bowel loop was noted which strongly favored acute bowel ischemia as a cause of his abdominal pain (). Incidental findings on CT of the abdomen were also strongly suspicious for large eccentric thrombus in the ascending aortic graft and the aortic root which were further investigated and confirmed with a CT scan of the chest (). Cardiology and cardiothoracic surgery were consulted. A CT scan of the head was performed to assess the recent CVA and showed a subacute hemorrhage along the left-sided temporal parenchyma (). CT head imaging was obtained from the facility where the patient presented 3 months prior for cerebral hemorrhage and in 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 68 year old male patient was presented to the outpatient department with a painful swelling on the dorsum of the right hand without any history of trauma. It was primarily considered to be cellulitis and treated with antibiotics for 10 days by the general practitioner. He had bronchogenic lung carcinoma which was diagnosed 5 months ago. He also had a bone scan done which did not reveal any metastases. Clinical examination revealed a palpable mass at the ulnar part of the dorsum of the hand (Figure ). The hand was warm, red and tender. Flexion and extension movements of the fingers were painful. There was no neurovascular deficit. No epitrochlear or axillary lymph nodes were palpable. The radiographs revealed a lytic lesion of the fifth metacarpal with destruction of its distal part (Figure ). Chest x-ray showed a large mass in the right upper lobe of the lung, in keeping with a bronchogenic carcinoma (Figure ). MRI of the hand revealed a large, solid mass originating from the fifth metacarpal and extending to the adjacent soft tissues (Figure ). Open biopsy showed metastatic carcinoma. The case was discussed with the Oncologist. We decided that, due to the broad extension of the mass to the hand, the patient should not receive any surgical treatment and he was referred to the oncology department.
The most common site of metastatic deposits to the hand is the distal phalanx. The incidence of metastasis to the metacarpals is 17%, phalanges 66% and carpal bones 17% []. Keramidas and Brotherston [] published a case with metastasis to both metacarpal and carpal bones, which is extremely rare.
It is rare to see bronchogenic carcinoma metastases to the bones distal to the elbow and knee. Floridis was the first to describe this rare entity in the United States in 1934 []. Depass (1958) was the first to report a metacarpal metastasis in the English literature [].
The lung is the most common source

[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 Indonesian female presented with progressive knee swelling and pain for a month after a minor sprain. She had previously enjoyed good past health. She had no other joint symptoms or any systemic symptoms such as weight loss, fever and night sweats. Physical examination revealed moderate knee joint swelling with joint effusion. The knee could not be fully extended. No redness or increase in temperature of the knee joint was present. There was tenderness at the medial joint line. All the inflammatory blood markers were negative. Knee joint fluid aspiration yielded slightly turbid fluid with a small number of lymphocytes and a negative Gram stain and bacterial culture. Knee radiography revealed moderate soft tissue thickening in the medial aspect of the knee with mild to moderate osteolysis of the medial femoral condyles and moderate resorption of the medial condylar cortex (). Ultrasound of the knee showed a small to moderate-sized joint effusion with severe synovial thickening at the anteromedial aspect of the knee, mainly at the medial patellofemoral recess and the medial side of the knee joint (). Moderate cortical irregularity of the medial femoral condyle was present (). Only very mild vascularity was present within this area of synovial thickening. MRI showed a large soft tissue lesion present on the medial side of the knee joint (), involving the synovium and adjacent medial femoral condyle with moderate periosteal elevation. This lesion extended deep to the medial collateral ligament and extended into the intercondylar notch posteriorly encompassing the femoral attachment of the medial belly of gastrocnemius muscle. The soft tissue mass was slightly T1-hypointense and T2-hyperintense to skeletal muscle (, ). No evidence of hemosiderin was present. There were two moderately enlarged popliteal lymph nodes present (). In addition, abnormal bone marrow signal (low in T1 and heterogeneously high in T2 FSE) was present in the distal femur consistent wi

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old male patient, who was working for a high school as an administrative staff, was referred for coronary bypass grafting due to recurrent left main coronary disease. Although he was physically active, he had been suffering from anginal pain for several years. Since coronary angiography taken at another center revealed no significant coronary lesion, no specific treatment was given. He also had a history of left carotid stent insertion due to repeated transient ischemic attacks (TIA) three and a half years prior.
A year previous to admission, the patient had suddenly collapsed while playing football. He was resuscitated from cardiac arrest at a nearby community hospital. On electrocardiography, ST-T changes were shown on precordial leads, and bedside echocardiography revealed akinesia of the antero-lateral wall suggesting the acute coronary syndrome. The patient was transferred to a tertiary medical center for further evaluation and appropriate management. Emergency coronary angiography was performed, and a tight left os lesion was managed with balloon angioplasty and stent insertion. After a month’s rehabilitation, he was discharged without sequelae.
One year later, a follow-up coronary angiography revealed recurrent stenosis in the distal left main coronary artery that was distal to the previous stenting site, extending to its bifurcation of the left anterior descending artery (LAD) and circumflex artery (). The patient was not obese; in fact, he is rather slim, exhibiting neither hypertension nor diabetes.
Further, bilateral internal thoracic artery (ITA) grafting was planned considering the patient’s age. While harvesting the right ITA after left ITA harvesting, a hemodynamic derangement developed suddenly. As the patient was unresponsive to a catecholamine infusion, cardiopulmonary bypass (CPB) was instituted hurriedly and a double bypass (left ITA to the left circumflex and right ITA to the left anterior descending) was carried out under standard hyp

[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 1-day-old male newborn (34 weeks of gestation) delivered by cesarean section with a birth weight of 2280 g had APGAR scores of 8 and 9 at 1 and 5 min, respectively. The infant was admitted to the NICU with respiratory distress syndrome and was managed by noninvasive positive pressure ventilation (NIPPV). The chest X-ray showed severe perihilar infiltrates bilaterally with a fine granular pattern [Fig. ]. The respiratory status of the infant deteriorated on his second day of life; he required intubation and received surfactant therapy. After surfactant administration, the condition of the infant showed no improvement. A second chest X-ray was requested, which showed severe lung disease with no evidence of pneumothorax or pneumomediastineum. Free intraabdominal air was noted [Fig. ]. The abdomen was mildly distended and soft to palpation. Bowel sounds were normal. The temperature, blood pressure, and capillary refill time of the infant were also normal. The laboratory results were all within the normal range except for a low serum calcium level.
Urgent laparotomy was done. There was no gastrointestinal perforation, and the bowels were grossly healthy. A few hours post surgery, the infant developed metabolic acidosis, followed by hypotension and delayed capillary refill. He was managed with inotropes and intravenous hydrocortisone. A head ultrasound was done, which showed bilateral grade 3 intraventricular hemorrhage. The infant had a severe drop in hemoglobin level that necessitated blood transfusion. This was later complicated by posthemorrhagic hydrocephalus that needed VP shunt insertion. The infant also developed a large ductus arteriosus, which responded well to fluid restriction and a 3-day course of oral paracetamol.
A follow-up abdominal X-ray showed no free air in the abdomen. The results of the abdominal examination remained normal, and the infant passed meconium on the second postoperative day. After he was taken off the inotropes, gradual enteral feeding

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


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

[User]
RADIOLOGY NOTE:
A patient in her late seventies was incidentally found to have a large infrarenal abdominal aortic aneurysm in 2013 for which she had undergone an uneventful percutaneous endovascular aortic repair with left chimney. She lived alone, remained independent in her activities of daily living, and was community ambulant without aid.
She was electively admitted in September 2019 for embolization of a type 2 endoleak by the interventional radiologist. Super selective cannulation of the distal aspect of the iliolumbar branch supplying the nidus with a micro catheter was performed. Embolization was carried out using Onyx® until complete exclusion of the nidus. This was followed by repeat aortogram, which showed complete exclusion of the nidus from right-sided branches. However, there was continued filling of the nidus from the left lumbar branches. It was therefore decided to embolize the left side. After embolization, angiogram showed complete exclusion of the endoleak and the left-sided branches supplying the endo leak.
Five hours after the procedure the patient complained of bilateral lower limb weakness and numbness, right more than left. Physical examination revealed lower motor neurone pattern of weakness over bilateral lower limbs, right worse than left (Table ). Sensation testing revealed normal sensation over left, impaired sensation for right L2 to S1. Proprioception at bilateral big toes was intact. Reflexes were absent in bilateral lower limbs.
Lumbar spinal drain was inserted to decompress the spinal cord to allow more arterial flow as there was concern with spinal cord ischemia. The patient was started on fluid replacement to maintain the mean arterial pressure above 80 mm Hg. Urgent CT aortogram followed by MRI thoracolumbar spine was performed. Aortogram showed postinterval embolization of bilateral feeding arteries. Onyx material was seen within a branch of the embolized right iliolumbar artery, which extends into the spinal canal at the level of L3 and appe

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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 27-year-old man (173 cm, 68 kg) was referred from the department of internal medicine to our pain management center for abdominal pain. He described the pain as being continuous and cramping in addition to being localized in the left lower quadrant. On physical examination, he had no tenderness in the abdomen. Large meals worsened his pain but the pain did not fluctuate in intensity. He had no change of bowel habits or sleep disorders. He stated that his symptoms had started with epigastric discomfort and soreness 7 to 8 years ago and was variable thereafter. He had received medical treatments at local internal and oriental medical clinics without a significant improvement and then visited this hospital 2 years ago. His numeric rating scale (NRS) for pain scored 7/10 (7 out of NRS scale of 10 [0: no pain, 10: imaginable worst pain]).
He had no other chronic disease, did not smoke or drink alcohol. The results of an esophagogastroduodenoscopy taken at this hospital 2 years ago had no specific findings except for chronic superficial gastritis. Abdominal ultrasonographic and blood tests were normal. Colonoscopic findings at a local clinic 16 months ago were also normal. He was prescribed proton pump inhibitors, antacids, digestants and prokinetics intermittently, but these had no beneficial effects. Five months ago, he had abdominal and pelvic computerized tomography, but there were no significant findings except for two simple cysts in the right kidney.
We decided to perform a diagnostic left thoracic splanchnic nerve block under the diagnosis of functional abdominal pain syndrome (FAPS). Informed consent for the block was obtained from the patient after explaining the purpose of and what was expected from the procedure and its potential complications. With the patient in the prone position, a pillow was inserted under the abdomen to reduce lumbar kyphosis. Electrocardiogram, pulse oximetry, and arterial blood pressure were monitored during the procedure, and peripr

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

[User]
RADIOLOGY NOTE:
The patient was an asymptomatic 62-year-old woman diagnosed with a tumor in the left hilum of the lung in 1995, who had refused to undergo treatment (imaging data of the physical examination had been misplaced). A chest radiograph obtained in 1999 indicated multiple abnormal nodular shadows in the left hilar field; the shadows were approximately 2.5 cm × 3 cm in size, which, in combination with the patient’s description of the original tumor size, indicated that the tumor had not enlarged in sized. A chest radiograph obtained in 2001 showed a slight increase in the lesion size. The tumor measured about 7 cm × 8 cm in 2009 (Figure
). A CT scan obtained in 2010 showed a giant soft-tissue mass in the left side of her chest, measuring 8.2 cm × 8.6 cm with scattered calcifications at the edge (Figure
). No positive results were obtained from any of the laboratory examinations conducted when the patient was admitted to the hospital. On intraoperative examination, a well-circumscribed hard tumor measuring 10 cm × 10 cm × 10 cm was found to be located in the fissure of the left lung; the tumor was found to be adhered to the superior lobe, inferior lobe, and posterior chest wall. A vascular endothelial tumor was diagnosed on the basis of intraoperative frozen-section analysis. PSH was confirmed by surgical resection and postoperative pathological diagnosis of a paraffin-embedded section, in which hemorrhagic, papillary areas appeared (Figure
A). The immunohistochemical results were as follows: thyroid nuclear factor 1 (positive; Figure
B), cytokeratins (negative), vimentin (positive), CD34 (positive), synaptophysin (negative), and epithelial membrane antigen (positive). The patient was discharged from the hospital after 8 days, without receiving any further adjuvant therapy after the surgery. One and a half years after the surgery, a CT scan indicated good expansion of the left lung and no sign of recurrence and metastasis (

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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 75-year-old male was admitted to the Thoracic Surgery Department in order to undergo an elective left lung upper lobe resection for a moderately differentiated lung adenocarcinoma. Patient medical history included diabetes mellitus, hypertension and dyslipidemia under medication. Moreover, the patient was a heavy smoker (140 Pack/Years). One year ago, he presented to his general practitioner (GP) suffering from cough, anemia, fatigue and weight loss of 12 kg during 3 months. The patient eventually underwent computed tomography (CT) scan, bronchoscopy and tumor biopsy, and he was diagnosed with a moderately differentiated lung cancer, stage IIIa, T3N2M0 according to seventh edition of the TNM staging system. T3 was attributed to tumor size (maximum diameter 10.8 cm) and N2 to metastasis to inferior mediastinal (subcarinal) lymph node according to the initial CT scan. The patient subsequently underwent six cycles of chemotherapy with pemetrexed and carboplatin. After that, a new CT scan, a fluorodeoxyglucose (FDG) uptake positron emission tomography (PET)-CT scan and a transthoracic echocardiogram were performed in order to evaluate tumor stage following chemotherapy. The tumor at that time was staged T3N1M0. Size was decreased (maximum diameter 9 cm) but remained T3, while only ipsilateral hilar lymph nodal metastases but no mediastinal nodes were found (downgrade to N1). Additionally, there was close proximity of the tumor to the aortic arch, but vessel wall invasion was not evident according to the radiology report (). Therefore, the patient was scheduled for left upper lung lobe resection.
Under general and thoracic epidural anesthesia, a left anterolateral thoracotomy was performed. In the left lung apex, the tumor was strongly adhered to the thoracic wall and the aortic arch and it seemed to invade the superior pulmonary vein, although this was not evident on the CT scan. Ligation of pulmonary vein and complete resection of tumor due to aortic arch invasion we

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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 56-year-old male patient with a history of cigarette smoking, hypertension, and a familial history of juvenile sudden death presented to the cardiology outpatient clinic with a 2-week history of anterior chest pain on exertion. He had been taking a calcium channel blocker (5 mg of amlodipine) and beta-blocker (10 mg of carvedilol) once daily for 2 years, and his hypertension was well-controlled. His chest symptom arose while he was riding a bicycle on the way to his office in the morning, and the symptom was relieved by resting. Chest pain did not occur at rest or on exertion in the afternoon. The patient had experienced work-related emotional stress in the days prior to the symptom onset. His blood pressure was 133/92 mmHg, and heart rate (HR) was 79 beats/min. Cardiac auscultation revealed normal heart sounds with no extra sounds or murmurs. The results of blood tests, including cardiac enzymes, lipid profile, and glucose level, were all within normal ranges. The resting 12-lead electrocardiogram (ECG) was within the normal physiological range, and transthoracic echocardiogram revealed no ischaemic wall motion or valvular abnormalities. The patient underwent coronary computed tomography angiography for suspected coronary artery disease, which detected the presence of a possible stenotic lesion in the circumflex branch (Figure ). Thus, hospitalization was arranged, and transcatheter coronary angiography (CAG) was performed. We did not perform exercise stress test prior to CAG, because our patient had new onset angina and stenotic lesion detected on coronary computed tomography might be a culprit lesion of his unstable angina. In CAG, however, only mild stenosis with small perfusion area was noted in the obtuse marginal branch (Figure , ). Left ventriculography revealed normal left ventricular wall motion (). We did not perform further haemodynamic assessment such as fractional flow reserve or instantaneous wave-free ratio to this stenotic lesion, because the perf

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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 51-year old woman with a 2-year history of rheumatoid arthritis presented with three weeks history of vertigo and vomiting. Her symptoms worsened progressively and she became unsteady on walking. She also felt episodes of tingling and numbness on the right side of the face. There was no prior history of neurological disease and no family history of multiple sclerosis.
She was maintained on Methotrexate 20 mg weekly for the arthritis, however due to inadequate response, subcutaneous Etanercept 50 mg weekly was begun three months prior to her admission with marked improvement in her joint symptoms. She had received the last dose of Etanercept four days prior to hospital admission. Past medical history was also significant for 1-year history of diabetes on Metformin, and hypercholesterolemia on Simvastatin 10 mg. The physical examination revealed a horizontal nystagmus with fast component towards left side and broad-based, ataxic gait with tendency to fall to the left side. Rest of examination was unremarkable and there were no signs of active joint disease.
Complete blood count, urea, electrolytes, and blood sugar were normal and Electrocardiography revealed occasional ventricular ectopic beats. Autoimmune tests including ANA, Anti-ds DNA and Anti-CCP were negative. Rheumatoid factor also was negative at admission.
MRI of the brain () revealed multiple rounded foci with iso-intense T1 and hyper-intense FLAIR and T2 signals involving the left side of the medulla, the right middle cerebral peduncle, the body of the corpus callosum and the sub-cortical white matter of both cerebral hemispheres, which were suggestive of demyelinating foci. The patient refused lumbar puncture.
Etanercept was discontinued immediately. Three days later she felt better, with reduction in intensity of vertigo and disappearance of nystagmus, however her gait remained ataxic.
Intravenous methylprednisolone pulse therapy was then started and three days later, she made a good recovery and was ab

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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 77-year-old female with hypertension, untreated hyperlipidemia, hypothyroidism, but without prior history of CAD or angina symptoms was referred to a cardiologist's office for a treadmill exercise test secondary to new onset palpitations. She denied any chest pain or pressure, shortness of breath, exertional dyspnea, or leg swelling. She quit smoking 36 years ago and has no family history of early cardiovascular diseases. She has a very distant cardiac work-up years ago, including a stress test and an echocardiogram, which the patient reported were unremarkable. Vital signs prior to the test were a blood pressure of 140/78, heart rate of 80, and a respiratory rate of 14. Physical exam was unremarkable except for a systolic ejection murmur that was graded II/VI at the base. EKG was at baseline with a normal sinus rhythm, normal axis, and occasional premature ventricular complexes (PVCs).
The patient underwent an exercise stress test using the Bruce protocol and was able to complete stage 1 with exercise for three minutes at a speed of 1.7 mph and a 10% incline. The test was terminated due to dyspnea and fatigue without chest pain. She reached a heart rate of 141 beats per minute which was 98% of predicted for her age. She accomplished 4.5 metabolic equivalents of exertion. With exercise, she had occasional atrial premature complexes and PVCs with a ventricular couplet in recovery. She started to notice tightness in her chest. Her peak blood pressure at the time was 218/90.
The patient was transferred onto a stretcher, and an IV line was started. She was given sublingual nitroglycerin, 325 mg of aspirin to chew, and one 5 mg IV push of metoprolol tartrate. She then received nitroglycerin paste and metoprolol tartrate IV every 5 min for two more doses. At that time, her EKG on the stretcher showed ST elevations in leads I, aVL, V5,

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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 43-year-old male with a history of radical nephrectomy in 2002 for (Tumor, Node, Metastasis staging) pT3a N0M0 poorly differentiated right kidney neoplasm that appeared to arise unusually from the collecting duct with sarcomatoid change. Post-surgery he was on regular follow up and remained asymptomatic and his imaging including CT scan and positron emission tomography (PET) scans did not show any evidence of recurrence. In August 2018, he presented with complaints of right shoulder and arm pain with restriction of movement for six months. Right shoulder joint pain was nonradiating, gradual onset with severity of 4/10, aggravated by movements and partially relieved by analgesia. The patient denied any other joint involvement. Rest of the systemic review was unremarkable. His general physical and systemic examination was normal. His right shoulder joint movements were restricted especially abduction and he could not abduct his arm more than 90 degrees. He also has two swellings over the scalp on the right side.
Diagnosis
On the basis of his symptoms, an X-ray for shoulder joint along with skeletal survey was advised (Figure ) which showed lytic lesions in the right humerus, right distal femur, and right iliac bone.
He subsequently had an MRI of the right shoulder joint (Figure ), which showed scapular soft tissue mass, humeral lesion showing significant uptake, suggestive of metastatic disease. The patient was hospitalized to the ward for further evaluation and pain management.
To assess the disease burden, the patient had a PET CT (Figure A-D) which showed abnormal fluorodeoxyglucose (FDG) uptake involving multiple bones (lytic and sclerotic in nature involving right rib, humerus, femur, and tibia) a soft tissue deposit involving the right side of skull with the suspicion of brain involvement, as well small nodules in both lungs. MRI of the brain (Figure ) was done to rule out brain involvement, which showed normal brain parenchyma but an expansile lesion

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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:
An 18-year-old female presented with a painful swelling in the left upper quadrant of her abdomen. She became aware of this problem 4 days before presentation. There was no history of previous illness, nor did she take any medication. Physical examination revealed a tender, painful spot and palpable mass in the left upper quadrant of the abdomen.
Biochemistry indicated an elevated C-reactive protein value (14 mg/dl, normal <1). Tumor marker carbohydrate antigen (CA) 125 was within normal range and the lactate dehydrogenase value was not elevated.
Ultrasonographic evaluation revealed a structure in the left upper quadrant, inferior to the left kidney measuring 7 × 9.5 cm. There were calcifications visible and the study in Doppler mode revealed no apparent blood flow.
Subsequent abdominal computed tomography (CT; fig. , fig. ) confirmed a nodular mass in the left upper quadrant measuring 6.5 × 7.5 × 10 cm. The mass was partially solid, partially cystic and had some calcifications. This mass was situated inferior to the left kidney. The spleen and pancreas were situated superior to this structure, the descending colon was posterior to this lesion and was closely related to it. The medial border of this mass was in close contact with the distal part of the transverse colon and the stomach. There was also contact with the jejunal part of the small intestine and a diffuse infiltration of the surrounding fatty tissue. There was no obvious lymphadenopathy and there were no intra-abdominal metastases.
A CT scan of the thorax did not detect thoracic metastases. Colonoscopy was normal except for a small nodule at the cecum, which anatomopathological investigations confirmed to be a submucosal lymphoid nodule.
Excisional surgery was planned and median laparotomy was performed. Exploration revealed that the tumor was located partially in the omentum majus and partially fixed in the retroperitoneum inferior to the spleen. There was no evidence of peritoneal or hepatic metastases

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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 24-year-old woman with a 6-month history of swelling in the left floor of her mouth was referred to our institution. Although she experienced slight difficulty in swallowing, she did not experience pain or tongue paralysis. Her medical and family histories were unremarkable.
Intraoral examination revealed a well-defined 3.5 × 3 × 2 cm-sized solid, spherical submucosal nodule adjacent to the sublingual gland; the nodule was covered with light bluish smooth mucus (Fig. ). The patient experienced slight pain when pressure was applied to the tumor. Mobility and sensory functions of the tongue were normal, and no lymphadenopathy in the submandibular region was detected on palpation. All relevant laboratory test results were normal. Enhanced computed tomography revealed a 2.8 × 1.8 × 2.1 cm-sized well-defined, solid, heterogeneous nodule that did not appear to involve the mandible (Fig. ). In addition, a three-dimensionally reconstructed image showed a nodular lesion occupying the left floor of the mouth with abundant blood flow (Fig. ). No enlarged lymph nodes were found in the submental or submandibular regions.
The initial clinical impression was a benign salivary gland tumor, dermoid cyst, or benign connective tissue neoplasm. The patient was scheduled for surgery via an intraoral approach. First, an elliptical incision was made around the periphery of the sublingual gland through only the oral mucosa, and a full-thickness tissue flap was prepared along the lingual aspect of the sublingual gland. After the sublingual gland was freed from its surrounding tissue with blunt dissection, a well-circumscribed tumor without capsular extension was found beneath the body of the sublingual gland and located above the submandibular gland duct and lingual nerve. The submandibular gland duct and lingual nerve were carefully freed from the tumor surface, and the complete tumor was excised along with the sublingual gland (Fig. ). The tissue sample was fixed with 10% formalin and s

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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 48-year-old Palestinian female patient with a history of trauma. The patient had slipped and fallen on her upper back, and she complained of progressively aggravating dyspnea at rest. Then, within the chest x-ray of trauma survey, found an incidentally huge mass occupying the left lung, irrelevant to the trauma. There was no past medical history, and the only surgical history consisted of one cesarean section 3 years prior to the visit. The patient was married and had four children. She was a non-smoker and had no recent history of traveling, weight loss or expectoration.
Examination showed that the patient was stable with mild tenderness on palpation of the posterior upper back. Auscultation demonstrated absent breath sounds on the left. An abdomen examination concluded that there were splenomegaly.
Chest x-ray showed well-defined huge opacity of most left hemithorax with a shift of mediastinum to the right (Fig. ). CT chest/abdomen/pelvis with IV contrast revealed 20 × 15 × 18 cm3 well-defined mixed cystic lesion within the left lung containing multiple parts of the heterogeneous density with soft tissue elements and fat content. It also showed spots of wall calcification, where the lesion probably originated from the mediastinum, involving most of the left hemithorax. The mass compressed the mediastinal structures, great vessels, and airways (Fig. ). It is surrounded by a consolidation collapsed with a marked shift of mediastinum to the right side (Figs and ). No mediastinal lymphadenopathy and the right lung was clear. The spleen was enlarged with multiple cysts that varied in size with no significant enhancement post IV contrast in arterial and portal phases (Figs and ). The liver was unremarkable. Hematological tests were within normal limits. Mantoux test and Sputum culture were negative.
The decision was to perform a standard left anterolateral thoracotomy to remove the thoracic tumor after expiration because the cystic tumor was found

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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 man was referred to our hospital because of two episodes of syncope within a fortnight. He had suffered from pleuritic chest pain and dry coughs for the previous two weeks, and antibiotics prescribed for pneumonia by an internist failed to prevent the exacerbation of the symptoms. The internist subsequently referred the patient to a cardiologist, who subjected him to an exercise stress test (to rule out coronary artery disease), during which he developed non-sustained ventricular tachycardia. The following day, he suffered a one-minute syncope while talking a walk in his yard. He was, therefore, once more referred to our hospital by the internist to evaluate ventricular tachycardia as a cause of syncope. When the patient arrived at our hospital, he had anxiety and had a respiratory rate of 30/min, pulse rate of 120/min, and supine blood pressure of 100/60 mmHg. Additionally, the patient’s lungs were clear and his heart sound and lower limb were normal. Chest X-ray revealed mild cardiomegaly, dilated right descending pulmonary artery, and oligemia in the right lung ().
On echocardiography, the left ventricle was normal; however, the right heart was dilated and trabeculated and there was also right ventricular dysfunction. The pulmonary artery pressure was elevated to 45 mmHg. The patient denied any history of deep vein thrombosis and mentioned only a six-hour car travel more than three weeks earlier. His family history for venous thromboembolism was weakly positive and one of his nephews had a history of pulmonary thromboembolism.
At this point, lung CT angiography was performed to rule out pulmonary embolism as the main cause of acute right ventricular enlargement. The CT angiography demonstrated bilateral pulmonary artery thrombosis from the first division of the right and left pulmonary arteries to the distal ones ( & ).
With a diagnosis of pulmonary embolism, the patient underwent thrombolytic therapy with recombinant tissue plasminogen activator (r

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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 53-year-old woman noted palmoplantar pustulosis after eating seafood with spontaneous remission in 2008. Thereafter, she developed gradual swelling and moderate pain in the bilateral sternoclavicular joints with a marked elevation of her erythrocyte sedimentation rate (ESR). Whole-body bone scintigraphy (WBBS) revealed tracer concentration in the superior margin of the sternum. Pathological examination following a sternal biopsy suggested aseptic chronic osteomyelitis. After treatment with antibiotics, her symptoms were temporarily relieved. In 2011, the patient presented with pain in the anterior chest wall (ACW), thoracic and lumbar vertebrae, and left hip. Magnetic resonance images of the spine obtained with various sequences indicated vertebral compression and multiple lesions with abnormal signals, which were suggestive of bone marrow edema and deposition of fat. A biopsy of the right sternoclavicular joint indicated pathological changes in accordance with chronic inflammation. The patient was therefore diagnosed with SAPHO syndrome according to the criteria proposed in 1988. A 1-month treatment regimen involving administration of NSAIDs and DMARDs was accordingly initiated, resulting in moderate improvement of her osteoarticular symptoms and a significant decrease in her ESR. However, the cutaneous abnormalities did not improve. In 2013, painful swelling of the ACW, vertebrae, and left hip relapsed with stiffness and limitation of activity in the cervical and lumbar regions. The ESR was also notably elevated. Various types of DMARDs were tentatively administered in sequence. Nevertheless, her symptoms were not resolved, and the bone lesions persisted as shown by further magnetic resonance imaging and WBBS examinations (). In 2015, bisphosphonate treatment was started, resulting in rapid remission of both her symptoms and inflammatory markers (). Nevertheless, the palmoplantar pustulosis and painful swelling of the axial skeleton reappeared and became progres

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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:
An 18-month-old male patient with Pompe disease was referred to our clinic due to swelling of his gingiva while he was being treated by enzyme replacement therapy in the intensive care unit of the university hospital. During the anamnesis, it was learned that the patient had a birth weight of 3.270 g from a normal term pregnancy and cesarean section, and his parents were second-degree relatives. The other child of the family had died at 16 months due to Pompe disease, and the patient had a 16-year-old healthy brother.
The medical history of the patient revealed severe muscle hypotonia, respiratory problems, gastric reflux, and a mild cardiomyopathy. His respiration was through a ventilator and he was fed by gastrostomy tube; he was conscious and cooperative but could not speak.
As a result of genetic assessment of the peripheral blood sample at the genetic department of another university, it was learned that a homozygous c.1408_1410 del mutation had been detected.
His first dental examination was performed by us when he was hospitalized at the intensive care unit. His mouth was found to be open due to macroglossia and respiratory failure, and a nonfluctuant, normal gingiva colored swelling at the right anterior region of the maxilla was detected. No color change, focus of bleeding, cystic formation, or infection was encountered at the region. Tooth eruption was noted for 61, 71, and 81 numbered teeth (). His anamnesis, obtained from his mother, revealed that gingival swelling was also present when 61 numbered tooth erupted. His parents were recommended to perform finger massage to the region of 51 numbered tooth. At the examination six months later, 51, 52, 62, and 74 numbered teeth had erupted (Figures and ), and there was fusion between 51 and 52 numbered teeth, and an enamel fracture at the mesial edge of 61 numbered tooth, which his mother was un

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

[User]
RADIOLOGY NOTE:
A 33-year-old man was referred by the Dermatology service with four nodules arising in a tattoo on his left anterior chest wall (). The tattoo had been carried out in the United Kingdom three years prior to the onset of the nodule formation. An initial nodule arose in the central left portion of his chest and this was followed several months later by three more nodules, all-arising within red parts of the multicolour tattoo. The patient was uncertain if there had been a mole on his left chest prior to getting the tattoo. He had no past medical history of any significance and he had worked for 10 years in the merchant navy yet claimed he had little sun exposure.
Excisional biopsies of these lesions revealed four melanomatous lesions, the maximum of which had a Breslow depth of 11 mm. Pathological assessment of these lesions felt that they consisted of a primary tumour of 11 mm depth and three in-transit metastases. Microscopy of the primary lesion demonstrated sheets of highly atypical cells, which extended into the underlying dermis as atypical spindled and stellate cells with prominent perineural invasion. Focal epidermal ulceration was present along with a junctional component in areas. Tumour cells stained positive with S100, but negative for HMB45, Melan A and AE1/AE3. It was felt that it was a nodular subtype melanoma with a Clark's level of IV with no features of regression. On clinical examination there was no cervical or axillary lymphadenopathy. A computed tomography (CT) thorax, abdomen and pelvis revealed some subcentimetre lymph nodes in the left axilla and jejunum. A subsequent positron emission tomography-CT did not show increased metabolic activity in these areas.
An en-bloc wide local excision of the nodules was carried out with a 2 cm margin down to pectoral fascia (, ). A sentinel node biopsy was also performed which was positive. The chest defect was reconstructed with a split-

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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 9-year-old girl was referred to our center with an Ewing sarcoma of the proximal humerus. Initially, she underwent curettage and cementation at an outside center for a pathological fracture of what was thought to be a benign cyst. The tumor progressed, and a biopsy showed Ewing sarcoma, which was confirmed by FISH for EWSR1 rearrangement, involving the proximal humeral metaphysis and epiphysis (Figure ). She was treated with neoadjuvant chemotherapy consisting of vincristine, cyclophosphamide, doxorubicin, ifosfamide and etoposide, and proton radiation therapy because of the soft-tissue contamination. A FVET was planned supplemented with a fresh frozen allograft and rotator cuff.
The proximal humerus was approached using an extended deltopectoral approach, and an intra-articular resection of the proximal humerus was performed (Figure ). The tendons of the rotator cuff cut at the myotendinous junction and tagged for repair. Owing to the previous nononcologic surgery, the anterior half of the deltoid and accompanying axillary nerve were resected. A FVET was harvested with the anterior tibial vessels. The articular surface of a cadaveric proximal humerus was removed with a saw, and the cancellous bone of the metaphsysis was removed with a burr to the cortical bone to allow for fitting of the fibular head, whereas the diaphysis was reamed to allow for the FVET to be intussuscepted within the humerus allograft with the articular surface of the fibula facing the glenoid at the level of the tuberosity. A window was created for the vascular pedicle on the medial aspect of the allograft. The anterior tibial artery was anastomosed to a side branch of the profunda brachii artery and vein. The distal end of the fibula was intussuscepted into the remaining host distal humerus, and the allograft was fixed with a compression plate. The remaining host rotator cuff was attached to the allograft cuff via heavy suture.
After fibula harvest, the lateral collateral ligament of the kne

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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 20-year-old female presented to our center with a telangiectatic osteosarcoma of the humerus. There was no history of malignancies within the family.
MRI examination and open biopsy were performed by the previous physician. At the time the results were thought to be malignant lymphoma. After several diagnostic trials, the patient visited our center to seek advice about her telangiectatic osteosarcoma (A).
We observed a circumferential mass on the distal part of the right arm with a slight deformity of the arm, with marked venous engorgmnt and distal edema. The mass was warm and solid on palpation. Function of the right hand was still preserved. From the laboratory findings, there were marked elevation of the alkaline phosphatase and lactate dehydrogenase. From humerus X-ray, there was mixed lesions along the humerus with pathological fracture on the midshaft (A). T2-weighted MRI showed iso-hyperintense and expansile lesions along the humerus (A). For the metastatic workup, chest X-ray showed no coin lesions or metastatic characteristics. Patient also had a PET scan and the result was unremarkable. From the Clinico Pathological Conference (CPC) forum, it was concluded that the diagnosis was osteosarcoma of the right humerus stage IIB according to the Enneking classification.
Patient took neoadjuvant chemotherapy regimen with Doxorubicin and Cisplatin for three cycles from January to March 2016. At the end of the third cycles, clinical and radiological evaluations were performed. Clinically the mass was not getting bigger compared to before chemotherapy (B). From x-ray, the mixed lesions became more marked compared to the previous x-ray (B). MRI showed that the mass was slightly became larger compared to the previous MRI with no involvement of neurovascular bundle (B).
Six months after the initial complaint, the surgery was performed. We used extensive deltopectoral approach with anterolateral extension through the proximal part and curved backward to complete the p

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


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

[User]
RADIOLOGY NOTE:
The patient, a 53-year-old female, was admitted to the hospital on April 05, 2019 in a car accident resulting in a fracture of the distal left tibiofibula, and was given routine heel traction and symptomatic treatment to reduce swelling after admission. On April 18, 2019, we performed “tibiofibular fracture incision and internal fixation + bone grafting,” after which we were given symptomatic treatment for swelling and pain relief. He was discharged from the hospital on May 16, 2019, and at the time of discharge there was still about 3 cm of poorly healed skin and localized redness and swelling in the lower and middle sections of the left ankle incision, and then continued to have the left ankle dressing changed at the local community hospital, and the wound never healed. One year after the operation, he was readmitted to the hospital for rehabilitation.
A follow-up X-ray showed that the metal internal fixation of the left inferior tibiofibular fracture was in place, no loosening was seen, the alignment of the severed end was acceptable, and the left inferior tibial segment was mildly osseointegrated (Fig. ).
On examination: the left ankle incision was interrupted for about 3 cm with poor healing, a small amount of muscle necrosis, fat liquefaction, a large amount of yellow purulent secretion overflow and necrotic material was seen in the local wound. The wound did not improve after routine dressing changes.
PRF gel preparation and application the preparation process was strictly aseptic: - A disposable screw-in 20 mL syringe with an 18G needle was used to draw 20 mL of autologous blood under strict aseptic conditions, and the screw-in syringe was tightened with a disposable plug, and the posterior projection and tail were cut off. Weigh, level, and centrifuge at 3000 r/min for 10 minutes. After resting, the blood sample was divided into 3 layers, the upper layer of yellowish clarified liquid was platelet plasma,

[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 woman presented with dizziness and headache. She had no neurological deficits, such as paralysis or sensory disturbances. Magnetic resonance imaging (MRI) revealed a 9 mm, unruptured, thrombosed aneurysm anterior to the brainstem []. Since the patient was asymptomatic, she was followed up on an outpatient basis. However, MRI at age 70 revealed increased aneurysm size (14 mm) and brainstem mass effect [ and ]. Three-dimensional digital subtraction angiography revealed a right proximal AICA aneurysm []. The AICA supplied the cerebellar hemisphere and did not anastomose with the posterior inferior cerebellar artery. Due to increased risk of rupture and mass effect, we decided to perform surgical intervention. Endovascular treatment was excluded because the aneurysm was of fusiform type. Parent artery occlusion posed a risk of cerebral infarction. Posterior transpetrosal approach was needed to perform complete trapping of the aneurysm. However, the approach could be too invasive to perform for asymptomatic patients. We decided to perform distal clipping of the aneurysm to combine its blind end with the occipital artery (OA)-AICA bypass to avoid cerebral infarction. Transcondylar fossa approach was selected because it is minimally invasive and makes reaching the distal end of the aneurysm and AICA easier. We did not approach the anterior brainstem. The distal AICA arose from the aneurysm body []; therefore, we clipped the AICA just distal to the aneurysm after the OA-AICA bypass [-]. We aimed to make the aneurysm thrombosed. Postoperative MRI demonstrated sporadic, asymptomatic cerebellar infarctions []. Indocyanine green video angiography showing the adequate flow of the bypass []. However, the bypass patency was not clear on MRI after the treatment. We considered the possibility that the bypass was not depicted due to an artifact or that the bypass was thrombosed due to lack of demand. The patient was discharged with a modified Rankin scale score of 1. Si

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old man presented with swelling and pain in left ankle joint without any history of acute trauma. He had experienced another episode of severe swelling and pain in left ankle area without any preceding trauma about 2 years before arrival. After definite diagnosis of ABC by another surgeon in another hospital, He had undergone curettage and autologous bone grafting via medial ankle approach and detachment of deltoid ligament.
Eight months after previous surgery, pain and swelling had begun again and continued till the time of second operation. On examination, swelling and tenderness on medial side was clearly evident. The neurovascular status of left ankle and foot was intact. Range of motion of ankle was limited to 25 degrees in plantar flexion and 10 degrees in dorsiflexion in comparison to the right ankle. Moreover it was painful particularly in full plantar flexion. Left ankle plain radiograph showed a cystic lesion in posteromedial of left talus with invasion to the articular surface of tibiotalar and subtalar joints (Figure ). As ankle CT scan clearly approved the size and intra-articular invasion of the lesion (Figure ), magnetic resonance imaging was not requested.
Surgery was performed under general anesthesia in the lateral position after inflation of a thigh tourniquet using sterile conditions. Through direct lateral approach to the lateral malleolus, fibular osteotomy from 10 cm above tip of fibula was done and completely resected. The articular surfaces of tibiotalar and subtalar joints were removed. The ABC was carefully resected because of adhesions to the posteromedial structure of the ankle joint. The pathologic report confirmed recurrent ABC. After curettage, the bone graft from the excised distal fibula bone was impacted in the arthrodesis site. The correct position of tibiotalar and subtalar joints for fusion was prepared and fixed by a Steinmann wire temporarily. Finally, the fixation was achieved utilizing a compression screw and a PHI

[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 was diagnosed with bladder cancer 6 years earlier, for which she had undergone transurethral resection six times. Oophorectomy for a right ovarian cyst and total hysterectomy for endometriosis had been performed under general anesthesia at the ages of 30 and 35 years, respectively. During the current surgery, she underwent radical cystectomy with creation of an ileal conduit and removal of pelvic lymph nodes. Her past history of multiple laparotomies resulted in intestinal adhesions and massive intraoperative bleeding. The total blood loss during surgery was 5340 ml. She received 1200 ml of autologous blood transfusion, and subsequent transfusion of 560 ml of red cell concentrates and 1200 ml of fresh-frozen plasma in the operation room. The surgical time was 6 h and 49 min. Administration of the antibiotic isepamicin (ISP: 200 mg) was started to treat a fever of 40 °C immediately after moving her to the ward. However, she developed a shock state 16 h after the operation (Fig. ). Her systolic blood pressure decreased to approximately 70 mmHg and urine output was less than 25 ml/h. Infusions of Ringer’s solution, albumin preparations, immunoglobulins, and vasopressors were started because we suspected septic shock. Administration of imipenem/cilastatin sodium (IPM/CS: 500 mg) was added to ISP because we thought that more intensive empiric antimicrobial therapy was necessary. Two days after the operation, she was transferred to the intensive care unit (ICU) because of deterioration in her respiratory and circulatory condition. Soon after moving her to the ICU, a subcutaneous hemorrhage-like skin rash appeared and extended rapidly over her left side (Fig. a). On admission to the ICU, blood tests indicated severe metabolic acidosis, liver and renal dysfunction, and signs of disseminated intravascular coagulation (DIC) (Table ). Her APACHE II (Acute physiology and chronic health evaluation) and SOFA (Sequential organ failure assessment) scores at this

[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 Indonesian female presented with a bend of the second to fifth fingers of both hands. She had been suffering from multiple joint pain, swelling, deformities, and fever as well as red patches on her face and erythematous nodules on both arms and legs for 4 years. She was initially diagnosed with systemic lupus erythematosus in the Internal Medicine Department, but after being treated, there was no improvement of her condition. She was then transferred to our department. We found a bacterial index of 4+ and a morphological index of 59.7% from the slit skin smear examination. The patient was then diagnosed with lepromatous leprosy with second-grade deformity and erythema nodosum leprosum reaction. She received multidrug therapy based on the World Health Organization multibacillary regimen for 12 months along with prednisone for 6 months. One year after release from treatment, multiple erythematous nodules reappeared, and she was diagnosed with erythema nodosum leprosum and received prednisone for 3 more months.
In the current examination, we found bilateral madarosis and hyperextension of the PIP joints and flexion of the DIP joints of the second to fifth fingers of both hands (Fig. , ). Neurological examinations showed ulnar nerve thickening by palpation and hypoesthesia without motor impairment of the fourth and fifth fingers of both hands. Bacteriological examination found no acid-fast bacilli. Radiograph examination revealed resorption of the end of the distal phalanges, cupping form deformity of the base of the proximal phalangeal joints of the second, third, and fifth fingers of the left hand and of the second and fifth fingers of the right hand. In addition, narrowing of the metacarpophalangeal joints of the second, third, and fifth fingers of the right hand and sclerosis of the second and fifth fingers of the right hand were also observed (Fig. , ). These results indicated abnormalities due to leprosy. Assessment performed by the Department of Phy

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old female presented with complaints of multiple, recurrent edema and ecchymosis of the left lower eyelid. The episodes, which first started three years prior to presentation, were spontaneous, and the subsequent swelling and discoloration were self-resolving. The patient also noticed one episode in the past when the ecchymosis developed after an episode of eye-rubbing. The patient had been in a vehicular accident involving a windshield injury 13 years prior. She had been operated upon immediately following the trauma and underwent two subsequent skin grafting procedures, the last being five years prior to presentation. On examination, the visual acuity in both eyes was 20/20 N6. The left eyebrow had focal loss of hair with scarring. The left lower lid had a shallow notch with some scarring over the skin. A dark, ecchymotic patch was seen involving the lateral half of the left lower lid extending downwards from the eyelid margin, measuring approximately 2 cm × 2 cm. Anterior and posterior segment evaluation of both eyes was unremarkable with normal intraocular pressure.
The patient’s recovery was uneventful with no recurrences of the swelling or ecchymosis. The patient had no measurable proptosis or enophthalmos and ocular motility was normal in both eyes. The orbital rims were normal on palpation and the eyelid skin showed no change on asking the patient to perform the Valsalva maneuver. On lid eversion, the conjunctiva was healthy with no visible scarring. CT of the orbits was performed, and the scans showed an unidentified, hyperdense object, measuring about 0.5 cm × 0.5 cm, with sharply defined edges sitting just within the left inferotemporal orbital rim (Figure ). On deep palpation, which elicited sharp pain, a small, hard, nodular mass was palpable. A diagnosis of an occult foreign body was made, and exploration was carried out through a skin incision which was made over the presumed location of the foreign body based

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


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

[User]
RADIOLOGY NOTE:
A previously well 46-year-old British Caucasian man was admitted with a 3 month history of a heavy dragging pain in his abdomen. The pain had been progressively worsening and was more noticeable when standing and moving. Despite having presented to medical personnel on a number of previous occasions, clinical examination revealed a 10-15 cm mobile mass in the centre of the abdomen. A plain abdominal radiograph did not show any features of obstruction. Ultrasonography of his abdomen prior to his admission had demonstrated gall bladder polyps, but no signs of cholelithiasis. Gastroscopy which had also been undertaken previously was found to be normal. A Computerized Tomography (CT) scan of his abdomen with oral and i.v. contrast was performed. This demonstrated a large soft tissue intraluminal mass arising from the distal jejunum measuring 11 cm × 8 cm × 5 cm with no signs of obstruction (). The clinical impression was that of gastrointestinal stromal tumour (GIST), lymphoma or small bowel adenocarcinoma. A laparotomy with small bowel resection and side to side stapled anastomosis was performed and recovery was uneventful. Within hours of the operation, the patient reported that the heavy sensation in his abdomen had completely abated.
Macroscopic examination of the specimen revealed a dumbbell-shaped, circumscribed fleshy white mass measuring 13.5 cm in maximum dimension (). This extended into the mucosa, forming an ulcerated polyp with intact serosa. Histopathology revealed variable cellularity, with spindle cells having bland nuclei and clear cytoplasm. There was an abundant inflammatory infiltrate comprising plasma cells, lymphocytes and eosinophils (). The lesion involved the entire thickness of the bowel wall with extensive ulceration of the overlying mucosa. On immunohistochemistry, the spindle cells were negative for cytokeratins, CD117 (c-kit), S100, Actin, Desmin, CD34, CD10 and Melan A. The morphological features were typical of IFP and the immunoprofile wa

[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 74-year-old man was referred to our hospital with severe aortic valve insufficiency and left ventricle dilatation. His past medical history showed hypercholesterolemia and a recent episode of de novo atrial flutter which was treated with electrical cardioversion. His medication included atorvastatin, nebivolol, and dabigatran. He stopped smoking 40 years ago and uses 14 units of alcohol per week.
The patient's vital signs were normal. Physical examination revealed normal pulmonary, abdominal, and neurological functions. Except for a diastolic murmur at the right lower sternal border, cardiovascular examination revealed normal heart sounds. Coronary angiography did not show significant coronary artery disease. Transthoracic echocardiography revealed a severe aortic valve insufficiency with a somewhat impaired function of the left ventricle. Cardiac MRI showed severe aortic valve insufficiency combined with a dilated aortic root (46 mm) and a severely dilated left ventricle with an ejection fraction of 50%. Aortic valve replacement with a biological device (Edwards Lifesciences Perimount 27 mm) was performed. No complications occurred during surgery. Except for a ventral pneumothorax, the patient's recovery was uneventful. He was discharged in good condition to the cardiology nursing ward of a peripheral hospital on postoperative day 4. At two weeks follow-up, the patient was doing well. He did not experience any cardiac complaints. For further recovery, the patient was referred back to the referring cardiology department. After 6 weeks, the patient was reevaluated for his recovery at the policlinic of cardiothoracic surgery, where no abnormal findings were observed during physical examination.
The excised aortic valve was tricuspid and measured 3.5 × 1.3 × 0.3 cm. The cusps were partially calcified. Microscopic examination of cross-sections of the aortic valve leaflets showed areas of calcification with focal ceroid, as can be found in the atherosclerotic valves [,

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


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

[User]
RADIOLOGY NOTE:
A 32-year-old female patient developed depression, anxiety and subtle gait disturbances during the second trimester of her first, otherwise uncomplicated pregnancy. Her main complaint upon her first visit to the emergency department was having difficulty finding words and concentrating, as well as having a fear of falling while walking. She felt anxious and hopeless and showed mildly decreased cognitive function, achieving a score of 24 points on the Mini Mental State Examination. Perinatal depression was suspected, and she was treated by the Department of Psychiatry for six months without significant improvement in her symptoms. Upon completion of her treatment, the patient displayed an unusual wide-based, shuffling, very slow and highly fluctuating gait. She walked in small steps and sometimes staggered severely, but her symptoms were variable, and she did not fall. Therefore, her gait disturbances were classified as psychogenic. However, cerebral MRI showed confluent white matter lesions suspicious for CADASIL. The patient had been treated for mild hypertension since the age of 29 but had otherwise been healthy. Her family history was negative for any hereditary diseases, but her reported history was fragmented because she had broken off all contact with her father at the age of 18.
The patient subsequently presented to us ten months after symptom onset and six months after she had given birth to a healthy girl. She presented with conspicuous global bradykinesia with severe slowing and hesitation in her fine motor skills and symmetric rigidity in all her extremities, but without tremor. She also exhibited reduced spontaneous speech with slight amnestic aphasia and ataxic dysarthria, with loss of modulation. Her gait disturbances had worsened, as she could walk only short distances independently, and she had difficulty lifting her feet of the ground without external instruction but showed no typical freezing behaviors. Apraxia was an important finding, as it was e

[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.