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

[User]
RADIOLOGY NOTE:
A 35-year-old man was referred to our clinic for evaluation of a lesion that developed on his hard palate. The patient became aware of the lesion one month prior to his first visit. During consultation, he complained that the lesion became sensitive when it came in contact with hot and salty foods, but he experienced no other specific symptoms. The patient had a history of an unknown sexually transmitted disease, which he contracted one year prior to his first visit and completely recovered from by the time of consultation. In addition, the patient had a 20-year history of heavy smoking. No other specific general diseases or exceptional medical history were noted. During the clinical examination, which was conducted during his first consultation, a soft sessile mass with a verrucous, papillary surface resembling a strawberry was found on the palatal gingiva of the left maxillary second premolar and first molar. The lesion was 2.5×1.0 cm in size, well demarcated, and pinkish in color. It was not painful when palpated. He also had a normal response in the percussion, mobility, and vitality tests of his teeth, however; the palatal aspect of his left maxillary first molar showed mild gingival recession. The radiological examination, including periapical and panoramic radiographs, did not yield specific results. Further, there was no enlargement or induration of his bilateral neck lymph nodes on palpation. Though we could not obtain more information about his medical history in regard to his sexually transmitted disease, we suspected a relationship. We diagnosed the lesion with differentials that included syphilis and malignancies such as squamous cell carcinoma or verrucous carcinoma. An incisional biopsy for a definitive diagnosis was performed one week after the initial examination. During histopathologic examination, histology slides obtained from the biopsy showed a papillary squamous epithelial cell layer covered with parakeratotic surface () and xanthoma cells in

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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:
The patient was a 40-year-old primiparous woman. She was diagnosed with submucosal fibroids by her previous gynecologist 5 years prior, based on chief complaints of atypical genital bleeding and hypermenorrhea. She underwent hysteroscopic myomectomy for one 1 cm sized and one 3 cm sized submucosal fibroid located between 2 and 3 o'clock in the uterine fundus. Asherman's syndrome was suspected after the patient exhibited secondary hypomenorrhea 10 months after surgery. Therefore, hysterosalpingography and magnetic resonance imaging (MRI) were performed. Intrauterine adhesions were suspected based on hysterosalpingography findings, while uterine cavity narrowing was identified using MRI. Hysteroscopy revealed filmy adhesions consistent with myomatous tissue at the excision site, and the patient was diagnosed with Asherman's syndrome.
Eight months after diagnosis, the patient underwent hysteroscopic adhesiolysis. The filmy adhesions observed on the left side of the fundus were easily separated with Hegar cervical dilators, and an intrauterine device was inserted after dilation. The patient was diagnosed with stage I Asherman's syndrome defined by European Society for Hysteroscopy classification of intrauterine adhesions, and menstrual flow returned to normal after the operation.
While the patient had a strong desire to bear children, her inability to conceive for 7 years led her to pursue in vitro fertilization (IVF). After having a miscarriage at 7 weeks of gestation, she underwent cervical dilatation and uterine curettage.
Six months after the miscarriage, the patient became pregnant again through IVF and was referred to our hospital at 7 weeks of gestation. At 19 weeks of gestation, tissues with a free edge were visualized within the amniotic cavity using obstetric ultrasound and were determined to be amniotic sheets on MRI at 31 weeks of gestation (). The course of pregnancy was uneventful thereafter, and an elective cesarean section was performed at 38 weeks and 2

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old Caucasian man presented to the emergency department of our hospital with a 1-week history of abrupt-onset blurry vision, dizziness, nausea, vomiting, and ataxia initially thought consistent with a posterior circulation stroke. The patient denied associated vertigo or headache. He had no prior history of stroke and had been taking prophylactic aspirin for years for a patent foramen ovale. Noncontrast head computed tomography (CT) performed in the emergency department demonstrated no visible masses or hemorrhage. A shrapnel adjacent to the patient’s eyes precluded the possibility of further visualization with magnetic resonance imaging (MRI). He was admitted for further workup and treatment. Carotid Doppler ultrasound showed no stenosis. Subsequent CT angiography did not clearly visualize the brain parenchyma but showed no vascular compromise. The initial working diagnosis was of a cerebellar stroke, and the patient was transferred to the acute inpatient stroke rehabilitation service.
Despite participation in rehabilitation therapies, his symptoms progressively worsened, prompting repeat noncontrast head CT 9 days after admission, which demonstrated indistinct, masslike lesions in the cerebellum, one with evidence of hemorrhage and surrounding vasogenic edema and mild hydrocephalus. Contrast-enhanced CT performed later that day revealed three intensely enhancing masses in the right cerebellar hemisphere (Fig. ). The patient was started empirically on steroids for his vasogenic edema, which produced rapid improvement in his symptoms. Because these cerebellar lesions appeared most consistent with metastatic disease, the neurosurgery service recommended metastatic cancer workup without immediate surgical intervention. CT with contrast enhancement and whole-body positron emission tomography failed to demonstrate a primary tumor of origin outside the central nervous system (Fig. ). The patient underwent right suboccipital craniotomy with partial resection of

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man with a background of sarcoidosis presented with an acute myocardial infarction and underwent emergency percutaneous coronary intervention and revascularization of his left anterior descending artery with an 8-Fr sheath access of the right common femoral artery. The patient was anticoagulated with unfractionated heparin during the procedure. The intervention went uneventfully and the arteriotomy site was closed with an Angio-Seal vascular closure device. The patient recovered well and was discharged after 2 days and was commenced on dual antiplatelet therapy.
One week following his cardiac intervention, he was noted to have a pulsatile mass in his right groin with an associated bruit. He underwent a Duplex arterial ultrasound scan, which showed a bilobed pseudoaneurysm (superficial aneurysm measures 20 mm in transverse diameter with a shallow neck 0.8 mm; deep aneurysm measures 12 mm in transverse diameter which extends off a 6 mm neck) arising just lateral to the femoral artery puncture site [].
He went on to have an ultrasound-guided percutaneous injection of the pseudoaneurysm with thrombin. The procedure proved to be extremely challenging due to rapid blood flow and the wide pseudoaneurysm neck (6 mm). Following 10 min of direct sonographic probe pressure, complete occlusion of the superficial pseudoaneurysm was observed but a small residual fleck of flow on power Doppler was evident to suggest an incomplete occlusion of the deep component of the pseudoaneurysm []. This was confirmed on repeat Duplex ultrasound scan the following day [].
The patient refused surgical repair and was offered a novel approach using an Angio-Seal vascular closure device. Informed consent was obtained from the patient for the “off-label” use of this device. A 6-Fr contralateral sheath was positioned in the distal right external iliac artery from the left common femoral artery and angiography was performed which demonstrated the pseudoaneurysm arising from the anterola

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old male patient was admitted to the hospital due to acute abdominal pain and diffuse peritonitis that lasted for 3 days. Due to severe septic shock, a central venous catheter was introduced through the right jugular vein during the operation to facilitate rapid fluid resuscitation and the application of vasoactive drugs. Two days after surgery, the hemodynamics was stable. On the third day, the patient had spontaneous exhaust and got out of bed with slight movement. The vasoactive agent was discontinued on day 5. On the 7th day, patient was given a small amount of liquid diet; parenteral nutrition fluid was introduced through central venous catheter, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On day 14, the patient was able to eat normally and had to stop parenteral nutrition treatment. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest and received emergency cardiopulmonary resuscitation. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein (Figs. and ; Additional file 1 [Long axial section of the right jugular vein showing the thrombus attached to the inner wall of the vessel and drifting with the blood stream.] and Additional file 2 [A short axial view of the right jugular vein shows thrombus drifting with blood flow.]). The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle (Additional file 3 [Lower section of the xiphoid process shows decreased systolic amplitude of the right atrium and right ventricle.]), widened and fixed inferior vena cava, and no variation with respiration (Fig. ). Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anteri

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


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

[User]
RADIOLOGY NOTE:
A 57-year-old female with known Muir-Torre syndrome presented to their dermatologist with two nonspecific sebaceous lesions, each appearing as yellow erythematous nodules with cystic features. The two lesions on the back were removed: 0.5 × 0.5 cm mid back and 0.5 × 0.4 cm lower back. Histologic examination of the lesion on the patient's mid back revealed a sebaceoma and was described by the pathologist as a well circumscribed lobulated tumor with regional cyst formation. The cellular population consisted predominantly of basaloid cells with a variable sebaceous component. The second lesion obtained from the lower back was diagnosed as a sebaceous adenoma and was described as demonstrating papillary epidermal hyperplasia, sebaceous lobules with a basaloid rim, focal parakeratosis, and mixed inflammatory infiltrate. Immunohistochemistry was able to confirm an HMSH2 mutation. Although being diagnosed with sebaceous neoplasms in the past, the patient has had several cutaneous lesions throughout her adult life that were not biopsied, including, most recently, an erythematous, nodular lesion on her scalp (). This lesion had been excoriated and subsequently removed prior to clinical examination and therefore a specific diagnosis was not determined.
The patient had three previous internal growths. The patient's past medical history revealed that she was diagnosed with endometrial adenocarcinoma in 1993, for which she underwent a radical hysterectomy. She was 36 years of age at the time of the diagnosis. After this first malignancy, the patient, as well as many of her family members, underwent genetic testing. Several years later in 2008 she was diagnosed with intramucosal adenocarcinoma of the ascending colon, for which a right hemicolectomy was performed. The patient underwent regular colonoscopies and endoscopies every 6 months for several years following the discovery of this colonic adenocarcinoma. In 2014, during her most recent colonoscopy/endoscopy, a tubular adenom

[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 44-year-old Caucasian male had previously had a right hemicolectomy for a paracecal mass. He had no significant past medical history, although his father and paternal grandfather had both been diagnosed with bowel cancer over the age of 70 years. The histology had shown myoepithelioma of uncertain malignant potential, arising from the paracecal mesentery, which had partially infiltrated the large bowel wall but which showed no origin from bowel mucosa. Three years later, the patient presented with abdominal distension and lower abdominal pressure. On examination there was a palpable lower right quadrant mass. He was found to have multifocal recurrent intra-abdominal disease. Imaging revealed multiple lesions up to 8.8 cm within the mesentery and abdominal wall (), which were confirmed by biopsy on laparoscopic evaluation to be recurrent myoepithelial tumor. He was subsequently treated with 6 cycles of single agent doxorubicin with stable disease by response evaluation criteria in solid tumors for a total of 8 months. On treatment his symptoms improved. He then developed abdominal pain and imaging revealed progressive intra-abdominal disease and he was commenced on gemcitabine and docetaxel. He received 6 cycles of this combination schedule, and after 6 cycles, repeat imaging demonstrated progressive disease. His symptom of abdominal pain also worsened on this schedule. On the basis of an excellent performance status, he was offered participation in a clinical trial assessing molecular and radiological markers of response to the VEGFR tyrosine kinase inhibitor, pazopanib. He continued on the clinical trial for 7 months, but unfortunately his disease progressed. He was subsequently treated within a Phase I trial, but the first restaging scan after 6 weeks on trial showed progressive disease. His symptoms are currently well controlled and he is on active surveillance. Due to the location of the metastatic disease, no radiation has been administered as it could potent

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


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

[User]
RADIOLOGY NOTE:
A 43-year-old deceased white male was found lying prone in front of his automobile, facing away from the vehicle and wearing only a black tank top shirt and two white socks. He was last seen alive by his brother two days earlier. A large pool of dried blood and spattered blood lay over the car's hood. Due to recent heavy rains, some of this blood had run down the front of the vehicle, onto the bumper, and settled onto the ground beneath. A distinct circular indention was observed on the hood. Beneath the deceased's head was a copious amount of blood, and clutched within his extended right hand was a tubular metal object thickly covered in dried blood. Upon further inspection, it was discovered that this metal object was in fact the housing tube for a vehicle radio antenna, which would extend from the housing when the automobile is running and retract when the vehicle was powered off. Approximately two inches of antenna extended from the housing tube when it was found in the deceased's hand (Figure ).
A search inside a metal storage shed in close proximity to the body uncovered assorted drug paraphernalia, including a metal spoon and empty syringe. It was confirmed through interviews with family members that the deceased abused illegal narcotics, including methamphetamine.
A search of the man's bedroom resulted in the recovery of a notebook containing two different handwritten and signed suicide-type notes, the first of which was an apparently compendious life statement, and the second an apology to his family. These notes had been written over two weeks prior to the discovery of the body.
The external examination was notable for moderate decompositional change and insect activity, concentrated over the head and chest. A 1/4 inch laceration was superior to the right eyebrow. No other injuries were noted externally. Inspection of the right

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old female reported to the Department of Oral and Maxillofacial Surgery with the chief complaint of pain due to decayed tooth in right lower back region since 2 months. The intraoral examination revealed partial edentulous lower jaw with 33, 34, 35, 36, 37, 43, 44, and 45 teeth present. Careful examination revealed swelling in the anterior mandible, which was not obvious for the patient to take treatment. The swelling was present from past 9 years and was asymptomatic with slow growth. There was no associated history of trauma. The anterior teeth 31, 32, 41, and 42 were extracted 4 years back by the dental surgeon due to loosening [Figure and ]. Patient was not advised for the intraoral radiographs before extraction. Patient was wearing removable partial denture in the lower anterior mandible, which impinged the underlying alveolar mucosa and appeared erythematous.
The medical history of the patient revealed her to be hypertensive and diabetic from past 2 years and is under medication for the same. The swelling appeared hard without any change in the color of overlying mucosa except in denture region. The extraoral examination showed mild swelling of the lower anterior mandible. The submandibular glands were palpable, nontender but hard, and appeared fixed to the underlying structures.
Introral periapical radiograph and panoramic radiographs were advised, which revealed well-defined lytic multilocular radiolucency involving the whole of the anterior mandible with its extension in the anteroposterior direction involving right and left body of the mandible [Figures and ]. Based on the clinical and radiographic finding, a differential diagnosis of odontogenic keratocyst and ameloblastoma were made. Fine-needle aspiration cytology (FNAC) was advised, which revealed only blood cells. Incisional biopsy was carried out, which on gross examination appeared as blood clots; but on histopathology, it showed ciliated cells with intraepithelial microcyst formation and

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old male presented to the outpatient clinic at the National Cancer Institute, Cairo University with epigastric swelling, upper abdominal pain, and vomiting for 3 days. On clinical examination, an epigastric mass (8 cm × 10 cm) was palpable. Biochemical laboratory investigations showed raised C-reactive protein (46 mg/L). All other investigations were within normal limits including pancreatic amylase, carcinoembryonic antigen (CEA), and CA 19-9. Initial imaging (liver ultrasound and chest/abdominal X-ray) showed a large epigastric swelling 11 cm × 8 cm that was closely related to the pancreas.
Magnetic resonance imaging (MRI) of the pancreas revealed a well-defined rounded cystic lesion abutting the ventral portion of the central pancreas. The cyst wall thickness measured 7 mm. Multiple low signal intracystic strands were noted floating within, associated with a distinctive hypointense ring of the pericystic lining. No daughter cysts could be seen indicating that the cyst can be classified CE Type 3 a (transitional hydatid cyst) as per the WHO Informal Working Group classification.[] The pancreatic duct was seen as a hyperintense line leading to the lesion []. Consequently, HD was confirmed with a positive indirect hemagglutination test.
A diagnosis of isolated HD of the pancreas was made and the case was discussed at the hepatopancreaticobiliary multidisciplinary team meeting, and all members approved a surgical plan for partial cystectomy and cystogastrostomy due to pancreatic duct involvement. The patient was started initially for a month at a high dose of albendazole (800 mg/day). His liver functions were checked 2 weeks into the course and were completely normal. He then spent 2 weeks free of medical therapy before resuming his second course at the same dose for a month before surgery.
Surgical exploration revealed a large cyst involving the body and tail of the pancreas densely adherent to the adjacent stomach and transverse colon. The rest of the abd

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


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

[User]
RADIOLOGY NOTE:
An eleven-year-old male child presented with complaints of headache for the past 6 months. Patient also had recurrent vomiting of 1 month duration. He also complained of numbness over the right side of face. On examination, patient was conscious and oriented. Sensory loss was present over right V2, V3 distribution of trigeminal nerve. His fundus examination revealed papilloedema. Patient did not have any motor deficits.
Noncontrast CT scan head revealed an isodense right middle cranial fossa lesion. On MRI scan, the lesion was hypointense on T1 weighted images and hyperintense on T2 weighted images. The lesion was homogenously enhancing. It was extra-axial in location, involved right middle cranial fossa and extended extracranially into the infratemporal fossa. The lesion was creating a significant mass effect with midline shift (). Routine haematological investigations and blood chemistry were within normal limits.
Patient underwent right frontotemporal craniotomy with zygomatic osteotomy. Intraoperatively, the tumor was present extradurally in right middle cranial fossa which was also extending through the dura into intradural compartment in temporal region as well as the posterior fossa into cerebellopontine angle cistern. The tumor was destroying temporal base and was extending extracranially into subtemporal region. The tumor was highly vascular, firm with good plane of cleavage with brain. The tumor was stuck to the lateral wall of cavernous sinus from which it was separable. The tumor extending into the posterior fossa was excised by drilling the petrous apex. Complete excision of intracranial part of tumor was done. As there was significant bleeding during the surgery, complete excision of infratemporal extension of the tumor was not attempted and only partial decompression was done. The dural defect at middle fossa floor was repaired with temporalis fascia. Postoperative course was uneventful.
Tumor tissue in 10% neutral buffered formalin was routinely proc

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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 25-day-old term baby female presented with neonatal jaundice and hyperbilirubinemia. A biliary cyst and a contracted gallbladder were diagnosed in a post-natal ultrasound from another institution. She was transferred to our hospital at day 19 of life. A repeat ultrasound showed a small gallbladder (length 1.7 cm; diameter 0.3 cm) connected to an extrahepatic cystic structure, which measured 1.4 × 0.6 cm (). The content of the cyst was anechoic and there was no dilatation of intrahepatic bile ducts. A hepatobiliary iminodiacetic acid scan on day 26 of life showed no biliary drainage up to 28 h. A PTTC on day 35 of life showed there was prompt opacification of the known extrahepatic cyst, followed by visualization of a small gallbladder. There was no passage of contrast into bile ducts or the duodenum. Aiming to demonstrate that there was no communication of this cyst with the biliary system as well as to mechanically remove any source of obstruction, the contrast injection was sustained until there was an extraperitoneal perforation of the cyst () (radiation dose: 1.1 mGy). The rationale to sustain the injection was to demonstrate a connection of the cyst with the biliary tree and our experience that there may be a benefit of mechanical lavage of the biliary tract in cases of obstruction by secretions or sludge, which has been reported by our institution in neonates with parenteral nutrition-related cholestasis. An uncomplicated ultrasound-guided biopsy was performed. Intravenous antibiotics were started owing to perforation of the cyst and the patient recovered well from the procedures. The biopsy result was consistent with extrahepatic biliary obstruction.
At the time of surgery, a cystic structure, distinct from the gallbladder, was encountered, which was located in the common bile duct. Proximally, the cyst was in continuity with a cord-like hepatic duct. A standard Kasaï procedure was performed with a hepaticojejunostomy. Subsequently, the patient’s jaundice r

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old male presented with a 1-week old history of sudden onset binocular diplopia. He had been diagnosed by his primary ophthalmologist, on day one, as right sixth nerve palsy of presumed ischemic origin and had been advised prism glasses. On examination, both eyes had visual acuities of 6/6 N6. Intraocular pressures, pupillary reactions, and dilated fundus examination of both eyes were normal. Ocular motility evaluation showed that the patient had an isolated right-sided abduction deficit [Fig. –]. There was no proptosis or enophthalmos. All other cranial nerves were normal. Systemically, the patient had no vasculopathic risk factors or other illnesses. On eliciting a detailed systemic history with pointed questions, the patient disclosed that he had been suffering from a dull toothache in the region of his right upper molars and had difficulty in chewing for the last one month; for which, he had not sought any treatment. Magnetic resonance imaging (MRI) of the head was performed. A mass measuring 4.2 cm × 3 cm × 2.2 cm was seen arising from the right half of the hard palate with solid contents eroding into the right maxillary sinus through the floor along with destruction of the right maxillary-alveolar ridge in the region of the molar teeth []. Posteriorly, it was seen extending up to and involving the right anterior cavernous sinus close to the right superior orbital fissure [Fig. and ]. A small portion of the right anterior Meckel's cave was also invaded by the tumor. An incisional biopsy of the hard palate was performed; the histopathological examination of which, showed basoloid tumor cells in a cribriform pattern with eosinophilic material-consistent with ACC. A positron emission tomography–computed tomography scan showed high uptake in the region of the primary malignancy as well as multiple cervical lymph nodes. All treatment options were explained to the patient who chose to undergo palliative radiation and received 30 cGy in

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

[User]
RADIOLOGY NOTE:
An 11-year-old Brazilian Caucasian boy from a rural area was examined in the orthopedic ward of our emergency department. Our patient reported a three-month history of pain in the right hip with intermittent claudication, and complained of recurring episodes of intense pain and an inability to walk, which he had been experiencing for the previous five days. He also presented with a fever that had persisted for two days. Our patient’s medical history did not include any clinical respiratory manifestations, skin lesions, history of trauma or immunosuppression risk factors.
A chest radiograph image (Figure ) appeared normal, although a pelvis radiograph (Figure ) showed an osteolytic lesion in the meta-diaphyseal region of the right femur and increased volume and soft tissue density in the intra-articular projection, which is consistent with the existence of an effusion. A computed tomography (CT) scan of the right hip showed an osteolytic lesion in the meta-diaphyseal region of the femur that was associated with a disruption of the cortical bone and hypodense intra-articular material that is consistent with an articular effusion (Figure ). From a magnetic resonance imaging (MRI) study, osteomyelitis and pyoarthritis in the meta-diaphyseal region of the femur were characterized by an area of low signal intensity on the T1-weighted image. The presence of diffuse enhancement was visualized with the use of a paramagnetic contrast agent and the existence of a periosteal reaction was identified in addition to joint effusion with the enhancement, indicating synovitis and edema of the adjacent muscle bellies (Figure ).
Pyoarthritis drainage and a bone biopsy were performed and intravenous antibiotics were administered to our patient. The results of a pathological study confirmed the presence of P. brasiliensis (Figure ) and fluconazole treatment was initiated (10mg/kg/day). Our patient is at the time of writing still undergoing treatment and showing significant improvements,

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

[User]
RADIOLOGY NOTE:
A 32-year-old African American male with a clinical family history of FAP in his mother and 1 of 2 siblings was diagnosed with medulloblastoma at age 10. This was treated with surgical resection followed by RT (54 Gy to posterior fossa, 36 Gy to craniospinal axis; ).
Thirteen years later he underwent near total thyroidectomy. Histopathologic examination revealed multifocal papillary thyroid carcinoma with an insular component involving both lobes. Extensive dense fibrosis precluded total thyroidectomy. The recurrent laryngeal nerve was not visualized, so a posterior portion of the gland was preserved. Five years later, he underwent re-excision of recurrent papillary thyroid carcinoma.
The patient’s family history of FAP prompted screening colonoscopy at age 24, during which 5 sessile polyps were removed from the sigmoid colon. He opted for an extended right hemicolectomy, but after dozens of sessile polyps were found the following year he underwent subsequent total colectomy with ileoanal anastomosis.
At the age of 30, the patient presented with a 1-year history of a painful enlarging right posterior cervicothoracic shoulder mass in the paraspinal trapezius musculature that extended medially to the posterior spinous processes (). Excisional biopsy revealed an 8.3 cm small cell soft tissue osteosarcoma; this was treated with 2 cycles of high-dose methotrexate followed by adriamycin and cisplatin (). Follow-up computed tomography showed residual tumor at the biopsy site. This was re-excised just over a year after the initial biopsy. Histopathologic evaluation demonstrated a 10.5 cm osteosarcoma with 40% tumor necrosis; a positive surgical margin at the trapezius muscle prompted a repeat resection with partial scapulectomy. Six months later, solitary metastatic osteosarcoma was found in the pancreas with subsequent widespread abdominal organ involvement. He underwent additional high-dose methotrexate, adriamycin, and cisplatin therapy, followed by exploratory laparotom

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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 34-year-old female was seen in the emergency department for abdominal pain. Her workup included a CT abdomen where she was found to have bilateral renal masses: 2.4cm on the right and 7.6 cm on the left (). Also noted were multiple small cysts in the lung bases. The rest of the workup was unremarkable and her abdominal pain resolved with conservative management alone. She was referred to urology where it was recommended that her left kidney tumor be resected and to defer the right pending pathology results. Notably, she had no prior medical history and no relevant surgical history and had otherwise been healthy and well. She has two siblings without lung, skin, or kidney symptoms and her parents are likewise healthy. She has a 15-year-old son who is healthy. There were no consistent skin findings on exam.
Pulmonary evaluation with a CT of chest identified basilar predominant multiple lung cysts with the largest cysts measuring approximately 1.6cm. Several <6mm partially solid nodules were noted as well. Spirometry, diffusion capacity, and plethysmography were all within normal limits. She did complain of mild dyspnea, but that this was intermittent and had a significant anxiety component.
She eventually underwent resection of the left kidney mass with a partial nephrectomy and a final pathologic diagnosis of an oncocytoma, which is a typical tumor type for Birt-Hogg-Dubé syndrome. Her postoperative course was unremarkable with a planned sequential right nephrectomy pending further evaluation.
Birt-Hogg-Dubé syndrome was suspected given this patient's basilar predominant multiple lung cysts and bilateral renal masses, but without skin findings the diagnosis was in question. There are no universally accepted diagnostic criteria, but typically either skin findings or a pathologic mutation must accompany the lung and kidney pathology to solidify the diagnosis. Genetic testing was thus obtained via a blood sample. The FLCN gene of the patient was sequenced with any del

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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:
Female patient, aged 27 years, reported dissatisfaction with protruding teeth and lack of passive lip sealing. The frontal facial analysis revealed symmetry, a good proportion between facial height and width and balanced facial thirds, characteristic of mesofacial individuals. The lateral analysis revealed a Pattern I face with good convexity and well-positioned maxilla and mandible. Lateral evaluation of the lower facial third did not reveal increased projection of the upper lip, but interposition of the upper incisors between the lips. This projection of incisors impaired passive lip sealing and promoted lower lip eversion, which compromised the facial esthetics.
In the evaluation of smile, the upper arch presented good vertical exposure of upper incisors and some gingiva. It also revealed increased exposure of incisors with the lips at rest (, and ). In a closer view, it was possible to observe the interference of upper incisors on the lips, with increased inclination, both at rest and when smiling, compromising the esthetics ( and ).
Analysis of the dental arches revealed an Angle Class I malocclusion, with excellent sagittal relationships of molars, premolars and canines, coincident upper and lower dental midlines, mild crowding in the lower arch and decreased overjet and overbite, due to the increased inclination of upper and lower incisors ().
The panoramic radiographic analysis showed the absence of lower third molars and the presence of upper third molars. The upper left third molar was mesially angulated and impacted on the second molar. Then, extractions of the upper third molars were requested. The other teeth and periodontal structures had normal conditions ().
The initial cephalometric analysis revealed a slight maxillary deficiency and good mandibular positioning; slightly divergent angles of the palatal, occlusal and mandibular planes; and normal height of the lower facial third, characteristic of mesofacial individuals ().
» Upper incisors had incre

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


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

[User]
RADIOLOGY NOTE:
A 54 year old male, with no comorbidities or significant social history presented to the emergency department with a three day history of intermittent generalized abdominal pain radiating to the back. He did not endorse a history of constitutional symptoms. Upon presentation to the emergency department he was hemodynamically stable. Physical examination revealed a soft abdomen with generalized tenderness particularly in the epigastric region. Initial lab results showed a WBC 6.77 × 109/L, serum amylase 79IU/L, urinary amylase 738IU/L, CRP 73.88 mg/L, D-dimer 13.66ug/ml, and a Lactate of 1.87 mmol/L. The patient was subsequently admitted under the gastroenterology service with the diagnosis of pancreatitis.
Preliminary CT Abdomen with oral and IV contrast showed acute pancreatitis with superior mesenteric and portal vein thrombosis and no evidence of mesenteric small bowel involvement (). He was managed conservatively on the ward by means of heparin Infusion and thereafter switched to LMWH and warfarin. A week later he developed sustained tachycardia and sudden drop in WBC with associated increase in lactate to 5.31IU/L. A follow up CT abdomen with IV contrast revealed diffuse wall thickening involving multiple loops of jejunum highly suspicious of bowel ischemia (). A decision was made to proceed with an exploratory laparotomy which revealed no evidence of full thickness necrosis but characteristics of small bowel edema secondary to SMV thrombosis. Additionally, the pancreas appeared inflamed and edematous with evidence of intraperitoneal calcification within the lesser sac. An ABthera vacuum dressing was applied in anticipation of a second look laparotomy. The patient was shifted to the ICU where he showed evidence of progressive acute hepatic failure with rising INR, bilirubin, and serum ammonia level. On re-evaluation of the bowel within 48 h, we noted viable but dusky appearing jejunum. An access sheath was inserted retrograde from the middle colic vein into the

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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 22-year-old intoxicated male without any medical comorbidity was involved in a motor vehicle accident when he lost control of his automobile in a residential area and ultimately collided into a house. The patient was unrestrained and did not lose consciousness in the accident. Emergency medical personnel at the scene did report the deployment of the airbags with the patient displaying a Glasgow Coma Scale score of 15. He was emergently brought to the trauma center in stable condition. His primary survey revealed diminished breath sounds over his right hemithorax in conjunction with an increased respiratory rate. On further examination, he did appear to have crepitus over his right clavicle and gross deformity in his right thigh. Neurologic and vascular examinations of his extremities were normal.
Radiographic analysis of his chest revealed a right proximal third clavicle fracture with inferior displacement complicated by a partial pneumothorax (). He had also sustained a displaced femoral shaft fracture. A chest thoracostomy tube was inserted emergently into the right pleural cavity and placed under suction to inflate the lung. Further radiographic studies including computerized tomography images confirmed that the fractured clavicle had penetrated the pleural cavity and caused a partial lung collapse (). The patient was initially placed in a sling for the clavicle fracture to allow access to the thoracostomy site. The patient underwent intramedullary nailing of his femur with a centromedullary device without complication the day of his injury. Due to the magnitude of displacement of the clavicle fracture, it was thought that achieving union with nonoperative modalities would be problematic. Pulmonary alveolar tissue seemed to be interposed in the fracture site further complicating the probability of union as well pneumothorax resolution with conservative treatment. The patient was counseled regarding both the orthopedic and cardiopulmonary risks of the surgery. I

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

[User]
RADIOLOGY NOTE:
A 58-year-old male patient presented with left knee lateral pain after a slip down injury a month ago. He had a history of ligamentous injury that occurred 20 years ago, for which no further diagnosis or treatment was done. He had been experiencing mild ‘giving way’ symptoms since then, but the symptom aggravated after the recent trauma. On the physical examination, we found that the range of motion of the patient’s left knee was normal. Medial joint line tenderness was present. The result of the posterior drawer test was grade 2 positive, and McMurray test was also positive-knee pain in external rotation. Plain X-ray showed unremarkable findings.
On magnetic resonance imaging (MRI), a longitudinal tear of the medial meniscus () and a horizontal tear of the lateral meniscus () were shown with high-intensity signal on the proton density spectral presaturation inversion recovery coronal image. There was also a slightly high-intensity signal shown in the posterior cruciate ligament (PCL), indicating a probable acute partial tear of the ligament or evidence of an old injury.
For diagnostic arthroscopy, we made an anterolateral portal for visualization and an anteromedial portal for performing surgery. By examining the intercondylar notch and articular surfaces of the femur and tibia through these portals, we arthroscopically confirmed a longitudinal tear of the medial meniscus but the lateral meniscus was intact without tear. Instead, we confirmed a cord-like structure, originating from the posterior 1/3 portion of the lateral meniscus and passing obliquely toward the medial femoral condyle in front of the PCL-anterior meniscofemoral ligament (ligament of Humphrey) (). There was no sign of a tear of the anterior cruciate ligament and PCL structures. The main cause of the knee pain was finally proven to be due to the medial meniscus tear because there was neither a lateral meniscus tear nor a PCL injury in this patient.
Arthroscopic partial medial meniscectomy was

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


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

[User]
RADIOLOGY NOTE:
A 50-year-old, right-hand-dominant man presented with left upper thoracic pain upon shoulder elevation. One year earlier, he was involved in a head-on car collision, which resulted in acute pain in the upper half of the body when moving his left arm forward. He was seated in the front right (driver's) seat and wearing a three-point seatbelt at the time of the accident. Cervical spine sprain and left shoulder contusion were diagnosed at an emergency hospital, and although he was treated with medication and rehabilitation, his symptoms did not improve. Physical examination of the left glenohumeral joint revealed no limited range of motion, muscle weakness, or signs of instability, but tenderness was noted around the sternoclavicular joint. Crepitus and severe pain in the left upper thorax occurred during moving the left shoulder downward from 80 to 70 degrees in flexion. A lower brachial plexus injury was also suspected because of a sensory disturbance in the C8 cervical root area and weak grip (10 kg; measured using a squeeze dynamometer). Although initial examination of the sternoclavicular joint on plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) revealed no obvious abnormalities, injection of corticosteroid and local anesthetic into the sternoclavicular joint temporally reduced the pain. As we assumed that his symptoms were caused by injury to the sternoclavicular joint disc accompanied by synovitis, we performed arthroscopic surgery of the left sternoclavicular joint. Because arthroscopic findings demonstrated synovitis and partial tear of the intra-articular disc of the left sternoclavicular joint (), synovectomy and partial disc excision were performed. Postoperatively, the patient's symptoms decreased by half, but another pain and crepitus at the inferior lateral portion of the sternoclavicular joint developed a few days after the initial surgery. Careful MRI reexamination revealed a high-signal intensity lesion on short time i

[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 pregnant 33-year-old woman with Marfan's syndrome was found to have an abdominal aortic aneurysm approximately 7 × 6 cm in diameter, stretching from the bilateral renal arteries to the common iliac arteries. After Caesarean section, she underwent a composite graft replacement for abdominal aortic aneurysm that bypassed her celiac, superior mesenteric, and bilateral renal arteries with a branched graft. Two weeks later, a thoracoabdominal aortic dissection suddenly occurred. This prompted the emergency replacement of her endovascular stent graft. The replacement of the stent and massive bleeding led to severe ischemic renal injury in both kidneys. Her renal function gradually decreased, and four months later, maintenance hemodialysis was required due to ESRD induced by irreversible ischemic renal damage.
She and her family had been considering a living kidney transplantation ever since she began maintenance hemodialysis. The donor was her 60-year-old mother, because her father had been diagnosed with Marfan's syndrome and had also undergone a composite graft replacement for thoracoabdominal aortic aneurysm.
For treatment of annuloaortic ectasia and preparation for kidney transplantation, our patient underwent aortic root replacement using the David aortic valve-sparing reimplantation technique two years after the commencement of maintenance hemodialysis. Her cardiac function has been stable since the aortic valve-sparing operation.
Although the patient had many anti-human leukocyte antigens (HLA) antibodies due to repeated blood transfusions, donor-specific HLA antibodies were not found. Blood type of donor and recipient were types B and O, respectively. The titer of anti-blood type B antibody was 64 : 1. The preoperative, 3-dimensional CT scan showed that there was no aneurysm or dissection of the iliac arteries ().
The patient received a living kidney transplantation from her mother 3 years and 5 months after the onset of hemodialysis. The initial immunosuppressi

[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 16-year-old male presented to our emergency department with a 3-week history of severe lower back pain radiating around his right flank and abdomen, which became more intense 1 week prior to evaluation. He denied trauma, bowel or bladder incontinence, sexual dysfunction, focal limb weakness or paresthesias. Additionally, he developed left facial weakness 5 days prior to hospital presentation consistent with peripheral VII nerve palsy evaluated by his primary care physician. The patient's history was significant for a high fever, headache and generalized body malaise 4 weeks prior to admission. Based on the history of constitutional symptoms, peripheral facial nerve palsy and endemic occurrence of Lyme disease, B. burgdorferi antibody testing was conducted. Serologic testing for antibodies to B. burgdorferi was conducted following the two-tier strategy. Both enzyme-linked immunosorbent assay and Western blot assay were positive. The patient denied other extra-neurological manifestations of Lyme disease, such as arthralgia or erythema migrans, and had no known history of a tick bite. Treatment with minocycline 100 mg twice a day for positive Lyme antibody was initiated. On hospital admission, his neurological examination was significant for left peripheral facial nerve palsy and subtle sensory level to below T7 dermatome to temperature. Strength was normal along with other sensory modalities. Due to the severity, persistence and abrupt worsening of the patient's back pain despite conservative measures and analgesics, a lumbar and thoracic MRI study without contrast was obtained. MRI revealed a diffuse signal abnormality of greater than two thirds of the cross-sectional area of the thoracic cord from T7 down almost to the level of the conus, predominantly involving the white matter consistent with LETM (fig. ). Additional investigations included cerebrospinal fluid (CSF) analysis which demonstrated nonspecific markers of active central nervous system inflammation, in

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


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

[User]
RADIOLOGY NOTE:
Patient 3: A 42-year-old female was admitted with back pain, gait disturbance, and moderate dysesthesia of right upper extremity. Symptoms were more apparent in the upper extremities than in the lower extremities. Assessment of neurological condition before surgery suggested Grade 3 on the modified McCormick functional schema and Grade 3 on the sensory pain scale. T2-weighted magnetic resonance images (MRIs) of the cervical spine showed local enlargement and intramedullary mixed signal of the spinal cord at C6 []. T2*-weighted gradient-echo MRIs showed mixed low signal within the spinal cord [], which was consistent with blood degradation products. Imaging diagnosis before surgery was intramedullary hemorrhage associated with cavernous malformation.
The patient underwent C5 to C7 osteoplastic laminotomy for evacuation of the intramedullary hemorrhage and total resection of the tumor. The spinal cord appeared slightly swollen []. Posterior spinal arteries on both sides were well differentiated from posterior spinal veins and the pial venous plexus []. Venous circulation of posterior spinal veins and the pial venous plexus appeared stagnant []. Crossing veins on the PMS were coagulated with a microbipolar coagulator at very low power levels under continuous saline irrigation. A PMS approach to the spinal cord revealed the intramedullary hemorrhage. Careful dissection within the spinal cord revealed the tumor–cord interface with the surrounding hemosiderin-stained tissue. The tumor was removed segmentally. The surrounding hemosiderin-stained tissue was not resected to avoid the damage of spinal tissue []. Posterior sulcal central veins were well visualized []. The pial edges were sutured together as much as possible to restore the shape of the spinal cord []. Supplemental digital content of surgical was provided.
T2-weighted MRIs obtained 3 months after surgery showed satisfactory recovery of the intramedullary signal of the spinal cord []. Assessment of neurological 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 66-year-old man was admitted to our hospital for repeated hemoptysis accompanied by fever for 8 months. A large amount of bloody purulent sputum was coughed out at the beginning, followed by brown pus. The largest amount was about 100 ml. He denied chest pain or dyspnea. The patient took amoxicillin and oral hemostatic drug and the symptoms were relieved. However, the symptoms recurred and gradually worsened. He was admitted to another hospital and received antibiotic therapy with levofloxacin and imipenem. His relevant past medical history included cholecystectomy for gallstone 5 years ago.
On admission, he had a temperature of 37.0 °C, heart rate of 80 beats per minute, blood pressure of 120/70 mmHg, and an oxygen saturation of 95% on room air. Physical examination revealed no positive sign. Chest CT scan demonstrated a consolidative mass located in the right middle lobe, together with scattered inflammation in the bilateral lower lobes and mediastinal lymphadenopathy (Fig. ). The patient received ceftriaxone and moxifloxacin intravenously with no improvement. Bronchoscopy exhibited no evidence of tumor or tuberculosis (Fig. ). Percutaneous lung puncture found inflammatory and tissue cells, and puncture fluid grew Escherichia coli. Pulmonary abscess was diagnosed and the antobiotic was changed to biapenem according to the drug sensitivity result (Table ). The condition improved and the patient was discharged.
However, the patient presented with hemoptysis again 2 months later but he refused surgery. So, he received right middle lobe arterial embolization. Digital substraction angiography showed a right bronchus common bronchial artery (canal-like expansion of right bronchial artery and right middle lobe pulmonary artery), a left and right common bronchial artery, and abnormal right inferior phrenic artery (tumor-like expansion at the traffic of right inferior phrenic artery and right middle lobe pulmonary artery).
Three months later, the patient suffered from he

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old woman at 35 weeks' gestation was referred to Department of Anesthesia for analgesia during vaginal delivery. She was 160 cm tall and weighed 57 kg. She suffered from tuberculous pleurisy at 11 years old, diagnosed with tuberculosis-induced destroyed lung at 20 years old, and finally got left pneumonectomy at 25 years old. After the surgery, remnant right lung was bronchiectatic. She had frequent respiratory failure due to respiratory infections and was treated by intermittent admission with mechanical ventilation. At the early period of this admission, due to pneumonia on right lower lobe followed by respiratory failure, she was ventilated mechanically via endotracheal tube. Soon after, she got tracheostomy for prolonged mechanical ventilation. The lowest PaO2 checked during that period was 36.9 mmHg. It was difficult for her to be weaned from mechanical ventilation after recovery from acute pneumonia, so her ventilation was supported by synchronized intermittent mandatory ventilation (SIMV) or continuous positive airway pressure (CPAP). At 3 months after admission, she was diagnosed as 20 weeks' gestation. The patient elected to continue pregnancy, despite medical warning against influences of prior frequent maternal hypoxemia and heavy medications on fetus, increasingly difficult ventilatory management as she was approaching confinement. She stayed at ICU during rest period of pregnancy with ventilatory support by CPAP. At 35 weeks' gestation, the obstetrician decided to induce delivery, and injected misoprostol 50 µg subcutaneously at 4 hour intervals. Her chest x-ray showed tuberculous scar at right upper lung field, compensatory emphysematous change of whole right lung combined to left pneumonectomy state (). The last arterial blood gas analysis (ABGA) before onset of labor showed pH 7.362, PaCO2 49.3 mmHg, PaO2 241.4 mmHg, HCO3- 27.7 mmol/L, and 99.8% of oxygen saturation, while the patient was under assisted ventilation with CPAP at FiO2 0.6. Pu

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


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

[User]
RADIOLOGY NOTE:
We present a case of a 60-year-old female who presented to the hospital with complaints of dull substernal chest pain. She had chronic atrial fibrillation, chronic obstructive pulmonary disease with home oxygen, osteoarthritis, and anxiety disorder as her comorbid conditions. On examination, she did have chronic dyspnea and was on home oxygen. She did not have any cyanosis, palpitations, paroxysmal nocturnal dyspnea, or orthopnea.
She was initially evaluated with a nuclear stress test that did not show any reversible ischemia but dilation of the right ventricle (RV); ejection fraction was identified to be 54%. The patient was further evaluated by a transthoracic echocardiogram (TTE) in order to evaluate the RV dilatation. TTE identified a complete absence of IAS and a CA (). The findings were confirmed with a positive bubble study (). Transesophageal echocardiogram (TEE) was performed that confirmed the absence of IAS, demonstrated free mixing of color flow, moderate to severe tricuspid regurgitation, normal mitral valve structure, normal left ventricular ejection fraction, and enlarged right atrium (RA) and RV.
The patient was evaluated with cardiac computed tomography angiogram (CCTA) that demonstrated the right coronary artery to be the dominant artery, all coronary arteries to be ectatic/aneurysmal and measuring up to 8-10 mm, a complete absence of IAS, marked dilation of CA and both ventricles, a coronary arteriovenous fistula (CAF) between the distal left anterior descending and coronary sinus, massive dilation of pulmonary arteries, and no mitral or aortic valvular abnormalities; left ventricular ejection fraction was measured to be 59% (Figures –).
The patient underwent an invasive angiography (IA) which demonstrated many abnormal findings. It showed that the patient had coronary artery aneurysms measuring 0.7 cm to 1 cm (). IA was instrumental in taking measurements regarding oxygen saturation and pressure at multiple levels identifying a large interatrial

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old man presented to our hospital with lung nodules at the right upper and right lower lobes, which were detected at a different institution during an examination for intermittent hemoptysis. The patient's past medical history was significant for hypertension, with a smoking history of 50 pack-years. Physical examination and routine laboratory tests revealed no significant findings. A chest computed tomography (CT) scan revealed a 2.1 × 1.7 cm sized mass in the posterior segment of the right upper lobe (RUL), along with a 3 × 2.3 cm sized mass in the superior segment of the right lower lobe (RLL)(Fig a). The nodule in the RUL was suspected to be primary lung cancer, while the nodule in the RLL was suspected to be a benign neoplasm or double primary lung cancer. Therefore, we performed a staging workup for suspected lung cancer. Positron emission tomography showed increased uptake only in the RUL and RLL (Fig b). Bronchoscopy showed no endobronchial involvement. As the pulmonary function test indicated no contraindication, we recommended surgery because of the possibility of malignancy in each nodule. Thoracoscopic wedge resection was performed with a frozen section for each nodule. The intraoperative frozen section revealed adenocarcinoma with poor differentiation in the RUL and non-small cell lung cancer with very poor differentiation in the RLL. CT findings showed a RUL lesion with spiculated margins and a RLL lesion with well-defined margins. We performed an additional upper lobectomy with mediastinal lymph node dissection after the thoracotomy considering the CT findings and an insufficient wedge resection margin of the RUL. The patient was discharged from the hospital without any complications on postoperative day eight.
The results of the biopsy revealed that despite poor differentiation of the tumor cells, the RUL mass was an adenocarcinoma positive for CK7 and TTF-1 (Fig a,b). The RLL mass was a tumor consisting mostly of cells that morphologically

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male presented to a peripheral hospital with acute-onset epigastric pain radiating to the back, associated with bilious vomiting and left inguinal swelling for the previous 7 days. The patient was misdiagnosed as having an obstructed inguinal hernia and inguinal exploration was carried out. The contents of the left inguinal canal were inflamed, with haemorrhagic fluid in the inguinal canal seen to be arising from the deep inguinal ring. The patient was then converted to midline laparotomy. At exploratory laparotomy, there was fat saponification of the greater omentum and peritoneum, suggestive of acute pancreatitis. The abdomen was closed and the patient was referred to our institute. The patient's clinical history revealed that he was chronically alcoholic and had a ‘binge’ of alcohol 15 days previously, after which he had developed abdominal pain. The swelling in the inguinal region had developed later when the pain worsened. The patient was evaluated with a contrast-enhanced computed tomography (CECT) of the abdomen and pelvis. There was pancreatic necrosis with fluid collection in the peripancreatic region, left pararenal space, extending to the pelvis along the left psoas muscle. There was inflammatory fat stranding in the region of the left spermatic cord and left scrotum with oedema and bilateral pleural effusion (A). The patient had a left inguinal wound, draining about 100 mL of dark, muddy fluid daily, and was managed with local dressings. Ultrasonography (USG)-guided pigtail catheter drainage of the lesser sac and pararenal space collections were done. The patient was managed with catheter irrigation with sterile saline, which would drain through the inguinal incision. He developed continued systemic sepsis and suspected colonic fistula through the inguinal wound. Laparotomy and pancreatic necrosectomy were done, as was a loop ileostomy and feeding jejunostomy. Closed drainage of the left retroperitoneal space and lesser sac was done. Later

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old female presented to the emergency department with a four-day history of signs and symptoms indicative of abdominal obstruction. Her past medical history included hypothyroidism due to autoimmune thyroiditis, managed with levothyroxine. In 2006 she underwent a right hemicolectomy for a myxoid liposarcoma grade 1-2 infiltrating the small and large bowels. The specimen weighed almost 3 kilograms with dimensions 25 × 22 × 11 cm. The removal was radical with free margins and an intact tumour capsule. Postoperatively, no adjuvant therapy was indicated and close followup was recommended.
During the current admission she was dehydrated, haemodynamically stable, and apyrexial. Abdominal examination revealed a distended abdomen, tympanic to percussion, with no signs of peritonism or abdominal wall hernias. Blood investigations showed a raised urea (8.7 mmol/L) and WCC 14.2 × 109. Abdominal X-ray revealed grossly dilated small bowel loops. The initial treatment was conservative with nil by mouth, intravenous fluid resuscitation, nasogastric tube, and urinary catheter for fluid balance. After twenty-four hours the patient showed no signs of improvement and underwent an exploratory laparotomy. An adhesional band was found to be the cause of the small bowel obstruction and was divided. The entire small bowel was viable and no evidence of intra-abdominal or peritoneal metastasis was identified. However, a dark purple, smooth pelvic mass was found attached to the pelvic wall by a small stalk with similar macroscopic appearance to that of splenic tissue (). The mass was carefully detached off the pelvic wall and sent for final histological analysis.
After the laparotomy the patient had an uncomplicated recovery and was discharged home on the eighth postoperative day. Histology confirmed a recurrence of the previous myxoid liposarcoma (). One month later a CT scan of the chest, abdomen, and pelvis showed a new well-defined oval hypodense mass in the right iliac fossa ad

[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:
47-year-old male patient presented to us with an open fracture of the right distal femur following a road traffic accident. He was resuscitated, hemodynamically stabilized according to the institutional advanced trauma life support protocol. He had a Gustilo Anderson Type IIIc open distal femur fracture with bone loss of approximately 20 cm, lacerated quadriceps muscles and femoral artery at distal thigh level. Radiographs showed extensive bone loss involving the entire metaphysis and the distal femoral diaphysis that it could not be classified, though technically it could be Muller AO type 33C2 []. Damage control protocol was applied, and the patient was immediately taken up for surgery by a team of trauma and vascular surgeons. Informed consent was obtained from the patient with particular mention that he might require multiple surgeries to reconstruct his limb. Femoral artery repair (within 3 hours of injury) was done with long saphenous venous graft to restore the vascularity. Quadriceps repair and wound debridement were performed; a knee spanning external fixator applied after achieving articular restoration by condylar fixation (). Partially threaded 6.5 mm cancellous screw was used to achieve interfragmentary compression of the distal femoral articular surface. Empirical antibiotic with Gram-positive, Gram-negative, and anaerobic cover was given preoperatively and for 72 hours after surgery (cefazolin, gentamicin, and penicillin). At relook debridement, antibiotic-impregnated (lyophilizedvancomycin) cement spacer was applied to maintain the soft tissue tension for future reconstruction. Anti-edema measures and anticoagulants were used following Stage 1 and Stage 2 surgical procedures, as advised by vascular surgeons. The antibiotic cover was tapered to cefazolin alone, which was continued for 48 hours and stopped. After soft tissue healing, at 2 weeks, external fixator was removed and above knee posterior slab was applied for pin tract healing. Pros and cons

[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 mother of a girl of 4 years old reported to the pediatric clinic of School of Dentistry in Araraquara (State University of São Paulo) complaining about the aesthetic involvement caused by the absence of primary mandibular incisors of the child. The mother of the patient said during the anamnesis the following statement: “My daughter did not smile anymore and every time she did it, she put the hand in front of the mouth”, which demonstrated the social and mental involvement that the absence of teeth was causing.
During clinical examination, besides the absence of mandibular incisors, the absence of upper lateral incisors was noted (). The patient was caries-free and had no history of trauma or even any conical tooth, deciduous teeth impacted or delay in eruption of them. In view of those clinical findings, a panoramic radiograph was requested to detect the absence of permanent teeth especially. The analysis of panoramic radiograph detected the agenesis of permanent teeth as lower incisors, upper lateral incisors, and upper and lower premolars (). Moreover, the patient had no clinical signs of any syndrome or disorder like ectodermal dysplasia or Down syndrome, which are usually syndromes related with oligodontia in primary dentition.
The treatment plan involved the installation of an adhesive partial denture for restoring only the lower incisors due to the lack of space for construction of an upper dental prosthesis (Figures and ). The choice of an adhesive prosthesis was due to the difficulty of the patient's adhesion to use a removable appliance.
In the first appointment, the clinical procedure was carried out as follows: upper and lower molding, interocclusal record in wax, and confection of partial dental prosthesis with lower incisors. The partial prosthesis had rods made of metallic steel wire located on each side of their lateral extremity (). These rods were designed to be fixed into the lingual surface of the canine and into the first deciduous molar lower

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male needed the extraction of an upper wisdom tooth; the patient complained of pain, posteriorly, on the upper left side of the maxilla. After clinical and radiographic examinations, the upper left wisdom tooth was found with deeply a carious lesion with pulpal involvement, causing the pain.
The patient seemed to be cooperative, compliant and confident with the dental team and the surgery, even though the clinical history and medical record showed previous episodes of moderate anxiety related to dental procedures. Before the surgical intervention, topical analgesia (Lidocaine 15% spray) was used prior to LA injection. LA injection was administered on the vestibular and palatal aspects, for both pain control and vasoconstriction (Ecocain, 2x 20 mg/ml, 1,8 ml, 1:50:000 adrenaline). However, due to pulpal involvement and the presence of an infection, good pain control was not achievable
. The patient showed distinct and comprehensible signs and symptoms of distress and an inability to withstand that surgical situation and the surgical steps. Thus, he rapidly became nervous and agitated. Not to lose the confidence and trust of the patient, we administered a benzodiazepine (bromazepam 15 drops
per os) and nitrous oxide (Inhalation; Start: 10% nitrous oxide and 90% oxygen, progressively reaching 40% nitrous oxide and 60% oxygen). After 20 minutes of relaxation, we could perform the extraction with the perfect compliance of the patient and a better control of the intraoperative pain. At the end of the procedure, we administered 100% oxygen for 10 minutes for patient recovery. The patient reported satisfaction for the previous treatment at the suture removal visit.
When facing a patient with special needs (anxiety and reduced compliance), especially before procedures such as a planned minor surgery, or an extraction or a mucogingival surgery or an osseous periodontal surgery or a simple case of implantology, the dental team should preserve patient confidence,

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


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

[User]
RADIOLOGY NOTE:
Patient 2, a 64 year old female was diagnosed, with acute nonspecific idiopathic pericarditis, and was referred to our clinic. She had a history of heart failure for six months prior to hospitalisation. On the day of arrival she presented with a decompensated heart failure. Tachypnoea, hepatomegaly and ascites were present. The patient had no complaints regarding the B symptoms. Arterial blood pressure was 100/70 mmHg. CBC and CPT were within normal limits. HIV tests were negative, the patient was immunocompetent. TTE revealed a severe dilatation of the right atrium and right ventricle, a large tumour in the right side of the heart and fluid accumulation in the pericardial sac. In order to specify the diagnosis a pericardiocentesis, cardiac magnetic resonance imaging (MRI) and percutaneous transvenous biopsy (PTVB) of the tumour were performed. The pericardial fluid exam showed that it was transudate with no cells. The MRI revealed a tumour in the right atrium appendage, which was invading the right atrium and ventricle and visceral pericardium. The large tumour (10 x 7.2 x 8 cm) was obstructing the right ventricle, the IVS was pushed towards the left ventricle and slightly interfering with its function (end systolic volume of the LV was 26 ml, end diastolic volume of the LV was 53 ml and LV EF was 52 %, cardiac index was 1. 8 l/min/m2) (Fig. ). PTVB of the tumour showed mild myocardial fibrosis. 11 days later the patient’s condition started to worsen. An open chest biopsy of the tumour was performed. A fast intra-operative histological exam of the tumour revealed that it was malignant. Because the tumour was inoperable, a decision to perform a Fontan procedure was made. It was intended to stabilise the patient’s hemodynamics. After the surgery the patient’s general condition was satisfactory. She was extubated twelve hours later. Breathing was spontaneous and SaO2 was 90

[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 five-year-old previously healthy bilingual (English and Spanish) boy presented to the ED with his parents due to insomnia for the previous two nights. The family history was negative for neurologic or psychiatric illness. The patient was a typically developing child born after a full term uncomplicated gestation and delivery. He had no prior history of injury, ingestion, psychosocial stressors, change in appetite, involuntary movements, or seizures. One week prior to presentation to the ED, he had been evaluated by his primary care physician after a three-day febrile illness and was diagnosed with a viral infection. Since that time, he had become more irritable and fussy, frequently having outbursts of crying without being able to articulate why he was crying. His father was concerned that he seemed scared during these episodes and was concerned about eye pain.
The patients' initial physical examination revealed normal vital signs, cardiovascular, pulmonary, and abdominal findings. He did not have dysmorphic features or a rash. Neuropsychiatric examination revealed an emotionally labile child with periods of calm and seemingly appropriate bilingual language development and behavior for age with episodes of extreme distress during which he would burst into tears and require physical restraint by family members against combativeness. Examination of the cranial nerves, motor tone, strength, coordination, and gait were normal and there was no sign of meningismus on physical examination.
Initial differential for this clinical presentation was broad including insomnia secondary to pain from corneal abrasion or other unidentified traumatic or infectious source, traumatic brain injury, thyrotoxicosis, developmental disorder with regression, encephalopathy due to acute intoxication, acute psychosis, postinfectious or parainfectious encephalitis, and autoimmune encephalopathy. Screening in the ED with urine drug screen, serum acetaminophen and salicylate levels, complete bl

[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 woman with chronic renal failure due to polycystic kidney disease and diabetes started peritoneal dialysis. Two months after the introduction of peritoneal dialysis, a chest radiograph showed right pleural effusion without any symptoms (Fig. A). The pleural effusion disappeared with diuretics, and peritoneal dialysis was continued. However, 9 months after the introduction, poor water removal interfered with peritoneal dialysis and computer tomography showed recurrence of the right pleural effusion. We diagnosed that right pleural effusion due to right pleuroperitoneal communication, disturbed peritoneal dialysis, and performed surgical treatment 11 months after the introduction of peritoneal dialysis. Considering the possibility of using a laparoscopy, we sterilized not only the chest, but also the upper abdomen before skin incision. We first attempted a right thoracoscopic approach with four intercostal ports in the left lateral decubitus position deflating the right lung and could not identify any defects in the diaphragm at all, although 2,000 mL of peritoneal dialysate mixed with 40 mg of indigo carmine was injected into the abdominal cavity or CO2 was insufflated with an abdominal pressure of 10 cmH2O from a peritoneal dialysis catheter. Next, we attempted a laparoscopic approach using two ports with a diameter of 5 mm in the upper right abdomen (Fig. B) in the semi-left lateral decubitus position and found a 2-mm-sized fissure in the central tendon of the right diaphragm (Fig. C). We laparoscopically grasped the fistula with the surrounding tissue and thoracoscopically sutured and closed the gripped part using an automatic suture device (Fig. D, E). The closure was reinforced with polyglycolic acid sheets and fibrin glue under thoracoscopy. A drainage tube was placed in the right thoracic cavity. No postoperative complications occurred. The patient continued peritoneal dialysis without recurrent right pleural effusion for several months (Fig. 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:
The patient was a 35-year-old female who presented to clinic for evaluation of abdominal pain compatible with symptomatic cholelithiasis. She described intermittent, cramping, right upper quadrant pain starting six months prior to presentation. The pain usually lasted up to one hour and was exacerbated by eating. She denied fevers, chills, nausea, vomiting, jaundice, and changes in the color of her stool and urine. Her past medical history was relevant for morbid obesity (BMI of 42), diabetes mellitus, hypertension, and irritable bowel syndrome. She had undergone recent colonoscopy but had no prior abdominal surgeries. On social history she endorsed occasional alcohol use but denied tobacco and illicit substance consumption. Her physical examination was only remarkable for obesity. Her right upper quadrant was non-tender to palpation and she had no palpable organomegaly, hernia, or mass. The patient had undergone laboratory work up which included a complete blood count, comprehensive metabolic panel, and liver function tests all of which were within normal limits. An abdominal ultrasound did not demonstrate a well-delineated gallbladder. There was increased echogenicity on the proximal edge of the gallbladder fossa compatible with a Wall Echo Shadow (WES) sign suggestive of either large calcified or multiple small calcified gallstones in the gallbladder (). No sonographic Murphy’s sign was elicited and the common bile duct measured 4 mm.
Taking into consideration the patient’s characteristics (obese female of childbearing age), along with the history of intermittent right upper quadrant pain, and the US findings, the decision was made to take the patient to the operating room for a laparoscopic cholecystectomy in the setting of presumed symptomatic cholelithiasis. Upon entry into the abdominal cavity using standard laparoscopic technique, the gallbladder was not appreciated. The right lobe of the liver was elevated but the gallbladder was not visualized (). Addition

[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 reported with the swelling arising from right maxilla. The lesion was initially small in size and has grown slowly to present size. There was no history of trauma and the medical history was non-contributory. Examination revealed a bony hard lesion on the right side of the face in the right maxillary region about 6.3 × 6.3 cm2 []. The overlying skin was stretched and there was no sensory deficit. Intra-oral examination revealed a circumscribed lesion extending from the right maxillary incisors to the right maxillary second molar region. There was normal overlying mucosa and right permanent canine was missing []. All the involved teeth were sent to endodontist for pulp vitality and were found vital.
Cone-beam computed tomography (CT) showed the lesion involving part of the right maxillary alveolar process, anterior wall of maxillary sinus, infraorbital rim and the right piriform rim measuring 63 × 63 × 65 mm. The right canine is seen in the center of the lesion with a well-defined hypodense tract seen extending 25 mm inferiorly from canine to alveolar process [Figures and ].
A differential diagnosis of an ossifying fibroma or osteoma was made and a biopsy confirmed the diagnosis. The histopathology report was that of a cortico cancellous osteoma. As the patient had no obstruction to his breathing, it was decided to surgically remove the protruding part of the lesion, that is in the region of maxilla, alveolar process, piriform rim, infraorbital rim, canine and tract extending from canine to alveolar process was removed.
Intraoperatively, the facially protruding part of the lesion was removed and the involved teeth were spared. Hemostasis was achieved and the surgical site was closed primarily. Postoperative healing was uneventful with no sensory deficit and the involved teeth were not devitalized.
Macroscopically, the lesion consisted of a homogenous bony appearance measuring 5 × 5.5 × 4.5 cm. Mic

[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 47-year-old Iranian male patient referred to our outpatient clinic in the Imam Khomeini Hospital, Sari, with a palpable and painless mass in his left shoulder.
The patient did not complain about pain or weakness in this location. On examination, the mass was small, mobile, firm, and nontender located in the soft tissue of left shoulder. The skin covering the mass was intact, and there was no ecchymosis and even erythema (). The shoulder range of motion had no functional impairment, and the patient was able to do the routine tasks with no neurovascular disturbance. Medically speaking, important clinical signs and symptoms such as fever, weight loss, and respiratory symptoms were not detected.
There was no visible fluctuation in this field, and it was estimated 0.5-1 cm in length and width. Tumor consistency was not similar to bone, and it seemed to be a soft tissue mass. The patient denied any history of trauma and also no significant family history was identified. Interestingly, the patient was operated by general surgeon 6 times because of relapses in a way the last one was 1.5 years ago. At the first time, the patient was referred to the outpatient clinic because of gradual mass enlargement. The patient was operated by wrong method as transverse approach in the lateral border of the shoulder ().
In the recent recurrence, chest X-ray showed no obvious lung or bone involvement ( and ). Magnetic resonance imaging (MRI) illustrated a small extraskeletal nodular lesion with ring enhancement and no bone involvement at subcutaneous fat on lateral aspect of shoulder measuring about 13 mm which could be due to a recurrence of the previous tumor ( and ). Unfortunately, no previous documentation such as MRI was found. Thus, this caused difficulty for interpretation of the course of the main disease.
First, we decided to operate the tumor as an incisional biopsy because we were not sure about the nature of the lesion. An important note in this approach was limited access to

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 13-year-old Caucasian girl suffering from axial rotation of the T5 to L4 vertebrae in the horizontal plane. The patient was otherwise fit and well, her reported medical history was free and both she and her parents were not familiar with any cases of scoliosis among members of her family. The patient (initially examined during a school screening study-Visit 1) was considered at first to be suspicious of suffering from scoliosis, due to a highly positive Adam's forward bending test. However, radiographic evaluation revealed the existence of axial vertebral rotation (Grades 1-2 according to the Nash and Moe method of radiographic assessment) [] without any deformity whatsoever in the sagittal and coronal planes (Table ). Her physical (and radiographic) examination failed to reveal the existence of any discrepancy in her limbs' length or any other skeletal abnormality. Due to the unfortunate fact that the patient shortly after her initial examination lost all her radiographs and in order to better evaluate both the structural deformity underlying the vertebral rotation and the possible co-existence of a thoracic cage deformity which could interfere with the interpretation of the Adam's forward bending test, a Computed Tomography (CT)-scan was suggested. Unfortunately, both the patient and her parents refused to consent to it.
Following an observation period of 12 months the patient was re-evaluated (Visit 2). Due to her young age, the recent reported menarche at the age of eleven (between Visits 1 & 2), her skeletal immaturity (Risser stage I-II), the fact that both the patient and her parents reported that the appearance of the patient's trunk worsened and the fact that the measured vertebral rotation deteriorated (Table ) (Figure ), the patient was given a modified Boston brace (fitted with derotational blades) which appeared to have had an immediate positive derotational effect on all but two vertebrae (Figure ). The patient was instructed

[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 right-handed 9-year-old boy fell on an outstretched hand two weeks before admitted to the hospital. The patient presented with a right wrist-drop and right elbow flexion stiffness. On the physical examination, the patient cannot extend his right wrist and thumb. There was also sensory deficit, anaesthesia sensation over the radial nerve distribution and hypoesthesia sensation on the ulnar nerve distribution. The median and ulnar nerve examinations were standard. The distal pulsation is solid and regular. The right elbow joint was stiff with a limited flexion-extension range of motion (60–90°). Radiographs showed a displaced SCF classified as Gartland type III. The parents first sought treatment from a traditional bonesetter before came to the hospital (, , ).
Surgical management is preferred for this case, and we decided to explore the nerve while simultaneously reduce and stabilize the fracture. First, we explored the ulnar nerve with a medial approach and found the ulnar nerve was entrapped in fibrous tissue and carefully released it. Then the lateral approach is utilized to explore the radial nerve. We found the radial nerve has lost its continuity and interposed by fibrotic tissue. The scar and fibrous tissue were carefully resected, leaving a 2 cm gap in the nerve. We approximate the nerve with end-to-end neurorrhaphy after the fracture was reduced and stabilized with 3-Kirschner wire. Postoperatively, the elbow was kept in long-arm cast with elbow flexed 90° to avoid nerve stretching for six weeks. The distal vascular status is good after the operation and cast application (, , , ).
At the 4-month follow-up, the fracture was united. The elbow range of motion has improved; 20° to 115° elbow flexion is seen. The neurological status showed an improvement. The patient could extend his right thumb and wrist but developed a tingling sensation in the posterior forearm, extending to the dorsum of the hand and lateral three and a half fingers;

[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 fifty-year-old, female patient underwent a severe pain at the cervical part and the left upper extremity from 1 day before her visit to the hospital and MRI was carried out. However, since the patient continuously moved due to the severe pain, the imaging was stopped after only the image of a part of the sagittal plane was taken. It was decided that the MRI should be carried out after pain control, and the patient was sent to the department of pain medicine. By the visual analogue scale, the pain was evaluated to be level 3 at the neck and level 9-10, which was very severe, at the left upper extremity. The Spurling sign was positive (+) and mild muscular weakness was found. It was decided to perform an epidural nerve block in order to control the pain. Under the C-arm guidance, the epidural nerve block was tried in the sitting position. The epidural space was found by the loss-of-resistance technique with air and 0.5 ml of a contrast material was injected to confirm the epidural space. Then, 2.5 ml of the contrast material was injected additionally and its diffusion to the C2-C3 position was verified. After that, 0.75% lidocaine 3 ml was injected and the epidural nerve block was carried out. For 1 hour following the nerve block, EKG, SpO2, blood pressure, and consciousness of the patient were monitored. The MRI was resumed since the pain was reduced to the degree where the patient was able to take the supine position for more than 10 minutes. In the T2 image of the sagittal plane that was taken for the second time, the C3-C4 and C5-C6 herniated disc were suspected (). However, the C3-C4 lesion which was suspected as the herniated disc was considered to be an air shadow in the CT cross-sectional image that was taken for the operation (). The T2 image of the sagittal plane that was partially taken

[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.