[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 normally developed 5-year-old girl presented to the emergency department with a 1 month history of worsening abdominal pain that localized to the right upper quadrant with intermittent vomiting and fevers over the week prior to presentation. On physical examination, the child was febrile to 37.6°C with abdominal distension. A tender right-sided abdominal mass was found extending from the costal margin to the pelvis and beyond midline. Bowel sounds were heard only on the left. Abdominal CT imaging identified a large mass arising from the right kidney with at least one smaller lesion in the left kidney (Fig. A). Serum WBC and electrolytes were normal, with a serum creatinine of 0.40 mg/dl and a BUN of 7 mg/dl. Chest X-ray and pulmonary CT scans were negative for malignant disease.
The patient was given a presumptive diagnosis of bilateral (Stage V) Wilms tumor. The family consented for her to participate in the Children's Oncology Group trial AREN0534 which called for pre-operative chemotherapy in order to facilitate nephron-sparing surgery at the time of tumor resection. A central venous catheter was placed, and neoadjuvant chemotherapy with vincristine, dactinomycin and doxorubicin was initiated. Within hours of starting her therapy, we found that lactate dehydrogenase and uric acid were both elevated (1134 U/l and 6.3 mg/dl, respectively; Fig. ). Serum potassium and phosphate were both normal. The patient's hyperuricemia was felt to be consistent with tumor lysis syndrome, and allopurinol and alkalinized fluids were administered. The hyperuricemia soon resolved, and the patient maintained normal serum creatinine, potassium and phosphorus levels throughout her hospital stay. A follow-up CT scan after 6 weeks of therapy showed a marked response to chemotherapy of the right-sided lesion (Fig. B). The left-sided mass remained stable in size. We decided to administer another 6 weeks of chemotherapy to improve her candidacy for right partial nephrectomy instead of whol

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


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

[User]
RADIOLOGY NOTE:
An 84-year-old male resident of a nursing home facility of Hispanic descent was brought to our emergency department (ED) for respiratory distress and altered mental status. He was intubated promptly on arrival to the ED. His past medical history was significant for intracranial aneurysm with bleeding following VP shunt placement, ischemic stroke with aphasia and paraplegia, and percutaneous endoscopic gastrostomy (PEG) tube placement. His vital signs and clinical laboratory results are presented in Table .
The clinical picture was suggestive of septic shock. We ordered a sepsis workup including two sets of blood cultures and urine culture. The patient was treated with aggressive intravenous fluid hydration and broad-spectrum antibiotics (vancomycin and meropenem).
A non-contrast computed tomography (CT) of the chest, abdomen, and pelvis revealed bibasilar pulmonary atelectasis without focal infiltrate and the presence of a right-sided VP shunt catheter traversing the right neck, the right chest, and the right abdominal wall; the tip of the catheter was located within the gastric lumen and had likely entered through the PEG tube insertion site (Figures -). The PEG tube was outside the gastric lumen, terminating in the abdominal wall that was evidenced in the repeat CT scan confirmed that patient had abdominal wall cellulitis and localized abscesses around the PEG tube insertion site (Figure ). Medical records from another facility confirmed previously normal positioning of the PEG tube and normal intraperitoneal positioning of VP shunt catheter one year prior.
Given the malposition of the VP shunt inside the gastric lumen, we suspected VP shunt infection or meningitis/encephalitis and subsequently lumbar puncture was performed; the results of the cerebrospinal fluid (CSF) analysis were unremarkable. Blood cultures and urine culture results were negative.
The wound culture was positive for Proteus mirabilis sensitive to carbapenems and piperacillin/tazobactam. We debr

[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 34-year-old male patient was referred to the Oral and Maxillofacial Surgery Department for the treatment of a calcifying odontogenic cyst that was localized in the right maxilla. He complained of a slow, progressive and painless growing lesion during the last 3 years. Physical examination revealed a bulging and hard mass, slightly effacing the right nasogenian fold. Intraoral examinations disclosed the expansion of the vestibular and palatal cortical bones ().
The computerized tomography (CT) showed a large expansive lesion, with soft tissue attenuation, occupying the totality of the right maxillary sinus, reabsorbing the sinusal walls and obliterating the maxillary sinus ostium ().
Due to the lesion size and its proximity to the lateral wall of the nasal cavity, orbital floor, and pterygopalatine fossa, it was was first decompressed under local anesthesia, what also rendered specimens for histological analysis. The cystic cavity was opened towards the oral cavity, and was left open until the second surgery, which was accomplished 9 months later ().
Clinically, 3 months after the decompression, one was noticed partial regression of the lesion ().
CT scan 5 months after the decompression, also demonstrated satisfactory regression of the lesion (). A new surgical approach under general anesthesia was undertaken, allowing total excision. In this procedure, the maxillary sinus ostium could be maintained, keeping adequate sinus drainage.
The anterior wall of the right maxillary sinus and the former decompression orifice were exposed followed by an ostectomy to enlarge the access to the cyst contents.
The whole lesion was more easily excised due to a defined cleavage plan between the tumor and the remaining bone. Additional curettage was performed. Dental elements 12 and 13 were removed as no surrounding bone was present. With the aim of maintaining normal sinus drainage, a perforation was made to communicate the maxillary sinus to the nasal cavity through which a fine

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

[User]
RADIOLOGY NOTE:
The patient is a 69-year-old woman. She was infected with pneumonia at the age of three and had a high fever for a long period. After the fever abated, she became aware of hearing loss. Because she lived in a mountain village, she rarely visited medical facilities. Since then, she had never worn a hearing aid, had gone to a school for the deaf from elementary school to high school, and communicated with people in sign language. Her husband also used sign language, so she had not used oral communication from elementary school to the present. In 2011, family stress triggered the onset of tinnitus. Because around the same time, she began suffering from sleep onset disorder (it took about one hour until sleep onset), nocturnal awakening, and palpitations, she went to a nearby psychosomatic medicine clinic. She received medication at the clinic but her tinnitus did not improve, so she was referred to our department in 2014.
Various questionnaires were given at her consultation. The result of THI (Tinnitus Handicap Inventory) [], which is used to evaluate the severity of tinnitus, was a high of 94, which indicates the most severe form of tinnitus. Also, an SDS (Self-rating Depression Scale) [] score, which is used to measure depression tendency, was as high as 61, showing that she had a tendency toward depression. The STAI (State-Trait Anxiety Inventory) [], which is used to measure anxiety tendency, returned a State Anxiety (STAIs) score of 69 and a Trait Anxiety (STAIt) score of 67, indicating that she had an extremely high anxiety tendency. As one of the personal features of her tinnitus, she had no concept of the “loudness of tinnitus” because she had been deaf since childhood.
In imaging tests, there were no abnormal findings except for a slight enlargement of the inner ear canals observed by temporal bone CT scan. Head

[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 at the Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital (Tokyo, Japan), with chest pain. She had no previous medical history or a family history of heart disease. Serum levels of the tumor markers CEA, NSE, CA 19-9, and SCC were not elevated. A computed tomography scan revealed an anterior mediastinal tumor extending to the sternum, pericardium, mediastinal pleura, left upper lobe of the lung, and left brachiocephalic vein. Histopathologic examination of a computed tomography-guided biopsy revealed squamous cell carcinoma of the thymus (). She underwent surgical resection of the thymus and the tumor-invaded surrounding organs, followed by reconstruction with a rectus abdominis musculocutaneous flap. The pathological diagnosis of the resected tumor confirmed thymic squamous cell carcinoma diagnosed after preoperative biopsy. Subsequently, the patient underwent postoperative chemoradiotherapy consisting of 60 Gy irradiation in 2 Gy fractions and one cycle of concurrent cytotoxic chemotherapy (150 mg of cisplatin on day 1 and 150 mg etoposide/m2 on days 1, 3, and 5). One year later, she presented with pain in her right foot joint. Magnetic resonance imaging showed round lesions in the distal part of the right tibia and the talus (). These lesions were approximately 12 mm in diameter, with rims of low signal intensity on T2-weighted imaging and enhancement following contrast administration. The diagnosis was therefore bone metastases. The initial plan was irradiation of the metastatic sites with 30 Gy, delivered in 2 Gy fractions, but because of persistent ankle pain, the patient was treated with a boosted dose of 50 Gy total irradiation, delivered in 2 Gy fractions. Bone scintigraphy performed 8 years after radiation therapy showed that the bone lesions had diminished in size (), and that there was no remnant of the tumor. In more than 15 years since the resection of the patient’s primary tumor, there have been no

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old woman (gravid 4, para 1) at 37 weeks of pregnancy with rapid enlargement in left anterior chest wall during pregnancy was admitted to our breast surgery unit. She first noticed a peanut size palpable accessory breast lesion at 10 weeks of pregnancy and during pregnancy the mass gradually increased along with pain. A similar symptom occurred in her last pregnancy 5 years ago, but the mass in left anterior chest wall was limited in the peanut size during the whole gestation period. A delayed surgical intervention was suggested. But the lump gradually regressed and disappeared after delivery.
On breast examination, two breasts looked symmetric with a couple accessory breasts below. The left accessory breast was obviously bigger than the right one that only had a light areola around a small nipple. An elastic, mobile well-circumscribed mass measuring approximately 15 cm × 15 cm was palpated on physical examination of the left accessory breast. Moreover, it was edematous and congestive with an increase in local temperature (Figure ). The breast ultrasound further demonstrated the mass was a relatively homogeneous solid with short stripe blood flow signal. A single live fetus of 37 weeks gestation was observed by abdominal ultrasound scan. So mammography and dynamic contrast-enhanced Magnetic Resonance Imaging(MRI) were not performed. The patient also refused the core needle biopsy.
Due to progressive enlargement of the lump, diabrosis with bleeding occurred on the third day after admission. Since the fetus had been mature in the 37th week of gestation, we decided to perform the excision of the mass and accessory breasts after caesarean section. After a 2850 g male neonate was delivered, the right accessory breast and the mass with left accessory breast were removed. The pathological result came out with a giant tubular adenoma of 15 cm × 15 cm × 12 cm, the resected specimen appeared as a solid white elastic mass with a smooth surface. The cut surface was re

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


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

[User]
RADIOLOGY NOTE:
This case report aimed to reconstruct a highly acetabular defect in an 86-year-old female patient. The first cemented THA was performed in the patient in 1973 at the age of 41 years due to secondary osteoarthritis in regard to hip dysplasia. A nonmodular stem combined with a fixed 33-mm head (Fa. Link) was used as the primary femoral component.
In 1998, more than 20 years after the primary arthroplasty, loosening of the cup was detected. A hip revision arthroplasty was performed with exchange of the acetabular component. An oblong revision cup was implanted to stabilize the defect. Inside the cup, a custom-made implant with an inner diameter of 33 mm was cemented into the acetabular cementless revision component.
Twenty years after the first revision arthroplasty, the patient presented with loosening of the acetabular component. A high acetabular defect classified as a type IIIb defect based on the Paprosky classification system was defined as an “up and in” defect with superior and medial migration of the femoral head > 3 cm (Fig. a). A lateral view radiograph (Fig. b) and computed tomography scan (Fig. c) demonstrated a high acetabular defect near an area of pelvic discontinuity. The cemented stem was still in place and did not demonstrate any signs of loosening 45 years after primary implantation.
Two main problems had to be considered in this revision procedure: first, the high acetabular defect with major bone loss, and second, the reconstruction of the center of rotation in this distinct case.
Revising the fixed stem in this elderly patient with a nonmodular stem would create a major femoral defect in this weak bone. With regard to this problem, a decision was made to create a custom-made polyethylene liner with an outer diameter of 54 mm and an inner diameter of 33 mm for the fixed head of the monobloc stem (Fa. Link). With this technique, revision of the fixed stem could be avoided.

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old adult female who is a known patient of fibromyalgia and spondylolisthesis at the lumbar vertebral levels L2, 3, 4 for the last 3 years presented with a 3-day history of acute onset very severe epigastric pain increasing in severity with time since onset. At presentation, the patient reported a score of 10 on a pain rating scale of 10. The quality of the pain was sharp, and it was radiating to the back with mild relief on bending forward. There were no known aggravating factors. The pain was associated with nausea and non-bilious vomiting with no traces of blood. The patient denied any similar episodes in the past and has no history of alcohol consumption. She has a history of cholecystectomy done 2 years back for abdominal pain, but the gallbladder was apparently devoid of any gallstones.
An ultrasound and a computed tomography of the abdomen and blood workup were performed to determine the cause of pain. At admission, the serum lipase levels were elevated to > 1,600 IU/L (laboratory reference level 10 - 53 IU/L). An ultrasound of the abdomen revealed a normal common bile duct with its diameter of 5.4 mm (). The abdomen CT findings were also consistent with the diagnosis of acute pancreatitis wherein there was stranding in the retroperitoneum and the abdominal mesentery with trace fluid in the perihepatic and pelvic space. There was edema of the head and body of the pancreas with peripancreatic edema but without any pancreatic pseudocyst. The remaining findings were unremarkable with no intrahepatic or extrahepatic biliary dilatation, patent mesenteric blood vessels and normal spleen and adrenal glands (). Further workup was done to look for other less frequent causes of pancreatitis. A magnetic resonance cholangiopancreatography (MRCP) was done which did not reveal any gallstones or sludge in the common bile duct (). IgG4 levels were normal thus ruling out autoimmune pancreatitis. Triglycerides were within the normal limits, and viral hepatitis panel

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old chinese woman with a history of previous cesarean section was referred to her local emergency room with 8 weeks’ delay of menstruation and frequent increasing pain in the right upper quadrant of her abdomen and intense reflex sensitivity in the right shoulder for a duration of one day. In her medical history there was no record of use of an IUD, endometriosis, pelvic inflammatory disease, tubal surgery, intrauterine device, or previous ectopic pregnancy. Laboratory evaluation showed quantitative hCG of 3129.94 IU/L and hemoglobin of 10.3 g/dL. TVS examination demonstrated no evidence of intrauterine pregnancy, a normal bilateral adnexa and a large amount of free fluid in the abdomen. Considering the above factors, a CT scan of the abdomen and pelvis was performed. A 90-mm-long mixed hypodense mass was evident on the upper surface of the right liver lobe. She was diagnosed with ectopic pregnancy implanted in the liver and advised to transfer the patient to tertiary referral center. The patient traveled to our hospital and presented to the emergency room with increasing abdominal pain and weakness. On examination, her pulse was 109beats/minute and blood pressure was 90/50 mmHg. Diagnostic abdominocentesis was performed and found blood uncoagulable. Given the concern for ruptured abdominal pregnancy and hemorrhagic shock, she was taken laparoscopic surgery immediately. The laparoscopy revealed a significant hemoperitoneum (of approximately 1500 ml of blood). The uterus and ovaries appeared normal, with a corpus luteum cyst in 50 mm on the left ovary. There was no evidence of bleeding from the pelvic organs while a mount of free blood appearred aroundding perihepatic and spleen. The upper abdomen was inspected and a active bleeding was discovered from the mass with the size of 80 mm* 50 mm on the surface of diaphragm (Fig. ). The mass was completely resected from the diaphragm. When villus tissues invade the diaphragm, bleeding occurred at the attachment s

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


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

[User]
RADIOLOGY NOTE:
In July 2013, a 40-year-old female presented to the Breast Center, General Hospital of Guangzhou Military Command of the People’s Liberation Army (Guangzhou, China) with an unusual post-traumatic mass in the right abdominal wall was admitted by our department. The medical history was only notable for a car accident that had occurred 6 months earlier. In that car accident, the patient was provided with thoracic surgery to treat the rib fractures and lung injury. Following this, the patient was admitted to the Breast Center, General Hospital of Guangzhou Military Command of the People’s Liberation Army due to the sudden onset of a protruding mass on the right abdominal wall, which was indicated to be breast tissue by CT imaging. Upon examination, the right mammary gland was missing from its normal position, leaving a nipple areola complex on the right chest (), and a mass ~11×15 cm in size was apparent in the right upper abdominal wall (). This was further viewed by chest CT and ultrasound scans. The CT scan showed no right mammary gland on the right chest wall (), but a mammary gland image of normal appearance was present in the right upper quadrant of the abdomen (). Moreover, the ultrasound scan also indicated that the protruding mass on the abdominal wall was a mammary gland ().
Reversion of the transposed breast to its original position was planned, however, the patient requested that it be removed. Therefore, a resection of the mass was performed resulting in complete removal of the transposed mammary gland (). Following surgery, an ultrasound scan was performed again to ensure complete resection of the mass (). The pathological diagnosis confirmed that the resected mass consisted of normal breast tissue () without notable necrosis. One month later, the patient returned for a follow-up examination, which showed that the abdominal wound had healed well. Consent was obtained from the patient for publication of this case study.

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


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

[User]
RADIOLOGY NOTE:
A 38-year-old Saudi female presented in July 2014 complaining of bilateral nasal obstruction for 10 years, for which she sought medical attention and underwent septoplasty and functional endoscopic sinus surgery 7 years ago at a different institute. Postoperatively, the patient noticed minimal improvement in her symptoms with persistence of right nasal obstruction. She also noticed right nasolabial fold fullness for a year, which increased in size over time associated with right facial pain. Clinical examination revealed a swelling in the right nasolabial fold measuring 2 × 1 cm. It was tender to palpation, hard in consistency, but with normal overlying skin. Anterior rhinoscopic examination of the right nasal cavity revealed lateral nasal wall swelling obliterating 90% of the nasal vestibule with normal overlying mucosa and skin colour externally. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a well-defined subcutaneous soft tissue density measuring 1.6 × 1.6 cm located in the right nasolabial fold. The lesion demonstrated isointensity with no drop in fat saturation T1 but showed hypointensity on T2 and homogeneous enhancement postcontrast ().
In August 2014, the patient underwent surgical excision of the mass through a sublabial approach, and the mass was found to be encapsulated with no infiltration to surrounding tissues and was excised completely with its capsule with uncomplicated postoperative period. Histopathological examination of the mass revealed spindle cells proliferation, forming fascicles and whorls on a background of collagen fibres. The fascicles were associated with foci of mixed inflammatory cells infiltrate composed mainly of lymphocytes and plasma cells, along with scattered eosinophils and neutrophils. The lesion infiltrates the surrounding striated muscles and fatty tissue with no infiltration to cutaneous and subcutaneous tissue. Moreover, immunohistochemical studies on the spindle cells revealed they are diffusely p

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old man with hypertension and diabetes presented with progressively worsening back pain radiating down the right leg, right flank pain, nausea, and vomiting. He denied hematuria, dysuria, or any problems with urination. He also had an unintentional weight loss of 5 kg during the past 6 months.
Based on systemic symptoms, CT scan was ordered to rule out malignancy. Radiographic findings were remarkable for hypodense liver lesions, pulmonary nodules, retroperitoneal lymphadenopathy, and increased bone density in L1 and L3 vertebral bodies as well as the right iliac bone. The patient also had moderate right hydroureteronephrosis of both renal moieties with delayed nephrogram and transition point within the proximal common right ureter ( and ). Lumbosacral MRI revealed right L5 nerve root impingement by a lumbar mass. Brain MRI showed abnormal signaling within right temporal lobe concerning for metastasis.
To further characterize the ureteral mass as well as to confirm the extent of collecting system duplication, the patient underwent a right ureteroscopy. Cystoscopy revealed bilateral orthotopic ureteral orifices with no ectopic orifice. Right retrograde pyelogram showed a filling defect at the proximal ureter with reduced amount of contrast moving in two levels more proximally, corresponding to a partially duplicated system (). A wire was placed into the upper pole of the kidney. A flexible ureteroscope was advanced alongside the wire confirming a bifurcation of a bifid collecting system at the level of the filling defect. The ureteroscope was advanced into the lower pole ureter, with multiple papillary tumors noted in this segment distally by the bifurcation. Selective barbotage cytology and tissue samples using a Piranha™ grasper (Boston Scientific, Marlborough, MA) were obtained. Narrowing of the proximal right lower pole ureter precluded advancement to the lower pole kidney. Attention was then turned to the upper pole ureter where multiple papillary tumo

[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 years old female who was diagnosed in the Department of Orthodontics in the University of Alabama at Birmingham. On clinical examination, the subject had a convex profile on a lateral view and occlusal cant. She had Class III molar relationship on the right side and Class I on the left side. An anterior open bite involving the lateral incisor on the left side and a retained primary canine was noted. Posterior open bite involving the right first molar was also documented. She had a lower midline shift to the left side in centric occlusion due to a functional shift. The subject had also spacing in the upper and lower arch [].
Panoramic radiograph was taken and no pathological abnormalities were detected. The subject had four missing third molars. She showed retained primary left upper canine with fully resorbed root and presence of permanent successor [].
Cephalometric findings showed maxillary and mandibular excess. ANB was − 0.5 which showed Class III tendency. The subject had proclined upper incisors, retroclined lower incisors, and steep mandibular plane [].
Nonextraction of permanent teeth and nonsurgical approach were recommended for the subject. The retained primary left upper lateral was extracted and nonsurgical extrusion of the permanent successor was done. Asymmetric elastics approach was used to treat the midline deviation. Class III elastic on the right side and Class II elastics on the left side were used with cross elastics anteriorly.
Kodak 9500 cone beam 3D system device (Carestream, Atlanta, GA) was used to take two CBCTS in two times frames: Initial (T1) and progress (T2). The radiation dose was 90 kV in a pulsed mode and frequency of 140 kHz. The tube focal spot was 0.7 mm with the sensor of a flat panel detector. Voxel size was (300, 300, 300) µm for the full field 3D image taken. The exposure time

[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 Chinese female, without any positive medical and family history, presented with recurrent chest discomfort on exertion for more than 10 years. Physical examination and laboratory tests were unremarkable.
On admission, the water bottle sign of the cardiac silhouette was found on the chest roentgenogram (Fig. ). Transthoracic echocardiography (TTE) revealed a large (10.2 × 7.5 × 3.8 cm) well-defined homogenous hypoechoic mass located in the pericardial cavity, encompassing the anterior walls of aorta and pulmonary artery. Further assessment by enhanced computed tomography (CT) showed a large lobulated low-density mass in the pericardial cavity (Fig. ). The tumor presented with septal enhancement and absence of parenchymal enhancement. Meanwhile, computed tomographic angiography (CTA) of the heart confirmed normal coronary arteries and no compression signs by the tumor. After extensive workup, a preoperative diagnosis of cardiac liposarcoma was made based on the extensive growth and the enhancement of the tumor septa, which made us believe complete tumor resection was of high difficulty. Debulking surgery was scheduled to release patient’s symptoms.
Intraoperatively, a giant lipoid tumor originating from RA was noted after pericardiotomy (Fig. ). The tumor was based predominantly on the entire free wall of the RA, stretching down from the RA appendage all the way to the orifice of the inferior vena cava (Fig. ). The RA was extremely deformed owing to the significant local mass effect. Due to well capsulation and no signs of local invasion, the tumor was considered a lipoma and therefore resectable. Complete tumor resection was achieved during beating heart surgery with cardiopulmonary bypass assistance. Excision required removal of most of the RA free wall. Direct suture for RA defect seemed to be impossible because of the large defect size and the high tension of suture. In addition, the deformation of RA could results in an unsatisfactory long-term outc

[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 Caucasian female presented to the emergency department with complaints of right hemiparesis, numbness, dysphagia, and ataxia. These complaints began as numbness over her right scapular area two weeks prior, and the numbness later progressed to include the right leg. Additionally, she reported five days of waking up during the night with severe headaches. Although she reported a history of migraines, which were usually accompanied by an aura, she stated that these new headaches were different in nature. She also had no known allergies and no previous surgeries. Her mother had a history of breast cancer, and her father had a history of ischemic heart disease. A review of systems was otherwise negative. After workup in the emergency department and consultation by neurology, she was referred to neurosurgery for management of a high-grade brainstem tumor.
Examination
On initial presentation, the patient was alert and oriented to person, place, and time with a Glasgow Coma Scale (GCS) score of 15. Her pupils were equal, round, and reactive to light. Cranial nerves II-XII were grossly intact. Motor testing revealed that strength was 5/5 in both upper and lower extremities. Pronator drift was noted in the right upper extremity. Dysmetria was noted in the right upper extremity during finger-to-nose testing, and discrimination of fine touch was subjectively diminished on the entire right side from the zygomatic process to the foot. Patellar reflexes were 3+ bilaterally. Over the course of her initial admission, the patient demonstrated a progressive decline, to include mild left facial droop, dysarthria, and a worsening dysphagia. A percutaneous endoscopic gastrostomy (PEG) tube was placed because the patient was unable to swallow without effort. These findings continued until her initial discharge. Upon readmission, the patient displayed similar findings. Left lower quadrant abdominal pain radiating to the shoulder and acute numbness of the left chest and shoul

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


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

[User]
RADIOLOGY NOTE:
In October 2007, a 14-year-old Asian female was referred for an ophthalmological evaluation for posterior uveitis and was referred to our outpatient clinic due to decreased visual acuity. She had a history of a severe sore throat 9 months previous and subsequent proteinuria. Her initial corrected visual acuity was 20 / 30 in the right eye and 20 / 25 in the left eye. The anterior segment and lens were clear in both eyes. Cells measuring 3+ right eye and 2+ left eye were found in the vitreous. Dilated fundus exam revealed blurred disc margins with disc swelling in both eyes (). Fluorescein angiography demonstrated retinal vasculitis sparing the posterior pole in both eyes (). Laboratory findings showed a mild elevation of white blood cells to 6,990/mm3. Results for tuberculin skin test and serological testing for syphilis, human immunodeficiency virus, hepatitis C virus, hepatitis B virus, toxoplasmosis, cytomegalovirus, varicella zoster virus, and herpes simplex virus were all negative. The chest radiograph showed nothing significant. Elevated anti-streptolysin O (ASO) of 630 IU/mL (normal <200) and an acute phase reactant erythrocyte sedimentation rate 16 mm/hr was noted. Urinalysis and serum chemistries showed no evidence of proteinuria, and renal function was normal.
After starting steroid eye drops and oral steroid (prednisolone 1 mg/kg), her symptoms and visual acuity improved, as did the vitritis and disc swelling. Topical and oral steroids were slowly tapered. In January 2008, her corrected visual acuity improved to 20 / 20 in both eyes. Fluorescein angiography demonstrated that retinal vascular leakage was improved, and steroid treatment was stopped.
After 3 weeks, the patient visited our clinic with visual loss and infection in the right eye. In the inferior of the right eye, an anterior chamber cell score of 4+ and posterior synechiae were noted. Vitreous cells were also noted. After starting oral steroid therapy, she recovered. Her best corrected

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old Saudi man, with no history of trauma, misdiagnosed as eventration of diaphragm for 20 years, reported to the clinic with abdominal bloating and intermittent dyspnea. CT revealed large right BH that contained stomach, pancreas, mesenteric fat, hepatic flexure, and transverse colon. The patient underwent elective laparotomy that started with mobilization of the left lobe of the liver to the left hepatic vein. The small and large bowel were reduced into the abdomen and the hernia sac was partially excised. The surgeon identified a hiatal hernia, approximated the diaphragmatic crura, and created a partial fundoplication. No other diaphragmatic defect was detected. The postoperative course was complicated by pulmonary sepsis, fever, and leukocytosis. Nine days postoperatively, thoracic and abdominal CT showed no change in size, site, or contents of BH, which implied failure of surgical repair. For the next 2 years, the patient complained of intermittent dyspnea and recurrent chest infections. Chest X-ray showed massive herniation of the stomach and bowel into the thoracic cavity []. The patient was referred for surgery in another hospital. However, patient habitually failed to show up for his appointments despite repeated reminders and rescheduling. Eventually, the patient presented to the emergency room in hypovolemic shock with severe abdominal pain, retching, and vomiting. After the patient's resuscitation, a thoracoabdominal CT was obtained. A giant BH with mediastinal shift to the left was evident []. The small bowel showed a high-grade closed loop obstruction at two sites above and below the diaphragm. The duodenojejunal flexure was incarcerated in the chest and obstructed with adhesions; the jejunoileal junction was obstructed with adhesions in the abdomen []. Hepatic flexure and transverse colon were incarcerated in the right chest []. Emergency laparotomy was performed which was followed by right anterolateral thoracotomy. Laparotomy confirmed the

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


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

[User]
RADIOLOGY NOTE:
A 78-year-old woman was referred to our hospital after being diagnosed with a pancreatic tumor in a routine abdominal ultrasound exam. The patient was asymptomatic and did not report losing weight nor any other complaints. Her previous medical history was unremarkable.
During the physical exam, the patient seemed well nourished, vital signs were within the normal range, and she was without masses in the abdominal exam. Routine blood laboratory results were within normal ranges. The referral ultrasound result reported a nodular hypoechogenic lesion with 4 × 3 × 3.3 cm in the pancreas tail, suspicious of an expansive process. An abdominal computed tomography (CT) revealed a globular shaped pancreatic body and a loss of cleavage plane between the splenic vein and the posterior face of the pancreas. For a better characterization, a pancreatic magnetic resonance imaging (MRI) was performed, showing a nodular lesion of the pancreatic body with 2.8 × 2.5 cm causing pancreatic tail atrophy and distal dilation of Wirsung's duct (Fig. ). These findings were mostly compatible with a neoplastic lesion. A thoracic CT was performed and was negative for metastatic pulmonary lesions.
The patient's clinical case was discussed in a multidisciplinary meeting, and she was proposed for a surgical procedure with the diagnosis of pancreatic neoplasia clinically staged as T2 N0 M0 (Stage IB – AJCC 8th edition) [].
She was submitted to a left subcostal laparotomy. During the procedure, a hard, bulky mass located in the transition of the pancreatic head/body was found. Intraoperative ultrasound showed close contact between the lesion and the portal vein (Fig. ), confirming local invasion after dissection. The performance of a tru-cut biopsy of the lesion and peri-regional lymphadenectomy (celiac trunk, interaortocaval, retropancreatic, and left renal artery lymph nodes) were decided on. There were no complications during or after the procedure, and the patient was discharged home on the nin

[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:
Our case reporting followed CARE recommendations (). A 49-year-old woman had sporadic episodes of rotational vertigo 12 years ago and abdominal pain 10 years ago. Ultrasonography and magnetic resonance imaging (MRI) of the abdomen revealed the presence of pancreatic cysts that did not show significant growth in imaging tests. Seven years ago, a computed tomography scan (CT) of the abdomen showed a solid mass in the lower pole of the right kidney. The patient was then submitted to right partial nephrectomy, and pathological examination revealed the presence of CCR. There was no need for adjuvant treatment. In the same year, the patient complained of altered visual acuity and a CT scan of the skull and orbit was made. The results show thickening with tortuosity of the left optic nerve, with a small area of nodular enhancement, with an extension about 0.8 × 0.5 × 0.4 cm. The right optic nerve had a conserved aspect. These results were considered suggestive of the presence of HB in the optic nerve of the left eye (). MRI of the head showed a gadolinium-enhancing well-circumscribed mass on the left optic nerve in the orbital (). The mother of the patient died at age 63 from an advanced kidney tumor, and her father is alive and healthy at age 80. The patient has one child, currently 27 years old, who has a recurrent headache complaint but refuses to undergo the investigation for VHLS, and a healthy, symptom-free, five-year-old grandson. The patient has five brothers and two sisters. One sister underwent partial nephrectomy due to carcinoma in the right kidney without the need for adjuvant treatment, another sister was operated on by HB from the CNS and had pancreatic cysts, and one brother had two HBs removed that were located in the brain and spine. A nephew of the patient at age 12 was diagnosed with HB from the CNS and died 4 years later due to complications of brain tumor that did not come to be removed.

[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 years old (height, 159 cm; weight, 85 kg; gravida 3, para 1) pregnant woman with SAS presented to our hospital and was scheduled to undergo elective CS under epidural anesthesia at 36 weeks of gestation. An echocardiographic examination at 34 weeks of gestation revealed that the diameter of the beginning portion of the aorta (under the aortic valve) was narrowed by about 17 mm. The diameter of the ascending aorta was normal, the average pressure gradient was 40 mmHg, and the ejection fraction was 67%.
In the operation room, her baseline vital signs were as follows: heart rate (HR), 82 bpm with normal sinus rhythm; noninvasive blood pressure (BP), 130/76 mmHg; and oxygen saturation (SpO2), 96%. Supplemental oxygen was administrated by a face mask at the rate of 3 L/min. Traditional epidural puncture was performed at the L1–2 and L3–4 interspaces in the left lateral position, and a catheter was inserted to a depth of 4 cm into the epidural space at the cranial and caudal ends of the surgical field. The patient was then placed supine in a left-tilt position; 3 mL of 2% lidocaine was injected as a test dose, and another 7 mL was injected 5 min later through the cranial catheter. Additionally, 3 mL of 1.5% lidocaine was injected through the caudal catheter. At 20 min after the lidocaine injection, the sensory block had reached T6. The patient had no discomfort, and her hemodynamic parameters were stable. The operating bed was adjusted from the left-tilt to horizontal position, and the operation was allowed. Two minutes later, the patient reported chest distress and difficulty breathing (HR, 110 bpm; BP, 80/69 mmHg; SpO2, 96%), and 3 mg of intravenous ephedrine was promptly administered. The patient immediately lost consciousness with no response (HR and BP were depressed to 40 bpm and 53/15 mmHg, respectively). The lowest BP at

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


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

[User]
RADIOLOGY NOTE:
In August 2009, a 75-year-old man (Chinese, ethnic Han) was referred to our clinic after a right pleural nodule was found on chest CT during a routine health examination. He was asymptomatic, and physical examination was unremarkable. Chest CT showed a soft tissue nodule with homogeneous enhancement arising from the right pleura, measuring 31 × 15 mm. The nodule had clearly demarcated margins and there was no evidence of invasion into the adjacent ribs. There was no enlargement of mediastinal lymph nodes (Figure ). Video-assisted thoracic surgery (VATS) revealed a smooth nodule on the parietal pleura at the fourth intercostal space, measuring 35 × 20 mm and not adherent to the adjacent lung. The nodule was completely resected. Postoperative histopathological examination revealed fibrous tissue hyperplasia with inflammatory cell infiltration and mesothelial cell proliferation, and a diagnosis of pleural mesothelioma was made (Figure ). The patient recovered quickly and was discharged from hospital on the seventh day after surgery.
In April 2011, he presented again with a 2-month history of right-sided chest pain, cough, sputum production, fatigue and weight loss. Physical examination revealed right chest wall tenderness and a hard, poorly delineated mass at the fourth intercostal space. Chest CT revealed right anterolateral pleural thickening, a soft tissue shadow in the adjacent chest wall, and clear lung fields with no enlargement of the mediastinal lymph nodes (Figure ). Based on imaging findings, he was thought to have recurrence of pleural mesothelioma. Preoperative tumor antigen testing detected an elevated squamous cell carcinoma antigen (SCCA) level of 5.7 μg/l (normal value < 1.5 μg/m1).
We performed right thoracotomy through the fourth intercostal space. The tumor in the subcutaneous tissues measured 5 × 4 × 4 cm, and was continuous with a pleural lesion measuring 7 × 8 × 8 cm, which had poorly demarcated margins and had invaded the upper lobe 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 22-year-old woman from the remote Dolakha district of Nepal presented with a gigantic swelling of her right lower limb and gluteal region in the outpatient department of the Department of Plastic Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. The mass was present since birth and had progressively increased in size, more so in the past 4 years making it impossible for her to walk (Figure ). There was no family history of neurofibromatosis. Though she had problems in ambulation since early childhood and used to walk with a limp, it was only after she could not walk that she sought for medical help. The delay in seeking medical help was also attributable to the very poor socioeconomic condition of the patient. The patient had to be transferred in a large custom-made wheelchair and needed the assistance of three to four people for any form of transfer.
The patient noticed multiple hyperpigmented lesions and multiple painless nodular lesions in her body since childhood. She dropped out of school when she was studying in grade six, not only due to the disability of having to walk a long distance to reach her school but also because she was stigmatized in the society. She suffered from peer teasing and had no friends. The people in her village thought that she had contagious elephantiasis and that by playing with her, their children would contract the disease.
Physical examination revealed a large, firm, soft tissue mass measuring 145 cms in length and 40 cms in width involving the entirety of the right lower limb, gluteal region, waist, and perineal region (Figure ). The skin overlying the gluteal region and the calf had giant Cafe-au-lait spots. The hip, knee, and ankle joints were dislocated, and the limb was in externally rotated position. The patient showed appreciable movements only in the toes. The largest circumference of the right thigh was 72 cms and that

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old African American female was diagnosed with left breast cancer with multiple bone and liver metastases in April 2009. She was treated with chemotherapy and intravenous bisphosphonate therapy with zoledronic acid. A follow-up bone scan redemonstrated the multiple bone metastases, now with a new focus of increased radiotracer activity in the left mandibular angle. Radiological interpretation suggested that this focus most likely represented either severe dental disease or a metastatic focus. Few months later, the patient developed severe pain in her mandible, for which dental evaluation led to a tooth extraction. However, following the tooth extraction, the patient's jaw pain progressed with worsened swelling of the left lower jaw. CT scan of the mandible () demonstrated a mandibular body bony lesion on the left with adjacent soft tissue stranding, again interpreted to be concerning for a metastatic bone lesion. Bone scintigram () demonstrated expansion of the mandibular lesion and slight progression of the multiple other skeletal metastases.
A referral was made to radiation oncology due to worsening jaw pain unresponsive to narcotic medications and imaging findings suggestive of a metastasis. Without exposed bone on physical exam, it was felt that she would benefit from palliative radiotherapy (RT) for her presumed mandibular metastasis. She underwent RT to her jaw lesion to a total dose of 2000 cGy in 5 fractions of 400 cGy each using a 3D-conformal technique. However, after the RT, the patient's jaw pain continued to worsen. Despite negative blood and bone cultures, she received courses of cephalexin and clindamycin, for a presumed jaw infection with no improvement.
Since the presentation was atypical and there was no therapeutic response, a bone biopsy of the mandibular lesion was obtained but revealed no evidence of metastatic disease. In light of the negative pathology and lack of clinical response, the diagnosis was now felt to be most consistent w

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old male patient had been suffering from a massive lymphedema of the lower extremities also including the scrotum for almost 20 years. Despite consequent lymph drainage up to four times per week, the patient showed progressive symptoms with suddenly occurring diarrhoea, a massive impairment of physical capabilities and a severe reduction in the quality of life. The patient's weight was consistent with 110 kg at a height of 184 cm [body mass index (BMI): 32.5 kg/m²]. Pulmonary, cardiac and hepatological diagnostics showed no underlying disease. Gastroscopy and colonoscopy gave no pathological findings. The only exceptional result was a protein deficiency with a chronic lowered total serum protein (47 g/l; normal range 64–84 g/l). Gel serum electrophoresis showed a general protein deficiency.
Since conservative treatment with lymph drainage showed no improvement of the patient's symptoms, further diagnostic steps including a push–pull enteroscopy revealed the PIL of the jejunum to an extent of about 50 cm (). Subsequent capsule endoscopy confirmed the limited involvement of the proximal to mid jejunum.
Due to the extensive impairment of the patient and the therapy-refractory course, the indication to exploratory laparoscopy with segmental intestinal resection was given.
During the laparoscopic operation, an extensive part of the small intestine appeared macroscopically clearly altered (). Thus, the laparoscopic-assisted resection of the conspicuous intestine (95 cm) with end-to-side anastomosis was performed.
Histopathological analysis confirmed the PIL with dilated submucosal and subserosal lymphatic vessels (Fig. a and b).
The patient was discharged on the seventh postoperative day. During an outpatient visit after 2 weeks, a slight improvement of the total serum protein to 52 g/l was obtained.
An outpatient follow-up after 6 months showed a reduction in the patient's weight from 110 to 105 kg (BMI: 31 kg/m²), and the frequency of lymph drainage had been 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 76-year-old female patient presented to the Department of Oral and Maxillofacial Surgery with the chief complaint of swelling in the left palatal region for the past 2 months. The patient had a history of loss of the upper left second molar tooth three years ago when the patient herself plucked it out due to pain and presumably damaging the alveolar socket in the process. Further, the patient had a history of extraction of the first molar tooth 5 months back elsewhere, supposedly a traumatic extraction of extended duration, following which the patient has been informed of possible involvement of the sinus floor after the procedure by the previous dental practitioner. The patient's past medical history revealed to be uncontrolled diabetic, hypertensive and under anticoagulants. There was no previous history of trauma, previous surgeries, or maxillary sinusitis.
On extraoral examination, mild swelling was evident in the left upper cheek region and the patient also had paresthesia on the left infraorbital region and left nose blockage for a duration of one month. On intraoral examination, palatal swelling of 2.5 cm × 3 cm was confined to premolar and molar region, not extending across the midline with obliteration of the left buccal vestibule and expansion of the alveolar segment over the molar region []. Skin overlying the swelling was of normal colour, and the swelling was slightly tender on palpation but not pulsating. The premolar teeth were not tender to percussion. Periodontal pocketing was absent and surrounding gingiva was of normal color and appearance. All teeth were vital. No intraoral or extraoral sinus openings were identified.
Preoperative computed tomographic (CT) scan showed an extensive radiolucent unilocular cystic lesion within the left maxillary sinus measuring 35 x 31 x 34 mm, which obliterated the left osteomeatal complex superiorly till the left infraorbital foramen. Resorption of both anterior and posterior wall of the maxillary sinus was evid

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old lady presented with painless progressive swelling on the right cheek and right side of palate for 2 months. On examination there was a 2 × 2 cm firm, non-tender swelling. She had undergone a surgery elsewhere 2 years back for a palatal swelling, the details of which were not available. Computed tomography (CT) revealed a 29 × 28 mm enhancing mass in the right side of hard palate with large defect in the palatine process, extending into right maxillary sinus and nasal cavity, anteriorly up to the vestibule and inferiorly into the oral cavity. Right inferior partial maxillectomy was done with excision of the tumor which was sent for histopathological examination. Intraoperatively there was an encapsulated 6 × 4 × 3 cm size mucosa covered mass filling right maxillary sinus.
Two years later, she presented with recurrent swelling in right infraorbital region for 4 months associated with mild pain. On examination, the swelling was small, firm and non-tender. CT revealed a tumor over anterior wall of right maxillary sinus extending to soft tissues anterior to right maxilla. The tumor was excised via Caldwell-Luc approach and sent for histopathological evaluation.
Subsequently, 1 year later, she presented with rapidly progressive swelling of bilateral cheeks and lateral surface of nose for a month, associated with breathing difficulty. On examination there was a 6 × 5 cm red tender swelling on the face with flattening contour of nose infraorbitally, extending to upper lip with obliteration of bilateral nasal cavities. On CT, there was an extensive heterogeneously enhancing soft tissue density lesion in both maxillary sinuses with destruction of the walls and extension into both ethmoid sinuses, nasal cavity, maxillary alveoli, soft tissue of upper lip, bilateral infratemporal region and both orbits. There was no intracranial extension. The mass was excised surgically. Intraoperatively, there was extensive friable tumor adherent to the skin, involving bilateral

[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 59-year-old Caucasian male presented to our center with a rapidly growing mass in his left axilla. He complained of weight loss, night sweating, and daily fevers. Physical examination revealed lymph node enlargement only in the left axilla, but neither loss of motor function of the left arm nor neurologic deficit presented. A full dermatological examination did not reveal any concerning lesions. Incisional biopsy of the mass demonstrated malignant melanoma metastatic to regional lymph nodes, which stained positively for S100 and MART-1. BRAF mutation status was found to be V600E using Cobas 4800. The patient underwent a total body CT with no further findings, except for the axillary mass, which was observed to be extensive, poorly circumscribed, and infiltrating adjacent structures, and therefore, it was assessed as unresectable (). The patient was thus diagnosed with stage IIIc unresectable melanoma of unknown origin. As he was a good candidate for BRAF inhibition, the patient was treated with vemurafenib tablets, 960 mg BID. From the first week of treatment he reported an immediate improvement in his general condition and shrinkage of the painful, ulcerating axillary mass.
Although the initial positive results of therapy were optimistic, because such improvement has been shown to be only temporary—often followed by a state of increased resistance and progression of the disease—one month after beginning treatment we decided to operate. Surgical resection revealed a mass of 14 cm in diameter that penetrated the pectoralis major and minor muscles and encircled the axillary artery, vein, and nerve. The entire mass, including the pectoralis muscle and skin above it, was removed. The pathological examination revealed foci of a totally necrotic tumor with no observable traces of viable tissue ().
Following his recovery, the patient returned to his homeland overseas and stopped treatment, despite medical advice to the contrary. Two months later he consented to undergo a

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old female patient presented to the Department of Anesthesiology of this hospital with the chief complaints of 1-month duration of pain and numbness in her right medial antebrachial region. She was referred to the Department of Rehabilitation for electrodiagnostic examinations. According to the patient's past history, she had undergone right carpal tunnel release 8 months before she visited our hospital. However, this did not relieve the complaint of right finger numbness that she had before the surgery. Therefore, she had undergone the surgery again one month earlier. The symptoms in the medial antebrachial region occurred thereafter. During the surgery, she was anesthetized by axillary brachial plexus block using ultrasound guidance. First, in a supine position, her arm was externally rotated by 90°, her elbow joint was flexed by 90°, and her head was turned to face the side opposite to the surgery. The ultrasonic probe was placed on the axillary region to find the axillary artery, the surrounding structures were checked, and a 23-G needle was inserted to inject a solution comprising a mixture of 2% lidocaine, 0.5% bupivacaine, and epinephrine (1:200,000) into the axillary sheath. Physical examinations revealed no muscle weakening but right thenar muscle atrophy. In sensory tests, the patient complained of decreased sensation and numbness in the right first, third, and fourth fingers, and in the medial antebrachial region. In particular, she reported that she suffered sleep disturbance due to the pain in the medial antebrachial region. The upper extremity deep tendon reflexes were all normal, but positive responses were obtained in the median nerve compression test. The symptoms were not accompanied by cervical and upper extremity pain, or decreased sensation. According to the electrodiagnostic examinations conducted 4 weeks after the onset of the symptom, the median and ulnar nerves were normal in motor nerve conduction studies. Sensory nerve conduction

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


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

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

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


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

[User]
RADIOLOGY NOTE:
The disease manifested in a healthy 53 years old female patient 7 weeks prior to the initial visit to our center with sudden onset of blurred vision, dizziness, disturbed gait and coordination impairment. Before the manifestation of symptoms patient was healthy, no prior dementia cases in patient’s family history were recorded. Two weeks after initial symptoms presentation patient was hospitalized in the Department of Neurology of Regional Hospital. Neither ophthalmologic examination nor blood test revealed any significant changes. Brain computed tomography (CT) (Fig. ) and MRI (Fig. ) were evaluated as normal. Although after retrospective reevaluation of MRI, slight increase in the occipital DW signal was found (Fig. ). EEG was performed on the 6th week since initial disease presentation did not show any specific changes. Initially, the patient was diagnosed with primary hypertension (blood pressure was 150/70 mmHg): Spironolactone 25 mg per day for arterial hypertension and Clonazepam 0,5 mg once a day for insomnia, Betahistine 3 mg three times a day were prescribed. On the sixth week after initial symptoms due to complaints of dizziness, impaired memory, insomnia, emotional lability, the possible causes were differentiated among cerebrovascular and somatoform/conversion disorder. As the symptoms progressed significantly, on the 7th week after the onset of symptoms, the patient was referred to the University Hospital. Clinical course of the disease and the major diagnostic tests are presented in Fig. .
During the hospital admission the patient complained of weakness, difficulties standing up and walking due to dizziness and visual impairment as well as difficulties concentrating during the interview. A neurological evaluation revealed vertical gaze palsy, extrapyramidal type increased right body side muscle tonus, involuntary stereotypical movements (purposeless raising and lowering of the left hand), weaker reflexes on the left side and ataxic gait. Arterial bloo

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


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

[User]
RADIOLOGY NOTE:
A 33-year-old male patient (weight 56 kg; height 174 cm) presented complaining of faintness and shivering on the left side of the body that had been occurring for 2 months, associated with unsteadiness toward the left and diplopia that worsened when looking to the right.
Magnetic resonance imaging showed a 12 × 13 × 9 mm extra-axial tumor lesion on the left middle cerebellar peduncle that accompanied a 24 × 35 × 21 mm cystic lesion under the tumor lesion ().
The preoperative diagnosis was hemangioblastoma. The patient had no abnormal findings with regard to salivary glands on the preoperative computed tomography scan. A right retrosigmoid suboccipital craniotomy was planned to remove the tumor. Operative position was right lateral-semiprone position with chin down ().
No anesthetic premedication was administrated. Anesthesia was induced with remifentanil with O2, air, and sevoflurane. Muscle relaxation was achieved with rocuronium bromide, and the patient was intubated uneventfully with a 8 mm internal diameter reinforced tube. To facilitate the surgical approach, the patient was placed in the extreme left lateral position and his sides were supported and pressure points secured.
The surgery proceeded uneventfully and all hemodynamic parameters as well as fluid input/output were maintained in the intraoperative period. At the end of the surgery, when the patient was found to be conscious and responding to commands, he was extubated in the operation theater. Total operation time was 4 hours and 23 minutes. Total anesthesia time was 6 hours and 8 minutes. Total infusion volume was 2,250 mL. Blood loss was 195 mL. Urine volume was 510 mL. Neurological assessment was satisfactory. However, a slight degree of right submandibular swelling was noticed after the extubation. An ultrasonic examination was performed by a dental surgeon who happened to be there at that time and pointed out the swelling of the right submandibular gland. As his vital signs were found to be within

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old male experienced an electrical burn after contact with a 440-volt line while working on a roof. On standing from squatted position, our patient's head came into contact with an exposed wire, resulting in brief loss of consciousness followed by recovery and a charred wound on vertex for which he was being treated at home. Since the wound did not heal and foul smell emanated from it, he was brought to a hospital to treat scalp injury; debridement of dehiscence and skin necrosis was performed. After 8 weeks of electrocution, he was transferred from local community hospital to our institution, he was fully conscious, and he had total amnesia about electrocution. The entry wound was through scalp, traversing through his neck and chest, into his groin, and exiting from his right thigh.
He had 15 cm × 10 cm scalp loss with charred area on the vertex bone with little smelling and fungation of brain matter through dura was merely visible.
Over the ensuing days, he was observed to move his legs less than his arms. The patient had neurologic deficits manifesting as spasticity, motor weakness, and sensory impairment along with bladder involvement. Spasticity of the lower extremities from hip to ankles was grade 2 on the Modified Ashworth scale. There were severe deficits in sensitivity to pain, light touch, and proprioception in the area below neck. Deep tendon reflexes were brisk and muscle weakness with medical research council grade of 3, and plantar responses were equivocal.
Investigation revealed normal hemogram and serum electrolytes. Plain computed tomography (CT) scan was done which showed vertex bone defect. No fracture or dislocation was seen by radiography. Cervical spine magnetic resonance imaging (MRI) and brain MRI done 1 week after injury did not show any specific abnormalities. Since the MRI findings did not match symptoms of patients, repeat MRI performed on admission demonstrated changes suggestive of cord edema and ischemic

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


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

[User]
RADIOLOGY NOTE:
The patient is a 44-year-old man who presented with a duodenal tumor recently diagnosed at an outside facility. He was admitted to another hospital with melena and anemia with a serum hemoglobin of 6.0 g/dL. Four units of red cell concentrate was transfused and upper gastrointestinal endoscopy performed for hemostasis of the duodenal lesion. Gastrointestinal bleeding was then stabilized for several days. The patient was discharged from that hospital and returned home with instructions to be evaluated at our hospital. Two weeks later, he presented with appetite loss and vomiting. Past medical history, family history and social history were unremarkable. The physical examination was unremarkable. Laboratory studies showed a serum hemoglobin of 7.8 g/dL. Serum tumor marker levels were within normal limits (CEA 0.7 ng/ml, CA19–9 7 U/ml, IL-2 receptor 323 U/ml).
Repeat upper gastrointestinal endoscopy showed a circumferential soft tumor with a friable surface in the second portion of the duodenum. It was difficult to insert the endoscope distally, and difficult to identify the papilla (Fig. ). Though four biopsies were taken from the tumor edge and a small round cell sarcoma was suspected, a definitive diagnosis could not be made.
Computed tomography (CT) scan showed a greater than 10 cm tumor with heterogeneous enhancement on a dynamic study and some air suggesting necrosis and infection inside the tumor (Fig. ). The tumor compressed the inferior vena cava and infiltrated the ascending colon. The common bile duct and intrahepatic bile ducts were dilated. No obvious metastases were seen in other viscera or the lung fields, and intraperitoneal lymph nodes were not enlarged.
Based on imaging studies, we considered a duodenal sarcoma with bleeding and necrosis. Due to gastrointestinal obstruction and bleeding, urgent surgical resection was recommended to the patient and undertaken. A pylorus-preserving pancreaticoduodenectomy with partial resection of the inferior vena cava

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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 50-year-old female patient was referred to the Oral Medicine Clinic, Faculty of Dentistry, Universitas Indonesia, complaining of a painful lesion located on her upper right buccal mucosa, in addition to the palatal mucosa. She had experienced throbbing pain in the mucosal tissue around tooth 17 a few days earlier. She reported the self-application of a cotton roll that had been damped in propolis to relieve the pain in the mucosal area. The cotton roll was left in contact with the mucosa overnight. She noticed the eruption of a painful oral lesion the next morning, which caused difficulty in eating. The eruption of the lesion was not accompanied by any systemic symptoms, and no other body areas were involved. She also reported the daily consumption of propolis diluted in her drinking water. A review of her medical history revealed an allergic history to chloramphenicol and occasional gastric pain. Otherwise, the patient was healthy and was not under any medication. A clinical examination revealed multiple shallow and irregular ulcerations on the right buccal mucosa, the right hard palate mucosa, and the gingival area surrounding tooth 17. The size of the ulcers ranged from 0.3 to 1.5 cm in diameter (). Tooth 17 was in the middle of endodontic treatment for wide and deep caries lesion, and the radiograph showed no periapical lesion (). Palpation and percussion of tooth 17 were within normal limits. However, the patient considered having tooth 17 extracted. Furthermore, enlarged and painful submandibular lymph nodes were noted on palpation and were possibly the result of inflammation related to tooth 17. A working diagnosis of propolis-induced mucosal burns was made. The patient was advised to discontinue propolis use and was prescribed tetracycline mouthwash three times daily for 3 days and Doloneurobion twice daily for 7 days to manage the pain. She was advised to make a followup consultation after 5 days.
On the followup consultation, extra oral examination indic

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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 75-year-old man with a history of persisting abdominal pain and mild diarrhoea for three months was referred by a general practitioner to the hospital. During this period the patient observed a weight loss of 2 kg, but did not show any B symptoms. A colonoscopy was performed without pathological findings. A subsequent CT examination of the abdomen showed two separate fat-containing retroperitoneal masses one in the adrenal gland and the second lateral of the psoas muscle inferior to the right kidney, outside the peri-renal adipose tissue. The lesions were separate and had no connecting tissue in between them (Figure ). To further confirm the obtained CT scan results an MR imaging was performed and showed again a fat-containing lesion in the adrenal gland and a 7 × 5 × 7 cm soft tissue-tumour inferior to the right kidney without invasion of the right kidney, urethra or renal vasculature. Both lesions appeared similar in the CT and MR imaging and were consistent with a well-differentiated liposarcoma (Figure ). Aware of the fact that a liposarcoma of the adrenal gland is extremely rare, a primary benign and fat containing tumour derived from the adrenal gland itself, such as a lipoma or myelolipoma was considered. Regarding tumour markers, only increased levels of CA 19-9 were detected (81.86 U/ml reference < 37 U/ml, CEA 2.2 μg/l, reference < 5 μg/l). To exclude a neuroendocrinological pathology additional tests were performed but did not reveal any noticeable conspicuities.
Consequently, we assumed a combination of a retroperitoneal liposarcoma and a primary benign, lipomatous tumour of the adrenal gland. Alternatively, the very rare case of the combination of a retroperitoneal liposarcoma and an adrenal liposarcoma was taken into consideration. Therefore, two therapeutic options were considered on these accounts. In the unlikely case of simultaneous liposarcomas an enbloc resection including both masses would be required after pre-treatment. But, in the probable

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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 35-year old male presents to the emergency department (ED) with what he describes as right-sided upper back and flank pain, which he attributes to a “cupping” procedure the day prior. The cupping procedure is an alternative medicine practice that uses local suction to theoretically stimulate blood flow and promote healing. He had no previous issues with the procedure. On further history he reported having had approximately 6 weeks of intermittent fevers, cough, anorexia and general malaise. He had seen multiple naturopathic physicians for these complaints, before an urgent care visit one week earlier. At that time, he had been started on azithromycin and doxycycline for a presumptive diagnosis of pneumonia. In the interim week he reported an improvement in his febrile symptoms and overall well-being. He was an otherwise healthy heterosexual male, without drug use or travel outside the country. He had no known sick contacts.
On physical examination his vital signs included a blood pressure of 116/75 mmHg, a heart rate of 119 beats per minute, and a respiratory rate of 20 breaths per minute. His temperature in the ED was 36.2°C. Oxygen (O2) saturation was 97% on room air. The patient was alert, and appropriate with no signs of respiratory distress. Pertinent physical findings revealed typical, non-tender cupping marks on his back. More concerning was an absence of breath sounds on the right side of the chest on auscultation. His abdomen was soft and non-tender. The remainder of the physical examination was non-contributory.
The initial diagnostic test ordered was a chest radiograph, which showed 80% opacification of the right hemithorax, consistent with pneumonia and associated parapneumonic effusion seen in . A bedside ultrasound was subsequently performed in the ED, initially in order to examine the size of the pleural effusion in which a startling discovery was made. The image of the right upper quadrant is shown in and corresponding

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


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

[User]
RADIOLOGY NOTE:
In August 2010, a 57-year-old Chinese male presented with epistaxis and decreased hearing for 1 month. No additional symptoms, such as a neck mass, nasal obstruction, headache, diplopia or other cranial nerve palsies, were noted. The patient had no history of previous or synchronous tumours or any family history of cancer. Nasopharyngoscopy revealed a large exophytic tumour that was covered by smooth mucosa, which grew from the right posterolateral nasopharyngeal wall in the right posterior naris. Magnetic resonance imaging (MRI) scans of the nasopharynx and neck using gadolinium enhancement demonstrated a 2.0 × 1.5 × 2.0 cm well enhanced mass over the right posterior nasopharynx with right retropharyngeal node enlargement. The tumour extended across the right parapharyngeal space and infiltrated into the medial pterygoid muscle. In addition, skull base erosion was detected with right alar lamina involvement (Fig. ). Cervical lymph node metastasis was not observed. Hematologic, hepatic and renal function tests revealed no abnormalities. The patients underwent chest and abdomen computed tomography (CT) as well as a bone scintigram, and no distant metastasis was found. A biopsy of the nasopharynx was performed.
In the biopsy specimen, normal salivary tissue was not present. The tumours were ill demarcated without encapsulation. Tumour cells were arranged in nests and nodules. Two morphologic patterns of the tumour cells were observed. Some small round cells exhibited dark nuclei and scant cytoplasm. Other large cells contained round to oval pale nuclei and eosinophilic to amphophilic cytoplasm. In the central region of the tumour cell nests, large cells displayed a solid growth pattern. Small dark cells were clustered at the periphery of the tumour cell nests and appeared palisaded. Prominent nucleoli and mitosis can be observed, and an average of three mitotic figures were observed per 10 high-power fields (original magnification × 400).
In the immunohistochemical an

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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:
In the beginning of November 2015, a male Asian patient (52 years old) noticed major discomfort and pain in his left TMJ. A week later, as the symptoms got worse and the patient began to experience difficulties in fully opening his mouth. He visited his general dentist, who observed that the patient had an evident limitation in fully opening his mouth (maximum mouth opening of 16 mm), with a discrete clicking noise and without deviation when opening.
An extraoral examination demonstrated the absence of asymmetry or bulging, but pain was confirmed when the left-side TMJ was palpated. An intraoral examination did not evince any disease of odontogenic etiology. The patient's medical history was not significant.
The general dentist suspected that the patient was affected by temporomandibular disorder and disc displacement. The patient was then medicated with analgesics (500 mg of paracetamol twice a day for 1 week) and radiographic examinations were carried out, with a provisional diagnosis of temporomandibular dysfunction.
Then, on the radiographic examination, the clinician observed a radiolucent lesion in the superior posterior border of the mandibular ramus (left side). Considering that lesions in mandibular ramus may cause neurological disorders, the dentist checked whether the patient had any neurological complaints, such as paresthesia on the left side of the mandible, but the patient did not report any neurological symptoms. The patient was therefore referred to the university clinic.
The panoramic radiograph revealed an oval-shaped radiolucency with well-defined borders that was unilocular and located near the upper third of the ramus, posterior to the mandibular foramen, and close to the mandibular posterior margin. The lesion was homogeneously radiolucent, had no sclerotic margins, no contiguity with the mandible border, and measured about 1 cm in its largest diameter. No alterations were observed in the surrounding tissues, such as periosteal reaction or ana

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 92-year-old lady with wet age-related macular degeneration who developed endophthalmitis after the 13th ranibizumab injection. The patient had been treated regularly for bilateral wet age-related macular degeneration. During her June 2015 visit, the patient received her 13th right eye and fifth left eye ranibizumab injections without any immediate complication. The patient developed severe right eye pain on her way home on the same day, but only presented to the hospital eye service 6 days later with no perception of light in the right eye. Preinjection best corrected visual acuity in the right eye was 6/48. The patient was otherwise healthy, and not taking any pills.
Ophthalmological examination showed an injected chemotic right eye with organized hypopyon and no view of the fundus. B-scan ultrasound examination revealed extensive vitreous debris []. A diagnosis of suspected endophthalmitis was made.
The patient was admitted to hospital on the same day. Aqueous and vitreous specimens were obtained for bacterial cultures and gram staining. During posterior vitrectomy, a very opaque and thick vitreous was observed and it was not possible to remove all debris due to an inadequate view. A white sheet of material remained in the posterior pole. Intravitreal Vancomycin 0.5 mg and Amikacin 200 μg was injected at the end of the procedure. The patient was also started on oral Levofloxacin 500 mg twice daily.
On the 1st day following vitrectomy, the right eye was comfortable, with the perception of light vision. Topical ofloxacin, cycloplegics, and steroids were started. Prolonged bacterial cultures on solid and liquid media were negative. In view of the possibility of a toxic posterior segment syndrome, the patient was started on oral prednisolone 40 mg/day 3 days after the anterior chamber and vitreous biopsies came back negative.
Three weeks after vitrectomy, 16s ribosomal ribonucleic acid (rRNA) polymerase chain reaction (PCR) of the culture-nega

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


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

[User]
RADIOLOGY NOTE:
A 45 year old female with the diagnosis of 10 years' progression of definite () bilateral type I Menière's Disease, according to the Lopez-Escamez classification (), with recurrent vertigo and hearing loss attacks symptomatically controlled with sulpiride (50 mg) on demand, was referred to the cochlear implants unit of a tertiary hospital center as a possible candidate for cochlear implantation, because of profound hearing loss (1997 BIAP) in the left ear and fluctuating moderate-severe (1997 BIAP) hearing loss in the right ear. The most recent vertigo episode occurred 10 days prior to her visit to the cochlear implant unit. No visual impairment or other alterations were found on otoneurotologic examination; normal ocular movements, normal smooth pursuit, and saccadic movement, absence of ocular misalignment on skew deviation test and no spontaneous nystagmus were also found, despite the recency of the last vertigo attack. Other neurological examinations and standard cerebral MRI were also normal for this patient.
In addition to the same tests as for case I, because of the bilateral MD diagnosis, the patient had received 3 months prior a 3 Tesla MRI examination of the inner ear using the HYDROPS MRI sequence (): this sequence is based on the digital subtraction of images produced by the different time diffusion of gadolinium along the inner ear fluids. This MRI showed bilateral cochlear and vestibular endolymphatic hydrops with left side hydrops predominating, as can be observed in Figure .
The instrumental vestibular testing was performed by the same senior neurotologist using a vHIT ICS Impulse™ USB hardware version with software version 4.1: this device was a different unit from the device used in case I. Figure shows enhanced vHIT eye velocity responses for both sides, with an aVOR gain value of 1.14 on right horizontal canal function test and 1.05 for left side. In this case, the vHIT calibration was repeated

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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 48-year old man presented in emergency department (ED) with a 2-day history of rightsided numbness in face and arm. He was obese with body mass index of 43.6, heavy smoker since the age of 18 and had a medical history of uncontrolled hypertension, diabetes and hyperlipidaimia. At the ED his behavior-raised questions as disinhibition and impulsivity dominated with patient urinating in public in the examination room. Mild incontinence was reported by patient lasting one year. He also reported being unemployed for three years due to difficulty performing tasks he could easily manage some years before. Neurological examination revealed subtle facial paresis of which patient was unaware. An urgent brain computed tomography scan (CT) revealed marked dilatation of the third and lateral ventricles and a calcified dolichoectatic basilar artery (). There was no papilledema or impaired eye movement on ophthalmological examination. During hospitalization and since there were no signs of mass effect on initial brain CT or papilledema patient underwent lumbar puncture (LP) in an attempt to perform a cerebrospinal fluid (CSF) tap test. Opening CSF pressure was 41 cm H2O and tap test was early terminated after removing 20 mL. Laboratory studies were unremarkable. Patient was assessed before and after LP with mini-mental state examination (MMSE), reported incontinence, walking pattern and distance measured. Even though a full CSF tap test was not performed, we did confirm improvement in all four tests and especially wide-based gait returning to normal. There was also striking improvement in disinhibition and impulsivity. Neuropsychological examination concluded in moderate cognitive impairment, with MMSE score of 20 out of 30, especially in the elements of registration recall, attention and complex command execution. Magnetic resonance imaging (MRI) of brain found dilated third and lateral ventricles and a dolichoectatic basilar artery causing compression, upward displacement of t

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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 27-year-old Caucasian woman was admitted to the Emergency Department of our Institution because of bloody diarrhoea – up to 10 bowel movements per day – during the last month, 3 weeks after quitting smoking. Physical examination showed no abnormalities but confirmed haematochezia on digital rectal examination. Colonoscopy showed continuous severe colonic inflammation with small ulcers from the anus to the descendent colon, classified as grade 3 in Mayo endoscopic sub-score and 3 points in Ulcerative Colitis Endoscopic Index of Severity (UCEIS); complete examination was not performed because of the risk of perforation. Empirical antibiotic treatment with ciprofloxacin and metronidazole, as well as oral and rectal mesalamine were started and partial symptomatic improvement was achieved. Venous thrombosis prophylaxis with subcutaneous enoxaparin, 40 mg per day, was started. At admittance, haemoglobin, white cell count, platelets, fibrinogen and C reactive protein (CRP) were within the reference range. Stool cultures were negative. Cytomegalovirus (CMV) infection was also ruled out in colonic biopsies (polymerase chain reaction – PCR – and, later, immunohistochemistry). As bloody diarrhoea persisted 48 h later, and histopathological examination of colonic biopsies showed crypt distortion, a mixed inflammatory infiltrate of the lamina propria and crypt abscesses suggesting the diagnosis of UC, intravenous methylprednisolone (1 mg per kg of weight, daily) was started. After 3 days of corticosteroids the patient achieved partial clinical response (6 bowel movements per day, Edinburgh index 2 points, CRP within the normal range); nevertheless, 2 weeks later infliximab therapy (5 mg/kg of weight) was started due to sustained clinical activity, with 10 bloody bowel movements per day and a progressive increase of CRP levels, up to 10 mg/dL. Three days after the first dose of infliximab, the patient presented a massive lower bleeding with haemodynamic instability and severe a

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