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

[User]
RADIOLOGY NOTE:
A 44-year-old man consulted on pain affecting his left leg. His previous medical record was uneventful with no previous hospital admissions or surgical interventions. The patient reported no weight loss and had no other symptoms rather than pain, which had progressively worsened in the last 2 months and prevented the patient from sleeping at night. The physical examination was unremarkable, but the MRI performed showed a huge soft tissue mass, affecting the adductor muscles of the left thigh and measuring 30 × 20 cm. Radiological diagnosis were liposarcoma or haemangioma. An incisional biopsy of the mass revealed a diffuse growing neoplasm. The predominant areas were of myxoid nature (Figure ), but there were also foci of round less-differentiated cells (Figure ). Immunohistochemistry showed a positive reaction for S100 protein, while the other markers (for muscle, vascular and epithelial differentiation and also p53 protein) were negative. The extension imaging study including CAT showed no evidence of metastasis and with the histopathological diagnosis of myxoid/round cell liposarcoma the patient underwent amputation of his left leg at the hip level, 15 days after the incisional biopsy. During the postoperative period of the first surgery he suddenly developed intense pain in his right leg, which he had not reported before. Physical examination revealed a 7 cm soft mass in the right hamstring and a core needle biopsy showed a tumour with the same histopathological features as those found in the left leg. The patient refused surgery and he underwent local radiotherapy of the mass. One year after initial diagnosis the routine follow-up CAT revealed a huge retroperitoneal mass suggestive of adipose origin. Chemotherapy was initiated with iphosphamide, adriamycin and DTIC with apparent stabilization of the mass. The general situation of the patient gradually worsened and he died with persistence of the retroperitoneal disease 23 months after initial diagnosis. No auto

[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 53-year-old man, who had undergone sternoturnover for pectus excavatum as a child, was diagnosed with acute myocardial infarction, and percutaneous coronary intervention was performed as the acute treatment of the culprit lesion. Two drug-eluting stents were implanted at the aneurysmal site of the left anterior descending artery and the high lateral branch. However, coronary angiography after coronary intervention demonstrated residual stenoses of the left anterior descending artery, high lateral branch, and left circumflex artery, and intravascular ultrasound revealed stent malappositions at the sites of the coronary aneurysm (Fig. ). Because the duration of patency of the stent implanted within the coronary artery aneurysm was unpredictable and a residual lesion was present, he was referred to our department for CABG. Echocardiogram showed left ventricular dysfunction with an ejection fraction of 19%. Enhanced computed tomography revealed bilateral occlusions of the internal thoracic arteries and a small fragile sternum after sternoturnover fixation (Fig. ). Considering postoperative respiratory dysfunction associated with instability of the thorax following median sternotomy, low left ventricular function, and left coronary artery as the only target vessel, we selected left thoracotomy for CABG without cardiopulmonary bypass.
The left radial artery and great saphenous vein were harvested with the patient lying supine under general anesthesia. He was then placed in a semi right lateral decubitus position (Fig. ). The thoracotomy was made by a left anterolateral incision at the fifth intercostal space. The pulmonary ligament was dissected to open a route for the grafts. The pericardium was opened posterior to the left phrenic nerve, and the target vessels were exposed. After systemic heparinization, the saphenous vein graft was anastomosed to the descending aorta using the PAS-Port System (Cardica Inc., Redwood City, CA, USA). The venous graft was sequentially an

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


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

[User]
RADIOLOGY NOTE:
64-year-old male with a previous medical history of prior tobacco use, gastroesophageal reflux disease and hypertension presented to the emergency department with recurrent and worsening epigastric abdominal pain for 1 month. The pain was associated with episodic bilious vomiting and which also contained food particles. The patient’s history was negative for recent unintended weight loss, hematemesis, melena or known malignancies. Laboratory findings revealed an elevated lipase level of 1300 U/L and leukocytosis of 18.0×109/L. Based on these initial parameters, the clinical suspicion was acute pancreatitis, although there was no family history of pancreatitis and no personal history of alcohol abuse. The patient subsequently underwent a contrast-enhanced CT scan of the abdomen and pelvis using a dedicated pancreas protocol which included soft tissue and bone algorithms as well as reformatted/MPR images. The total amount of intravenous contrast administered was 95 ml omnipaque 350. Oral contrast was not administered. The CT demonstrated marked dilatation of both the stomach and duodenum with an abrupt transition point corresponding to the location of the third portion of duodenum secondary to mass effect by a large AAA (). Additional findings included diffuse atherosclerotic calcifications of the aorta with aneurysmal dilation measuring 9 cm in transverse and 11 cm craniocaudal dimensions. There was no CT evidence of extravasation of contrast or other signs of impending aneurysmal rupture. The ER clinician consulted both vascular and gastrointestinal surgery. Due to the elevated lipase levels and the acute bowel obstruction, vascular surgery was not a viable management option at the time of presentation. The benefits and risks of open aortic surgery versus endovascular repair (EVAR) were discussed in detail and, following nasogastric tube decompression, the patient underwent EVAR of the AAA as the preferred treatment option.
The patient was discharged home after succ

[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 30-year-old, healthy, male patient visited the private dental clinic for bleeding gum during tooth brushing especially at lower anterior teeth. Intraoral examination revealed two impacted mandibular last molar, fissure caries on lower first molars, calculus at upper left molar region and lower anterior teeth. He followed normal oral hygiene practice and did not receive regular dental check-up. He did not have any systemic disease and had good general health. On clinical examination, extra cusp was detected at the palatal side of upper right lateral incisor extending from cement-enamel junction to incisal edge, which was confirmed to be a talon cusp (Fig. ). No caries were observed and gingiva around the affected tooth was healthy. There was no interference in occlusion as the corresponding lower tooth was located at a lingual position. Moreover, it did not cause irritation to the tongue during speech and mastication. The patient also did not suffer discomfort due to this tooth. A few months ago, he noticed that this tooth was slightly larger than normal and unsightly. However, he did not consult with any dentist at that time due to lack of pain and discomfort. His family members do not have this dental anomaly. The tooth responded well during pulp vitality test including cold test and electric pulp tester. There was no pain on percussion on this tooth both horizontally and vertically. Intraoral periapical radiograph of upper right lateral incisor (Fig. ) showed the V-shaped radiopaque structure consisting of enamel, dentine and a small radiolucent area of pulp tissue [black arrow]. Moreover, two keyhole-shaped radiolucencies that are surrounded by radiopaque structures in the coronal portion of the affected tooth [white arrow]. According to the clinical and radiographic findings, the case was confirmed to be the type I true talon cusp together with double type I dens invaginatus in a permanent maxillary right lateral incisor. The study model indicated the cusp

[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 Caucasian male presented with a swelling on the lateral and posterior aspects of his left thigh and buttock, complaining also of leg weakness. He admitted using nasally insufflated recreational drugs resulting in loss of consciousness for about eight to ten hours on a staircase. He was aware of the symptoms upon regaining consciousness. His past medical history included chronic intravenous drug use and hepatitis C.
On examination, the lateral aspect of the left thigh was markedly swollen along with the left buttock. They were no signs of redness or skin injury. Left ankle dorsiflexion was weak, with a muscle power grade (MRC) of 3/5, whereas vascular supply was intact. Sensory and motor assessment revealed a left lateral leg deficit indicating left peroneal nerve palsy.
Patient’s biochemistry on admission showed high levels of creatine phosphorkinase (CPK) and lactate dehydrogenase (LDH). Both suggested muscle death and tissue breakdown (Table ). Imaging with an ultrasound (US) showed non-uniformly swollen left buttock muscle compartments. A CT angiogram was performed to rule out hemorrhage or infection and it revealed signs of muscle and subcutaneous tissues oedema. Moreover the intramuscular fat planes were obliterated. No active arterial or venous bleeding or any abscess was detected. (Figures and .)
Subsequently, the patient became anuric with high levels of urea and creatinine, suggesting acute kidney injury (AKI), which was managed with temporary hemodialysis. Later on, he lost the ability to plantarflex and dorsiflex his left ankle suggesting sciatic nerve palsy. In light of the sciatic nerve palsy and the AKI a diagnosis of GCS made.
He immediately underwent hemodialysis and an urgent fasciotomy to decompress the muscle compartments was performed as soon as the patient was stabilized (12 hours post admission). Post- operatively he required eight units of blood, five units of fresh frozen plasma and five units of platelets. No further hemodialys

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 31-year-old Caucasian woman, gravida 3, para 1, who was referred after a second trimester fetal anatomy screening at 20 weeks gestational for a suspicion of a complex fetal cardiac malformation, for which several specialized opinions tried to reach consensus.
The obstetrical history of the patient includes a previous Caesarian section with a normal course of parturition and a spontaneous miscarriage. The current pregnancy presented a low risk for aneuploidy according to the performed cell-free fetal DNA test. The classical karyotype performed after the abortion did not reveal any chromosomal abnormalities.
Previous ultrasound evaluations were incongruent and reported the following findings:an isolated aortic arch anomaly (supposedly aneurysmal dilation from which the left common carotid artery emerges) and coarctation of the aorta with the anterograde flow; ventricular septal defect, coarctation of the aorta, and a vascular formation located superior from the aortic arch with the appearance of an arteriovenous fistula; aneurysmal dilation located above the pulmonary trunk bifurcation and a dilated left common carotid artery with a retrograde flow; minor ventricular septal defect with a normal ductus venosus triphasic flow.
We performed fetal echocardiography, which demonstrated a mild cardiomegaly with a left deviated 72-degree heart axis, normal aspect of the four-chamber view, a small membranous ventricular septal defect, and ductal aortic coarctation; the ductus venosus flow was normal (, and ). In addition, we identified an aneurysmal structure measuring 1.63/1.25/1.16 cm with turbulent Doppler flow, situated above the emergence of the pulmonary trunk and continued by a dilated vascular structure that bifurcates in the cervical region; the aneurysm seemed connected to the left pulmonary artery as well. A dilated left subclavian artery was also suspected (, and ).
In the context of complex cardio-vascular malformations, the patient request

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


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

[User]
RADIOLOGY NOTE:
A 1-year-old male presented to us with an absent anal opening and transverse colostomy, which was performed on day 2 of life at another hospital. Upon clinical examination, he had a flat bottom, two sacral pieces, and absent anocutaneous reflexes, which are consistent with high anorectal malformation.
An ultrasound of the abdomen showed single kidney on the left side. A micturating cystourethrogram showed grade IV reflux with anterior diverticulum of the urethra. A distal cologram was showing a distended colon without any fistula []. A renal scan confirmed the absence of the right kidney with a normal functioning left kidney.
Because of the single kidney with reflux, the patient initially underwent Cohen's transtrigonal ureteric reimplantation along with an excision of the dorsal diverticulum of the anterior urethra. After 2 months, the patient was scheduled for a posterior saggital anorectoplasty (PSARP). Intraoperatively, after opening the sphincter muscle, a complex rectal pouch was identified. The rectal pouch was opened at the midline at the distal most summit as done in routine posterior saggital anorectoplasty. This revealed a blind pouch with a recto-prostatic fistulous opening, which was an unusual finding for us. We tried to mobilise the rectum from below in the sub mucosal plane as further operation was not possible from the posterior route. The decision was made to mobilize the rectum through the abdominal route. The abdomen was opened by a left hockey stick incision and the rectum was mobilized. The rectum was dilated proximally; on opening of rectum, the diaphragm was found about 2 cm proximal to the distal end []. The terminal end of the rectum along with diaphragm was excised and a closure of the fistula was performed. The dilated rectum was tapered and an anoplasty done.
A histopathological examination of the excised specimen was consistent with the diagnosis of diaphragm. The patient is on regular follow-up of 8 months with no complaints. He underw

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old woman with an unremarkable medical history was found to have a suspected pancreatic mass during a regular medical checkup in December 2018. However, she did not undergo further follow-up because of the absence of specific symptoms. In July 2019, the patient was admitted because of a 1-month history of progressive right upper quadrant pain. She denied any nausea, vomiting, fever, and jaundice during the course of her pain. Physical examination revealed that her abdomen was soft with right epigastric tenderness, and routine hematological tests showed no significant abnormalities. Computed tomography (CT) showed a 3.9- × 3.2-cm solid mass in the pancreatic head, with a mildly dilatated pancreatic duct and multiple nearby swollen lymph nodes (). Both the portal vein and splenic vein were encased by the mass. Moreover, abdominal ultrasound, enhanced CT of the chest and abdomen, and magnetic resonance cholangiopancreatography showed that apart from the enlarged lymph nodes, there was no evidence of liver, lung, or peritoneal metastasis. The patient continued to undergo further examination in our department to attain a definitive diagnosis.
After admission, the patient underwent conventional upper endoscopy before pancreatic biopsy, and mucosal erosion was observed in the gastric pylorus (). Narrow-band imaging showed that the capillary structure and glandular opening morphology of the lesion were generally normal. Forceps biopsies were carried out routinely. We then performed contrast harmonic echo–endoscopic ultrasound, which revealed a hypo-enhancing and inhomogeneous mass measuring 3.6 × 3.1 cm in the pancreatic head (). Based on the CT images and endoscopic manifestations, we considered the pancreatic mass to be the primary lesion and performed endoscopic ultrasound-guided fine needle aspiration to obtain a definitive diagnosis. Pathologically, the pancreatic section showed poorly differentiated invasive adenocarcinoma. Moreover, the biopsies taken from

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


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

[User]
RADIOLOGY NOTE:
A 47-year-old male presented with a mass in the anterior mediastinum. The mass was incidentally detected on a chest X-ray during the evaluation of a minor trauma that he had sustained two months prior to his presentation to Asan Medical Center (). As such, he was referred to our hospital for further evaluation. On his admission, a chest computed tomography (CT) scan was taken, which revealed an 8.9 cm×7.1 cm×8.0 cm heterogeneous mass in the anterior mediastinum. The mass was located anterior to the ascending aorta and the main pulmonary artery in the left hemithorax (). The mass was well demarcated without the overt signs of invasion to the adjacent structures. Also, there was neither pleural effusion nor lymph node enlargement. The differential diagnosis for this tumor based on the radiologic findings indicated a thymoma, a germ cell tumor, or a mediastinal sarcoma. Due to the proximity to the aorta and pulmonary artery, a pre-operative tissue biopsy was not considered. Instead, it was decided that the patient undergo an excision. The procedure was performed via median sternotomy. Intraoperatively, a well-encapsulated mass was identified and noted to arise from the thymus. There was neither adhesion nor invasion to the adjacent structures such as the aorta, pulmonary arteries, or lung parenchyma. The tumor was excised completely with negative margins for a residual tumor. The intraoperative frozen biopsy revealed a rhabdomyosarcoma. The postoperative course did not show any particular issue; the patient was discharged on postoperative day four. The final pathology report identified a mature teratoma with embryonal rhabdomyosarcoma (). Postoperatively, the patient underwent five cycles of chemotherapy and subsequent radiotherapy. However, six months after the primary surgery, the patient was found to have a nodule, which was highly suspected to be a tumor recurrence, in the upper lobe of the left lung. On the serial follow-up CT scans, we learned that the nodule had

[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 male was referred to the urology clinic in 2012 for suspected renal cystic disease discovered incidentally on CT. There were no significant findings on examination and the patient was asymptomatic.
A contrast enhanced CT noted small SRCs bilaterally, the largest being 1.2 cm in width. A 10.5 cm upper pole simple cyst was also noted in the left kidney. It contained a small soft tissue focus in the lateral wall, however, no calcification, septations or convincing solid components were noted. The lesion fit the criteria for Bosniak stage IIF and the patient was placed on 12-month interval CT surveillance.
In 2013, significant increased global cyst size was noted in the left kidney, the largest being a 7.5 cm lesion in the left lower pole with a small focus of wall calcification. The left kidney upper pole cyst had increased in size to 10.7 cm with new focal soft tissue calcification noted. However, these findings were still consistent with Bosniak stage IIF. A decision was made to alter CT surveillance from 12- to 6-month intervals.
In 2014, the lower pole cyst in the left kidney had increased in size from 7.5 to 9.4 cm. A further 9.3 cm cyst had developed from the anterior midpole. The upper pole cyst had increased in size from 10.7 to 11.4 cm. The radiographic findings still indicated these cysts to be simple in nature. At this time the patient reported weight loss of 5 kg and fatigue over the last 6 months. eGFR had deteriorated to 29 ml/min. MRI corroborated CT results at this stage. MRI also demonstrated the left renal upper pole cyst to contain extensive thick walled septations. T1 gadolinium imaging demonstrated significant underlying haemorrhage. MRI findings upgraded the lesion from Bosniak IIF based on CT findings to Bosniak III. MRI and CT images illustrating these findings are outlined in Fig. .

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


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

[User]
RADIOLOGY NOTE:
A 36-year-old Brazilian male patient was admitted to the hospital with a palpable lump in his right breast, located at the junction of the upper quadrants of the right breast (Fig. ). On physical examination, the lesion appeared firm with irregular margins. Axillary lymphadenopathy was negative and there were no palpable supraclavicular nodes. On breast imaging, ultrasonography showed a hypoechoic mass with partially defined contours measuring 4.0 × 3.0 cm, located at the upper region of the right pectoralis major muscle at the 12 o’clock position with muscle infiltration (Fig. ). Histological examination of core biopsy samples revealed a malignant tumor. Preoperative exams, such as X-rays and chest CT scan, abdominal US did not show any signs of disease. Radical mastectomy was then performed, due to pectoralis major muscle infiltration, consisting in removal of the breast along with the major and minor pectoralis muscles. Biopsy of the sentinel lymph node was performed. Gross examination revealed a solid tumor measuring 3.7 × 3.5 cm with a yellowish-tan cut surface and local foci of hemorrhage. Histopathology showed intravascular papillary proliferation of endothelial cells, spindle cell areas and necrosis, atypia and prominent mitotic figures, consistent with the diagnosis of high-grade angiosarcoma with areas of infiltration of the pectoralis major muscle (HE staining, magnification of 400×) (Fig. ). Histopathology also demonstrated a surgical specimen with clear margins, absence of angiolymphatic and perineural invasion, in addition to sentinel lymph node free of metastasis. Immunohistochemical study revealed a tumor positive for CD31 marker (Fig. ), confirming the vascular nature of the tumor. At the two-week follow-up of the surgical procedure, adequate wound healing was observed, without any evidence of the disease. The patient was transferred to the clinical oncology department, where he presented with severe headache and seizures after the second cycle of 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 60-year-old woman underwent transurethral resection of bladder tumor (TURBT) at our institute in 2004; her pathological diagnosis was a high-grade UC with adenocarcinomatous differentiation (pT2a, G2>G3). Radical cystectomy was conducted. Only carcinoma in situ (CIS) was found in the surgical specimen, and the surgical margin was negative. There was no cancer cell infiltration in the resected uterus or anterior wall of the vagina, and no lymph node involvement was detected. The patient developed continuous pain and bleeding from the residual vagina in 2010, and a tumor was found in the residual vagina; magnetic resonance imaging (MRI) showed it to be located on the anterior wall (). A biopsy of the tumor revealed a pathological diagnosis of adenocarcinoma (). Computed tomography (CT) and bone scintigraphy revealed no metastasis. Based on a preoperative diagnosis of a primary adenocarcinoma occurring on the residual vagina, tumor resection was performed (). The sigmoid colon was partially resected as it was strongly adherent to the tumor. On pathological examination, adenocarcinoma and SCC were detected (); on immunohistochemistry, sections of the tumor were positive for the SCC markers CD56, chromogranin A, and synaptophysin and were negative for the urothelial carcinoma markers GATA-3, p63, uroplakin, thrombomodulin, and 34βE12. We then reexamined the original TURBT specimen and confirmed the presence of SCC (). Adenocarcinoma and SCC were mostly present in the superficial layer of the TURBT specimen, while high-grade UC was found in the deeper layers where muscle invasion was present. Based on these findings, the tumor was diagnosed as a recurring bladder tumor. Local recurrence and pelvic bone metastasis were detected via MRI 3 months after the patient underwent surgical resection of the vaginal recurrence, whereupon she underwent radiation therapy (52 Gy, 26 fractions). She developed ileus in January 2011 and underwent release surgery. Subsequently, multiple l

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


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

[User]
RADIOLOGY NOTE:
A 72-year-old woman with chronic atrial fibrillation, temporal arteritis, and avascular necrosis of the right hip requiring hemiarthroplasty that was complicated by deep venous thrombosis in the past, now presents with new onset left upper extremity clumsiness. A head computed tomography (CT) scan and subsequent magnetic resonance imaging study revealed a hemorrhage into the right parietal and occipital regions of the brain. In view of these findings, warfarin therapy was discontinued and as part of the workup a transesophageal echocardiogram (TEE) was performed and revealed a 4 × 6 mm mass on the aortic valve and a patent foramen ovale (PFO) with bidirectional shunting (right to left after the intravenous injection of agitated saline), mild bi-atrial enlargement, mildly dilated but normally functioning right ventricle, normal left ventricular systolic function and no significant valvular regurgitation. The patient was afebrile and blood cultures were negative. The patient was referred to our institution for surgical evaluation given the TEE findings and the patient clinical presentation. Surgical resection of the aortic valve mass and closure of the PFO were recommended.
Upon examination of the aortic valve, a filamentous mass was identified on the leading edge of the noncoronary cusp midway between the ranula and the commisure. The mass was excised with sharp dissection. A second 2 × 3 mm mass was also observed on the underside of the leaflet and was excised in a similar fashion. Lesions were also observed at the commisure and on the left coronary cusp and were also excised. Pathologic examination subsequently revealed that these lesions were small fragments of myxoid tissue with hyalinization. A modified Maze procedure was also performed at the time of surgery and it required mobilization of the pulmonary veins bilaterally with application of radiofrequency lesions just proximal to the entrance of the left and right pulmonary veins. Another radiofrequency lesion

[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 25years old male marble layer who presented to the eye clinic of the University of Benin Teaching Hospital on the 4th of April 2006 with a history of trauma and poor vision in the right eye of two weeks duration. He was using a machine to cut marble when a piece flew into his right eye resulting in severe pains, tearing and loss of vision. He used some traditional medication without relief.
He is not a known diabetic or hypertensive. There was no previous history of trauma to the eye or any other ocular disorder. He has no known drug allergy. He does not smoke but drinks alcohol occasionally.
His visual acuity was light perception in the right eye and 6/5 in the left eye. In the right eye, the conjunctiva was injected, there was a sealed corneal laceration of about 2.5mm representing the entry point of the foreign body at about the 2 o'clock position, the anterior chamber was shallow and there was some lens matter inferiorly. The pupil was mid-dilated, irregular, with posterior synechiae at about the 2 o'clock position. The lens was opaque. The fundus could not be visualized. The left eye was normal. The intraocular pressure, measured with the pulsair non-contact tonometer was 10mmHg in the right eye and 16mmHg in the left eye. An impression of sealed corneal laceration, traumatic cataract and retained intraocular foreign body in the right eye was made. Ocular ultrasound scan showed echogenic debris within the vitreous humour in the right eye suggestive of a vitreous hemorrhage and an acoustic shadow suggestive of a foreign body in the posterior aspect of the right eye (). He was placed on topical steroids to suppress inflammatory reaction and topical cycloplegics to rest the eye.
He was subsequently booked for right extracapsular cataract extraction with a posterior chamber intraocular lens implant under local aneasthesia with the aid of an operating microscope. During

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


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

[User]
RADIOLOGY NOTE:
A 35-year-old male presented to a regional urban hospital two days following an assault-related blunt traumatic injury. The evening before arrival at the emergency department, he noticed swelling around his chest and neck. It was worse the next morning, precipitating his presentation to hospital. On initial assessment, the patient had a Glasgow Coma Scale of 15, and vital signs were BP 125/66, HR 92, and SpO2 95% on oxygen at 5 litres per minute via nasal cannulas. At the time of presentation, the patient displayed moderate subcutaneous emphysema on physical examination and subcutaneous emphysema on chest X-ray ().
Computed tomography of the chest, abdomen, and pelvis revealed a left-sided pneumothorax and subcutaneous emphysema (Figures and ). Significant laryngeal swelling was also noted (). The patient was found to have multiple rib fractures, a lacerated scalp, and a Grade 1 liver laceration. A chest tube was not inserted at this time, after consultation with a thoracic surgeon at the nearby Level 1 trauma hospital. Upon reviewing the CT, it was suggested that the relatively small amount of pneumothorax for the degree of subcutaneous emphysema indicated potential pleural adhesions. The view of the thoracic surgery service and trauma was that an incorrectly placed chest tube at the regional centre may have risked entering the lung parenchyma. The patient was transferred to a Level 1 trauma centre 4 and 1/2 hours after presentation arriving 30 min later.
The extent of the subcutaneous emphysema was such that the patient could not be placed in a cervical spine collar for transport to the referral facility. His cervical spine was instead immobilized with towel rolls. Vital signs remained stable in transit, and the patient arrived at the trauma centre awake, alert, and breathing spontaneously on supplemental oxygen. The patient was assessed by the trauma service and thoracic surgery.
Over the next two hours, the patient's condition deteriorated. While the patient had

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old previously healthy woman, a college student, was on a waterslide at an amusement park, when her left arm became caught between the side of the waterslide and adjacent rocks. She sustained a forceful twisting and loading injury to her left upper extremity which resulted in a severe pain and deformity to her left arm, forearm, and wrist. She was brought by ambulance to our emergency department. On physical exam, her injuries were closed, her arm and forearm compartments were soft, and she was neurovascularly intact. Radiographs of the humerus, forearm, and wrist demonstrated a left distal third humeral shaft fracture () as well as a left Galeazzi fracture, with a midshaft radius fracture and disruption of the distal radioulnar joint (Figures and ). She was placed in a well-padded long arm posterior plaster splint extending from the posterior shoulder to the fingers, with an additional coaptation component to the splint to stabilize the humerus fracture.
Within 24 hours of admission, the patient underwent open reduction and internal fixation of both her humeral shaft and radial shaft fractures. The decision was made to reduce and fix the humeral shaft first. The humeral shaft fracture was amenable to reduction and fixation with an extraarticular locking plate through a posterior approach with the patient in the lateral decubitus position. Because of the manipulation of the forearm, which may be required during reduction and plating of the humerus, we chose to avoid fixation of the radius and the possible transfixion of the distal radioulnar joint until after the operation on the humeral shaft was completed.
The surgery was performed under general anesthesia. The patient was positioned on a radiolucent table in the lateral decubitus position with the left arm which was supported over a foam roller. The left upper extremity was then prepped and draped, and 2 grams of cefazolin was administered prior to incision

[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 man visited Gyeongsang National University Hospital with a penetrating trauma in his right chest. He had undergone a left pneumonectomy due to a pulmonary tuberculosis infection 24 years ago. He had symptoms of dyspnea and hemoptysis. His respiratory rate was 23 breaths per minute, and his oxygen saturation was 90% in room air. He was conscious, fully responsive to questions, and his initial vital signs were stable. His blood pressure was 150/90 mm Hg, and his heart rate was 100 beats per minute without the use of inotropic drugs. The laboratory findings were as follows: hemoglobin level, 12.2 g/dL; and partial oxygen pressure, 60 mm Hg. Chest computed tomography revealed a 1.7-cm foreign body in the medial basal segment of the right lower lobe and a fracture of the right seventh rib without pneumothorax or hemothorax (). Although his vital signs were stable, dyspnea and hemoptysis were ongoing, and the foreign body could have caused additional lung parenchymal damage and infection. Based on these findings and considerations, we decided to perform emergent surgery. Under general anesthesia and using an intermittent apnea technique, we performed a mini-thoracotomy via the right mid-axillary line of the sixth intercostal space. After adhesiolysis of the whole lung field, we retracted the lung toward the apex and identified the opening site of the penetration tract at the right lower lobe of the medial basal segment. We also confirmed that there was no damage to the major vessels or hilar structure airways. With Duval clamps placed parallel to the wound tract, a linear stapler was placed through the tract and was fired to separate the lung parenchyma and expose the bleeding focus and injured airway (). Hemostasis and airway control were achieved with multiple 3-0 polypropylene interrupted- suture ligation. A 1.3-cm metal fragment was extracted at the end of the distal wound tract. A 28-Fr right-angled chest tube was indwelled in the

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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 37-year-old woman was admitted to the emergency department with sudden-onset severe headache, vomiting, and loss of consciousness. She was unconscious and intubated at admission. The Glasgow Coma Scale (GCS) was detected as 5 eye response (E): 1, verbal response (V): 1, and motor response (M): 3 in a neurologic examination. Light reflex could not be taken bilaterally and pupils were miotic. Flexion response to painful stimuli was obtained. It was determined that the patient was pregnant at admission. The patient who was G7 P4 A0 D&C 2 had not received any obstetric care during pregnancy. A single live fetus compatible with 34 weeks’ gestation and oligohydramnios was found. A vaginal examination revealed a multipara dilatation and no active vaginal bleeding. Her blood pressure was 120/70 mm Hg. The complete blood count and biochemical parameters were found within normal limits. Cranial computed tomography (CT) and CT angiography were decided to perform as a result of neurology and neurosurgery consultations. Cranial CT and CT angiography were performed with protection of the abdomen. A hematoma was detected in the left Sylvian fissure. Additionally, there was hemorrhage in all ventricles, which was compatible with stage IV SAH according to the classification of Fisher (). The Yasargil classification was compatible with grade IV.
After the evaluation of the clinical status of the mother, a cesarean delivery was decided. The cesarean section procedure was performed under emergency conditions and a 2520 g live male baby with a 9-10 Apgar score was delivered. External ventricular drainage was performed from the right Kocher point by a neurosurgery team for the SAH of the patient immediately after the cesarean delivery. The mean arterial structures and Sylvian fissure were reached with an approach from the left side. A ruptured aneurysm with active bleeding was seen in the left MCA tract, which was clipped. The patient was taken to the intensive care unit after the oper

[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 61-year-old woman was seen in a clinic complaining of fever and dyspnea lasting 2 weeks. She was diagnosed with left pneumonia by computed tomography (CT) and referred to our institution. At the time of presentation, she had dyspnea and a fever over 38 °C. Her Eastern Cooperative Oncology Group (ECOG) performance status score was 2, and her Hugh-Jones classification was IV. Rhonchi were evident in the anterior chest. Laboratory studies showed an increased inflammatory response. All tumor markers were within normal limits. The chest X-ray revealed an infiltrative shadow in the lower left lung field. CT imaging showed a solid left main bronchial tumor with carinal involvement. Cartilage destruction was apparent, and the boundaries between the tumor and the esophagus and descending aorta were unclear (Fig. ). Therefore, tumor infiltration into the esophagus and descending aorta was suspected. We diagnosed her with obstructive pneumonia due to a tracheobronchial tumor. For the purposes of securing the airway, performing a tissue diagnosis and evaluating the extent of tumor progression, rigid bronchoscopy was initially performed. The tumor almost completely occluded the left main bronchus, and tumor hemorrhage was evident. By coring out the tumor, the left main bronchus was reopened, and detail of the involved area was revealed. The tumor originated from the left main stem bronchus and occupied almost the entire left main stem bronchus. Two tracheal cartilage rings above the carina and one right main stem bronchial ring distal from the carina were invaded by the tumor (Figs. and ). The pathological examination showed three typical types of histology (cribriform, tubular, solid pattern), and she was diagnosed with tracheobronchial adenoid cystic carcinoma. The rigid bronchoscopic treatment resulted in a significant improvement in the patient’s general condition and cardiopulmonary function (PS 2 → 0, H-J IV → I). Fluorodeoxyglucose-positron emission tomography (FDG-PET)

[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 64-year-old lady with end-stage renal disease on haemodialysis through an internal jugular tunnelled dialysis catheter was referred with intermittent dysphagia. She had multiple co-morbidities including type 2 diabetes mellitus, hypertension, dyslipidemia, hypothyroidism and hyperuricemia. Her dysphagia became more pronounced over several months with accompanying reduced appetite and weight loss (5 kg within 2 months). At around the same time, she also began suffering from dysphonia and frequent dizzy spells. An oesophagoduodenoscopy (OGD) was performed a month later, and this revealed left vocal cord palsy and gastritis, but no other oesophageal pathology to account for the dysphagia. Left vocal card paralysis was reconfirmed by an indirect laryngioscopy. A chest X-ray showed soft tissue opacity in left upper zone with displaced aortic calcification. A subsequent computed tomography (CT) scan confirmed an aortic aneurysm with 4.4 cm of aneurysmal sac arising from the arch of the aorta containing significant atheroma. The aneurysm commenced proximal to the origin of the left subclavian artery and was associated with cardiomegaly. The patient was recommended for surgical intervention but she declined. She was admitted 4 months later with worsening dysphagia and bradycardia. Her dysphagia had deteriorated to the point that she could not swallow food without coughing. In addition, she was increasingly troubled by dizzy episodes which were attributed to junctional bradycardia. Her heart rate dropped to 38 beats/min with significant pauses in the rhythm. Despite the bradycardia, she continued to suffer from high blood pressure (up to 180/100 mmHg) necessitating adjustments to her numerous antihypertensive medications. During the course of her admission, she suffered from septicaemia from Staphylococcus aureus, presumably from her internal jugular dialysis catheter. She was treated with a prolonged course of flucloxacillin which was later changed to vancomycin because o

[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 28-year-old single female with family history of depression, was admitted to the psychiatric hospital due to suspicion of auditory hallucinations, with voices encouraging her to do self-harm acts. The patient has a congenital hearing impairment that was diagnosed at the age of two. The patient began learning sign language at the age of ten, and had previously only communicated by lip reading and talking. From the age of ten to 16, the patient received schooling in sign language techniques in a specialized institution for deaf children in Aalborg. Currently, the patient speaks understandable Danish; she still reads lip, but adequate two-way communication is dependent on sign language.
The patient was interviewed using the Danish version of the Present State Examination (PSE) []. Both the patient and the examiner received a transcript of the PSE questions, thereby allowing the patient to read the questions for herself, while they were read out loud by the examiner. Additionally, an interpreter was present to translate each question into sign language for the patient. Due to the general difficulties in the diagnostic process of nonhearing patients, the Atkinson interview was also employed []. Ninety-four questions enable the interviewer to identify how much auditory meaning the patient is putting into voice hallucinations how much of it is a communication act with lip reading and sign language, and also if any other types of hallucinations are present.
In October 2009, during a period of two weeks, the patient's full field of vision was blurry on both eyes. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the cerebrum were conducted in relation to these symptoms, and the results were normal. In November 2009, Benign intracranial hypertension (BIH) was diagnosed with spinal pressure of 33 mmHg that was accompanied with symptoms of fatigue, headache, and poor concentration. She was treated with acetazolamide, carbonic anhydrase inhibitor, du

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


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

[User]
RADIOLOGY NOTE:
A four-year-old male was admitted to our hospital with left elbow swelling and pain. Plain radiography in anteroposterior and lateral view revealed a Gartland type 3 left supracondylar humerus fracture (Figure , ).
There was no neurological deficit. Under general anesthesia, using c arm control, closed reduction of the fracture was done by an orthopedic trainee under consultant supervision. After maintaining the reduction in hyperflexion and pronation of the elbow, a 1.6 mm diameter K-wire was inserted using the lateral entry point. After drilling the lateral column, it was felt that the wire was skiving proximally in the medullary canal, hence, further drilling was done to obtain purchase in the medial cortex. While the wire was being drilled it broke near the entry point and the broken end disappeared under the skin, leaving the remnant portion buried in the distal humerus (Figure ). Since the reduction was acceptable in anteroposterior and lateral views, three more 1.6mm K-wires were inserted from the lateral to the medial side (Figure ).
Fixation of fracture was confirmed under fluoroscopy. After fracture fixation, attempts were made to remove the broken K-wire but it was not possible to grab the tip, as the broken end was buried under the cartilaginous bone. At this point, intraoperatively we scrubbed out and discussed complications with the family and after taking their consent we proceeded further under the same anesthesia. A skin incision was made over the broken K-wire, surrounding tissue and bone were cleared off and the tip was exposed. Using a needle nose plier, the tip was held and the wire removed in a rotatory motion and confirmed under c-arm (Figure ). An above elbow slab was given for further stability. At one week postoperatively, the patient was found comfortable in the slab without any complaints. Follow-up at four weeks showed radiologic union and removal of K-wires was done

[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 British Caucasian female patient aged 12 years and 9 months presented to our institution with a right thoracic scoliosis, which was first noted at the age of 12 years and 5 months. She was diagnosed with DWS on the basis of her craniofacial dysmorphism and confirmed on a magnetic resonance imaging (MRI) scan obtained at age 2 years. The patient was born prematurely at 27 weeks and was ventilated for the first 12 weeks of life followed by another 2 months of oxygen support, leaving her with chronic neonatal lung disease. She was slow to achieve developmental milestones and walked independently at age 3 years. At age 5 years and 6 months, she underwent cardiac surgery to close a patent ductus arteriosus (PDA). The patient suffered from chronic constipation and dysphagia but was otherwise medically well. She also had mild coordination difficulties affecting her hands and learning problems but attended mainstream school. There was no family history of neurological/syndromic conditions or scoliosis.
At presentation to our clinic, she reported a 6-month history of increasing thoracic back pain, causing sleep disturbance. She was premenarchal, with height 147.2 cm, arm span 148 cm, body weight 32.1 kg, and BMI 14.8. On clinical examination, the patient was slimly built with normal physical characteristics for her age. She had a severe right thoracic scoliosis, which was rotated to the right and produced a right-sided rib prominence on the posterior chest wall, adjacent to the convexity of the curve. There was also thoracic translocation with listing of the trunk to the right and mild elevation of the right shoulder. There was waistline asymmetry with prominence of the left side of the pelvis, which was level. She had normal thoracic kyphosis and increased distal lumbar lordosis with anterior pelvic tilt. There was no evidence of leg-length discrepancy. There were no abnormalities to the skin or subcutaneous tissues overlying the spine, and the patient did not report any

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


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

[User]
RADIOLOGY NOTE:
A 69-year-old Caucasian male was referred to our hospital with 3 weeks of abdominal distension and worsening right lower quadrant pain. He was diagnosed with IgG kappa multiple myeloma four years prior to presentation. He was initially treated with bortezomib/dexamethasone with monthly zolendronic acid with good response initially; however, a year after diagnosis, he was found to have disease progression which manifested as a right radius fracture. His regimen was switched to lenalidomide with dexamethasone with good response and clinically depressed levels of paraproteins. After completion of 9 months of therapy, he underwent autologous stem cell transplant with high-dose melphalan. 7 months after bone marrow transplant, his disease progressed with involvement of pericardial fluid. Salvage therapy was initiated with pomalidomide, bortezomib, and dexamethasone which was discontinued a year later due to peripheral neuropathy; however, at the end of treatment, there was no evidence of ongoing disease.
When the patient presented to our hospital, he had an acute abdomen. Initial blood work revealed a normocytic anemia with hemoglobin of 8.4 g/dl and elevated ESR of 44. He also had acute kidney injury with creatinine of 3 mg/dl (baseline of 1.9 mg/dl). CT scan of the abdomen and pelvis revealed extensive stranding seen throughout the abdomen within the peritoneal space with edema in the mesentery ().
He underwent an exploratory laparotomy which revealed induration of the entire base of the mesentery and retroperitoneum. He had an IgG level of 4407 units with predominantly kappa light chains whose level was 4833 units (kappa to lambda ratio 540). Pathology revealed extensive mesenteric infiltration by kappa restricted plasma cells positive for CD138 on immunohistochemistry, without evidence of amyloidosis. Bone marrow biopsy revealed a 30% involvement by plasma cells (Figures –). Cytogenetics showed 1q22 duplication, trisomy 7 and 15, and gain of 8q24.1. The skeletal surv

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male came to our observation complaining of pain localized in the posterior side of his right inferior limb since at least 2 years. Over the last 6 months, he progressively developed numbness in the same dermatome. There was neither obvious relief nor precipitating factors.
At the admission, the neurological examination was unremarkable. Physical examination revealed no palpable mass within the abdomen.
Spinal CT scan without contrast medium () revealed a 44 mm × 55 mm inhomogeneous soft-tissue mass arising from the right L5-S1 neural foramen and its most anterior portion had a clear colliquative aspect. The mass extended along the lumbar column up to the sacrum and to the ipsilateral sacroiliac joint and eroded the right posterolateral portion of the L5 vertebral body. It developed as well in the retroperitoneal space, posteriorly to the iliac vein, up to the psoas muscle with wide erosion of the omolateral conjugate foramen.
Magnetic resonance image (MRI) showed () a neoplastic lesion with homogeneous low signal in T1WI, heterogeneous signal in T2WI, and strong enhancement in postgadolinium examination. The mass extended along the right side of the L5-S1 intervertebral foramen with erosion of the L5 body without injuring its stability. Besides, displacement of the right psoas muscle was also noted.
Electroneurography and electromyography at the lower extremities showed neurogenic damage with denervation signs of the right L5 nerve.
We decided to perform a one-step combined approach with the vascular surgeon because the lesion was too huge to allow a complete resection via a posterior approach and furthermore its tight relationship with the psoas muscle and the iliac vessels in the retroperitoneal space should be more safely managed via a retroperitoneal approach.
First we dissected free the nerve root from the tumor's capsule debulking the lesion and decompressing the spinal canal and then removed the residual portion after the control of the psoas m

[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 lady presented to the clinic for bilateral retro-orbital headache with tinnitus most severe upon waking up in the morning for 3 months, without evidence of nausea, vomiting, or insomnia. Vital signs were within the normal range. The neurologic exam was non-focal. Enhanced brain magnetic resonance imaging (MRI) revealed a T1 hypointense, T2 hyperintense, homogenously enhancing Pineal tumor of 2 × 1.89 × 1.61 cm (anteroposterior × transverse × height) compressing the posterior wall of the third ventricle with evidence of moderate hydrocephalus (). The patient was scheduled for craniotomy for resection of the mass. In the operating room, an external ventricular drain was inserted in the right occipital horn followed by craniotomy and resection of the mass through a right occipital transtentorial approach. Gross total surgical resection was achieved under microscopic navigation (). The patient was extubated. Upon extubation the patient started to have chewing-like movement of her lips on the ET tube, afterward, she was transferred to the intensive care unit for monitoring. On postoperative day 1, we noticed that the patient was still having chewing-like movements typical of orofacial dyskinesia with evidence of buccal mucosal injury and swelling of the lips (). She was also complaining of inability to sleep. The patient was on regular postoperative medications (esomeprazole, cefazolin, paracetamol, morphine, dexamethasone, levetiracetam). An enhanced postoperative brain MRI was done for evaluation and confirmed complete resection of the lesion without any bleeding or ischemic changes (). The chewing like movements lasted for 72 hours and spontaneously resolved afterward. Pathology confirmed pineal parenchymal tumor of intermediate differentiation (WHO Grade III). The patient was treated with adjuvant radiotherapy. This is an unreported complication post pineal gland tumor resection in humans. Below we review the literature reporting abnormal facial movemen

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


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

[User]
RADIOLOGY NOTE:
The patient was a 39-year-old female who had experienced a gradually progressive decrement in visual acuity of the right eye during the past 2 months. Her medical history indicated that she had been treated for breast carcinoma, which had been originally diagnosed in her right breast 6 years ago, with no signs of metastases. Histopathological evaluation confirmed invasive ductal adenocarcinoma of the breast. She had been since treated by mastectomy and adjuvant chemotherapy with docetaxel until 3 years ago when her treatment with oral tamoxifen was begun. The treatment limited the neoplastic process and there were no clinical or radiological signs of progressive disease during these years.
The patient had no significant medical history. She was taking tamoxifen. She had no history of alcohol or tobacco use and there was no environmental toxic exposure. Her family history was negative for breast cancer and other diseases.
Office examination revealed a best-corrected visual acuity of counting fingers at 2 meters in the right eye and 10/10 in the left eye (by Snellen E chart from six meters). There was a 3+ relative afferent papillary defect in the right eye. Extraocular motility was intact in both eyes. Intraocular pressures were within normal limits in both eyes in applanation tonometry. Color plate testing results (by Ishihara’s color plate test) was 1/14 for the right eye and 14/14 for the left eye. Anterior segment examination was unremarkable. Dilated fundus examination of the right eye demonstrated 1+ cells in the vitreous, optic disc swelling, obscuration of vessels and infiltration by a large yellowish mass that disrupted the normal structure of the optic disc, and flame-shaped hemorrhages in the peripapillary (PP) region (). Fundus examination of the left eye was normal. Humphrey visual field testing in the right eye showed an altitudinal defect with enlarged blind spot (). PP optical coherence tomography (OCT) demonstrated significant retinal nerve fiber lay

[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 female patient suffering from neurofibromatosis type 1 (NF1) complained about chest discomfort and dyspnea at rest. On past history, she underwent total thyroidectomy for nodular hyperplasia, and mass excision with skin flap operation for a huge sacral ulcerative neurofibroma. The plain chest X-ray showed a well-defined, huge cystic mass and compression of the right whole lung (Fig. ), and magnetic resonance imaging (MRI) revealed 14 x 11.5 x 11 cm, and 9.2 x 9.1 X 8.6 cm double cystic masses connected with T4-5 and T5-6 neural foramens in the right posterior mediastinum (Fig. ). We decided to do a surgical resection due to a symptomatic huge mediastinal mass. However, because this case had compression symptoms by a huge neurosurgical lesion, which could result in neurological problems or difficult manipulations during thoracic surgery, we performed a neurosurgical collaborative management. As for a preliminary treatment, the patient underwent the CP shunt procedure under general anesthesia by a neurosurgeon. A percutaneous catheter was inserted into the meningocele by transthoracic puncture with a needle at the T3-4 level under the fluoroscopy guidance, and a peritoneal catheter was placed through a limited abdominal incision. At postoperative 12 days, the CP shunt revision was performed due to accidental break of a cystic catheter. But the symptoms continued and the size of cystic mass and the amount of newly developed pleural effusion did not change significantly. We expected initial CP shunt would to perform functions to the patient, however, it was not sufficiently effective due to the thick wall of meningocele. Thus, surgical correction was decided and thoracotomy was the only choice since meningocele was extremely large to fill hemithorax. The CP shunt catheter was preoperatively removed at operative room, and then posterolateral thoracotomy was performed through the 5th intercostal space in the left down decubitus position. Two large meningocel

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old woman with a chronic persistent cough presented with enlargement of a left neck tumor, diagnosed as goiter 20 years ago. Upon physical examination, a soft solitary thyroid mass was palpated. There were no palpable neck lymph nodes. No abnormalities were found on flexible laryngoscopy. Laboratory examination showed normal levels of serum TSH, T3, and T4. The CT scan revealed a thyroid mass originating from the left lobes and extending into the mediastinum. The caudal end was situated above the superior edge of the aortic arch (shown in Fig. ). The width between the caudal ending, and the sternum notch was 37 mm. The goiter compressed the trachea, but there was no apparent invasion of the surrounding tissues. Fine-needle aspiration cytology findings were consistent with the Papanicolaou class IIIa (shown in Fig. ) []. No follicular tissue dysplasia was noted, suggesting the diagnosis of adenomatous goiter (shown in Fig. ).
Although adenomatous goiter is a benign neoplasm, surgery was indicated for the patient because of the presence of upper respiratory symptoms secondary to the extension of the mass. Preoperative CT scan in the extended neck position was performed to decide whether sternotomy was necessary. Two rolled towels were inserted under the patient's scapula to extend the neck. In this position, the goiter was withdrawn cranially 18 mm from the sternal notch (shown in Fig. ).
Sternotomy is typically performed in cases wherein the goiter cannot be resected via a cervical incision. However, in this case, thyroidectomy was performed using the cervical approach. The goiter originated from the left thyroid lobe and extended between the trachea and the left common carotid artery. Adhesion to the surrounding tissues was not observed. The goiter was resected with the lower pole bluntly dissected (shown in Fig. ) to enable its mobility (shown in Fig. ). The recurrent laryngeal nerve and the parathyroid glands were preserved, and the goiter was successful

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


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

[User]
RADIOLOGY NOTE:
A 52-year-old male was brought to the trauma center after a high speed motor cycle collision. The patient was not wearing a helmet and had altered mental status on the scene requiring emergent intubation with a King laryngeal tube (Ambu Inc., MD, USA). On arrival at the trauma center his airway was secured with an endotracheal tube and a cervical collar was placed. He had bilateral breath sounds and his oxygen saturation was 100%. His distal pulses were 2+, blood pressure 98/60 mm Hg and pulse rate was 89 beats per minute (bpm). He had a negative focused abdominal examination for trauma (FAST) exam. His Glasgow Coma Score (GCS) was three with pupils two mm bilaterally and reactive. On log roll there was no rectal tone, but the patient had received succinylcholine 100 milligram (mg) for the endotracheal intubation. A foley catheter was placed and no hematuria noted, his pelvis was stable. The patient’s repeat blood pressure was 70/49 mmHg and pulse 85 bpm with a weak thready radial pulse and warm extremities. He was given two units of packed red cells and two units of fresh frozen plasma. His repeat blood pressure was 79/62 mm Hg as measured by a right femoral arterial line. A massive transfusion protocol was initiated with the patient receiving another five units of packed red cells, four units of fresh frozen plasma, one pack of platelets, and one gram of Tranexamic acid. Simultaneously the right femoral arterial line was exchanged for the 7 French introducer catheter and connected to the arterial line with good waveform. The REBOA catheter was placed at 42 centimeter (cm) into zone one. Inflation was done with 2 milliliters (ml), then 4 ml, then 6 ml of saline for a total of 6 ml of saline with improvement in the blood pressure to 112/62 mm Hg. The REBOA catheter was locked and sutured in place. His abdominal X

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old boy presented to our outpatient clinic with abdominal pain. He reported recurrent epigastrial pain for the past 3–4 months, which has increased in severity and frequency, thus prompting the parents to seek medical help. The patient also developed diarrhea during the last month prior to presentation. On closer questioning, he described awakening at night with pain, accompanied by sweating and extreme paleness during the painful episodes. The description of the symptoms was alarming, prompting further investigation.
On clinical examination he did not have specific findings: he was pale and his lower abdomen was tender and full. Routine full blood count and biochemistry revealed normal values apart from a slight normocytic anemia, the patient was found to have normal immunoglobulin levels. A subsequent abdominal ultrasound (US) showed an ~20–22 mm-wide band-like cystic mass stretching in front of the right psoas muscle and above the bladder. A follow-up US 10 days later, by the same radiologist identified a gross increase in the size of the abdominal mass, now dislocating the bowels and causing an obstruction (). In order to specify the exact location, origin and nature of the mass, an abdominal MRI scan was performed. Based on the imaging, we had a strong suspicion of dealing with a solid tumor originating from the retroperitoneal space or the mesenteries ().
Pediatric surgeons performed a laparotomy. They located the mass to be in the middle part of the ileum and the attaching mesentery containing numerous cysts with localized infiltration of the bowel wall. A 30 cm long, macroscopically abnormal part of the ileum was resected. Pathologic examination was consistent with intestinal lymphangiectasia based on the dilated lymphatic system/vessels in the submucosa, subserosa and even in lamina propria (). The edges of the resection line revealed normal histologic features.
Secondary causes of intestinal lymphangiectasia (IL) (eg, cardiac conditions, lymphoma

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


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

[User]
RADIOLOGY NOTE:
A 56-year-old Caucasian woman was referred to our hospital after a chest X-ray showed a dense mass in the left middle lung (). The patient had been complaining of increasing dyspnea during exercise since one year and symptoms of chronic bronchitis for several weeks, which was resistant to therapy. No family history of cancer was reported and the patient had no history of smoking. Clinical examination was without any pathological findings except for dullness and reduced breath sounds over the right lung. Chest computed tomography (CT) showed a 3.0 × 5.0 cm intrathoracic tumor, which was surrounded by pneumatocele ( and ). This seemed most consistent by morphological criteria with an extrapulmonary, mediastinal benign solitary fibrous tumor. No metastases where found in lymph nodes or distant organs.
Bronchoscopic examination revealed a constriction of the left upper lobe but no endobronchial tumor. CT-guided percutaneous needle biopsy was performed and histological H&E examination at the Institute of Pathology Medical University Innsbruck showed a monomorphic cell rich spindle cell proliferation with mild nuclear atypia. The characteristic H&E morphology of the core biopsy together with homogenous vimentin positivity, bcl-2 positivity and focal keratin (CAM 5.2, CK7, CK19) as well as EMA positivity together with the absence of S-100 Protein (rules out malignant peripheral nerve sheath tumor with focal keratin expression), calretinin (rules out mesothelioma together with the clinical picture and the negative history for asbest exposure) and CD34 (rules out solitary fibrous tumor) led to the diagnosis of a monophasic synovial sarcoma.
Discussion at the multi-disciplinary bone and soft tissue tumor board (MUI) as well as in the lung and mediastinal tumor board (MUI) decided to do primary surgery as there was no spread of disease, no metastases on X-ray and CT. The tumor was surgically resected by thoracotomy (). The mediastinal mass was in close association with the phr

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


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

[User]
RADIOLOGY NOTE:
A 41-year-old woman presented with intermittent pharyngeal obstruction and repeated vomiting after meals. Concerning her previous history, she had undergone the resection of a fibroma in the right side of her neck 7 years earlier, and complained of a voice change over the past 3 months. The family history was not contributory. The physical and nutritional status were good. There were no abnormal physical findings in the thoracic or abdominal regions. Palpation did not reveal any abnormalities in the superficial lymph nodes or neck. The blood biohistochemistry showed no abnormal findings. Neck and chest computed tomography (CT) revealed an 3.6 cm oval mass with slightly low attenuation in the upper esophagus, and a 7 mm nodule in the left lobe of the thyroid gland (). Esophagogastroscopy showed a 3.5 cm smooth, soft, dark purple, mobile mass which was located just beneath the upper esophageal sphincter with a possibility of airway obstruction (). The thyroid nodule was diagnosed as thyroid papillary carcinoma through sonography guided fine-needle aspiration cytology. We decided to perform a combined operation for total thyroidectomy with dissection of the central neck nodes followed by resection of the esophageal tumor through cervical esophagotomy.
Under general anesthesia with a single lumen endotracheal tube, a 6 cm transverse neck skin incision just above the clavicle was performed. After meticulous dissection, total thyroidectomy with central neck node dissection was completed by a head and neck surgeon. Esophageal dissection was performed to the level of the hypopharynx. In palpation, there was no mass in the cervical esophagus even after direct visualization of the intraluminal space through cervical esophagotomy. With a laryngoscope, the mass was seen at the level of the arytenoid cartilage in the hypopharynx. After a gentle push of the mass with a long Kelly in the direction of the esophagus, it could be extracted through the esophagotomy opening (). Mucosal

[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 male was referred to our hospital. He had presented to another hospital 6 months earlier with drowsiness and a 54-mm diameter mass had been observed in the right temporal lobe on non-contrast CT scan. The patient had undergone surgery and cobalt-60-based external beam radiotherapy for pituitary adenoma 43 years ago. Parallel–opposed lateral radiotherapy targeting the pituitary lesion was employed with a total dose of 50 Gy in 25 fractions. The patient had recovered without residual symptoms but required hormone replacement for panhypopituitarism. He had also developed pontine infarction at 57 years of age. The results of physical and neurological examinations at the time of admission were normal. Laboratory evaluations of complete and differential blood counts, and serum chemistry were also normal.
The patient underwent a contrast-enhanced brain MRI that revealed a well-demarcated mass in the right temporal lobe (). A mass consisting of hyper- and hypo-intensities was observed on T
2 weighted imaging. There was extensive vasogenic oedema around the mass. The T
1 weighted image showed a hypointense mass with hyperintense areas in the periphery, suggesting haemorrhagic foci. Contrast-enhanced T
1 weighted image of the brain showed significant contrast enhancement in the hypointense area on the pre-enhanced T
1 weighted image. The mass was supplied by the inferior branch of the right middle cerebral artery, and conventional angiography showed spotty stains in the arterial phase and spreading and pooling of the contrast medium in the venous phase, which suggested the presence of blood sinus-like structure in the mass (). CT images of the chest, abdomen and pelvis were normal (data not shown). Because hyperintense areas in the bilateral temporal lobes, indicating radiation-induced changes, had been detected on the T
2 weighted image 1 year before (), the mass was considered to arise within the radiation field of the previous radiotherapy, which probably inv

[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 male reported to the department of oral pathology and diagnosis after being referred by an oral surgeon. The patient gives a very interesting history of an appearance of an asymptomatic small elevation on the labial mucosa in the maxillary region in relation to 13 and 14. The swelling is recurrent and disappears within 1–2 days. There was no noticeable extraoral swelling, lymphadenopathy or fever associated. Numerous clinical diagnoses of mucocele, epulis and salivary ductal obstruction were rendered, but since the entity appeared for short duration and used to get resolved by itself, it was never indicated for surgical intervention.
On inspection, there was a mild diffuse oval elevation of 0.5 cm × 0.7 cm having normal mucosal color and was barely noticeable []. There was no sign of inflammation or discharge. On bidigital palpation, the swelling was firm to hard in consistency, nonfixed to the underlying tissue. A provisional diagnosis of minute salivary duct calculi was given and was posted for surgery after hematological examination.
Surgical intervention revealed no association or presence of minor salivary glands or salivary ducts along with the mass. The mass was firm in consistency resembling a small rubber ball measuring 0.5 cm × 0.6 cm, dark creamish black in color surrounded by loose tissue []. The mass was not fixed to underlying deeper structures. The entire mass was sent for histopathological evaluation. The mass was slightly compressible on bidigital pressure. Grossing of the sample was done []. The entire mass was embedded into one block, and gradual sections of 4 μm were obtained.
The H&E-stained section revealed a trilaminar cystic structure surrounded by the loose fibrous tissue [Figure and ]. The outermost layer or pericyst, intermediate layer was avascular dark eosinophilic refractile layer or exocyst and the inner most layer or endocyst projecting toward the lumen can be appreciated [Figure and ]. The lumen was filled by amorphous

[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 29-year-old pregnant woman who was being treated with azathioprine for autoimmune hepatitis consulted at 32 weeks of gestation for decreased fetal movement. Obstetric ultrasound revealed many heterogeneous, hypervascular fetal tumors in the left armpit (), intra-abdominal organs, and subcutaneous space (). There was no sign of fetal cardiac insufficiency or anemia (no pericardial effusion and the middle cerebral artery peak systolic velocity was 50 cm/sec or 1,07 MoM).
Fetal wellbeing was monitored daily and fetal lung maturity was induced at 32 weeks of gestation and 2 days with 12 mg of betamethasone repeated at 24 hours.
Two days later, a caesarian section was performed because of signs of fetal distress by fetal heart rate monitoring. The child presented immediately difficulties in adapting to extrauterine life and was cared for in the pediatric intensive care unit (). First aid revealed that the child was anemic at birth (hemoglobin at 11,8 g/dl) with a pulmonary arterial hypertension on cardiac ultrasound. A body scan () and a biopsy of a cutaneous tumor were performed and showed characteristics of a rhabdoid tumor (small round nuclei, granular chromatin, and eosinophilic cytoplasm). The immunohistochemical analysis revealed a loss of SMARCB1 protein expression and pathological examination of the placenta showed an invasion of both fetal and maternal compartments (). Because of prematurity, circulatory failure, and severe renal dysfunction with anuria, chemotherapy was contraindicated, and the decision was made with the parents to withdraw care. The child died at day 5 of multivisceral failure. The mother underwent a whole-body MRI to identify potential metastasis, but none was found.
The INI1/SMARCB1 analysis conducted by Sanger sequencing of all exons and exon/intron boundaries and a Multiplex Ligation-dependent Probe Amplification (MLPA) to detect copy number alterations revealed a homozygous deletion of the 9 exons in tumor DNA. This alteration was not f

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


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

[User]
RADIOLOGY NOTE:
A previously healthy 14 year-old boy presented to the Emergency Department (ED) for evaluation of right eye injury that was sustained one to two hours prior to arrival. According to the patient, he was standing on a street corner on his way to school when he was struck in the right eye with a rock thrown from a passing car. He reported no loss of consciousness and no other injury. He denied nausea or vomiting. His past medical history and family history were not significant. The patient did not have any prior ocular injuries, history of ocular disease, or prior ocular surgeries. The patient reported that he does not wear glasses.
In the ED, he was alert, awake, answering questions, and following commands with a GCS of 15. His only complaint was pain to the right eye. His vital signs were as follows: temperature 98°F, heart rate 79 beats/minute, respiratory rate 18 breaths/minute, blood pressure 151/73 mmHg, and oxygen saturation 99% on room air. On examination, blood was oozing and pooling in his right eye with eye lid swelling and surrounding abrasions ().
The patient expressed severe photophobia in his right eye and was unable to open it. Detailed examination of the right eye could not be performed due to the possibility of right ocular globe rupture. A metal eye shield was placed on the patient's right eye for protection. His left eye refractory status was normal with a visual acuity of 20/20. The patient had a negative battle sign, no hemotympanum, no rhinorrhea, and no cervical spine tenderness. The remainder of his examination was noncontributory.
A non-enhanced CT scan of the orbits was obtained and revealed rupture of the right globe with associated orbital and periorbital swelling with intraconal hematoma ().
An ophthalmology consultation was obtained. He was then taken to the operating room where a 20 mm linear laceration was noted crossing 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:
In October 2007, a 60-year-old male arrived for assessment in our clinic with the major complaint of pain and torpor at the region of the tongue, mental nerve and infraorbital nerve. He mentioned that he had previously, for 3 weeks, taken up antibiotics without any remarkable improvement. The clinical examination involving the face and the oral cavity revealed nothing pathological concerning the mentioned symptomatology, except for tenderness in the suborbital region. The patient was soon after referred for radiological examination. The orthopantomography which was carried out revealed a 1.5 × 1 cm radiolucent lesion with rough margins located at the body of the mandible at the region distal of 46 in close relation with the mandibular canal [].
The extraction of 46 and ectomy of the bone lesion were considered as the indicated and more appropriate therapeutic approaches. The extraction of 46 was carried out due to the non-retroverting periodontal infection (large gingival recession of the tooth with more than two-thirds of the root exposed) and serious bone absorption as demonstrated in , which made the prognosis of the tooth very poor. Tooth extraction was followed in the same operation by the local ectomy of the bone lesion. After the elevation of a mucoperiosteal flap, the lesion was abstracted en bloc and the surrounding bone was debrided until health margins (bleeding bone). The procedure of debridement indeed led to the perforation of the lingual mandibular plate. The abstracted lesion was sent for histopathologic examination and antibiotics were administered to the patient for 10 days.
The histopathologic report, which arrived in our clinic 10 days later, concluded findings compatible with benign fibroxanthoma. The macroscopical findings reported included 13 brown and yellow-brown friable fragments of tissue, with 2–5 mm as the greatest diameter. Microscopically, many foamy histiocytes in dense arrangement and fewer spindle-shaped cells in fascicular and stor

[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:
Case 1. A 69-year-old man presented with 2 episodes of visible haematuria. He had computed tomography scan which revealed diffuse thickening of the bladder wall and moderate hydronephrosis. There was no evidence of lymphadenopathy or metastatic disease. He did not have urine cytology examination. He underwent cystoscopy and bladder biopsy from the trigone and histological examination of the specimen revealed muscle-invasive urothelial carcinoma involving the trigone. Immunohistochemical staining of the tumour revealed immunoreactivity for high-molecular weight cytokeratin 903 and cytokeratins 7 and 20 and negativity for prostatic specific antigen and prostatic acid phosphatase. He underwent radical cystoprostatectomy. Macroscopic examination revealed that the mucosa of the urinary bladder was oedematous, with focal haemorrhage and necrosis around the trigone. The urinary bladder wall was diffusely thickened and infiltrated by tumour; the trigone of the urinary bladder was most markedly involved, with obstruction of the ureteric orifices (see ). Microscopic examination revealed that with the exception of the surface mucosa, the bladder wall was extensively infiltrated by neoplastic cells, which were arranged in a diffuse pattern of relatively ill-defined and variably sized nests (see Figures and ). There was also evidence of focal urothelial carcinoma in situ and multiple foci of urothelial dysplasia. The cytologic characteristics of the underlying main neoplasm were markedly distinct from those of the surface urothelial mucosal lesions. The neoplastic cells exhibited clear/pale or amophilic/eosinophilic cytoplasm with poorly defined borders and rounded nuclei with inconspicuous nucleoli. The chromatin was finely granular and distributed in an even fashion. Rarely, the tumour cells exhibited clear and signet ring characteristics. On the whole, there was no evidence of significant nuclear pleomorphism, and mitosis was rare (see ). Rarely, large atypical cells were obs

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old man with no previous medical history visited our hospital with complaints of fever and sore throat. A polymerase chain reaction (PCR) test confirmed that he had COVID-19, and he was hospitalized in a negative pressure isolation ward. He had difficulty breathing, which gradually worsened. Ten days after admission, he was intubated and mechanical ventilation began. Diffuse viral pneumonia was identified on chest radiography and computed tomography (Fig. ). After a month of mechanical ventilation, he was weaned off of the ventilator. However, critical illness and prolonged treatment in the ICU resulted in severe muscle wasting and deterioration of physical function.
For a comprehensive rehabilitation treatment, he was referred to the Department of Rehabilitation Medicine. During the initial assessment, he needed moderate support for static sitting balance and scored 0 on the Berg Balance Scale and 8 on the Modified Barthel Index. The strength of both the upper and lower limbs was grade 3 following the Medical Research Council (MRC) grade. He was clinically diagnosed as ICU-acquired weakness because the MRC sum sore consisting of both wrist extension, elbow flexion, shoulder abduction, ankle dorsiflexion, knee extension, and hip flexion was 36 points, which was less than 48 points suggested by the guideline.[ Various types of rehabilitation exercises were carried out in a step-by-step manner according to the patient's function (Fig. ). The bed manual joint range of motion (ROM) exercise (step 1) and position change were performed six times daily for 10 minutes by a healthcare provider authorized to enter the quarantine ward while wearing Level D protective equipment. After two consecutive follow-up PCR tests were negative for COVID-19, the patient was transferred to the general ward. There, rehabilitation therapy was performed by a physical therapist and an occupational therapist. In addition to the ROM exercises previously performed, sitting balance train

[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 male recruit complained of pain in the both hips for several weeks without a history of direct trauma in his hip and pelvis. He also complained of right chest wall pain and a painful swelling in his left foot. His symptoms appeared during his basic military training such as repetitive running and marching in an army recruit training center. Approximately four years before the occurrence of the recent painful episodes, he underwent surgery for a fracture of the right femoral neck caused by a fall in a bathroom. With the exception of this surgical history, he had no remarkable history of disease or treatment with medication. The plain radiograph showed no evidence of complications from the previous surgery for a fracture of the right femoral neck, but revealed bilateral non-displaced fractures with callus formation at the junction between the inferior pubic ramus and the ischial ramus (), which were overlooked by an orthopedic surgeon. In order to exclude any surgery-related complications such as osteonecrosis, MR imaging (Signa Excite, GE Medical Systems, Milwaukee, Wis.) of the pelvis was performed, which showed transverse fracture lines through the overlying callus formation and high signal intensity around the adductor magnus muscles bilaterally (). A bone scan (E.CAM, Siemens, Erlangen, Germany) with 99mTc-MDP revealed symmetric focal areas of increased uptake at the same regions as the plain radiograph and MR imaging (). In addition, scintigraphy demonstrated rib fractures of the right 5th and 6th ribs, and a fatigue fracture of the left 4th metatarsal bone. His symptoms gradually improved with rest and some analgesics. Six months later, follow-up MR imaging and bone scan were performed. The follow-up MR images demonstrated discrete callus formation with a resolution of the abnormal signal intensity around adjacent soft tissues (). In the follow-up bone scan, the focal tracer activities still remained but were much improved () compared with the ini

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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 previously healthy 39-year-old woman was referred to our hospital because of a cystic lesion in the liver demonstrated by abdominal ultrasonography (US). Laboratory studies, including liver function tests, and tumor markers were also within the normal limits. Serological markers for hepatitis B or C viral infection were undetectable. Abdominal US revealed a well demarcated, heterogeneously low-echoic mass 170 mm in diameter in right lobe of the liver. Abdominal computed tomography (CT) during hepatic arteriography (CTHA) revealed early ring enhancement in the peripheral area in the arterial phase and slight internal heterogeneous enhancement in the delayed phase (Figures and ). Magnetic resonance imaging (MRI) showed that the tumor had low signal intensity on T1-weighted images and some foci of high signal intensity on T2-weighted images. Gadolinium ethoxybenzyl (Gd-EOB) MRI revealed no uptake in the corresponding area (Figures , , and ). Abdominal angiography demonstrated a large avascular region in the liver corresponding to the tumor, although no typical features of cavernous hemangioma were evident (). 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed no abnormal FDG uptake. With these radiological findings, malignant liver tumor could not be excluded, such as biliary cystadenocarcinoma, cholangiocarcinoma, mesenchymal tumors, and hepatocellular carcinoma associated with cystic formation.
The patient underwent posterior sectionectomy. Intraoperative examination revealed a relatively soft dark red tumor (); the resected specimen weighed 1.1 kg and measured as 170×100×80 mm. The cut surface of the tumor revealed a white, solid, and cystic mass that was elastic, soft, and homogeneous with a yellowish area considered to be myxoid degeneration (). Histological examination showed that the tumor mostly consisted of sclerotic area and cavernous hemangioma area is partly observed (). Sclerotic area presents diffuse fibrosis () and the typical histol

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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.